Nicole was a young woman born in China who was adopted by American parents. However, she went back to China as a young adult to find her biological parents, but when she found them she was rejected by them. She immediately started suffering symptoms which persisted on her return to New Jersey. She was portrayed by actress Samantha Quan.
Medical History[]
The patient was born in China but spent most of her life in the United States. However, she had recently travelled to China. She had a long history of drug abuse dating back to adolescence, and was a smoker and heavy drinker.
Case History[]
While on a trip to China, Nicole was in a Buddhist temple when she started having terrible abdominal pain and vomiting blood. The doctors in China cut out part of her bowel, but when she returned to the United States the pain continued to get worse. She went to the emergency room at Princeton-Plainsboro Teaching Hospital. Dr. House found out about the case and took the file. He ordered Dr. Kutner to get the medical file translated from Chinese. Dr. Hadley thought it was Meckel's diverticulum. Dr. House agreed it was possible and went to do an ultrasound. He talked to the patient who was coughing. Her adoptive parents came in with all the pharmaceuticals they could find in her apartment. Dr. House paid attention to the licorice root, which is used in China to treat SARS. SARS would cause all the symptoms so Dr. House ordered her started on ribavirin and interferon.
Dr. Kutner asked the patient for a list of her contacts so he could treat them for SARS. However, her abdominal pain came back and she developed tachycardia. Dr. Kutner called for a crash cart. He did a physical examination and realized her liver was failing, which ruled out SARS.
Dr. House was given a temporary leave of absence to attend his father's funeral. His team contacted him by telephone to tell him that Nicole had a clot in her hepatic vein but Dr. Chase had removed it. Tumor and vein malformation had been ruled out, but Dr. Hadley believed it was due to her addictions - combined with a genetic disorder it would cause clotting. However, Dr. Foreman realized that to choose the right anticoagulant they would need to know which genetic disorder she had.
When Dr. Kutner returned to Nicole's room, she was missing. He found her outside smoking and started to draw blood for tests. She talked about her issues being raised by a Caucasian family, and Dr. Kutner told her that he was raised by a Caucasian family too. However, Dr. Kutner saw that she was bleeding profusely from the site where he took the blood. He rushed her back inside.
Dr. Kutner reported that he needed a six-pack of FFP to stop the bleeding. Dr. Cameron expressed disbelief that she was bleeding and clotting at the same time. She also had schistocytes on her blood smear indicating DIC, which meant she had cancer. Dr. Cameron thought it might be leukemia, but her white blood cell count was normal. Dr. Foreman thought it might be a tumor in her digestive tract even though she already had an ultrasound. He ordered a CT scan.
The team called Dr. House to tell him that Nicole had a mass in her pancreas - a large cyst, at least 8 cm in the head of the pancreas. However, he was interrupted just as he made a metaphor about a steamroller. His team tried to figure out what he meant. Dr. Foreman wanted to focus on the size and location of the mass. Dr. Foreman went to Dr. Chase & Dr. Cameron about it. Dr. Chase noted that the large size ruled out a diffused process like scleroderma or lupus. Dr. Cameron noted it therefore had to be a single process that only affected the pancreas. The only ones that do are gallstones and pancreas divisum. Since it was in the head, it had to be gallstones. Dr. Kutner reached the same conclusion independently. A CT scan confirmed and Dr. Chase was called in for a surgical consult. However, he noted that her urine had turned brown. Dr. Taub noted that her kidneys had been working fine earlier in the day, so the kidney failure was recent and couldn't be explained by the gallstones.
The team finally managed to contact Dr. House. He never thought it was gallstones. He thought the cyst was a multiple cyst that had spread to other organs. However, exploratory surgery was not an option given her kidney failure. Dr. Hadley came up with the idea of injecting air bubbles into the cyst and seeing if they spread elsewhere.
Dr. Taub tried to inject the air bubbles into the cyst, but the patient couldn't remain still. Dr. Kutner realized she was suffering from delirium tremens because she wasn't drinking. They realized they had to give her phenobarbital to keep her from twitching and treat the DTs.
Dr. House called the team who reported the cyst wasn't the problem, she had advanced dilated cardiomyopathy. They did an echocardiogram which showed a mass in her left atrium. It might be a atrial myxoma, but the ultrasound was grainy. Dr. House realized that the scans weren't grainy - she had too much iron in her system. That much iron makes ultrasounds look grainy, causes the pancreas to fail and causes clotting. Dr. Kutner still thought the mixoma was more likely. Dr. House ordered a MRI for a better look. He then contacted Nicole's translator in China to ask her if the patient's parents showed dark skin characteristic of hemochromatosis. The translator denied they were not darker skinned, and also noted that he did not think they were her parents after all. The father had said they had no daughter, and the mother looked confused and frightened.
Dr. House started a differential with Dr. Wilson. He realized that due to China's one-child policy, she shouldn't be alive. Girls born in rural areas after 1979 were always abandoned in favor of sons. They realized the mother was not aware that the daughter could still be alive. Dr. Wilson thought it might be a fat-soluble toxin.
Dr. House finally returned to the hospital, but found out that the patient's MRI hadn't been completed because she started vomiting when they started the scan. He ordered Dr. Taub to complete the scan despite the vomit. He told his team his parents had tried to kill her and that lifting the Buddha set it off. Dr. Hadley suggested its weight might have stressed her, but Dr. House thought it was unlikely unless she had never lifted anything before. However, Dr. Kutner noted that she only got sick when she tried without success to lift it the second time. Dr. House realized the Buddha had been kept in place the second time by a powerful electromagnet. He immediately cancelled the MRI and ordered an X-ray of her brain. They found numerous small pins which had been inserted into the soft fontanelle of her skull and an infant. Her hair would cover the entry points. However, they didn't kill her and the electromagnet in the Buddha and the MRI pushed pins deeper into her sympathetic nervous center which she felt as abdominal pain. They only needed to remove the pins surgically.
The X-ray of Nicole's brain, showing the pins
The adoptive parents didn't want to tell her about the pins, but Dr. Kutner noticed one of the pins was pressed directly on her addiction center. Her personality would probably change once the pins were removed.