SOCIO-DEMOGRAPHIC INFORMATIONS | |||||
1 | Gender | 1. Female 2. Male | /__/ | ||
2 | Age | In years | /__/__/ | ||
3 | Marital status | 1. Single 2. Married 3. Divorced 4. Widow (er) 5. Not applicable | /__/ | ||
4 | Profession/Occupation | 1. Unemployed 2. Pupil /Student 3. Civil servant 4. Trader 5. Farmer 6. Worker/artisan 7. Self-employed person 8. Retired 9. Other to be specified (___) 10. Not applicable | /__/ | ||
5 | Place of residence | 1. Urban 2. Peri-urban 3. Rural | /__/ | ||
6 | Religion | 1. Christian 2. Muslim 3. Endogenous 4. Atheist 5. Other | /__/ | ||
7 | Ethnic group | 1. Fon and related 2. Dendi 3. Bariba and related 4. Yorouba and related 5. Peulh 6. Ditamari and related 7. Mina 8. Adja and related 9. Unspecified 10. Other (______________) | /__/ | ||
SOCIOECONOMIC INFORMATIONS, LIFESTYLE AND MEDICAL HISTORY | |||||
8 | Alcohol consumption | 1. Yes 2. No | /__/ | ||
9 | Tobacco consumption | 1. Yes 2. No | /__/ | ||
10 | Number of body washes per day | 1. Once 2. Twice 3. Thrice 4. More than three times | /__/ | ||
11 | Towel change interval | 1. At one week 2. >one week and ≤at one month 3. >at one month | /__/ | ||
12 | Bedding change interval | 1. At one week 2. >one week and ≤at one month 3. >at one month | /__/ | ||
13 | Clothes change interval | 1. Every day 2. Every two days 3. Every three days 4. After a week | /__/ | ||
14 | Regular medication use | 1. Yes 2. No If yes which | /__/ | ||
15 | Use of water for bath | 1. Well water 2. Borehole water 3. SONEB water 4. Others ( ) | /__/ | ||
16 | Temperature of water used for bath | 1. Hot 2. Cold 3. Lukewarm |
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17 | Type of sponge used for bath | 1. Toilet net 2. Glove towel 3. Traditional net | /__/ | ||
18 | Medical history | 1. No medical history 2. Diabetes 3. AHT 4. Drépanocytose 5. Hemodialysis 6. HIV 7. Others ( ) | /__/ | ||
19 | History of itchy skin or systemic conditions | Yes / / No / / if yes which (urticaria, lichen planus, prurigo, contact eczema, atopic dermatitis, varicella, bullous pemphigoid, dermatitis herpetiformis, psoriasis, toxidermitis, leucémia, others) |
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20 | Notion of atopy | 1. Yes 2. No | /__/ | ||
21 | If yes which | 1. Asthma 2. Sinusitis 3. Allergic rhinitis 4. Allergic conjunctivitis 5. Others ( ) |
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22 | Family history | 1. No family history 2. AHT 3. Rhinitis 4. Sinusitis 5. Asthma 6. Diabetes 7. HIV 8. Drépanocytose 9. Other (_______________) | /__/ | ||
23 | Recent deworming | 1. Yes 2. No | /__/ | ||
DATA RELATED TO THE USE OF COSMETICS | |||||
24 | Use of body milk | 1. Yes 2. No | /__/ | ||
25 | If yes which | 1. Depigmenting body milk 2. Perfumed body milk 3. Unscented body milk 4. Body cream 5. Body ointment 6. Body balm 7. Others ( ) 8. Unspecified | /__/ | ||
26 | Use of body soap | 1. Yes 2. No | /__/ | ||
27 | If yes which | 1. Detergent 2. Antiseptic 3. Superfatted 4. Enlightening 5. Marseilles 6. Neutral 7. Others ( ) 8. Unspecified | /__/ | ||
28 | Perfume | 1. Yes 2. No | /__/ | ||
29 | Nail polish | 1. Yes 2. No | /__/ | ||
30 | Use of depigmenting products | 1. Yes 2. No | /__/ | ||
INTERROGATION AND PHYSICAL EXAMINATION | |||||
| Patient | 1. Case; 2. Control |
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| if case continue ; if control end of filling |
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31 | Duration of symptoms | 1. | /__/ | ||
32 | Spawn mode | 1. Progressive 2. Sudden | /__/ | ||
33 | Evolution mode | 1. Permanent 2. Intermittent 3. occasional | /__/ | ||
34 | Schedule of pruritus | 1. Diurnal 2. Nocturnal 3. Without schedule | /__/ | ||
35 | Nocturnal upsurge | 1. Yes 2. No |
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36 | Period of onset of symptoms | 1. Dry season 2. Rainy season | /__/ | ||
37 | Intensity | 1. Light 2. Moderate 3. Severe | /__/ | ||
38 | Existence of factors that can cause pruritus | Yes / / No/ / if yes which ( medication intake, food, cosmetic application, water, toilet net, heat, cold, sun exposure, physical exercise, others) |
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39 | Aggravating factors | 1. Medication intake 2. Food 3. Cosmetic application 4. Water 5. Toilet net 6. Heat 7. Cold 8. Sun exposure 9. Physical exercise 10. Others ( ) |
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40 | Calming factors (cite) |
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41 | Background of familial pruritus | 1. Yes 2. No | /__/ | ||
42 | Accompanying signs | 1. Weight loss 2. Asthenia 3. Anorexia 4. Diarrhea 5. Abdominal pain 6. Insomnia 7. Fever 8. Pallor 9. Icterus 10. Dehydration folds 11. Malnourishment folds 12. Hepatomegaly 13. Splenomegaly 14. Adenopathies 15. None 16. Others | /__/ | ||
43 | Previous treatment | 1. Antihistamines 2. Dermocorticoid 3. Corticosteroids 4. None 5. others | /__/ | ||
44 | Prescribed by | 1. Self-medication 2. Physician/Nurse 3. Dermatologist 4. Unspecified |
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45 | Presence of scratch marks | 1. Yes 2. No | /__/ | ||
46 | If yes which | 1. Punctiform excoriation 2. Linear streaks 3. Lichenification 4. Impetiginization | /__/ | ||
Complementary examinations NB: P = positive, Neg = negative, N = normal, AN = abnormal, B = Low, E = High | |||||
47 | Complete blood count | RBC…. WBC…. Hb…. Platelets…. |
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48 | Blood sugar |
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49 | Hepatic transaminases | ALT… AST… |
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50 | Blood creatinine |
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51 | Gamma glutamyl transferase |
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52 | Alkaline phosphatase |
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53 | Bilirubin |
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54 | Liver markers | Anti-HBs / / Anti-HCV/ / |
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55 | HIV serology |
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56 | Thyroid hormones | TSH… T3… T4… |
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57 | Protein electrophoresis |
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58 | Calcemia |
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59 | Skin biopsy |
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60 | Others |
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ETIOLOGICAL DIAGNOSIS OF GENERALIZED PRURITUS SINE MATERIA | |||||
61 | General infectious diseases | HIV infection / / Viral hepatitis / / |
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62 | Metabolic, endocrine and neuropsychiatric causes | CKD/ / Diabetes mellitus/ / Hepatic cholestasis/ / Hyperthyroidism/ / Hypothyroidism/ / Thyrotoxicosis/ / Hyperparathyroidism/ /Neurogical disease/ / Anxiety or depression/ / Others/ / Specify |
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63 | Blood disorders | Polycythaemia/ / Iron deficiency/ / Hodgkin’s disease/ /Hématological malignancies/ / |
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64 | Neoplasia | Yes/ / No/ / |
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65 | Drug-induced pruritus | Yes/ / No/ / |
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66 | Cosmetic-induced pruritus | Yes/ / No/ / |
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67 | Pruritus due to professional substances | Yes/ / No/ /
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68 | Pruritus due to climate change | Yes/ / No/ / |
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69 | Aquagenic pruritus | Yes/ / No/ / |
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70 | Senile pruritus | Yes/ / No/ / |
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71 | Internal parasites | Yes/ / No/ / |
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72 | Idiopathic generalized pruritus sine materia | Yes/ / No/ / |
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