Medical History[edit | edit source]
Joey chewed nicotine gum to get rid of his smoking addiction.
Case History[edit | edit source]
Joey collapsed after eating a meal and standing up to go to the washroom. He could not be revived by federal agents who were with him, and was admitted to Princeton-Plainsboro Teaching Hospital in a coma. Dr. House was subject to a federal court order to treat the patient, but objected. He reconsidered when Dr. Cuddy refused to pay for legal counsel to fight the court order.
Dr. House examined the patient and found his pupils were unresponsive to light and he had no pain reflex. The patient did not respond to sounds.
Dr. House brought the case to his team. Dr. Chase noted that the patient had had his stomach pumped and Dr. House explained it was a precaution because of the fear of poisoning. They discussed what causes comas and Dr. House noted he had assessed the patient as an 8 on the Glasgow Coma Scale, meaning the patient was lucky to still be alive. The patient had no history of recent head trauma. All the metabolic causes, such as organ failure, had been ruled out.
His brother, who was also a lawyer and had ties to the mob tried to cajole or persuade Dr. House to delay diagnosing, treating or releasing the patient until he could convince his brother not to testify because he felt he would be killed if he did.
Joey was given an MRI and they found a sub-dural hematoma. This explained the coma, but Dr. House also noticed pseudomembranes, which take time to form. Dr. Cameron checked his medical history and noted he had been hit in the head with a tire iron in 1996, which could explain the hematoma. His liver function was slightly low, but not low enough to explain a coma. Dr. Foreman suggested evacuating the cavity to see if the patient would come out of the coma. However, as they were discussing the necessity of drilling into his skull, Joey spontaneously came out of his coma. Dr. Foreman examined him and found no unusual neurological responses - his pupil response was normal.
However, Dr. House did not want to release the patient until he determined what caused the original coma (fearing the brother would object if he released the patient). Dr. Foreman agreed with Dr. Chase that the patient could be released. Dr. Foreman still wanted to evacuate the hematoma, but it was clearly not an immediate threat. Dr. Cameron wanted to release him as well. However, as attending, House decided to send for a hepatitis serology and an autoimmune panel.
However, Chairman of the Board Edward Vogler, tipped off anonymously about the situation, contacted admitting and they decided to have the federal agents remove him. Dr. House confronted Mr. Vogler and Dr. Cuddy, but Mr. Vogler had copies of the patient's medical records sent to the judge who issued the court order and she had reclined it.
However, two hours later, Joey returned after having collapsed and fallen unconscious. The federal agents asked Mr. Vogler why the patient had been certified as ready for release.
The patient's liver function had declined since his release, but he was not in a coma, merely unconscious. The patient had tested positive for hepatitis C and Dr. Chase thought the coma had been induced by the hepatitis. It also explained the new symptoms - vomitting and abdominal pain. Dr. House wondered why the coma had come on fast, suggesting an acute condition - not hepatitis. However, Dr. Chase also pointed out his estrogen levels were high, suggesting a chronic condition. Dr. House ordered a liver biopsy. He also agreed to let Chase treat the patient for hepatitis C.
However, when Dr. Chase told Joey's brother that the most likely reason for transmission was either homosexual sex or drug use he slapped Chase across the face and told him not to treat the patient for it despite the positive test. Dr. House determined that the patient had been in prison and the brother confirmed that this would destroy the patient's reputation. House offered to alter the patient's chart so as to protect his reputation not mention the treatment, interferon. However, Dr. House also told the brother that the interferon probably wouldn't cure the patient.
Joey's blood pressure started to drop. Dr. Foreman pushed fluids and got his systolic blood pressure up to 100 and stabilized him. Dr. Chase thought it was varices bleeding into the patient's liver, a common complication of hepatitis C. Dr. House brought in the biopsy result - lymphocytic infiltrate and no breaching fibrosis. This ruled out hepatitis C as the causes of the patient's major symptoms. The patient also tested positive for toxins and Dr. House believed the patient had been deliberately poisoned. The problem was that the tests to determine which toxin would take at least four hours, and the patient's liver would be gone in two hours. Dr. House decided to run the patient's blood through a pig, allowing the pig's liver to substitute for the patient's.
The patient's white blood cell count was low, which was probably because of the illness and not the liver. Dr. House asked if the patient smoked. He checked the patient's chest x-ray and noted early signs of emphysema, meaning the patient had smoked for some time. Dr. Cameron confirmed the patient had recently quit. Dr. House found out the patient was using chai-yu, a Chinese herb, in an attempt to quit. The herb lowers white blood cell count and is toxic in large doses. He planned to leave the patient on the pig profusion and then discontinue the herb.
The patient came out of his coma and asked for a meal. Dr. House wanted to observe him overnight, but he expected to release him the following morning. He came in the following morning to announce to Mr. Vogler and Dr. Cuddy that the patient was ready for release. Dr. Cuddy reviewed the patient's chart and wondered how the chai-yu could cause the symptoms. Dr. House admitted it was a medicine interaction with the interferon that wasn't mentioned on the chart. However, just as the patient was about to be released, he relapsed back into a coma. He was stable, but comatose and on a respirator. Dr. Chase still thought it was the hepatitis. However, given that the patient still had the herb in his system, they couldn't give him interferon. Moreover, Joey's high level of estrogen didn't seem to be linked to his other symptoms. Dr. Chase suggested treating the hepatitis with a non-nucleoside allosteric inhibitor to change the virus. However, Dr. Foreman noted that this would likely be fatal to the patient. Dr. Chase countered the patient was dying anyway.
Dr. House wanted to focus on the patient's high estrogen level, but there were no other apparent causes. They decided to go with the inhibitor. However, Dr. House realized that there was one other cause of high estrogen levels - the patient was deliberately taking estrogen. He started to concentrate on what conditions cause intermittent comas, and toxic comas were the most likely culprit. However, Dr. House considered a food sensitivity. However, Dr. Chase had ruled out any relationship between the patient's meals and his condition - steak and potatoes before the first coma, and fish sticks before the second coma. However, Dr. House got the brother to admit that he got the patient a steak in place of the fish sticks. Dr. House then was able to suggest Ornithine Transcarbamylase Deficiency - an inability to process the protein in beef. The brother rarely ate beef before. He suggested stopping all treatment because if that were the case, the coma would resolve itself. However, this disorder would not explain the patient's estrogen level. This could only be explained away if the patient was taking estrogen in the form of an herbal aphrodesiac marketed to gay men. However, the brother refused to accept that his brother was gay. Dr. House told him that if he really didn't believe his brother was gay, that they should continue with the current treatment. However, he reminded the brother that if Joey was gay, the treatment would kill him. The brother agreed to discontinue all treatment. Dr. House believed that Joey was homosexual and was willing to testify in order to join the witness protection program and be able to live his life without the pressure from his homophobic mob family.
Three hours later, the patient woke up and asked for his brother. The brother accepted that Joey was gay and agreed to let him testify. However, they agreed to say that the herbs he took were the wrong ones and that was what caused his illness.
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