Theme Interpretation Illustrative quotes
NEED TO ORGANISE TO CORRECT SUBTHEME/CODE GROUPING
1. Diabetic counselling units should be established in hospitals manned by trained diabetic health counselors whose duties will include patient counselling on the symptoms of poor metabolic control and complications of diabetes. Patients should be advised to see their health care provider once symptoms of metabolic decompensation occur.
2. Emphasis should be on prompt and adequate management within the first 24 hours (this was when most of the mortality in this study occurred) as this will go a long way in ensuring reduction in morbidity and mortality.
3. Infections should be treated urgently, with appropriate antibiotics in diabetic patients since this has been identified as the commonest precipitating factor of HEs with the attendant morbidity and mortality.
4. Healthcare facilities should be equipped with appropriate laboratory equipment in addition to manpower training and development to enable close monitoring of biochemical indices especially electrolytes of patients with hyperglycaemic emergencies with a view to reducing morbidity and mortality.
5. The National Health Insurance policy should be strengthened and implemented in order to assist the poor and socially disadvantaged in the society (with hyperglycaemic emergency) in procuring drugs and getting adequate healthcare.
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- 98 - APPENDIX I
- 99 - APPENDIX II
QUESTIONNAIRE Section 1. Socio-demographic data.
a) Serial Number
b) Age
c) Hospital Number
d) Sex
e) Marital Status f) Occupation
g) Level of Education: Primary ( ) Secondary ( ) Tertiary ( ) Numbers of completed years.
h) Residence i) Religion
j) Tribe
k) Smoking history yes/no No of pack years - Cigarette
- Pipe/cigar
l) Alcohol history No of g/day.
Section 2: Medical History.
a) Age at diagnosis of DM b) Duration of DM
c) Type of DM
d) Precipitating factors
- Non tolerance to medication - Chest infection
- Urinary tract infection - Post surgery
- Diabetic foot syndrome - Newly diagnosed - Meningitis - Substance abuse
- Pregnancy
- CVA
- Myocardial infarction
- 100 - - Others (specify)
e) Level of consciousness at presentation
- Coma
- Drowsy GCS=
- Conscious
f) Current treatment modality of DM - Insulin
- Oral hypoglycaemic drugs - Combined OHA and Insulin - Others (specify)
g) Family history of DM.
- Parent (mother/father) - Siblings (brother/sister) - Others (state).
h) History of chronic diseases.
- Hypertension - Retroviral infection - Chronic hepatitis - Psychiatry illness - Others (state) i) Drug history - Steroids - Antipsychotics - Thiazides - Others (specify) j) Review of systems.
General:
Fever, weight loss, etc.
i) Cardiovascular system Chest pain
Palpitation Orthopnea Dyspnea
Postural dizziness ii) Genitourinary system
Dysuria
- 101 - Facial swelling
Frequency
Erectile dysfunction/sexual dysfunction iii) Chest:
Cough Chest pain
Dyspnea, wheezing etc.
iv) Abdomen:
Pain Vomiting Diarrhea Haematemesis Constipation Easy satiety Dysphagia
i) CNS:
Seizures Neck pain Paraesthesia
Section 3. CLINICAL DATA a) Weight (kg)
b) Height (m)
c) BMI
d) Waist circumference e) Hip circumference f) Waist: Hip ratio (WHR) g) Level of dehydration h) Pallor
i) Jaundice
j) Temperature (oc)
k) Cardiovascular system (Lt) (Rt) Pulse rate (Supine)
Pulse rate (erect) Blood pressure (supine) Blood pressure (erect)
- 102 - Dorsalis pedis artery
Posterior tibial artery
l) Central Nervous System (CNS):
Level of consciousness Sensory neuropathy
DMFS (Lt) (Rt)
Grade:
Limb Amputation
m)Examination of the eye (Lt) (Rt)
Cataract Retinopathy n)Respiratory Rate
Kussmaul breathing Chest pathology
Section 4: INVESTIGATION.
a) Blood glucose: At presentation=
At discharge=
b) Glycosylated Hemoglobin (HbA1c) c) Hb genotype
d) Serum Electrolytes, Urea & Creatinine at presentation + phosphate e) Serum Osmolality.
f) Anion gap g) Urinalysis : Ketones=
Protein=
Glucose=
Nitrites=
h) Urine MCS.
i) Fasting serum lipids j) Malaria Parasite (MP)
k) Sputum MCS.
l) Blood culture m) Chest X-ray
n) ECG
o) Serum amylase
- 103 - p) Full blood count
q) Serum/urine Ketones r) Pregnancy test.
s) Arterial blood gases.
Section 5. COMPLICATIONS
Section 6. OUTCOME Discharge home
Death within 24hours Death after 24hoours Amputation
Total duration of stay:
A/E=
Ward=
TOTAL=
- 104 - APPENDIX III
PLASMA GLUCOSE ASSAY
Plasma glucose levels were estimated according to the method of Trinder using the glucose oxidase method. The glucose oxidase was buffered in phenoxylate and dissolved in Sornson buffer (colour reagent). One litre of this solution contains;
1). Potassium dihydrogen phosphate 9.073g 2). Disodium hydrogen phosphate 9.465g 3). Glucose oxidase 10ml (250ug/ml) 4). Phenol 0.4ml (37.6mg/ml)
5). 4-Aminophenazone 200mg 6). Sodium Azide 100mg
This solution was stored at 4oC in between usage. Determination of glucose oxidase was based on the procedure below:
Two test tubes were used for each assay run: 2mls of glucose oxidase solution was added to the first test tube containing 20µl of plasma sample (from centrifuged blood specimens in fluoride oxalate bottles) and 20µl of a standard glucose solution (concentration = 100mg/dl). The second test tube which was used as “blank” contained only glucose oxidase solution.
Tests on the standard glucose solution were performed in duplicate. For each assay, three test tubes containing plasma samples of known glucose concentrations were included. A water bath was used to incubate the test tubes for 15minutes at 37oC. After incubation, the test tubes were allowed to cool to room temperature following which the optical densities (OD) were read off on the spectrophotometer at a wavelength of 540nm. The “blank” test tube was used as the reference point against which the optical densities of all the other test tubes were determined. Subsequently, the optical density for plasma glucose was compared to that of a standard glucose solution with known glucose concentration. The mean values obtained from replicate tests of the standard glucose preparation were utilized in calculating the plasma glucose levels in the test samples. Glucose level was estimated using the formula:
Plasma glucose = OD of Sample x Concentration of Standard OD of Standard