Medical History Edit
Patrick suffered a traumatic brain injury at the age of ten. Although his general mental faculties were affected, he started to exhibit great musical talent when he exhibited none before the accident. For example, he has absolute pitch - the ability to name a note simply by hearing it. However, his functional age is erratic and has never progressed beyond a four year old. He is unable to perform simple, logical tasks such as tying his shoes or buttoning his shirt. He displays echolalia as a mechanism when he doesn't understand a question but knows he needs to respond. He also suffers from seizures, but these have largely been controlled by medication.
Case History Edit
Patrick was brought to the emergency room at Princeton-Plainsboro Teaching Hospital after suffering from a severe headache while performing during which the fingers of his left hand became contorted by dystonia.
The case was referred to Dr. House who called in his fellows late at night to deal with the case. His team did not believe the matter was urgent, but Dr. House was intrigued how a healthy ten-year old with no history of musical talent became talented after a severe brain injury. He ordered a CDC with platelets, chem panel, thyroid and adrenal function tests.
Dr. Foreman performed a physical examination of Patrick. He was unable to distinguish right from left, he repeated what he hears when he doesn't know how to respond, but otherwise he appeared engaged and had normal responses to a full battery of neurological tests. Dr. Foreman wanted to discharge him. However, Dr. House went to see the patient and brought a piano with him. Dr House played the introduction to "I Don't Like Mondays" by the Boomtown Rats and Patrick played it note for note. He also named an entire set of notes played at once. Dr. House wanted to admit him. He then started playing an incomplete composition of his own, which Patrick completed after Dr. House stopped. Dr. House ordered an fMRI.
They gave Patrick an fMRI while they played music, but he showed no unusual brain response. However, Dr. Foreman suggested they get him to play music instead, and Dr. House asked him to pretend to play a piano. Patrick did so and several areas of his brain lit up and his heart rate rose despite the lack of an emotional response. That suggested a heart problem. Dr. House ordered an echocardiogram. The echo did indiate a heart problem - his left hand wasn't distorted by dystonia, but was reacting to the constriction of the arteries in his arm.
Dr. Foreman performed a heart ablation to correct the problem. However, during the procedure, Patrick developed tachycardia and his heart rate rose to 160. Dr. Foreman called for a defibrilator and managed to stabilize the patient.
The heart attack indicated there was no vasoconstriction, so the heart problem couldn't have caused the hand problem. The only explanation was that there was a lack of blood flow to the affected areas. Dr. House figured he was bleeding somewhere and ordered them to do an endoscopy and colonoscopy and if they couldn't find the problem, to do exploratory surgery.
They could not put Patrick under sedation for the scoping because of the risk his throat would collapse. However, Patrick refused to cooperate with the test and covered his mouth. They finally managed to start the procedure by having his father assist with the procedure by holding his arms away.
The exploratory surgery found the problem - Patrick had bleeding behind his kidney that filled the retroperitonial cavity. However, there didn't appear to be any reason for the bleeding. Cancer and a damaged artery had been ruled out. The bleeding explained the symptoms, but there was no explanation for the bleeding. In addition, Patrick suffered a grand mal seizure while he was being closed up, which made no sense because he was on anti-convulsants. Dr. House asked his team for an explanation, and Dr. Foreman pointed out that anti-convulsants don't stop seizures, they merely make them less severe when they do happen. It was obvious that if he was having a grand mal that his seizures were getting worse. Dr. House ordered that the anti-convulsants be discontinued. Once the seizures started to get worse, they could pinpoint the brain damage by doing a PET Scan.
Patricks seizures did start to get worse and Dr. House had a technician do a PET Scan as his team was busy. He presented the PET Scan to his team, but although there were numerous hot spots, they were spread out and non-specific. It also indicated the left side of his brain was working harder than the right side. Bleeding in the brain could cause the worsening seizures, which meant he needed an angiogram. However, his team said they were still busy, so Dr. House went to do the angiogram himself. It confirmed the presence of blood throughout the right hemisphere of his brain. This narrowed it down to trauma, cancer, aneurysm or an autoimmune disease. However, Patrick's previous EEG showed nothing specific. Dr. House wanted to do a brain biopsy, but without a specific target, his team pointed out that Patrick would most likely die before they found the right spot.
However, Dr. Foreman came up with an idea. The external EEG may have been confused if there were multiple structural abnormalities. He suggested doing an internal EEG - attaching the leads directly to the brain. It was risky and invasive, but less so than random biopsies, and it could give them an idea where to biopsy next. Dr. House directed Dr. Foreman to gest consent for the procedure.
Dr. Foreman explained the procedure to Patrick's father. He wanted to know if cancer or an autoimmune disease was a better diagnosis, but Dr. Foreman told him neither was a good result. The father consented to the procedure.
However, the results were astounding - Patrick's entire right hemisphere showed no activity whatsoever - it was brain dead. However the left hemisphere was showing normal brain activity. It appeared that whatever happened, his right brain died while they were treating him. The initial EEG could not have missed that much brain death, his respiration was falling and his seizures were getting more frequent. However, Dr. House was not totally convinced. Patrick was still able to speak even though, as a left-handed person, his speech center should be in the right hemisphere.
They went to test Patrick. He could recognize a piano with his right eye covered, but not when his left eye was covered. However, he could still play a piano keyboard and remember musical compositions. As music is a global process, had the brain been damaged after he was admitted, his ability to play should have deteriorated. Dr. House thought the dead right brain was unrelated to his current problems. If that was the case, vasculitis was the likely diagnosis. Tests quickly showed it was Takayasu's arteritis and treatment with steroids was started. Patrick rapidly improved - his respiration rate rose and his seizures started to subside.
However, Dr. House wanted to propose something radical. He surmised the patient's dead right brain was holding back the left side and suggested to Dr. Cuddy that they remove the dead right hemisphere. This would probably stop his seizures. It might also restore some function to the left hemisphere. Dr. Cuddy agreed if the father would consent to the procedure.
Dr. House went to see the father. The father was aware the seizures were getting better and hoped that Patrick could be released soon. However, Dr. House suggested the hemispherectomy. The father didn't see the point as the seizures were manageable, but Dr. House suggested that if Patrick's left hemisphere was more or less intact, removing the seizures could improve its function. He would probably never play the piano again, but he could probably hold down a regular job. Dr. House reminded the father that most parents have to live with their children maturing and taking care of themselves instead of caring for them, and that having a regular life might be better than having a gift.
The father talked to Patrick, wanting to know whether or not he was happy. Patrick didn't understand the question. The father agreed to the hemispherectomy.
The hemispherectomy went well and Patrick went to the recovery room, although it took some time before he regained consciousness. Once he did, his neurological responses were normal, but he was unable to speak. However, all of a sudden, he started buttoning up his own shirt, and then he smiled.