Title:
Original airdate12/14/2004
Episode: 106
Synopsis: A schizophrenic woman falls ill with a pulmonary embolism while in the care of her son. House is intrigued, thinking nothing about this family is as it appears.
Patient: Lucille Palmero, age 38
Initial symptoms: DVT, pulmonary embolism

*****Spoilers below*****

Differential diagnosis:

Lucy Palmero is sitting in the New Jersey Department of Employment Development office listening to voices inside her head while her son Luke tries to get her disability payments extended. Luke handles the paperwork while Lucy rocks, twitches, and insults Sally, the civil servant assisting Luke.  Lucy grabs her calf in pain, and demands that a glass frog on Sally's desk be quiet. Luke asks for some water for his mother, which Sally goes to retrieve. Luke gives Lucy a small bottle of vodka to soothe her, which she gulps down. While Luke tries to assure her that the voices are not real, Lucy grabs her chest and collapses to the floor.

Lucy is taken by ambulance to PPTH, where Luke waits for word on his mother's condition. He paces the lobby, rubbing his wrist, which he smacked against the glass frog while coming to his mother's aid.  House sits in the lobby, reading a newspaper and ignoring Cuddy's pages. Luke asks House if PPTH is a good hospital, but House unhelpfully replies that he likes the chairs.

The ER doctor explains to Luke that Lucy had a pulmonary embolism caused by a deep-vein thrombosis while Luke takes extensive notes. He asks to speak to Luke's father because he has some concerns. Luke tries lying, saying his father is "running late," but the ER doc looks dubiously at Luke's notebook. Luke confesses that his father is dead, and that he takes care of his mother.

The ER doc is concerned that Lucy's blood alcohol level is 1.2 at 10:30 in the morning. Luke tells the doctor that he gave it to her himself to "cool her out," and it's the first she's had in three days. The ER doc ascribes the DVT to immobility caused by alcoholism, and dismisses Luke's statement that she only drinks what he gives her, and he's very careful. He tells Luke that Lucy has been given blood thinners, and can probably go home the next day.

Luke insists that Lucy is not an alcoholic, so there must have been some other cause. House butts in at this point, somehat sarcastically saying that the doctor would not claim Luke's mother was an alcoholic without evidence. He must have checked her esophagus, looked for varices, and run all kinds of tests. The ER doc gives House the case, dryly noting House's unusually keen interest.

House presents the case to his team, asking them what could have caused the DVT. Foreman isn't much interested, and rattles off a list of possible causes (oral contraceptives, smoking, diabetes, obesity), and suggests heparin to prevent future clots.

House points out that Lucy is twenty years too young for a DVT. Foreman counters that he had a 12-year-old DVT patient once; a soccer player who had been kicked in the leg. House tells the team that there has been no trauma, and Lucy has none of the other risk factors, dropping in the fact that Lucy has schizophrenia, but it is not relevant to the DVT. Cameron expresses surprise that House took a patient's history, but he tells her the information comes from Luke's copious notes.

A bit later, House mentions to Wilson that the DVT may be related to the schizophrenia, since they know so little about it. Wilson notes that House is only interested in Lucy because of her craziness, not her DVT. He announces (loudly) that Galen treated schizophrenics by fumigating the vagina. He finds it interesting that ancient doctors thought voices in the head were caused by malposition of the uterus, and notes that modern treatment of the disase hasn't advanced very much.

House spends a long time talking to Lucy, to Foreman's astonishment. From this, he learns that Lucy hasn't shaved her legs in two months. Her tremors cause her to cut herself, but Lucy has had tremors before, so House thinks Lucy's shaving cuts must have bled a lot more, starting two months ago. He orders clotting studies (PT, PTT, factor V, and proteins C and S) and stops her psych meds.

Foreman tries to draw Lucy's blood, but she becomes agitated and paranoid, and spits in Foreman's face. Several nurses rush in to restrain Lucy, and Foreman orders five milligrams of Haldol.

As Luke sits at Lucy's bedside reading to her, Lucy begins to cough, then vomit large amounts of blood. House rips Foreman for giving Lucy the Haldol, saying the side effects will confuse their diagnosis. Foreman defends himself, and a shouting match ensues. Chase returns with the results of the clotting studies, which are normal except for a prolonged PT time. From this, House thinks Lucy has a vitamin K deficiency, which would explain the clot and the bleeding, because without vitamin K, protein C doesn't work.

Cameron thinks the bleeding may have been caused by ampicillin interacting with the heparin, because Lucy was prescribed ampicillin two months previously for a sore throat. Chase thinks that House's explanation is unlikely, and that all of Lucy's symptoms are due to alcohol abuse and cirrhosis.

House sends the team to check the home for ampicillin and diet, and orders an ultrasound of Lucy's liver to test Chase's theory. Foreman and Chase find the apartment small, but tidy and rigidly organized. Forman finds a strongbox full of Lucy's medications, including trifluoperazine, Thorazine, and Clozaril. He also finds the ampicillin, untouched. Chase heads to the kitchen and finds a nearly empty fridge, and a freezer full of microwave hamburgers.

Luke is distressed when House tells him that the burgers lack vitamin K, which is why Lucy had the DVT.  Luke angrily yanks the strap of his backpack and exclaims in pain from his wrist injury. House suggests he have it looked at. While examining the x-ray, House assures Luke that his wrist isn't broken. He then points to the epiphyseal plate in Luke's arm, telling him that for those who know how, it can be used to determine how old someone is. House makes a fairly accurate estimate of Luke's true age, after which Luke confesses that he has only just turned fifteen the week before.

Chase refuses to believe that Lucy is not an alcoholic, or that Luke is not feeding her "a steady diet of booze." While performing the ultrasound of Lucy's liver, Chase thinks his diagnosis of cirhosis is confirmed, although Cameron points out the liver scarring is minimal. They are both surprised to find a large tumor.

Lucy would not qualify for a transplant, and at 5.8 cm the tumor is too large to remove, according to the surgical guidelines, so House and Wilson decide to shrink the tumor to 4.6 cm by injecting it with ethanol. Lucy's surgery goes well, though the surgeon is furious at the deception. While Chase is explaining to Luke about Lucy's chemotherapy, a social worker from Children's Services arrives to remove Luke. Luke believes House turned him in, but since he knows he did not, he checks the phone records for Lucy's room. He finds only one call had been made, to Social Services.

The epiphany:
The magnitude of Lucy's decision to call Social Services, combined with Lucy's age when she was diagnosed and the ineffectiveness of the psych meds, leads House to believe that Lucy is not schizophrenic. He leafs through Luke's voluminous notes and calls Lucy's previous doctors, which is fruitless, since they don't seem to appreciate being called in the middle of the night and hang up on him.

He drags the Doclings out of bed to brainstorm. He notes that doctors sometimes see patients through the filter of their own specialties, and if Lucy's original diagnosis was wrong, he asks what physical conditions present with psych symptoms. Cameron suggests porphyria, or a genetic tendency to accumulate too much copper, for which Chase recalls the name Wilson's Disease.

Foreman scoffs at the idea, accusing House of wishful thinking. House presents as evidence an appointment that Lucy made with an opthalmologist. He reminds Foreman that Wilson's sometimes causes cataracts, and also cirrhosis. They team wakes Lucy to examine her eye for Keyser-Fleischer rings around her corneas, which they find. Lucy is treated for Wilson's disease and recovers.




Diagnosis
: Wilson's disease


Incidental terms:
dopaminergic pathways

Galen
lobotomy
rubber room
electric shock treatment
Socratic method
Rueben sandwich
scurvy
plague
drain
huffing
crabs

Soap Opera:
House's fasicnation with Lucy gives his team some insight into his mind, though sometimes misinterpreted.  House's team, Foreman in particular, is puzzled as to why House took the case, since a simple DVT is no zebra. Chase believes it is because crazy people are interesting to House, or at least not boring.

Wilson believes House sees people, and their illnesses, merely as puzzles to solve, and that it's Lucy's schizophrenia that makes her interesting to House.

Cameron wishes House a happy birthday, but House is oblivious. She seems unable to believe that someone would forget his own birthday, or sieze upon an "excuse to be happy."

House clashes with Cuddy yet again over medical protocols. Despite ripping into House for shrinking Lucy's tumor, Cuddy urged Bergin to finish the surgery.

Even after the vitamin K deficiency diagnosis is confirmed, Chase remains passionate about his alcohol theory to a degree that leads Forman to ask Chase if he has had close experience with alcoholism. Chase doesn't respond, but when Luke is reunited his mother after her treatment, Chase observes the scene with an air of sadness.

Comments
:


Lucy's favorite poem is "Her Praise" from "The Wild Swans at Coole" by WB Yeats.

Clinic Patients:

Wendy, who does not have strep
Clark, the hiccup man


Everybody Lies:

Luke tells Sally that he is 18, and that Lucy's dependent is a fictional younger brother. He also lies about his age to House.

.
People: 

Luke Palmero
Sally
ER doc
Terri - Wendy's Mom
Dr. Joe Bergin
Dr. Wyland (unseen)
Trina Wyatt
Truant Officer
Dr. Jeffrey Walters
Dr. Karn
Dr. Shopius (unseen)

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