What history needs to be extracted in a patient with Systemic Lupus Erythematosus (SLE), considering demographics, symptoms, past medical history, and previous treatments?

History Extraction in Systemic Lupus Erythematosus Patients

A comprehensive history in SLE patients must systematically evaluate clinical manifestations, immunological markers, comorbidities, treatment history, and cardiovascular risk factors to determine prognosis and guide management decisions.

Demographics and Basic Information

• Age and sex: SLE predominantly affects women of childbearing age, with approximately 90% of patients being female 1, 2.
• Ethnicity: Document ethnic background as disease prevalence and severity vary across populations 2.
• Pregnancy history and plans: Critical for women of childbearing age, as pregnancy affects disease activity and requires specific management 1.

Disease-Specific Clinical Manifestations

Mucocutaneous Symptoms

• Skin lesions: Document number, type, and distribution of rashes, including malar rash, discoid lesions, photosensitivity, and oral ulcers 1.
• Sun exposure history: Assess ultraviolet light exposure patterns and photoprotection practices 1.

Musculoskeletal Symptoms

• Arthritis: Elicit history of joint pain, swelling, morning stiffness, and functional limitations 1.
• Myalgias: Document muscle pain and weakness 2.

Cardiopulmonary Manifestations

• Serositis: Ask about pleuritic chest pain, pericardial pain, and shortness of breath 1.
• Cardiovascular events: Document any history of myocardial infarction, stroke, or thrombotic events 1.

Neuropsychiatric Symptoms

• Seizures or psychosis: Specifically inquire about these major neurological manifestations 1.
• Cognitive dysfunction: Assess for confusion, memory problems, or acute confusional states 1.
• Peripheral neuropathy: Document numbness, tingling, or weakness 1.
• Headaches: Characterize pattern and severity 3.

Renal Manifestations

• Proteinuria history: Ask about foamy urine or previous urine protein findings 1.
• Hematuria: Document gross or microscopic blood in urine 1.
• Edema: Assess for facial or lower extremity swelling 2.

Hematologic Symptoms

• Anemia symptoms: Fatigue, pallor, shortness of breath 1.
• Thrombocytopenia: Easy bruising, petechiae, or bleeding episodes 1.
• Thrombotic events: Deep vein thrombosis, pulmonary embolism, or arterial thrombosis 1.

Past Medical History

Comorbidities

• Infections: Document history of urinary tract infections and other recurrent infections 1.
• Atherosclerosis: Prior cardiovascular or cerebrovascular disease 1.
• Hypertension: Current or past diagnosis 1.
• Dyslipidemia: Elevated cholesterol or triglycerides 1.
• Diabetes mellitus: Current or past diagnosis 1.
• Osteoporosis: Bone density testing results and fracture history 1.
• Avascular necrosis: Joint pain or imaging findings 1.
• Malignancies: Particularly non-Hodgkin's lymphoma, cervical cancer, breast cancer, and lung cancer 1, 3.

Pregnancy and Reproductive History

• Miscarriages: Number and timing of pregnancy losses 1.
• Stillbirths: Document any fetal deaths 1.
• Premature deliveries: Gestational age at delivery 1.
• Preeclampsia: History in previous pregnancies 1.
• Intrauterine growth restriction: Small for gestational age infants 1.
• Neonatal lupus: Congenital heart block in offspring 1.

Immunological and Laboratory History

Autoantibody Profile

• Anti-dsDNA antibodies: Previous positive results and titers 1.
• Anti-Ro/SSA antibodies: Associated with photosensitivity and neonatal lupus 1.
• Anti-La/SSB antibodies: Often present with anti-Ro 1.
• Antiphospholipid antibodies: Lupus anticoagulant, anticardiolipin, anti-β2-glycoprotein I 1.
• Anti-RNP antibodies: Associated with mixed connective tissue disease features 1.
• Anti-C1q antibodies: Correlates with lupus nephritis 1.
• Antinuclear antibody (ANA): Titer and pattern 2, 4.

Complement Levels

• C3 and C4: Document previous low levels indicating active disease 1.

Routine Laboratory Abnormalities

• Anemia: Hemoglobin levels and type (hemolytic vs. chronic disease) 1.
• Thrombocytopenia: Platelet counts 1.
• Leukopenia: White blood cell counts 2.
• Elevated creatinine: Renal function trends 1.
• Proteinuria: Quantification (24-hour urine or spot protein/creatinine ratio) 1.
• Active urinary sediment: Red blood cells, white blood cells, or cellular casts 1.

Treatment History

Current and Past Medications

• Antimalarials: Hydroxychloroquine or chloroquine dosage and duration 1, 5.
• Glucocorticoids: Current and maximum doses, duration of use 1.
• Immunosuppressive agents: Azathioprine, mycophenolate mofetil, methotrexate, cyclophosphamide—dosages and durations 1.
• Biologic agents: Belimumab, rituximab, anifrolumab—response and adverse effects 2.
• NSAIDs: Frequency and complications 1.
• Anticoagulation: Aspirin, warfarin, or direct oral anticoagulants for antiphospholipid syndrome 1.

Treatment Response and Adverse Effects

• Disease flares: Frequency, severity, and triggers 1.
• Remission periods: Duration and maintenance therapy 2.
• Drug toxicity: Specific adverse effects from each medication 1.
• Ophthalmologic screening: Retinal examination results for hydroxychloroquine toxicity 5.

Cardiovascular Risk Factor Assessment

Traditional Risk Factors

• Smoking history: Current, former, or never; pack-years 1.
• Physical activity level: Exercise frequency and intensity 1.
• Family history: Premature cardiovascular disease in first-degree relatives 1.
• Oral contraceptives: Current or past use 1.
• Hormone replacement therapy: Current or past use 1.

Metabolic Parameters

• Blood pressure: Current readings and hypertension history 1.
• Body mass index: Current weight and height 1.
• Waist circumference: Central obesity assessment 1.
• Lipid profile: Total cholesterol, LDL, HDL, triglycerides 1.
• Glucose levels: Fasting glucose or hemoglobin A1c 1.

Lifestyle and Social History

Modifiable Risk Factors

• Smoking status: Current use and cessation attempts 1.
• Alcohol consumption: Frequency and quantity 1.
• Diet: Saturated fat intake and fish oil consumption 6.
• Exercise habits: Type, frequency, and duration 1.
• Weight control efforts: Recent weight changes 1.

Bone Health

• Calcium intake: Dietary and supplemental 1.
• Vitamin D intake: Dietary and supplemental 1.
• Fracture history: Previous fragility fractures 1.

Infection Risk Assessment

Vaccination History

• Live vaccines: Avoid if on immunosuppression 1, 6.
• Pneumococcal vaccine: Status and timing 1.
• Influenza vaccine: Annual administration 1.
• Hepatitis B vaccine: Status and titers 1.
• Herpes zoster vaccine: Recombinant vaccine preferred 1.

Infection Screening

• HIV status: Based on patient risk factors 1.
• Tuberculosis screening: PPD or interferon-gamma release assay 1.
• Hepatitis B and C: Serologic testing 1.

Quality of Life Assessment

Functional Status

• Patient global assessment: 0-10 visual analog scale for overall well-being 1.
• Fatigue severity: Impact on daily activities 2.
• Pain levels: Severity and location 1.
• Work disability: Ability to maintain employment 1.

Psychosocial Factors

• Depression and anxiety: Screening for mood disorders 3.
• Social support: Family and community resources 1.
• Stress levels: Major life stressors 6.

Critical Pitfalls to Avoid

• Distinguishing disease activity from damage: Active inflammation requires immunosuppression, while irreversible damage does not 3.
• Infection versus flare: Maintain high suspicion for infection in immunosuppressed patients before escalating immunosuppression 1, 7.
• Pregnancy planning: Assess contraception needs and counsel about teratogenic medications (methotrexate, mycophenolate mofetil, cyclophosphamide) 1, 8.
• Antiphospholipid syndrome recognition: Thrombotic events or pregnancy losses require specific anticoagulation management 1.
• Glucocorticoid toxicity: Document cumulative exposure and screen for osteoporosis, diabetes, hypertension, and avascular necrosis 1.