Pisa xxx - Annals of the Rheumatic Diseases



|(Id here) |

Sociodemographic data

|Age: | |Sex |( woman |Ethnicity |( Caucasian |Education |( None |

| | | |( man | |( Black | |( Primary |

| | | | | |( Asian | |( Secondary |

| | | | | |( __________ | |( University |

Clinical data

|Fulfils ACR criteria for SLE: |( yes |Date at first clinical manifestation: | |

| |( no | | |

Cardiovascular risk factors and other comorbidities

|Weight: |kg |Height: |cm |BMI | Kg/m2 |Waist circumpherence: |cm |

| | |Specify method of identification. Comments. |

|Obesity (BMI>25) |( yes ( no | |

|Diabetes |( yes ( no | |

|Hypertension |( yes ( no | |

|Dyslipidemia |( yes ( no | |

|Smoker |( yes ( no | |

|Familial CV events |( yes ( no | |

|Cancer |( yes ( no | |

|Osteoporosis |( yes ( no | |

|Tuberculosis[1] |( yes ( no | |

|Hepatitis B |( yes ( no | |

|Hepatitis C |( yes ( no | |

|HIV |( yes ( no | |

|CMV |( yes ( no | |

Current medications and dose

|Medication |Dose (mg, g) |Schedule (/wk, d, ...) |Comments |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

Patient assessment

|Disease activity | |

|Damage (once a year) | |

|General quality of life by patient history or 0-10 VAS | |

Organ involvement I (labs)

|Laboratory assessment |Ordered |Result |Comments |Organ involvement |

|ESR |( | | | |

|CRP |( | | | |

|CBC count |( | | |Hematological ( |

|Serum albumin |( | | |Kidney ( |

|Serum creatinine |( | | | |

|EGFR |( | | | |

|Urinalysis |( | | | |

|protein/creatinine ratio |( | | | |

|24 h proteinuria |( | | | |

|C3 |( | | | |

|C4 |( | | | |

|Autoantibody assessment |Ordered |Result |Comments |

|ANA[2] |( | | |

|anti-dsDNA2 |( | | |

|anti-Ro2,[3] |( | | |

|anti-La2,3 |( | | |

|anti-RNP2 |( | | |

|anti-Sm2 |( | | |

|aPL2,[4] |( | | |

Organ involvement II (examination)

|( Joints |Arthralgias: |Inflamed joints: Comments: |

| |( yes |[pic] |

| |( no | |

|( skin |Lesions: |( lupus specific |

| |( yes |( lupus non- specific |

| |( no |( lupus mimickers |

| | |( drug-related |

| |Comments: |

|( CNS |Fatigue |( yes ( no |Comments: |

| |Headache |( yes ( no | |

| |Epilepsy |( yes ( no | |

| |Depression |( yes ( no | |

| | |

|( Lung |Chest pain |( yes ( no |Peripheral edema |( yes ( no |Comments: |

| |Dyspnea |( yes ( no |Heart murmur |( yes ( no | |

| |Cough |( yes ( no | | | |

|( Heart |Crackles |( yes ( no |Heart rate: | | |

| |Rales |( yes ( no |NYHA: | | |

| |Pleural effusion |( yes ( no |Systolic/diastolic BP | | |

|( Eye |(Examination by an ophthalmologist or an optitician) |

| | |

| | |

|( Vascular |Raynaud's |( yes ( no |Comments: |

| |Thrombotic risk factors |( yes ( no | |

| |Claudication |( yes ( no | |

|( g.i. |Symptoms. Comments: |

Decision. Comments:

| |

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[1] Screen according to local guidelines and treat before immunosuppressive treatment or high dose steroids.

[2] At baseline

[3] Re-evaluate before pregnancy

[4] Re-evaluate in previously negative patients prior to pregnancy, surgery, transplant, and oestrogen containing treatments, or in the presence of new neurologic or vascular event

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