Case History Edit
The patient was admitted when she had difficulty breathing after being dropped from shoulder height during rehearsal. There were no signs of trauma, tumors, punctures to the lungs, bruising or STDs. Despite being on supplemental oxygen, her blood oxygen level was never higher than 60% and her lungs kept collapsing despite the presence of a chest tube. Her white blood cell count was normal and she had no fever, which ruled out pneumonia. Dr. House thought it might be a pulmonary contusion, but a CT Scan had showed no inflammation of the lungs. Her BUN and creatinine levels were high, but within the normal range. Dr. House suggested that dehydration from overexertion could have hidden the symptoms of an infection and ordered intravenous fluids and antibiotics on the assumption it was merely pneumonia.
The patient did not respond to antibiotics. Dr. House wanted to test for pneumonia, but the patient's lungs were still collapsed which ruled out a bronch. Dr. House wanted to perform a transtracheal aspiration, but Dr. Foreman objected because the sensation is similar to drowning. Dr. House persisted as the patient was critical and there was no other testing procedure available. Dr. Foreman and Dr. Taub performed the procedure. Dr. Foreman performed a tracheotomy and started the water, but the patient slipped out of Dr. Taub's grip. He noticed her skin had come off in his hands. Soon, the patient's skin was sloughing off quickly and they were having difficulty replacing it with artificial skin. The patient's ANA was negative, ruling out autoimmune disorders. Dr. House thought it might be a liver tumor which had progressed to the lungs and ordered an ultrasound and a biopsy if any masses were found. Dr. House believed that the skin problem was a reaction to the antibiotics - toxic epidermal necrolysis - and was not caused by her underlying disease. Dr. House ordered a swab of her skin to confirm the necrolysis. Dr. House apologized to the patient for giving her antibiotics before confirming that she had an infection.
Although the ultrasound found a mass in the liver, Dr. Foreman could not perform a biopsy as the patient's skin was still too thin and she would bleed to death from the procedure. Dr. House ordered the biopsy to be performed through her jugular vein, which would mean any bleeding would drain into her veins. Dr. Chase performed the procedure. A small heart flutter was noted, but it later developed into a complex tachycardia. Dr. Chase manage to complete the procedure.
The biopsy was negative for cancer. The patient's heart could not be tested until it was beating regularly. Dr. Wilson suggested metoprolol to correct the heart rhythm, but it had already been tried. Dr. House suggested inducing a cardiac arrest, then doing the MRI before restarting the heart. However, Dr. Hadley noted that it would take at least four minutes to perform the scan, and Dr. Foreman reminded Dr. House that brain damaged would be almost certain after three minutes. Dr. House still wanted to proceed.
Dr. Chase defibrillated the patient to induce cardiac arrest and they started the MRI. Dr. Foreman noticed a shadow near her aorta, but the patient had to be revived before it could be fully explored. The patient passed her cognitive tests.
The team discussed the shadow on the aorta, but it could be a lesion, tumor, or an abcess. However, it could also be an artifact on the monitor. Dr. Taub noted that a biopsy of the area would be dangerous as she would most likely go into cardiac arrest. However, Dr. House was intrigued by the patient's boyfriend and believed he might be feeling guilty. If the shadow on her heart was an abscess from gonorrhea, as Dr. Foreman pointed out the blood test would have been negative but the infection would still be damaging her heart. Dr. House ordered the boyfriend tested for gonorrhea and if it was positive, surgery to remove the abscess. The boyfriend tested positive, although Dr. Foreman surmised that he had caught the infection from her as he was asymptomatic and insisted he had been faithful. The patient was prepared for surgery.
However, the patient soon developed sepsis and surgery became impossible until they could get her blood pressure to rise. She was not responding to fluids. Dr. House had to remove himself from the case, leaving Dr. Foreman as attending physician. Dr. Taub suggested putting her on heart-lung bypass, but Dr. Hadley noted that the real problem was that due to her sepsis, her blood vessels could not be expected to hold together. Dr. Foreman suggested a high dose of dopamine. This would constrict her blood vessels and keep her from bleeding to death during surgery. However, Dr. Taub felt that much dopamine would overtax her heart. However, given the lack of options, Dr. Foreman decided on dopamine.
The surgery proceeded with the patient's blood pressure at 90/60. Dr. Chase found the abcess and noted that none of the other tissue surrounding it seemed to be damaged. However, he noted the patient's fingers and toes were turning black from gangrene from lack of circulation.
The patient was taken off anesthetic and advised that her hands and feet had to be amputated to prevent the spread of gangrene. However, the patient refused the procedure. The team worked to find an alternative treatment. Dr. Taub finally decided to use a vasodilator to counteract the effect of the dopamine. However, the procedure was dangerous as a clot could kill the patient. However, the procedure went well and circulation was restored to the patient's hands and feet. She was expected to make a full recovery.