Title: Occam's Razor
Original airdate: 11-30-2004
Synopsis: A young man collapses after enthusiastic sexual intercourse with his fiancee. The team is perplexed, since no one condition explains all his symptoms.
Patient: Brandon Merell
Initial symptoms: cough, low blood pressure, rash, nausea, abdominal pain, fever.

*****Spoilers below*****

Differential diagnosis:


Brandon calls in sick to work, telling his boss he has a cough, fever, and is feeling nauseous. Mindy, Brandon's fiancee, also notices a rash on his skin. Despite not feeling well, Mindy easily talks him into having vigorous sex, but he passes out immediately after.

Wilson brings Brandon to House's attention because, among all his other symptoms,  Brandon's low blood pressure is not responding to IV fluids, which is odd.

Chase's initial idea is Yersinia infection, though it does not present with a rash or cough. Foreman suggests arthritis with accompanying vasculitus, but this does not explain the blood pressure problem. Cameron, the allergist, suggests allergy, which wouldn't explain the abdominal pain. Chase suggests carcinoid, after which Cameron notes that no condition accounts for all the symptoms.

House points out that unless they control Brandon's blood pressure, he'll soon be "circling the drain." He orders treatment for sepsis, broad-spectrum antibiotics, an Cort-stim test, and an echocardiogram.  Brandon's fiancee, Mindy, confides to Chase her concern that she may have made Brandon ill with overly rough sex, but he assures her that was not the cause.

Foreman thinks Brandon's illness could be viral, and suggests they run gels and titers. Test results arrive from the printer, on which Foreman notes that Brandon's BP is still falling, his lungs are filling with fluid, and his creatinine is rising, which indicates Brandon's kidneys are shutting down.  The antibiotics could be doing more harm than good.

Foreman suggests an odd presentation of a viral heart infection, which would explain all the symptoms except the cough and the rash. House scoffs at the idea. House uses the white board and various colored markers to encircle clusters of symptoms with all the previous theories, and includes hypothyroidism, parasites, and sinus infection.

He concludes that Cameron was right; no one condition explains all the symptoms, but the symptoms circled with orange and green cover everything. House orders Unasyn for the sinus infection and levothyroxine for hypothyroidism.

Foreman thinks House's two-illness theory is wrong, and heads to the lab to run more tests for viral infections. Chase accompanies him, though he thinks random testing is a bit silly.

Further testing reveals that Brandon has acute interstitial nephritis, which means the antibiotics did not cause the kidney failure.  Brandon's condition is improving, for which House bluntly taunts Foreman. The taunting, however, was designed to goad Foreman into continuing to try to prove House wrong, which works. Foreman runs a TSH, T3 and T4, which show Brandon does not have hypothyroidism. He insists it can't be two illnesses, and Brandon might be getting better just because his body is successfully fighting the infection. House sends Foreman to check Brandon's white count. If he is fighting an infection, his white count should be high. The test results, however, surprise everyone. Brandon's white count is so low that he needs to go into a clean room, as he is now unable to fight infections. If he gets a so much as a cold, he is likely to die.

Foreman does a bone marrow biopsy to look for a virus or fibrosis to explain the low white count.

The epiphany:
House has Wilson fill his Vicodin prescription, but grabs the wrong bottle from the pharmacy counter. After prolonged brooding, ball-tossing, and internet and library research, House announced that Brandon had been given colchicine, a gout medication, instead of cough medicine when he had his prescription filled.

Cameron points out that Brandon was improving, but then he got worse, which does not fit the theory.  Upon questioning, Brandon's mother confesses that she gave Brandon more of the cough medicine immediately before his decline.  Chase questions the pharmacist who filled the original bottle, but the pharmacist insists, rather huffily, that he did not make a mistake. Brandon's mother and Mindy confirm that the pills from the pharmacist look exactly like the ones Brandon was taking before.

This causes House to doubt his colchicine theory. Wilson suggests lymphoma, but House says Brandon's CT scan showed no adenopathy, the CBC showed a normal differen-smear, and there were no signs in the bone marrow. Wilson then advises House to abandon testing and do an exploratory laparotomy to see what going on inside Brandon's body.  Even though House believes the surgery could kill Brandon in his weakened an immuno-compromised state, he agrees to do it anyway for a lack of a better idea.

The Doclings perform a procedure to place sensors in Brandon's lungs by running a tube through his heart and into his pulmonary artery. During the procedure, Brandon complains of numb fingers. Chase tells Foreman that Brandon's heart monitor shows ectopy, and warns him that he can't tolerate any cardiac arrythmia in his condition, and tells him to stop. Foreman continues, and Brandon's blood pressure plummets and he develops VF (ventricular fibrillation). Chase shocks Brandon with the defibrillator, and he resumes a sinus rhythm.  Brandon is too unstable for the surgery.

Cameron thinks the clean room may have gotten contaminated, and Brandon may have an infection. She recommends doubling his dosage of G-CSF  to boost his white count.  She also reports the pain in Brandon's fingers.

House finds this interesting, and barges into the clean room without a mask or gown. He declares that even if the pharmacist didn't screw up the cough medicine, Brandon's symptoms dictate colchicine poisoning. He suggests ecstasy use, which Brandon confesses to taking twice, much to Mindy's chagrin. He lists the symptoms, which match Brandon's, including the new ones, which are neuropathy (the finger pain), and hair loss, upon which he easily yanks out a hank of Brandon's hair.

He orders FAB fragments for the colchicine poisoning and Tylenol for the hair he ripped out. Although Brandon is improving rapidly, he still has the cough. Brandon noticed the pills Cameron gave him have a letter on them, and the previous pills did not.  House obsessively rummages the pharmacy until he finds a colchicine pill that is nearly identical to the cough pill.

Diagnosis: Colchicine poisoning

Incidental terms:
absidia
Stockholm Syndrome
Coxsackie B
Epstein-Barr
Parvovirus B19
atrium
RV (right ventricle)
tricuspid valve



Soap Opera: House and Cuddy butt heads over clinic duty again.  Annoyed that he is an hour late for clinic, she makes a crack about his leg. ("I could run home and..." "No, you couldn't.") As a response to that, House gives a short, but alarming, speech to the patients waiting in the clinic. Cuddy is unfazed by this, and sends a horrified patient to see him anyway.

House begins a major power play to get out of clinic duty by calling for unnecessary consults.  Cuddy quickly becomes hip to his game and sends Wilson instead.  House eventually loses the game and has to "kiss her ass."  She rewards him by allowing him to knock off clinic duty early, but, as a parting shot, he sends her a patient who needs to have an MP3 player removed from his rectum.

Cameron runs her own head game on Chase, when he mentions Mindy's concerns about rough sex, she asks for details, presumably to embarrass Chase for his giggly attitude, which she finds childish. However, when Foreman tells her she's now in his head, she corners Chase in the office. She claims to be uncomfortable talking about sex, but launches into a vivid description which leaves Chase sweating with his mouth hanging open.


Comments
: Even though House assures Jerry Morris that he's been a doctor for long enough that he won't be shocked by anything, he still looks a bit nonplussed at the idea
of a rectal MP3 player.


Clinic Patients:

Jodi Matthews
Shelly Lever
Adam Brown
Jerry Morris



Everybody Lies:
House feigns uncertainty about clinic diagnoses to irritate Cuddy.
Cameron claims to be uncomfortable discussing sex, but her speech to Chase was remarkably aggressive.
PPTH People: 

April

Other People
:

Suburban Pharmacist



Cast:
cast

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