Which of the following is most likely to be observed in this patient?

A 30-year-old African-American female presents to the emergency room complaining of chest pain. She also complains of recent onset arthritis and increased photosensitivity. Physical examination reveals bilateral facial rash. Which of the following is most likely to be observed in this patient?

1.Pain improves with inspiration
2.Pain relieved by sitting up and leaning forward
3.High pitched diastolic murmur
4.Displaced apical impulse
5.Mid systolic click

sol:

Arthritis, photosensitivity, and facial rash in an African-American woman are consistent with systemic lupus erythematosus (SLE). The most common cardiovascular syndrome associated with SLE is pericarditis.
SLE is a multisystem inflammatory disease. Pericarditis is a common manifestation of SLE. Pericarditis presents as severe, constant chest pain radiating to the shoulders, arms, and back. The pain is pleuritic and postural (relieved by sitting up and leaning forward). Auscultation of pericarditis will reveal a pericardial friction rub.
Gill et al. review that the antinuclear antibody (ANA) titer is the primary laboratory test used to diagnose SLE. However, because the prevalence of SLE is low in the general population, ANA has a low predictive value in patients without typical clinical symptoms and it should only be obtained in patients with unexplained involvement of two or more organ systems. While an ANA titer of less than 1:40 usually rules out SLE, patients with persistent, characteristic multisystem involvement may be evaluated for possible ANA–negative disease.
The American College of Rheumatology (ACR) criteria for classification of SLE has 85% sensitivity and 95% specificity for SLE when any 4 or more of 11 criteria are noted serially or simultaneously in an individual patient. The criteria include: malar rash, discoid lupus, photosensitivity, oral or nasopharyngeal ulcers, nonerosive arthritis, pleuritis OR pericarditis, renal involvement (usually proteinuria), seizures OR psychosis, hematologic disorder, immunologic disorder, and positive ANA.
Illustration A is an example of a malar rash. Note the sparing of the nasolabial folds.
Illustration B is an example of discoid lupus, erythematous raised patches with adherent keratotic scaling.
Illustration C is an ECG showing pericarditis. Notice the ST elevation in all leads and PTa depression in the precordial leads (depression between the end of the P-wave and the beginning of the QRS-complex).