What essential questions should be asked when taking a history from a patient with systemic lupus erythematosus?

Essential History Questions for SLE Patients

When taking a history from a patient with systemic lupus erythematosus, you must systematically assess disease activity across all organ systems, screen for cardiovascular and infection risks, evaluate treatment-related complications, and assess quality of life—this structured approach directly impacts morbidity and mortality outcomes. 1

Constitutional and Quality of Life Assessment

• Ask about fatigue severity using a 0-10 visual analog scale at every visit, as this is the most common symptom affecting quality of life 1, 2
• Document weight changes (both loss and gain), as constitutional symptoms occur in approximately 48% of SLE patients 2
• Assess overall disease impact on daily activities, household tasks, and work capacity to evaluate functional status 1

Mucocutaneous System

• Inquire specifically about malar rash (present in 38% at initial presentation), photosensitivity (35%), and discoid lesions (~18%) 3, 2
• Ask about hair loss (alopecia), which occurs in approximately 39% of patients 2
• Document oral or nasal ulcers, as these are classification criteria features 3, 4
• Characterize any skin lesions as LE-specific, LE-nonspecific, LE mimickers, or drug-related to guide management 1, 3

Musculoskeletal Manifestations

• Ask about joint pain (arthralgia), present in approximately 69% of patients 2
• Document muscle pain (myalgia), occurring in ~56% of cases 2
• Inquire about frank arthritis (joint swelling), seen in ~48% of patients 2

Renal System—Critical for Mortality Prevention

• Ask about edema (facial, periorbital, or lower extremity swelling) 3
• Document foamy urine, which suggests significant proteinuria 3
• Inquire about hematuria (visible blood in urine) 3
• Ask about changes in urinary frequency or volume, as these may indicate renal involvement 3
• Screen for hypertension symptoms including headaches and vision changes, as blood pressure control is essential in lupus nephritis 3

This is critical because approximately 40% of SLE patients develop lupus nephritis, and 10% of those progress to end-stage kidney disease within 10 years 4

Neuropsychiatric Assessment—Often Overlooked

• Screen for seizures and any history of convulsive episodes 1, 3
• Ask about headache patterns (frequency, severity, associated symptoms) 1, 3
• Document cognitive dysfunction by specifically asking about:
  • Problems with multitasking 1, 3
  • Difficulty completing household tasks 1, 3
  • Memory problems 1, 3
  • Attention and concentration difficulties 1, 3
  • Word-finding difficulties 1, 3
• Screen for mood disorders, particularly depression 1, 3
• Ask about peripheral neuropathy symptoms (numbness, tingling, weakness) 1, 3
• Document any stroke-like symptoms or transient neurological deficits 3

Hematologic and Thrombosis History—High Mortality Risk

• Ask about any history of blood clots (arterial or venous thrombosis) 3
• Document arterial events including stroke, TIA, or myocardial infarction, especially at young age 3
• Inquire about venous thrombosis including DVT and pulmonary embolism 3

Identifying antiphospholipid syndrome is essential as it significantly increases morbidity and mortality 3

Obstetric/Gynecologic History

• Ask about recurrent miscarriages (≥3 consecutive pregnancy losses) 3
• Document history of preeclampsia, intrauterine growth restriction, or stillbirths 3
• Inquire about use of oral contraceptives or hormonal therapies, as these affect cardiovascular risk 1, 3

Cardiovascular Risk Factors—Major Cause of Mortality

SLE patients have accelerated atherosclerosis and increased cardiovascular mortality that cannot be fully explained by traditional risk factors alone 1, 3

• Document smoking status (current, former, pack-years) 1, 3
• Ask about history of vascular events (MI, stroke, peripheral vascular disease) 1, 3
• Assess physical activity level and sedentary lifestyle 1, 3
• Obtain family history of premature cardiovascular disease 1, 3
• Screen for diabetes symptoms and known diagnosis 1
• Document known hypertension and control status 1
• Ask about dyslipidemia history 1

Infection Risk Assessment—Leading Cause of Death

Infections are a major cause of morbidity and mortality in SLE patients, particularly those on immunosuppression 3, 5

• Screen for HIV, hepatitis C, and hepatitis B risk factors before initiating immunosuppression 6, 3
• Assess tuberculosis exposure risk according to local epidemiology 6
• Document recent or recurrent infections (frequency, severity, sites) 3
• Ask about vaccination status (pneumococcal, influenza, COVID-19) 3

Osteoporosis Risk Factors

• Assess calcium and vitamin D intake (dietary and supplemental) 1, 6
• Document exercise habits and weight-bearing activity 1, 6
• Inquire about history of fractures (especially vertebral or hip) 1
• Ask about sun avoidance behaviors, which may contribute to vitamin D deficiency 1

Osteoporosis prevalence ranges from 4-24% in SLE patients, with vertebral fractures in 7.6-37% 1

Medication History and Drug Toxicity

• Document all current immunosuppressive medications with doses and duration 1
• Record glucocorticoid exposure (current dose, cumulative exposure, highest dose ever) 1
• Ask about hydroxychloroquine use and duration (for retinopathy risk stratification) 1
• Screen for medications that can cause drug-induced lupus (hydralazine, procainamide, isoniazid, minocycline) 3
• Inquire about antimalarial use and last ophthalmology examination 1
• Document cyclophosphamide exposure if applicable (for cancer screening) 1

Cancer Screening History

Cancer incidence is increased in SLE, particularly hematological malignancies, cervical, breast, and lung cancer 1

• Ask about last cervical smear test (abnormal cervicovaginal cytology in up to 16% of patients) 1
• Document last mammogram (if age-appropriate) 1
• Inquire about colonoscopy screening (if age-appropriate) 1

SLE patients undergo cancer screening less frequently than the general population despite higher risk 1

Disease Activity Assessment

• Ask about new or worsening symptoms in any organ system since last visit 1
• Document flare frequency and triggers (sun exposure, medication non-adherence, infection) 7, 8
• Assess medication adherence, particularly hydroxychloroquine, as non-adherence increases mortality 4, 7