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Appendix G VA Phase I} Protocol UNIFORM CASE ASSESSMENT PROTOCOL (UCAP) 1. Phase I Level Laboratory Evaluations a. Complete Blood Count (CBC) b. Urinalysis, and c. Blood Chemistry- SMA-6 2. Phase II Level Evaluation Protocol. Phase II Level Evaluations are recommended for those veterans after complete clinically indicated evaluations are conducted and the physician determines that the patient has an unexplained illness. Individuals who after completing Phase I or Registry evaluations, have a disability and do not have a clearly defined diagnosis which explains their symptoms, must receive the following supplemental baseline laboratory tests and consultations. a. Supplemental Baseline Laboratory Tests (1) CBC, (2) Sedimentation Rate Ery~rocyte Sedimentation Rate (ESR), (3) C-Reactive Protein, (4) Rheumatoid Factor, (5) Anti-Nuclear Antibody (ANA), (6) Liver Function, (7) Creatine Phosphokinase (CPK), (8) Hepatitis Serology, 117

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118 ADEQUACYOF THE VA PERSIAN GULFREGISTRYAND UCAP (9) Human Immunodeficiency (HIV), (10) Venereal Disease Research Laboratory (VDRL), (11) B-12 and Folate, (12) Thyroid Function Test, (13) Urinalysis, and (14) Tuberculosis (TB) Skin Test Purified Protein Derivative (PPD). b. Consultations to include: (1) Dental, but only if participant's annual screening is not done. (2) Infectious Disease. (3) Psychiatry, but only with physician administered instrument. (a) Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised (DSM III-R). NOTE: Delete modulesfor mania And psychosis. (b) Clinician Administered Post Traumatic Stress Disorder (PTSD) Scale (CAPS). (4) Neuropsychological Testing, but only as indicated by a psychiatry consult. c. Symptom-Specific Examination. Individuals who have the following symptoms should have the listed minimum work-up. (1) Diarrhea, to include: (a) Gastrointestinal (GI) consults, (b) Stool for Ova and Parasites (O&P), (c) Stool Leukocytes, (d) Stool Culture, Stool Volume, (f) Colonoscopy with biopsies, and (g) Esophagastroduodenoscopy (EGD) with biopsies and aspiration. (2) Abdominal pain to include: (a) GI consult, (b) EGD with biopsy and aspiration, (c) Colonoscopy with biopsy, (d) Abdominal ultrasound, (e) Upper Gastrointestinal (UGI) series with small bowel follow through, and (f) Abdominal Computed Tomography (CT) Scan. Headache (a) Magnetic Resonance Imaging (MRI) of the head, and (b) Lumbar Puncture (LP) to include: 1. Glucose, 2. Protein,

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APPENDIX G 119 3. Cell Count, 4. VDRL, 5. Oligoclonal (lgG), 6. Myelin basic protein, 7. Opening pressure, and 8. Neurology (4) Muscle Aches and/or Numbness (a) Electromyogram (EMG), and (b) Nerve Conduction Velocity (NCV). (5) Memory Loss, only if verified by neuropsychological testing' to include. (a) Magnetic Resonance Imaging (MRI), (b) LP,NOTE: See tests on headache evaluation. (c) Neurology consult, (d) Neuro-psychological testing. (6) Vertigo andlor Tinnitus, to include: (a) Audiogram, (b) Electronystamogram (ENG), and (c) Brainstem Auditory Evoked Response (BAER). (7) Chronic Fatigue, to include: (a) Polysomnography, and (b) Multiple Sleep Latency Test (MSLT). (8) Chronic Cough and/or Shortness of Breath, to include: (a) Pulmonary Consult, (b) Pulmonary Function Test (PFT) with exercise and Arterial Blood Gases (ABG), (c) If routine PFTs are negative, perform Methacholine challenge test, and (d) Bronchoscopy with biopsy and/or ravage which is to be considered if PFTs are normal. (9) Chest Pain and/or Palpitations, to include: (a) Electrocardiogram (ECG), (b) Exercise Stress Test, and (c) Holter monitor. (10) Skin Rash, to include: (a) Dermatology consults, and (b) Consider a biopsy. (11) Reproductive Concerns, to include for: (a) Males, an urology consult; and (b) Females, a gynecology (GYN) consult. (c) Additional elements recommended for the evaluation of Persian Gulf veterans with complaints of Reproductive Health Problems (RHP):

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120 ADEQUACY OF THE VA PERSIAN GULFREGISTRYAND UCAP 1. Detailed genitourinary history and/or problems, e.g.: a. Sexual, b. Genitourinary symptoms, c. Menstrual, d. Contraceptive practices, Pregnancy-related, f. Conception, g. Birth defects, h Congenital disorders, i. Menopause, i Prior infections, k. Prior surgery, and 1. Exposures to toxic agents, etc. 2. Detailed genital/pelvic examination 3. Laboratory and ancillary testing, e.g' _. Pap tests;and b. Tests for genitourinary infections. ,. . 4. Urologist consultations for male veterans who have RHP that cannot be diagnosed or managed successfully by primary care practitioners. 5. Gynecology consultation for female veterans who have RHP that cannot be diagnosed or managed successfully by primary care practitioners. (d) Additional elements for evaluation of Persian Gulf veterans with complaints of infertility. 1. Detailed menstrual and reproductive history (such as the infertility questionnaire utilized by Walter Reed Army Medical Centered. 2. Semen analysis, e.g.: a. Volume, b. pH, c. Liquefaction, d. Spend concentration, e. Motility, f Progressive motility, g. Sperm viability, h Leukocytes, and i. Morphology. 3. Referral to an infertility specialist or program.

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APPENDIX G 121 (e) Additional elements for evaluation of Persian Gulf veterans with complaints related to bird defects or genetic disorders in offspring conceived during or after Persian Gulf service. 1. Detailed history of congenital or genetic disorders (such as the Patient Genetic Screen Questionnaire utilized by Walter Reed Army Medical Centered. 2. Detailed occupational exposures questionnaire (such as Worker and Supervisor Questionnaires utilized by National Naval Medical Centered. 3. Referral to a genetic disease specialist or program. *For copies of these questionnaires (Items d-1 and e-1 and 29, contact VA Environmental Agents Service f103A) at 202-565-4183.

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