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Megan was badly injured when the building she was in collapsed after a gas explosion. She was trapped under rubble for six hours before she was rescued. She was brought to Princeton-Plainsboro Teaching Hospital for two emergency surgeries to treat multiple bone fractures and burns, which went well despite her severe internal injuries. However, she did not recover well after surgery and ran a fever.
Just before the explosion, she had been talking to her boyfriend Ben, who advised the doctors that she had not been feeling well before the accident, complaining about being tired and needing to go home to rest instead of going out that evening. She had been sneezing most of the day.
Dr. Cuddy brought the case to Dr. House, explaining that Megan was the only patient in the collapse whose body temperature had not returned to normal. Dr. House recommended anti-pyretic medication, but Dr. Cuddy told him that had been tried but she was still running a fever of 104F. Dr. House agreed to take the case as long as Dr. Cuddy agreed to leave him alone for the next week if he got to the diagnosis within a day. They also discussed the recent loss of his team, but Dr. House insisted he didn't need a team anymore.
Dr. House started to work on his whiteboard, noting that the fever had not responded to antibiotics or anti-pyretics and she was fluctuating in an out of consciousness. In order to stimulate his thinking process, he started talking to the janitor. Dr. House asked him to pretend a ceiling had collapsed on a floor buffer and was overheating. The janitor suggested that the falling debris had damaged the electrical parts of the buffer. Dr. House thought Megan might have hypothalmic deregulation due to brain damage, but realized that the emergency room would have done an MRI and would have seen that. The janitor suggested that liquid had seeped into the buffer. Dr. House though that Megan's injuries had allowed multiple entry point for a parasite or fungus. The janitor then suggested lupus because his grandmother had it. Dr. House ordered an autoimmune panel although he thought an infection was more likely.
Dr. House went to see Megan's boyfriend and mother to take a medical history with the janitor coming along to take notes. The boyfriend denied she had traveled anywhere and denied she had been near any farms. The boyfriend said she had complained about being ill, but he thought it was probably a cold. The janitor reassured the family, and later admonished Dr. House to be nicer to family members.
A medical team had already ruled out the explosion site as the source of anything harmful, so Dr. House wanted to do an environmental scan of the patient's house. However, the janitor refused to help unless he was given at least $50. Instead, Dr. House misled Dr. Wilson into helping him instead on the pretext of taking him to lunch. Dr. House found some mold on the windowsill and asked Dr. Wilson to get a sample. He also found the patient's diary, which indicated that she was feeling depressed until about three months previously. He thought she might be on MAOIs and if they had given her demerol it would have caused a serious medicine interaction.
Dr. House reported back to the patient's family, and the boyfriend insisted he would know if Megan was taking pharmaceuticals or seeing a psychiatrist. The janitor presented the consent form so they could start dialysis. However, the family realized the janitor wasn't a doctor and approached Dr. Cuddy about it. She apologized for Dr. House's behavior, but also told the family that Dr. House was probably right and dialysis was a good idea. Dr. House read from Megan's diary that she was unhappy when she was around her boyfriend. However, Dr. House admitted there was nothing in the diary saying she was taking drugs, and he also admitted he found no drugs at the house. The boyfriend insisted that they were having a fight when the diary entry was made. Dr. House insisted that the symptoms fit perfectly and reminded the mother that since Megan wasn't married, she was her medical proxy. The mother consented to dialysis.
Megan rapidly improved as her fever when down and she regained consciousness. Dr. Cuddy explained to Megan what had happened and that she was likely to recover with no permanent injury. Megan was unable to speak because she was intubated, but was able to communicate by blinking. She confirmed she was seeing a psychiatrist and was on MAOIs. However, her heart rate started to increase to 200. Dr. Cuddy cleared the family from the room and used the defibrillator.
Dr. Cuddy managed to get Megan back into sinus rhythm but she still had tachycardia. She went back to Dr. House to explain the new complications and to insist that he had not correctly diagnosed the patient. Dr. House argued that he had - Megan improved under treatment and had confirmed her use of MAOIs. Dr. House did agree to do a differential for fever and persistent tachycardia with Dr. Cuddy, who suggested endocarditis. Dr. House pointed out there was no infection to support that diagnosis and left her to work it out. When he came back, Dr. Cuddy had no other explanation. She agreed the MAOIs might explain the fever, but didn't explain the tachycardia. However, Dr. House put that down to the trauma - crushed muscles would release potassium that would cause the accelerated heartbeat - crush syndrome. However, Dr. Cuddy was skeptical - if that were the case, she would have developed tachycardia immediately, not two days after the accident. Dr. House put the delay down to microvascular occlusions - it could take two days for the blood to profuse through the damaged muscle. Dr. Cuddy realized this would mean she would have a baggy heart and asked Dr. House to confirm it.
Dr. House did what he felt was a useless echocardiogram, but was surprised to find out there was nothing wrong with her heart. However, the family noticed Megan was sweating again - her fever had returned. Dr. House realized what the problem was, but was reluctant to discuss it with the family until they went to see Dr. Cuddy. In her office, he revealed that he though Megain was suffering from Delirium tremens. The mother was incredulous, as was the boyfriend. To get the DTs, Megan would have to be a serious alcoholic and neither of them had seen signs of serious drinking. Dr. House offered to do liver enzyme tests to confirm, but Dr. Cuddy admonished him in front of the family - the liver enzymes would be high in any case because of her injuries. The mother agreed to the treatment over the objections of the boyfriend - intravenous alcohol that would be withdrawn slowly over a course of days.
The treatment was successful - her fever and sweating abated and her heart started to work normally. However, her family noted she had been opening her mouth over and over again for the past couple of hours. They though she might be trying to talk, but Dr. Cuddy realized she was screaming from intense pain.
Dr. Cuddy intercepted Dr. House when he arrived the next morning to tell him that Megan's amylase and lipase levels were very high - she had pancreatitis. Dr. House put it down to the intravenous alcohol and Dr. Cuddy agreed. However, Dr. House realized she wasn't arguing with him, and she admitted she thought he was wrong. She told him she wasn't going to listen to him anymore, and Dr. House reminded her if he was wrong Megan would probably die. Dr. Cuddy informed him that he needed someone else to bounce ideas off of and should hire a new team.
Dr. House was sure he was right, but Dr. Cuddy came back to him asking why the boyfriend missed both depression and severe alcoholism. She asked him to do an MRI to look for abnormalities on the pancreas to confirm the diagnosis. Dr. House eventually agreed to perform the MRI and found no abnormalities. He realized he was wrong about the diagnosis. However she had an increased T2 signal in her hepatic capsule. He realized she was about to start bleeding from her mouth and anus.
Megan was rushed into surgery to correct the internal bleeding. Dr. House met Dr. Cuddy in the operating viewing room and she felt compelled to point out that the bleeding obviously caused the pancreatitis and asked Dr. House to explain what caused the bleeding. He though it was the trauma, but Dr. Cuddy pointed out that if that was the case, she should have started bleeding when the accident happened four days ago. She was now bleeding from five independent sites. Dr. House pointed out she was given warfarin when her hip was repaired. Dr. Cuddy pointed out the unlikelihood that her problems were caused by three independent conditions, but Dr. House pointed out that every time he treated her for those conditions she improved. Dr. Cuddy told him he needed a team to help him, but at that point he noticed the patient's uterus was enlarged, most likely from a recent pregnancy. He went into the operating room and examined her vagina, finding evidence that Megan had recently had an elective abortion. Since the boyfriend didn't mention it, he figured he wanted a child and she didn't, so she had the abortion secretly and then started taking the pill to allay suspicion and prevent further pregnancy. Since the pill is also a blood thinner, the combination with the warfarin started her bleeding profusely.
Dr. House went to the boyfriend to find the mother, but was pressed by the boyfriend into admitting she had an abortion and was on the pill. However, he told him that the news was good - they could successfully treat her with tamoxifin. However, the boyfriend denied that Megan would have an abortion - they wanted to have a child. However, Dr. House had confirmed the pregnancy with blood tests. The boyfriend left the hospital.
Dr. House went to the emergency room for help with a differential, but was told by a young doctor that Dr. Cuddy had issued a memo telling the staff not to help Dr. House. However, after Dr. House left the ER, the young doctor followed him and suggested a fungal infection, but it would have spread to her eyes by now. She suggested haemophilus, but this wouldn't explain why the fever came and went. She suggested acute respiratory distress syndrome, but this only explained the breathing difficulties. She then suggested crush syndrome, but this wouldn't explain the breathing. Dr. House realized that a combination of ARDS and crush syndrome would explain all the symptoms and asked her why that diagnosis wouldn't be correct even though both are caused by severe trauma. She realized if it was, the patient would be terminal. Dr. House praised her and asked for her resume.
Dr. House went back to Megan and found the boyfriend had returned. He explained that Megan had ARDS and crush syndrome and that her body was unable to repair itself. Her only hope was that she would improve on dialysis. However, he noticed Megan had a lump on her arm and realized that his diagnosis might be wrong. He ordered a biopsy. Dr. House managed to convince Imelda to help him out by faking another memo and having her do an MRI. The MRI showed multiple eosinophilic granulomas. This indicated an allergic reaction to cephalosporin, the only drug she was given in sufficient quantities to have a reaction to. Dr. Cuddy started Megan on steroids. However, Megan's medical history showed she had been given cephalosporin two months ago with no adverse reaction. The mother was furious - Megan had three adverse reactions to treatment and now had an allergy to something she couldn't be allergic to.
However after having a run-in with Dr. Wilson about moving one of his patients, Dr. House realized something. He started reviewing the charts of all the accident victims. He found a chart for Liz Masters, who had died a little earlier. Liz was had the same build and hair color as Megan, was taking MAOIs, had admitted to heavy alcohol use, had a recent abortion, and was allergic to cephalosporin.
Dr. House went to "Megan"'s room and gave the patient amphetamines to bring her back to consciousness. He had realized that since "Megan" was allergic to something she couldn't be allergic to, it was most likely the chart that was wrong rather than the patient's family. The boyfriend knew Liz Masters and Dr. House told them the patient was Liz, not Megan. EMTs are trained to never second guess a family's identification, and thus Liz was mistaken for Megan. The boyfriend insisted it was Megan and that Liz had died. However, when House asked the patient her name, she said it was Liz. Megan's mother was distraught, but Dr. House comforted the boyfriend by telling him that Megan had never lied to him. Her boyfriend Ben went to visit her in the morgue.
Dr. House insisted to Dr. Cuddy that he had solved the case all on his own. However, Dr. Cuddy pointed out his team would have solved it days ago. Dr. Cameron would never accept that the boyfriend knew nothing about Megan, although Dr. House dismissed the family's protests. Dr. Foreman would never agree with the premise that a patient's problems were the result of multiple diseases, although Dr. House did because his treatments seemed to work at first. Finally, Dr. Chase trusted Dr. House so much that he would have worked hard to confirm every diagnosis Dr. House made, but Dr. House merely made his diagnosis with confirming it at every step. She insisted he hire a team.