Table 3.
Domain Organization for Clinical Assessment and Documentation in SSc. Each sub-domain is often characterized by onset, coincident intervention, and changes over time.
| Domains | Sub-Domains | Assessment Considerations |
|---|---|---|
| Background | Biological sex | |
| Ethnicity and race | ||
| Environmental exposure history | e.g. chemicals via occupation or proximity | |
| Cardiovascular history | Especially noting hypertension | |
| Disease Duration | Raynaud’s phenomenon onset (month/year) | |
| What was 1st non-Raynaud’s phenomenon symptom | ||
| Onset of 1st non-Raynaud symptom (month/year) | ||
| Physician diagnosis of SSc (month/year) | ||
| Skin Thickening | Onset month/year | |
| Distribution (mRSS) | ||
| Pruritus | ||
| Pigmentation disturbances | e.g. hypo-, hyer- or poikiloderma | |
| Telangiectasia and Calcinosis | Recorded here or under the vascular domain | |
| Vascular Manifestations Please see and incorporate components of Table 7 for document template | ||
| HEENT | Facial Changes | Oral aperture |
| Eyes | Dry Eyes | |
| Oral | Tooth loosening, Chewing difficulty Oral pain Dry mouth Dental caries |
|
| Naso-pharyngeal | Post Nasal Drip (lung irritant) Hoarseness of voice (vocal cord fibrosis or acid injury) |
|
| Cardiopulmonary | History of symptoms Dyspnea/Cough / Exercise Intolerance NYHA Symptom Category |
1st noticed symptoms to now Tables 9–10 for contextualizing history taking Although a categorical variable that limits utility, a worsening NYHA classification marks significant clinical worsening |
| Cardiac symptoms including lower extremity edema, orthopnea | Arrhythmias/conduction disturbances, heart failure | |
|
Gastrointestinal Consider following SCTC-GIT or Geissen tools for overall GI impact |
Swallowing difficulty | Proximal Distal Choking, coughing |
| Acid related | Heartburn Hoarseness Cough, timing e.g. morning |
|
| Gastric | History of GAVE Early satiety Regurgitation of food Emesis of food Bloating / distension / pain |
|
| Biliary | History of primary biliary cholangitis Itching, jaundice, pruritus, but may be asymptomatic Bilirubin and transaminase profiles, possible anti-mitochondrial antibody presence |
|
| Small bowel | Diarrhea, pain, weight loss, malabsorption Cramping Bloating |
|
| Large bowel | Constipation Fecal soiling |
|
| Muscular | Atrophy, Muscle strength, Muscle endurance, Aerobic capacity (submaximal test) Hand grip and pinch strength |
MMT-8 TST/30-sec CST^ FI-2/FI-3 ^ Ebbeling treadmill test* Astrand cycle test* 6 MWT* Jamar or Grippit dynamometer* Pinch meter* |
| Joint | AROM upper extremity, AROM/PROM hands/fingers |
FSA* Goniometer* HAMIS* Cochin Hand Function Scale* DAS-28 |
6MWT: 6 minute walk test for distance, CST: Chair-Stands Test, DAS-28: Disease Activity Scale-28, FI-2: Functional Index 2, FI-3: Functional Index 3, FSA: Function Shoulder Assessment, HAMIS: Hand Mobility in Scleroderma, mRSS: modified Rodnan Skin Score, NYHA: New York Heart Association
*
implemented routinely by OT, PT
^
implemented by PT, OT but can be performed in clinic by physician or staff