CN105342555A

CN105342555A - Comprehensive diabetic patient assessment method

Info

Publication number: CN105342555A
Application number: CN201510590949.6A
Authority: CN
Inventors: 曹宏
Original assignee: Individual
Current assignee: Individual
Priority date: 2015-09-09
Filing date: 2015-09-09
Publication date: 2016-02-24

Abstract

The invention discloses a comprehensive diabetic patient assessment method. Basic information, basic medical history, important medical history, physical examination, risk factors, laboratory examination, complications, drug therapy, exercise, diet, diabetes education, index monitoring and the like of a diabetic patient in a period of time are analyzed to obtain a comprehensive conclusion report so as to determine a major target value and a minor target value of treatment in the next phase.

Description

Diabetics comprehensive estimation method

Technical field

This operational approach analyzes in the basic document of diabetics within a period of time, basic medical history, important medical history, physical examination, risk factor, lab testing, complication, Drug therapy, motion, diet, diabetes education, Monitoring Indexes etc., thus draw the report of a comprehensive conclusion, determine the primary goal value that next stage treats and by-end value.

Background technology

At present to the assessment of diabetics, mainly doctor is according to oneself clinical experience, and combine and to have a medical check-up and laboratory examination results is passed judgment on, other factors is considered to lack, and does not provide a formal assessment report.Same patient is because of the clinical experience difference of different doctor, and the factor considered during assessment also can be different, and the content considered when same doctor also can not assess same patient per keeps completely the same.

Summary of the invention

In order to overcome, existing quantum evaluation is few, quantum evaluation is inconsistent, do not have the problems such as formal report, this operation using method provides a kind of appraisal procedure, it is by gathering related data, automatically for patient provides the report of a comprehensive eye exam, and printable output, the factor ensure that anyone, considering when assessing any time is all the same.

This operation using method solves the technical scheme that its technical problem adopts: by gathering the basic document of diabetics within a period of time, basic medical history, important medical history, physical examination, lab testing, Drug therapy, motion, diet, diabetes education, after the data such as Monitoring Indexes, automatic decision risk factor, the primary goal value of complication and next stage treatment and the content of by-end value, and the content in primary goal value and by-end value can adjust automatically according to patient profiles and therapeutic effect, doctor only need make oneself suggestion to above quantum evaluation according to oneself clinical experience.

The beneficial effect of this operation using method is, any a doctor is that any patient can provide the assessment report that portion has 11 projects at any time, is convenient to patient and accomplishes to know what's what to the current and following treatment situation, therapeutic goal quantification.

Accompanying drawing explanation

Fig. 1 is the diabetes comprehensive assessment reporting format of this operation using method, by 11 item designs.

Detailed description of the invention

Whole assessment report is by 11 item designs, and the equal Automatic sieve of each project selects positive value, and list display.

1, individual basic document: comprise individual numbering, name, sex, date of birth, nationality, schooling, age, occupation, marriage, expense category, phone, medical insurance numbering, address, unit, drug allergy history, go out admission date etc.

2, the basic medical history of individual: comprise first visit/further consultation/periodic evaluation, diabetes (suspects/making a definite diagnosis), classify and typing, make a definite diagnosis the date, make a definite diagnosis hospital, smoking, drink, occurred to go into a coma.

3, diabetes education: comprise the DM study class in this hospital, the DM Nurse Education in this hospital, the DM education of DM association, self-DM monitor at least 4 times/year, monitoring mode, to receive an education number of times etc. every year.

4, important medical history: comprise cardiovascular system (hypertension, angina pectoris, heart failure, coronary heart disease, myocardial infarction, VABG/ angioplasty), (apoplexy remains sequela to central nervous system, post-stroke recovers completely, diagnosis date), (hands refers in amputation, below wrist, wrist-elbow, more than elbow, cut, below ankle, ankle-knee joint, more than knee joint, the amputation date), complication (DM retinopathy, DM foot, atherosclerosis, DM peripheral neuropathy, DM nephropathy, DM autonomic neuropathy, DM heart disease, DM cataract, coronary heart disease, lower extremities, apoplexy, other), (PVD treats (Coronary Artery Bypass/angioplasty) for other, transplant, dialysis, malignant tumor, important symptom [is walked lamely, urinary incontinence, urine retention, libido reduces, intermittence is told, intermittent constipation, intermittent night or early morning suffer from diarrhoea, fecal incontinence, numbness of lower limbs, upper limb numbness, lower limb pain, upper extremity pain, blurred vision, visual deterioration], Diabetes specialist follow-up number of times in 1 year in the past, within 1 year, whether be special outpatient clinic in the past to go to a doctor, hospitalizations in past 1 year, [blood glucose is out of control for reason of being in hospital, suspect complication, urinary system infection, pulmonary infection, diabetic foot, heart disease, oculopathy, gastrointestinal pathological changes, biliary tract infection, peripheral neuropathy, central neuropathy, other], the Other diseases merged, the course of disease etc.

5, physical examination: comprise height, body weight, BMI, waistline, buttocks encloses, WHR, foot checks (dorsal artery of foot, gangrene or ulcer, xerosis cutis, the instep sense of touch of 10g filament, toes are out of shape, ankle systolic pressure), examination of eyes (naked vision, correct defects of vision, cataract, cataract extraction, intraocular pressure/glaucoma, intraretinal microvascular abnormality, RI, glass excises, new vessels, hard exudate, retinopathy by stages, microangioma, vitreous hemorrhage, traction detachment of retina, retinal edema, retina can be seen, laser cicatrix, maculopathy, hemorrhage, SE), artery ultrasound checks (carotid artery, femoral artery, popliteal tremulous pulse), electrocardiogram is (normal, left ventricle high voltage, left ventricular hypertrophy, Left atrium enlargement, left bundle branch block, left anterior fascicular block, left posterior fascicular block, right bundle branch block, indefinite form intraventricular block, in every conduction block, ST-T changes, ventricle wall re-infarction, right atrium expands, right ventricle is plump, myocardial ischemia, ischemic-type T ripple changes, ischemic ST-segment changes, ischemic ST-segment declines, constitutional T ripple changes, acute subendocardiac muscle ischemia, acute Epicardium ischemia, ariant angina, front partition myocardial infarction, Anterior wall myocardial infarction, front side wall myocardial infarction, high lateral myocardial infarction, rear wall myocardial infarction, inferior wall myocardial infarction, myocardium of apex of heart infarction, right ventricle infarction, extensive Anterior wall myocardial infarction, outmoded phase myocardial infarction, acute myocardial infarction, ventricular aneurysm, other), ultrasound cardiogram, ([during deep breathing, heart rate per minute is poor in autonomic nervous function inspection for other, vertical clinostatism 30/15 ratio, vertical clinostatism blood pressure difference], gastrointestinal function checks [cholelithiasis, gastric emptying, clectrogastrogram], sensory nerve conduction velocity [common peroneal nerve, median nerve, ulnar nerve], it is [numb that foot checks, pain, pigmentation, fungal infection, ulcer scars, callus, toes are out of shape, the sense of touch of the 10g filament foot sole of the foot, first toe vibration sense, internal malleolus vibration sense, first toe back acupuncture is felt, the Achilles jerk, PVD, ankle/buttocks systolic pressure ratio], carotid artery is fought ultrasound diagnosis [atheromatous plaque, endarterium thickness], diabetic neuropathy [thumb vibration sense, thumb dorsal stylet thorn is felt, the sense of touch of thumb back of the body 10g filament, strength is tested, thumb vibration sense, finger extension, thumb stretches, the ankle back of the body is bent, reflex, biceps brachii m., triceps brachii, upper arm musculus quadriceps]) etc.

6, risk factor: comprise that smoking, hypertension, blood fat disorder, albuminuria, obesity, glycemic control are poor, DM Positive family history, History of Coronary Heart Disease, apoplexy history, hyperuricemia, high free fatty acid hyperlipemia, high hsCRP etc.

7, lab testing: comprise fasting glucose, 2 hours blood glucoses after the meal, glycolated hemoglobin, C reactive protein, T-CHOL, triglyceride, high density lipoprotein, low density lipoprotein, LDL, blood urea nitrogen, serum creatinine, free fatty, uric acid, routine urinalysis, urinaryalbumin is quantitative, urinaryalbumin/Cr ratio, oral glucose tolerance test, insulin release test, C peptide release test, CBG monitoring (on an empty stomach, 2 hours after the meal, ante prandium, after lunch 2 hours, before dinner, after dinner 2 hours, 22:00, 0:00, 3:00) etc.

8, complication: the positive value in important medical history.

9, desired value: comprise " primary goal value " and " by-end value ", after they and respective normal range value contrast, automatic decision anomaly item, and list display.

Primary goal value: comprise BMI, WHR, blood pressure, fasting glucose, after the meal 2 hours blood glucoses, glycolated hemoglobin, T-CHOL, triglyceride, HDL-cholesterol, LDL-cholesterol etc.

By-end value: comprise ulnar nerve sensory nerve conduction velocity, center sensory nerve conduction velocity, common peroneal nerve motor nerve conduction velocity, Carotic Intima-media Thinkness, respiratory heart rate variance, found clinostatism 30/15 ratio, serum creatinine, uric acid, free fatty, urinaryalbumin are quantitative, fasting insulin, after the meal 2 hour insulin, blood urea nitrogen etc.

10, treat (Current therapeutic, from now on treatment): doctor, according to automatic evaluation report content, engages clinical experience and lists present therapeutic scheme and next step therapeutic scheme to patient respectively by 5 aspects such as glucose-lowering treatment, insulinize, lipid-lowering therapy, Treatment of Hypertension, coronary heart disease treatments.

11, doctor advised: list this assessment after doctor specifically content.

Claims

1. a comprehensive estimation method for diabetics, by gathering related data, automatically for patient provides the assessment report that portion has 11 projects, and printable output.It is characterized in that: be that 11 projects such as the basic document of diabetics within a period of time, basic medical history, important medical history, physical examination, risk factor, lab testing, complication, Drug therapy, motion, diet, diabetes education, Monitoring Indexes are analyzed, thus draw the report of a comprehensive conclusion, determine the primary goal value that next stage treats and by-end value.

2. the comprehensive estimation method of diabetics according to claim 1, it is characterized in that: 11 projects such as individual basic document, the basic medical history of individual, diabetes education, important medical history, physical examination, risk factor, lab testing, complication, desired value (primary goal value, by-end value), treatment (Current therapeutic, from now on treatment), doctor advised occur on one page, and the projects such as risk factor, complication, desired value (primary goal value, by-end value) all can produce automatically.