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Richard McNeil was the paralyzed Irish American man who became the patient in Meaning.
Eight years ago (before the episode), Richard was diagnosed with brain cancer. Surgery was performed to completely remove the cancer, but it left him in a vegetative state, unable to walk or talk. He has an electronic wheelchair, as he still has some control over his fingers. Over the past eight years he has had 214 symptoms, many of them repeating.
Lisa Cuddy thought that the case would be a good one to give to Dr. House, who was returning from a long convalescence. However, Dr. Wilson thought he'd be bored because there would be nothing left to diagnose. Dr. House surprisingly agreed to take the case, along with another case of a paralyzed young woman. He thought the treatment would be interesting. However, he did realize that Richard did suffer from brain cancer and that his oncologists hadn't screwed up that badly. Dr. Wilson reminded Dr. House that Richard probably tried to commit suicide because he can't talk or move. However, Dr. House thought that since his muscles had atrophied, he might be in pain and Dr. House could find a course of treatment to improve his quality of life.
Richard still had fluid in his lungs, House told his team to give him an oxygen mask. His leg muscles had atrophied, his tendons had shortened from disuse, causing intense pain. Tendon surgery would make him more comfortable.
They proceeded with the tendon surgery. The family didn't think he would kill himself. His son Mark thought he was confused or it was an accident. House told him that he hoped he was trying to commit suicide because that meant there was something left to kill. The wife thanked him.
After the surgery, Dr. House checked Richard's heart rate, which was a little high due to post-surgical discomfort. House increased his morphine slightly. The wife said that he had been nice to them. All the other doctors had been so focused on the cancer just trying to fix him, House had actually cared about the quality of his life. His heart rate came down as the morphine took effect.
Richard recovered and was ready to go home. He eventually wouldn't have any pain as he recovered. Dr. House suggested putting him in a long-term care facility, without a pool. But he was her sons father so she wouldn't. She didn't feel she could abandon him. Dr. House realized she didn't want to take care of him either. As she was putting Richard in his wheelchair, he started making grunting noises. House told her that he thought Richard was talking.
House told his team about the talking. However, Dr. Chase thought the patient was merely grunting. Dr. House told hist team to go over his eight year medical history, with grunting being in the differential.
Dr. Wilson thought Dr. House was bored and was trying to invent a mystery. Dr. House admitted he hadn't told the wife it was only a grunt as she would not have consented to the testing. Dr. Wilson feared that Dr. House was giving the wife too much false hope, but Dr. House didn't want to let her down.
Dr. Foreman thought it could be a neurological issue because the patient had dry eyes, which could indicate an autonomic dysfunction. However Dr. Cameron noted that dry eyes are a common symptom and are easily treatable. Although Dr. Foreman thought the work they were doing was worthwhile, Dr. Cameron thought that the exercise was pointless and that Dr. House was searching for a problem when there wasn't one. They wrote all his previous symptoms on the whiteboard, coming up with 214 symptoms since the patient's brain surgery. Dr. House started a new differential. Dr. Chase noted that fever and frequent urination could mean prostatitis. However, Dr. Foreman pointed out that a urinary tract infection could cause the same symptoms. However, the patient's normal white blood cell count ruled out an infection. Dr. Foreman suggested that those symptoms and pain meant a problem with the kidneys. When Dr. House expressed approval, Dr. Chase pointed out that Richard's creatinine and BUN were normal. However, Dr. House thought the pain might indicate a pancreatic cyst. However, Dr. Cameron pointed out that the typical symptom, abdominal pain, was not on the white board. Dr. House thought that the grunt might indicate abdominal pain. However, Dr. Cameron pointed out all the symptoms were merely random and didn't point to any disease. However, Dr. House pointed out it could be a disease with a long incubation period. He told them to do an upper endoscopic ultrasound. However, Dr. Foreman pointed out that this procedure would most likely result in a collapse of the upper airways due to Richard's muscle weakness and would result in a tracheotomy. However, Dr. House pointed out that Richard had shown no other signs of muscle weakness in his neck, such as choking on food. Dr. House directed Dr. Cameron to get the wife's consent.
Dr. Foreman and Dr. Chase performed the ultrasound. They prepped Richard by using a topical anesthetic for his throat. He had to manually close his mouth and nose to get him to swallow it. Dr. Chase inserted the endoscope. The pancreas looked clean. However, as Dr. Foreman predicted, his throat collapsed. Dr. Chase could not remove the endoscope. Dr. Foreman sterilized Richard's neck and Dr. Chase made the incision for the tracheotomy. They were able to endoscopically remove they probe, and got him breathing again.
When informed about the procedure, Dr. House noted Richard's throat was sedated which meant the brain should not have sent a signal to gag and spasm. Dr. House suggested cancer or a new type of muscular degeneration. Dr. Cameron told Dr. House to stop trying to find something wrong with the patient as if he was wrong, they were torturing the patient. Dr. House noted it took a half-hour to remove the endoscope, which meant the throat didn't collapse, it locked down. The muscle was only contracting, which meant the signal from the brain to relax it was not coming through. However, Dr. Foreman pointed out the patient had no lesions on his brain that would interrupt brain signals. He also pointed out that there was no evidence that there was any communication problem with the brain. Dr. House thought it might be a microtumor on his meninges, which would mean taking a look at the lining of Richard's brain. However, Dr. Chase pointed out that the amount of contrast material needed would most likely, as Dr. Foreman pointed out, make the patient bleed into his brain. Dr. House didn't think that was likely, but Dr. Cameron told Dr. House to get the consent himself.
Dr. House talked to the wife, who was concerned that the cancer was coming back. Dr. House told her that it wouldn't be the original cancer, it would be new, and could be treated. The wife wanted to know if this would make him better, but Dr. Cameron gave her an emphatic no. However, Dr. House said that there was a small small chance of him getting some brain function back and they could find ways to communicate with him. She consented to the procedure. Cameron told her that the test was very risky, he could die. However, the wife replied that he was already dead.
They began the procedure on Richard by injected contrast into his spinal canal. The contrast material reached his brain. There were no parenchymal bleeds. His blood pressure was high but holding. The meninges were intact. They finished the test, but noticed that Richard was bleeding out of his ear.
A surgeon repaired the CSF leak. His team reminded Dr. House that the were lucky he didn't die, and that he hemorrhaged just as they predicted. However, Dr. House noted the patient didn't bleed into his brain as they predicted, he bled out of his ear. House looked at all his previous tests and wondered what they had missed. He started going over the patient's previous head scans with Foreman. One from 1998 showed the tumor, which was no longer relevant. There was a small speck on the next scan, which was merely a benign regrowth. The next one merely showed scar tissue from a biopsy. Dr. Cameron thought all the indications on the scans were merely the result of the previous surgeries and didn't indicate a new disease. He told his team to redo the blood tests and scan Richard's head. Dr. Foreman and Dr. Cameron refused but Dr. Chase agreed.
However, Dr. House needed Dr. Cuddy's consent to continue the testing and she would not give it. She felt that Dr. House was only acting on a hunch. She did up the order to discharge Richard at 7:00 A.M. the next morning. Dr. House tried to get Dr. Wilson to help, but Dr. Cuddy had already contacted him and told him not to try.
Later that night, Dr. House was out jogging and stepped into a fountain to cool off. Suddenly, he realized something. He woke up Dr. Cuddy at her home and came to her window. He told her that the circumventricular system senses cytokines released in the early stages of the immune system response, but the CVOS releases prostaglandins that reset the hypothalmic set point upward unless it's countered by anti-pyretic therapy, which meant that Richard felt like his brain was burning. The suicide attempt was not a suicide attempt; he drove his wheel chair into the pool because he couldn't regulate his body temperature. He had hypothalamic disregulation. If the scar tissue of his hypothalamus is resting against the pituitary gland, the adrenal gland would shut down causing Addison's disease. Dr. Cuddy noted that he didn't see any scar tissue on the MRI or the CT Scans and his current body temperature was normal. She thought it was a wild guess without any substantiating proof. Dr. House noted that they could test his theory by injecting him with cortisol, a low risk procedure. If he was right, the patient would start walking and talking almost immediately. However, Dr. Cuddy refused - despite the low risk, Dr. House had to learn that he can't just test theories without any proof.
Dr. Wilson went to see Dr. House, partially surprised that Dr. House wasn't trying to inject the patient himself. He agreed he had no objective reason to believe he was right.
However, as Richard was leaving, Cuddy gave him the cortisol on the pretext it would fight infection. There was no immediate improvement or response. However, about thirty seconds later, he reacted to having his hand touched. He then moved his hand to the seat belt on his wheelchair, undid it, moved his legs in front of him and moved to stand up. He then nodded in response to his wife's questions, hugged his son and started laughing.
Richard's improvement was rapid. In the next episode, he came to the clinic. Dr. Cameron got the case, and when Nurse Previn told her that Dr. Cuddy wanted it she took it anyway because Dr. Cuddy was busy. Cameron was shocked to see his sitting up and talking. He told her about the Addison's disease and the cortisol. He wanted to have sex with his wife, and Dr. Cameron wrote him a prescription for Viagra.