- House is off his game without the team, and Wilson uses an extreme tactic to force him into interviews.
- House is without a team, but is unfazed by it. Cuddy and Wilson both try to get him to hire a new team, but House argues he doesn't need a team. Cuddy presents him with a case of a woman caught in an collapsing building, and challenges him to diagnose her on his own, without help, before the day is through. House accepts, hijacks a janitor to serve as soundboard, and diagnoses the woman. Once treatment is started, new symptoms arise. Every time House diagnoses a new problem, another crops up. The woman's boyfriend and mother seem to have no idea about what went on in her life. They claim she was a happy young woman, but House can prove she was on anti-depressants when he finds her diary. They are sure she was no drinker, but House proves she was a heavy drinker. The boyfriend claims they wanted children, but House finds evidence of at least one abortion, and traces of anti-conception medication. When she proves to be allergic to a drug she has recently taken without problems, House starts to suspect something else is going on. People lie, but the facts never do. Yet here, the facts seem to lie as well. Wilson has another way of forcing House to hire a team : he kidnaps House's new guitar. House goes overboard about this, and kidnaps one of Wilson's patients. The realization that the patient could be mistaken by the staff for someone else, finally sets House on the right path to solve the problem at hand. He grudgingly admits that, with a team, he would have solved the case much faster, and decides to hire new people. Of course, he will do it "the House way".—damienklael
- As the episode starts, a young woman named Megan is at work talking on the phone to her boyfriend, Ben. He is trying to persuade her to go to a movie that evening, but she declines, citing fatigue and sneezing. She tells him that she thinks shes having hallucinations because the building seems to be shaking. There is a sudden roar as her office building collapses in a gas main explosion.
Its now two days later. Megan is one of the few survivors of the explosion, but she is still very severely injured. She has been through multiple surgeries for fractures and burns. Cuddy consults House because Megan has been running a persistent fever despite being on antipyretics (fever reducing medication like acetaminophen or ibuprofen). She has also been lapsing in and out of consciousness. Cuddy wants to use this case as a goad to get House working with a team again, but he refuses. He cuts her a deal: if he can solve the case by himself that day, she will not bug him for a week.
House ropes a passing janitor into helping him. He describes the case to him in mechanical terms, and asks him what he would do. The two of them come up with several possible diagnoses: brain damage with hypothalamic dysfunction (which House discards because it would have shown up on the brain MRI she already had), infection (possible parasitic or fungal infection, admits House), or Lupus (the janitors grandmother had Lupus). House wants to break into Megans house, but the janitor refuses (or at least refuses for the amount of money House is offering him). In the end, House shanghais Wilson to help him search the house. They find a diary which reveals that Megan had a history of fatigue and feeling blue. From this, House infers that Megan has depression. He then makes the leap that she was on a certain kind of antidepressant (an MAO Inhibitor a class of antidepressants used only rarely, if that, because safer more effective drugs are now available), that when combined with Demerol (a narcotic pain killer) she received in the ER, can cause Serotonin Syndrome, of which fever is one symptom (This is true, but there are other symptoms of Serotonin Syndrome which should have shown up as well. Serotonin Syndrome appears rapidly, and should have shown up within a few hours of receiving Demerol, and should have resolved by now, several days since she has had either antidepressants or Demerol.) House decides to place Megan on dialysis to remove the drugs from her system (not a common treatment for Serotonin Syndrome, but it has been used in severe cases). Her boyfriend insists that Megan was not depressed, seeing a psychiatrist, or on antidepressants, but House believes that Megan was just hiding it from him. He gets her mother to sign the consent.
After the dialysis she wakes up and confirms through blinking that she was seeing a psychiatrist and was on an MAO Inhibitor. She then develops ventricular tachycardia and slips into unconsciousness and cardiac arrest. Cuddy has to defibrillate her back into a normal rhythm.
House considers his deal with Cuddy done and himself the winner, but Cuddy disagrees. She wants him to figure out why Megan developed tachycardia. Endocarditis (an infection of the heart) is considered at first, but discarded because blood cultures were negative. Cuddy and House now consider that Megan may have cardiac damage from Crush Syndrome. Crush Syndrome occurs when a patient has been trapped under a heavy object, crushing part of their body and cutting off blood flow. The damage from the crush injury causes an increase in toxic chemicals in the affected parts of the body. When the patient is then released from the heavy object and blood flow resumes, these chemicals circulate throughout their body, causing a variety of serious problems (Shes been in the hospital for 3 days at this point, routine labs should have shown any Crush Syndrome by now; its not going to show up suddenly this late). House and Cuddy suspect the high potassium from the crush injury combined with microvascular occlusion have caused the heart problem, but luckily, this will show up on an echocardiogram. The echocardiogram is obtained, but it is completely normal. Taking the tachycardia (but normal echocardiogram), sweating, and fever into account, House now decides that Megan is suffering from delirium tremens (alcohol withdrawal). Her boyfriend again objects, saying that he would have noticed if she were an alcoholic. House ignores him and starts her on IV ethanol, which does correct her fever and tachycardia. In real life, IV alcohol is not the recommended treatment for delirium tremens because it doesnt solve the dependency problem, just prolongs it. Plus, it can lead to electrolyte abnormalities (which Megan already has), gastritis, pancreatitis, and hepatitis. Benzodiazepines (such as Valium, Ativan, or Librium) are the treatment of choice.
When Cuddy visits Megan and her family, she realizes that Megan has been silently screaming in pain for the past 2 hours (but apparently the pain wasnt enough to raise her blood pressure or heart rate noticeably). Labs show an elevated amylase and lipase, meaning that Megan has developed pancreatitis. The alcohol was the most likely cause for the pancreatitis, but there can be other causes as well. House obtains an MRI which shows a normal pancreas (when it should at least show pancreatitis). The MRI also shows an abnormality around the liver consistent with blood. Sure enough, Megan starts to bleed out both ends and is rushed to surgery with multiple sources of internal bleeding. Watching the surgery, House notices that Megan has an enlarged uterus. He enters the OR and takes a look, realizing that Megan has had a recent abortion. He then hypothesizes that she has been taking birth control pills, which when combined with the Warfarin (a blood thinner) she has been on since hip surgery (which would have been nice to know earlier), led to her bleeding (The effect, if any, oral contraceptives have on Warfarin is not clear. The combination probably does slightly increase the risk of bleeding, so House may be right. Of course, every other medication mentioned in this episode including MAO inhibitors, ethanol, cephalosporins, tamoxifen, and antipyretics also increase the chance of bleeding while on Warfarin, only moreso). House puts her on Tamoxifen to block the effects of the birth control pills (this is not a recommended use of Tamoxifen). This revelation that Megan had an abortion is too much for her boyfriend, who leaves the hospital, but he return later to sit by her side.
The bleeding improves, but now Megan develops kidney failure and breathing problems. Her fever returns. House wanders the ER looking for a doctor to bounce ideas off, but discovers that Cuddy has put out a memo prohibiting anyone from talking with him. One young resident decides ignore the memo and talk with him anyway. At first she suggests a fungal infection or haemophilus infection, but House rules these out. She then mentions Crush Syndrome (which House states wouldnt explain the breathing problems) and ARDS (Adult Respiratory Distress Syndrome which House complains would only explain the breathing problems). House rethinks the differential diagnoses, and now concludes that the patient is suffering from both Crush Syndrome and ARDS, which is bad news for Megan since these conditions have a poor prognosis. As he is talking with her mother and boyfriend, he notices a large lump in her arm. An MRI shows multiple similar lumps scattered throughout the body which are shown to be Eosinophilic Granulomas, which they say is a sign of an allergic reaction (I dont know what they are referring to here. Eosinophilic Granuloma is a type of Langerhans Cell Histiocytosis, a rare disease that has nothing to so with allergies. Im wondering if they are confusing it with feline eosinophilic granuloma, a very different condition.) Apparently Megan is allergic to the antibiotics she was given in the hospital medications which she has taken before without any problem. Finally, House realizes the solution to this patients problems she isnt Megan. Both Megan and a similarly appearing girl named Liz survived the explosion. There was a mistaken identification and Megan was identified as Liz and vice versa. Megan died several days ago, and the patient House has been treating is Liz whose medical records confirm everything House has suspected including the antidepressants, abortion, and use of birth control pills.
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