When Past Is Prologue

A CLINICAL PROBLEM-SOLVING article by Nihar Desai from Brigham and Women's Hospital, Boston.
A 36-year-old man presented to the emergency department with a 2-week history of lower-extremity edema, progressive fatigue, and exertional dyspnea.
The patient's medical history was notable for a fall from a roof 10 months before this presentation. He had traumatic head injury with multiple cranial fractures, including a basal skull fracture, and underwent bifrontal craniotomies. After an extensive rehabilitation period, he achieved almost full functional recovery. Eight months before this presentation, dyslipidemia was diagnosed.
Atorvastatin was started but then discontinued because of myalgias and elevated levels of creatine kinase and aspartate aminotransferase. One month later, his symptoms had improved, but the creatine kinase level had risen to 1200 U per liter. The thyrotropin level was 0.32 mIU per liter.
On examination, the patient appeared chronically ill and in mild respiratory distress.
Rales, S3 gallop, and elevated jugular venous pressure indicate severe left ventricular dysfunction with volume overload. The constellation of hypotension, narrow pulse pressure, and cool extremities is consistent with what has been described as the “cold and wet” classification of acute heart failure, which is a type of cardiogenic shock.
In this case, the first priority is to stabilize the patient. As the patient is being medically stabilized, ongoing investigations of the underlying disease process should continue to focus on possible causes of both his clinically evident cardiomyopathy and a skeletal myopathy.

タイトルは、シェークスピアの戯曲「テンペスト」アントーニオのセリフ"Whereof what's past is prologue, what to come In yours and my discharge."(Act II Scene I)
から。