Variations on a Theme

A CLINICAL PROBLEM-SOLVING article by Zachary Goldberger from Veterans Affairs Puget Sound Health Care System, Seattle, Washington
A 57-year-old man presented to the emergency department with a 2-week history of progressive dyspnea with exertion, edema of the upper and lower legs, a nonproductive cough, and scant hemoptysis. He also reported the occasional passage of bright red blood from his rectum and intermittent nausea and vomiting during the previous 4 days.
The patient's medical history included hypertension, type 2 diabetes mellitus, hyperlipidemia, and gastroesophageal reflux with Barrett's esophagus. He was a heavy smoker and he had worked with paint solvents approximately 2 weeks before coming to the hospital but reported no previous exposure to hydrocarbons.
On admission, the patient had tachypnea and his oxygen saturation was mildly depressed. There was conjunctival pallor and dried blood in the oropharynx. Crackles were heard at both lung bases. The cardiac examination revealed an early systolic murmur, grade 1 out of 6. A rectal examination revealed external hemorrhoids.
This seemingly unrelated array of symptoms cannot be readily explained by a single diagnosis, but their simultaneous development tempts the clinician to find a unifying cause.
This case of multiorgan disease has classic themes with interesting variations. A good clinical history with rigorous analysis enabled the discussant to deduce combined diagnoses.

タイトルは、「主題による変奏曲」の意味。