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OCR for page 113
Appendix F
VA Phase ~ Protocol
PROTOCOL FOR CONDUCTING THE PHYSICAL
EXAMINATION AND ORDERING DIAGNOSTIC STUDIES
1. It is essential that a complete medical history, physical examination and
interview be performed and documented on appropriate forms. The required
forms that must be Filly completed are: Standard Form (SF) 88, Report of
Medical Examination, Department of Veterans Affairs (VA) Form 10-9009A,
Persian Gulf Registry Code Sheet, and SF 509, Progress Notes (for follow-up).
These are to be maintained in the veteran's Consolidated Health Record (CHR).
NOTE: This should be accomplished by or under the direct supervision of the
Veterans' Registry Physician CORPS. Examination data will be recorded in the
veteran's medical record as routinely as done for any other medical
examination. The complete medical history should address the following:
(a) Family history;
(b) Occupational history;
(c) Social history including tobacco, alcohol, drug use;
(d) Civilian exposures history to possible toxic agents;
(e) Psychosocial history; and
(f) Review of systems.
2. The person actually performing the physical examination will be
identified by name, signature and title (i.e., Doctor of Osteopathy, Doctor of
Medicine, Physician's Assistant, etch. A physician's countersignature is
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114
ADEQUACY OF THE VA PERSIAN GULFREGISTRY AND UCAP
required if We examiner is other than a physician. Under normal circumstances,
VRP will provide such countersignatures.
3. When a Persian Gulf Registry (PGR) examination is done as part of a
compensation and pension examination, the physical examination will be done
by/or under the direct supervision of the VRP.
4. The physician should be aware of the variety of exposures endemic to
the Persian Gulf area. These are listed in Appendix 2C and on VA Form 10-
90009A. There has been a wide distribution of major categories of diagnosis
reported by VA VRPs; however, no significant variation in occurrence of major
categories of medical problems has been identified. We are listing below (for
informational purposes) some of the health problems and/or disease which
should be considered:
NOTE: Unfortunately the International Classif cation of Diseases, 9th Edition,
Clinical Modif cation (ICD-9-CM9 coding systems does not give sufficient codes
to correctly identify all symptoms and diagnoses. A number of diagnoses that
have been reported by Veterans' Registry Physicians do not have ICD-9-CM
codes for specif c identif cation in the Veterans Health Administration (VHA)s
database. To correct this, three new codes have been created. They are Apnea,
Sleep (99OOlj, Chronic Fatigue Syndrome (CFSJ (99002), and Fibromyalgia
(990039. Make certain these codes are used when completing the Persian Guf
Registry code sheets for patients who have these diagnoses. As a result of
inadequate coding designations, there has been confusion between the
symptoms (complaintsJ and diagnoses listed on the PER code sheets. Example
one: Arthralgia Diagnostic code 7194J has been usedfor the symptom ' pain in
the joint," where the symptom code 7819 bother symptoms involving nervous
and musculoskeletal systemsJ would be more appropriate. Example two:
Symptom ICD-9-CM code 78051 has been designated for insomnia with sleep
apnea; however, sleep apnea is more correctly identif ed as a specif c diagnosis
which has the new code 99001. Symptom code 78051 may still be used for
insomnia with sleep apnea. Example three: Symptom ICD-9-CM code 7807
has been used to designate CFS and the symptoms of malaise andfatigue. The
new code 99002 has been determinedfor CFS, so ICD-9-CM code 7807 should
be usedfor medical complaints of malaise andfatigue.
OCR for page 115
APPENDIX F
Diagnoses
(1) Amebiasis
(2) Apnea, sleep
(3) Arthralgia
(4) Asthma
(5) grill's Zinsser disease (recrudescent typhus)
(6) Bronchiectasis
(7) Bronchopneumonia, organism unspecified
(8) B~ucellosis
(9) Chronic obstructive pulmonary disease, not else
where classified
(10) Chronic bronchitis
(11) Chronic Fatigue Syndrome
(12) Chronic Laryngotracheitis
(13) Chronic respirator conditions due to Ames and
vapors
(14) Emphysema
(15) Fibromyalgia
(16) Giardiasis
(17) Leishmaniasis
(18) Malaria
(19) Other and unspecified diseases of upper respiratory
tract
(20) Pneumoconiosis due to other silica or silicates
(21) Pneumoconiosis, unspecified
(22) Unspecified chronic respiratory disease
(23) Respiratory conditions due to unspecified external
agent
(24) SaIldfly fever (phlebatomus fever)
(25) Schistosomiasis (bilharziasis)
(26) Toxoplasmosis
(27) Typhoid fever, also carrier V02.1
(28) Tuberculosis, specify variantts)
(29) Viral hepatitis
(30) Memory loss
(31) Polyneuropathy
(32) Skin rash
(33) Adjustment disorder, including Post Traumatic
Stress Disorder (PTSD)
(34) Alcohol dependence syndrome
(35) Drug dependence
115
International
Classification of Diseases
ICD-9-CM Codes
006
99001
7194
493
0811
494
485
023
496
491
99002
4761
5064
492
99003
0071
085
084
4789
502
505
5199
5089
0660
120
130
0020
010-018
070
310
356-357
680-709
309
303
304
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ADEQUACY OF THE VA PERSIAN GULF REGISTRYAND UCAP
5. In gathering these data, it is important to determine and record, the:
a. Time of onset of the symptoms or conditions,
b. Intensity,
c. Degree of physical incapacitation, and
d. Details of any treatment received.
6. Each veteran will be given the following baseline laboratory studies
(Phase I Registry Examination):
a. Complete Blood Count (CBC);
b. Electrolyte Glucose (SMA-6, SMA-12), or equivalent blood
chemistries and enzyme studies; and
c. Urinalysis.
7. Appropriate additional diagnostic studies should be performed and
consultations obtained as indicated by the patient's symptoms and the physical
and laboratory findings. NOTE: If individuals hoe unexplained illnesses, after
a Phase I registry examination is performed, a Phase II examination is
mandated (See Ch. 3, App 3A, for instructior~s.J
a. Other diagnostic studies, such as pulmonary function tests, sperm
counts, should be performed if medically indicated.
b. Laboratory tests results should be filed in the CHR.
Representative terms from entire chapter:
diagnostic studies
