House - Episode 11 (Season 2)
This medical review of House contains spoilers galore, so don’t say I didn’t warn you…
Margo Dalton is a driven woman. She is an involved mother, a career woman, and a charity organizer. She is taking fertility treatments so that she can have a child with her second husband. Suddenly one day, she develops a sudden movement disorder: uncontrollable twitches and spasms of her muscles, mostly in her limbs, but also involving her face. She is brought to the hospital for evaluation. Cameron suspects it is due to increased estrogen from her (unnamed) fertility treatments. Foreman thinks it is Huntington’s Disease (also known as Huntington’s Chorea, a particularly nasty inherited condition leading to movement disorders and dementia), while House suspects it may be a side effect of pregnancy.
The pregnancy test is negative and an MRI is obtained which shows no brain injury. While her young daughter is visiting, Margo becomes suddenly very irritable and has a full psychotic episode a short time later, suffering violent paranoid delusions.
The genetic test for Huntington’s comes back negative, and House is wondering about Margo’s “spontaneous schizophrenia.” Toxins are considered as a possible cause, as are drugs. A search of her car turns up a bottle of Ritalin which she reluctantly admits to taking. House believes the problem to be solved, so Margo is discharged from the hospital but has a stroke on the way out. Ultrasounds are obtained of the heart, arms, and legs to look for a source of the clot that caused the stroke, but all the tests are normal (but notice that no ultrasound was obtained of the carotid arteries, a frequent source of stroke-causing clots). The team now becomes concerned that Margo has a uterine cancer that led to her stroke (cancers cause the blood to clot easier, which makes clots and strokes more likely). A uterine ultrasound is normal, but House wants an endometrial biopsy performed. Before the procedure even begins, Margo begins bleeding uncontrollably and is discovered to have a vascular tumor in her liver. House determines that Margo has secretly been taking birth control pills so she won’t become pregnant despite being on fertility treatments; she doesn’t want to tell her her husband she doesn’t want another child. These birth control pills have led to her stroke and liver tumor. In the end, rather than admit the truth to her husband, Margo elects to have the tumor removed surgically.
This was another episode where the writers violated Occam’s Razor, a rule they emphasized in the first season (in fact, one of the first episodes was named Occam’s Razor). Put simply, Occam’s Razor suggests that the simplest solution is generally the right one; if a patient has multiple symptoms, the diagnosis that explains them all is most likely correct. This is the second episode this season where three separate diagnoses were required to explain the patient’s symptoms, about as far from Occam as you can get. The sad thing is that in this case the third diagnosis was completely unnecessary. Any treatment that raises the estrogen high enough to cause movement disorders is also going to place the patient at risk for blood clots and liver disease. The fertility medication could have explained the movement disorder, stroke, and liver tumor. In fact, now that I’ve taken a moment to look it up, psychosis has also been associated with fertility treatment, so that alone could explain all of Margo’s symptoms. (Yes, I know the Ritalin and birth control pills were required to show how driven Margo is and how she keeps secrets from her husband, but from a medical mystery point of view, both were redundant).
Annoyances:
- Ritalin is a controlled substance. You don’t get “three refills in three weeks” without somebody noticing.
- Treatment with Clomid (which I’m assuming is the unnamed fertility treatment, as it fits the description the best) is recommended for no more than six months, not thirteen months.
- The OR scene annoyed me as well. Chase is handed the tumor, looks at it under the microscope, and determined that it is not malignant. First, where was his sterile technique? The microscope wasn’t sterile yet his hands were all over it. If he didn’t need to be sterile (and he probably didn’t), then why was he scrubbed in? A specimen also needs to be specially treated before it can be examined for cancer (usually rinsed with a special stain and sliced less-than-paper-thin with a special machine). You just don’t plunk it down and take a gander at it.
The soap opera was hot and heavy this week. House and Stacey both seemed to have enjoyed their flirtation and kiss in Baltimore and end up in bed this episode. Stacey is ready to leave her husband for House, but in the end House calls it off. He says he’s stopping the affair because it won’t work and her husband is better for her than House, but Wilson suspects that House just likes to be miserable. A second soap opera plot involved Cameron’s HIV test (after she was exposed to infected blood in a previous episode). The test was negative, but House put her through hell to find out.
This episode earns an A for the mystery, but only a C for the solution because too much logic was sacrificed for story, resulting in a B for the medicine overall. The soap opera aspect earns an A-.
February 10th, 2006 at 1:47 pm
This is not related to House, but to comics instead. I was wondering if you ever read Steven Seagle’s DC/Vertigo graphic novel, “It’s a Bird…”? In it, the main character, Steven, is worried that he may have Huntington’s Disease (aha, the reason for this seemingly unrelated comment). The medicine wasn’t too involved (working from memory here), but there were some basics about Huntington’s. Just thought I’d put it on your radar.
EM
P.S. Great blog.
February 10th, 2006 at 5:01 pm
-Chase is handed the tumor, looks at it under the microscope, and determined that it is not malignant.
Maybe he has magival powers? Seriously though, in my Physics class one of the questions was about heat transfer and why it goes a certain way and one of the answers was ‘Magic!’. Now the teacher refers to use as his ‘magical pixie dust class’. Seems like a similiar thing helps House and his ducklings around.
Sorry, I couldn’t resist saying that. I may not be a medical expert, but that’s one of the sorts of mistakes on House that bug me.
February 12th, 2006 at 11:31 pm
The minute they said “three refills in three weeks” I howled at the screen. NO, you can’t get three scrips of Ritalin (or Adderall, which is what I used to take) in three weeks. I had a dickens of a time getting a replacement prescription when I accidently dropped a weeks’ worth of medication down the sink.. and this was after I’d been on it almost a year.
February 16th, 2006 at 4:02 am
There have been many story-lines where spouses are lying to one another about significant things, and this could have been an episode where the pressures of trying to please everyone and fulfill society’s contininuing pressure for women to want children was addressed with real depth, and the pathology of THAT be explored, perhaps with a psychiatric consult that gave us a different focus, with the medical problem being in the background and quickly (and accurately) cleared up. It felt like a missed opportunity to me. House himself has a few times come through nicely with the psychological stuff, so he could have been (secretely) human, even. With so many people on Ritalin, to make such an elementary error is pretty bad, and having watched pathologists prepare and then analyze tumor tissue with great care and in the Path Dept, not the OR, I was stunned to see Chase flop the lump down and declare it benign. Unless it was clearly nothing but fatty tissue (a lump in my breast was taken out with me awake, and my surgeon and I looked at it as he held it in his forceps, and he was able to tell that it was more than likely benign due to its structure, texture, etc,); but still, he put it in a sterile jar and sent it off to pathology, merely telling me it was probably fine, but he’d let me know after he got the report. Not until he got the report a couple of days later did he pass it as certainly benign. And as I’d seen tumors examined in the past, I knew that it would be shaved in more than one place, in case the lump was heterogeneous. But maybe Chase is really an Aboriginal Shaman, and doesn’t require such technology. The blonde hair is a very good disguise!
April 22nd, 2006 at 1:17 pm
Yes, but you can persciption shop. This woman was a driven career woman. Three doctors (unknown to each other) writing three perscriptions.
December 17th, 2006 at 1:04 pm
The scene where she started bleeding vaginally right before beginning to crash seemed quite improbable to me. Perhaps you can correct me if I am wrong. But the explanation gave was that she was bleeding from her liver which caused her abdominal cavity to fill up and then the blood to leak into her fallopian tubes and consequently out her vagina. Is that even possible? If the blood was from a uterine bleed, it looked like that while it would probably be a serious OB/GYN concern, it was not nearly enough to cause a woman who is not pregnant to start crashing. Or if there was enough blood to force its way into the fallopian tubes (perhaps the opposite effect of endometriosis?) then I would imagine that her abdominal cavity would have to be pretty much full which would mean that she had bled out and crashed long before that with the many signs & symptoms of internal bleeding. Is any of this correct?
March 24th, 2007 at 9:42 am
Which surgeon will operate on a liver, without a PA diagnosis? The tumor seems easy to puncture before any surgery has been ordered. When thinking of a pill adenoma it is not ethical to remove this part of the liver. The bleeding vaginaly from a liver adenoma is pure crap. And as mentioned earlier a proper PA diagnosis will take several hours or even days.
April 25th, 2007 at 2:58 pm
Annie, you’re right, you can’t get 3 scripts of methylphenidate in 3 weeks in the States. I went to a med school (the name is withheld, of course), and one of the psych profs was such a complete bonehead that he’d give the stuff out like candy, all a student had to do was walk into his office, take an ADD test, purposely fail and he’d make sure you got the meds. I don’t know exactly how it was done, but as a result of this one of my friends who was really stressed before a final overdosed on the stuff! Sorry, just wanted to share, that was the first thing I thought of when they said that much Ritalin.
May 29th, 2007 at 7:47 pm
I’m pretty sure prescription shopping would get caught after a while - if nowhere else, then when she went to the pharmacist to get them filled out.
I know that my pharmacy (Shoppers Drug Mart) gives me a little ‘personal medication history’ pamphlet that lists my allergies and the last twelve prescriptions I’ve had filled or refilled, whenever I pick up my medication, along with how many refills each of them has left. Possibly this is just Shoppers - or even just the Canadian Shoppers. But still - wouldn’t the pharmacy notice something like that and, at the least, call the doctors to check it out?
Or am I being naive in assuming (hoping?) that the pharmacy would even raise an eyebrow at someone presenting them with not one, but *three* separate scrips for a controlled drug?
Granted, she could’ve scattered the scrips around, to keep from attracting attention…but wouldn’t they have mentioned if she was not only getting more than one refill, but refills from several different pharmacies?
July 2nd, 2007 at 9:45 pm
Something not mentioned earlier in this post but worth bringing up is that the Hospital (Princeton-Plainsborough Teaching Hosptial) would most likely be associated with Princeton University in New Jersey.
The scene with Dr. Wilson rolling joints for one of his cancer patients is inaccurate as NJ has no law concerning the medical usage of marijuana and even terminal cancer patients are not given this option. See norml.org for state by state listing of legislation.
September 2nd, 2007 at 4:16 pm
I have a question about the HIV test method: I have always thought that you can only determine an HIV infection through a blood test. Is it really possible to use a saliva sample?
October 24th, 2007 at 5:57 pm
i work at a pharmacy and i know for sure that they can not fill three scrips adderall in three weeks. since it is a class II controlled substance, no refills are given. new scrip is needed each time. since i’m guessing she used her insurance to pay for it, they would be able to tell if she bought it at different pharmacies. i guess she could get it off the street but then they wouldn’t know she had three refills in three weeks.
November 22nd, 2007 at 9:09 am
What test did House get Cameron to do? It’s a cheek swab so I assume antibody, but hasn’t she already done the antibody and viral load tests?
December 5th, 2007 at 1:49 pm
Here’s my biggest problem with this episode, something no one else has commented on yet:
Why the hell is Margot actually taking both fertility drugs and birth control pills at the same time? Wouldn’t she be smart and just throw out the fertility drugs without taking them? If by chance her husband watches her take the pills, then couldn’t she replace them with something similar-looking but more benign, like a vitamin?
Any person with intelligence, which she clearly has, would realize that not only would taking drugs with opposite effects have serious bad consequences on the body, but it’s also possible that the fertility drugs could win out over the birth control pills and she could still get pregnant (at least in theory).
If the fertility drug is in fact an injection that she needs to be given at a doctor’s office, so she actually has to take both drugs, then that may be an answer that the writers left totally unexplained. However, Clomid, the drug suggested above, is taken orally.
There is one other major problem with this episode:
Wouldn’t Cameron and Foreman have found the birth control pills when they searched Margo’s house? They did, after all, find the Ritalin she was secretly taking in her car. Wouldn’t a busy and necessarily organized person like her hide all the medication she’s secretly taking in the same place?
So a couple major flaws in the core of the plot. I’d take the grade down a letter or two for that.
December 14th, 2007 at 5:00 am
Actually, a driven and goal-orientated person like her would probably use multiple doctors, multiple pharmacies, and pay cash. If she had any children, she might use their names or other fake names, too, depending on how “cooperative” the prescribing doctors were.
American pharmacies, generally because of privacy concerns, don’t keep or share the same kind of real-time records that other countries might. It’s the insurance companies, really the HMOs, that track down any problems.
February 5th, 2008 at 12:00 pm
Wow. Nice episode, but some of the early differential diagnosing in this one had me giggling at how terrible it was. House seems to have forgotten that Huntington’s is inherited. It’s dominant, and unless this was a spontaneous mutation, this *would* have shown up in the family history (unless she was adopted or the show was about her not knowing who her parents “really” were, of course). And the onset is waaaaaaaaaaay too fast for Huntington’s, which evolves over *decades*. Chase even points that out and amazingly, gets shot down by House (”she went from 0 to 60 in world-record time”) and then ignored by a freakin’ neurologist, who should certainly know better. Also, Huntington’s has what I’ve read is a fairly unique “writhing” that itself is distinctive looking - it’s not “just” twitching. And I got a kick out of House’s casual “just start her on Huntington’s meds,” line, making their pharmacy perhaps the only one in the universe to have such things. Apparently they’re filed right next to the HIV vaccine and the Alzheimers disease meds.
It’s a pity the writers apparently have no clue what Huntington’s actually is, because if they’d REALLY wanted to stab then twist the knife, and make probably the bleakest House episode ever, they could have settled on that for their final diagnosis, which not only would have given her an incurable progressive physically and mentally debilitating disease, but would mean her daughter had a 50% chance of having it too, and even better for plot purposes, it’s (or so I just read) considered unethical to test minors, so the episode would have to end with us not knowing if the daughter had inherited. Youch.
On a different subject, I don’t know much about schizophrenia, but I could’ve sworn I’d read an earlier review on this site that pointed out that it usually comes out in the early to mid 20’s. Hearing Foreman say she was the right age to develop schizophrenia definitely got a groan from me, not to mention that her symptoms don’t even come *close*.
April 2nd, 2008 at 9:04 am
That’s a good point about Huntingston’s - it was tossed around very casually in the first three seasons. I remember in season one, in the episode Paternity, Foreman asks if there’s any excuse they can give the parents for running a DNA test (to settle a bet), and Chase says “we could tell them he has Huntington’s”. That’s a very casual way to talk about a devastating and incurable disease, and one with the potential to be passed on to the children.
On the other hand, season four has reversed this trend, at least to some degree. I thought the episode where Thirteen revealed her mother had died from Huntington’s was very well done. I don’t like the way the characters have talked about it since then (Kutner asking “so you have Huntington’s?” was very crude), but they’ve handled it better than in previous seasons…
May 10th, 2008 at 6:44 pm
What bothered me at the beginning of the show was the absolute lack of common sense (or as House’d say it; What’s the differential for getting into a car to go driving, when you just had 2 episodes of uncontrollable jerking of the arm in under ten minutes?)…
That would also explain why she’d take the birth-control along with the fertility drugs, she’s an idiot…
Plus i was also amazed by Chase and his magical microscope, even as a layman, i knew that that biopsy sample couldn’t be processed so easily…
May 25th, 2008 at 11:13 pm
It’s quite common for ADHD patients to get too many pills in the beginning, while the doses are being adjusted. I’ve still got tons left over, as the doctors didn’t realize that I’m hyper-sensitive to medication. Refills.. not so easy, but it would have been trivial for her to say either that the pills are working only slightly or that her daughter’s ability to concentrate is weaving in and out in order to get more pills. Also, in switching between short-acting and extended release it’s easy to get extra pills. It’s a shame I don’t know how to sell these things on the black market… ;)
June 1st, 2008 at 11:09 pm
As a 1st yr medical student I was extremely suspicious as to how Chase could just take the specimen straight to the microscope. Having spent a lot of this year with histological specimen I know that stains such as H&E are needed to see stuff clearer as usually appear dull and undifferentiated when not stained.
The main concern I had though was about the thickness of the specimen since even if the surgeon had tried to get as small a piece as possible it;d still been dubiously thick for light to shine through for the microscope.
It was also dubious how quickly he was able to focus the microscope as well as changing from x40 all the way to the common max magnification of x400 since usually (unless different in lab situations in real life) you’ll focus at lower resolution to make it easier to focus on higher resolution.
As a last point, that specimen thickness also would have meant to cover slide. Surely that alone makes it harder to get an image. Poor mistake by the House doctor researchers.
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