Clarance had committed four homicides - he had murdered his girlfriend, a prison guard, and two of his fellow prison inmates.
Clarence was a death row inmate who started to hallucinate about the people that he killed during his exercise period. He screamed to be let out of the exercise yard and then collapsed on the floor. The prison sought medical assistance from Princeton-Plainsboro Teaching Hospital as they were unable to treat his tachycardia in their infirmary. Dr. Cuddy assigned the case to Dr. Nolo, a cardiologist, but Dr. House asked to be assigned the case as he was intrigued to hear that the patient’s heart was beating so quickly that it pumped air instead of blood. There were no conditions that caused tachycardia that bad and Dr. Nolo would be hard pressed to come up with a diagnosis based solely on the condition of the patient's heart. Dr. Cuddy agreed to assign him the case in exchange for two clinic hours.
Dr. House proceeded to Mercer State Prison to see the patient. He reminded his team about a key tenet of medical ethics, that care should not be withheld because of the previous criminal behavior of the patient. When House arrived, he was told in addition to the homicides, the patient had a long history of violent conduct. Because it was too dangerous to have the patient in the infirmary (where he would have access to sharp objects), he was being housed in a cell reserved for office supplies and he was cuffed and shackled to the bed just before Dr. House arrived. Dr. House's cane was also not allowed in the cell. House examined Clarence and noted a bluish tinge to his lips and fingernails, indicating he was hypoxic. He listened to Clarence's lung sounds with his stethoscope and realized there was fluid in his lungs and his respiration rate was 50. He needed to be intubated and put on a respirator or else death was imminent in about sixty minutes. Dr. House called for an ambulance, but the warden insisted that death rows inmates were not allowed to leave the prison under any circumstances.
Dr. House convinced the hospital's general counsel to obtain a court order allowing them to obtain custody of Clarence. Unfortunately, Dr. House misled counsel about Dr. Cuddy's support for the order. When Dr. Cuddy realized what had happened she confronted Dr. House, but Dr. House noted he had been ordered to treat the patient.
Dr. House asked his team for a differential diagnosis for tachycardia and pulmonary edema. Dr. Foreman thinks heroin might be the cause of Clarence’s tachycardia, and that tachycardia would have led to pulmonary edema. Dr. House ordered a drug test on Clarence's hair, blood and urine. Dr. Foreman went to perform the test, but the patient came out of sedation and became extremely agitated, breaking some of his restraints and removing his breathing tube. However, the only thing he asked for was water. Dr. Chase figured the patient was dehydrated and gave him more saline. This seemed to satisfy the patient's thirst. However, the test results come back with no sign of opiates in Clarence’s system. Dr. House asked if there were any other unusual results in the blood tests. The only out of place result was low bicarbonates. Dr. House thought this might be the result of the other symptoms, but Dr. Cameron thought it might be the cause. In any case, she thought the patient should be put on a bicarb drip. Dr. House admonished Dr. Cameron for merely treating symptoms without caring about the underlying cause. He ordered an arterial blood gases test.
Dr. Foreman went to draw blood from Clarence’s femoral artery. Clarence asked for a local anesthetic and Dr. Foreman used lytocaine. However, he drew the blood before the lytocaine took full effect and apologized for the pain. The tests showed a pH of 7.28 and decreased HTO3, indicating anion gap acidosis, a new symptom. The team mulls over the causes of anion gap acidosis. Dr. Foreman believes the patient may have taken something he thought was heroin. Dr. Chase suggested methanol, uremia and diabetes, while Dr. Cameron suggests formaldehye, INH (a drug for tuberculosis) and lactic acid. House realizes INH is common in prison because many prisoners suffer from tuberculosis. He surmises someone cut up their INH and sold it to Clarence. INH poisoning would explain all the symptoms. Dr. House sends Dr. Chase to the prison to do an environmental scan to find Clarence’s heroin stash. In the meantime, Clarence started suffering from bradycardia and his heart rate slowed to 30 bpm with blood pressure of 78/52 and oxygen saturation of 90%. Dr. House administered atrophine, even though this was only a temporary solution.
Dr. Chase refused to speak with any of the prison inmates, but searched both of his cells. When he called Dr. House and said that there was copier toner in one of the cells, Dr. House figures out that Clarence drank spirit duplicator copier fluid in a suicide attempt. He ordered Dr. Chase back to the hospital. By convincing Clarence he was having a last drink with him, he convinced the patient to have several ounces of alcohol, He then told Clarence he figured out he drank copier fluid and the alcohol would bind with the formic acid which was a by product of the poisonous methanol in the copier fluid and allow it to pass harmlessly in his urine. Clarence told Dr. House that the urge to commit suicide came on suddenly and he didn't want to take prison routine anymore. Dr. House was intrigued by the patient's impulsive thought.
Although the patient improved quickly, Dr. House still thought there was an underlying cause for his tachycardia and wanted to keep testing him. He informed his team that the patient's suicide attempt is also probably a symptom of his underlying condition. He noted the patient had just filed an appeal, and the state of New Jersey had not actually executed anyone in over thirty years. He also noted the patient's tachycardia came before he drank the methanol. He ordered tests for intracranial lesions, brain infections, autoimmune diseases, as well as a lumbar puncture, CT Scan and a full neurological work-up.
Dr. Foreman performed the lumbar puncture. Dr. Chase and Dr. Foreman performed the CT Scan and found no lesions or other abnormalities.
Dr. House had confided in Stacy Warner that his patient was well enough to be released. However, she reports this to Dr. Cuddy, who insists the patietn be released back to the custody of the prison. When Dr. House refuses, she decides to make the declaration herself. However, when she tries to send Clarence back to the prison, he complains of tremendous stomach pain, an acute pain like being stabbed. Dr. Cuddy believes Clarence is faking, but Dr. House pulls back Clarence’s sheets, revealing a large pool of blood on the bed, most likely from rectal bleeding.
Clarence is rushed to surgery where the surgeons remove almost a foot of necrotic bowel from Clarence. House is wondering why Clarence killed his fourth victim, a fellow prison inmate, the only case that didn't appear to have a motive, and the only one where the patient didn't feel justified about killing the victim. Dr. House asked Clarence why he did it. Clarence replies that he was in the library, he became extremely anxious and felt like the victim could stare straight through him. He flew into a rage. Dr. House approached his team for a differential for sudden rage. Dr. Forman suggests testosterone while Dr. Chase suggests adrenaline. The latter suggestions leads Dr. House to think about a pheochromocytoma a benign tumor which sits on top of the adrenal gland and randomly dumps abnormally high amounts of adrenaline into the system. Although extremely rare, it explains all the symptoms they have seen, including the incident where he had the strength to overcome his restraint when he was tied to his hospital bed. Dr. House orders an MRI to confirm. The only complication is that Clarence's tattoos contain metallic ink which will cause him pain while he is in the machine. Clarence undergoes the procedure and cries out until they confirm the presence of the pheochromocytoma. They schedule surgery and successfully remove it.
Dr. Foreman points out to Dr. House that the pheochromocytoma was most likely responsible for the four murders Clarence committed as he was not able to control his rage. However, Dr. House pointed out that other people have the same condition and don't commit murder. Some even use the condition to their advantage, becoming "lawyers and race car drivers." Nevertheless, Dr. Foreman plans to testify at Clarence’s appeal hearing, and Dr. House doesn't object as long as he does it in his free time.
Clarence is returned to prison to serve out the rest of his sentence.