Medical History Edit
The patient is morbidly obese. He weighed well over the weight of the hospital's largest scale, which goes up to 450 lb. With a waist size of over 84 inches, it was estimated that he weighed over 600 lb. However, his blood sugar, blood pressure and cholesterol levels were well within normal range; indeed they were on the low side for the normal range. He tested negative for hormone imbalances and indeed all his hormone levels were also within normal range.
Case History Edit
The patient was found unconscious in a state mimicking death in his own bed - he had no radial pulse, detectable heartbeat, his body temperature was close to the ambient temperature of the room, he had lost control of his bladder, was not breathing and his pupils were fixed and dilated. However, while the firefighters were attempting to remove him, they detected flatulence and one of them checked for a pulse. They finally found one in his femoral artery and called for medical assistance. The firemen used an ambubag and hooked him up to a portable EKG. The patient was lowered to the ground through a hole in the wall of his apartment and rushed to Princeton-Plainsboro Teaching Hospital where it was determined he was in a comatose state. Dr. Cuddy brought the case to Dr. House's team and advised them that apart from the patient's weight and coma, there did not appear to be anything wrong with him. Dr. Chase thought it must be diabetic hyperglycemia, but his blood sugar was normal. His tox screen was clean and there was no indication of trauma. All the lab work had been repeated three times to rule out the possibility of error.
The patient's EEG and neurological exam were both normal. Dr. Chase suggested a food related illness, and Dr. Cameron suggested puffer fish toxin which could cause coma and would not show up on a standard tox screen. However, Dr. Foreman noted that pufferfish toxin would have killed him in six hours and he has been in a coma for at least 24 hours. Dr. House arrived late but had already been briefed on the matter. He believed he had Pickwickian syndrome and ordered treatment. However, Dr. Foreman pointed out the patient's blood gases were normal. Dr. House also wanted a detailed medical history, so he ordered an environmental scan including speaking to neighbors.
Dr. Cameron did the environmental scan. His neighbor had not notice any personality changes or trouble with balance, but also admitted she had not seen him that often. George had a huge pantry, but the neighbor wasn't sure if he ate unpasturized cheese or wild game, but suggested she check his regular market. The neighbor also thought he was probably using prostitutes.
Dr. Foreman ruled out Pickwickian syndrome because ventilation with oxygen and steroids had no effect. George had also developed a fever. Dr. Cameron suggested Syphilis, but Dr. House noted that men tend to use condoms with prostitutes - you get an STD from partners you trust. He suggested doing an MRI on his brain to look for clots, but Dr. Foreman pointed out the weight limit was 450 lb. Dr. House asked for a CT Scan instead, but the weight limit was only 350 lb. Dr. House ordered blood thinners, but Dr. Foreman was afraid the coma was caused by bleeding and thinners would only make it worse. Dr. House reminded him that the longer George was in a coma, the less likely he was to come out of it. He told his team to either treat or find a way to do the MRI.
Dr. Cameron insisted that they try the MRI because they only had to scan his brain. Dr. Foreman and Dr. Chase noted he was well over the weight limit and would most likely break the table. With the help of six nurses and orderlies, they managed to get him on the table. They started the scan, but they didn't see anything abnormal. Dr. Cameron suggested they try a lumbar puncture to see if they could track down an infection, but Dr. Chase thought the patient's weight ruled it out. Suddenly, George awoke from his coma, tore out his ventilator and started to panic. Although Dr. Foreman told him to calm down, his struggles broke the MRI table. They finally managed to get him out of the machine.
George's recovery still didn't explain why he was in a coma. Dr. Chase thought it might be head trauma and his weight hid the swelling. However, trauma wouldn't explain the fever, although the steroids they gave him would. Dr. Cuddy came in to admonish Dr. House for breaking the MRI, but he denied instructing his team to give him the MRI. Dr. Cameron admitted it was her idea and that she did it to avoid a discrimination lawsuit on the basis of morbid obesity. Dr. Cuddy let the matter drop. Dr. Foreman suddenly realized that an acute adrenal gland deficiency could lead to a coma. However, Dr. Chase noted this would result in a lower than normal body temperature, not a fever. Dr. Foreman thought he fever might not be related and wanted to run an ACTH stimulation test and check for acanthosis nigricans. Dr. Cameron still thought it was an STD and she wanted to do a full panel and check for chancres on his genitals. Dr. Chase wanted to keep him for observation - if he continued to improve it was probably just a hematoma that healed spontaneously. Dr. House allowed Dr. Foreman and Dr. Cameron to run the tests they suggested.
Dr. Foreman did an examination for skin discoloration, but the patient said that he had been frequently checked for hormone imbalances and that was never the problem. He also said he had been checked several times for diabetes mellitus. Dr. Foreman asked if he had vision problems, but there was nothing but the nystagmus the patient had since birth. Dr. Cameron tried to convince him that the coma indicated a serious condition, but George said he felt fine now and wanted to be released. He was afraid of medical mistakes and hospital related infection. He played down the risk of his obesity and noted that the MRI breaking on him put his life at risk. Dr. Cameron said it was the only way to rule out a stroke or brain hemmhorage, but now that those had been ruled out, George wanted to leave.
Dr. Foreman's examination showed no abnormalities, and the STD panel was negative. They also told Dr. House he wanted to be released. When Dr. House thought about that, he thought George might know what was wrong with him and went to see him. He told him that given that he didn't want to know what caused the coma, he was either mental illness or he knew what caused it. However, George denied it. He denied trying to commit suicide, having been sexually abused, and having inherited OTC deficiency. George noted that both his parents were still alive, living in Florida. Dr. House suggested he had thyrotoxic periodic paralysis, but George had not even heard of that. When Dr. House suggested leukoencephalopathy, George lost his temper and said he would tell Dr. House if he knew. He said he wasn't miserable, just overweight.
Dr. House ordered the patient released, but Dr. Cameron objected. She accompanied him on his release and, although she insisted he remain in a wheelchair until they reached the outside of the hospital, he got up and immediately collapsed, destroying a tempered glass window in the process.
When Dr. Foreman suggested that the disorientation and loss of balance could indicate a neurofibramatosis, Dr. Cameron admitted she sedated George with 3g of phenytoin to keep him in the hospital. Dr. House reviewed his discharge report and realized he hadn't eaten breakfast. Together with coma and fever, anorexia indicated Chagas disease. Dr. Cameron noted George had never left the United States, but Dr. House noted he ate a lot of imported food. He ordered a CSF sample to see if there were parasites in his brain. However, because the patient was too big to do a lumbar puncture, they sought his consent to drill a hole in his head to take a sample. Dr. Cameron explained that the parasite could have lived inside a plant and would not have been taken away by washing. George was still angry that Dr. Cameron thought he might have gotten a parasite by eating more food than other people who ate the same food. He wanted a theory that had nothing to do with his weight, but Dr. Cameron insisted this theory fit and if they didn't treat it, it would get worse. George finally agreed.
They started the procedure, but after they finished the hole, George complained that he had gone blind and started to panic again.
However, there was no inflammation in his optic nerve and his retina was intact, which meant there was a problem with his brain. There was also no sign of any parasites in his CSF. There was also no chance the procedure damaged his vision - Dr. Foreman was never near George's visual cortex. Dr. House thought they must have missed a tumor on the MRI, but Dr. Foreman insisted it was clean. Dr. Foreman thought it might be multiple sclerosis - the symptoms fit. However, Dr. House noted that coma is never the first symptom of MS. He thought the combination of blindness and coma meant it had to be diabetes mellitus. Dr. Cameron countered his glucose level, urine test and A1c were all normal. Dr. House ordered him tested again, together with a glucose tolerance test and an HEC. He also told Dr. Foreman he could test the CSF sample for MS once the other tests were finished.
However, George refused to undergo the glucose tolerance test. He was still angry about his blindness, but Dr. Cameron pointed out there was no way the doctors could have caused his coma. Despite Dr. Cameron's insistence, he refused the test. He pointed out that although he had been overweight for years, he had only been sick for a few days. He agreed to tests only if they weren't related to his weight.
Dr. House returned and was told that the MS test was negative, but that George had refuse to be tested for diabetes. Dr. House went to do the glucose tolerance test himself. He confronted George who still refused to believe he was diabetic. George struggled with Dr. House until Dr. House grabbed George's fingers and realized something - his finger bones weren't just fat, they were clubbed. He ordered an x-ray of George's hands, a bronch, a sputum cytology and a test of his CSF for anti-Hu antibodies. When Dr. Cameron asked how they would get George to cooperate, he told his team that he thought George had lung cancer.
The x-rays confirmed the clubbing and the remainder of the tests confirmed small cell lung carcinoma. The blindness and coma were caused by paraneoplastic syndrome. The cancer had metastitized to his lymph nodes and was inoperable, but there was radiation treatment. However, his prognosis at best was only a few more months before death. George noted that he had never been a smoker and accepted the diagnosis.