When I was a fledgling MD2B (doctor of medicine to be—aka, medical student), I followed the traditional method taught to us to obtain a thorough history, the open-ended approach. Basically, this approach was based on letting the patient prattle on for an eternity describing his or her problems and conditions from a historical perspective. Unfortunately, the open-ended approach netted me valuable information about what the patient thought was important (e.g., the patient’s diet for the past month, meal by agonizing meal). I quickly mastered this approach and was able to do a history in about a short hour and a half. However, I knew there had to be more . . .
I was very impressed with the ability of more experienced clinicians to hone in on a medical problem by simply asking a series of questions. The problem was that, if you don’t ask the question, you don’t get the answer. You see, when patients are only questioned, they tend to answer only what you ask them with little or no prattle. Lack of information leads to poor outcomes, so I quickly lost respect for that system as well.
My solution was to take a history based on “controlled prattling.” You start off with an open-ended approach, then when the patient starts to drift off into another multiverse via an ocean of nonrelated ideas, you nudge the individual back using focused questioning.
My next hurdle was to create a question bank that was based on information about a subject I did not know or understand. One day, I came upon a checklist system that allowed me to organize my thoughts quickly and efficiently. Basically, you start asking generalized questions. When you get a pertinent positive or negative answer, you move to a subcategory on the checklist, and you follow this sequence until you arrive at the end.
The checklist system allowed me to understand how to obtain a functional focused history. It provided a structured set of questions and a flowchart for moving through the subcategories of questions, forever narrowing the list of possible causes down to the correct answer.
We will provide you now with a checklist to follow as you approach any WCT (Figure 37-1). As you master the flow, you will not need the list any longer, but it is a great tool to get started. Note that it is not an all-inclusive list of criteria or observations, but it is one that follows the mainstream of a system on approaching the WCTs. Feel free to add to, subtract from, or alter the list to match your particular needs or approach. Keep what you feel works for you and discard the rest.
Figure 37-1 WCT checklist.
Data from: Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83(5):1649-1659; and Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008;5(1):89-98.
DescriptionNow that you’ve reviewed the checklist, do you see how using it will allow you to concentrate more on diagnosis and not on procedural minutiae? Get used to the rhythm and flow of the important questions or observations by moving through the sections in an organized manner (the criteria that favor VTach have red checkboxes). If you get stuck at any point, move on and come back to it later. Remember, there is a tremendous amount of redundancy in these criteria and you can easily make a definitive diagnosis even if all of the criteria are not met.
AUTHOR’S NOTE
The clinical scenarios that follow were each chosen for a particular purpose. Sometimes the arrhythmia will be the main culprit causing the problem; other times the arrhythmia is just a complication of another underlying problem. Finally, for the purposes of these scenarios, we will be spending some additional time on the history and physical examination because of the wealth of information we can derive from them. Some of the concepts may be more advanced than you are used to, but you should be able to follow the logic and use them to aid your deductive reasoning skills. Once again, you can skip over these sections if you’d like, but we urge you to give them a try.