David Hawkins - The Thinkers Guide to Clinical Reasoning: Based on Critical Thinking Concepts and Tools

Copyright 2010 Foundation for Critical Thinking

Foundation for Critical Thinking Press
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ISBN 978-0-944583-42-5

The elements of clinical reasoning that appear in the diagram below provide the basis for analyzing the structures present in all thinking. Whenever we think, we think for a purpose within a point of view based on assumptions leading to implications and consequences. We use concepts, ideas, and theories to interpret data, facts, and experiences in order to answer questions, solve problems, and resolve issues.

Each of these structures has implications for the others. If you change your purpose, for example, you change your questions and problems. You are then forced to seek new information and data. And this changes the implications and consequences of your conclusions and decisions.

Note: When we understand the structures of thought, we ask important questions implied by these structures.

A 53 year old man complains of severe pain in his left big toe for the past 2 days. The patient has a past medical history of two episodes of acute gouty arthritis in the past 3 months, hypertension for 10 years, and dyslipidemia. He is currently receiving a thiazide diuretic for his high blood pressure, atrovastatin for his high cholesterol, and one aspirin tablet daily to prevent heart attacks. Laboratory studies revealed a serum urate concentration of 10mg/dL and a very high urinary urate concentration. The patients blood pressure is 130/80 mmHg. A positive diagnosis of acute gouty arthritis was confirmed by taking a sample of the patients synovial fluid taken from the affected joint and examining it under a polarizing microscope.

To treat the acute attack and to prevent recurrent attacks.

1. 1.What is the most effective way to treat this patients acute attack?
2. 2.What is the most effective way to prevent recurrent attacks in this patient?
3. 3.What adjustments, if any, need to be made to this patients other medications?

1. 1.Colchicine will not work in this case.
2. 2.Baby aspirin will not significantly increase serum urate concentrations.
3. 3.Traditional medicine has the best answers in a case like this, so we dont need to consider alternative therapies.

1. 1.A conservative approach would be to treat the acute attack and discontinue the thiazide diuretic because it increases serum uric acid concentration and therefore the propensity for recurrent attacks.
2. 2.A more aggressive approach would be to initiate preventive therapy irrespective of the decision to continue or discontinue the diuretic.

1. 1.Either colchicine or a non-steroidal anti-inflammatory agent can be used to treat acute attacks.
2. 2.Colchicines effectiveness diminishes 48 hours after onset of pain.
3. 3.Either probenecid or allopurinol can be used to prevent recurrent attacks.
4. 4.Probencid increases urinary uric acid excretion.