Andres Tavares is confused. He knows that he's with his wife, Natalie, but he doesn't know where or why. "We're in the car, honey. We're going to the hospital for some tests," she reassures him. He gives her a half-smile. But by the time they arrive at Princeton-Plainsboro, Andres is lost again. Natalie patiently leads him to the doctor's office.
Dr. Shriya Banerjee holds up a can opener and looks at Andres. "Can you tell me what this is called?" she asks him. "You use it to get food from inside," Andres says. He knows that much, but he can't think of the name. "Is it a spatula?" Dr. Banerjee asks. He knows it isn't. "Good," she says. "Is it a can opener?" "No," Andres says right away, as Natalie looks down. "It's um . . . it's um . . ."
Andres is suddenly full of rage. "You're trying to make me look stupid!" he accuses the doctor. "You can go to hell! Why don't you kill yourself!" Natalie strokes his arm and calms him down. "You just need to answer a few more questions. Then we're going home and we'll have lunch, OK?" she asks.
Andres smiles and nods. "I'm sorry," he says to Dr. Banerjee. "I have Alzheimer's." Natalie tells her the mood swings come on quickly. "But it's under control," she says, holding Andres hand. "Don't worry," Dr. Banerjee says. "He's actually perfect for the drug trial." Andres and Natalie look relieved. But just as the doctor is telling them that Andres can start the trial as early as next week, Andres begins violently coughing and vomiting blood.
"Early onset familial Alzheimer's. Brazilian descent. Blood chemistry showed high ammonia." Foreman is leading Andres' DDx with the team as House walks in. "Vomiting stopped after the ER put him on anti-emetics." No recent health issues, apart from a sore throat a few weeks ago. Foreman tells them Natalie shut down her floral company to stay home and feed Andres every meal for the past four years.
"We owe this case to your guilt at having ignored your own forgetful mommy?" House asks Foreman. "My guilt over my mom is why I put up with my dad," Foreman tells him. "You're taking this case because we're running a Phase 2 trial on an Alzheimer's drug."
Since Taub is absent with a sick kid, Foreman wants to sit in - except that House denied Taub's request for a personal day. "After I'd already approved it," Foreman says. "Which you knew because I sent you a memo."
House is prepared for the power struggle. He tells Adams to reach under the table for an index card he's taped there and read it aloud. "Wednesday, 2:43 p.m. A black pawn will believe he's the black king and attempt to capture the white . . . Head of Diagnostics." House takes a bow. Never mind that it's 10:15 a.m. on Friday.
"The point is I saw this coming," House tells them. "Dr. Foreman and I did not always see eye-to-eye, but he never had the power to overrule me. Now that he has the power, he won't be able to resist the temptation to use it. With great power comes great micromanaging. And great vests."
Foreman concedes that House is the better diagnostician and vows not to interfere. "Could be transient nitrogen load from a GI bleed," Park suggests. But they'd have to know if the vomiting is persistent, so House wants to take Andres off the anti-emetics to find out.
"Wait," Foreman says. "He's puking his guts out. We'd risk aspiration." Hmm, so much for not interfering. Foreman smiles. "I'm just disagreeing, not overruling." They'll take him off the anti-emetics and do an upper endoscopy to check for bleeds.
Meanwhile, Wilson is examining a pretty young woman in the clinic. "It could be a bladder infection," he says. "We'll run a pregnancy test." She insists that there's no way she could be pregnant. "Any type of birth control can fail," he tells her. But she isn't having sex at all with her husband. And she never has. "We kiss, and cuddle. But neither one of us is interested in sex," the woman says. She says she's not celibate. "Celibacy is a choice. This is our orientation. We're asexual," she tells Wilson, who's puzzled as to what box exactly he should check on the patient form.
Chase thinks that Foreman is wasting his opportunity to mess with House. "If I had the power to veto him, after all the crap I've put up with over the years, I don't know if I could use it objectively." But Foreman's been down that road before, though he did think it might be a little different this particular week. "I'm supposed to talk to his PO about getting his ankle monitor off early." House's behavior doesn't seem rational. "Which makes me think it's rational in a way I'm not privy to," Foreman says. "He always has a plan." He's also self-destructive, Chase points out. "He may just be shooting himself in the ankle."
"I know it seems strange. Dr. Chase is just looking in your throat. We're in the hospital." Natalie helps Andres adjust to being in his hospital room, with a tube down his throat. They've set up a small whiteboard with the names and pictures of the team to help him out, and Natalie has brought pictures from home, and a big trophy that Chase notices. "He coached youth soccer," Natalie says. "Took a team that was 0-6 all the way to the state finals at Long Branch." Parks tells Natalie she takes very good care of Andres. "I love him. Sickness and health, right?"
The upper esophagus is clear, so Chase moves to the gastroesophageal junction. A man enters the room and is greeted by Natalie, but Park tells him only family members are allowed in. Natalie asks if he can stay. "Joseph helps me with my husband sometimes. He's a good friend." Park is adamant, so Chase tells Natalie to show Joseph where the visitors' lounge is while he finishes the endoscopy. He spots a Mallory-Weiss tear on the monitor.
"Did you know that close to one percent of the population identifies as asexual?" Wilson is reading up on his clinic patient's condition in the cafeteria with House. According to the article, asexuality is a valid sexual orientation. "Yeah, I think I read that, too. Is that Fugliness Weekly?" House asks. But she's perfectly fine-looking and has been married for ten years. "To a guy who loves penis enough for both of them," House guesses.
Wilson explains that the husband is asexual, too. And after a complete physical of the wife, he turned up nothing but a common bladder infection. "$100 bucks says I can find a medical reason why she doesn't want to have sex," House bets. Wilson is smart enough not to let House anywhere near his patient. But all House needs is the file and any blood samples. "No contact whatsoever," Wilson says. "You talk to her, the bet is void."
Foreman is hunched over the desk in his office with a calculator when House and the team come in with the endoscopy results. The tear below the esophagus explains the bleeding, but not why Andres was vomiting so violently he ripped the hole in the first place. "His liver enzymes were slightly elevated," Adams says. She thinks maybe it's gallstones, but there haven't been any complaints of pain. "Steatohepatitis would make his AST and ALT levels rise," Foreman says. House orders statins for Andres and a biopsy to confirm. "And knock him out. I've heard he's a wiggler," House says.
"There's no need to put him under," Foreman objects. "We can confirm fatty liver with an ultrasound." House gives him a look. "Just making an observation," Foreman says. "Well done," House tells him. "Now, as a member of my team, you can make the equally useful observations that the sky is blue, I'm wearing pants . . . and I'm ignoring your first observation." Foreman thinks that House is just trying to mess with his confidence. "If I wanted to do that, I'd tell you how much the nurses hate you," House says. "Do the ultrasound," Foreman orders him.
"You don't think I knew House was going to tell you to ignore me and not do the ultrasound?" Foreman stops Chase and Adams in the hallway outside Andres' room. But they're pushing an ultrasound machine. "Which you're going to use to do an ultrasound-guided biopsy. Probably got a kit stashed here," Foreman says, rummaging around the machine. Instead he finds another index card from House, which Adams reads: "Cuddy Dark will waste his afternoon chasing conspiracy theories." House is really getting inside Foreman's head.
Suddenly, Natalie walks in; Andres is vomiting again. Chase tells her that's why they stopped the anti-emetics, to see if the vomiting was a symptom or not. As she brings a bowl over to Andres to vomit into, he pushes her hand away. "Get your hands off me!" he yells. Natalie tries to comfort him, but he lunges at her and punches her so hard that she's knocked back. When Foreman and Chase rush over to subdue Andres, they see blood on the front of his gown. It's from his urine.
"We resumed the anti-emetics and increased the sedation. He really went after her." Adams fills House in on Andres' outburst. Was it because he found out about her "good friend," Joseph? Chase thinks it's just paranoid rage, a typical Alzheimer's symptom. House doesn't even think it could be considered infidelity for Natalie to sleep with Joseph. After all, she's not really married. "If marriage is feeding and cleaning someone, limiting conversation to repeating a few simple commands, then I was married to my pet rat, and a lot of people owe me wedding gifts," House says.
The two divorced team members, Adams and Chase, have opposing views: Adams thinks that you have to take the good with the bad, while Chase says Alzheimer's is different, since Natalie doesn't really have her husband anymore. Meanwhile, Foreman's caught up with them. He says he was right about Andres: if they'd left him on the anti-emetics, he wouldn't have flown into a rage and punched Natalie. But House reminds him if they'd done the biopsy like he wanted, Andres would have been anesthetized, and unable to punch Natalie, plus they were able to learn more about his condition.
"Unless one of your index cards actually predicted the guy was going to punch his wife, everything you're saying is post hoc rationalization," Foreman says. So, House asks Park to reach under her chair for an index card that reads: "The patient will punch his wife." Foreman is sure House wrote that after it happened, so House produces yet another card predicting Foreman's accusation.
Trying to get back to the case, Foreman thinks that rhabdomyolysis fits the vomiting, pigmenturia and the renal failure. "No muscle symptoms, and the urine had no myoglobin," Adams counters, suggesting TTP instead. House orders plasmapheresis to replace the damaged red blood cells clogging Andres' kidneys.
"How's the eye feeling?" Chase is talking to Natalie and Joseph outside Andres' room. She says she's OK but thinks maybe Joseph should leave. Chase tries to look away when Joseph kisses her goodbye. "We're not having an affair," she tells Chase, breaking down. "I mean, not really. Because nothing's happened. We've talked about it a lot, and it's just really hard doing this by myself." Chase tells her to take the night off and go home for a good night's sleep.
"Why doesn't Chase have to be here?" House has Park and Adams in the lab working on Wilson's case. "You think he knows anything about women who don't want to have sex?" House asks her. Why does it matter if the woman doesn't want to have sex? House argues that sex is the fundamental drive of our species.
"I suppose it could be psychological intimacy issues caused by childhood abuse," Adams says. She argues that the woman's life is probably better off without sex. "It eliminates most of her insecurities, she's immune to most advertising and can have honest relationships with men." He should just accept that she doesn't want to have sex, and there's nothing wrong with her. "Lots of people don't have sex. The only people who don't want it are either sick, dead, or lying," House says. But he has an idea . . .
The next morning, Andres is nowhere to be found. "Police have been notified. I have staff searching," Foreman tells them all in Andres' room. Natalie is furious at Chase. "You told me it was OK to leave! He has Alzheimer's! It's freezing outside, and he's sick. I mean, you don't even know what it is yet, do you?"
But when she tries to leave to go find him, House stops her. He thinks that she just feels guilty because she wasn't here for him - she was having sex with Joseph. "Personally, I applaud your decision to step down off your cross and get on with your life, but your misplaced guilt is shutting down your brain. We need you to sit, focus, and answer our questions."
They try to work out how Andres might react if he woke up on a Saturday morning at home. Natalie mentions soccer practice, and Chase notices that the soccer trophy is gone. The practice field is close, so Chase and Adams go to look for him with EMTs. They find him passed out in the snow, nearly frozen.
"He has no heartbeat. He's not breathing. How can he not be dead?" Natalie is looking down at her husband from an observation room with Foreman, while the team works on him below. Foreman explains that the body slows down when it cools, but it doesn't totally shut down. They're warming his blood outside his body and then putting it back in. Hopefully, they can raise his temperature enough so that his heart will start naturally, and then they'll shock it back into rhythm.
Down below, Adams wonders if maybe Andres tried to run away, knowing what he is putting his wife through. Chase has a darker suspicion: that Andres tried to kill himself. "It's what I'd do, if I were him," he says. Adams can't believe it. "I just believe people are capable of more than you do, apparently," she says.
Chase explains that when he was a teenager, his father left him to care for his alcoholic mother and baby sister. "I spent half my time cleaning diapers and the other half cleaning up my mom's vomit. Mom died after a few years. It was ugly and painful, and she went with me hating her. My sister ended up drinking half of her life away, and hating me because I couldn't help. After mom, I had nothing left. So, do I wish mom had used a gun instead of a bottle? Yes." Suddenly, Andres' monitor shows atrial fibrillation, and Chase is able to shock his heart back into a normal rhythm.
"Well, I've just got to do a standard battery of tests: blood, urine, EEG . . ." House is examining a man in the clinic, who doesn't understand why he'd need all those tests for a free flu shot. And who is that pounding on the door? "I specifically said the bet was off if you contacted the patient," Wilson tells House out in the hall. But House didn't contact the patient; he brought her husband in instead. House thinks that the wife is lying, and that it's really the husband with the problem and she's just going along with it. "It's a tale as old as time. Boy meets girl. Girl falls for boy. Boy says, 'I'm asexual.' Girl says, 'Yeah, me too.'" He doesn't believe that they're as happy as the wife claimed to
Wilson."He just opened his eyes a little while ago. His heartbeat's doing well, and his body temperature's stabilized." Park is removing Andres' breathing tube while Natalie watches. He starts speaking Portuguese to Natalie, but she doesn't understand, and it's making him agitated. His temperature starts to rise.
"Vomiting, liver, kidneys, and now fever." Foreman is leading the DDx again, but House interrupts to point out that the newest symptom might not really be a symptom. "It could come from the patient's illness, or from the fact that you allowed him to saunter out of your hospital and take a nap in the snow." A virus couldn't have come on that quickly, but hypothermia could have caused cell necrosis. Foreman wants to add the violence toward Natalie and his loss of English to the list, too. "Disseminated viral infection with encephalitis. Patient complained of a sore throat a few weeks ago," he says. House agrees and orders interferon.
"Encephalitis makes his brain swell, which causes symptoms that are hard to distinguish from his Alzheimer's. With the interferon, his English should come back, and the aggression should subside." Chase and Adams are explaining Andres' condition to Natalie. But she's concerned that they're not sure of the diagnosis, and they're not even sure whether he has brain damage from being frozen.
"So, best case scenario, I've just had a glimpse into his future?" she asks. "We married six months after I met him. A year after that, he started forgetting things. I've known my husband longer with his Alzheimer's than without. I've watched more of him disappear than I ever got to know. I can't take care of him anymore."
"You lose! Blood work shows high levels of prolactin. Add that to some peripheral red-green confusion, puts my money - excuse me, your money, soon to be my money - on a tumor near his pituitary." House is convinced that he's discovered the truth behind the husband's asexuality. Wilson agrees it would have lowered his libido and caused erectile dysfunction.
"Put him on dopamine agonist, and he'll be a sex-crazed creep just like the rest of us," House says. But they could have wrecked a marriage. "It could destroy his identity," Wilson says. "It's like a gay person being told they're really straight." House's solution? Don't tell him, since it's a slow-growing tumor. Now Wilson is in another impossible position, put there by House.
"You played me! This whole thing was about your ankle monitor." Foreman walks into House's office, with the petition House's PO sent over about getting the monitor removed. "You weren't trying to undermine my confidence. You were trying to inflate it. You manufactured conflict with me so eventually you could let me win. You knew it was encephalitis, but you waited for me to say it. Because, then, with my ego boosted, you thought I'd be in the mood to take off your monitor. Because I'd think I could control you."
"You're right," House tells him. "Take off my monitor. See, the beauty of the plan is that if it works, then you think you can control me. If it fails, then you actually will have proven that you can control me. It's pretty genius." He puts his ankle up on his desk and points to the monitor. "These are your training wheels. If you think you're up to the job, it's time to lose them." Foreman rips up the form. "The second half of my plan might need work," House concedes.
Suddenly, both their beepers go off. Andres is having a ventricular fibrillation episode on a gurney in the hallway. House grabs the paddles, while Foreman is still checking Andres' pulse. Adams pulls him away just as House shocks Andres back to normal rhythm."I sure hope this Alzheimer's drug trial is worth a lot to this hospital, because we're wasting a crap load of time and man power, just to let this guy watch his mind shrivel and keep his wife miserable." House is pacing in his outer office with the team, plus Foreman, who points out that a heart attack while on interferon rules out encephalitis. But he still thinks he's right about the neurological symptoms. "It's probably aseptic meningitis," he says.
"Dr. Foreman, could you please reach under your chair?" House instructs. But all Foreman pulls up is wet gum. "Where's the card?" he asks. "What card?" House says. House thinks that it's toxins, possibly from a previous unsupervised walk. Even if Natalie keeps the doors locked, he could have gotten into something inside the house. What about toxins left over from when she was a florist? House orders the team to do a home search.
"Stop," Foreman says. "You're not infallible. You were wrong about encephalitis. Run a CSF test. Find out what's causing the meningitis." "You said you weren't going to overrule me diagnostically?" House says. "And you said I wouldn't be able to help it," Foreman answers. "Apparently, you were right about that one."
"What about gifts from South America? Did anyone send any fruits or vegetables?" Since House can't go to their home, he's going to quiz Natalie on any possible toxins. He catches a bit of the Portuguese Andres is speaking. "He's repeating 'blue shack.' Do you know what that is?" he asks Natalie. It's where they had their first date.
House wants to know more about toxins, but Natalie begs him to translate more of what Andres is saying. He reluctantly agrees: "When I saw her waiting, waiting for me at the table, the way her eyes looked when she smiled, I felt like crying. I knew that she was the one that I wanted to marry. Every time I see her, I say, 'There she is.'"
Natalie cries. "He still in there," she says. Andres says something else and she asks House to translate. "He asked who you are." He tells her to have Joseph collect samples from the house.
"How'd you even know to look for a tumor?" Wilson is showing the test results to the husband and wife, who asks if there are any side effects to the treatment. Wilson tells them that, in addition to nausea and dizziness, there will be behavioral changes. "The tumor interferes with certain natural systems. It lowers libido and causes erectile dysfunction." When he learns that the treatment might make him want to have sex, the husband begins to balk.
"I know who I am," he says. "I'm not one of them." His wife says that they'll adjust, but he doesn't want to put her through having sex, which he thinks will be terrible. "It's actually . . . pretty fun," she tells him, to both the husband's and Wilson's surprise. "Look, I knew I wanted to spend my life with you. And I also knew that meant making certain sacrifices. But a girl has needs."
"If you want my money, I'll need to see a five-year plan." Foreman is talking to donors in his office, who are nervous about the management changes at the hospital, and its subsequent lower ranking. Foreman is trying to pay attention, but his eye catches a vase of flowers. "Am I boring you?" the man asks. "No. Those flowers are from last week. They should be dead by now," Foreman says. He can't keep his mind on the meeting. "Sorry," he tells them. "I've got to go."
"It's Reye syndrome." Foreman finds House in the lab. "Patient had a sore throat a few weeks ago before he was admitted." Reye's as an adult? Even if he took aspirin, it's still a reach, especially considering Natalie had all the medicine cabinets locked up. "It wasn't in the medicine cabinet," Foreman says. "Wife used to run a floral company. Still does a few orders from home. She uses crushed aspirin in the water to make the flowers last longer." He could have easily taken a massive amount of aspirin, because every time he realized he had a sore throat he thought it was the first time.
Foreman is pretty pleased with himself. He's already told Chase to put Andres on steroids. "Then why are you telling me?" House asks. "Because I wanted you to hear it from me," he says, and walks out.
"There she is." Andres greets his wife the next morning. "Your eye. What happened?" he asks, seeing the damage he doesn't realize he did. "Nothing I can't handle," she tells him.
"MRI confirmed macroprolactinoma. He's doing the treatment," Wilson tells House, in House's office. "And the wife?" House asks. Wilson knows he's lost the bet and pulls out his wallet. "Come on," House says. "You saved a man's life. Corrected two people's wildly screwed up world views. Not bad for a day's work."
Wilson thinks that the two of them were happy, even if it was based on lies. "Most happiness is," House says, handing Wilson a cigar. "Better to have schtupped and lost then never to have schtupped at all," he says, burning the money he just made from Wilson and using it to light his cigar and then Wilson's. There's a knock at the door. "Is one of you Dr. House?" a uniformed man asks. "I've got an order here to remove his ankle monitor."
"Robby? It's been years." Chase is calling his sister. "I know," he tells her. "I thought of you on Mom's birthday. I just wanted to see how you were."
"Bikes go faster without training wheels." Foreman barely even looks up when House comes to see him. "Now get out. I have work to do." House goes but not before purposely knocking over cup full of pencils and pens. "Whoops."