Billy brought Margaret to Princeton-Plainsboro Teaching Hospital after she started complaining about stomach pains and started vomiting. The case was assigned to Dr. House. Dr. Foreman reported that apart from the severe stomach pain and vomiting, the patient had been suffering from lesser pain for the prior three days and her LFTs were elevated. Dr. Taub suggested lead poisoning. Dr. Benedict suggested hepatitis A, but her serology was negative. She then suggested appendicitis, but Dr. Foreman noted that an inflamed appendix would have ruptured by now. Dr. Foreman thought it was hepatic fibrosis. Dr. House ordered a liver angiogram to look for fibrosis and an environmental scan for heavy metals.
Dr. Chase and Dr. Benedict performed the angiogram. They found scarring in the liver, probably from a previous surgery, and evidence that she had broken five or six ribs in the past. Dr. Benedict was surprised that the patient had not included that information in her medical history.
Dr. Taub and Dr. Foreman did the environmental scan, but found no sign of lead. However, they found evidence she had been in Trenton when she said she had been in Summit. They confronted the patient, who said she merely got the dates mixed up. She said she broke her ribs ten years ago in a cycling accident and didn’t mention it because she didn’t think it was relevant. Dr. Chase said they needed to check her medical records because the scar they found on the liver might not be fibrosis but a surgical error. She directed them to the University of Massachusetts Hospital.
However, Dr. Benedict could not find any records at the U. Mass Hospital, and she checked and found that the patient had never been admitted at the University of Massachusetts. Dr. Benedict had also checked the other hospitals in Boston and found no record. She then checked Margaret’s social security number, and found that although it matched her name, the number was issued in 1945 and the patient had no credit history until three years ago. She determined that the patient had stolen someone’s identity.
The patient suffered a supraventricular tachycardia with a heart rate of 150 bpm. Dr. Taub tried a massage of the jugular vein with no effect. Dr. Foreman ordered adenosine and Dr. Taub ordered a pacemaker.
The patient finally regained consciousness and they confronted her about her identity and her lack of medical records. She claimed that she had been married five years ago and changed her identity to escape her abusive ex-husband. He was responsible for breaking her ribs. She changed her identity after he poisoned her dog. She was in Trenton in a support group. Billy demanded to know the name of the abusive ex-husband. The patient admitted her real name was Jenny.
Dr. House asked Dr. Benedict to provide another differential. She suggested gastritis, but that would only explain the stomach issues, not the heart issues. She suggested atrial fibrillation, which would explain the arrhythmia, but not the stomach problems. She suggested cystitis, then cholecystitis, but the former explained nothing and the latter would have shown up in the physical examination. Dr. House concentrated on the abusive ex-husband, the fact she had just eaten, and the open door of her house, and suggested that the ex-husband had tried to poison her. Dr. Benedict argued that violent abusers don’t suddenly become poisoners, but Dr. House pointed out the ex-husband had already poisoned the patient’s dog. Dr. House ordered pyridoxine on the assumption it was organophosphate poisoning.
Billy was angered by the ex-husband’s action and Margaret’s failure to tell him about it, and found a person he thought he was the ex-husband and got into a fight that resulted in a trip to the emergency room. However, he realized it wasn’t the right man and he had only acted stupidly.
Suddenly, Margaret developed a fever of 103F, which was rising. This ruled out a toxin. Dr. Foreman suggested endocarditis, but Dr. Benedict pointed out that her EKG was normal and there were no Osler nodes. She had also run an echocardiogram which showed no vegetations and clear heart valves. She suggested legionellosis because Dr. Taub saw an old air-conditioner in the patient’s home. Dr. Foreman argued there was no lung involvement, but Dr. Benedict argued that dehydration from the fever would hide the pneumonia. Dr. House ordered fluids and treatment for legionellosis. However, Dr. Foreman was suspicious - Dr. Taub hadn’t written up the air conditioner in his report and had only told Dr. Chase. He figured Dr. Chase was feeding diagnoses to Dr. Benedict and she admitted it.
Dr. Chase confronted Dr. Foreman about his dislike of Dr. Benedict. He accused Dr. Foreman of maintaining an attitude of superiority that was not justified by his duties or salary. He told Dr. Foreman that it was clear that he was picking on Dr. Benedict because he was afraid of confronting Dr. House. Dr. Chase also reassured Dr. Benedict and advised her to use her skills as a psychiatrist to attempt to figure out what is going on with the patients.
Dr. Benedict found Billy, who found out that Margaret had lied about being in a support group in Trenton. Dr. Benedict assured him that Margaret’s behavior was typical of abuse victims. She advised him not to wake her to confront her about it at this point, and he agreed.
Margaret regained consciousness and Billy tried to discuss her deceptions, but Margaret’s speech didn’t make sense and it turned out she was having hallucinations. Whatever she had reached her brain and the scans showed an opacity on her left temporal lobe. Dr. Taub thought it might be an abscess, and Dr. Chase suggested lymphoma or granulomatosis with polyangiitis, but they would need a biopsy to be sure. Dr. Benedict suggested that the patient might have more than one condition. The patient’s delusions were consistent with mental illness. She suggested it might be the onset of bipolar disorder, but Dr. House dismissed the notion that the onset of bipolar would coincidentally follow a physical illness. Dr. House still wanted a biopsy.
They started to prepare the patient for the brain biopsy. However, just as Dr. Chase was about to start, Dr. Taub stopped him and pointed out that the patient’s body temperature was normal. Dr. Chase put it down to the cooling blankets they had been using, but Dr. Taub noted they hadn’t used them in an hour. Dr. Chase directed Dr. Benedict to inform Dr. House.
They thought that it might have been legionellosis and it was getting better, but the patient had been re-hydrated and there was still no lung involvement. Dr. Taub suggested another infection, such as malaria or Dengue fever, both of which would cause an intermittent fever. However, Dr. House reviewed the patient’s chart and found that the patient’s body temperature never dropped below normal. A patient without a fever who was under cooling blanket should have hypothermia. Dr. Benedict admitted that she had turned down the cooling blankets as the patient’s body temperature had gone down. Dr. House admonished Dr. Benedict for not informing them the patient’s fever had disappeared the previous afternoon. A short duration fever pointed to a reaction to medication, perhaps the antibiotics. However, a fever caused by antibiotics would most likely cause vomiting as well, and the patient had not vomited since she was admitted. Dr. House started to believe all the patient’s initial symptoms had disappeared. He turned off the patient’s pacemaker and her heart returned to normal sinus rhythm. The only remaining symptom was delusions. Dr. Benedict returned to bipolar disorder, and stated the disorder could have been set off by the physical symptoms. However, Dr. House realized that Dr. Benedict had it the wrong way around. He ordered haloperidol and lorazepam and directed them to let him know when she woke up.
The patient was still having hallucinations, but was lucid. Dr. House realized that the reason Margaret hadn’t told them where her hospital records were was that she was sure she was going to be released before they could check them. She was hiding the fact she had schizophrenia was being treated with risperidone. When she started having stomach pains, she went to her psychiatrist in Trenton, who recommended she taper off the drug as stomach pain is a common side effect. The risperidone was causing all of her initial symptoms. When it wore off, those symptoms went away but her schizophrenia reasserted itself. Dr. House admonished Dr. Benedict for missing it. Dr. House started her on a new anti-psychotic drug.
Billy came to Dr. House to ask for advice, but Dr. House told him it was his problem to deal with. However, he told him she was still the same person he married.
Dr. House told Dr. Chase that it was up to him as to whether Dr. Benedict could remain on the team.
Billy went back to Margaret to comfort her.
Dr. Chase went to see Dr. Benedict, who announced that she was going to leave before Dr. House fired her.
|#01||"Now What?"||#09||"Larger than Life"||#17||"Fall From Grace"|
|#02||"Selfish"||#10||"Carrot or Stick"||#18||"The Dig"|
|#03||"Unwritten"||#11||"Family Practice"||#19||"Last Temptation"|
|#04||"Massage Therapy"||#12||"You Must Remember This"||#20||"Changes"|
|#05||"Unplanned Parenthood"||#13||"Two Stories"||#21||"The Fix"|
|#06||"Office Politics"||#14||"Recession Proof"||#22||"After Hours"|
|#07||"A Pox on Our House"||#15||"Bombshells"||#23||"Moving On"|
|#08||"Small Sacrifices"||#16||"Out of the Chute"|