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:
| |
-----------------------
[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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