 Hand pain , small joints pain of both hands
 Skin rash






Ask the patient about Nature of the pain ( burning , dull , electric like, pins
and needles ) to differentiate between polyarthritis , Raynaud’s and carpal tunnel

Site of pain :Unilateral or bilateral (symmetry) which joint involved
(knuckles – near joints or far joints)?

Worsening factors ie movement , cold weather

Improving factors .i.e. rest , any drugs

Timing → more at morning or night .. carpal tunnel more at sleep time .

Any other joint involved? Back pain?

Grade of the pain →from 0 -10.

Morning stiffness? → For how long?

Systemic review:
 any color changes when exposed to cold weather (Raynaud’s phenomenon)
 skin rash ,analysis of the rash, does the rash worsened by exposure to sun
 loose motions (enteropathic arthritis)
 burning micturition (reactive arthritis)
 eye symptoms i.e. pain , redness

Ask about other criteria of SLE

Mouth sores
Falling of hair ( discoid lupus)
Joint pain ( arthritis)
Chest pain,racing of heart beats ,SOB on exertion , on lying down , awaken
him from sleeping , leg swelling (2nd pulmonary HPN) , ( pleuritis ,
pericarditis , myocarditis , libman-sacs endocarditis)
Bombs or lumps ( lymphadenopathy )
Any pallor or fatigue ( anemia)
Any change in urine amount , color , frothy urine , eye puffiness ( lupus
nephritis )?
Seizures , weakness , pins and needles (lupus cerebritis)
Symptoms of Anti phospholipid syndrome: hx of abortion , blood clot , FH
of blood clot ?

For Mixed connective tissue disease →
Hand deformity , SOB , any finger color changes in cold weather (
Raynaud’s) →RA
SOB, cough , Difficulty of swallowing , (Raynaud’s) →SS
Proximal myopathy ( difficulty of combing hair or getting up from a
chair ) , muscle pain →Dermatomyositis
Dry mouth , gritty eye sensation →Sjogren

Social history

Job and how much impact job and usual daily activity?→If do say: I am
sorry I will refer u to a social worker to solve this problem for you ( very

With whom he is living?

Financial support

Smoking + alcohol

M .H : DM , HPN , IHD
F.H: of similar condition , DM , HPN
Drug history: What is your drug list?

o LOOK : for joint swelling, deformity scars , pigmentation

o FEEL : for warmness by comparing by dorsum of the same hand
between hand joints and forearm and soreness by delicate
compression of the joints between your fingers .

o MOVE (Functional status) : prayer sign , reversed prayer sign
, fest compression , picking up coins , buttoning and unbuttoning .
o Examine for proximal myopathy→ by both arms power (
dermatomyositis , steroid therapy )

 Cushingoid features→, butterfly rash , plethoric ,round face (steroid
therapy complication)
 The oral cavity for any mouth sores.
 Examine the SCALP : for hair falling or scarring
BODY:for truncal obesity , intrascapular, supra clavicular fat bad , stia alba and
rubra ( complications of steroids )
CVS : jvp , murmurs for libman-sacs endocarditis , bibasal lung auscultation .
LL : edema ( as a complication of cardiac or renal involvement)

N.B : don’t forget in jaccod arthropathy in SLE the is hand finger deformity
looks like RA in which the deformity is non erosive , can be corrected and no X
ray changes like RA

What could be the cause doctor ?
Most properly you have a disease called SLE , due to disturbance in your
defensive system , attacking many systems in your body .

We have to do for you further blood tests and imaging to confirm our
diagnosis , then we will refer you to a multidisciplinary team involving
rheumatologist , social worker , psychiatrist , to give you the plan of
management .
N.B If there is symptoms or signs of Lupus nephritis , tell the patient that a
snip from the kidney may be needed under aseptic condition and anesthesia
to make staging for the disease .

Is it curable doctor ?
I’m sorry it’s not curable , but it can be controlled by restrict and
compliance on medications and fellow up .

‫نسألكم الدعــــــــــــــــــــاء‬