Microsoft word - dc_case note extraction_v1a_21 dec 2007.doc

STUDY NO.:
Casenotes Extraction Form
PERSONAL INFORMATION
STUDY NO.:
Casenotes Extraction Form
 Record dates in the format DDMMYYYY.
 Tick ‘estimated’ if date estimation is likely to be more than 1 year in range.
 All questions must be responded to.
Enter ‘6’(s) if data is missing
Enter ’7’(s) if it is not applicable
Enter ‘9’(s) if unknown/not indicated
PART A. GENERAL INFORMATION
 9. Others: ___________________________________ Is there documentation that the patient has received medical care for diabetes from other healthcare institution besides the current one? Please indicate the institution:  10. Other local healthcare institution: __________________________________  11. Overseas healthcare institution: ___________________________________ Was patient diagnosed in the current healthcare institution? PART B. DIABETES
Is there any specific indication that the patient has any particular type of diabetes? [Tick all that apply]  1. Type 1 (also previously known as IDDM)  2. Type 2 (also previously known as NIDDM)  3. Type 3 (specific types, e.g. chemical, MODYs) Note down the HbA1c values from 16 Oct 2001 – 15 Oct 2006 Date when patient first started using oral hypoglycaemic agents Date when patient first started using insulin injections Date of last prescription (before 2006) for control of diabetes, Mode(s) of treatment used within 2005 [Tick all that apply] Latest documented mode of treatment for blood glucose control  2. Oral hypoglycaemic agents only (w/w out diet/exercise)  3. Oral hypoglycaemic agents + Insulin (w/w out diet/exercise)  4. Insulin only (w/w out diet/exercise) PART C. BLOOD PRESSURE
Note down blood pressure values over the past 5 years [If there is more than one reading in a day, note resting and last reading] When was patient first recorded as having systolic BP>140 mmHg or diastolic BP>90mmHg? [Enter only if date is earlier than 5 years ago from date of extraction] Type(s) of antihypertensive medication within 2005 [Tick all that apply] Central acting & other antihypertensives Date when patient first started antihypertensive medication PART D. LIPID PROFILE (TRIG, CHOL, HDL, LDL)

D1
Note down lipid values from 16 Oct 2001 – 15 Oct 2006 [If more than 1 reading that day, record all] [F = Fasting; R = Random; Write the units if the unit is not mmol/L] Mode(s) of lipid lowering treatment within 2005 [Tick all that apply] Date patient first started on any lipid lowering drug PART E. KIDNEY COMPLICATIONS

Note down serum creatinine results from 16 Oct 2001 – 15 Oct 2006 [If more than 1 reading that day, record all. Write the units if it is not µmol/L] On which date was the highest SCREAT value first recorded? [Enter only if date is earlier than 16 Oct 2001] What is the date (earlier than 16 Oct 2001) when the SCREAT was first >125µmol/L (1.41 mg/dL)? What is the date (earlier than 16 Oct 2001) when the SCREAT was first >250µmol/L (2.83 mg/dL)? If patient is currently on dialysis, which mode of dialysis is being used?  7. Not applicable, i.e. not currently on dialysis On which date did the patient start dialysis If patient had renal transplantation, on which date was this done? Note down the urine analysis results for qualitative Dipstix and FEME tests from 16 Oct 2001 to 15 Oct 2006 E7b Note down the urine analysis results from 16 Oct 2001 – 15 Oct 2006 (Refer to Table 1)

Date first recorded for detection of microalbuminuria [Enter only if date is earlier than 16 Oct 2001] Date first recorded for detection of proteinuria [Enter only if date is earlier than 16 Oct 2001] Is there any indication that patient has kidney disease?  1. Yes, please tick all that applies:  b. Renal insufficiency of unexplained origin  c. Recurrent urinary tract infection  d. History of rapidly progressive renal failure  h. Others, please specify : _________________________________ PART F. EYE COMPLICATIONS
Has the patient ever been followed up by an eye specialist?  h. Private institutions: _____________________________________  i. Others: ________________________________ Is there any indication of diabetic retinopathy in the casenotes? Date first recorded by OPD/doctor as abnormal
Date last recorded by OPD/doctor as normal
Date first recorded by a specialist as normal
Date first recorded by a specialist as abnormal
What is the most advanced stage of diabetic retinopathy recorded (either eye)? Did patient ever undergo laser treatment for diabetic retinopathy?  1. Yes, date of first recorded laser eye treatment  Did the patient have documented macular disease? Has this patient ever been diagnosed with cataract (either eye)? Did patient ever undergo eye surgery for cataract removal? PART G. MACROVASCULAR COMPLICATIONS
What is the documented date of the first event of an ischaemic heart disease/coronary artery disease/cardiovascular disease What is the documented date of the first stroke/cerebrovascular What is the documented date of the first amputation of the leg, toe Within 2005, is patient on anti-platelet drugs (e.g. Aspirin, Persantin, Ticlid, Plavix)? DRUG LIST REFERENCE
A) Treatment of Diabetes (Standard issue drugs in bold)
Sulphonylurea GROUP
Chloropropamide
Glibenclamide (Daomil)
Gliclazide (Diamicron)
Tolbutamide
Non-Sulphonylurea Secretogogue GROUP
Biguanide GROUP
Metformin
Thiazolidinediones GROUP
Alpha-glucosidase inhibitors GROUP
Insulin GROUP
Isophane – Insultard, (Humulin N)
Soluble insulin –Actrapid (Humulin R)
(Intermediate)
Mixtard 30/70 vial
Zinc suspension – Monotard (L)
B) Treatment of Hypertension (Standard issue drugs in bold)
Angiotensin converting enzyme inhibitors (ACEIs) GROUP
Captopril
Enalapril (Renitec)
Angiotensin receptor blocker (ARBs) GROUP
Alpha-blocker GROUP
Prazosin (?)
Beta-blocker GROUP
Atenolol
Propranolol
Calcium channel blocker GROUP
Amlodipine
Nifedipine (Adalat)
Diltiazem
Nifedipine LA (Adalat LA)
Diltiazem SR
Verapamil
Diuretics GROUP
Frusemide (Lasix)
Spironolactone
Hydrochlorothiazide
Central acting and other antihypertensives GROUP
Methyldopa
Hydralazine
C) Lipid lowering agents (Standard issue drugs in bold)

Fibrates GROUP
Fenofibrate (lipanthyl)
Gemfibrozil (Lopid)
Statins GROUP
Lovastatin
Simvastatin (Zocor)
Pravastatin
Bile salt binding drugs GROUP
Cholestyramine (?)
Nicotinics GROUP
Nicotininc acid
Others GROUP
Bromocriptine
Urine Analysis Units
Normoalbuminuria Microalbuminuria
Proteinuria

Source: http://www.nus-cme.org.sg/pdf/DC_Case%20Note%20Extraction_V1a_21%20Dec%202007.pdf