In the earlier stages of the disease, patients appear well, while in the late stages of the disease, patients are clearly ill with multi-organ involvement. The patient may show a wide range of skin manifestations including urticaria, bullous lesions, malar rash, and scarring alopecia. The patient may develop nasal and oral ulcers. Arthritis may lead to a decreased range of motion, joint effusion, and arthralgia. Neurological manifestations including psychosis, cognitive impairment, and hallucinations, may also be present. 

• Patient appears well in the earlier stages of the disease
• Patient appears ill in the late stages of the disease due to multi-organ involvement

• Fever higher than 38 after the exclusion of infection
• Tachycardia/bradycardia depends on the accompanying complication
• Tachypnea/bradypnea depends on the accompanying complication

• Cyanosis
  • Secondary to respiratory complications
• Jaundice
  • Secondary to hepatitis
• Pallor
  • Secondary to anemia
• Generalised erythema
• Bruises
  • Secondary to thrombocytopenia
• Urticaria
• Bullous lesions
• Sclerodactyly
• Skin ulceration
• Malar rash: the classic lupus ‘butterfly’ rash
  • Erythematous, elevated lesion, pruritic or painful, in a malar distribution, commonly precipitated by exposure to sunlight
• Annular or psoriasiform skin lesions
  • Small, erythematous, slightly scaly papules that evolve into either a psoriasiform (papulosquamous) or annular form and tend to involve shoulders, forearms, neck, and upper torso
• Scarring chronic alopecia
  • Mostly present on face, neck, and scalp
• Telangiectasias
• Dyspigmentation (hyperpigmentation or hypopigmentation) of skin in scar places
• Follicular plugging
  • Discrete, erythematous, slightly infiltrated plaques covered by a well-formed adherent scale that extends into dilated hair follicles
• Nodules
  • Can be firm (Lupus profundus) and painful
• Photodistributed lesions with chronic pink indurated plaques or broad lesions that are slow to heal (more seen in lupus tumidus)
• Thin hair that easily fractures (lupus hair)
• Irregularly shaped raised white plaques, areas of erythema, silvery white scarred lesions, and ulcers with surrounding erythema on the soft or hard palate or buccal mucosa
• Periungual erythema
  • Dilated tortuous loops of capillaries and a prominent subcapillary venous plexus along
  • Involves the base of the nail and edges of the upper eyelid

For more pictures of the rash presentation in lupus, click here.

• Ophthalmology^[4][5]
  • Nystagmus
  • Visual retinal changes from systemic lupus erythematosus cytoid bodies, retinal haemorrhages, serous exudate or haemorrhage in the choroid, optic neuritis (not due to hypertension, drugs or infection)
  • Cataract
  • Optic nerve atrophy
  • Icteric sclera
  • Cotton wool spots in the retina in ophthalmoscopic exam
• Nasal ulcers^[6]
  • Mostly painless
  • Mostly in lower nasal septum and bilateral and parallel
  • Nasal perforation secondary to vasculitis may happen rarely
• Oral ulcers^[7][8]
  • Mostly painless
  • White plaques with areas of erythema, or punched-out erosions or ulcers with surrounding erythema on the soft or hard palate or buccal mucosa

• Jugular venous distension
  • Secondary to hypertension and cardiac complications
• Lymphadenopathy
  • Lymph nodes are soft, non-tender, discrete
  • Usually detected in the cervical, axillary, and inguinal

• Fine and coarse crackles upon auscultation of the lung
  • May be due to pneumonitis
• In case of pleural effusion:
  • Asymmetric tactile fremitus
  • Asymmetric chest expansion

• Chest tenderness or discomfort upon palpation
  • May be due to costochondritis
• Diastolic murmur, or systolic murmur >3/6 due to valvular disease
• Loud second heart sound (due to pulmonary hypertension)
• Loud S1-S2 due to cardiomegaly
• Decrease heart sounds if associated with pericardial effusion

• Abdominal distention
• Ascites
  • Due to nephrotic syndrome
• Abdominal pain
  • Due to mesentric vasculitis
• Hepatomegaly
• Splenomegaly
• Costo-vertebral angle tenderness

• Clubbing
• Cyanosis
• Muscle atrophy or weakness
• Livedo reticularis
  • Reddish-cyanotic, reticular pattern on the skin of the arms, legs, and torso, particularly with cold exposure
• Arthritis
  • Symmetrical
  • Polyarticular
  • Mostly involve knees, carpal joints, and joints of the fingers, especially the proximal interphalangeal (PIP) joint
  • Decrease range of motion in affected joints
• Joints erythema
  • Due to synovitis
• Joint effusion
• Muscle atrophy
• Fasciculations in the upper/lower extremity
• Claudication
• Loss of digit or limb

• Patient is usually oriented to persons, place, and time based on the disease course
• Cognitive impairment
• Hallucinations
  • Visual
  • Auditory
• Memory deficit
  • Loose associations
  • Impoverished thought content
  • Illogical thinking
  • Bizarre disorganised or catatonic behaviour

• 
  Skin: Lupus, systemic erythematosus; Discoid skin lesion in patient with SLE. Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology.^[29]
• 
  Skin: ulcer, necrotic; lupus anticoagulant in thigh. Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology.^[29]
• 
  Skin: lupus, erythematosus, subacute; Papulosquamous diseases. Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology.^[29]
• 
  Skin: lupus, erythematosus; Papulosquamous diseases. Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology.^[29]
• 
  Skin: lupus, erythematosus; papulosquamous diseases. Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology.^[29]
• 
  Skin: discoid lupus, face. Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology.^[29]