Case History Edit
The patient came to Princeton-Plainsboro Teaching Hospital complaining about intense intermittent ear pain. She had already seen six other doctors who could not come up with a diagnosis. Dr. House agreed to take the case.
Dr. Chase thought it might be a vitamin deficiency – Valerie had recently changed her diet. However Dr. Foreman pointed out that her diet had actually gotten better – she was eating more fruits and nuts. However, Dr. House noted that her cholesterol was already high and it may have affected the nerve sheaths in her heart. This would cause blockages and the resulting arythmia might present as ear pain. The team was sent to examine Valerie.
The examination showed an arythmia, but her arteries showed no sign of obstruction. They decided to start her on medication, but they still had to find the underlying cause of the arhythmia.
However, after an altercation with a co-worker who accused Valerie of poisoning him, the team felt that the co-worker was projecting and had actually poisoned Valerie. Dr. House asked if the co-worker had dry skin and thin eyebrows. The team confirmed it and Dr. House said it was most likely hypothyroidism. His medication for it would cause the exact symptoms Valerie was suffering from. Dr. Foreman wanted to try beta blockers, but Dr. Hadley protested – she wanted to know why they believed Valerie and not the co-worker. She pointed out that the co-worker had vomitted on her shoes just before she had symptoms and that she had not mentioned it to them or her husband. Dr. House disagreed and ordered beta blockers. Dr. Foreman ordered Dr. Hadley to administer the medication even though she was the one who thought he was wrong.
However, Dr. Hadley decided to do an fMRI. She questioned her about emotional subjects, like what she likes and hates. However, there was no activity in her paralimbic system, which administers emotions. All the activity was in her language centers. This showed that she understood the emotions, but couldn’t feel them – she was a psychopath.
When this was reported to Dr. House, he decided to meet the patient. Dr. Foreman realized that having the husband there would interfere with their questioning, so Dr. House asked him to leave. He asked Valerie how long she had been a psychopath, but after denying it, Dr. House said it was most likely medically relevant to her present condition and she finally admitted it. She also admitted giving the co-worker Valium and an emetic to make him look drunk in front of their boss. She admitted being married to her husband because he had a trust fund.
Dr. House believed the psychopathy and heart problems were related, but Dr. Hadley pointed out they appeared to happen decades apart. Dr. Foreman suggested that it might be tertiary syphilis, causing the psychopathy years ago and the heart problems as it came back. Dr. House ordered penicillin, but also asked him to rule out Wilson's disease and Hashimoto’s disease.
As they were explaining the treatment to Valerie, she started coughing. When her husband left the room to get water, Valerie stopped coughing and threatened Dr. Hadley that she would have her medical license pulled if she told her husband anything. However, when the husband returned, Dr. Hadley examined the patient’s arm and when she turned it over, she broke it.
The patient asked to have Dr. Hadley removed from the case, but Dr. House examined the patient’s test results and noted her BUN creatinine levels were low, indicating the bones were brittle from kidney failure. Dr. House dropped the psychopathy as a symptom and concentrated on the kidney failure. It ruled out syphilis and the other tests were negative. Dr. Foreman suggested it might be paraneoplastic syndrome from lymphoma. Dr. House wanted to start radiation therapy, but Dr. Hadley protested – it was protocol to do immunoassays on a patient’s urine first. However, Dr. Foreman pointed out that with the kidney failure, that wasn’t an option. Dr. Hadley pointed out that there was leftover from her initial tests, but Dr. Foreman pointed out there wasn’t enough for a completely accurate result. Dr. House told Dr. Foreman and Dr. Hadley that their attitude towards each other had to change.
Dr. Hadley told the patient and her husband that radiation therapy was the only option. However, she also told the husband that they hadn’t ruled out environmental causes. She then told him to check out the landscaping class Valerie said she had every Thursday, even though she knew that was the night Valerie actually spent with her co-worker.
Dr. House oversaw the radiation therapy.
The husband came back and confronted Valerie about her lying about the landscaping classes. She managed to talk her way out of it by claiming she was actually at work.
Valerie complained to Dr. Cuddy and wanted Dr. Hadley fired, but Dr. Cuddy pointed out that Dr. Hadley had a valid medical reason to ask about the landscaping classes and did not reveal any confidences. However, she said Dr. Hadley would no longer be working on the case.
Valerie then made a sexual harassment complaint against Dr. Hadley and Dr. Hadley confronted her. Dr. Chase and Dr. Foreman took control of the situation and got Dr. Hadley out of the patient’s room. Dr. Foreman then spoke to Dr. Hadley about the stupidity of her actions and apologized for firing her earlier when he was in charge. He convinced her to stay away from the patient and that if she did, the accusations would go away on their own.
Valerie soon had trouble with her liver and blood backed up into her esophagus. This appeared to rule out lymphoma. Dr. Foreman explained to the husband that they would put banding around the bleeding but it was so extensive that may not work. He wanted to put a shunt in to bypass blood flow around the liver. However, they could only leave the shunt in so long before the toxins that were usually cleaned by the liver would start damaging her brain. The husband finally consented to the procedure.
If they could not treat her, the prognosis was that Valerie would die in 1-2 days. Dr. Hadley suggested amyloidosis, but there were no speckles on the MRI. Dr. Chase suggested alpha 1-antitrypsene deficiency, but there was too much kidney failure. Dr. Taub suggested primary hepatic fibrosis and Dr. House felt it was most likely and ordered steroids. However, Dr. Chase pointed out that given the patient’s condition, the liver probably wouldn’t be saved and she would need a transplant. She would not qualify for one without a confirmed diagnosis. A voluntary donation didn’t seem to be an option because the husband wasn’t a match. They started looking for other family members.
However, Valerie’s sister Sarah came to visit her and even took the test to see if she could donate, but wasn’t a match. She talked to Dr. Hadley and told her that Valerie protected her from their abusive father even though Valerie was younger. She also said that Valerie’s personality changed as she got older, probably due to the abuse.
However, Dr. Hadley reported to Dr. House that she now believed the psychopathy was a symptom. It didn’t appear until Valerie entered puberty. Dr. House realized that Valerie’s new high nut diet would introduce more copper into her system. That would explain why her organs only started failing recently and her psychopathy started at puberty, but only if she had Wilson’s disease. However, Valerie didn’t exhibit Kaiser-Fleischer rings. Dr. House noted Wilson’s patients don’t always have them and went to examine the patient’s cuticles. They were blue, confirming Wilson’s. Dr. House ordered chelation therapy. Valerie asked if it would treat her psychopathy, and Dr. Hadley had to admit it was possible, if unlikely.
Dr. Hadley warned the husband that Valerie would most likely just pretend to improve, but he told her that the love she seemed to have for him felt real and he was willing to live with that.
Valerie started to improve quickly. Although she still might need a liver transplant, she would now qualify to be on the transplant list. However, when her husband told her he was looking forward to her getting better, she started insulting him about being so pathetic and he left the room. Dr. Hadley and Valerie realized that she was feeling emotional pain.