Las nuevas tecnologías

therapy to achieve maximal benefit from diabetic care. If it becomes impossible to complete the evaluation in one clinic visit (estimated time:

45-60mins per patient), then a follow up visit will be arranged and the cost of transportation (to and from the hospital) for the second visit will be borne by me. If you accept to participate in the study then I shall require a verbal consent from you. If however you decline, this will not negatively influence your contact with staff of this hospital.

Thank you.

Date…………

Serial No……

Hospital Number…………

Section A: Socio Demographic characteristics 1. Age…

2. Gender: …

3. Initials: …………

4. Place/State of Origin: ………

5. Usual Place of Abode: ………

6. Source of referral: ………

7. Current Occupation: ………

8. Marital Status:

1. Married II. Divorced III. Separated IV. Widowed

V. Single, Never married VI. Co-habiting

10. Highest Educational attainment 1. Never attended

II. Primary III. Secondary

IV. Post secondary, non university

E.g. College of Education, Polytechnic, School of Nursing V. University

11. Smoking history

1. Smoker. Has smoked for at least 1 year

II. Ex-smoker. Stopped for at least 1year after smoking regularly III. Non-Smoker. Has smoked cigarettes before, but not regularly IV. Non-smoker, never smoked

12. For patients who smoke/had smoked, what is the number of sticks smoked per day and how long did they or have they smoked for?

13. Alcohol intake history 1. Not at all

II. Took alcohol regularly before, but has now stopped

III. Took alcohol regularly before but now takes only occasionally IV. Takes alcohol only occasionally

V. Takes alcohol regularly

14. If patient took/takes alcohol, what amount was/it taken weekly?

Section B: Medical history

15. Is patient hypertensive? Yes No 16. Type of diabetes: ………

17. Duration of diabetes: …………

18. Has the patient had a previous foot ulcer? Yes/No

19. If answer to question 18 is yes, state which foot and the site of ulcer………

20. Has the patient had a previous lower limb amputation? Yes/No

21. If answer to question 20 is yes, state which limb and the type of amputation?

22. Is patient partially sighted or blind? Yes No Don’t know 23. Does the patient live alone? Yes No Don’t know

24. Drugs used for treatment of diabetes mellitus?

1. None

II. Oral hypoglycemic agents III. Insulin

IV. Oral hypoglycemic agents and insulin V. Native medication/herbs

VI. Others (please specify)………..

25. List any other medications used by the patient below

………..

26. Medical history relating to DM and its complications (if any)

……….

27. Any history suggestive of claudication in the lower limb? Yes No 28. Is there any foot ulceration presently? Yes No

29. If answer to question 28 is yes, specify the affected limb and ulcer location:

30. United Kingdom screening test (a. Modified neuropathy symptom score)

Patients to be asked about their experience of the following symptoms in their legs and a score assigned:

Symptoms Scores

Sensory numbness or tingling 2

Fatigue, cramping or aching 1

Above symptoms experienced in feet 2 Above symptoms experienced in calves 1 Above symptoms experienced elsewhere 0 If symptoms wake patient up from sleep 1 Maneuvers reducing the symptoms:

* walking 2

* standing 1

* sitting or lying down 0

Maximum score = 9

Score of 3 - 4 = mild symptoms Score of 5 – 6 = moderate symptoms Score of 7 - 9 = severe symptoms

31. Are there any other symptoms suggestive of neuropathy? (State below)

Section C: Physical examination

32. Weight (kg)……….

33. Height (meters)……… Body mass index…….

34. Waist circumference………

35. Hip circumference……… Waist Hip ratio …………

36. Blood pressure today: Systolic Diastolic 1)

2)

37. Are any of the abnormalities below present in the patient? Put a tick next to those that are present

Small muscle wasting in lower limbs Deformities of toes and forefoot Pes cavus

Pes Planus

Other foot deformities (describe)………

Callous/corns

Charcot arthropathy Oedema of the foot Dry cracked skin

Interdigital fungal infection Anhidrosis

Inappropriate footwear

Other foot abnormalities identified (please specify below)

………

38. United Kingdom screening test (b. Neuropathy disability score) Sensation Score Vibration threshold (apply 128-Hz turning fork

to apex of great toe)

Normal (can distinguish between presence and

Absence of vibration) 0

Abnormal 1 Temperature (to dorsum of hot, apply a turning

Fork placed in beaker of ice water or warm water

Normal (can distinguish between hot and cold) 0

Abnormal 1

Pinprick (apply pin proximal to great nail to barely depress skin)

Normal (can distinguish sharpness or lack of sharpness) 0

Abnormal 1

Achilles Reflex

Present 0

Present with reinforcement 1

Absent 2

Total for one foot 0-5

Total maximum score = 10

Score of 3 - 5 = evidence of mild neuropathic signs Score of 6 - 8 = evidence of moderate neuropathic signs Score of 9 – 10 = evidence of severe neuropathic signs 39. Peripheral pulses; state whether palpable or not palpable Left Right

Dorsalis pedis Posterior tibia

40. Footwear:

I. Type

II. Heel height

III. Is there any presence of wear and tear on the shoe? Yes/No IV. Fitness of foot wear: 1. Shoes fit well 2. Shoes don’t fit well

41. Shoe examination; the shape of the patients” feet is outlined on a cardboard with a marker and traced out with a scissors. The cut out outline is then inserted to the shoe to assess the ease of insertion and non rumpling (evidence of adequate accommodation).

42. Eye Examination

43. Other complications identified in the patient (indicate in space below).

Section D: Laboratory investigation result

44. Fasting blood glucose………..

45. 2 Hour post prandial blood glucose………

46. Fasting lipid profile

47. Glycated haemoglobin level

APPENDIX IV: Social Class Classification

I. A Job usually requiring a University Degree

The professional occupations e.g. doctors, University lecturers, secondary school teachers

II The white collar workers, either:

a. owning a trade etc, e.g. shop owner, bus owner, or

b. A job requiring O’ level qualification e.g. technicians, primary school teachers.

c. Bank tellers

Below this level, there are no educational requirements

III A formally trained occupation – overalls not required.

The clean trained workers e .g. Policemen, medical assistants, chefs, clerks, drivers

IV A formally trained occupation – overalls required.

The Artisans e.g. welders, machine operators, motor mechanic assistants.

V An untrained occupation – overalls not required. The clean untrained workers e .g postmen, waiters, shop assistants, messengers, guards.

VI An untrained occupation – overalls required. The laborers e .g gardeners, dustmen, general laborers, street cleaners.

Source: Castle W. M. Measurement of Socio-economic Status in an Urban African Community. Trop. Doctor. 1978; 8: 44 – 48

APPENDIX V: United Kingdom Neuropathy Screening Test