Name

Birth Date

Age

Gender

Male Female

Residency

--< Select >-- Cairo Giza Alexandria Port Said Suez Demiatt Dakahlia Sharkia Qalyoubia Kafr Shaikh Gharbia Menouffia Behaira Ismaillia Beni Suif Fayoum Minia Assuit Sohag Qena Asswan Luxor Al Bahr Al Ahmar Al Wadi Al Gaddid Matrouh N. Sinai S. Sinai Other Country

Occupation

Weight (kg)

Height (m)

BMI (Body Mass Index)

Smoking

Yes No

Sclerodermal subtype

Limited Diffuse

Family History of Scleroderma

Informed Consent

Onset of Raynaud's (in years)

Symmetry of Raynaud's

Symmetrical Asymmetrical

Painful attacks of Raynaud's

Yes No

Skin Thickening

Proximal to MCPs Proximal to Elbows, Knees

Sclerodactyly

Yes No

Digital tip ulcers

Yes No

Fingertip pitting scars

Yes No

Telangectasia

Yes No

Calcinosis

Yes No

GIT Affection

GERD Dysphagia Malabsorption Fecal incontinence

Cardiac Affection

Dyspnea Arrythmia Pericardial Effusion Cardiomyopathy

Pulmonary affection

Exertional dyspnea Cough Chest pain

Interstitial Pulmonary Fibrosis (IPF)

Yes No

Scleroderma Renal Crisis

Yes No

Arthtitis

CBC

ESR

CRP

Kidney Function Tests

Normal Abnormal

Liver Function Tests

Normal Abnormal

ANA (Anti-Nuclear Antibodies)

Positive Negative

Anti SCL-70 antibodies

Positive Negative Not done

Anti Centromere antibodies

Positive Negative Not done

Anti RNA polymerase antibodies

Positive Negative Not done

Anti U1-RNP antibodies

Positive Negative Not done

HRCT

Honey Comb Appearance Ground Glass Appearance

ECHO

DLCO

Right side heart catheterization

Upper Endoscopy

Normal Wide mouth diverticula

DEXA

Normal Osteopenia Osteoporosis Severe Osteoporosis

Spirometry

Normal Abnormal

Capillaroscopy

Normal (non dilated loops) Abnormal (Distorted dilated, enlarged, tortous, or area of avascularity)

Pulmonary hypertension

Yes No

Heart failure

Yes No

Gangrene

Yes No

GAVE (Gastric Antral Ventral Ectasia)

Yes No

Modified Rodnan score

EScSG activity index

Medsger's Severity scores

NSAIDs

DMARDS

Methotrexate Leflunomide Sulphasalazine Hydroxychloroquine

Immunosppressive Drugs

Cyclophosphamide Azathioprine MMF Cyclosporine

Raynaud's, Pulmonary HTN medications

Calcium channel blockers (CCB) PDE5 inhibitors Prostacyclin Endothelial receptor antagonists

GIT medications

PPIs Prokinetics Antibiotics

Hypertensive renal disease medications

ACEIs ARBs CCB Prostacyclin

Biological agents

--< Select >-- Humira (Adalimumab) Enbrel (Etanercept) Simponi (Golimumab) Cimzia (Certolizumab) Remicade (Infliximab) Actmera (Tocilizumab) Kineret (Anakinra) Stelara (Ustekinumab) Cosentyx (Secukinumab) Xeljanz (Tofacitinib) Mabthera (Rituximab) Orencia (Abatacept)