History

Take a full history, including any previous episodes (and especially note any current or recent therapy given for the previous episodes; this would ensure that consideration is given as to whether or not the current presentation is a flare, or intercurrent infection or other comorbidity).

Ask about illicit drug use.

Consider whether or not the patient's current symptoms fit with a pattern of previous features that might be in different systems (e.g. the patient may present with weight loss, fever and rash; however, they may have a history of chronic nasal discharge, hearing loss or neuropathy).

Pattern recognition is very important. Upper airway and lower airway features in combination typify granulomatosis with polyangiitis (GPA), a small-vessel vasculitis, which often involves the kidney, with asymptomatic haematuria and proteinuria. By contrast, upper airway involvement is not common in microscopic polyangiitis (MPA), where there is mainly lung and (usually asymptomatic) renal involvement.

Examination

Do a full physical examination, including weight (important in helping to make the diagnosis but also useful in calculating the dose of some treatments).

Assess eyes for redness and or tenderness, afferent pupillary defect or evidence of haemorrhage (request a slit lamp examination if uveitis is suspected).

Check for sensorineural hearing loss.

Inspect mouth for ulcers (and genital areas if symptoms of genital ulceration).

Look for evidence of infarcts, purpura, ulceration, gangrene or other skin lesions compatible with vasculitis.

Palpate for lymph node enlargement.

Check pulses in all four limbs and blood pressure in both arms (and legs if there appears to be a discrepancy in strength of pulses) especially if suspecting large vessel vasculitis. Feel for artery tenderness in suspected large vessel vasculitis. Listen to large arteries for bruits.

Listen to the chest (e.g. pleural inflammation or effusion, consolidation) and heart (reduced sounds due to pericardial inflammation, murmurs, failure).

Feel the abdomen for organomegaly. Palpate and listen to the aorta.

Check for evidence of neuropathy or central nervous system involvement (cranial nerves, reflexes, power, sensation, orientation, speech).