Medical History Edit
The patient has been trying to become pregnant and has been on fertility medication for the past thirteen months.
Case History Edit
The patient developed uncontrollable muscle spasms in her arms and legs shortly after getting into her car. She drove the car through the back wall of her garage but did not appear to suffer any trauma as a result. She was taken to the emergency room of Princeton-Plainsboro Teaching Hospital. Dr. Cameron brought the case to Dr. House.
Dr. Foreman thought the movement disorder was the result of a head trauma from the accident, but Dr. Cameron told him that the patient reported minor spasms before she even got in the car. She was also presenting with a facial twitch. Dr. Cameron thought it might be excess estrogen from the fertility treatments. Dr. Foreman thought it might be Huntington's disease. Dr. Cameron noted that it would take a full day to check for Huntington's and they should put her on tamoxifen in the event it was her fertility medication. However, Dr. House thought it might be pregnancy and ordered a rabbit-based pregnancy test to double check the negative finding on the urine-based pregnancy test. If she were pregnant, the tamoxifen would cause a miscarriage. Dr. Foreman, who was acting as Dr. House's supervising physician due to a discipline matter, agreed with this course of action. Dr. House also ordered an MRI of her head and uterus. He also ordered them to give her a paralytic to keep her flailing from hurting one of the doctors.
The patient was informed and, despite the low risk to a developing fetus, did not want to do the MRI until the pregnancy test came back negative. Dr. Foreman administered vecuronium, which cuts off the nerve connections between the brain and muscles, to stop the spasms.
The patient was taken off vercuronium after the MRI, which was clear, and the pregnancy test was negative. Dr. Foreman planned a test for Huntington's and Dr. Cameron started the patient on tamoxifen in the event that the estrogen was causing her symptoms. The patient started having spasms again, and snapped at her daughter.
Dr. Foreman noted the patient was hyperviligent and exhibited sudden irritability, which were also symptoms of Huntington's. Dr. House told him that since he was the attending, Dr. Foreman should start her on medication for it if he thought he was right. Dr. Cameron wanted to wait because the treatment, valproic acid, could destroy her liver. However, Dr. House was concerned the patient might proceed to psychosis if she wasn't treated. However, Dr. Chase was skeptical - the symptoms appeared to be progressing too quickly. However, the patient did have a psychotic break and started trashing her hospital room. Dr. Chase ordered 10mg of adivan, which Dr. Foreman quickly administered.
However, the patient tested negative for Huntington's despite the fact she seemed to have all the symptoms. Moreover, the psychosis eliminated the fertility medication from consideration. Dr. Foreman noted the patient was the right age to develop spontaneous schizophrenia, but there was no family history of mental illness. Dr. Chase suggested it might be a toxin, but no one else in her home, office or volunteer organizations were sick. Dr. House started to wonder how she kept so active and suggested she might be using cocaine. Dr. House sent Dr. Cameron and Dr. Foreman to look for drugs at the patient's home. They could not find anything in the house, but Dr. Cameron suggested searching her car. They found a bottle of ritalin that was prescribed to the daughter. They brought it to House who thought it explained all her symptoms. As her symptoms were improving, he wanted to discharge her. However, Dr. Foreman wanted to confirm the diagnosis with a tox screen.
Instead, Dr. House went to see the patient and asked the daughter if she was on any medication. He then confronted Margo with the ritalin. She admitted that she didn't give her daughter any medication, but denied taking them herself. However, Dr. House said he had already done the tox screen and it showed she was positive for ritalin. She finally admitted it, but Dr. House had not done the tox screen - he was only holding a cafeteria menu. He ordered the patient discharged.
The patient was prepared to leave, but as she was heading to the exit, she suddenly collapsed in the lobby. Dr. Cameron called a code blue. Dr. Cameron called Dr. House to let him know that Margo had suffered a stroke.
When Dr. House arrived at the hospital, Dr. Cameron informed her that the patient had no arythmia and so the ritalin hadn't caused the stroke. The stroke was caused by a clot, but they couldn't find the source. Ultrasounds of her arms, legs and heart were all clear. Dr. Foreman thought it might be complement Protein C deficiency, but this would not explain the spasms. Dr. House thought it might be more than one disease. The ritalin would account for the psychosis and flailing, the fertility medication could have caused endometrial cancer which could throw off clots and explain the stroke. Dr. House ordered an ultrasound of her uterus. However, it showed no thickening or masses, ruling out cancer. However, given that the patient didn't get pregnant from the fertility treatments, Dr. House thought that a tumor was still likely and ordered a biopsy. However. Dr. Foreman wouldn't approve it. However, his authority over Dr. House ran out at that moment and Dr. House ordered the team to perform the biopsy.
While he waited for the result, the patient's daughter wandered into his office. As he went to return her to her parents, she let him know that although her parents generally got along, they did argue when they discussed having another child. She also told him that both of her parents avoided confronting each other. Dr. Chase went to perform the biopsy, but before he started, Margo started bleeding heavily from her vagina. He started looking for the source of the bleeding. He did an ultrasound and found the blood was coming from her liver and had gotten into her fallopian tubes. They figured she had a tumor in her liver. They performed an MRI and found the mass on her liver. However, they could not perform a biopsy as the tumor was in a blood vessel.
However, Dr. House wondered how a liver tumor could cause all her symptoms. He started concentrating on the patient's personality instead of the tests. Dr. Cameron noted Margo liked to please people. Dr. Chase noted she turned to drugs instead of asking for help. Dr. House wondered why, given how busy she was, why she wanted another child. He started thinking again that it might be two diseases. Assuming that the psychosis was the result of the ritalin, the stroke, clotting, flailing and liver tumor could all be explained by her being on the pill, which caused a benign hepatocellular adenoma.
Dr. House went to confront Margo about being on fertility medication and contraception at the same time. However, she denied it, and Dr. House was unable to bluff her with the cafeteria menu again. He told her to stop taking the pill and the tumor would go away on its own - he canceled the surgery. She didn't want to explain to her husband why the surgery was being canceled and insisted on having it.
The patient contacted Dr. Cuddy, who refused to allow Dr. House to cancel the surgery based on his supposition in the face of the patient's denials. He pointed out that the patient could die on the table. She pointed out that if House was wrong, the hospital would be sued, so she ordered him to do the surgery.
The surgery was successful and the tumor turned out to be benign as Dr. House predicted. However, they had to remove half of her liver to remove the tumor. Dr. Foreman assured the patient and her husband that her symptoms would go away. When her husband left, she asked Dr. Foreman to lie to her husband that she could no longer take fertility medication. However, although Dr. Foreman was duty bound not to tell the husband about the reason behind her tumor, he refused to lie to him. He told her that if she kept using contraception with fertility treatment, she would most likely kill herself. The patient told him that she was going to continue on the same course until her husband gave up.