Table 1

Main epidemiological, clinical, and laboratory data to be recorded in the clinical chart

Section 1 Sections 2–3–4
Demographic dataTotal skin score (TSS)1-153
Generalised complaints
Historical dataArticular/muscular manifestations
ACR classification criteria fulfilled1-150 Mucocutaneous manifestations
Clinical subset1-151 Ocular manifestations
Serological subset1-152 Cardiopulmonary manifestations
Onset manifestation(s)Vascular manifestations
Organs previously affectedGastrointestinal manifestations
Treatment: Past and discontinued
Haematological alterations
Renal alterations
Neuropsychiatric manifestations
Laboratory investigations
Treatment:Used in the past
Currently prescribed
  • 1-150 Masi et al 7;

  • 1-151 according to Le Roy et al 9;

  • 1-152 anti-DNA topo I, anticentromere antibodies, others;

  • 1-153 according to Kahaleh et al.24