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Append& B Outline of the Standardized Medical Protocol: Selected Pages from the Comprehensive Clinical Evaluation (CCEP) Gliide, January 5, 1995, U.S. Department of Defense

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48 EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSIAN GULF COMPRElIENSI1lE CLINICAL EVALUATION PROGRAM FORM REQUIREMENTS At the MTF level, the CCEP record should include all CCEP forms and relevant medical data to the program. Blank forms included with this guide supersede previous editions of these forms and are intended to be used with the new CCEP. All individual forms will be complete and legible. Forms forwarded to NMIMC and maintained in the participant record shall be in the following order: Phase I completed: MTF Phase I Diagnosis Form Patient Questionnaire Provider-Administered Symptom Questionnaire Information Release Form Declination/Completion Form Phase II completed: RMC Phase II Diagnosis Form Declination/Completion Form MEDICAL PROTOCOLS The CCEP is based upon a thorough clinical evaluation which emphasizes comprehensive and continuous primary care. The local MTF primary care provider maintains responsibility for patient evaluation and care throughout the CCEP process. Medical Treatment Facility (Phase I) Phase I will consist of a comprehensive history and medical evaluation with completion of Phase I questionnaires and related forms. The examination, both in content and quality, should parallel an in-patient admission work-up. The Phase I examination will include a complete medical history including: family, occupation, social (including tobacco, alcohol and drug use), exposure to possible toxic agents, psychosocial condition and review of

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APPENDIX B 49 symptoms. The provider will specifically inquire about the symptoms listed on the CCEP Provider-Administered Patient Questionnaire. A comprehensive medical evaluation, with focused attention to the patients symptoms and health concerns, should be conducted. Individuals who after completing MTF Phase I evaluations do not have a clearly defined diagnosis which explains their symptoms should be reviewed by the CCEP designated physician for further evaluation and consultations needed and/or for referral to the RMC. Phase II Level Evaluations are performed only after complete clinically indicated evaluations (including appropriate specialty consultations) are conducted at the MTF and the RMC. Phase I Laboratory Tests CBC UIA SMA-12 Regional Medical Center (Phase II) Phase II evaluations consist of the following laboratory tests, consultations and as necessary, symptom-specific examinations. Elements of the Phase II evaluation may be accomplished by the local MTF as needed in the comprehensive evaluation of the Phase I patient in order to obtain a definitive . . c .lagnosls. Phase II LaboratorY Tests CBC Sedimentation Rate (ESR) C-Reactive Protein Rheumatoid Factor ANA Liver Function CPK Urinalysis TB skin Test (PPD) with controls Chest X-ray Hepatitis Serology HIV testing VDRL B12 & Folate Thyroid Function Tests

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50 EVALUATION OF THE U.S. DEPARTMENT OF DEFENSE PERSL'4N GULF COMPREHENSIVE CLINICAL EVALUATION PROGRAM Phase II Consults (if not accomplished at MTF level) Dental: Dental only if participant's annual screening not done. Infectious Disease Psychiatry: With Physician Administered Instruments: Structured Clinical Interview for DSMIII-R (SCID) (delete modules for mania and psychosis) Clinician Administered PTSD Scale (CAPS) Neuropsychological Testing: Only as indicated by psychiatry consult SYMPTOM SPECIFIC EXAMINATIONS The RMC CCEP Physician insures that Phase II patients with the following undiagnosed symptoms receive the tests and consultations listed below. Diarrhea Abdominal Headache GI consult GI consult MRI - head Stool for O&P EGD with biopsy/aspiration LP (glucose Stool Leukocytes Colonoscopy with biopsy protein, Stool Culture Abdominal ultrasound cell count, Stool Volume UGI series with small VDRL, Colonoscopy with bowel FT oligoclonal biopsies Abdominal CT Scan myelin, basic EGD with biopsies protein, & aspiration pressure) Neuro consult Muscle Aches Memory Loss Vertigo/ /Numbuess (Only if Tinnitus verified by psych Audiogram evaluation) ENG EMG/NCV MRI - Head BAER Lumbar Puncture Neuro consult Neuro Psych Testing

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APPENDIX B Chronic Fatigue Polysomnography & MSLT Chronic Cou~h/SOB Chest Pain/Palpitations Skin Rash Pulmonary Consult ECG Dermatology Pulmonary Function Exercise Stress Test consult Tests with Exercise Hotter Monitor Consider biopsy & ABG Methacholine Challenge if PFTs are Normal Consider Bronchoscopy with biopsy/ravage Reproductive Concerns Urology consult GYN consult 51

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