What are the key review of system questions for a patient with suspected Systemic Lupus Erythematosus (SLE)?

Review of Systems Questions for Suspected Systemic Lupus Erythematosus

When evaluating a patient for suspected SLE, conduct a systematic organ-based review focusing on constitutional symptoms, mucocutaneous manifestations, musculoskeletal complaints, renal symptoms, neuropsychiatric features, hematologic abnormalities, and cardiovascular/thrombotic events, as these represent the most common and clinically significant presentations that impact morbidity and mortality. 1, 2

Constitutional Symptoms

• Fever: Ask about unexplained fevers, particularly those not responding to antibiotics, as fever is a key clinical factor in SLE classification criteria 2
• Fatigue: Inquire about persistent, debilitating fatigue that interferes with daily activities, as this represents one of the earliest complaints in most patients 3
• Weight loss: Document unintentional weight changes 4

Mucocutaneous System

• Rashes: Specifically ask about:
  • Malar (butterfly) rash across cheeks and nose 2
  • Photosensitive rashes that worsen with sun exposure 4
  • Discoid lesions (raised, scaly patches) 5
  • Subacute cutaneous lupus lesions 5
• Oral/nasal ulcers: Ask about painless mouth or nose sores 3
• Alopecia: Inquire about hair loss, particularly non-scarring alopecia 3
• Raynaud's phenomenon: Ask about color changes in fingers/toes with cold exposure 4

The European League Against Rheumatism recommends characterizing mucocutaneous lesions as LE-specific, LE-nonspecific, LE mimickers, or drug-related 5

Musculoskeletal System

• Arthritis/arthralgia: Ask about joint pain, swelling, and morning stiffness, particularly in small joints of hands, wrists, and knees 2, 3
• Myalgia: Inquire about muscle pain and weakness 3
• Joint deformities: Document any joint deformities, though these are less common than in rheumatoid arthritis 4

Renal System

This is critical as approximately 40% of SLE patients develop lupus nephritis, and 10% progress to end-stage kidney disease within 10 years 2

• Edema: Ask about swelling in legs, ankles, or around eyes 5
• Urinary changes: Inquire about:
  • Foamy urine (suggesting proteinuria) 5
  • Hematuria 5
  • Changes in urinary frequency or volume 5
• Hypertension symptoms: Ask about headaches, vision changes 5

Neuropsychiatric System

The European League Against Rheumatism specifically recommends focused history for neuropsychological symptoms 5

• Seizures: Ask about any seizure activity or loss of consciousness 5, 2
• Headaches: Document severe, persistent, or migraine-like headaches 5
• Cognitive dysfunction: Specifically ask about:
  • Problems with multitasking 5
  • Difficulty with household tasks 5
  • Memory problems 5
  • Attention and concentration difficulties 5
  • Word-finding difficulties 5
• Mood disorders: Inquire about depression, anxiety, or psychosis 5
• Peripheral neuropathy: Ask about paresthesias, numbness, or weakness 5
• Stroke symptoms: Document any transient or persistent neurological deficits 5

Hematologic System

• Easy bruising or bleeding: Ask about spontaneous bruising, prolonged bleeding, or petechiae 2
• Anemia symptoms: Inquire about excessive fatigue, pallor, shortness of breath 2
• Thrombosis history: Document any history of blood clots (DVT, PE, stroke) 5, 2

Cardiopulmonary System

• Chest pain: Ask about pleuritic chest pain (worse with deep breathing), suggesting serositis 4
• Shortness of breath: Inquire about dyspnea at rest or with exertion 4
• Pericarditis symptoms: Ask about positional chest pain 4

Ophthalmologic System

• Vision changes: Document any visual disturbances, as these may indicate retinal vasculitis or other complications 5
• Dry eyes: Ask about sicca symptoms 5

Obstetric/Gynecologic History (for women)

• Pregnancy complications: Specifically ask about:
  • Recurrent miscarriages (≥3 consecutive) 5
  • Preeclampsia 5
  • Intrauterine growth restriction 5
  • Stillbirths 5
• Menstrual irregularities: Document any changes in menstrual patterns 4

Vascular/Thrombotic History

This is essential for identifying antiphospholipid syndrome, which significantly increases morbidity and mortality 5

• Arterial thrombosis: Ask about stroke, TIA, myocardial infarction at young age 5
• Venous thrombosis: Inquire about DVT, PE, or unusual site thromboses 5

Medication and Environmental Exposures

• Drug-induced lupus: Ask about medications known to trigger lupus-like syndromes (hydralazine, procainamide, isoniazid, minocycline) 5
• Sun exposure: Document patterns of sun exposure and photosensitivity 4

Family History

• Autoimmune diseases: Ask about SLE, rheumatoid arthritis, Sjögren's syndrome, or other autoimmune conditions in family members 4

Cardiovascular Risk Assessment

The European League Against Rheumatism emphasizes cardiovascular risk screening as SLE patients have accelerated atherosclerosis 1

• Smoking status 1
• History of vascular events 1
• Physical activity level 1
• Use of oral contraceptives/hormonal therapies 1
• Family history of cardiovascular disease 1

Common Pitfalls to Avoid

• Do not dismiss vague constitutional symptoms as these may be the earliest manifestations before organ-specific involvement becomes apparent 3
• Do not overlook cognitive complaints as subtle cognitive dysfunction is common but often underrecognized unless specifically queried 5
• Do not fail to ask about pregnancy history as recurrent miscarriages may be the presenting feature of antiphospholipid syndrome associated with SLE 5
• Do not neglect to assess for infection risk factors as infections are a major cause of morbidity and mortality in SLE patients 1, 4