The Heart of the Matter

A CLINICAL PROBLEM-SOLVING article by Laura Tarter from Stanford University Medical Center, Palo Alto, California.
A 22-year-old woman presented to the emergency department with a 4-week history of cough, progressive shortness of breath, subjective fevers, and malaise. On the day of admission, she was unable to walk farther than one city block without stopping to rest. She noted new swelling in both legs.
The patient reported having arthralgias in her hands and knees that had begun 3 months before admission and were worse in the morning.
The patient was a well-nourished woman who appeared anxious, with mildly increased respiratory effort. She had tachycardia with a regular rhythm, a loud first heart sound, and a normal second heart sound. A grade 2/6 systolic murmur was best heard at the base, and a low-pitched grade 2/4 rumbling diastolic murmur was best heard at the apex. Subtle synovitis was present in four metacarpophalangeal joints and in her left wrist, and she had three, bilaterally distributed subungual splinter hemorrhages.
The patient remained afebrile throughout her hospital stay.
Although SLE was a leading consideration at multiple points in this case, the clinicians and the discussant were repeatedly forced to consider whether additional data supported a diagnosis of SLE and SLE-related phenomena or provided contradictory information that could change the working diagnosis. This cognitive process involved both pattern recognition and analytic reasoning.