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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 113

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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.

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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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116 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.