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tients may not always be accurate in describing the extent of their symptoms, though relatives may be able to do so.

Comprehensive assessment of persons with symptoms attributed to Gulf War deployment would benefit from an understanding of the types of symptoms and problems that such patients experience. The evaluation begins by gathering a thorough history of signs and symptoms, which the subject attributes to Gulf War experiences, such as when the problems began in relationship to deployment, their nature and onset, and their course over time. Have the symptoms been chronic? Episodic? Has their severity fluctuated? Physicians should try to determine the onset of the symptoms and how the patient became aware of his or her symptoms, should inquire about diagnostic techniques or treatment measures used by clinicians he or she may have seen, and should document the patient's response to these interventions.

The clinician should attempt to exclude medical conditions suggested by the patient's symptom profile. This will involve recording detailed information about current and past medical illnesses, medications used, surgical procedures, typical allergies, previous diagnostic workups and treatments, and the patient's pattern of medical care utilization. Obtaining past medical records is especially helpful, particularly when the patient is a poor historian or the past history is confusing. Evaluation of a patient must also include the patient's psychiatric history since the presence of psychiatric comorbidity may suggest particular treatment strategies or approaches, as well as a possible explanation for some of the reported symptoms.

The committee recognizes that alcohol and other substances are frequently used as a self-medication strategy by patients who learn, through experience, that these drugs alleviate some of their symptoms, particularly depression, stress, and anxiety. While the committee did not choose to examine effective treatments for use and misuse of alcohol and other substances, such use, if undetected, will complicate the management of any underlying conditions. This is especially true in those situations where alcohol is in some way synergistic with the medication being prescribed.

It is very important, therefore, that health care practitioners explore these issues with all patients, including Gulf War veterans. Commonly used screening tools such as the CAGE and AUDIT interviews about alcohol use are excellent, well-validated tools for measuring the degree of alcohol use.

The patient's history should be followed by a thorough physical examination and routine laboratory testing. A physical examination and screening laboratories could help uncover a diagnosis that may explain, in part or in full, the patient's symptoms attributed to Gulf War deployment. The assessment should include routine laboratory tests such as a complete blood count, serum electrolytes, serum glucose, and urine analy-



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