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Bob arrived at Princeton-Plainsboro Teaching Hospital exhibiting ventricular fibrillation. However, he showed no signs of any heart pathologies or any other symptoms. His file was referred to Dr. House. He reported he was sitting at his desk at work when he had shortness of breath and chest pain. However, Dr. House noted his chart showed fresh abrasions on his knees. Dr. Adams said the patient reported getting them in flag football game, but Dr. House though it was more likely he was engaged in recent sexual activity that he didn’t want the doctors to know about. Dr. House ordered an exercise stress test to see if they could induce ventricular fibrillation again. Dr. Park noted this could put him into cardiac arrest, but Dr. House felt it was the only way to determine what set off his original attack. Dr. Chase told Dr. Park it was preferable to have a cardiac event in a hospital where he could be treated rather than somewhere else.
Dr. Adams and Dr. Chase confronted the patient about having sex. When they threatened to ask his wife, he finally admitted he was having sex with another woman. He assured the doctors it was the only time anything like that ever happened. He told them he was having sex when he started feeling light-headed. The next thing he knew he was on his back, barely able to breathe. They explained the exercise test to the patient.
However, the patient was in excellent shape and they had difficulty raising his heart rate. To put him under stress, Dr. Chase pretended that he had told Bob’s wife that he wanted to talk to her about the affair. The patient got worried and he started to feel dizzy and soon collapsed. However, Dr. Taub reported there was nothing wrong with Bob’s heart. Dr. Chase examined the patient and found he was having a seizure.
A review of the EKG showed no abnormal heart activity during the seizure, which meant it wasn’t caused by ventricular fibrillation. Dr. Chase suggested myocarditis from a viral infection weakening the wall muscles of the heart. It would require a heart biopsy to confirm. However, Dr. House noted that myocarditis wouldn’t explain the seizure. Dr. Taub suggested Brugada syndrome, but evidence of it would have appeared on the EKG. Dr. Park suggested a pheochromocytoma, which would explain both the heart problem and seizures. However, Dr. House thought was photic epilepsy and ordered an EEG.
Dr. Chase apologized for his deception, and Bob said he understood, although he was feeling increasingly guilty for hiding it from his wife. They ran an EEG while flashing lights. However, the EEG showed no abnormal brain activity.
Dr. House returned to Dr. Park’s idea of a pheochromocytoma. He told her it was a decent diagnosis, but ruling out photic epilepsy only takes a couple of hours, when searching for a pheochromocytoma could take half a day. He ordered EEG monitoring, urine tests and blood draws every two hours. He sent Dr. Adams and Dr. Chase to do the tests, while sending Dr. Park and Dr. Taub to do an environmental scan of the hotel where the patient was having sex.
During the night, one of the EEG sensors came loose. When Dr. Adams went to fix it, she noticed a large mass on the patient’s neck. This ruled out pheochromocytoma.
The patient also started to develop a fever, which was rising. The blood and urine tests also showed no signs of excess adrenaline. Dr. Park suggested meningitis, but Dr. Chase pointed out that the patient had no neck stiffness and his mental status was normal. The tests on the motel showed semen, vaginal secretions, saliva, and both human and animal fecal matter. There were also five different types of pathogenic bacteria. Dr. House asked if one of them was fusobacterium necrophorum. Dr. Park was astounded that he knew, but Dr. House said it would explain the mass on the neck - the bacteria moved into the parapharyngeal space and from there into the jugular vein causing a thrombus - Lemierre‘s syndrome. He ordered amoxicillin, clavulanic acid and surgery to remove the clot.
Bob still wanted to tell his wife about the affair, but Dr. Park told him not to rush it. However, he would not consent to surgery until he told her. His wife soon arrived and the patient sent his children and doctors out of the room. His wife soon rushed out of the room as well, but she assured the doctors that although she was upset, she would be back to deal with the matter.
However, as Dr. Chase performed the surgery, they found no clot, only swollen lymph nodes. The realized the swelling was from tissue inflammation. This pointed to lymphoma and Dr. Chase did a biopsy. However, after he completed it, the patient’s blood pressure started to drop precipitously from 160/85 to 66/47. Dr. Chase looked for bleeding at the biopsy site, but saw none. Dr. Adams finally noticed a yellow tinge in Bob’s sclera - jaundice, most likely from liver failure.
The biopsy results were normal. Dr. Park suggested that the patient may be a heavy drinker and was going through alcohol withdrawal, but Dr. House pointed out that it wouldn’t explain swollen lymph nodes. He still thought it pointed to an infection, just not Lemieere’s. Dr. Park pointed out blood cultures would probably take too much time given the state of the patient’s liver failure. Dr. House ordered broad-spectrum antibiotics, but Dr. Adams said this would destroy what was left of the patient’s liver. Dr. Chase suggested giving him a liver transplant first. Dr. House liked the idea.
The patient was put on the transplant list. The doctors also told his wife about the possibility of a live donor transplant. However, the patient was concerned about the health of the donor given that the recovery time was close to four weeks. Bob said that given the risks, he had to tell everyone about the affair so they knew what kind of man was getting their donation.
Dozens of Bob’s friends and family came to be tested. He asked to speak to all of them. He told them about the affair, and his wife told the crowd she had forgiven him. However, Bob went on - admitting he had cheated most of them on car repairs, and that he had stolen from a scholarship fund and lost the money gambling. After his speech, only two people came forward to be tested, and neither of them matched.
Dr. House realized that with there being a very small chance of getting a matching donor in time, they had to do something drastic. He ordered a CT Scan of the liver so they could do surgery to remove the damaged parts. Hopefully, there would be enough left that they could treat with antibiotics.
Dr. Foreman came to ask Dr. Chase why they were considering risky surgery instead of waiting for a transplant. Dr. Chase reminded Dr. Foreman that livers don’t just show up when you need them and this was the patient’s best chance. Dr. Foreman told him if the patient died of liver failure, there was no liability to the hospital, but if he died during surgery they would be sued for malpractice. Dr. Chase told him that he didn’t consider malpractice suits when a patient only had a few hours to live unless they did something. However, the discussion was made moot when Dr. Adams compared the patient’s liver CT scans - the liver had actually started healing over the last ten hours.
The patient’s liver function continued to improve, buying them time, but the patient kept telling his wife about past affairs and they were constantly arguing. Dr. House wanted to concentrate on why the liver was getting better. They started to think of an allergy - it would explain why his symptoms came on so rapidly and why his liver was recovering. He ordered a scratch test, steroids and epinephrine. He also ordered them to find the woman he had cheated with, Cindy, to see if she was the source of the allergic exposure.
Dr. Chase and Dr. Adams examined the woman, who said she gave him a condom, but she didn’t know what kind it was.
The patient told the doctors his wife never wanted to see him again. As they did the scratch test, he said he felt like they were poking him with a hot poker. Dr. Park was testing for wheat allergies, but the patient said he ate wheat all the time and never had a problem with it. The welts on his body started to spread and soon they covered most of his chest. His vital signs started to crash.
Dr. Park ran blood samples to double check the positive result on wheat, but the lab samples were negative. Dr. Chase wondered if the steroids were to blame, but Dr. Taub told him they hadn’t even started the steroids when it happened. Dr. Chase suggested that it might be latex from the condom and gloves, but the patient tested negative for latex allergy as well. All the standard tests were negative, so they started trying to think of other things he was allergic to. Dr. Chase decided to start steroids to see if the welts cleared up.
However, Bob’s condition soon worsened. His skin started sticking to his bed sheets and clothing and peeling off. He was in tremendous pain. He didn’t respond to steroids and epinephrine and kept getting worse. This appeared to rule out an allergy.
Dr. House got his team back together. After an awkward silence, Dr. Park broke it by saying what everyone was thinking - Stevens-Johnson syndrome, a terminal and untreatable condition. It even explained why he got worse after he got steroids. Dr. House dismissed his team, but Dr. Chase agreed to stay with the patient.
Dr. Chase told Bob they couldn‘t give him more painkillers as they would only make his condition worse. Bob said he had a final confession - he had killed four or five people. However, Dr. Chase was sceptical and decided to run an MRI. He realized the patient’s confessions weren’t real, they were a neurological symptom. He found an aneurysm in the anterior communicating artery of his brain. This would affect his impulse control and compulsion. As the aneurysm grew larger, so did the confessions. Dr. Chase called the team back and demonstrated the problem by complaining to the patient that his one of his shoes was missing. Bob apologized for stealing the shoe and said he sold it for money. Dr. Park couldn’t think of any neurological condition that would explain the skin peeling off, but Dr. House realized the peeling skin and aneurysm were both symptoms of one disease - Kawasaki disease. They didn’t think of it because it’s almost exclusively suffered by children of Asian descent. However, Dr. House had noted that certain rug cleaning chemicals have been known to set it off - his rug burns on his knees were probably what caused it. He ordered gamma globulin and monitoring of the aneurysm to see if they had to repair it or whether it would resolve itself.
Bob started to recover. His wife found out about the false confessions from Dr. Chase and confirmed he never stole from the scholarship fund because all the money was still there. Bob lied to her and told her his confession about the affair was false too.