| Patient features may have been present in the past or at present. | ||
|---|---|---|
|
| ||
| Clinical case presentation and progress (include disease duration): 65 year old female with disease duration for 30 years | ||
| Clinical features | ||
|
| ||
| □ Yes | ⊠ No | Skin thickening |
| Describe location, extent, progression: | ||
|
| ||
| ⊠ Yes | □ No | Abnormal nailfold capillaries consistent with scleroderma |
| ⊠ Yes | □ No | Calcinosis |
| □ Yes | ⊠ No | Digital pulp loss or acro-osteolysis |
| ⊠ Yes | □ No | Dysphagia for solids |
| □ Yes | ⊠ No | Esophageal dilation |
| □ Yes | ⊠ No | Finger flexion contracture |
| □ Yes | ⊠ No | Finger tip ulcers or pitting scars |
| □ Yes | ⊠ No | Puffy fingers |
| ⊠ Yes | □ No | Interstitial lung disease or pulmonary fibrosis |
| ⊠ Yes | □ No | Pulmonary arterial hypertension |
| ⊠ Yes | □ No | Gastro-esophageal reflux disease |
| ⊠ Yes | □ No | Raynaud’s phenomenon |
| □ Yes | ⊠ No | Renal crisis |
| ⊠ Yes | □ No | Telangiectasias |
| □ Yes | ⊠ No | Tendon or bursal friction rubs |
|
| ||
| Laboratory features | ||
|
| ||
| ⊠ Positive | □ Negative | Antinuclear antibody |
| □ Positive | ⊠ Negative | Anti-centromere antibody |
| □ Positive | ⊠ Negative | Anti-topoisomerase-I antibody |
| □ Positive | ⊠ Negative | Anti-PM-Scl antibody |
| □ Positive | ⊠ Negative | Anti-RNA polymerase III antibody |
|
| ||
| Investigations | ||
|
| ||
| ⊠ Yes | □ No | DLCO < 80% predicted |
| ⊠ Yes | □ No | FVC < 80% predicted |
|
| ||
| Any other information which may be relevant to the probability this patient has Systemic Sclerosis: | ||
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