The patient came to the clinic with breathing problems that she thought were due to asthma. She and her father were seen by Dr. House. Her father said that her breathing problems had persisted for about a week, and she said the problems weren’t severe. Dr. House asked when she had last seem a doctor, and she said she went to a clinic in Trenton about five months ago and was treated for strep throat with amoxicillin. She asked for a prescription for an inhaler, but Dr. House refused because he suspected Callie and her “father” were unrelated. She went to leave, but Dr. House stopped her because she was bleeding out of her ear. His immediate thought was that it was a skull fracture, but she denied any trauma. Dr. House didn’t believe her denials, but examined her and found no sign of tenderness or pain, which seemed to confirm her story. He examined the bleeding ear, but found nothing wrong with the ear canal. He checked and found no fever. He had no immediate diagnosis and told the patient she should be admitted. However, she refused because she did not want social services to find her. Dr. House agreed to falsify her age on the admission form and she agreed to be admitted.
Dr. House convened his team. They had done a CT Scan, which confirmed there were no fractures. Hoewver, Dr. Adams didn’t think the patient was 18 and wanted to call social services. Dr. House admitted he suspected the same thing, but told Dr. Adams that the patient would flee the hospital if social services was called. Once Dr. Taub learned she was homeless, he noted that malnutrition, drug use and HIV would all explain her symptoms. However, Dr. Chase reviewed the chart and saw there were no other signs of malnutrition, the tox screen was negative and her STD panel was clean. He thought it was a squamous cell middle ear tumor, which would cause the bleeding ear, with related paraneoplastic syndrome that explained the breathing problems. Dr. Taub noted that her ear examination showed no sign of a tumour, but her third ventricle was thickened. He thought it was a cerebral infection. Dr. Adams agreed - it would not have caused a fever in that location and pneumococcus is common among the homeless. Dr. Adams wanted to ask the patient if she had been vaccinated for it, but Dr. House thought that would be pointless - the patient was hiding her identity, so he told Dr. Adams to start her on ceftriaxone.
Dr. Adams tried to connect with the patient by telling her that she had run away as a teenager as well. However, the patient said her case was much different - she left a terrible home life. Dr. Taub suggested there were other options, but the patient knew about them and had rejected them. Dr. Adams searched the patient’s belongings. The patient told her to stop, but all Dr. Adams found were school textbooks. The patient said she did have plans.
Dr. Adams and Dr. Park went to the patient’s school and found out she had been vaccinated for pneumococcus. Dr. Adams called Dr. Taub to have the ceftriaxone discontinued. However, although the patient lied about her name to the school authorities, the address she gave was an abandoned house and they went to do an environmental scan. Dr. Adams found mold growing under the sink.
The patient was upset that the doctors had gone to her school - it meant they would call social services and now she couldn’t go back there. She went to leave but Dr. Adams warned her she needed treatment for a fungal infection. However, the patient realized she only needed fluconazole and said she would find a clinic. However, when she got up to leave, she collapsed complaining she couldn’t feel her legs. This appeared to rule out a fungus as the cause.
Dr. House convened his team to discuss the paralysis. Dr. Chase thought it might be transverse myelitis, but Dr. House noted that the patient’s posterior column function was normal. Dr. Adams wanted to call social services because there was no chance of the patient leaving the hospital at this point. Dr. Taub suggested endocarditis with septic embolii. Dr. House countered the patient had no heart murmur or Osler nodes. Dr. Chase finally suggested vasculitis, and Dr. House agreed and ordered steroids. Dr. House also agreed to let Dr. Adams call social services.
The patient improved on steroids. However, when the social worker came, Dr. Adams was suspicious because the social worker was wearing stiletto heels. Dr. House admitted to cancelling the call to social services and hiring someone to pretend to be the social worker. Dr. Foreman called social services and the police so they could track down the patient’s parents.
The patient found out about social services and, as she had regained the use of her legs, once again tried to leave the hospital. She told the doctors that her mother used to abuse her. Dr. Adams told her that they had no idea if her improvement would hold and she couldn’t leave. However, the social worker arrived with a woman named Ellen Rogers who identified herself as the patient’s mother. The patient was identified as Callie Rogers. Callie and Ellen started arguing, but all of a sudden Callie had trouble clearing her throat and started coughing up blood. Dr. Adams had to suction the blood out of her throat.
Dr. House re-convened his team. Luckily, the bleeding stopped on its own, but as the patient got worse on steroids, vasculitis and other autoimmune conditions appeared to be eliminated. Dr. Park noted they didn’t know where the blood had come from, her sinuses, lungs or digestive tract, and without knowing they couldn’t use the bleeding in the differential diagnosis. Dr. Adams discussed whether Callie was lying about the abuse she suffered at the hands of her mother. Dr. Chase thought that the bleeding could be the result of sinusitis combined with a bleeding disorder. However, Dr. Taub pointed out the patient didn’t complain about a headache. Dr. Adams pointed out that if the bleeding was from the digestive tract, it could be Zollinger-Ellison syndrome. The acid reflux could have resulted in the asthma, and the acid could have eroded her stomach to cause the bleeding. Dr. House agreed and ordered an upper endoscopy. He also ordered Dr. Adams to make sure that she got consent from the mother.
Ellen asked if the procedure would be painful. When Dr. Adams said that Callie had accused her of hitting her, Ellen denied ever hitting Callie, but admitted that she had been addicted to oxycodone. However, she gave it up when Callie left.
Dr. Adams confronted the patient, and the patient admitted that she lied about the abuse. She felt that no-one would understand what she went through. Dr. Adams agreed to listen and Callie told her that her mother had no job and spent all their money on oxycodone. She had to get a job to support them and felt it would be easier supporting herself. She felt her mother could not stay sober when things got tough.
Dr. Chase and Dr. Adams performed the endoscopy. They found an ulcer high in the esophagus, ruling out Zollinger-Ellison. The ulcer started to bleed and they had to start a lavage. They managed to cauterize the bleeding.
Dr. Taub thought that the patient’s homelessness could have made her immunocompromised, leading to a HPV infection. However, the previous STD panel also ruled out HPV. Dr. Adams turned to the mother’s addiction and thought that Callie might have been abusing alcohol leading to alcohol induced esophagitis. However, Dr. House noted that the patient had never shown signs of drunkenness, had never been seen drinking, and was not suffering from delirium tremens. Dr. Adams argued the patient’s elevated blood pressure could be from delirium tremens. However, this made Dr. House think that it might be a berry aneurysm that was expanding and contracting with the patient’s blood pressure. It explained why the symptoms were intermittent. Dr. House wanted to do an angiogram to confirm, followed by surgery.
Dr. Taub and Dr. Adams went to the patient and her mother to explain Callie needed brain surgery. Callie realized that Dr. Adams thought Dr. House was wrong and Dr. Adams told the mother she thought that the symptoms were due to alcohol abuse. Dr. Adams pointed out the patient came to the hospital with beer and they found more where she was living. Callie admitted to drinking an occasional beer with friends, but said she mostly used it as currency with other homeless people and denied she had a problem. She said she wanted the surgery, but Dr. Taub reminded her that it was her mother’s decision. Callie denied being an addict, but her mother reminded her that’s what she had always said about her oxycodone use. Callie once again denied being anything like her mother and told her mother to approve the surgery. The mother asked for time to decide.
Dr. House was angry for speaking to the patient and her mother about her alcoholism theory. Dr. House reminded Dr. Adams that the mother was already guilty about her daughter and would almost certainly choose the option that confirmed her guilt. He went to speak to the mother, but Dr. Adams asked him not to bully her because she felt bad enough. Dr. House told Dr. Adams that the mother would feel worse if the aneurysm burst while they were arguing about what to do.
Dr. House went to the mother and told her that her daughter had an aneurysm and that she was in no condition to overrule her daughter. He told her the best course of action was to leave the hospital so that he could treat Callie as he saw fit. He told Ellen he was going to go and do the surgery. In an attempt to trap her, he left Vicodin behind. However, Ellen caught up with him, returned the Vicodin, and told him to treat Callie for alcoholism.
Dr. Adams discussed the positive social services report with Callie, but Callie said her mother always did well on the reports. Dr. Adams told her about her mother giving back the Vicodin and asked that Callie let her sleep in the room. However, Callie was angry that her mother had believed Dr. Adams instead of her about the alcohol use.
Callie started to stabilize. Her mother brought her some muffins and, after a discussion about a trip to Florida, Callie allowed her to stay in the room. However, Callie immediately collapsed. Dr. Adams thought that Dr. House must have been right about the berry aneurysm.
Callie was rushed into surgery. However, the angiogram showed no burst aneurysm or leakage. However, Callie’s blood pressure started to drop and Dr. Chase started her on pressors.
They realized the patient would only last a couple of hours on pressors. Dr. Adams though her improvement on steroids may have been due to it attacking cancer cells. However, there was no hypercalcemia or elevated blood proteins. Dr. Adams thought the patient’s trip to Florida may have exposed her to dengue fever or cholera, but Dr. House replied those diseases would not have affected her two years after exposure. However he suddenly thought of one that would.
Dr. House asked the mother if Callie had ever swam in a lake, pond or swamp in Florida. The mother said she had swum in a canal. He went to the operating room with the mother to tell her that Callie had ascariasis, a parasitic worm found in feces. She was most likely exposed when animals defecated in the canal. They were most likely asymptomatic, but a small trauma likely released them to spread into her ear, lungs and legs. The steroids forced them into the esophagus and heart. She only needed mebendazole.
Callie improved quickly on mebendazole, but after she improved, she fled the hospital. She left a note saying she didn’t want to be around when her mother slipped and wanted to remember her as she was.