Derrick was admitted with a massive nosebleed and dizziness which developed during his cheerleading practice. He was given a CT scan of his head by the emergency room attending, but it was normal. The case was assigned to Dr. House. Dr. Taub thought it might be a minor stroke, but Dr. Adams pointed out this did not explain the patient’s nosebleed. Dr. House thought it was probably a mid-line granuloma and ordered a PET scan.
The PET scan appeared to be normal, but Dr. Taub noted that Derrick’s temporal lobe was active, showing response to speech. He thought the patient had overheard them on the microphone, but Dr. Park had checked and it was off. The room was otherwise silent, and Dr. Taub was confused about what the patient was hearing.
Dr. Taub asked the patient if he was hearing anything, but the patient denied it. The team ordered a psych consult and reported to Dr. House, and Dr. Park noted that the patient was at the right age to present with schizophrenia. Dr. House agreed it was most likely some form of mental illness, but Dr. Taub thought it might be due to illegal drug use. Dr. Adams noted that the patient’s tox screen was clean, but Dr. House allowed an environmental scan of the patient’s dormitory room.
Dr. Taub and Dr. Adams performed the scan and found the patient’s roommate, who assured them that Derrick didn’t do drugs. However, when they searched the patient’s belongings, they found a hidden picture of a six-year old boy.
The team found the patient with his girlfriend and after giving him an opportunity to have the girlfriend leave the room, confronted him with the photograph. The patient said it was nobody, but they asked him why it was hidden. He finally admitted it was a picture of his late brother Christopher. He also admitted that it was his brother’s voice he heard in his head and that he had been hearing it for the past ten years.
Dr. Taub suggested the patient had viral encephalitis, but Dr. Park pointed out that since the symptoms appeared to last at least for the last ten years, encephalitis couldn’t be the cause. Dr. Taub next suggested temporal lobe epilepsy combined with a trauma that explained the nosebleed.
Dr. Taub and Dr. Adams went to get the patient for tests, and found him fighting with his girlfriend. He asked her to leave and not come back.
They attempted to induce a seizure or other physical reaction like sensations of taste or smell, but nothing they could do affected the patient and his EEG was normal. She asked him why he didn’t admit to hearing voices. He said he was raised not to talk about such things. He told Dr. Adams that his father had become an alcoholic and left the family, and his mother had gotten rid of all the other photographs of his brother. He then complained of seeing spots in his right eye, and then losing sight in the eye completely. Dr. Adams did a quick examination and saw it was a clot in the artery behind his eye and vigorously massaged the eyeball to break it up. Derrick’s eyesight returned, although it was blurry. However, Dr. Adams had no idea why the patient developed a clot.
Dr. Adams thought that the patient had a mix of physical and psychological symptoms from suppressing grief about his dead brother. Dr. Taub wondered if she meant that thinking about his dead brother was making his physical symptoms worse. Dr. Park agreed that anxiety disorders can manifest as a physical illness. However, Dr. House insisted they treat all the symptoms as if they were physical. Dr. Taub suggested polycythemia vera. Dr. Adams noted that the patient’s red blood cell count was only slightly elevated. Dr. Taub then suggested Hodgkin’s lymphoma but Dr. Park noted it would have shown up on the PET scan. Dr. Adams suggested that the patient might have got hurt, hid it, and then developed DIC.
Dr. Park did a lumbar puncture to look for a sub-arachnoid hemorrhage which would explain the DIC. She asked about his voices, and suggested that he heard his brother because his mother suppressed his memory. She suggested counselling. However, as she completed the lumbar puncture, she realized his cerebro-spinal fluid pressure was far above normal.
Derrick’s mother finally arrived at the hospital. Dr. Adams explained that the high CSF pressure and other symptoms may have just been due to a severe migraine. She started him on medication and scheduled an MRI. When Derrick’s mother saw the photo of Christopher, Dr. Adams explained that Derrick had been hearing his brother’s voice for ten years and the suppression of his grief may be the cause of some of his symptoms. Derrick asked his mother to tell him about Christopher, but instead she made an excuse to leave the room.
However, the MRI showed his blood vessels were not reactive, ruling out a migraine. Derrick started complaining he didn’t feel well and Dr. Park assured him they were almost finished. However, when they removed him from the machine, Derrick mistook Dr. Park for Dr. Adams. However, they were interrupted when the ceiling collapsed and water poured into the MRI room. This had the effect of knocking out power to the entire wing of the hospital and causing extensive water damage.
Dr. Park told Dr. House about the patient’s error in mistaking her for Dr. Adams. Dr. House grabbed a hypodermic syringe and told his team to follow him. When he reached the patient, he asked his team what would happen if he stuck the needle into the patient’s eardrum. Dr. Adams realized the patient would feel severe pain. Dr. House proceeded and asked what would come out when he drew back the plunger and Dr. Park noted that there is nothing behind the eardrum but air. However, when Dr. House showed them, the syringe was full of blood. The patient was suffering from a persistent stapedial artery, an artery that usually disappears in the developing fetus. It pressed on the temporal lobe causing the auditory hallucinations, dizziness and nosebleed. He just needed surgery. The patient realized that the voices would disappear.
However, the surgery had to be delayed because the patient attempted suicide by drinking ammonia. Dr. Park reported this to Dr. House, who went to see the patient. Dr. House assaulted the patient, saying that if he wanted to die, he was willing to help. When the patient struggled, Dr. House noted that it was clear his instincts were to stay alive. Dr. Park and the patient’s mother tried to stop him, but were overpowered. He was only stopped when Dr. Park struck him on the head with his cane.
Derrick’s mother removed the picture of Christopher from his room. He agreed to surgery if she agreed to bring it back, and she agreed.
The surgery went well and Derrick was on the road to recovery. He had stopped hearing voices. His mother returned the picture, and finally brought him several other photos of his brother.