Chapter 22: Gout Medication for a Simple Cough? Death Wish!
Facing Foreman's provocation, David responded calmly:
"If you suspect I'm tardy or ducking out early, I suggest you check my time cards."
Foreman scoffed again, stopped talking, and brushed past David into the conference room.
Cameron tugged on David's sleeve and whispered:
"House tore into him yesterday for that surgical error. He's just pissed. Don't let it get to you."
David smiled and indicated to Cameron he was fine.
He then strode into the conference room.
Foreman's attitude was trivial—the patient's condition was what demanded his focus.
He saw that House, who'd entered earlier, had already pulled out the glass whiteboard and was rapidly writing symptoms with a dry-erase marker.
David scanned what was written—the current presentation of the patient who'd been admitted to the ER.
"Cough, abdominal pain, rash, nausea, fever, kidney failure, hypotension."
After writing, House turned and asked the team seated in the conference room:
"Thoughts?"
Cameron glanced at everyone frowning in concentration and spoke first:
"Could be an allergic reaction? Allergies could explain abdominal pain, rash, nausea, and fever."
After Cameron led off, Chase followed with his assessment:
"Yersinia infection?"
His suggestion was immediately shot down by Foreman:
"No, that wouldn't cause cough or rash.
I'm thinking inflammatory arthritis with vasculitis leading to peripheral neuropathy."
Foreman's hypothesis was countered by Cameron.
"No, that wouldn't cause the blood pressure crash. Maybe parasitic infection?
Parasites could account for four or more of these symptoms."
Seeing Cameron refute him, Foreman immediately attacked her theory.
"No, that's impossible—"
"Stop!"
Foreman was cut off mid-sentence by House, who impatiently slammed open a thick medical reference in front of him:
"Foreman, if you want to list every disease this isn't, I suggest you go alphabetically. It'll be faster."
Foreman took a deep breath, swallowing his irritation with House.
Then he closed the book in front of him and looked at David, who'd remained silent:
"Since you clearly think all our diagnoses are garbage, why don't you ask your star intern over there?"
Hearing Foreman's bitter comment, Cameron couldn't help interjecting:
"Foreman, he's just an intern. You don't need to keep gunning for him."
"Hmph, intern? So interns just get a free ride here?
If he's here for clinical training, he should contribute something. Sitting there like a potted plant won't build any experience."
Chase, sitting nearby, caught the implication in Foreman's words—he wanted David to propose a diagnosis so House could shoot him down.
"Alright, ease up on him. None of us can think of a disease with all seven characteristics simultaneously, so he can't either."
"Really? How do you know he can't unless he speaks? Chase, you're not telepathic, are you?"
Chase shook his head at Foreman's sarcasm and went quiet.
Foreman right now was like a rabid dog, snapping at anyone within reach.
And David, meeting Foreman's hostile stare, spoke unhurriedly:
"Actually, I do know what could cause this constellation of symptoms."
As soon as those words left his mouth, even House looked at David sharply.
The purpose of Diagnostic Medicine was collaborative differential diagnosis—eliminate impossible options one by one through everyone's input, and thus identify the correct pathology.
That's why House had everyone voice their theories, to see if they could reason their way to the answer.
But until just now, he hadn't identified any matching disease entity.
And David claimed he knew? This was absurd!
Although House often said outrageous things, in reality, he was supremely confident in his abilities.
If he couldn't crack it, David didn't have the expertise to either!
So he narrowed his eyes and asked:
"You know?"
"I know. Among the seven symptoms, the cough needs to be considered separately.
The other six symptoms all point to one thing: colchicine toxicity!"
Hearing the word 'colchicine,' Foreman immediately burst out laughing and interrupted David.
"Come on, kid. Colchicine is primarily used to treat gout!
Does he have urate crystal deposits in his joints?
Does he show pain, swelling, erythema, or joint rigidity?
Because I'm not seeing any of that. If you're going to bullshit, at least make it convincing—"
Foreman's voice trailed off because he noticed House actually looked thoughtful.
Which meant David wasn't talking nonsense—colchicine poisoning was genuinely possible!
Seeing Foreman fall silent, David continued his reasoning:
"Correct, the patient doesn't have gout, but he likely took gout medication by mistake.
The cough was his initial complaint, and he probably saw his PCP for it.
Afterward, either the pharmacy tech dispensed the wrong medication, or there was an error in the physician's e-prescription.
Either mistake is equally probable.
Bottom line, his cough didn't improve—instead, by mistakenly taking colchicine, he inhibited mitotic spindle formation and halted cell division.
This caused widespread cell death without replacement, triggering cascade symptoms.
Including but not limited to abdominal pain, rash, nausea, fever, acute kidney injury, and hypotension.
Sound familiar? Those are the six major symptoms on the whiteboard.
Next should come bone marrow suppression, then peripheral neuropathy, paresthesias in the extremities, alopecia, and eventually death.
All we need to do is administer colchicine-specific Fab fragments to neutralize the toxin, plus some acetaminophen for symptomatic relief, and we'll save his life."
After listening to David's diagnostic analysis, the conference room fell completely silent.
Everyone present had medical training, and they all recognized that David's reasoning was remarkably sound.
As for verifying whether David was right, the method was straightforward: obtain the cough medication the patient took and have it analyzed.
So after a brief moment of shock, House suppressed his surprise and instructed:
"Then David, you're tasked with retrieving that cough medicine from the patient."
David nodded and exited the conference room.
Only after David left did Chase speak in admiration:
"You realize he's a prodigy, right?
It's like he's got a diagnostic algorithm running in his head, instantly pulling the correct answer."
Cameron chuckled softly:
"This intern is genuinely exceptional. Best I've ever worked with."
"Haha, and the best-looking too, right?"
Chase teased.
Cameron rolled her eyes at Chase and didn't respond.
Only Foreman maintained a dark expression, clearly brooding.
House rapped on the table:
"Everyone, reserve your assessments until we see the actual medication.
Even a diagnosis that's ninety-nine percent accurate needs empirical evidence to support it."
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