S8E12: Chase

This is a preserved copy of "Chase", originally published at politedissent.com. Wayback capture: 2012-09-30. Original URL: http://politedissent.com/archives/8647.

As the title suggests, this episode deals primarily with Chase, and how he is recovering from his injuries — physical and mental — suffered in the previous episode.

⚠️ Spoiler warning — plot details for this episode follow.

Chase is not dealing particularly well with his near-death experience, not that he’d admit it, and is trying to avoid House. Foreman convinces him to at least work some hours in the clinic, and that is where we meet Moira. She is a postulate nun, very close to permanently joining a convent. She is in the clinic complaining of left shoulder pain. The shoulder exam is normal, but Chase notes some enlarged cervical lymph nodes. He suggests that she may have breast cancer or angina (pain in the heart — or in this case radiating to the shoulder — from blocked or narrowed arteries in the heart). A quick breast exam reveals a small mass, so she is admitted to the hospital for further work-up. The breast radiology is normal, and a cardiac stress test is also normal, so breast cancer and angina are no longer in the diagnosis. House, inserting himself into the case, suggests she has a fungal infection from the unprocessed flour they use at the convent. Just as she is started on antifungal medication (looks like amphotericin), she complains of nausea and begins to vomit. House now suggests Moira has ascending cholangitis (a life-threatening infection of the bile duct), but then she complains of a numb left foot. On examination, Chase cannot find a pulse. Blood clots are suggested, but Adams suggests vasospasm (the tiny smooth muscles around arteries constrict, stopping blood from flowing to the involved tisses). This seems to fit the case best, so Moira is started on calcium channel blockers (drugs which relax smooth muscles) and improves markedly. She is discharged from the hospital and on her way to taking her vows.

Later that night, Chase finds Moira waiting outside his apartment; she has had second thoughts about becoming a nun. They enjoy a night of fun and frolic, but the next morning, she suddenly develops tinnitus (ringing in the ears) and Chase notices a pulsating mass in her neck . She starts coughing up blood (what is this, the third week in a row?). Chase recognizes this as a carotid artery dissection, a medical emergency (because the carotid artery supplies blood to the brain, and any interruption of blood flow can cause a stroke and brain damage), and rushes her to the hospital. He wants to operate immediately, but the rest of the team points out that he is emotionally involved and should not be involved. House points out that Chase is the most qualified surgeon available for the dissection repair and lets Chase proceed with the surgery. The dissection is repaired and the clot removed and Moira is doing well. Chase tells House he found some nodules during surgery and he thinks it may be lupus, but the labs don’t support that diagnosis. House points out what Chase thought were nodules may be plaques and Moira may have tertiary syphilis. While discussing the diagnosis with Chase, Moira mentions a near-death experience she had while on the operating table. He tells to accept it as a sign of solace.

Foreman takes Chase off Moira’s case due to his involvement with her. Unfortunately, things are going poorly for her now. She is complaining of right upper quadrant abdominal pain, which turns out to be liver failure (of course). The differential diagnosis is now hypotension (low blood pressure) during surgery, another clot, Trousseau syndrome (a type of blood clot seen with certain cancers), or disseminated T-Cell lymphoma. Everyone seems to agree the lymphoma — a fatal condition — is the most likely diagnosis, except Chase, who is still grasping at straws and suggests sarcoidosis. Later, while he is sitting at Moira’s bedside, waiting for the latest results, she mentions her jaw muscles feel heavy. He recognizes this as jaw claudication and realizes that she has giant cell arteritis (also known as temporal arteritis, a type of vasculitis), a treatable condition. She is started on steroids and improves. As a result of what she saw during her near-death experience, Moira decides one again to join the convent. Chase wants to talk her out of it, but House ultimately persuades him to let her go.

For the first time in quite a while, I had not major problems with the medicine in tonight’s episodes. That’s not to say it was perfect — far from it — there were the usual plethora of missed opportunities, strange diagnostic choices, and atypical symptoms, but there were no deal-breakers this week (though I’m sure others will disagree in the comments). So, no red complains this week, modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

Uncommon presentations of carotid dissection (hemoptysis, but no headache) and giant cell arteritis. I’m assuming the shoulder pain, carotid dissection, and claudication are all being blamed on the arteritis. Apparently, they’re also blaming it for the nausea, vomiting, liver failure and vasospasm as well?

When a young woman comes in complaining of left shoulder pain, breast cancer and angina are not going to be the first two diagnoses I think of. They’re going to be pretty far down the list. (History of trauma or not, I would still consider a musculoskeletal casue the most likely in that situation).

Let’s say Adams was correct and Moira’s big problem was vasospasm. I can’t believe they’d let it end there and not perform a work-up to determine why she was having ischemia-inducing vasospam. That is very out-of-character for the doctors, and the show itself.

When Chase found the nodules during surgery, why didn’t he biopsy them then?

Surely someone on the team ran a sedimentation rate on Moira, particularly after her dissection. There aren’t that many non-surgical causes of an aortic dissection in that young a patient. AN elevated ESR would have clued them in to the GCA very quickly.

I know his reasoning was good, but performing a breast exam without a chaperone present is definitely not recommended from a medical-legal point of view.

I can (almost) understand Chase or Taub always doing being called on to play surgeon, but surely there are better assistants than non-surgeons Adams and Park.

I found the medical mystery to abnormally low key this week (you’re going to admit someone for shoulder pain — really?) though it become more complicated in leaps and bounds. I can only give it a C. The final solution was certainly possible, unlikely, but possible. It earns a B. The medicine was full of bizarre choices and overlooking the obvious, but still it was better than it’s been in quite a while: B+. The soap opera was strong and it was nice to see a Chase-centric episode again: A.