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Clinic Case: Size Matters [House
limps toward Exam Room 1 and as he reaches the door, taps his cane twice
rapidly on the door, but doesn't wait for a response before he turns the knob
to go in. He sees a very pretty young
woman in her early 20's sitting on the exam table. He closes the door behind
him, and pulls her chart out from under his arm. As he opens it, she speaks.] Patient:
My
head hurts on Tuesdays. House: On
Tuesdays? Patient:
Yes. House: Only on
Tuesdays? [Slaps her chart shut and
stuffs it back under his arm.] Patient:
Yes House: And – this is [looks up as if reviewing a calendar in
his head] -- Monday. Why are you here? Patient:
Well,
I want to see a doctor, to try to figure out why this is happening and stop
it. House: I got
that, but why aren't you here when it hurts? Patient:
Because
I have classes all day on Tuesdays. House:
Classes, what kind of classes? Patient:
Education classes, at House: [Sits back for a second and looks her up
and down, as if to size her up.] Dispensing or sponging? Patient:
What? House: Right,
sponging it is. Patient:
What? House: Given
your age and the fact that you didn't get that, I'm guessing that you're not
dispensing the wisdom, you're there to suck it up like a passive little
sponge. Patient:
[A look crosses her face as
if to say that she's trying to figure out whether she was just insulted or
not.] Do
you think you can help my headaches, or not? House: So, you
couldn't manage to skip just one day of classes to come to the clinic when you
have a headache? Patient:
No,
because these classes are held only once a week, so a big part of the grade
is attendance. I've already missed two
days this semester. House: What's
the topic? Patient:
I'm
in my last year. My major was in Photography, but now I'm taking the classes
so I can get certified to teach in high school. House: Do your
own darkroom work? Patient:
What?
House: You know, that place with lots of
nasty chemicals for developing? And it
usually has one more feature, what is it now, oh yeah - It's DARK. Patient: You gotta be kidding. Ever hear of the word
digital? House: Yeah,
ever hear of the word digit? How many am I holding up? [Holds up his hand with his palm facing the woman, all five fingers
spread open.] Patient:
Five. House: Wrong,
one-zero-one. Patient:
You're
not making any sense. What does that have to do with my headaches? Can I
maybe see a different doctor? House: [Authoritatively.] I'm making perfect
sense. In a digital world anyway. That was a vision test. If you had said 10,
or 3, or just about anything besides five -- or one-oh-one, which happens to
be digital speak for “five” by the way -- then we could probably attribute
your headaches to a vision problem. And no, you can't see another doctor. I'm
still paying off a certain bachelor party, and all the other doctors are
nursing headaches of their own. So, what do you normally do about your
headache? Patient:
Well,
I take a couple of Ginkgo Biloba tablets when I feel it coming on, wash them
down with chamomile tea, and take them a couple more times on Tuesday. Usually the headache is gone by Wednesday
morning. House: Uh huh.
Ginkgo Biloba and Chamomile Tea. Then
you haven't tried aspirin? [Patient
shakes her head no.] Tylenol? [Again
patient shakes her head.] If you know the pattern is Tuesdays, then I'm
guessing this has been going on for a while. Patient:
Yeah,
at least ten weeks. Pretty much whenever the semester started. House: Well,
that narrows it down. How many weeks left in the semester? Patient:
Eight.
House: Then I predict you'll be all better in nine
weeks. Patient: You aren't seriously suggesting that I keep
suffering with these headaches for the rest of the semester? House: I'm
seriously suggesting that I have nine more weeks to figure out what's causing
them. Patient:
You're
seriously mistaken if you think I'm coming back here to see you again. House: And
you're seriously mistaken if you think I care. If you come on Mondays, I'm
the one you'll get. And you'd be seriously mistaken to think that you
can find another doctor in this hospital better than I am at diagnosis. Patient:
What.
Ever. House: So,
back to the headaches. Are they sharp and intense, like someone jabbing a
pencil into your skull, or more dull and throbbing, like your head in-- Patient:
A
vice. Like I'm in a bugs bunny cartoon and someone's screwing a big giant
vice down on my head, and it's about to crush at any minute. House: Do you
drink caffeine? Patient:
God
yes. On Tuesdays I’ll suck down lattes all day just to stay awake in class. House: Uh uh,
let's keep God out of this one. Unless you can prove to me that he’s become
your bestest buddy in the universe because he’s friended you in Facebook and
dispenses medical insights to you in his spare time on Twitter. Patient:
What? House: Stop
saying What. How many lattes do you
drink a day? Patient:
[Shrugs] Maybe
three. House: How
about non-caffeinated beverages? Patient:
What? [Sees
the look on his face] What about
them? House: [Sighs in frustration] Do you drink
them? Patient:
Well
of course, I have the chamomile tea in the morning, that doesn’t have
caffeine. And sometimes sodas. House: How
much do you drink on Tuesdays? Patient:
I
dunno, I never really thought about it. My lattes keep me going, and I guess
I have a soda with lunch, but I don't think I really drink much the rest of
the day. House: And
when do the headaches start? Patient:
On
Tuesdays. House: [Looks away for a second, pained by her
simplistic and unhelpful responses. Then looks up as if selecting a number
from the air.] 72. No, maybe 74. Patient:
What's
that? House: I'm
going to write that number on your chart here. If you need to come back, then
we'll look at it. [Writes a number on
her chart, then makes a point of circling it several times, slowly and deliberately,
almost as if thinking before speaking again.] Let's try this again. What time
of day do your headaches usually start? [Pause] On
Tuesdays? Patient:
They
usually start out first thing in the morning and last all day. House: [Pulling his prescription pad.] All
right then, starting tonight, I want you to drink two glasses of water
before bed, and take two aspirin. Tomorrow, I want you to have only one
latte, but at least three 20oz bottles of water throughout the day. If that
doesn't fix your headache, come back next week. Patient:
What?
That's it? “Take two aspirin and call me in the morning?” House: Close.
Call me next week, but yeah, that's it. Headaches can be one of the signs of
dehydration. They usually start in a while after you stop peeing, and
sometime before your skin starts to turn pale and you stop sweating. That
caffeine that you load up on so much in the morning is what's called a
diuretic [he says this word slowly, and
drags it out deliberately, almost as if speaking to someone hard of hearing].
Diuretics make you pee a lot more, and in the end have a dehydrating effect
because your body wants to get rid of the diuretic so fast that you end up
without enough fluids. Start drinking that water in the afternoon and take
the aspirin, and you'll be good as new. [End scene, and fade out.] [The following Monday, House
enters Exam Room 1, and finds the same patient.] Patient:
I
still had a headache last week. I did everything you said, but it was worse. House: How
much worse? Patient:
A
lot? [Her inflection says this is a
question, because she knows he's not going to like that answer.] House: [Frustrated.] Think of the pain as a
scale of one to ten. A one is something like this-- [he pinches her arm] Patient:
Ow!
That hurt! House: A five
is maybe something like a sprained ankle, or a sore neck from sleeping wrong.
An eight might be the pain you might have from broken bone, or a having to
endure a Hannah Montana concert. Patient:
Hey,
I like-- House: [continues without stopping to let her
finish] A ten would be the worst possible pain you could imagine ...
start thinking along the lines of childbirth, or water-boarding, or that
maybe having your guts splayed open with a butcher knife might be preferable
to the pain you're experiencing. [As an
afterthought.] Or, if you've never experienced any of those, then think
what it's like to cart around a bum leg with a missing thigh muscle. Patient:
Um,
well, the headache last week was around a six. Maybe before that they were
fours or fives. House: And no
headache Wednesday thru today? Patient:
No. House:
Plain water on Tuesday? Patient: What? House:
On Tuesday, you used regular old bottled
water, nothing with artificial sweeteners or caffeine, right? Patient: Yes. House: When I
pinched you a moment ago, your skin bounced back nicely without staying up
like a pitched tent. So that shows you're well hydrated. Patient:
That's
right. House: I know,
I'm going to regret asking this, but tell me what your schedule is like the
rest of the week. Try to be brief, but leave in the important stuff. Patient:
Well,
let's see. On Wednesdays I .... [We see
her begin to tell him, but he takes out a Gameboy and motions for her to keep
talking while he starts playing. Fade
in and out to show time passing.] Patient:
[continuing].... so Mondays I just have
the one class so the rest of the day is sort of my catch-up day. I get
laundry done, finish my homework that's due Tuesday. House: [Moving the Gameboy around a lot, as if
having reached a high level, and working very hard at the game.] And what
was last Monday like? Take me thru the whole day. Patient:
Well,
in Early Education, we got back a test and went over that. Then there was a
lec-- House: [Stops abruptly and puts the Gameboy down.
Very interested now.] You got back the results of a test? Patient:
Yes, it was the first test we had with that
teacher. Got it back and we went over it as a class. House: Would
you happen to have the paper with you today? Patient:
It
wasn't a paper, it was a test. House: [Closes his eyes as if just punched in the thigh.] The
paper on which the test was printed. Do you have it? Patient:
Yeah,
I have it in my backpack. [She nods
toward the backpack but makes no move to get it.] House: [Incredibly frustrated.] Could I see
the paper on which the exam is written, pretty please? [pause while she reaches for the backpack and starts digging thru it]
Ideally, I'd like to see the side of the paper on which the text is printed. [pause] You know, as opposed to the
white side of the paper with nothing printed on it. Patient: [Looks at him as if to say “well duh”] Yeah, I kind of figured that.
House: Just
trying to be as clear as possible! Patient: [Handing
him the paper.] I don't see what this has to do with my headaches. House:
Nothing. [Reaches for the patient's
chart.] Patient:
Then
why do you need to see it? House: [Comparing the paper against the chart.
Then leans toward her in order to show her both documents, and points to
something on the chart.] See? 74. I was right! Patient:
You
guessed the score I would get on my test? House: [shrugs] Sure, college test. That's the
number I was thinking of. I'm really sure you don't know what else I
was thinking. Patient: [Face
wrinkles as she puzzles over it. IQ
never crosses her mind.] House: OK,
back to your headaches. What else did you do on Tuesday? Patient:
I
don't like you. House: Now that
number would be a lot higher. Patient:
What
number? House: The
number of people who'd agree with you on that point. Patient:
[sighs] OK, so
after that class, I did my laundry, did some homework, did more laundry,
finished an art project, and then I went out to the barn for my riding lesson
which was from 7 to 8, then I went home and went to bed. House: Riding
lesson? Patient:
Yeah,
I needed a phys ed credit. I'm taking
horseback riding lessons. House: Ah hah!
So that’s a pretty drastic environmental change from your dorm room and
classes. Patient:
Well,
it's at a barn, sure. House: So, I
don’t suppose there’s any chance your headache actually starts on Monday
nights, is there? Patient:
Hey,
you know, you're right. I never really thought about that before, but you are
so right! I guess sometimes I’ve got the headache when I get home from the
barn, but usually I go right to bed afterwards, so I didn’t really think of
that. You've been so annoying asking
me all these questions, but I guess they were for a reason, huh? House: Yes, I
frequently do have reasons behind my actions, believe it or not. This opens
up the playing field. Your headaches could be allergies, could be a reaction
to a fly spray, a chemical used to keep the dust down in the riding arena,
any number of – [he
stops in mid sentence, having just come upon an idea] Patient:
What?
House: Western
or English? Patient:
What? House: [loudly] Do you ride Western or
English? Patient:
I
heard you, I just was surprised you'd ask. House: Which
is it? Patient:
English. House: Tonight,
I want you to follow everything I asked you to do last week, the extra
hydration, the aspirin, everything. But then after your lesson, I want you to
come straight back here with everything you normally wear and use during the
lesson. Patient:
What?!?
You mean like the saddle and bridle and stuff? House: Yep,
everything. Patient:
But
I usually stink after a lesson, are you sure? House: Very
sure. My office is on the third floor, right across from the elevators. I
want you to bring it all with you. Patient:
OK,
if you say so. I don't own the saddle, so I don't know I they'll let me take
it -- House: Tell
them I'll write you a note if you need it. It's absolutely critical to a
proper diagnosis. Patient:
[acting really puzzled] Well, OK
... [leaves the exam room] [House pulls out his phone, then
dials.] House: [scene fades] [Scene opens in House's office.
It's dark out, and Wilson and House are playing cards and smoking cigars. In
the background, we see that the elevator door opens, and the patient is
walking out of it, dressed in a riding outfit, with a saddle perched on her
hip.] House: [Before the patient has opened the door,
House speaks in a low voice to House: [rolls his eyes and looks up at the ceiling] Pullleeeeze,
not that word again! [The patient opens the door,
struggling with all the stuff she's carrying.] House: [looks up for a second as if to remember the
patient’s name, then decides it doesn’t matter] Equestrian, I’d you to meet Dr. Wilson, and
oncologist. Patient:
A
what? House: [rolls his eyes and looks up at the ceiling] Pullleeeeze, not
that word again! Patient:
Isn't
that a cancer do-- House: How's
the headache? Patient:
I
don’t have a headache. They usually
start in the morning. House: [ignores her and starts going thru the things she's set
on the table] The saddle, the bridle, the [pauses] ... and you're wearing the pants, the boots, [pauses again] the helmet, where's the
helmet? Patient:
Oh,
I left that in the car, I didn't think-- House: Why
does that not surprise me? Patient:
I'll
go out and get it, can I leave this stuff here? House: Yes,
leave it here. Go, get the helmet. Patient:
OK [leaves] House: Relax,
she's legal. House: Horse
is already out of the barn on that one I think. House: She's
here strictly for diagnosis. I thought you'd appreciate this one, and the eye
candy is just icing on the cake. It's the diagnosis I figured you'd like. House: No,
even better. You're going to like this one. [the patient is stepping back out
of the elevator] House: Watch. [he stands up and starts poking thru the
horse things again; when she's in the room again, he turns to her] Put
the helmet on. Patient:
What?
House: [rolls his eyes] Ground control to Major
Tom, put the helmet on!!! Patient:
[shrugs] OK [She proceeds to put the helmet on, and struggles with it for a
moment, leaving the chin strap hanging.] House: Chin
strap too. Patient:
[Now she really struggles,
tugging, and pulling, and eventually gets the chin strap snapped together.
House approaches her, lifts his hand, and slams it down onto the helmet.
She's shocked.] House: There,
how was that? Patient:
It
hurt! House: But the
helmet didn't budge, did it? Patient:
[loudly] No, it
didn't. Is that good? House: Take it
off. Patient:
Sure,
I hate this thing. It always feels too tight. [House
takes the helmet from her, and begins to adjust the inner strapping system so
that it's now larger. When finished, he turns it back over and slaps it on
her head. It goes on much easier now.] Patient:
Hey,
I didn't know you could do that! House: Why
does that not surprise me? Patient:
So
all this time, my headache-- House: Yep. Patient:
And
I could've-- House: Yep. Patient:
And
you figured that-- House: Yep. Patient:
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