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Moira came to the clinic complaining of intense sudden onset pain in her left shoulder. She was seen by Dr. Chase. The patient’s chaperone told Dr. Chase that nothing they had done to relieve the pain had worked. She had no chest pain or light-headedness. She had been sitting and praying when the pain came on. The chaperone explained that Moira had been helping out that morning, but had not done anything to exert herself or anything that required repetitive motions. Dr. Chase noticed that Moira’s lymph nodes were enlarged. He wanted to rule out breast cancer and asked the chaperone to leave for the breast examination. When she did, Dr. Chase explained to the patient that he deliberately wanted the chaperone to leave so he could ask her about a second possible cause - stress induced angina. He had noted she was a postulant from her blue veil and was obviously getting ready to take her vows and withdraw from contact with the rest of the world. Major life changes can often cause the pain she experienced. He proceeded with the breast exam while she admitted she was having second thoughts and was in a heightened emotional state as a result. Dr. Chase assured her that her reaction was normal, but found a mass in her breast and admitted her for further tests.
However, the mass was just a benign fat deposit. Moira was given a stress test, which was normal as well, ruling out angina. Dr. Chase ran into Dr. House, who suggested it was merely a strain, but Dr. Chase rejected the suggestion. Dr. House next suggested a fungal infection from unprocessed wheat, which would explain both the shoulder pain and the swollen lymph nodes.
Dr. Chase sought out Dr. House for another differential. He suggested descending colingitis, but Dr. Chase pointed out Moira’s bilirubin levels were normal, but Dr. Hosue noted that clinical symptoms of the condition could show up days before the tests for it were positive. Dr. Chase returned to Moira, who was now suffering from full paralysis in her right foot, the result of ischemia.
Dr. Chase realized he needed more assistance from Dr. House and went to see him and his team. Dr. House suggested a clot, but Moira’s D-Dimers were normal. Dr. Adams suggested a vasospasm. Dr. Chase realized that this explained all the symptoms except the swollen lymph nodes, and that could just be a minor infection. The patient needed calcium channel blockers.
The patient improved quickly on calcium channel blockers, with the color of the foot, capillary refill and arterial pulse coming back to normal. Her shoulder pain had also disappeared. Dr. Chase discharged her.
However, the next morning, Dr. Chase arrived at the hospital with Moira, who was suffering from a carotid artery dissection which had clotted, which kept her from bleeding to death. He called for an O2 level. Dr. Park tried to prepare her to draw a sample for arterial blood gasses, but Dr. Chase instructed her to get a reading from her pulse instead. He told Moira she needed immediate surgery, but her response told him she was having trouble verbalizing - Broca‘s aphasia. He rushed her to the operating room.
Dr. Chase and Dr. Taub prepared for surgery when Dr. House arrived. Dr. Chase explained Moira’s pulse was bounding 4 plus, where it was at 3 plus twenty minutes before. Dr. House became confused because he knew Dr. Chase had just arrived at the hospital and wondered how he knew the patient’s pulse rate from twenty minutes ago. He looked at Dr. Chase and saw the patient’s dried blood on his neck as well and realized that Moira had been with Dr. Chase at his apartment that morning and that they had most likely spent the night together.
However, Moira’s clot broke, which caused her to start bleeding out. Dr. Chase ordered her nose packed to stop the bleeding and told the staff to take her directly to the OR. However, Dr. Adams and Dr. Taub objected given the nature of Dr. Chase’s relationship with the patient. However, Dr. Chase pointed out that Dr. Nagu and Dr. Carlyle were unavailable and that he had done more dissections than Dr. Riley. However, Dr. House backed Dr. Chase. Dr. Adams accused Dr. House of making his decision based on his troubled relationship with Dr. Chase. Dr. House countered that Dr. Chase was a better surgeon that Dr. Riley.
Dr. Chase called for a vascular clamp. Dr. Taub realized that they were not going to put Moira on bypass, but Dr. Chase argued that would take at least 30 minutes. Dr. Adams pointed out the clamping out the carotid could result in a stroke, but Dr. Chase countered that Moira was already exhibiting neurological symptoms and an extra 30 minutes would definitely cause brain damage. He was certain that he could accomplish the repair in five minutes, which would avert a stroke. Dr. Adams accused him of making the choice that the patient would either be fine or dead and that he wasn’t able to think objectively, and noted there was no way he could be sure it would only take five minutes. Dr. Chase proceeded with the clamp at 09:46:23. He called for vascular scissors and prepared to suture the damage. However, he was not finished within five minutes. Dr. Chase stopped soon thereafter and called for ultrasound, which showed good arterial flow. He then ordered her to be weaned off anesthesia. Dr. Taub asked if he didn’t want to close the incision first, but Dr. Chase said he didn’t. Moira regained consciousness and had her verbal skills back.
Dr. Chase reported to Dr. House that he found nodules on the artery he removed. Dr. House thought it might be lupus, but the patient’s ANA was normal. Dr. House though the nodules were really plaques, indicating syphilis, which would explain the symptoms in the shoulder and foot as well.
Moira insisted she had not had sex in years before the previous night, but Dr. Chase explained that her symptoms showed that she had contracted the disease several years ago. He reassured her that she was probably not contagious. She asked if it caused hallucinations, but Dr. Chase thought that was unlikely. She described that when she was on the operating table, she had a vision of the young boy for whom she had served as a nanny several years before who had accidentally been killed. She said he had acted like he had forgiven her.
Dr. Foreman was told that Dr. Chase had slept with Moira and had him removed from the case. Dr. Chase countered he had saved the patient from brain damage to no avail. Dr. Adams had reported Dr. Chase to Dr. Foreman and told Dr. Chase that before his injury three weeks before, he would never have had sex with a patient or operated on her afterwards.
Dr. Park thought the liver failure was from intra-operative low blood pressure. However, Dr. Chase had checked the surgical records, and Moira’s blood pressure had been steady. Dr. Chase thought it might be another clot, but Dr. House pointed out the abdominal ultrasound was normal. Dr. Taub noted Trousseau's syndrome would explain the clots while macrocytosis would explain the enlarged lymph nodes and Dr. Park realized both could be caused by disseminated T-cell lymphoma. Dr. Chase noted that Dr. Wilson had already reviewed her scans for breast cancer, but Dr. House pointed out that Dr. Wilson wasn’t looking for other types of cancer. Dr. Chase suggested sarcoidosis, but Dr. Adams pointed out Moira’s ACE level was normal. Dr. Chase countered that ACE levels aren’t necessarily definitive, but Dr. Taub agreed with Dr. Adams - the patient’s X-rays were also negative. Dr. Chase wanted to try a biopsy, but Dr. House started to agree with Dr. Foreman that Dr. Chase’s objectivity was compromised by his relationship with the patient and backed the diagnosis of lymphoma.
They started the test for lymphoma, but Dr. Chase explained that chemotherapy could only extend her life at this point, not cause the cancer to go into remission. However, as Dr. Chase sat with Moira, he noticed she was having trouble talking again. He was worried, but she reassured him she was able to speak, but her chewing muscles felt heavy when she did. He realized that it was jaw claudication. He went to speak to Dr. House. Together with the carotid dissection, this pointed to giant cell arteritis. Dr. House agreed and ordered steroids.
Moira improved quickly on steroids. However, she decided she wanted to return to monastic life. She was soon discharged.