Sophia's parents died the year before. When she didn't want to enter foster care, she took and passed the GED and got her self legally emancipated. She then began working at a factory with immigrants.
Case History Edit
The patient was brought to Princeton-Plainsboro Teaching Hospital after she collapsed onto an assembly line at her place of work while having a discussion with one of her subordinates. She was aspirating saliva and apparently had a seizure. The patient had fluid in her lungs, but no previous trauma, respiratory or cardiac issues. Her gram stain was negative showing no bacteria or pneumonia. Dr. Taub thought it might be a parasite, but Dr. Foreman pointed out the patient had no issues with her digestive tract. Dr. Foreman thought it might be a pregnancy causing a fluid overload that hit the lungs. Dr. Kutner pointed out the patient said she was not sexually active, but Dr. Foreman thought she was probably lying. Dr. House ordered a pregnancy test. Dr. Hadley thought it might be drugs which caused damage to the heart and a fluid imbalance that built up in the lungs. However, the patient's tox screen was clean. However, Dr. House ordered an environmental scan of the patient's home and workplace to look for toxins or drugs, and ordered Dr. Kutner and Dr. Foreman to do an echocardiogram.
Dr. Kutner did the echocardiogram and asked the patient about drugs, but she denied using them. Her heart was healthy.
Dr. Taub and Dr. Hadley did the environmental scan of Sophia's apartment. They found a bong. When confronted with it, Dr. Kutner said it was irrelevant if she used drugs because they couldn't be the underlying cause if her heart was still healthy. However, although the heart was structurally undamaged, Dr. House thought drugs could cause intermittent tachycardia that would explain her pulmonary edema. However, Dr. Kutner thought that vasculitis was more likely. However, Dr. Taub pointed out that her blood work did not show any signs of vasculitis and it also causes fatigue, which would make it impossible for her to do factory work. Believing that since she built her own furniture she was unlikely to miss work because of a little fatigue, Dr. Kutner wanted to give her steroids for the vasculitis, but Dr. House pointed out they could make any arythmia worse. He ordered Dr. Foreman to give her beta blockers. Dr. Foreman directed the rest of the team to do it.
Dr. Kutner explained to the patient that the beta blockers would prevent the fluid buildup caused by the arythmia. She said she thought her heart had tested fine, but Dr. Kutner explained the arhythmia may be intermittent. When confronted about the bong, she said it belonged to her ex-boyfriend and that's why she broke up with him. Dr. Kutner told the patient it could be vasulitis, but if her heart was damaged by drugs, steroids would kill her. When she still denied using drugs, Dr. Kutner administered steroids.
However, the patient soon developed a psychotic break and became defensive and violent. Dr. Kutner managed to subdue her while Dr. Taub sedated her. When Dr. Taub asked how beta blockers could cause psychosis, Dr. Kutner admitted he gave her steroids instead. She was given haloperadol and was stabilized. The lab tests showed that the delerium was not caused by a metabolic problem. When Dr. House admonished Dr. Kutner for giving her steroids, he pointed out that the patient was not on steroids long enough and that it must be another symptom. However, the delerium ruled out vasculitis and arhythmia. Dr. Foreman suggested Prinzmetal's angina. When Dr. House told him that several tests showed the patient's heart was fine, he suggested that the angina was instead in her head, causing an artery to spasm causing both delerium and pulmonary edema. Dr. House ordered Dr. Foreman to give her ergonovine to set off another spasm and do a functional MRI and to make sure he did not pass it off to someone else. However, Dr. Foreman ordered the rest of the team to prepare the patient.
Dr. Foreman arrived as they started the MRI. However, it appeared to be clean. Dr. Kutner chatted with the patient to relax her, but spotted something strange. He questioned her further and realized she was lying because blood was flowing to her limbic region which controls imagination. Dr. Kutner realized her parents weren't dead. She said that she lied about it and became emancipated because her father raped her and her mother denied it.
The MRI showed no sign of vascular spasm, impeded blood flow or brain dysfunction. This ruled out Prince Metal. Dr. Taub suggested an STD. Dr. Foreman suggested gonococchal endocarditis would explain the symptoms, but there was no sign of it in her blood tests. Dr. Kutner suggested the patient could be lying about the rape. Dr. House thought it might be a manifestation of extreme stress. Dr. Foreman pointed out that there was no hormone imbalance or cardiac symptoms, but Dr. House persisted as extreme stress can result in asymmetric function in the mid-brain causing delerium and the pulmonary edema could be explained by an interruption of the heart-brain coupling. Dr. Hadley pointed out that the treatment would merely be anti-anxiety medication - very safe. Dr. House ordered Dr. Hadley to administer diazepam and ordered Dr. Foreman to ensure that she administered it.
Dr. Hadley explained how the stress could manifest itself as illness. The patient wondered where Dr. Kutner was. Dr. Hadley counseled the patient to report the rape to the police, but she refused. However, Dr. Foreman told Dr. Hadley not to give her the tranquilizers as the patient's urine had turned brown, which could not have been caused by stress.
Lab tests of the urine showed that the color was caused by shredded red blood cells. Dr. Kutner thought it might be E. coli, and Dr. Hadley suggested shigella, but Dr. Foreman pointed out that neither of these bacteria would cause lung symptoms. Dr. Foreman thought it was Legionnaire's disease, but the patient's sodium was normal. Dr. House wondered about the patient's home made furniture, and realized it was made with pressure treated lumber, which contains arsenic. Although there was no arsenic in her blood tests, Dr. Foreman pointed out that it accumulates in organs and may not show up in her blood. He told Dr. Hadley to test the patient's hair for arsenic and, if it were positive to start chelation therapy.
They managed to remove all the arsenic from the patient's body. However, the patient soon started having seizures. Dr. Hadley ordered 4 mg of lorazepan. Dr. Hadley did a new MRI which showed new lesions. It was too fast for cancer, but it could be an infection such as MRSA. However, the patient's white blood cell count was not elevated. Dr. House ordered the administration of arsenic because it was apparently treating another underlying condition. Dr. Kutner pointed out that arsenic was used against Syphilis before penicillin was available, but Dr. Taub pointed out that given her prior level of arsenic, there should be no syphillis in her system. She had also tested negative for other STDs. Dr. Hadley suggested acute promyelocytic leukemia is treated with arsenic, but she would still need a bone marrow transplant. Dr. House ordered a biopsy of the lesions to confirm and arsenic if APL was found. He told them to get the patient ready to approach her parents as bone marrow donors. Dr. Hadley explained this to the patient as she performed the biopsy, but the patient refused to approach her parents, even if she would die as a result. Dr. Taub lied and told the patient he had Huntington's Disease and he wished he had the option to find something that would treat it. However, the patient asked Dr. Taub if he had ever been raped.
When Dr. Hadley objected about Dr. Taub using her illness to attempt to manipulate the patient, he admonished her for not trying harder to convince the patient to do the right thing. The biopsy was positive for APL, meaning the patient needed a bone marrow transplant. Dr. Hadley wanted to find the patient's parents despite the patient's objections.
Dr. Hadley found the parents, but found out that they already had a daughter named Sophia Elizabeth Velez living at home. Dr. Hadley realized the patient had stolen that girl's identity and had probably forged her emancipation papers. Dr. Hadley told the patient that, as a minor, the doctors had every right to seek permission from her parents. The patient begged Dr. Hadley to reconsider, but Dr. Hadley pressed to find the girl's real parents. However, the patient refused treatment, knowing that if her condition worsened, they would have to treat her as an emergency case and wouldn't need parental consent.
The patient was getting worse, but the best match in the donor bank was a 3 of 6, which would most likely be rejected. Dr. Taub said that the patient wanted to deny her parents the satisfaction of saving her life. Dr. House thought that Taub was merely rationalizing the patient's emotional response, but both Dr. Hadley and Dr. Taub confirmed that these were the patient's own words, as well as being the first thing she said. Dr. House thought this response was very rational for a person in her condition. He wondered why the patient wasn't more emotional and figured that the rape was hiding an even worse trauma. He went to the patient to ask her what she did wrong, and why she thought she didn't deserve to live. She finally admitted that she had killed her brother - he drowned in the bathtub while she was supposed to be watching him. Dr. House told her that if she let herself die, that she would be killing another of her parent's children. He convinced her to call her parents. They rushed to the hospital for a reunion with their daughter.
The bone marrow transplant was a success and the patient started to recover quickly.