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Medical History Edit
The patient has a frontal nasal encephaloseal with a mid-line cleft, which has badly deformed the left side of his face. It is a mid-line deformity. A documentary production agreed to cover the costs of a facial bipartion, a 10 hour surgery to repair most of the damage caused by the deformity. As a result of his condition, the patient suffered from numerous headaches and used a great deal of acetaminophen to treat them.
Case History Edit
While the patient was being prepared for his surgery but before anesthesia was administered, he started to suffer from tachycardia and his heart rate shot up to over 180 bpm. The patient went into defibrilation and cardiac arrest and had to be shocked to restore normal heart rhythm. His heart rate continued to be irregular and he was fitted with a temporary pacemaker wire. The reconstructive surgery had to be postponed.
Dr. House was assigned to diagnose the condition causing the irregular heart rhythm. He advised his team the patient had a second-degree infranodal heart block, post-arrest. There were no reports of light-headedness or fainting. Dr. Taub believed increased intercranial pressure from the enlarged head could cause the heart block. However, Dr. House dismissed it as there was no reason for the condition not to have presented earlier if it was due to his deformity. Dr. Terzi believed the patient might also have a mid-line deformity of the heart. However, Dr. House once again pointed out that the patient had been under continuous medical treatment for his entire life and it was unlikely the previous doctors would have missed it. Dr. Cole believed it might be endocarditis. However, this would only make sense if the patient was an intravenous drug user. However, Dr. House agreed there was no reason to rule it out at this point, but due to darkened skin below his nose, the addiction was most likely inhaling freon, a refrigerant. However, Dr. Taub put down the darkened skin to acanthosis nigricans, a common discoloration in such deformities. Dr. Hadley noted similar discolorations on the cheeks and forehead. Dr. House ordered a nuclear study to determine if there were any scarring of the heart.
However, the patient's father strongly resented the implication that his son was using drugs, but agreed to the test. However, there was no sign of scarring. Dr. Taub believed it might be toxoplasmosis. However, Dr. House pointed out toxoplasmosis would cause enlarged lymph nodes. He believed Dr. Taub merely wanted to do a lumbar puncture to test for intracranial pressure. Dr. Taub asked to do a CT Scan, but Dr. House still believed it was drugs. Dr. House noticed a decreased uptake on the membranous septum. Dr. Kutner believed it was merely an artifact of the test and wanted to re-perform it. However, Dr. House ordered an EP study. Dr. Taub objected because it would require stopping the patient's heart.
Dr. Taub prepared the patient for the EP study and once again asked the patient if he did drugs. The patient admitted to using cocaine and LSD. However, Dr. Taub soon realized the patient was lying. The patient did admit to alcohol use, but Dr. Taub refused to perform the test. Suddenly, the patient started coughing up blood. Dr. Taub called for help to intubate the patient.
Dr. Kutner believed the blood indicated a mallory weiss tear, but there was no pallor or melanin. Dr. Volakis believed it was a nasal papilloma which hemmorhaged and overwhelmed the heart. However, Dr. House pointed out the hemorrhage came after the block. Dr. Terzi believed it might be a bleed in his digestive tract, perhaps a peptic ulcer. However, Dr. Foreman pointed out the patient had no abdominal pain or anorexia, and the digestive tract has no connection to the heart. Dr. Hadley believed it was a nasal-fringal angiofibrosis, but Dr. House had already ruled out any tumor in the nasal cavity. Dr. Cole believed it might be stomach cancer - the cancer caused the bleeding and paraneoplastic syndrome affected the heart. Dr. House ordered Dr. Taub and Dr. Cole to do an endoscopy to find the tumor. However, Dr. Taub believed this would be dangerous - the bleeding might be caused by liver failure related to high intracranial pressure. However, Dr. House dismissed the suggestion as he did not believe that intracranial pressure could affect the liver. However, Dr. Taub was not allowed to explain how high intracranial pressure can cause an increase in the cavernous sinus pressure which in turn causes high pressure in the superior vena cava which shuts down the liver. However, he went with Dr. Cole to perform the test. Dr. Cole agreed with Dr. Taub that the endoscope could cause more bleeding if this was the case.
During the procedure, the patient started bleeding again, and it took 20 minutes of banding to stop the bleeding. No tumor was found. Dr. Taub insisted that this showed the bleeding was the result of liver failure and increased intracranial pressure. Dr. House agreed he was wrong about the tumor, but pointed out that if Dr. Taub was correct the patient should also have nosebleeds and labored breathing. Dr. Terzi believed it might be an autoimmune disorder, such as scleraderma. However, Dr. Foreman noted that the patient did not have tight skin on the hands, muscle weakness, and was 14 years too young to develop it. Dr. Hadley believed it might be a mitochondrial disorder. Dr. House ordered Dr. Volakis to look for retinal degeneration, but Dr. Taub once again insisted it was intracranial pressure and they would only see swelling.
Dr. Volakis was unable to use the opthamology machine to perform the scan because of the patient's deformity, so Dr. Taub used a scope. He only found swelling and once again attempted to convince Dr. House that it was increased intracranial pressure. However, Dr. House still did not believe that the pressure was the underlying cause, particularly of the liver failure. However, Dr. Taub pointed out that the patient's constant use of acetaminophen may have damaged the liver. Dr. House believed it was juvenile rheumatoid arthritis, which would explain all the symptoms. He ordered steroids. However, Dr. Taub pointed out this would delay the reconstructive surgery for months if Dr. House was wrong. Dr. Taub agreed to speak to the father, but secretly told the father that he thought Dr. House was wrong and should be removed from the case.
Dr. Cuddy admonished Dr. Taub for his insubordination as the patient's father refused to consent to steroids. Dr. Taub pointed out that the patient had a fluid filled cyst that wasn't draining properly and the patient needed surgery. Dr. Cuddy refused to fire Dr. Taub because he was the only doctor the patient's father trusted. She instructed Dr. House to perform a CT Scan to confirm the juvenile rheumatoid arthritis before giving the patient steroids.
The patient was given a CT Scan. Dr. Taub believed it showed the facial deformation was pressing on his right frontal lobe causing a herniation. Dr. House believed it was increased pressure from the juvenile rheumatoid arthritis. Dr. Cuddy agreed with Dr. House and told Dr. Taub to keep away from the patient's father. She allowed Dr. House to give the patient steroids. Dr. House met with the patient and told him he needed steroids despite the delay to the facial reconstruction surgery. The father gave consent. The patient improved on steroids.
Dr. Taub reported finding a mass lesion in the left temporal lobe surrounded by edema. However, Dr. House pointed out that if he did have such lesion, the patient should be struggling to breathe. However, it did mean the patient was ready for surgery. However, Dr. House pointed out the patient now had a twitch in his little finger. This indicated that the diagnosis was wrong. Dr. House ordered the surgery canceled.
Dr. Taub believed the twitching was just nervousness. Dr. Foreman agreed and believed that the patient did have juvenile rheumatoid arthritis and it was improving. However, Dr. Hadley pointed out that Lyme disease would explain they symptoms and why he seemed to improve on steroids. However, Dr. House noted there was no target shaped rash that was indicative of the disease. Dr. Volakis thought it might be rheumatic fever, which would also explain the symptoms and why he improved on steroids. However, it didn't explain liver failure. Taub suggested removing the pacemaker wire. If House were right, the patient would go into cardiac arrest, but if the patient were fine, there would be no effect. Dr. Taub removed the wire with Dr. Kutner standing by with the defibrillation paddles. The wire was removed, the patient's heart rhythm and blood pressure were normal, and the patient was scheduled for surgery.
However, Dr. Hadley remained convinced that Dr. House was right and went to observe the surgery. She noticed some pictures taken of the patient about 3 weeks previously. She saw acanthosis nigricans on the pictures, but the pictures did not show any discoloration near his hairline, although there was discoloration there now. The patient's hair was shaved at the hair line showing the target shaped rash and confirming Lyme disease.
The patient was treated and eventually had the facial reconstruction surgery.