Case History Edit
While taking in a magic show, Dr. Cole realizes a trick has gone wrong when he notes blood coming out of the magician's mouth. He called Dr. Kutner to the stage as well and they manage to recussitate him.
Dr. Kutner brings the case to Dr. House and the other fellowship applicants. He tells him that Flynn had a cardiac arrest while hanging upside down in the water cell. However, Dr. House is uninterested in a simple case of cardiac arrest due to drowning. However, Dr. Cole backs up Dr. Kutner - Flynn lost consciousness as soon as he hit the water. Dr. Kutner also states the patient has no history of heart disease and no angina. Dr. House believes the patient lied about his medical history to cover up the fact he screwed up the trick and almost drowned. Dr. Kutner argues that even if he did drown, the cardiac arrest happened too quickly unless there was an underlying problem. Dr. House tells Dr. Kutner he can run tests, but if he's wrong about the patient, he loses his chance at a fellowship position.
Dr. Kutner runs an echocardiogram but finds no valvular regurgitation, wall movement abnormalities or structural defects. Dr. Hadley comes in to assist and asks Flynn if he's had any recent heaviness in his legs, but he denies it. He's asked if he's had any shortness of breath or tightness in his chest or arms. When Dr. Hadley tells him that Dr. House believes he drowned accidentally, the patient says that he must be an idiot. They prepare him for a transesophageal echocardiogram under sedation. However, it was normal as well. They also ruled out clotting.
Faced with dismissal, Dr. Kutner sought help from Dr. Forman. He suggested oxygen saturation of the lungs could have set off the cardiac arrest. Dr. Kutner thought the emergency room would have ruled it out, but Dr. Foreman suggested they may have missed it in the race to keep the patient stable. He suggested an MRI.
The patient was incredulous that there might be a fungus in his lungs. However, when Dr. Kutner started the MRI, the patient started having terrible pains in his stomach. Dr. Kutner noted Turner's sign, indicating internal bleeding. Dr. Hadley rushed to book a surgeon.
The surgeons gave Flynn 3 units of AB+ blood, but couldn't find the source of the bleeding. Trauma had been ruled out. Dr. Kutner suggested liver disease or Vitamin K deficiency. Dr. Hadley thought it was an intestinal infarction. Dr. Foreman pointed out the cardiac arrest could be linked to the infarction. Dr. House asked to see the MRI results and was told there was none because the patient started screaming even before Dr. Kutner could sit down. This led Dr. House to an obvious conclusion. He went to the operating room where the surgeon told him that there were lacerations in his intestines and his spleen was shredded. Dr. House felt inside the patient until he discovered a metal lockpick. He told Dr. Kutner to drop the case and went to see the patient to discharge him. Flynn denied screwing up the trick, but Dr. House pointed out the obvious explanation for his symptoms was forgetfulness and incompetence. The patient demonstrated his competence by making Dr. House's chosen card appear on the other side of a glass panel six feet away. The patient then developed a severe nosebleed and Dr. House agreed to keep working on his case.
Dr. House looked for a new differential for severe nosebleed and cardiac arrest. Since the patient's heart was fine, Dr. Volakis suggested it might be the blood vessels in the heart - polyarteritis medosa, which also caused high blood pressure which caused the nosebleed. Dr. Taub noted cocaine would cause tachycardia and nosebleed as well. Dr. House ordered Dr. Taub and Dr. Kutner to perform an environmental scan of Flynn's apartment and check his belongings. He ordered Dr. Volakis and Dr. Cole to biopsy a blood vessel from around the heart to check out polyarteritis.
Dr. Taub found marijuana, but no cocaine. He also found some rabbits, suggesting the patient might have tularemia which caused pericarditis. Dr. House administered antibiotics and told Flynn he would be better in a couple of days.
However, the patient soon lost consciousness. An ultrasound revealed bleeding around his heart and they had to drain 100cc of blood. It was clear the antibiotics weren't working, ruling out tulerimia and any other infection. Dr. Taub thought the bleeding was merely the result of Dr. Cole's biopsy - a clumsy procedure. Dr. Hadley suggested a clotting problem and Dr. Volakis suggested DIC. Cancer would explain both cardiac arrest and DIC, but the patient's chest scans had been clean. Dr. Taub suggested the main mass might be elsewhere, throwing off clots. Dr. House instructed his team to look for the cancer.
They prepared Flynn for another MRI to look for a tumor. He complained about his hands feeling numb, which Dr. Cole put down to the blood loss. However, the patient was convinced he would be dead by that time the next day. There was fluid in his lungs, but no masses. There was a dark spot, but it was only damage from where the key was ripped through during the previous MRI. Suddenly, they saw more bleeding in his kidney, thigh and several other sites.
Dr. Cole though the patient's sense of impending death may be a symptom. Dr. Volakis agreed - adrenal gland disorders, blood issues and anaphylaxis can all cause it. However, Dr. House felt it was just a third rate magician trying to make a prediction that no-one would remember if he did live. However, Dr. Kutner pointed out the feeling started right after a transfusion and that tainted blood can cause a sense of doom. Dr. Foreman noted the patient's immunoglobulin levels were low. Together with the other symptoms, this suggested amyloidosis. However, Dr. Volakis noted that there was too much bleeding for amyloidosis to be the explanation. The team was paged that Flynn was having a seizure and Dr. Kutner went off to stabilize him. Dr. House ordered them to review the medical history to see if there was any joint pain, fatigue or other symptom of amyloidosis.
The patient was stabilized - conscious, but unresponsive. He was given fluids and anti-convulsants. There was a slight amount of swelling that could indicate a kidney problem. All of a sudden, the patient hade another seizure, indicating kidney failure caused by sodium deficiency. Dr. House thought this confirmed amyloidosis, but Dr. Hadley pointed out there as nothing in his medical records to support that. Dr. Kutner thought it was still more likely the patient was given tainted blood - that would cause the same symptoms. However, Dr. House pointed out tainted blood didn't explain the heart or liver problems. Dr. Kutner admitted that the heart attack was probably caused by drowning, but the rest of the symptoms were caused by the transfusion. Dr. House was not convinced and wanted to do a bone marrow transplant. However, Dr. Wilson pointed out that this would require using radiation therapy to destroy the existing bone marrow and his immune system. He ordered a subcutaneous fat biopsy to confirm amyloidosis. Dr. Hadley asked Dr. House if she and Dr. Kutner could at least check the blood supply for errors. He gave them two hours, the time it would take Dr. Cole to complete the biopsy.
The blood supply's red blood cells were intact and the storage facility was operating within normal operation. Dr. House came in half an hour hearly to announce that the biopsy was inconclusive. He wanted to do a biopsy of the lungs, kidney and liver. However, this would risk further bleeding. House directed his team to treat for amyloidosis, but Dr. Foreman countermanded him and threatened to take up the matter with Lisa Cuddy. In order to move things along, Dr. House agreed to act as a guinea pig for the suspect blood as he was also AB+.
They monitored Dr. House for signs of adverse reaction. Dr. Hadley noted he was sweating and running a fever. Dr. Kutner thought it was pneumococcus, but Dr. House put it down to a beningn transfusion reaction. Dr. Volakis noted that pseudomonas would present with an armpit rash and asked Dr. House to remove his shirt. They then suggested giving Dr. House the biopsy instead of the patient, but he refused. Dr. Taub asked if there was any diarrhea, but Dr. House still said it was a transfusion reaction; they are more likely if you have had other transfusions such as the ones he had earlier. He said he wasn't sick and the fever would only last a couple of hours. However, when he stood up, he felt dizzy and his mouth was dry. His team tried to convince him he was sick, but he realized dizziness and dry mouth are the result of a dose of narcotics. He lost consciousness and Dr. Hadley and Dr. Cole took the biopsies while he was unconscious. However, he did regain consciousness in time to watch Dr. Hadley perform the liver biopsy. She also admitted to being the one who drugged him.
However, all of the biopsies were clean and the patient was scheduled for radiation the next morning. However, Dr. House started talking about blood types with Dr. Wilson and realized something. He went to see the patient to tell him he wasn't dying and asked him what his blood type was. He said he was type A - not AB+. He realized they gave him the wrong type blood. Blood type is tested by testing antibodies and, if his immune system had an autoimmune disease, he would test postiive for type B antibodies even though his blood didn't have them. The autoimmune disease that best explains this symptom as well as all the others is lupus. He ordered the patinet's blood flushed with saline followed by four units of type A blood and steroids.