House — Episode 21 (Season 8): “Holding On”

AppId is over the quota
AppId is over the quota

While the soap opera aspect of this penultimate episode of House was outstanding, the actual medicine left much to be desired

Derrick is a 19 year-old cheerleader who was admitted after suffering from dizziness and a massive nosebleed (and dropping his partner). A head CT was normal. Taub suggests a “mini-stroke” (though you’d think a doctor would use the correct term TIA, especially when talking to other physicians), but House tells them it is a midline granuloma and has them check a PET scan. The scan is negative for any cancer, but it does show activity in the auditory area, suggesting that Derrick is hearing to something, though no sounds are present. He denies hearing voices, but the team suspects otherwise. They suggest schizophrenia or drug use. His dorm room is searched, and though his roommate is an active participant in the drug culture, he insists Derrick is clean. A thorough exam of the room finds a picture of a young boy hidden in the back of a drawer. Confronted with this evidence, Derrick explains that the picture is of his long dead brother, and reluctantly admits to hearing his voice for the past ten years.

The differential diagnosis now consists of viral encephalitis (though, as pointed out on the show, an infection of the brain wouldn’t persist for ten years) or temporal lobe epilepsy. The team runs tests on Derrick trying to trigger a seizure, but nothing happens — except that he suffers a sudden blindness in his right eye which Adams diagnoses as a “clot in the artery behind the eye” (i.e. a retinal artery occlusion, and massage is one of the treatments supported by anecdotal evidence) and rubs out of existence. The team debates how many of Derrick’s symptoms are physical, and how many are psychological. Park is a firm believer that years of purposefully avoiding grief over the death of his brother has left Derrick with an anxiety disorder that appears as physical symptoms (though this wouldn’t explain the clot). Taub is more prosaic and believes in a physical cause. He suggests polycythemia vera (blood that is thicker than normal), Hodgkin’s lymphoma, or DIC (disseminated intravascular occlusion) due to some trauma suffered in cheerleading (I can believe this: I see more injuries due to cheerleading than any other high school activity. Basketball is second, and football a distant third.). A spinal tap is obtained. It shows no evidence of bleeding (and therefore, no trauma), but an abnormally high opening pressure (reflecting the intracranial pressure) tells them something else is going on. The suspect a “extreme” migraine as the cause. An MRI is obtained, but shows no evidence of migraine – and then the ceiling collapses due to a prank House pulled on Foreman. Before the collapse, Park noticed that he misidentified her as Adams, and that is enough for House to deduce that Derrick has a persistent stapedial artery. This is a small artery in the fetus that should fade away before birth, but sometimes it remains. In Derrick’s case, this artery has been pressing against his temporal lobe causing dizziness and hallucinations. After surgery to remove the artery, his symptoms should resolve.

Neither House nor Wilson is doing well now that they’ve learned that the chemotherapy didn’t work and the tumor remains. Wilson decides to go without any more chemo, figuring he has five months left to live. House refuses to accept this. He wants Wilson to take the chemotherapy and extend his life another couple of years. He tries a number of tricks on Wilson to get him to agree: he doses him with Propofol (a potent IV general anesthetic – what killed Michael Jackson) to mimic death, he fills a room with former patients, he has a quiet nostalgic dinner with him – but nothing he does convinces Wilson to try chemotherapy. Instead, it drives a wedge between them.

Foreman buys House season tickets to the New Jersey Devils, with seats next to his, in a bid to help House get over Wilson, but House decides to stuff the tickets down the hospital bathroom drain. This leads to a massive water overflow, ultimately collapsing the ceiling over the MRI and requiring the city emergency crew to be brought it (apparently, there is no way to shut the water off at Princeton Plainsboro).

In the end, Wilson decides to go through with the chemo for House’s sake, but House tells him not to, and they’ll just enjoy the time left. They are making plans for the next few months, when the Foreman and the hospital lawyer walk in (but why is the hospital lawyer acting as an accusing officer hear? He should be protecting his doctors, not acting like a DA), telling House his plumbing stunt was severe enough to draw police attention and his parole is being revoked and he must server the remainder – six months – of his sentence.

As usual, with a soap opera heavy show (not that I’m necessarily complaining, just noting), the patient and medicine are given short shrift. Major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

The main issue with this week’s diagnosis is what I call the “have your cake and eat it too” problem — commonly seen on House — but not usually this blatantly. In this case, Derrick has a persistent stapedial artery significant enough to cause a rise in intracranial pressure (leading to clots and bloody noses) and large enough to press against the temporal lobe causing hallucinations – yet, this large artery is not seen on CT or MRI, and the patient has none of the common symptoms such as hearing loss or tinnitus (ringing in the ears). The writers want to have it both ways — bad enough to cause extreme symptoms, but yet small enough to be missed by every exam until the last minute.

TA midline granuloma would have been seen on CT.

I see little evidence (really noevidence) in the literature of a migraine, even an extreme migraine, causing an elevated intracranial pressure. Now, an elevated ICP can cause a headache, sometimes even a migraine, but that’s the opposite of what’s suggested here.

I notice they make no effort to actually lower the elevated ICP – other than the initial spinal tap.

How did misidentifying Park as Adams lead House to the final diagnosis?

Here’s one I have no answer to, and so I’m not really calling it an error; I’m just wondering. Would an auditory hallucination light up the same areas of the brain as actually hearing something would, or would it light up different areas?

The medical mystery would be boring for any medical show, but was particularly pedestrian for House. It earns a meager D. The final solution made a little sense, but not much when you consider the so big to cause major symptoms, yet too small to be noticed paradox. I give it another D. The medicine overall was just OK. Not horrible, but not particularly brilliant. I give it a C. Once again, the soap opera was quite good. Both Laurie and Leonard deserve kudos for their scenes. I give it an A.

The review of the previous episode of House
A list of all prior House reviews

View the original article here

Read More

House — Episode 21 (Season 8): “Holding On”

AppId is over the quota
AppId is over the quota

While the soap opera aspect of this penultimate episode of House was outstanding, the actual medicine left much to be desired

Derrick is a 19 year-old cheerleader who was admitted after suffering from dizziness and a massive nosebleed (and dropping his partner). A head CT was normal. Taub suggests a “mini-stroke” (though you’d think a doctor would use the correct term TIA, especially when talking to other physicians), but House tells them it is a midline granuloma and has them check a PET scan. The scan is negative for any cancer, but it does show activity in the auditory area, suggesting that Derrick is hearing to something, though no sounds are present. He denies hearing voices, but the team suspects otherwise. They suggest schizophrenia or drug use. His dorm room is searched, and though his roommate is an active participant in the drug culture, he insists Derrick is clean. A thorough exam of the room finds a picture of a young boy hidden in the back of a drawer. Confronted with this evidence, Derrick explains that the picture is of his long dead brother, and reluctantly admits to hearing his voice for the past ten years.

The differential diagnosis now consists of viral encephalitis (though, as pointed out on the show, an infection of the brain wouldn’t persist for ten years) or temporal lobe epilepsy. The team runs tests on Derrick trying to trigger a seizure, but nothing happens — except that he suffers a sudden blindness in his right eye which Adams diagnoses as a “clot in the artery behind the eye” (i.e. a retinal artery occlusion, and massage is one of the treatments supported by anecdotal evidence) and rubs out of existence. The team debates how many of Derrick’s symptoms are physical, and how many are psychological. Park is a firm believer that years of purposefully avoiding grief over the death of his brother has left Derrick with an anxiety disorder that appears as physical symptoms (though this wouldn’t explain the clot). Taub is more prosaic and believes in a physical cause. He suggests polycythemia vera (blood that is thicker than normal), Hodgkin’s lymphoma, or DIC (disseminated intravascular occlusion) due to some trauma suffered in cheerleading (I can believe this: I see more injuries due to cheerleading than any other high school activity. Basketball is second, and football a distant third.). A spinal tap is obtained. It shows no evidence of bleeding (and therefore, no trauma), but an abnormally high opening pressure (reflecting the intracranial pressure) tells them something else is going on. The suspect a “extreme” migraine as the cause. An MRI is obtained, but shows no evidence of migraine – and then the ceiling collapses due to a prank House pulled on Foreman. Before the collapse, Park noticed that he misidentified her as Adams, and that is enough for House to deduce that Derrick has a persistent stapedial artery. This is a small artery in the fetus that should fade away before birth, but sometimes it remains. In Derrick’s case, this artery has been pressing against his temporal lobe causing dizziness and hallucinations. After surgery to remove the artery, his symptoms should resolve.

Neither House nor Wilson is doing well now that they’ve learned that the chemotherapy didn’t work and the tumor remains. Wilson decides to go without any more chemo, figuring he has five months left to live. House refuses to accept this. He wants Wilson to take the chemotherapy and extend his life another couple of years. He tries a number of tricks on Wilson to get him to agree: he doses him with Propofol (a potent IV general anesthetic – what killed Michael Jackson) to mimic death, he fills a room with former patients, he has a quiet nostalgic dinner with him – but nothing he does convinces Wilson to try chemotherapy. Instead, it drives a wedge between them.

Foreman buys House season tickets to the New Jersey Devils, with seats next to his, in a bid to help House get over Wilson, but House decides to stuff the tickets down the hospital bathroom drain. This leads to a massive water overflow, ultimately collapsing the ceiling over the MRI and requiring the city emergency crew to be brought it (apparently, there is no way to shut the water off at Princeton Plainsboro).

In the end, Wilson decides to go through with the chemo for House’s sake, but House tells him not to, and they’ll just enjoy the time left. They are making plans for the next few months, when the Foreman and the hospital lawyer walk in (but why is the hospital lawyer acting as an accusing officer hear? He should be protecting his doctors, not acting like a DA), telling House his plumbing stunt was severe enough to draw police attention and his parole is being revoked and he must server the remainder – six months – of his sentence.

As usual, with a soap opera heavy show (not that I’m necessarily complaining, just noting), the patient and medicine are given short shrift. Major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

The main issue with this week’s diagnosis is what I call the “have your cake and eat it too” problem — commonly seen on House — but not usually this blatantly. In this case, Derrick has a persistent stapedial artery significant enough to cause a rise in intracranial pressure (leading to clots and bloody noses) and large enough to press against the temporal lobe causing hallucinations – yet, this large artery is not seen on CT or MRI, and the patient has none of the common symptoms such as hearing loss or tinnitus (ringing in the ears). The writers want to have it both ways — bad enough to cause extreme symptoms, but yet small enough to be missed by every exam until the last minute.

TA midline granuloma would have been seen on CT.

I see little evidence (really noevidence) in the literature of a migraine, even an extreme migraine, causing an elevated intracranial pressure. Now, an elevated ICP can cause a headache, sometimes even a migraine, but that’s the opposite of what’s suggested here.

I notice they make no effort to actually lower the elevated ICP – other than the initial spinal tap.

How did misidentifying Park as Adams lead House to the final diagnosis?

Here’s one I have no answer to, and so I’m not really calling it an error; I’m just wondering. Would an auditory hallucination light up the same areas of the brain as actually hearing something would, or would it light up different areas?

The medical mystery would be boring for any medical show, but was particularly pedestrian for House. It earns a meager D. The final solution made a little sense, but not much when you consider the so big to cause major symptoms, yet too small to be noticed paradox. I give it another D. The medicine overall was just OK. Not horrible, but not particularly brilliant. I give it a C. Once again, the soap opera was quite good. Both Laurie and Leonard deserve kudos for their scenes. I give it an A.

The review of the previous episode of House
A list of all prior House reviews

View the original article here

Read More

House — Episode 21 (Season 8): “Holding On”

AppId is over the quota
AppId is over the quota

While the soap opera aspect of this penultimate episode of House was outstanding, the actual medicine left much to be desired

Derrick is a 19 year-old cheerleader who was admitted after suffering from dizziness and a massive nosebleed (and dropping his partner). A head CT was normal. Taub suggests a “mini-stroke” (though you’d think a doctor would use the correct term TIA, especially when talking to other physicians), but House tells them it is a midline granuloma and has them check a PET scan. The scan is negative for any cancer, but it does show activity in the auditory area, suggesting that Derrick is hearing to something, though no sounds are present. He denies hearing voices, but the team suspects otherwise. They suggest schizophrenia or drug use. His dorm room is searched, and though his roommate is an active participant in the drug culture, he insists Derrick is clean. A thorough exam of the room finds a picture of a young boy hidden in the back of a drawer. Confronted with this evidence, Derrick explains that the picture is of his long dead brother, and reluctantly admits to hearing his voice for the past ten years.

The differential diagnosis now consists of viral encephalitis (though, as pointed out on the show, an infection of the brain wouldn’t persist for ten years) or temporal lobe epilepsy. The team runs tests on Derrick trying to trigger a seizure, but nothing happens — except that he suffers a sudden blindness in his right eye which Adams diagnoses as a “clot in the artery behind the eye” (i.e. a retinal artery occlusion, and massage is one of the treatments supported by anecdotal evidence) and rubs out of existence. The team debates how many of Derrick’s symptoms are physical, and how many are psychological. Park is a firm believer that years of purposefully avoiding grief over the death of his brother has left Derrick with an anxiety disorder that appears as physical symptoms (though this wouldn’t explain the clot). Taub is more prosaic and believes in a physical cause. He suggests polycythemia vera (blood that is thicker than normal), Hodgkin’s lymphoma, or DIC (disseminated intravascular occlusion) due to some trauma suffered in cheerleading (I can believe this: I see more injuries due to cheerleading than any other high school activity. Basketball is second, and football a distant third.). A spinal tap is obtained. It shows no evidence of bleeding (and therefore, no trauma), but an abnormally high opening pressure (reflecting the intracranial pressure) tells them something else is going on. The suspect a “extreme” migraine as the cause. An MRI is obtained, but shows no evidence of migraine – and then the ceiling collapses due to a prank House pulled on Foreman. Before the collapse, Park noticed that he misidentified her as Adams, and that is enough for House to deduce that Derrick has a persistent stapedial artery. This is a small artery in the fetus that should fade away before birth, but sometimes it remains. In Derrick’s case, this artery has been pressing against his temporal lobe causing dizziness and hallucinations. After surgery to remove the artery, his symptoms should resolve.

Neither House nor Wilson is doing well now that they’ve learned that the chemotherapy didn’t work and the tumor remains. Wilson decides to go without any more chemo, figuring he has five months left to live. House refuses to accept this. He wants Wilson to take the chemotherapy and extend his life another couple of years. He tries a number of tricks on Wilson to get him to agree: he doses him with Propofol (a potent IV general anesthetic – what killed Michael Jackson) to mimic death, he fills a room with former patients, he has a quiet nostalgic dinner with him – but nothing he does convinces Wilson to try chemotherapy. Instead, it drives a wedge between them.

Foreman buys House season tickets to the New Jersey Devils, with seats next to his, in a bid to help House get over Wilson, but House decides to stuff the tickets down the hospital bathroom drain. This leads to a massive water overflow, ultimately collapsing the ceiling over the MRI and requiring the city emergency crew to be brought it (apparently, there is no way to shut the water off at Princeton Plainsboro).

In the end, Wilson decides to go through with the chemo for House’s sake, but House tells him not to, and they’ll just enjoy the time left. They are making plans for the next few months, when the Foreman and the hospital lawyer walk in (but why is the hospital lawyer acting as an accusing officer hear? He should be protecting his doctors, not acting like a DA), telling House his plumbing stunt was severe enough to draw police attention and his parole is being revoked and he must server the remainder – six months – of his sentence.

As usual, with a soap opera heavy show (not that I’m necessarily complaining, just noting), the patient and medicine are given short shrift. Major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

The main issue with this week’s diagnosis is what I call the “have your cake and eat it too” problem — commonly seen on House — but not usually this blatantly. In this case, Derrick has a persistent stapedial artery significant enough to cause a rise in intracranial pressure (leading to clots and bloody noses) and large enough to press against the temporal lobe causing hallucinations – yet, this large artery is not seen on CT or MRI, and the patient has none of the common symptoms such as hearing loss or tinnitus (ringing in the ears). The writers want to have it both ways — bad enough to cause extreme symptoms, but yet small enough to be missed by every exam until the last minute.

TA midline granuloma would have been seen on CT.

I see little evidence (really noevidence) in the literature of a migraine, even an extreme migraine, causing an elevated intracranial pressure. Now, an elevated ICP can cause a headache, sometimes even a migraine, but that’s the opposite of what’s suggested here.

I notice they make no effort to actually lower the elevated ICP – other than the initial spinal tap.

How did misidentifying Park as Adams lead House to the final diagnosis?

Here’s one I have no answer to, and so I’m not really calling it an error; I’m just wondering. Would an auditory hallucination light up the same areas of the brain as actually hearing something would, or would it light up different areas?

The medical mystery would be boring for any medical show, but was particularly pedestrian for House. It earns a meager D. The final solution made a little sense, but not much when you consider the so big to cause major symptoms, yet too small to be noticed paradox. I give it another D. The medicine overall was just OK. Not horrible, but not particularly brilliant. I give it a C. Once again, the soap opera was quite good. Both Laurie and Leonard deserve kudos for their scenes. I give it an A.

The review of the previous episode of House
A list of all prior House reviews

View the original article here

Read More

Monday PSA: The Flushing Remonstrance

AppId is over the quota
AppId is over the quota
Filed under: Comics

What seems at first to be a rather dry “history lecture” public service ad is actually a subtly pointed affirmation of the Freedom of Religion — a lesson that could bear repeating today.

Click on the image for the full ad

The PSA presents a fairly abridged version of the Flushing Remonstrance, but then it is only a five panel PSA intended for 8 to 12 year old boys.
Wikipedia has a nice summation of the Remonstrance.
The full text of the Flushing Remonstrance

Since this PSA was published just the one time, and because it is more political than most, I wonder what was going on in the country in 1957 that prompted Schiff to write it?

Remonstrance is a fun word to say; flushing is too.

This PSA can be found in DC comics from February, 1958. The script was by Jack Schiff, with the art by Bob Brown.

More PSAs

View the original article here

Read More

Monday PSA: The Flushing Remonstrance

AppId is over the quota
AppId is over the quota
Filed under: Comics

What seems at first to be a rather dry “history lecture” public service ad is actually a subtly pointed affirmation of the Freedom of Religion — a lesson that could bear repeating today.

Click on the image for the full ad

The PSA presents a fairly abridged version of the Flushing Remonstrance, but then it is only a five panel PSA intended for 8 to 12 year old boys.
Wikipedia has a nice summation of the Remonstrance.
The full text of the Flushing Remonstrance

Since this PSA was published just the one time, and because it is more political than most, I wonder what was going on in the country in 1957 that prompted Schiff to write it?

Remonstrance is a fun word to say; flushing is too.

This PSA can be found in DC comics from February, 1958. The script was by Jack Schiff, with the art by Bob Brown.

More PSAs

View the original article here

Read More

Monday PSA: The Flushing Remonstrance

AppId is over the quota
AppId is over the quota
Filed under: Comics

What seems at first to be a rather dry “history lecture” public service ad is actually a subtly pointed affirmation of the Freedom of Religion — a lesson that could bear repeating today.

Click on the image for the full ad

The PSA presents a fairly abridged version of the Flushing Remonstrance, but then it is only a five panel PSA intended for 8 to 12 year old boys.
Wikipedia has a nice summation of the Remonstrance.
The full text of the Flushing Remonstrance

Since this PSA was published just the one time, and because it is more political than most, I wonder what was going on in the country in 1957 that prompted Schiff to write it?

Remonstrance is a fun word to say; flushing is too.

This PSA can be found in DC comics from February, 1958. The script was by Jack Schiff, with the art by Bob Brown.

More PSAs

View the original article here

Read More

House — Episode 20 (Season 8): “Post Mortem”

AppId is over the quota
AppId is over the quota

Another episode with the team being mostly on their own while House and Wilson do their own thing. Not a bad episode, overall.

Dr. Treiber is the hospital’s outspoken pathologist. In the middle of an autopsy, he suddenly decides to cut his own scalp open with a scalpel and complains of being cold. He is admitted to House’s service — but House quickly runs off on a buddy trip with Wilson, so the team is left to solve the case on their own. Before he leaves, House suggests Treiber may be suffering from the Cotard delusion (a mental disorder where people believe they are dead — therefore House thinks Treiber was trying to perform an autopsy on himself), but the history doesn’t fit well. Other suggestions include liver failure due to hepatitis C, toxin exposure in the morgue (in particular, dimethyl sulfate), or blood clots. An ultrasound is obtained but shows no clots, and an examination of the lab turns up no toxins, but does reveal that Dr. Treiber is a big fan of energy drinks, the team now suspects he is suffering from stimulant psychosis, due to all the caffeine he consumes.

Treiber soon develops abdominal pain and distention, meaning that something else besides stimulant psychosis is going on. Adams still suspects the caffeine is behind most of his symptoms, except the abdominal ones, which she believes are caused by a bowel obstruction. Other thoughts are diabetes or ulcerative colitis (a type of inflammatory bowel disease). Chase finally suspects an intussusception (a collapsing of the bowel in on itself) due to cancer. They obtain an x-ray which is normal, but Treiber wants Chase to go ahead and check the small bowel surgically for the intussusception. Chase agrees to perform the surgery, but no abnormalities are found.

The team now decides that Treiber must have intermittent porphyria (an inherited metabolic disorder) and starts him on hemin (a treatment for acute intermittent porphyria). Despite the treatment, Treiber continues to decline and develops bilateral pleural effusions (fluid build up around the lungs). At this point, Treiber finally learns that House is nowhere to be found, and Foreman is brought on to the case. He immediately suspects a cardiac cause (not unreasonable, given the pleural effusions) and obtains a cardiac MRI which shows an enlarged left ventricle. Foreman takes this to mean that Treiber has an infiltrative disease of the heart (an accumulation of some substance in the heart muscle that is not supposed to be there), probably sarcoidosis, and wants a heart biopsy. Chase suspects a prion disease (a neurological disease spread by infected proteins) and wants a brain biopsy; he also wants to start him on amphotericin to treat the suspected prion disease. Unfortunately, only one biopsy can be performed and Foreman elects to go with the heart biopsy. Chase heads down to the morgue to find the source of his suspected prion disease The cardiac biopsy shows fibrosis, not infiltration, meaning Foreman was wrong about sarcoid, but Chase was also wrong about a prion cause (because no prion disease causes fibrosis in the heart). Foreman now suspects a viral infection (like a viral cardiomyopathy) and obtains cultures and starts antivirals, but Chase remains in the morgue, convinced the answer is down there. Overnight, Treiber falls into a coma, making Foreman and the rest of the team rethink their diagnosis. They come to the morgue to talk to Chase who has reluctantly decided that Treiber is too fastidious to have caught a disease in the morgue – but then he realizes it is that fastidiousness – or more specifically, the antibacterial soap he repeatedly uses – that is the source of the problem. The repeated exposure to Triclosan (an antibacterial in soap), plus a high dose of caffeine from the energy drinks, caused Treiber’s thyroid to shut down and Treiber ended up in a myxedema coma (a severe form of hypothyroidism).

As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

While triclosan has been implicated in thyroid problems in bullfrogs and mice, human studies haven’t shown this effect (admittedly it was a limited study looking at triclosan in toothpaste).
Similarly, there haven’t been any studies linking high caffeine intake and hypothyroidism in humans (there is a study showing caffeine can interfere with absorption of thyroid medication, but that’s a different situation).

No one thought to check thyroid studies for an unexplained coma?

Studies have suggested that amphotericin may play a role in treating certain prion dieases, but it’s never been tested in humans.

They can’t perform both biopsies because of the amphotericin Chase wants to use because it might theoretically limit the possible prion disease the patient might have. Problem easily solved. Hold the ampho (it’s never been tested in humans for this anyway) then you can perform both biopsies.

That was simply a horrible code, but then, I think it was supposed to be one because it was supposed to be a bad doctor. Just for starters: only two people involved (not counting the patient), and one is just idly looking at IV bags. Shocking a flatline. No airway.

A small amount DMSO applied to the knees got converted to a toxic amount of dimethyl sulfate via several brief shocks to the chest?

Did no one think to ask Treiber why he was cutting his own scalp? The answer would likely have been revealing.
Despite the hypothyroidism/myxedema coma worsening, his mental status was fine in his hospital stay, despite it being his presenting complaint.

Here’s what I could get off of Chase’s whiteboard (or whiteboards) — hopefully someone got a better screenshot. In no particular order: Neimann-Pick disease, Japanese encephalitis, Creutzfeldt-Jakob disease, Q fever, impetigo (really?), typhoid, schistosomiasis, leptospirosis, gastroenteritis, neurofibromatosis, fatal familial insomnia, Tay-Sachs disease, cronobacter, syphilis, kuru, lyme, aortic aneurysm, shigelloisis, malaria, HIV, Klinefelter syndrome, yellow fever, cryptosporidiosis, dengue, German-Straussler-Scheinker syndrome, hypoglycemia.

The medical mystery was interesting, if less so once the patient was admitted. I give it a B+. The final solution made a modest amount of sense, if you accept the fact that the condition has never been seen in humans — that’s a few point off, in my book. I give it a C-. The medicine overall was thorough — on Chase’s end, at least — but missed some obvious possibilities, with myxedema coma topping that list, and easily testable. I give it a weak B. I thought the soap opera was good. The House/Wilson last fling was somewhat cliché, but Chase’s dilemma was well done. I give it an A-.

The review of the previous episode of House
A list of all prior House reviews

View the original article here

Read More

House — Episode 20 (Season 8): “Post Mortem”

AppId is over the quota
AppId is over the quota

Another episode with the team being mostly on their own while House and Wilson do their own thing. Not a bad episode, overall.

Dr. Treiber is the hospital’s outspoken pathologist. In the middle of an autopsy, he suddenly decides to cut his own scalp open with a scalpel and complains of being cold. He is admitted to House’s service — but House quickly runs off on a buddy trip with Wilson, so the team is left to solve the case on their own. Before he leaves, House suggests Treiber may be suffering from the Cotard delusion (a mental disorder where people believe they are dead — therefore House thinks Treiber was trying to perform an autopsy on himself), but the history doesn’t fit well. Other suggestions include liver failure due to hepatitis C, toxin exposure in the morgue (in particular, dimethyl sulfate), or blood clots. An ultrasound is obtained but shows no clots, and an examination of the lab turns up no toxins, but does reveal that Dr. Treiber is a big fan of energy drinks, the team now suspects he is suffering from stimulant psychosis, due to all the caffeine he consumes.

Treiber soon develops abdominal pain and distention, meaning that something else besides stimulant psychosis is going on. Adams still suspects the caffeine is behind most of his symptoms, except the abdominal ones, which she believes are caused by a bowel obstruction. Other thoughts are diabetes or ulcerative colitis (a type of inflammatory bowel disease). Chase finally suspects an intussusception (a collapsing of the bowel in on itself) due to cancer. They obtain an x-ray which is normal, but Treiber wants Chase to go ahead and check the small bowel surgically for the intussusception. Chase agrees to perform the surgery, but no abnormalities are found.

The team now decides that Treiber must have intermittent porphyria (an inherited metabolic disorder) and starts him on hemin (a treatment for acute intermittent porphyria). Despite the treatment, Treiber continues to decline and develops bilateral pleural effusions (fluid build up around the lungs). At this point, Treiber finally learns that House is nowhere to be found, and Foreman is brought on to the case. He immediately suspects a cardiac cause (not unreasonable, given the pleural effusions) and obtains a cardiac MRI which shows an enlarged left ventricle. Foreman takes this to mean that Treiber has an infiltrative disease of the heart (an accumulation of some substance in the heart muscle that is not supposed to be there), probably sarcoidosis, and wants a heart biopsy. Chase suspects a prion disease (a neurological disease spread by infected proteins) and wants a brain biopsy; he also wants to start him on amphotericin to treat the suspected prion disease. Unfortunately, only one biopsy can be performed and Foreman elects to go with the heart biopsy. Chase heads down to the morgue to find the source of his suspected prion disease The cardiac biopsy shows fibrosis, not infiltration, meaning Foreman was wrong about sarcoid, but Chase was also wrong about a prion cause (because no prion disease causes fibrosis in the heart). Foreman now suspects a viral infection (like a viral cardiomyopathy) and obtains cultures and starts antivirals, but Chase remains in the morgue, convinced the answer is down there. Overnight, Treiber falls into a coma, making Foreman and the rest of the team rethink their diagnosis. They come to the morgue to talk to Chase who has reluctantly decided that Treiber is too fastidious to have caught a disease in the morgue – but then he realizes it is that fastidiousness – or more specifically, the antibacterial soap he repeatedly uses – that is the source of the problem. The repeated exposure to Triclosan (an antibacterial in soap), plus a high dose of caffeine from the energy drinks, caused Treiber’s thyroid to shut down and Treiber ended up in a myxedema coma (a severe form of hypothyroidism).

As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

While triclosan has been implicated in thyroid problems in bullfrogs and mice, human studies haven’t shown this effect (admittedly it was a limited study looking at triclosan in toothpaste).
Similarly, there haven’t been any studies linking high caffeine intake and hypothyroidism in humans (there is a study showing caffeine can interfere with absorption of thyroid medication, but that’s a different situation).

No one thought to check thyroid studies for an unexplained coma?

Studies have suggested that amphotericin may play a role in treating certain prion dieases, but it’s never been tested in humans.

They can’t perform both biopsies because of the amphotericin Chase wants to use because it might theoretically limit the possible prion disease the patient might have. Problem easily solved. Hold the ampho (it’s never been tested in humans for this anyway) then you can perform both biopsies.

That was simply a horrible code, but then, I think it was supposed to be one because it was supposed to be a bad doctor. Just for starters: only two people involved (not counting the patient), and one is just idly looking at IV bags. Shocking a flatline. No airway.

A small amount DMSO applied to the knees got converted to a toxic amount of dimethyl sulfate via several brief shocks to the chest?

Did no one think to ask Treiber why he was cutting his own scalp? The answer would likely have been revealing.
Despite the hypothyroidism/myxedema coma worsening, his mental status was fine in his hospital stay, despite it being his presenting complaint.

Here’s what I could get off of Chase’s whiteboard (or whiteboards) — hopefully someone got a better screenshot. In no particular order: Neimann-Pick disease, Japanese encephalitis, Creutzfeldt-Jakob disease, Q fever, impetigo (really?), typhoid, schistosomiasis, leptospirosis, gastroenteritis, neurofibromatosis, fatal familial insomnia, Tay-Sachs disease, cronobacter, syphilis, kuru, lyme, aortic aneurysm, shigelloisis, malaria, HIV, Klinefelter syndrome, yellow fever, cryptosporidiosis, dengue, German-Straussler-Scheinker syndrome, hypoglycemia.

The medical mystery was interesting, if less so once the patient was admitted. I give it a B+. The final solution made a modest amount of sense, if you accept the fact that the condition has never been seen in humans — that’s a few point off, in my book. I give it a C-. The medicine overall was thorough — on Chase’s end, at least — but missed some obvious possibilities, with myxedema coma topping that list, and easily testable. I give it a weak B. I thought the soap opera was good. The House/Wilson last fling was somewhat cliché, but Chase’s dilemma was well done. I give it an A-.

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House — Episode 20 (Season 8): “Post Mortem”

AppId is over the quota
AppId is over the quota

Another episode with the team being mostly on their own while House and Wilson do their own thing. Not a bad episode, overall.

Dr. Treiber is the hospital’s outspoken pathologist. In the middle of an autopsy, he suddenly decides to cut his own scalp open with a scalpel and complains of being cold. He is admitted to House’s service — but House quickly runs off on a buddy trip with Wilson, so the team is left to solve the case on their own. Before he leaves, House suggests Treiber may be suffering from the Cotard delusion (a mental disorder where people believe they are dead — therefore House thinks Treiber was trying to perform an autopsy on himself), but the history doesn’t fit well. Other suggestions include liver failure due to hepatitis C, toxin exposure in the morgue (in particular, dimethyl sulfate), or blood clots. An ultrasound is obtained but shows no clots, and an examination of the lab turns up no toxins, but does reveal that Dr. Treiber is a big fan of energy drinks, the team now suspects he is suffering from stimulant psychosis, due to all the caffeine he consumes.

Treiber soon develops abdominal pain and distention, meaning that something else besides stimulant psychosis is going on. Adams still suspects the caffeine is behind most of his symptoms, except the abdominal ones, which she believes are caused by a bowel obstruction. Other thoughts are diabetes or ulcerative colitis (a type of inflammatory bowel disease). Chase finally suspects an intussusception (a collapsing of the bowel in on itself) due to cancer. They obtain an x-ray which is normal, but Treiber wants Chase to go ahead and check the small bowel surgically for the intussusception. Chase agrees to perform the surgery, but no abnormalities are found.

The team now decides that Treiber must have intermittent porphyria (an inherited metabolic disorder) and starts him on hemin (a treatment for acute intermittent porphyria). Despite the treatment, Treiber continues to decline and develops bilateral pleural effusions (fluid build up around the lungs). At this point, Treiber finally learns that House is nowhere to be found, and Foreman is brought on to the case. He immediately suspects a cardiac cause (not unreasonable, given the pleural effusions) and obtains a cardiac MRI which shows an enlarged left ventricle. Foreman takes this to mean that Treiber has an infiltrative disease of the heart (an accumulation of some substance in the heart muscle that is not supposed to be there), probably sarcoidosis, and wants a heart biopsy. Chase suspects a prion disease (a neurological disease spread by infected proteins) and wants a brain biopsy; he also wants to start him on amphotericin to treat the suspected prion disease. Unfortunately, only one biopsy can be performed and Foreman elects to go with the heart biopsy. Chase heads down to the morgue to find the source of his suspected prion disease The cardiac biopsy shows fibrosis, not infiltration, meaning Foreman was wrong about sarcoid, but Chase was also wrong about a prion cause (because no prion disease causes fibrosis in the heart). Foreman now suspects a viral infection (like a viral cardiomyopathy) and obtains cultures and starts antivirals, but Chase remains in the morgue, convinced the answer is down there. Overnight, Treiber falls into a coma, making Foreman and the rest of the team rethink their diagnosis. They come to the morgue to talk to Chase who has reluctantly decided that Treiber is too fastidious to have caught a disease in the morgue – but then he realizes it is that fastidiousness – or more specifically, the antibacterial soap he repeatedly uses – that is the source of the problem. The repeated exposure to Triclosan (an antibacterial in soap), plus a high dose of caffeine from the energy drinks, caused Treiber’s thyroid to shut down and Treiber ended up in a myxedema coma (a severe form of hypothyroidism).

As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

While triclosan has been implicated in thyroid problems in bullfrogs and mice, human studies haven’t shown this effect (admittedly it was a limited study looking at triclosan in toothpaste).
Similarly, there haven’t been any studies linking high caffeine intake and hypothyroidism in humans (there is a study showing caffeine can interfere with absorption of thyroid medication, but that’s a different situation).

No one thought to check thyroid studies for an unexplained coma?

Studies have suggested that amphotericin may play a role in treating certain prion dieases, but it’s never been tested in humans.

They can’t perform both biopsies because of the amphotericin Chase wants to use because it might theoretically limit the possible prion disease the patient might have. Problem easily solved. Hold the ampho (it’s never been tested in humans for this anyway) then you can perform both biopsies.

That was simply a horrible code, but then, I think it was supposed to be one because it was supposed to be a bad doctor. Just for starters: only two people involved (not counting the patient), and one is just idly looking at IV bags. Shocking a flatline. No airway.

A small amount DMSO applied to the knees got converted to a toxic amount of dimethyl sulfate via several brief shocks to the chest?

Did no one think to ask Treiber why he was cutting his own scalp? The answer would likely have been revealing.
Despite the hypothyroidism/myxedema coma worsening, his mental status was fine in his hospital stay, despite it being his presenting complaint.

Here’s what I could get off of Chase’s whiteboard (or whiteboards) — hopefully someone got a better screenshot. In no particular order: Neimann-Pick disease, Japanese encephalitis, Creutzfeldt-Jakob disease, Q fever, impetigo (really?), typhoid, schistosomiasis, leptospirosis, gastroenteritis, neurofibromatosis, fatal familial insomnia, Tay-Sachs disease, cronobacter, syphilis, kuru, lyme, aortic aneurysm, shigelloisis, malaria, HIV, Klinefelter syndrome, yellow fever, cryptosporidiosis, dengue, German-Straussler-Scheinker syndrome, hypoglycemia.

The medical mystery was interesting, if less so once the patient was admitted. I give it a B+. The final solution made a modest amount of sense, if you accept the fact that the condition has never been seen in humans — that’s a few point off, in my book. I give it a C-. The medicine overall was thorough — on Chase’s end, at least — but missed some obvious possibilities, with myxedema coma topping that list, and easily testable. I give it a weak B. I thought the soap opera was good. The House/Wilson last fling was somewhat cliché, but Chase’s dilemma was well done. I give it an A-.

The review of the previous episode of House
A list of all prior House reviews

View the original article here

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