History of Systemic Lupus Erythematosus and Hypertension

A26-year-old black woman with a history of systemic lupus erythematosus (SLE) and hypertension presented to the Hermann Hospital emergency department with a 1-week history of retrosternal chest pain described as constant and sharp. She stated that the pain occurred at rest, increased with deep inspiration, was not related to position or meals, and lasted all day long, although she did note episodes of pain lasting 5 to 30 minutes at a time. She was previously evaluated as an outpatient for similar symptoms 1 week before admission, and her usual dose of prednisone was increased with minimal relief. On the day of admission, the chest pains became more intense and were also associated with nausea, diaphoresis, and dyspnea. She denied symptoms of upper respiratory infection, paroxysmal nocturnal dyspnea, palpitations, cough, or fevers. She did have mildly increasing lower extremity edema over the previous week. Her past medical history included the diagnosis of SLE in 1977 at the age of 15, SLE-related pericarditis in 1983, preeclampsia complicating her first pregnancy in 1984, and premature labor and nephrotic syndrome complicating her second pregnancy in 1985. At that time, a renal biopsy revealed membranous glomerulonephritis. Her medications on admission included Elavil 50 mg PO once a day and prednisone 40 mg PO once a day. She was able to walk two flights of stairs before becoming fatigued, although she did state that she was feeling more fatigued over the past 2 months. Physical examination revealed a slightly overweight, anxious woman described as in obvious pain. Vital signs included a temperature of 96.40F orally, pulse of 80 and regular, respirations of 22, and a supine blood pressure of 130/90 mm Hg. There was no pulsus paradoxus. She had mild alopecia with anicteric sclerae. Pupils were