CLINICIAN'S GUIDE

MARCH 2002

# Table of Contents

Table of Contents 2

PREFACE 4

Chapter 1 -- INTRODUCTION TO COMPENSATION AND PENSION 5

> Worksheet -- Aid and Attendance or Housebound Examination 16
>
> Worksheet -- General Medical Examination 18

Chapter 2 -- DISEASES OF THE SKIN INCLUDING SCARS 22

> Worksheet -- Skin Diseases (Other Than Scars) 28
>
> Worksheet -- Scars 29

Chapter 3 -- BIRTH DEFECTS IN CHILDREN OF VIETNAM VETERANS 30

> SECTION I: Children with spina bifida who are the children of Vietnam
> veterans 30
>
> SECTION II: Children with birth defects who are the children of women\
> Vietnam veterans 32

Chapter 4 -- EYE 34

> Worksheet -- Eye Examination 39

Chapter 5 -- EAR, MOUTH, NOSE AND THROAT 42

> Worksheet -- Audio 57
>
> Worksheet -- Dental and Oral 59
>
> Worksheet -- Ear Disease 60
>
> Worksheet -- Mouth, Lips and Tongue 62
>
> Worksheet -- Nose, Sinus, Larynx, and Pharynx 63
>
> Worksheet -- Sense of Smell and Taste 64

Chapter 6 -- RESPIRATORY 65

> Worksheet -- Respiratory (Obstructive, Restrictive, and Interstitial)
> 71
>
> Worksheet -- Respiratory Diseases, Miscellaneous 73
>
> Worksheet -- Pulmonary Tuberculosis and Mycobacterial Diseases 75

Chapter 7 -- CARDIOVASCULAR SYSTEM 77

> Worksheet -- Arrhythmias 88
>
> Worksheet -- Arteries, Veins, and Miscellaneous 90
>
> Worksheet -- Heart 93
>
> Worksheet -- Hypertension 95

Chapter 8 -- DISEASES OF THE DIGESTIVE SYSTEM 96

> SECTION I: ESOPHAGUS 96
>
> SECTION II: STOMACH 101
>
> SECTION III: INTESTINE 103
>
> SECTION IV: RECTUM AND ANUS 107
>
> SECTION V: ALIMENTARY APPENDAGES 110
>
> Worksheet -- Esophagus and Hiatal Hernia 115
>
> Worksheet -- Digestive Conditions, Miscellaneous 116
>
> Worksheet -- Intestines(Large and Small) 117
>
> Worksheet -- Liver, Gall Bladder, and Pancreas 118
>
> Worksheet -- Rectum and Anus 120
>
> Worksheet -- Stomach, Duodenum, and Peritoneal Adhesions 121

Chapter 9 -- GENITOURINARY SYSTEM 122

> Worksheet -- Genitourinary Examination 126

Chapter 10 -- GYNECOLOGICAL CONDITIONS AND DISORDERS OF THE\
BREAST 128

> Worksheet -- Gynecological Conditions and Disorders of the Breast 133

Chapter 11 -- MUSCULOSKELETAL 135

> Worksheet -- Bones (Fractures and Bone Disease) 143
>
> Worksheet -- Chronic Fatigue Syndrome 145
>
> Worksheet -- Feet 147
>
> Worksheet -- Fibromyalgia 149
>
> Worksheet -- Joints (Shoulder, Elbow, Wrist, Hip, Knee, and Ankle) 150
>
> Worksheet -- Hand, Thumb, and Figers 153
>
> Worksheet -- Muscles 155
>
> Worksheet -- Residuals of Amputations 157
>
> Worksheet -- Spine (Cervical, Thoracic, and Lumbar) 160

Chapter 12 -- NEUROLOGICAL EXAMINATION 161

> Worksheet -- Brian and Spinal Cord 171
>
> Worksheet -- Cold Injury Protocol Examination 173
>
> Worksheet -- Cranial Nerves 176
>
> Worksheet -- Epilepsy and Narcolepsy 177
>
> Worksheet -- Neurological Disorders, Miscellaneous 178
>
> Worksheet -- Peripheral Nerves 179

Chapter 13 -- MENTAL DISORDERS 181

> Worksheet -- Eating Disorders (Mental Disorders) 189
>
> Worksheet -- Mental Disorders (except PTSD and Eating Disorders) 191

Chapter 14 -- POST-TRAUMATIC STRESS DISORDER (PTSD) 194

> Worksheet -- Initial Evaluation for Post-Traumatic Stress Disorder
> (PTSD) 205
>
> Worksheet -- Review Examination for Post-Traumatic Stress Disorder
> (PTSD) 212

Chapter 15 -- INFECTIOUS DISEASES, IMMUNE DISORDERS, AND\
NUTRITIONAL DEFICIENCIES 217

> Worksheet -- HIV-Related Illness 225
>
> Worksheet -- Infectious, Immune, and Nutritional Disabilities 226

Chapter 16 -- ENDOCRINE CONDITIONS 227

> Worksheet -- Acromegaly 233
>
> Worksheet -- Cushing's Syndrome 234
>
> Worksheet -- Diabetes Mellitus 235
>
> Worksheet -- Endocrine Diseases, Miscellaneous 237
>
> Worksheet -- Thyroid and Parathyroid Diseases 239

Chapter 17 -- HEMIC AND LYMPHATIC SYSTEMS 240

> Worksheet -- Hemic Disorders 245
>
> Worksheet -- Lymphatic Disorders 246

Chapter 18 -- RADIATION EXPOSURE 247

Chapter 19 -- FORMER PRISONERS OF WAR (POWS) 250

> Worksheet -- Prisoner of War Protocol Examination 257

Chapter 20 -- GULF WAR VETERANS 261

> Worksheet -- Guidelines for Disability Examinations in Gulf War
> Veterans 263

Chapter 21 -- HERBICIDE EXPOSURE/AGENT ORANGE 266

# PREFACE

Clinician Guide version 3.0

Edited by Lewis R. Coulson, M.D.

March 2002

## 0.1 Purpose of the Clinician's Guide

This guide is designed to assist clinicians when performing compensation
and pension (C&P) examinations. Since C&P examinations differ markedly
from traditional medical examinations, special clinician guidance is
required. This guide provides information for performing examinations
that meet the requirements of the federal law.

Since the federal law (rating schedule) is written in legal language, it
is often misinterpreted by clinicians. This guide, therefore, bridges
this gap and explains the law in clinical terms.

Both this Guide and the worksheets should be utilized when performing
C&P examinations.

## 0.2 How to use this guide

I. View in a word processor with the table of contents to the left and
text to the right (select View, Document Map)

> or

II\. Print

## 0.3 Acknowledgements

This guide was written and edited by the following people, and in part
excerpted from the former Physician's Guide:

Marjorie Auer, Esq. (BVA), Troy Baxley (VHA), Joseph Enderle (VHA),
Caroll McBrine, M.D. (VBA)

and Lewis R. Coulson, M.D. (VHA)

Cover designed by Kim Kokoshka (VHA)

## 0.4 Edition

Version 3.0, March 2002

# Chapter 1 - INTRODUCTION TO COMPENSATION AND PENSION

## 1.1 What is the clinician's guide?

The Clinician's Guide and any of its parts (worksheets) are intended
solely as a guide for clinicians, and it is not legally binding on a
clinician to perform all portions of the examination protocol. However,
there are requirements for certain examinations, e.g., specific
audiologic testing for hearing impairment and a METs measurement by
stress testing, or, if not feasible, a METs estimate, for certain heart
diseases that must be provided by the examiner to make the examination
sufficient for rating purposes. A clinician should understand the
specific questions being asked by the Veterans Benefits Administration
(VBA) or the Board of Veterans' Appeals (BVA) for rating purposes and
then determine the type of examinations and which clinicians should
perform them. Clinicians are expected to use good clinical judgment in
deciding which examinations are most appropriate to answer the specific
questions asked, and they should utilize appropriate textbooks of
medicine as guidelines when making diagnoses.

## 1.2 What is the compensation and pension program?

Compensation and Pension (C&P) includes several different programs,
which provide monetary and other benefits to veterans.

## 1.3 History of U.S. compensation and pension programs.

In 1776 the Continental Congress established disability pensions for
United States veterans in order to increase enlistments and to raise
morale. At that time, the states were asked to pay these pensions,
although not all did. By 1789, veterans' benefits were paid out of the
Federal budget as a reward for service. Until 1818, pensions were
granted only to veterans who were disabled by injuries in service. The
amount of pension (now called disability compensation) was originally
based on the military rank of the veteran.

Since 1818, disability compensation has been paid by the U. S.
Department of Veterans Affairs (VA) to veterans for disabilities
resulting from injuries or diseases incurred or aggravated in active
military service. Some diseases are presumed to be service connected
because they are presumed, under certain regulations, to have been
incurred in service, even if they did not manifest for some time after
the veteran's discharge from the military.

Disability pension is paid for those veterans with wartime service who
meet income threshold requirements and who are permanently and totally
disabled as a result of non-service-connected condition(s), not the
result of their own willful misconduct.

## 1.4 What is disability compensation?

Disability compensation is money paid to veterans who are disabled by
service-connected conditions (conditions related to military service).
It compensates veterans for average loss of earning potential due to
current disability resulting from disease or injury, which was incurred
or aggravated (pre-military conditions) in active military service.

## 1.5 What is pension for non-service connected disability?

Pension for non-service-connected disability is a needs-based program
for wartime veterans (veterans with 90 days or more of active military
service, at least one day of which was during a period of war or
veterans who were discharged or released from service during a period of
war for a service-connected disability) who are permanently and totally
disabled from non-service connected disability or a combination of
service-connected and non-service-connected disability, not the result
of their own willful misconduct.

## 1.6 Common terms

### 1.6.1 Aid and Attendance (A&A)

> An additional amount of money payable monthly to a veteran receiving
> compensation or pension, who needs the aid and attendance of another
> person to assist with activities of daily living.

### 1.6.2 Board of Veterans' Appeals (BVA)

> Directly responsible to the Secretary of Veterans Affairs, the BVA
> adjudicates de novo the decision made by a Veterans Service Center on
> a claim. If a claimant still disagrees with a BVA decision, he or she
> may timely appeal it to the United States Court of Appeals for
> Veterans Claims (CAVC).

### 1.6.3 Code of Federal Regulations (CFR)

> The regulations applying to compensation and pension benefits are
> contained in title 38 of the Code of Federal Regulations. The statutes
> established by Congress that apply to veterans' benefits are contained
> in title 38 of the United States Code.

### 1.6.4 Claims File or Folder (C-FILE)

> Folder that contains the veteran's or claimant's service medical
> records, claim correspondence, evidence including medical records and
> documentation of all benefit awards. This folder is confidential and
> the veteran may not have access to this claims folder without the
> presence of a Rating Veterans Service Representative (RVSR). Claims
> folder [may not]{.underline} be given to veterans to carry from one
> clinic to another or from the Medical Center to the Veterans Service
> Center.

### 1.6.5 Court of Appeals for Veterans Claims (CAVC)

> CAVC (previously called the United States Court of Veterans Appeals or
> COVA) has exclusive jurisdiction to review decisions of the BVA. The
> Court's precedent decisions are binding upon the [entire]{.underline}
> Department of Veterans Affairs and are effective on the day they are
> issued. Failure to comply with the Court\'s decisions and orders may
> subject the Department to legal action.

### 1.6.6 Decision Review Officer (DRO) - formerly Hearing Officer

> A Veterans Service Center (VSC) employee who may conduct personal
> hearings with veterans who disagree with a VSC decision and have
> requested a personal hearing to present testimony and evidence to
> support their claim. The DRO may also overturn a decision made by the
> rating agency that is unfavorable to the claimant, based on difference
> of opinion, or one that is either favorable or unfavorable if the
> decision is erroneous.

### 1.6.7 Housebound

> An additional amount of money payable monthly to a veteran receiving
> compensation or pension. The housebound payment may be paid if the
> claimant, due to disability, is factually housebound, that is,
> substantially confined to his or her dwelling and the immediate
> premises or, if institutionalized, to the ward or clinical areas, and
> it is reasonably certain that the disability and confinement will
> continue throughout his or her lifetime. Alternatively, the housebound
> allowance may be paid if there is a permanent disability rated at 100
> percent and there is additional disability ratable at 60 percent or
> more, separate and distinct from the disability rated at 100 percent
> and involving different anatomical segments or bodily systems.

### 1.6.8 Non Service Connected (NSC) Disability

> A disability resulting from a disease or injury, which was not
> incurred or aggravated in active military service.

### 1.6.9 Rating Veterans Service Representative (RVSR) -- formerly Rating Specialist

> A Veterans Service Center (VSC) employee who, based on service and
> medical records, determines whether or not a claimed disability
> exists, the relationship of the disability to military service, and
> the degree to which it renders the claimant disabled.

### 1.6.10 Veterans Service Center (VSC) - formerly Regional Office -- (VARO or RO)

> A field office of the Veterans Benefits Administration, which
> adjudicates claims to VA benefits and delivers other services to
> veterans. There are currently 58 such offices, at least one in each
> state.

### 1.6.11 Remand 

> Appeals returned (remanded) by the BVA to the Veterans Service Center
> or by CAVC to BVA for additional evidence or action, including new
> examinations or medical opinions.

### 1.6.12 Service Connected (SC) Disability

> A disability resulting from a disease or injury which was incurred or
> aggravated during a period of active military service from which the
> veteran was discharged under other than dishonorable conditions and
> which was not the result of willful misconduct of the veteran. A
> service-connected disability evaluated 10% or more disabling entitles
> a veteran to disability compensation.

### 1.6.13 United States Code (U.S.C.)

> Statutes of Title 38 U.S.C. apply to VA benefits.

### 1.6.14 Veterans Benefits Administration (VBA)

> Administration responsible for a wide variety of benefit programs
> authorized by Congress, including disability compensation, disability
> pension, burial assistance, rehabilitation assistance, education and
> training assistance, home loan guarantees, and life insurance
> coverage.

## 1.7 What are the steps in the disability evaluation process?

**1. Veteran Files a Claim**: A veteran files a claim with the VSC,
submitting statements or evidence to substantiate the claim.

**2. RVSR Initial Review**: A Rating Veterans Service Representative
reviews the claim, service medical records, and other evidence of record
and any past disability or pension decisions. A decision must be made on
the medical and lay evidence in the claims file.

**3. Compensation and Pension Examination Request**: If the Rating
Veterans Service Representative determines that a medical examination is
needed to decide the claim, he or she submits an appropriate examination
or opinion request to a Veterans Health Administration (VHA) medical
facility or to a contract examination company.

**4. Compensation and Pension Examination Performed**: Clinicians
conduct an examination following the appropriate worksheets to perform a
complete and adequate (for rating purposes) examination, answering all
questions and providing opinions.

**5. Rating Veterans Service Representative Determination**: The Rating
Veterans Service Representative uses the Rating Schedule, a guide for
determining disabilities, percentage ratings, and impairment in earning
capacity, to make a final decision. This person must interpret all
examination reports in the context of the veteran's entire recorded
history, reconciling the various reports so the current rating
accurately reflects the current disability, reflecting the impairment on
the claimant's ability to work. A claimant's disability claim may
require re-rating in accordance with changes in laws, new medical
knowledge, and the changing physical or mental condition of the
claimant. When reasonable doubt exists, that is, the evidence for and
against an issue is in equipoise, that doubt will be resolved in favor
of the veteran. (38 CFR 4.3)

**6. Review by the VSC**: If a veteran is dissatisfied with the decision
made by the Veterans Service Center, he/she may appeal the decision. The
appeal must be filed within one year of notification of the decision by
submitting a Notice of Disagreement (NOD). An appeal may result in a new
examination (particularly if the veteran submits additional evidence
with the appeal).

**7. Appeal to the BVA**: If a veteran disagrees with the final rating
decision of the VSC, he or she can appeal it to the BVA. The BVA can
make a ruling or remand (send) it back to the VSC for further
development of the evidence. The VSC, after gathering additional
information and evidence, such as another medical examination, renders
another decision and sends it back to the BVA for its review.

**8. Appeal to the CAVC**: If a veteran disagrees with the decision of
the BVA, he or she can appeal it to CAVC, which can make a ruling or
remand (send) it back to the BVA for more information or evidence. The
BVA, after gathering additional information or evidence, such as
additional information or evidence from the VSC or another medical
examination, renders a decision. Any party to a decision made by CAVC
may appeal it to the U.S. Court of Appeals for the Federal Circuit with
respect to the validity of any statute or regulation or interpretation
thereof that was relied on by CAVC.

**9. Appeal to the U.S. Supreme Court:** A veteran can also petition the
U.S. Supreme Court for review following an adverse decision by the
Federal Circuit Court.

## 1.8 What is a compensation and pension examination?

Many of the claims filed by veterans for compensation and/or pension
necessitate a medical examination. The report of the examination,
together with service medical records and other evidence, is used by the
VSC to determine the veteran's eligibility for benefits and the level of
compensation.

## 1.9 How is a C&P examination different from a medical examination?

Although a traditional medical examination requires diagnoses for
treatment purposes, a C&P disability examination requires diagnoses to
prove whether or not a claimed disability actually exists and the
functional effects of the disability on the veteran. The purpose of the
C&P exam is to provide very specific information in order to ensure a
proper evaluation of the claimed disability rather than to provide
medical treatment. A treatment examination is written for clinicians to
understand, but a compensation and pension examination is written for
RVSRs, lawyers, and judges to understand.

## 1.10 How do I perform a C&P examination?

**1. Read the VSC request**, including any remarks, specific questions,
directions, or requested opinions.

**2. Review the claims file, service records, medical records, previous
C&P examinations, and BVA Remand instructions, if available.** BVA
Remand [instructions generally require]{.underline} the examiner to
review the claims file and the BVA Remand instructions and to so state
in the final report.

**3. Explain the examination process to the veteran** and confirm the
claimed **c**onditions.

**4. Examine the veteran** following the appropriate worksheets for all
claimed conditions.

**5. Order any required tests and procedures** to establish diagnoses
for rating purposes unless the diagnosis is already well established.

**6. Prepare a complete typed report**, including claimed conditions,
specific requests of the VSC or BVA, and whether or not the claims file
was available and reviewed by the examiner.

## 1.11 How much information should be included in the report?

Include all the important history and physical findings required to
substantiate diagnoses for all claimed conditions unless the diagnosis
is already well established. Describe current signs and symptoms, and
include any limitation of activity imposed by the disabling condition.
Report current treatment and any side effects. If, during the
examination, the examining physician gives the veteran any advice as to
treatment, including advice as to discontinuance or curtailment of
ordinary activities, such advice should be recorded in the report of
examination. Do not include any irrelevant, redundant, or expansive
narratives. If an examination report does not contain sufficient details
to adequately support the diagnoses (unless the diagnosis is already
well established) or sufficient information about the current findings
and effects on functioning, the RVSR will return the report as
inadequate for rating purposes. (38 CFR 4.2)

## 1.12 Diagnoses do's (also see diagnoses don'ts) 

**1. Definite diagnosis**: Give a definite diagnosis or use the
previously established diagnosis.

**2. No Diagnosis found**: If no diagnosis is found for any claimed
condition, state this. For example, state "Lower back pain: There is
insufficient evidence to warrant a diagnosis of an acute or chronic low
back disorder or its residuals." Explain in detail the reason why a
diagnosis cannot be established for the condition claimed.

**3. Diagnosis of Unknown Etiology**: If a disability does exist but a
definite diagnostic name cannot be given to it, state this. For example,
state "Muscle strain of unknown etiology". (See Gulf War Examination
Worksheet concerning "undiagnosed illnesses" in Gulf War veterans.)

**4. Support each diagnosis**: Support each diagnosis with subjective
(history) and objective (physical) data.

**5. Effect on daily activities and work**: Comment on the disability's
effect on the veteran's daily activities and his ability to work.

## 1.13 Diagnoses don'ts (also see diagnoses do's) 

**1. Non-committal diagnosis**: Don't use phrases such as "differential
diagnosis" or "rule out".

**2. Symptoms or signs**: Don't use symptoms (pain) or signs
(tenderness) for a diagnosis if a more exact diagnosis is known. If a
disease appears to exist but an etiology cannot be determined, you may
say, for example, "fatigue of unknown etiology".

**3. Opinion for further studies, evaluations, or laboratory tests**: If
further studies, evaluations or tests are necessary, perform them before
making a final decision. Otherwise the examination is incomplete and
will be returned as inadequate.

**4. Change the previously established service connected diagnoses**:
Don't change previously established diagnoses, unless you carefully
explain the discrepancy and adequately substantiate the new diagnoses.

## 1.14 How do I perform special examinations?

### 1.14.1 Musculoskeletal examination

> A musculoskeletal examination for compensation and pension purposes
> differs from a traditional medical examination in that it requires
> specific detailed assessment of functioning of all areas to be
> examined. Include anatomical damage to muscles and joints and any
> atrophy or skin changes. Since disabilities of the musculoskeletal
> system affect the ability of the body to perform normal working
> movements such as excursion, strength, speed, coordination and
> endurance, VA regulations, as interpreted by the CAVC, require every
> musculoskeletal examination to include the degrees of functional loss
> due to pain, weakened movement, excess fatigability, or
> incoordination. (from 38 CFR 4.40, part of the basis of the Court's
> DeLuca v. Brown precedent opinion).

### 1.14.2 Board of Veterans' Appeals (BVA) remand examination

> The BVA is one of the appellate levels available to veterans after an
> initial decision has been made by a VSC. VSC and BVA adjudicators
> require sufficient medical information to be able to assess the merits
> of a claim. A substantiated claim for service connection has medical
> evidence of a current disability, occurrence or aggravation of a
> disease or injury in service, and established injury, disease, or
> event in service and a nexus (connection) between the in-service
> injury, disease, or event and the current disability. Additional
> examinations may be requested when the available examination report
> contains insufficient details for rating purposes or does not
> adequately reveal the current state of the claimant\'s disability, or
> when no definite diagnosis is given. Examiners must review the claims
> folder and any BVA remand instructions carefully before examining the
> veteran and clearly state this fact in the written summary report. The
> examiner should answer all questions, if possible. Because of CAVC
> decisions, examiners are now being asked for medical-legal opinions,
> and they need to express their opinions and diagnoses so that they
> will stand up to the scrutiny of the CAVC.

### 1.14.3 Board of two (or three) examiners

> Many claims involve complicated questions of causality, diagnosis, or
> relationship, or contrary opinions of previous examiners. The VSC or
> the BVA may request an examination by a board of two (or, rarely,
> three) examiners to resolve such questions. Two (or three) clinicians
> should examine the veteran, consider all the evidence, consult with
> one another, and submit a [single report]{.underline} signed by both
> (or all three) containing joint diagnoses and addressing all of the
> questions asked. If differences cannot be reconciled, or questions
> cannot be answered, the report should clearly explain why.

### 1.14.4 Competency for VA purposes

> See 13.8 "How and why should an examiner consider mental
> incompetency?"

### 1.14.5 Total disability 

> Total disability exists when there is impairment of mind or body which
> is sufficient to render it impossible for the average person to be
> gainfully employed. Total disability may or may not be permanent.
> Total disability ratings are not generally assigned for temporary
> exacerbations or acute infectious diseases.

### 1.14.6 Permanent total disability 

> Permanent total disability exists when total disability is reasonably
> certain to continue throughout the life of the claimant. Examples are
> permanent loss of use of both hands or of both feet, or of one hand
> and one foot, or of the sight of both eyes, or becoming permanently
> helpless or permanently bedridden.

### 1.14.7 Aid and attendance benefits

> The need for Aid and Attendance means that the claimant is completely
> helpless or so nearly helpless as to require the continuing aid and
> attendance of another person for activities of daily living such as
> bathing, dressing, and eating, due to such things as total blindness
> or being bedridden.

### 1.14.8 Effects of a disability on employment

> The examiner should explain in detail the effects of the disability
> being examined on the veteran's ability to work. This should include
> any limitations such as inability to bend, lift, stoop, walk, sit for
> extended periods, etc.

## 1.15 Should opinions of merit or percentage of disability be given by the examiner?

The examining clinician must avoid expressing an opinion regarding the
merits of any claim or the percentage evaluation that should be assigned
for a disability. An opinion should not be given to the claimant
regarding insurability, degree of disability, incurrence or aggravation
by military service, or the character and sufficiency of treatment
during military service or subsequently thereto. When asked about
employability, the examiner should not state that an individual veteran
is or is not individually unemployable, but should describe in full the
effects of the conditions being examined on functioning, and how that
relates to employment.

## 1.16 How do I give an opinion for nexus (relationship to a military incident?

When asked to give an opinion as to whether a condition is related to a
specific incident during military service, the opinion should be
expressed as follows:

**1. "is due to"** (100% sure)

**2. "more likely than not"** (greater than 50%)

**3. "at least as likely as not"** (equal to or greater than 50%)

**4. "not at least as likely as not"** (less than 50%)

**5. "is not due to"** (0%)

## 1.17 What if reported symptoms appear out of proportion to signs or test results?

If the examiner feels that the claimant's symptoms are not consistent
with physical signs or test results, he should state that the physical
examination or laboratory tests do not support the severity of
disability suggested by the complaints. In this case, complaints should
be recorded in the veteran\'s own unprompted language within quotation
marks, so that it will be clear that they are complaints and not the
opinions of the examining physician.

## 1.18 What if I suspect malingering or misrepresentation of facts?

If malingering is detected or suspected, the examining physician should
so state, together with reasons for the opinion. Any detection of
evasion or misrepresentation of facts that can be substantiated by
findings should also be reported.

## 1.19 Use of clinical photographs

Non-retouched color photographs and sketches of skin lesions should be
made and properly labeled when verbal description is not adequate.

## 1.20 Geriatric veterans

Geriatric veterans (over 70 years old) may present a special challenge
for the examiner. Not only may they have diseases and residuals of prior
injuries like younger veterans, they may also have difficulty
communicating or responding to questions or physical demands. The
examiner should allow appropriate time and provide sufficient support to
ensure that an adequate examination is performed.

## Worksheet - AID AND ATTENDANCE OR HOUSEBOUND EXAMINATION

Name: SSN:

Date of Exam: C-number:

Place of Exam:

[Narrative:]{.underline} Once the existence of at least one permanent
disability rated at 100% has been established, additional benefits may
be payable if the veteran requires:

> 1\. The regular assistance of another person in attending to the
> ordinary activities of daily living,
>
> 2\. Assistance of another in protecting himself or herself from the
> ordinary hazards of his or her daily environment, and/or
>
> 3\. If the veteran is restricted to his or her home or the immediate
> vicinity thereof, including the ward or immediate clinical area, if
> hospitalized.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

> 1\. Indicate whether or not the veteran requires an attendant in
> reporting for this exam, and if so, identify the nurse or attendant
> and the mode of travel employed.
>
> 2\. Indicate whether or not the veteran is hospitalized, and if so,
> state where and the date of admission.
>
> 3\. Indicate whether or not the veteran is permanently bedridden.
>
> 4\. Indicate whether or not the veteran\'s best corrected vision is
> 5/200 or worse in both eyes.
>
> 5\. State whether the veteran is capable of managing benefit payments
> in his or her own best interests without restriction. (A physical
> disability which prevents the veteran from attending to financial
> matters in person is not a proper basis for a finding of incompetency
> unless he or she is, by reason of that disability, incapable of
> directing someone else in handling financial affairs.)
>
> 6\. Capacity to protect oneself from the hazards/dangers of daily
> environment:
>
> a\. Describe briefly any pathological processes involving other body
> parts and systems, including the effects of advancing age, such as
> dizziness, loss of memory, poor balance affecting ability to ambulate,
> performing self- care, or travel beyond the premises of the home (or
> the ward or clinical area if hospitalized).

b\. Describe where the veteran goes and what he or she does during a
typical day.

C. Physical Examination (Objective Findings):

Comment on:

1\. General appearance.

2\. Height and weight (including maximum and minimum weight for past
year).

3\. Build and posture.

4\. State of nutrition.

5\. Gait.

6\. Temperature, pulse, respiration.

7\. Blood pressure.

8\. Upper extremities (reporting each upper extremity separately):

> a\. Describe functional restrictions with reference to strength and
> coordination and ability for self-feeding, fastening clothing,
> bathing, shaving, and toileting.
>
> b\. If amputated, indicate level of amputation (or length of stump and
> state whether or not use of a prosthesis is feasible).

9\. Lower extremities (reporting each lower extremity separately):

> a\. Describe functional restrictions with reference to extent of
> limitation of motion, muscle atrophy, contractures, weakness, lack of
> coordination, or other interference.

b\. Indicate any deficits of weight bearing, balance and propulsion.

> c\. If amputated, indicate level of amputation (or length of stump and
> state whether use of a prosthesis is feasible).

10\. Spine, trunk and neck:

> a\. Describe any limitation of motion or deformity of lumbar,
> thoracic, and cervical spine.

11\. Note if deformity of thoracic spine interferes with breathing.

12\. Ambulation:

> a\. Indicate whether the veteran is able to walk without the
> assistance of another person and give the maximum distance.
>
> b\. Indicate any mechanical aid used or recommended by the examiner
> for ambulation.
>
> c\. Indicate the frequency, and under what circumstances, the veteran
> is able to leave the home or immediate premises.
>
> 13\. Except as to amputations and other anatomical losses, indicate if
> any restrictions noted in the examination are permanent.

D. Diagnostic and Clinical Tests:

> 1\. No specific diagnostic testing required unless required to
> evaluate the veteran as required above.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. Diagnosis:

Signature: Date:

## Worksheet - GENERAL MEDICAL EXAMINATION

Name: SSN:

Date of Exam: C-number:

Place of Exam:

[Narrative:]{.underline} This is a comprehensive base-line or screening
examination for all body systems, not just specific conditions claimed
by the veteran. It is often the initial post-discharge examination of a
veteran requested by the Compensation and Pension Service for disability
compensation purposes. As a screening examination, it is not meant to
elicit the detailed information about specific conditions that is
necessary for rating purposes. **Therefore, all claimed conditions, and
any** **found or suspected conditions that were not claimed, should be
addressed by referring to and following all appropriate worksheets, in
addition to this one, to assure that the examination for each condition
provides information adequate for rating purposes**. This does not
require that a medical specialist conduct examinations based on other
worksheets, except in the case of vision and hearing problems, mental
disorders, or especially complex or unusual problems. **Vision, hearing,
and mental disorder examinations must be conducted by a specialist**.
The examiner may request any additional studies or examinations needed
for proper diagnosis and evaluation (see other worksheets for guidance).
All important negatives should be reported. The regional office may also
request a general medical examination as evidence for
nonservice-connected disability pension claims or for claimed
entitlement to individual unemployability benefits in service-connected
disability compensation claims. Barring unusual problems, examinations
for pension should generally be adequate if only this general worksheet
is followed.

A. **Review of Medical Records:** Indicate whether the C-file was
reviewed.

B. **Medical History (Subjective Complaints):**

Discuss: Whether an injury or disease that is found [occurred during
active service, before active service, or after active
service]{.underline}. To the extent possible, describe the
circumstances, dates, specific injury or disease that occurred,
treatment, follow-up, and residuals. If the injury or disease occurred
[before active service]{.underline}, describe any worsening of residuals
due to being in military service. Describe current symptoms and
treatment.

> 1\. Occupational history (for [pension]{.underline} and [individual
> unemployability]{.underline} claims): Obtain the name and address of
> employers (list most current first), type of occupation, employment
> dates, and wages for last 12 months. If any time was lost from work in
> the past 12-month period, please describe the reason and extent of
> time lost.
>
> 2\. Describe details of current treatment, conditions being treated,
> and side effects of treatment.
>
> 3\. Describe all surgery and hospitalizations in and after service
> with approximate dates.
>
> 4\. If a malignant neoplasm is or was present, provide:
>
> a\. Date of confirmed diagnosis.
>
> b\. Date of the last surgical, X-ray, antineoplastic chemotherapy,
> radiation, or other therapeutic procedure.
>
> c\. State expected date treatment regimen is to be completed.
>
> d\. If treatment is already completed, provide date of last treatment.
>
> e\. If treatment is already completed, fully describe residuals.

**C. Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings: The
examiner should incorporate results of all ancillary studies into the
final diagnoses.

> 1\. [VS]{.underline}: Heart rate, blood pressure (see #13 below),
> respirations, height, weight, maximum weight in past year, weight
> change in past year, body build, and state of nutrition.
>
> 2\. [Dominant hand]{.underline}: Indicate the dominant hand and how
> this was determined, e.g., writes, eats, combs hair with that hand.
>
> 3\. [Posture and gait]{.underline}: Describe abnormality and reason
> for it. Describe any ambulatory aids.
>
> 4\. [Skin, including appendages]{.underline}: If abnormal, describe
> appearance, location, extent of lesions. If there are laceration or
> burn scars, describe the location, exact measurements (cm. x cm.),
> shape, depression, type of tissue loss, adherence, and tenderness. For
> each burn scar, state if due to a 2nd or 3rd degree burn. Describe any
> limitation of activity or limitation of motion due to scarring or
> other skin lesions.
>
> **NOTE:** If there are disfiguring scars (of face, head, or neck),
> obtain [color]{.underline} [photographs]{.underline} of the affected
> area(s) to submit with the examination report.
>
> 5\. [Hemic and Lymphatic:]{.underline} Describe adenopathy,
> tenderness, suppuration, edema, pallor, etc.
>
> 6\. [Head and face]{.underline}: Describe scars, skin lesions,
> deformities, etc., as discussed under item #4.
>
> 7\. [Eyes]{.underline}: Describe external eye, pupil reaction, eye
> movements.
>
> 8\. [Ears]{.underline}: Describe canals, drums, perforations,
> discharge.
>
> 9\. [Nose, sinuses, mouth and throat]{.underline}: Include gross
> dental findings. For sinusitis, describe headaches, pain, episodes of
> incapacitation, frequency and duration of antibiotic treatment.
>
> 10\. [Neck]{.underline}: Describe lymph nodes, thyroid, etc.
>
> 11\. [Chest]{.underline}: Inspection, palpation, percussion,
> auscultation. Describe respiratory symptoms and effect on daily
> activities, e.g., how far the veteran can walk, how many flights of
> stairs veterans can climb. If a respiratory condition is claimed or
> suspected, refer to appropriate worksheet(s). Most respiratory
> conditions will require PFT's, including post-bronchodilation studies.
> Describe in detail any treatment for pulmonary disease.
>
> 12\. [Breast]{.underline}: Describe masses, scars, nipple discharge,
> skin abnormalities. Give date of last mammogram, if any. Describe any
> breast surgery (with approximate date) and residuals.
>
> 13\. [Cardiovascular]{.underline} : NOTE: If there is evidence of a
> cardiovascular disease, or one is claimed, refer to appropriate
> worksheet(s).
>
> a\. Record pulse, quality of heart sounds, abnormal heart sounds,
> arrhythmias. Describe symptoms and treatment for any cardiovascular
> condition, including peripheral arterial and venous disease. Give NYHA
> classification of heart disease. A determination of METs by exercise
> testing may be required for certain cardiovascular conditions, and an
> estimation of METS may be required if exercise testing cannot be
> conducted for medical reasons. (See the cardiovascular worksheets for
> further guidance.)
>
> b\. Describe the status of peripheral vessels and pulses. Describe
> edema, stasis pigmentation or eczema, ulcers, or other skin or nail
> abnormalities. Describe varicose veins, including extent to which any
> resulting edema is relieved by elevation of extremity. Examine for
> evidence of residuals of cold injury when indicated. See and follow
> special cold injury examination worksheet if there is a history of
> cold exposure in service and the special cold injury examination has
> not been previously done.
>
> c\. Blood pressure: (Per the rating schedule, hypertension means that
> the diastolic blood pressure is predominantly 90mm. or greater, and
> isolated systolic hypertension means that the systolic blood pressure
> is predominantly 160mm. or greater with a diastolic blood pressure of
> less than 90mm.)
>
> 1\. If the diagnosis of hypertension has not been previously
> established, and it is a claimed issue, B.P. readings
> [must]{.underline} be taken two or more times on each of at least
> three different days.
>
> 2\. If hypertension has been previously diagnosed and is claimed, but
> the claimant is not on treatment, B.P. readings [must]{.underline} be
> taken two or more times on at least three different days.
>
> 3\. If hypertension has been previously diagnosed, and the claimant is
> on treatment, take three blood pressure readings on the day of the
> examination.
>
> 4\. If hypertension has not been claimed, take three blood pressure
> readings on the day of the examination. If they are suggestive of
> hypertension or are borderline, readings [must]{.underline} be taken
> two or more times on at least two additional days to rule hypertension
> in or out.
>
> 5\. In the diagnostic summary, state whether hypertension is ruled in
> or out after completing these B.P. measurements. Describe treatment
> for hypertension and side effects. If hypertensive heart disease is
> suspected or found, follow worksheet for Heart.
>
> [14. Abdomen]{.underline}: Inspection, auscultation, palpation,
> percussion. Describe any organ enlargement, ventral hernia, mass,
> tenderness, etc.
>
> [15. Genital/rectal (male)]{.underline}: Inspection and palpation of
> penis, testicles, epididymis, and spermatic cord. If there is a
> hernia, describe type, location, size, whether complete, reducible,
> recurrent, supported by truss or belt, and whether or not operable.
> Describe anal fissures, hemorrhoids, ulcerations, etc. Include digital
> exam of rectal walls and prostate.
>
> [16. Genital/rectal (female)]{.underline}: Pelvic exam, including
> inspection of introitus, vagina, and cervix, palpation of labia,
> vagina, cervix, uterus, adnexa, and ovaries, rectal exam. Do Pap smear
> if none within past year. If unable to conduct an examination and Pap
> smear, or if there is a severe or complex problem, refer to a
> specialist.
>
> [17. Musculoskeletal]{.underline}:
>
> a\. For all joint or muscle disorders, state each muscle and joint
> affected.
>
> b\. Separately examine and describe in detail each affected joint.
> Measure active and passive range of motion in degrees using a
> goniometer. In addition, provide an assessment of the effect on range
> of motion and joint function of pain, weakness, fatigue, or
> incoordination following repetitive use or during flare-ups. (See the
> appropriate musculoskeletal worksheet for more detail.) NOTE: The
> diagnosis of [degenerative or traumatic arthritis of any joint
> requires X-ray confirmation]{.underline}, but once confirmed by X-ray,
> either in service or after service, no further X-rays of that joint
> are required for disability evaluation purposes.
>
> c\. Describe swelling, effusion, tenderness, muscle spasm, joint
> laxity, muscle atrophy, fibrous or bony residual of fracture. If joint
> is ankylosed, describe the position and angle of fixation.
>
> d\. Describe any mechanical aids used by veteran.
>
> e\. If foot problems exist, also describe objective evidence of pain
> at rest and on manipulation, rigidity, spasm, circulatory disturbance,
> swelling, callus, loss of strength, and whether condition is acquired
> or congenital.
>
> f\. If there is amputation of a part, see the appropriate worksheet.
>
> g\. With disc disease, also describe any neurological findings.
>
> 18\. [Endocrine]{.underline}: Describe signs and symptoms of any
> endocrine disease, effects on other body systems, and current and past
> treatment. See endocrine worksheets for further guidance.
>
> 19\. [Neurological]{.underline}: Assess orientation and memory, gait,
> stance, and coordination, cranial nerve functions. Assess deep tendon
> reflexes, pain, touch, temperature, vibration, and position, motor and
> sensory status of peripheral nerves. If neurological abnormalities are
> found on examination, or there is a history of seizures, refer to
> appropriate worksheet.
>
> 20\. [Psychiatric]{.underline}: Describe behavior, comprehension,
> coherence of response, emotional reaction, signs of tension and
> effects on social and occupational functioning. (This is meant to be a
> brief screening examination. If a mental disorder is [claimed, or
> suspected based on the screening]{.underline}, an examination for
> diagnosis and assessment should be conducted by a psychiatrist or
> psychologist.) State whether the veteran is capable of managing his or
> her benefit payments in his or her own best interests without
> restriction. (A physical disability which prevents the veteran from
> attending to financial matters in person is not a proper basis for a
> finding of incompetency unless the veteran is, by reason of that
> disability, incapable of directing someone else in handling the
> individual\'s financial affairs.)

D. **Diagnostic and Clinical Tests:**

> 1\. Include results of all diagnostic and clinical tests conducted in
> the examination report.
>
> 2\. Review all test results before providing the summary and
> diagnosis.
>
> 3\. Follow additional worksheets, as appropriate.

E. **Diagnosis:** Provide a summary list of all disabilities diagnosed.
Include an interpretation of the results of all diagnostic and other
tests conducted in the final summary and diagnosis. For each condition
diagnosed, describe its effect on the veteran\'s usual occupation and
daily activities.

Signature: Date:

# Chapter 2 - DISEASES OF THE SKIN INCLUDING SCARS

## 2.1 General

In some cases, scarring will be included as part of an overall
evaluation of muscle injury wounds. See Chapter 11. Scars are the most
common skin condition that will be examined.

## 2.2 What may be important to record in the history (depending on the particular condition being examined)?

Military. Include a detailed military history, including theater of
operations with dates of assignments. Report unusual exposure to
chemicals, heat, cold, sunlight, irradiation, drugs, etc.

Occupational. State present and previous occupations. Give details of
duties and exposure to chemicals, paints, dyes, etc.

Past and current treatment and results. Include both systemic and
topical medications and describe any side effects or reactions.

Present health status. Include systemic diseases such as respiratory,
gastrointestinal, circulatory, genitourinary, hepatic, hemic, metabolic,
or mental disorders.

**Present skin disease**

Date of onset, nature and progress of the disease, including a
description of the skin changes, when the disorder first appeared, and
the progression of the illness since that time. Note whether remissions
or exacerbations occurred and whether they were related to occupation or
treatment. Include the duration of remissions and factors that may have
influenced the course of the disorder.

Subjective symptoms. List the types of complaints such as itching,
burning, pain, and anesthesia. Note whether environmental factors such
as temperature or seasonal changes affected the severity of symptoms.
Give details of any associated constitutional symptoms.

Treatment past and present. Include names of the treating clinics,
hospitals, and physicians.

List the types of therapy that have been used providing specific names,
if known. Include treatment with physical agents such as X-ray or
ultraviolet light.

Mention reactions or side effects to medications.

## 2.3 What objective findings are useful?

**Distribution.** Report the overall distribution (for example,
widespread, symmetric, or localized to one extremity, etc.).

**Configuration and characteristics**. Describe the configuration of the
lesions and precise listing of their important characteristics such as
size, color, consistency, shape, and outline.

**Useful descriptive terms.** The descriptive terms that are useful
include macular, papular, nodule, plaque, vesicle, pustule, cyst, wheel,
comedo, burrow, scale, crust, fissure, erosion, ulcer, excoriation,
scar, and atrophy.

## 2.4 What is meant by the term "Dermatitis"?

The term dermatitis may be used interchangeably with eczema. It
indicates a specific type of inflammatory reaction in the skin that
involves the epidermis. Dermatitis may be acute, subacute, or chronic.
Acute phases of eczema are characterized by blister formation, weeping,
crusts, and erythema. Sub-acute and chronic forms are manifest as
scaling plaques and lichenification.

## 2.5 What are the common forms of eczema?

**Contact Dermatitis.**

May be either acute or chronic. Is a reaction to an externally applied
substance. If the patient shows a specific sensitivity to a chemical
agent, the disorder is known as *allergic contact dermatitis.* If the
inflammation is in response to an irritant to which the patient is not
specifically sensitive, the reaction is known as *primary irritant
dermatitis.* In cases of contact dermatitis, it is important for the
physician to gather information regarding the exposure of the patient to
potentially irritating or sensitizing topical agents. A careful history
and the use of patch tests are useful in identifying the specific agent
involved.

**Atopic Dermatitis.**

A form of eczema that develops in individuals who have dry skin, a
history of respiratory allergies, and who may show certain
characteristics, such as atopic pleats under the eyes and an increase in
skin folds on the palms.

Often presents as hand eczema (dyshidrotic dermatitis), localized
patches of eczema (lichen simplex chronicus) or, in rare instances, as a
generalized exfoliative dermatitis.

**Seborrheic Dermatitis.** Presents as a scaling erythematous reaction
diffusely over the scalp, eyebrows, eyelids, nasolabial folds, and
central area of the chest. Tends to be chronic and often recurs after
treatment.

**Stasis Dermatitis.**

Develops in the lower parts of the legs secondary to chronic venous
stasis. Often presents as an itching and scaling erythema that is
associated with other evidence of stasis such as hyperpigmentation and
varicosities.

**Hand Dermatitis.**

May arise from several causes, for example, may be a localized
manifestation of atopic eczema or a reaction to a topically applied
allergen or irritant. Chronic fungal infection of the hands may mimic
hand dermatitis.

**Exfoliative Dermatitis.**

A widespread or universal scaling erythroderma that may appear acutely
or develop slowly. Edema of the skin is widespread and pruritus is
severe. The causes of generalized erythrodermatitis include psoriasis,
atopic eczema, chronic contact eczema, and T-cell lymphoma of the skin
(mycosis fungoides).

## 2.6 What are the common pyodermas?

**Impetigo.**

Presents as crusted erythematous plaques. Areas of dermatitis may become
secondarily infected.

**Folliculitis and furunculosis.**

First appear as inflammatory reactions around hair follicles. Chronic
folliculitis in the axillary area, groin, or other areas that contain
apocrine glands is known as hidradenitis suppurativa. Cultures should be
obtained to identify the specific pathogens in all cases of suspected
pyoderma.

## 2.7 How does tinea pedis (athlete's foot) present and how is it diagnosed?

Fungus (dermatophyte) infections of the feet may present in two distinct
patterns. In the more common variety, the soles and sides of the feet
present with a diffuse redness and scaling. The toenails are thickened
and dystrophic. In the second, less common variety, an inflammatory
reaction is found between the toes. In both varieties, the diagnosis is
confirmed by KOH examination or fungus culture.

## 2.8 How does tinea manus present and how is it diagnosed?

Presents as a dry, erythematous scaling reaction of one or both palms.
The fingernails may be involved. Often seen in patients who have
bilateral diffuse tinea pedis. The diagnosis is confirmed by KOH
examination or fungus culture.

## 2.9 How does tinea cruris ("jock itch") present and how is it diagnosed?

Tinea cruris is the most common cause of a groin eruption in adult
males. An erythematous, scaling plaque is found on the thighs. The
border is usually well demarcated with scale and redness. The diagnosis
is confirmed by a KOH examination or fungus culture.

## 2.10 How does tinea corporis (ringworm of the body) present and how is it diagnosed?

Tinea corporis usually presents as single or multiple scaling plaques
with a scaling border and a slowly clearing center. The diagnosis is
confirmed by KOH examination or culture of scales from the border
region.

## 2.11 When does onychomycosis (tinea unguium) occur?

Onychomycosis is usually found in patients who have the diffuse type of
tinea pedis. Should be distinguished from nail dystrophy based on
vascular insufficiency (onychogryphosis).

## 2.12 How does psoriasis present and what is its course?

Psoriasis is a common papulosquamous eruption that presents as well
demarcated erythematous plaques covered by silvery scales. Common sites
of involvement include the elbows, knees, and scalp. Patients with
extensive disease may develop lesions over the trunk, extremities, face,
etc. In severe cases, the nails are often involved showing both lateral
and distal onycholysis and a pitting deformity of the nail plate. May be
associated with disabling rheumatoid-like arthritis. The course of the
illness is irregular; remission can be induced with appropriate therapy.
Treatments include topical medications, psoralen-ultraviolet-light
therapy (PUVA), methotrexate, isotretinoin, and others.

## 2.13 What is pityriasis rosea?

Pityriasis rosea is an acute, self-limited eruption that presents as
oval, scaling patches over the trunk and extremities. The generalized
eruption is preceded by a herald patch 5 to 10 days before. It clears
spontaneously in 6 to 8 weeks, but artificial or natural sunlight may
hasten clearing.

## 2.14 How does lichen planus present?

Lichen planus is a chronic papulosquamous disorder. It presents as
multiple small flat-topped, polygonal, violaceous papules over the volar
aspects of wrists and ankles. Itching is a prominent complaint. Many
patients have net-like whitish patches on the buccal mucosa opposite the
molars. No treatment is needed other than symptomatic in most cases. In
severe cases, systemic corticosteroids, PUVA therapy, or other
medications may be needed.

## 2.15 What are the important elements of an examination for acne?

Areas of involvement should be described and recorded. The presence of
pustular and cystic lesions should be noted, and the degree of scarring
and disfigurement should be described. The response of the patient to
topical and systemic therapeutic regimens should also be mentioned.

## 2.16 What causes pseudofolliculitis barbae and how does it present?

Pseudofolliculitis barbae is a chronic, low-grade bacterial infection
associated with irritation from hair, especially tightly curly hair. It
consists of small, perifollicular papules in the beard area. The papules
develop when beard hairs become embedded in the infundibular portion of
the hair follicles. A change in shaving habits often can provide relief.

## 2.17 How does rosacea present?

Rosacea affects adults of middle age and older. Presents as diffuse
erythema associated with pustules and telangiectasia in the central area
of the face. Conjunctivitis and keratitis may accompany rosacea. A late
consequence is enlargement of the nose (rhinophyma). Often treated with
topical medications and broad spectrum antibiotics.

## 2.18 What causes chloracne and how does it present?

Chloracne is an acneform rash with many comedones, cysts, and pustules
primarily involving the malar areas, the angles of the jaw, and the area
behind the ears. It may also appear in the axillary and inguinal areas.
There may be associated itching. Straw colored epidermal inclusion cysts
may form that have a tendency to progress to abscess formation. It
develops after exposure to herbicides such as dioxin or certain other
toxic chemicals that contain halogenated aromatic hydrocarbons. It
develops a few months after swallowing, inhaling, or touching the toxic
chemical and persists after exposure ends. Persistence for at least 30
years has been reported. Chloracne is distinguished from acne by the
predominance of open comedones and the typical chloracne distribution.

## 2.19 Benign Neoplasms

The number and location of skin growths should be noted. Benign
neoplasms include seborrheic keratoses, which may range in color from
black to light tan, moles, epithelial nevi, and epidermal inclusion
cysts. Residuals following treatment, such as scars, should be fully
described.

## 2.20 What are actinic keratoses?

Actinic keratoses are common precancerous lesions. They appear as
roughened, scaly patches overlying an erythematous base. The extent and
degree of actinic damage to the skin should be described.

## 2.21 What are the common skin malignancies?

Cancer of the skin includes basal cell epithelioma, squamous cell
epithelioma, melanoma, Bowen's disease, and carcinoma metastatic to the
skin. Describe any treatment used, dates of treatment, and residuals. In
the case of melanoma, report any systemic involvement.

## 2.22 What are the pertinent issues in examining scars?

The exact size, shape, color, and extent of scars (including measurement
of width and length) should be reported. Describe any tenderness of the
scar. Mention should be made of skin texture in the area of scarring,
whether scar is elevated or depressed, whether scars are attached to
underlying bone, joint, muscle, or other tissues, and whether there is
loss of tissue under the scar.

For scars of the face, head, and neck, the degree of disfigurement
should be recorded, including a description of distortion or asymmetry
of any facial features. Color photographs are advisable.

Tattoo or scars related to their removal also should be described in
detail. In the case of burn scars, careful measurements of each scarred
area should be reported, and an indication given of the burn degree.
Report whether there is any scar tissue breakdown, current or
intermittent.

## 2.23 How does scabies present and how is it diagnosed?

Scabies is caused by an infestation of mites in the skin. It presents as
pruritic papules in the genital region, buttocks, and finger webs. The
diagnosis is confirmed by finding evidence of the mites or eggs within
burrows in the skin.

## Worksheet - SKIN DISEASES (Other Than Scars)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Onset of disease and course - intermittent, constant.

2\. Current treatment - include side effects.

3\. Symptoms - pruritus, pain, etc.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Extent of disease - specify what exposed areas are involved and how
large they are.

2\. Ulceration, exfoliation, or crusting.

3\. Associated systemic or nervous manifestations.

D. **Diagnostic and Clinical Tests:**

1\. Biopsy, scrapings if indicated.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. Take [color photographs]{.underline} if disfigurement or disfiguring
scars are present.

Signature: Date:

## Worksheet - SCARS

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

1\. Type of injury or infection causing the wound or scar, its date, the
treatment used and

the response to such treatment.

2\. Current symptoms.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings (for
each scar):

1\. Location, measurements (cm. x cm.), and shape of each scar.

2\. Tenderness.

3\. Adherence.

4\. Texture.

5\. Ulceration or breakdown of skin.

6\. Elevation or depression of scar.

7\. Extent of underlying tissue loss.

8\. Inflammation, edema, or keloid formation.

9\. Color of scar compared to normal areas of skin.

10\. Disfigurement.

11\. For each burn scar, state if due to a 2nd or 3rd degree burn.

12\. Limitation of function by scar.

13\. An attachment is provided in the Handout of Instructions for
Compensation and

Pension Examinations for plotting the location of scars.

D. **Diagnostic and Clinical Tests:**

1\. With disfigurement or disfiguring scar of head, face, or neck,
submit

[color photographs]{.underline}.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

# Chapter 3 - BIRTH DEFECTS IN CHILDREN OF VIETNAM VETERANS

## SECTION I: Children with spina bifida who are the children of Vietnam veterans

## 3.1 What is the basis of payments for spina bifida in children of Vietnam veterans?

Under Public Law 104-204, VA is authorized to provide a monetary
allowance, health care, and vocational rehabilitation to children with
spina bifida who are the natural children of Vietnam veterans, both men
and women. This in turn was based on a March 1996 report by the National
Academy of Sciences (NAS) entitled "Veterans and Agent Orange: Update
1996," which noted what it considered "limited/suggestive evidence of an
association"\' between herbicide exposure and spina bifida in the
offspring of Vietnam veterans.

## 3.2 When will examinations for disability due to spina bifida be needed?

In most cases, extensive private medical information dating back to
infancy will be available for these individuals, and a VA examination
will be unnecessary. However, in rare cases, VBA may request a
disability examination. Claimants for VA benefits may be of any age,
although pediatric-age patients would be examined at a non-VA facility.

## 3.3 What are the main findings in spina bifida?

a\. Spina bifida is a birth defect that is a type of neural tube defect
in which there is incomplete closure of the vertebral column. There is
usually an associated defect involving the spinal cord or its membranes.
A sac protruding over the vertebral defect that contains meninges only
is a meningocele, one that contains the spinal cord only is a myelocele,
and one that contains both is a myelomeningocele.

b\. Spina bifida may be associated with other congenital abnormalities
such as hydrocephalus, harelip, and cleft palate, but only spina bifida
itself and any condition directly due to spina bifida is the basis of a
VA monthly monetary payment at one of three levels.

c\. The signs and symptoms of spina bifida depend on the level and
extent of spinal cord and nerve root involvement. Meningoceles may occur
without any symptoms, but this is very unlikely with myelomeningocele.

d\. If the defect is at the lumbar level, findings may include:

> 1\) partial or complete (flaccid) paralysis of the leg muscles below
> the involved level with atrophy
>
> 2\) abnormal gait
>
> 3\) loss of deep tendon reflexes
>
> 4\) abnormal bowel and bladder function with incontinence
>
> 5\) decreased lumbar and sacral sensations.

e\. If the defect is at higher levels, there may be signs and symptoms
resembling complete or incomplete transection of the spinal cord, or
combined root and cord symptoms.

f\. Hydrocephalus occurs frequently and may be related to aqueductal
stenosis or Arnold-Chiari malformation.

## 3.4 What is the basis of the monthly monetary benefit?

a\. The monetary payment is based upon certain neurologic impairments
and their effects on functioning. Specifically, it is based upon

> 1\) intellectual impairment (as measured by IQ)
>
> 2\) functioning of the upper and lower extremities
>
> 3\) bowel and bladder functioning.

b\. Other disabling conditions secondary to spina bifida that affect
daily functioning to the same extent as the specified neurologic
impairments can also affect the level of payment.

## 3.5 What should be included in the examination?

A general neurologic examination should be conducted. A brief overview
of the course of the condition and any major medical events should be
provided. For rating purposes, the examination should focus on current
disability and specifically address:

a\. IQ measurement, unless already of record.

b\. Lower extremities - whether braces or other assistive devices or a
wheelchair are required as the primary means of mobility in the
community.

c\. Upper extremities - sensory and motor loss of, whether the
individual is able to grasp a pen, feed him- or herself, and perform
self care.

d\. Bladder - whether the individual is continent without the use of
drugs, intermittent catheterization, or other mechanical means. If not,
whether incontinence is complete or not, with the extent of incontinence
expressed as the duration in hours of periods of dryness, specifically
how many times a week the individual is unable to remain dry for three
hours at a time during waking hours.

e\. Bowel - whether the individual is continent of feces without the use
of mechanical means. If not, whether incontinence is complete or not;
whether fecal leakage is severe or frequent enough to require wearing of
absorbent materials, and how many days a week this is required; whether
the individual regularly requires manual evacuation or digital
stimulation to empty the bowel; and whether the individual has a
colostomy, and, if so, whether the individual must wear a colostomy bag.

f\. If there are additional disabling medical conditions due to spina
bifida, such as seizures, hydrocephalus (include presence and status of
shunt), neurocognitive disorder, visual or hearing loss, mental
disorder, pressure sores or other skin problems, latex allergy, or renal
insufficiency, address:

> 1\) how the condition is related to spina bifida
>
> 2\) current signs, symptoms, and treatment
>
> 3\) effects of the condition on daily activities.

## SECTION II: Children with birth defects who are the children of women Vietnam veterans

## 3.6 What is the basis of payments for certain birth defects in children of women Vietnam veterans? 

a\. Under Public Law 106-419, the Veterans Benefits and Health Care
Improvement Act of 2000, VA is authorized to provide a monetary
allowance, health care, and vocational rehabilitation to children with
certain covered birth defects who are the children of women Vietnam
veterans.

b\. The basis of the statute is a report titled "Women Vietnam Veterans
Reproductive Outcomes Health Study," a comprehensive health study of
8,280 women Vietnam era veterans that was mandated by Public Law 99-272.
The study was conducted by the Environmental Epidemiology Service of the
Veterans Health Administration. A report of part of the study,
"Pregnancy Outcomes Among U.S Women Vietnam Veterans," was published in
the American Journal of Industrial Medicine (38:447-454 (2000). The
spina bifida benefits are based on a presumption of the parent's
exposure to herbicides in Vietnam between January 9, 1962,and May 7,
1975, but these birth defects benefits are based solely on the fact that
the mother served in Vietnam between February 28, 1961 and May 7, 1975,
rather than on a specific exposure in Vietnam.

## 3.7 What does the statute do?

a\. The statute authorizes VA to make monthly payments to women Vietnam
veterans' children with certain covered birth defects at one of four
levels. The level of payment will be based on the degree of disability
suffered by the child, and there must be permanent physical or mental
disability resulting from the birth defects to qualify.

b\. The statute specifically excludes disabilities due to: 1) a familial
disorder, 2) a birth-related injury, or 3) a fetal or neonatal infirmity
with well-established causes.

c\. Regulations implementing the legislation have not been published as
of the date of completion of this document. When they are published (the
deadline is December 2001), they will provide more details about which
birth defects are included and which are excluded, and the evaluation
criteria that will form the basis of the monthly monetary payment. The
regulations will determine the needs of the examination.

# Chapter 4 - EYE

## 4.1 What are the general guidelines for conducting disability examinations of the eye?

Visual functional impairment due to disease or injury of the eye is
based upon losses or reductions in central visual acuity, visual fields,
extraocular muscle function, binocular fusion, and related factors. If
more than one loss is present, each should be measured and reported. The
far and near central visual acuities for each eye (best corrected and
uncorrected), their visual fields, muscle balances, phorias and/or
tropias, must be measured and recorded.

**a. Great care in testing** is required, particularly for low vision
and visual field losses as these losses may warrant disability
compensation. Small inaccuracies in measurement or failure to measure
the degree of low vision may produce significant changes in the
disability percentage evaluation and therefore in the amount of
compensation to be paid.

**b. Associated conditions**, such as loss of eyebrows or lashes,
injuries of the adnexa, lid deformities, ptosis, lagophthalmos or lid
lag, lacrimal duct or other occlusions, epiphora, deformed pupils, and
other conditions, should be recorded along with indicated detailed
symptomatology.

**c. Errors in color and light sense** that may be due to neurological
or psychiatric conditions should be examined by the vision specialist in
conjunction with a psychiatrist or neurologist. Examples are
chromatopsia, achromatopsia, color field inversion, photopsia,
metamorphopsia, as well as other visual defects, which might stem from
intracranial neoplasms, inflammation, or ischemia.

**d. Tonometer measurements** **of intraocular pressure** should be made
for all claimants. (A noncontact tonometer may be used). If the
tonometer shows a consistent reading equal to or greater than 22 mm, or
a difference exists of more than 3 mm between eyes having pressures
below 22 mm, further tests for the diagnosis of possible glaucoma should
be performed.

> **1) Special tests**. When necessary, exophthalmometery or other
> special tests may be used.
>
> **2) Report of examination.** Retinoscopic, slit lamp,
> ophthalmoscopic, perimetric, and all other relevant findings should,
> in every case, be legibly recorded along with the examiner's
> signature, title, and date.
>
> 3\) If detected, **conscious exaggeration of disability** will be
> noted and supported by appropriate tests, which will be specified by
> type in the report of examination.

## 4.2 What are the requirements for measuring central visual acuity?

**a. Who can conduct examinations for impairment of central visual
acuity?** These examinations must be performed by a licensed vision
specialist, either an optometrist or an ophthalmologist.

**b. What are the required measurements for central visual acuity?** The
central visual acuity must be measured and recorded for both distance
and near, with and without best optical correction. A notation of the
manifest refraction should be made. Special test charts and greater care
may be required for low vision patients.

**c. Can measurements of visual acuity be made using contact lenses?**
The use of contact lenses may, in the presence of irregular corneal
astigmatism due to injury or disease, improve central visual acuity
beyond what can be achieved with conventional ophthalmic lenses alone.
However, practical impairments of fitting, inability of the patient to
develop tolerance, and the fact that contact lenses are at times
medically contraindicated are important factors to consider. Therefore,
in general, conventional ophthalmic lenses will be used to determine
best-corrected vision. In the absence of contraindications, however, if
a patient with ketatoconus is well adapted to contact lenses and wishes
to wear them, such vision may be listed as best corrected.

**d. What if there is still vision reduction after best optical
correction?** Supporting fundoscopic, slit lamp, or other findings that
might explain any vision reduction remaining should be reported.

**e. What is the procedure when there are large dioptric differences
between the eyes?** In patients other than monocular aphakes, any
difference of more than four diopters of spherical correction between
the two eyes will be recorded. The best possible corrected visual acuity
of the poorer eye, with a lens not more than four diopters different
from that used for the better eye, will be taken as the visual acuity of
the poorer eye. When a large dioptric difference exists between eyes, an
explanation should be provided, and consideration should be given to a
possible congenital refractive error.

**f. What is the necessary level of illumination for measuring visual
acuity?** For determining distance visual acuity, the chart should be
illuminated so as to provide adequate contrast and comfortable
brightness (at least 5 foot candles). For determining near visual
acuity, adequate and comfortable illumination should be diffused on the
test card.

**g. How should central visual acuity for distance be measured and
recorded?** Best corrected and uncorrected central visual acuity for
distance should be tested using a Snellen type chart and should be
expressed *as* a Snellen fraction. For the numerator, record the test
distance in feet (usually 20 feet). For the denominator, record the
smallest line read *with no errors* and the ratio of missed to correctly
read letters on the next smaller line (i.e., 20/40 **+** 3/5). If
patients cannot read the large "E" type (i.e., 20/200) they should then
be slowly walked towards the chart until they can first read the 20/200
letter. Their acuity is then recorded as x/200 where x is the distance
from the chart in feet where the 20/200 letter can first be read.

**h. Why are careful measurements of distance vision especially
important at levels below 20/200?** It is particularly important that
acuities below 20/200 be very carefully measured and recorded, for they
are the basis for monetary compensation and possible referral. Slight
changes (e.g., 6/200 to 4/200) may produce a sizeable increase in
compensation.

**i. How should central visual acuity at near be measured and
recorded?** Best-corrected and uncorrected central acuities for each eye
at near shall also be tested and the results reported. A Snellen type of
notation using inches instead of feet is preferred but a comparable
Jaeger, Sloan, or point-type notation may be used if reported as a
Snellen ratio. The distance at which the reading card is held should be
14 inches from the eye.

**j. What are the additional requirements in low vision patients?** In
low vision patients, further and more careful examination should then be
conducted to determine the greatest distance in feet at which hand
movements and then finger counting can be accomplished. If only light
can be perceived, this should be noted and also whether its direction
can be accurately located (light projection). Only in the absence of all
the above shall a finding of NLP (no light perception) be made.

**k. When should a referral be made to a visual impairment service?** An
opinion should then be noted on the record as to whether the veteran
might benefit from low vision aids (because of limited vision) in either
walking about, reading, or while engaged in other ordinary or desired
activities. Any necessary referral should then be made to a visual
impairment service such as VICTORS, Blind Rehabilitation Center, or
other low vision clinic.

**l. How is visual acuity measured in patients who cannot read
English?** For patients unable to read English, special charts are
available. These take the form of "tumbling E's" or pictographs.

## 4.3 How must visual fields be measured?

**a. Goldmann perimeter**. The visual field extents will be measured by
a Goldmann perimeter using the target III/4e in the kinetic mode, and an
examination of the 8 meridians of Table 4.1 recorded. Extents should be
plotted to the nearest 5 degrees.

**b. Charting and reporting visual fields**. In all cases, perimeter
type, illumination light level, test object size, color, and test
distance must be recorded and testing done from unseen to seen with at
least 16 meridians, about 20 degrees apart, charted for each eye. All
charts are to be attached to the examination reports, signed, and dated.
Two independent field recordings will be made. More detailed studies
should then be done for the areas of visual loss.

**c. Scotomas**: Careful attention must be paid to scotoma or other
regions of lowered or lost visual acuity located in the central field of
view since these drastically lower the patient's mobility and reading
ability. These areas should always be plotted with great care, going
from invisible to visible, perpendicular to the boundaries so as to find
any projecting scotoma. Where available, the examination for visual
field extents should be supplemented by the use of other field plotters
to detect and plot scotomas. Although the extent of visual field loss
cannot be determined accurately for scotomas, an approximation can be
obtained by subtracting the width of the scotoma from the peripheral
visual field value at those same meridians. A similar estimation of
visual field loss can be applied to enlargement of the blind spot.

**d. Supplementary testing as indicated**. A standard campimeter,
tangent screen, or other appropriate device may be used in addition to
Goldmann perimetry. The Amsler chart should be employed as a screening
test for small scotoma, lesions, or retinal distortion.

**e. Testing in aphakic patients**. For aphakic patients, the Goldmann
target should be the IV/4e in the kinetic mode. If the aphakic patient
is well adapted to contact lens or intraocular lens implant correction,
the test should be done with the Goldmann III/4e target on the Goldmann
perimeter.

**f. Loss of a quadrant or half field and other defects**. Where there
is loss of a quadrant or a half field, one-half the value in degrees of
the boundary meridians shall be used as the loss at this meridian(s)
with full loss used for each meridian between these boundary meridians.
Visual field loss can be calculated for other defects in a similar
manner.

> Table 4.1
>
> **NORMAL VISUAL FIELD EXTENT AT 8 PRINCIPAL MERIDIANS**
>
> [Meridian]{.underline} [Normal degrees]{.underline}\
> Temporally 85\
> Down temporally 85
>
> Down 65
>
> Down nasally 50
>
> Nasally 60
>
> Up nasally 55
>
> Up 45\
> Up temporally 55
>
> **\
> **Total Normal Field 500

## 4.4 How should eye muscle function be examined and reported?

Binocular functions must be measured when the ocular history or
phoria/tropia imbalance findings could reflect either service-connected
disease or injury of the extrinsic ocular muscles or their motor nerves.

**a. Use of Goldmann perimeter chart**. If diplopia is constant and not
correctable, indicate which sectors of the visual field are affected
using the Goldmann Perimeter Chart and the standard III/4e target,
charting actual areas of diplopia. Diplopia outside these areas is not
considered disabling but can be used in evaluation of the underlying
disease or injury.

> Central 20 degrees

  ----------------- ----------------- ----------------- -----------------
  21 to 30 degrees: down              31 to 40 degrees: down

                    right lateral                       right lateral

                    left lateral                        left lateral

                    up                                  up
  ----------------- ----------------- ----------------- -----------------

**b. Repeat examination and record of pathology**. When diplopia is
found, the test should be repeated. Such impairment of binocular
function should be supported in each case, if possible, by an
appropriate record of the actual pathology.

**c. Tropia testing where authenticity of diplopia is suspect**. In
cases where the diplopia's authenticity is suspect, specific tropia
testing should be performed using other tests such as:

Alternate cover, uncover, or Worth 4 dot, other red-green tests.

Lancaster or Hess screen studies.

Demonstration and measurement of tropia by means of the phoropter's
prism.

Disparity fixation or other appropriate polaroid tests.

**d. Unexplained diplopia**. When not otherwise explained, binocular
diplopia should lead to investigation into possible abnormalities of the
central nervous system, thyroid or endocrine dysfunction, electrolyte
imbalance, psychiatric problems, neuromuscular disease (e.g., multiple
sclerosis), or other nonophthalmological factors.

**e. Suspended vision or eccentric fixation**. In addition, some
patients with a true longstanding tropia will have learned to suspend
vision in one eye (test object appears pure white or red) or will have
become an eccentric fixator, and tests for simultaneous vision are then
required, since diplopia is not reported.

**f. Monocular and binocular diplopia**. A distinction must be made
between monocular and binocular diplopia so that any further appropriate
tests may be made.

**g. Occasional or correctable diplopia.** Usually diplopia which is
only occasional or is correctable by lenses which can be tolerated in
spectacles should not be con­sidered a disability as this is transitory
and compensation at work is usually possible.

## Worksheet - EYE EXAMINATION

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Pain.

2\. Duration and frequency of periods of incapacitation, and rest
requirements.

3\. Visual symptoms, including distorted or enlarged image, etc.

4\. Current ophthalmologic treatment.

5\. For malignant neoplasms, state type of treatment and last date. If
treatment is current,

describe.

C. **Physical Examination (Objective Findings):**

Address each of the following, **[as applicable]{.underline}**, and
[fully describe current findings]{.underline}:

1\. Visual Acuity:

a\. Examine each eye independently and record the refractive information
indicated

below.

b\. Use conventional lenses for correction unless the patient has
keratoconus, is

well adapted to contact lenses and wishes to wear them, and contact
lenses

result in best corrected visual acuity. In that case, use contact lenses
to

determine best corrected visual acuity.

c\. Use Snellen\'s test type or its equivalent.

d\. Carry out an examination with the pupils dilated unless
contraindicated, and

record the ophthalmic findings.

e\. For visual acuity worse than 5/200 in either or both eyes, report
the distance in

feet/inches (or meters/centimeters) from the face at which the veteran
can count

fingers/detect hand motion/read the largest line on the chart. If the
veteran

cannot detect hand motion or count fingers at any distance, state
whether

he or she has light perception.

f\. If keratoconus is present, state whether contact lenses are required
or adequate

correction is possible by other means.

**NEAR FAR**

Right Eye Uncorrected \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_

RIGHT EYE CORRECTED \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_

**NEAR FAR**

LEFT EYE Uncorrected \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_

LEFT EYE CORRECTED \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_

2\. Diplopia:

a\. Perform the measurement of muscle function using a Goldmann
Perimeter

Chart and chart the areas in which diplopia exists. Include the chart as
part of

the examination report to be sent to the regional office.

b\. If diplopia is present, state whether it is constant or
intermittent, whether it is

present at all distances or only for near or distant vision, and whether
it is

correctable by use of lenses or prisms.

c\. If diplopia is constant and not correctable, indicate which sectors
of the visual

field are affected and provide the Goldmann perimeter chart showing the
actual

areas of diplopia, according to the format below. Diplopia outside these
areas

should also be reported even though it is not considered disabling
because it

may be used in the evaluation of the underlying disease or injury.

[CENTRAL 20 DEGREES]{.underline} \_\_\_\_\_\_\_\_\_

[21 TO 30 DEGREES]{.underline}

[DOWN]{.underline}

RIGHT LATERAL \_\_\_\_\_\_\_\_

LEFT LATERAL \_\_\_\_\_\_\_\_

[UP]{.underline}

RIGHT LATERAL \_\_\_\_\_\_\_\_

LEFT LATERAL \_\_\_\_\_\_\_\_

[31 TO 40 DEGREES]{.underline}

[DOWN]{.underline}

RIGHT LATERAL \_\_\_\_\_\_\_\_

LEFT LATERAL \_\_\_\_\_\_\_\_

[UP]{.underline}

RIGHT LATERAL \_\_\_\_\_\_\_\_

LEFT LATERAL \_\_\_\_\_\_\_\_

3\. Visual Field Deficit:

a\. Chart any visual field defect using a Goldmann Perimeter Chart and
include the

chart as part of the examination report to be sent to the regional
office.

b\. For an aphakic eye which cannot be fitted with contact lenses or
intra-ocular

implant, use the IV/4e test object. For all other cases, use the III/4e
test object.

c\. If the examiner determines that charting with other test objects is
indicated,

those test results should be reported on a separate chart. All charts,
along with

an explanation of the need for using a different test object and an
explanation of

any discrepancies in results, should be included as part of the
examination

report.

d\. All scotomas should be plotted carefully in order to allow
measurements to be made for adjustments in the calculation of visual
field defects.

4\. Details of eye disease or injury (including eyebrows, eyelashes,
eyelids) other than loss

of visual acuity, diplopia, or visual field defect:

D. **Diagnostic and Clinical Tests:** (Other than for visual acuity,
diplopia, and visual fields, as

described above.)

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis**:

Signature: Date:

# Chapter 5 - EAR, MOUTH, NOSE AND THROAT

## 5.1 What may be needed in an examination of the oral cavity?

**a. Lesions of mouth and tongue.** A veteran with oral lesions should
have a systemic history and general medical examination, including
serology, urinalysis, and complete blood count because of the many
possible systemic diseases that can cause oral lesions. These include
leukemia, syphilis, agranulocytosis, pemphigus, skeletal diseases,
erythema multiforme, dermatitis medicamentosa, hypothyroidism,
pernicious or other anemia, polycythemia, pellagra, lead poisoning,
epilepsy, and others.

**b. Lips and buccal mucous membranes, gingivae, tongue, palate, floor
of mouth, and ostia of the salivary ducts.** Report all abnormalities
and the condition of the dentition related to the gingivae.

**c. Tongue** -- Report abnormal contour, mobility, or ulceration,
fibrillations or atrophy.

**d. Soft palate**. Note movement on tongue depression and gagging.

## 5.2 What may be needed in an examination of the pharynx?

**a. Faucial tonsils.** Size, consistency, ulceration, presence of
exudate in crypts, and any associated cervical lymphadenopathy should be
noted. If removed, note presence and position of residual or recurrent
lymphoid tissue.

**b. Peritonsillar region and lateral wall of pharynx.** Swelling or
displacement of faucial tonsils may indicate a neoplasm or abscess.

**c. Posterior pharyngeal wall.** Report any mucoid, purulent, or
crusted exudate. Describe hypertrophied lymphoid tissue, swelling, or
ulceration.

## 5.3 What may be needed in an examination of the nasopharynx?

**a. Method of examination.** Full view of this region can be obtained
by the use of a nasal mirror and a nasopharyngoscope. Reason for
post-nasal obstruction, exudation, and bleeding may be determined solely
by this examination.

**b. What structures should be examined?**

> 1\. Adenoid tissue - presence and size.
>
> 2\. Pharyngeal orifices of eustachian tubes - report excessive
> lymphoid tissue.
>
> 3\. Fossae of Rosenmuller - report lymphoid tissue or evidence of
> neoplasm.
>
> 4\. Vault of the nasopharynx - look for evidence of tumor mass.
>
> 5\. Inferior turbinates - note size and appearance of posterior ends.
>
> 6\. Posterior ends of the inferior meati or from the region of the
> spheno-ethmoidal recesses above - note exudates.

## 5.4 What may be needed in an examination of the hypopharynx and larynx?

**a. Method of examination -** laryngeal mirror. If the veteran cannot
cooperate and gags excessively, anesthesia can be obtained by swabbing
with an appropriate topical anesthetic. If the symptoms warrant it, and
the larynx cannot be visualized adequately, the veteran should be
hospitalized for a direct laryngoscopy.

**b. What should be examined?**

> 1\. Base of tongue and valleculae.
>
> 2\. Lingual tonsils.
>
> 3\. Pyriform recesses - pooling of secretions indicates abnormal
> swallowing functions and should prompt further diagnostic studies
>
> 4\. Posterior wall of hypopharynx.
>
> 5\. Epiglottis and aryepiglottic folds.
>
> 6\. Ventricular bands, ventricles, and vocal cords.
>
> 7\. Subglottis larynx.
>
> 8\. Function of the vocal cords.

Note abduction and adduction in inspiration, expiration, and phonation.
If cord motion is limited, note position of cords and search for
evidence of a localized cause, e.g., edema, erythema, or ulceration of
the arytenoid prominences or the interarytenoid space.

Biopsy is indicated for ulcerative or proliferative lesion.

Chronic hoarseness and dysphagia should raise suspicion of a hiatus
hernia with impaired esophageal sphincter tone and associated
eructation. Hiatus hernia may cause esophagitis and pharyngitis.

## 5.5 What may be needed in an examination of the nose and sinuses

a\. Method of examination -

> 1\. The anterior nose is inspected with a nasal speculum.
>
> 2\. Adjuvant procedures for sinus examination include:

Transillumination - not definitive, but may help for unilateral
maxillary or frontal sinus disease. A darkened room is essential. Light
is transmitted from frontal sinus floors to brows, and from anterior
maxillae to the palate intraorally.

Diagnostic needle puncture or natural ostium cannulization and
irrigation for maxillary, frontal, and sphenoid sinusitis. Diagnostic
lavage of the maxillary antra through the inferior meati or through the
natural ostia are outpatient procedures. Probing and irrigation of the
frontal and sphenoid sinuses require considerable expertise.

X-rays. Routine sinus films should include an AP Water's view at 27
degrees elevation from the horizontal plane. Other projections may be
indicated for individual sinuses. Radio-opaque dye studies may be used,
especially in maxillary sinuses. Polytomography, electronic or
photographic subtraction techniques, and arterial or venous angiography
are additional techniques that may be of value.

b\. What structures should be examined?

**1. External nose.** Note any deformity, congenital or acquired, of the
nasal bones, ascending processes of the maxillae, alae, tip, and
columella.

**2. Nasal vestibule.** Note any scarring, crusting, ulceration, edema,
and tenderness.

**3. Nasal cavities.** Note hyperemia and edema in the region of the
sinus ostia, exudate in specific areas. Cytologic study of secretions
may indicate type and location of a sinus infection. Normal nasal mucosa
with no intranasal drainage does not preclude the presence of sinusitis.
Turbinate shrinkage by spray or small cotton tampons soaked in a
vasoconstrictor solution may reveal exudate in the region of the ostia
of the involved sinuses.

> Septum. Look for alterations in color, thickness, ulceration, or
> crusting of the mucous membrane. Search for bleeding points or
> abnormally superficial vessels, particularly in Kiesselbach's area low
> and anteriorly on either side.
>
> With a history of recent trauma, unilateral or bilateral bulging of
> the mucous membrane may suggest a hematoma, or abscess. Describe the
> position, direction, and extent of deflection of the septum from the
> midline. Note if there is obstruction to the airway by an inferior
> spur projecting into the inferior meatus or a high deviation impinging
> against the middle turbinate.
>
> Floor of the Nose. If a discharge is present, note its character -
> serous, mucoid, purulent, or sanguineous. Remove the discharge by
> aspiration. If moderate or profuse in amount, examine a stained smear
> to determine bacteria, epithelial cells, and leukocytes present.
> Cultures for specific bacteria and fungi may be indicated in diffuse
> exudative and granulomatous disease.
>
> Inferior Meatus. Look for neoplasms and foreign bodies.
> Vasoconstriction and probing may be necessary for adequate evaluation.
>
> Inferior Turbinates. Color, size, and consistency may suggest
> hypertrophy or atrophy.
>
> The Middle Meati. The mucous membrane may simulate that of the sinuses
> whose ostia open into this region. If polyps are present, gentle
> probing will assist in determining their site of origin. The
> inspection of the middle meati before and after shrinkage of the
> mucous membrane is important for evaluation of nasal accessory sinus
> disease. Purulent exudate from the anterior, middle, or posterior
> meatus is a significant clinical finding.
>
> The Middle Turbinate. Note abnormality of size, color, shape, or
> consistency. This structure may contain ethmoid cells and present a
> bulbous appearance that will not decrease in size after decongestion.
>
> The Spheno-ethmoidal Recess. May not be visible on routine anterior
> rhinoscopy. It should be inspected either directly or with the
> nasopharyngoscope in every case of suspected posterior ethmoid or
> sphenoid sinus disease. Congested mucous membrane and exudate should
> be noted.
>
> The Olfactory Area. Polyposis and edema may cause disturbances in the
> sense of smell. If no local abnormalities are found, the individual
> with a disturbed sense of smell should have a careful neurological
> examination.

**4. The Paranasal Sinuses.** Examination for sinus tenderness should
include pressure applied over the anterior wall and floor of the frontal
sinuses, the medial orbital walls, and the anterior maxillae.
Hyperesthesia or anesthesia in the distribution of the supra-orbital or
infra-orbital nerves may indicate a neoplasm. External swelling in
forehead, orbit, cheek, and alveolar ridge may be associated with sinus
disease.

## 5.6 What may be needed in an examination of the auricle, external ear canal, tympanic membrane, and mastoids?

**a. Auricle**. Note deformities, cicatrices, ulcerations, or other
dermatologic and cartilaginous abnormalities.

**b. External Canal.** Note any abnormality in size or shape of canal.
Note edema, erythema, or ulceration of the skin lining. If lumen
obstructed, note whether the cause is cerumen, foreign body, or exudate.
Record whether any exudate is serous, purulent, sanguineous, mucoid,
odorous, profuse, scanty, or pulsating. If the external canal has a
small diameter, a small speculum and adequate cleansing with a small
cotton-tipped applicator or a suction tip may be necessary for adequate
evaluation.

**c. Tympanic Membrane**. Remove all exudate and debris from the canal
for a satisfactory examination. The entire drum membrane should be
visualized. Report any abnormality in the landmarks indicating scarring,
retraction, bulging, or inflammation. Use a Siegel speculum to determine
membrane mobility. Note and describe any perforations and their size and
position (whether marginal or central).

**d. The Tympanum.** With a perforation of the drum membrane, the status
of the middle ear can often be ascertained. Particularly, reference
should be made to hyperplastic tympanic mucosa, granulation tissue,
cholesteatoma, and ossicle necrosis. With a cooperative patient and the
gentle use of a silver probe or an attic hook, one may specifically
diagnose an attic perforation. A detailed examination should allow
evaluation of an infectious process in the middle ear; the type of
treatment (medical or surgical) required; and often the prognosis re
hearing.

**e. The Mastoid**. Information regarding the condition of the mastoid
can often be determined during the examination of the middle ear.
Adjuvant procedures are helpful and on occasion may be specifically
diagnostic.

Mastoid tenderness. This sign is elicited during acute disease by firm
palpation over the mastoid process. Local erythema, induration, and a
fluctuant mass may be present.

Mastoid X-rays. Correlate X-ray abnormalities with clinical findings.
Polytomography may reveal cellular or cortical erosion not visible with
conventional techniques.

## 5.7 What are the essentials of an audiological examination?

**a. What is the significance of a hearing impairment?** The
significance depends upon the type and degree of hearing loss. The
participation restriction (handicap) a person experiences in everyday
life is related both to loss of hearing sensitivity and loss of speech
discrimination.

**b. What are the methods of measuring hearing loss?** Although the more
desirable methods of measuring hearing loss involve **quantitative**
procedures such as calibrated audiometry, there may be instances where
**qualitative** tests (such as whispered voice tests and tuning fork
tests) have been used in classifying hearing loss. However, qualitative
procedures do not substitute for calibrated audiometry as measures of
hearing impairment or disability.

> **Whispered or spoken voice tests** were used extensively before
> calibrated audiometry was widely available in the military (before
> 1970). These tests involve a gross assessment of hearing impairment
> using spoken or whispered words without visual cues. These tests are
> inherently insensitive to high frequency hearing loss, the type of
> hearing loss most commonly caused by noise exposure.
>
> The most commonly used **tuning fork tests** are the Weber Test, the
> Rinne Test, and the Bing Test.
>
> **Weber Test.** The Weber Test involves the placement of a tuning fork
> on the forehead. The patient is asked to indicate where the tone is
> heard. If the tone is heard in the middle of the head, then one may
> infer that the patient has normal hearing, equal sensorineural loss in
> both ears, or equal conductive components in both ears. If the tone
> lateralizes to either ear, then one may infer that there is a
> conductive component or lesser sensorineural hearing loss in the
> lateralized ear.
>
> **Rinne Test.** The Rinne Test complements the Weber Test. The Rinne
> Test involves the presentation of tones by air conduction and bone
> conduction. For air conduction, the examiner presents a tone near the
> ear canal. For bone conduction, the tuning fork is moved to the
> mastoid process. The patient is asked to indicate if the tone is
> louder by air conduction or bone conduction. If the patient hears the
> tone louder by air conduction, the ear has a sensorineural hearing
> loss (a positive Rinne). If the patient hears the tone louder by bone
> conduction, the patient has a conductive component (a negative Rinne).
>
> **Bing Test.** The Bing Test is also used to differentiate conductive
> hearing loss. The test involves the presentation of a tone via bone
> conduction (Weber Test). The ear is occluded by plugging the ear with
> a fingertip. The patient is asked if the tone changes in loudness or
> lateralizes. If the tone increases in loudness or lateralizes to the
> occluded ear, the Bing Test is positive and indicates normal hearing
> or a sensorineural hearing loss. If the patient reports no change in
> loudness or the tone does not lateralize to the occluded ear, the
> patient has a conductive component (negative Bing).
>
> Because of uncertainty as to which ear is responding to a test, tuning
> fork tests are difficult to interpret unless effective masking is used
> in the non-test ear.

**c. How are audiometric tests conducted?** Audiometric examinations are
quantitative and indicate the magnitude of the hearing impairment. The
examination must be conducted without the use of hearing aids. Both ears
must be examined for hearing impairment even if the hearing loss in only
one ear is at issue.

> **1. Calibration**. Audiometers utilized in basic audiological
> procedures are calibrated to the American National Standards Institute
> *Specifications for Audiometers* (ANSI S3.6-1989). The ANSI standard
> was adopted by the VA in July 1975. Prior to that time, the American
> Standards Association specifications (ASA 224.5-1951) were used. When
> reviewing audiometric results, it is important to note the date of the
> examination. Audiometric test results based on the ASA standards will
> show better hearing sensitivity than tests results based on the ANSI
> standard.
>
> **2. Approved rooms**. Tests must be conducted in approved sound
> treated rooms that meet the American National Standards Institute
> *Maximum Permissible Ambient Noise Levels for Audiometric Test Rooms*
> (ANSI S3.1-1991).
>
> **3. Presentation of stimuli**. Most basic tests involve the
> presentation of pure tones or recorded speech material through
> circumaural or insert earphones. Bone conduction involves the
> presentation of stimuli through a bone vibrator located on the mastoid
> process or the forehead.
>
> **4. Examiner requirement.** An examination of hearing impairment must
> be conducted by a state-licensed audiologist (38 CFR 4.85).
>
> **5. Basic testing**. The basic evaluation includes a controlled
> speech discrimination test using an approved recording of the Maryland
> CNC Test and pure tone audiometry.
>
> **6. Air and bone conduction test frequencies.** Air conduction
> audiometry must include the following frequencies: 250, 500, 1000,
> 2000, 3000, 4000, 6000, and 8000 Hz. Bone conduction audiometry must
> include the following frequencies: 250, 500, 1000, 2000, 3000, and
> 4000 Hz.
>
> **7. Other tests for assessment.** In addition, the basic audiometric
> assessment includes speech reception thresholds (SRT), tympanometry,
> and acoustic reflex tests.
>
> **8. Tests for non-organicity.** When necessary, tests for
> non-organicity (such as the Stenger Test) and otoacoustic emissions
> (OAE) are obtained. Other more advanced tests such as auditory evoked
> potentials may be indicated.
>
> **9. Details of testing**. Bone conduction tests are obtained when the
> air conduction thresholds are poorer than 15 dB HL. A modified
> Hughson-Westlake procedure is used to obtain thresholds. Appropriate
> masking is used. Stenger Tests are administered whenever pure tone air
> conduction thresholds at 500, 1000, 2000, 3000, or 4000 Hz differ by
> 20 dB HL or more between ears.
>
> **10. Speech reception threshold.** The speech reception threshold
> (SRT) is defined as the level (in dB HL) at which the patient
> correctly identifies 50% of a set of two-syllable (spondee) words. The
> SRT should be in agreement with the average of pure tone thresholds
> from 500 to 2000 Hz.
>
> **11. Speech recognition tests**. Speech recognition tests involve the
> presentation of approved monosyllabic words. Speech recognition must
> be obtained with a VA-approved recording of the Maryland CNC Test. The
> audiologist presents word lists at increasing intensity levels until
> no further change in speech recognition score occurs. However,
> presentation levels will not exceed the patient's level of discomfort
> or 105 dB HL, whichever is lower. This procedure is known as a
> Performance-Intensity function. The maximum speech recognition score
> is reported.
>
> **12. Other tests**. In addition to the basic audiometric test
> battery, other electrophysiological or behavioral tests may be
> reported to determine the degree of hearing loss or the site of
> lesion.

[Immittance testing (tympanometry]{.underline}) is a procedure which
assesses middle-ear function by measuring the mobility of the tympanic
membrane and middle ear structures. Immittance equipment measures the
flow of energy through the middle ear in response to a tone introduced
through a probe in the external auditory canal. The amount of sound
energy reflected from the tympanic membrane is recorded by a microphone
in the probe. Middle-ear pressure can be estimated by measuring the
response to applied pressure variations. The results are compared to
normal values and assist in differential diagnosis of middle ear
disorders.

[Acoustic reflex tests]{.underline} involve the presentation of a loud
tone intended to elicit a contraction of the stapedius muscle in the
middle ear. The acoustic reflex test provides objective information on
the status of the middle ear as well as the integrity of the auditory
nerve.

[Otoacoustic emissions (OAE)]{.underline} are another frequently used
electrophysiological measure. Otoacoustic emissions are propagated from
normal cochleae by outer hair cells and are measured in the ear canal by
use of a tiny microphone probe placed in the ear canal. Transient OAEs
are evoked by presenting a series of clicks to the ear and recording the
amplitude and time and frequency spectra of the emission response.
Distortion product OAEs involve the presentation of two tones and
recording the amplitude and time and frequency spectra of distortion
products created in the cochlea. OAEs are not usually observed in ears
with hearing losses greater than 30 dB HL or with conductive
involvement.

Most other auditory tests contribute additional information about site
of lesion. These tests are most effective when viewed as a battery of
diagnostic tests. The selection of the appropriate audiometric tests or
test batteries that should be incorporated in the assessment of the
veteran's hearing impairment is predicated upon the results obtained
from the basic audiometric assessment. The audiologist is best qualified
to determine which tests are appropriate and to interpret such tests.

## 5.8 How are test results reported? 

**a. VA Forms 10-2364 or 10-2364a** may be used to report the majority
of audiometric tests conducted within the VA. VBA Worksheet 1305
(AUDIO), or its electronic equivalent, is used to record audiometric
thresholds and rating narratives.

**b. History.** Under the Medical History section of Worksheet 1305, the
audiologist reports the patient's chief complaint, the situations of
greatest difficulty, pertinent medical, family, social, and military
history, and history of military, occupational, and recreational noise
exposure.

**c. Physical examination section.** Under the Physical Examination
section, the audiologist reports the pure tone air conduction thresholds
at 500, 1000, 2000, 3000, and 4000 Hz in each ear, the four-frequency
pure tone average (1000, 2000, 3000, and 4000 Hz), and the maximum
speech recognition score on the Maryland CNC Test in each ear.

When only pure tone thresholds should be used to evaluate hearing loss,
the audiologist will certify that language difficulties or other
problems make the combined use of pure tone averages and speech
recognition scores inappropriate.

**d. Tinnitus**. If tinnitus is present, the audiologist should state
date and circumstances of onset, whether it is unilateral, bilateral, or
unlocalized, whether it is recurrent (if periodic indicate the frequency
and duration), and the most likely etiology. If hearing loss is present
at any frequency, the audiologist must state if the tinnitus is due to
the same etiology or causative factor(s) as the hearing loss.

**e. Diagnostic and Clinical Tests section.** In the Diagnostic and
Clinical tests section, the audiologist describes the results of all
tests conducted during the examination. In cases where there is poor
inter-test reliability and /or positive Stenger Test results, the
audiologist obtains and reports estimates of hearing thresholds using a
combination of behavioral techniques, Stenger interference levels, and
electrophysiologic tests such otoacoustic emissions (OAE) and auditory
evoked potentials (ABR).

**f. Diagnosis section.** In the Diagnosis section, the audiologist
summarizes the audiologic test results. The audiologist also notes if
medical follow-up is needed for an ear or hearing problem and whether
there is a problem that, if treated, might change hearing thresholds.

## 5.9 When is hearing disabling for VA compensation and pension purposes?

For adjudication purposes, hearing impairment is disabling when pure
tone thresholds at 500, 1000, 2000, 3000, or 4000 Hz are 40 dB HL or
greater; or when pure tone thresholds for at least three of these
frequencies are 26 dB HL or greater; or when speech recognition scores
are less than 94%.

## 5.10 How is the degree of hearing impairment classified? 

The degree of hearing impairment is classified in terms of the effect of
the loss on the person's ability to understand speech in everyday
situations. Hearing is considered to be normal when hearing thresholds
are 25 dB HL or less.

**Mild hearing loss** occurs when the four frequency (1000, 2000, 3000,
3000, and 4000 Hz) pure tone average (PTA) is 26 to 40 dB HL A mild
hearing loss may cause difficulty hearing faint speech or normal speech
in the presence of background noise.

**Moderate hearing loss** occurs when the PTA is 41-54 dB HL. A moderate
hearing loss may cause difficulty with speech at normal conversational
levels, especially when background noise is present.

A **moderately severe hearing loss** occurs when the PTA is 55-69 dB HL.
A patient with a moderately severe hearing loss may have difficulty
hearing or understanding all but loud speech. Speech recognition may be
nearly impossible in the presence of background noise.

A **severe hearing loss** occurs when the PTA is 70-89 dB HL. A patient
with a severe hearing loss may have extreme difficulty understanding
spoken words, even in quiet situations.

A **profound hearing loss** occurs when the PTA is 90 dB HL or worse. A
patient with a profound hearing loss is functionally deaf and may not
understand even amplified sounds.

## 5.11 How are the types of hearing loss classified and what are their causes? 

The type of hearing loss may be described as conductive, mixed,
sensorineural, or central. Conductive hearing losses are due to lesions
that reduce transmission of sound through the external auditory canal,
tympanic membrane, or middle ear. In purely conductive hearing losses,
cochlear function is normal. Sensorineural hearing losses occur in
lesions of the cochlea and auditory nerve. Mixed hearing losses involve
both conductive and sensorineural components. Central hearing losses
occur in lesions of the central nervous system from the brainstem to the
auditory cortex. Audiologists are qualified to perform site of lesion
tests to differentiate these types of hearing loss.

**a. Conductive hearing loss** may result from congenital malformations
of the auricle, external canal, and middle ear. More commonly,
conductive hearing loss results from otitis media, pathologies of the
tympanic membrane, or pathologies involving the ossicles. Untreated
middle-ear disease may be lead to erosion of the ossicles or
cholesteatomas. This type of hearing loss also results from foreign
bodies, cerumen, inflammation of the external auditory canal. Neoplasms
of the ear are relatively uncommon, with glomus tumors, middle-ear
polyps, and carcinomas being the most common.

Otosclerosis, a localized disease of the otic capsule sometimes
affecting the stapes footplate, accounts for about one half of bilateral
conductive deafness in adults.

Other diseases of the otic capsule are osteogenesis imperfecta, Paget's
Disease, lipoid dystrophies, and Wegener's granulomatosis.

**b. Sensorineural hearing loss** may result from congenital hypoplasia
of bony or membranous structures in the petrous pyramid, prenatal
rubella, syphilis, Rh incompatibility, anoxia, meningitis, and
cytomegalovirus.

The most common causes of sensorineural hearing loss are aging and
traumatic noise exposure.

Sensorineural loss may also result from drug-induced ototoxicity. The
most common ototoxic factors are antibiotics such as streptomycin,
neomycin, kanamycin, vancomycin, polymixin B, and gentamicin,
salicylates (aspirin), platinum-based anti-neoplastics such as
cis-platin, and loop diuretics such as ethacrynic acid.

Sensorineural loss may also result from temporal bone fracture or closed
head injuries, labyrinthitis, syphilis, other viral and bacterial
infections, vascular disease, meningitis, autoimmune disorders, tumors
of the cerebellopontine angle, and endolymphatic hydrops (Meniere's
Disease).

**c. Central hearing loss** may be caused by congenital or developmental
factors, trauma, space-occupying lesions, meningitis, autoimmune
disorders, demyelinating diseases, and cerebrovascular disease.

## 5.12 What are the disabilities related to the vestibular system? 

With vestibular dysfunction, an individual usually complains of
dizziness, but an attempt should be made to differentiate dysequilibrium
and true vertigo.

**Vertigo** is the illusion of motion, usually accompanied by a
characteristic jerking motion of the eyes called nystagmus. If the
symptoms occur in attacks, the examiner should ask the patient to
describe the typical attack, premonitory signs, syncope, motion
intolerance, associated nausea, vomiting, or sweating, changes in
sensorium, direction of falling or spinning, duration, and after
effects.

The relationship to headaches or migraines, epilepsy, hearing or
tinnitus should also be noted. Any association of symptoms with fatigue,
excitement, medication or drug use, tobacco, or caffeine should be
noted. Psychogenic disorders are often characterized by symptoms of
weakness, faintness, nuchal or cranial pressure, malaise, or dyspnea.

If symptoms are persistent or severe, a general medical examination with
emphasis on myocardial infarction, hypertension, and diabetes is
indicated. A neurological examination with evaluation of cranial nerve
and cerebellar function, and an ophthalmologic examination of the vision
and oculomotor nuclei should be performed. However, symptoms that
persist for weeks or months are usually not of vestibular origin or have
a psychogenic overlay.

**Oculomotor function and the presence of nystagmus** can be observed in
the office using Frenzel lenses (20 diopter lenses) to eliminate visual
fixation. If the eyes are directed 45^ο^ or more from central gaze,
physiologic or endpoint nystagmus may be induced. However, observation
in the office does not substitute for complete medical evaluation
including objective balance assessment using electronystagmography (ENG)
or other electrophysiological techniques.

## 5.13 What does a vestibular examination include? 

A vestibular examination includes:

**a. Observation of gaze nystagmus.** Spontaneous nystagmus occurs in
the absence of a stimulus and may indicate acute or uncompensated
disease. Gaze nystagmus that is strongest for gaze in the direction of
the fast phase is usually caused by peripheral lesions. According to
Alexander's Law, first-degree nystagmus is strongest with lateral gaze
in the direction of the fast phase. Second-degree nystagmus occurs when
gaze nystagmus is noted in the primary position and with lateral gaze in
the direction of the fast phase. Third degree nystagmus occurs when gaze
nystagmus is also noted with lateral gaze in the direction of the slow
phase.

Congenital nystagmus is usually characterized by pendular or jerk
nystagmus, but the nystagmus is usually distorted with eyes open.
Congenital nystagmus may have null point at which the nystagmus
decreases or disappears. Congenital nystagmus is rarely vertical. During
upward gaze, the nystagmus is usually horizontal, not vertical.
Congenital nystagmus also tends to decrease or disappear with
convergence of the eyes on a target.

**b. Tests of positional nystagmus**. Positions include sitting, supine,
lying lateral on the right side, lying lateral on the left side, and
supine with head hanging. Positional nystagmus is abnormal if the
direction changes in any one position, it is present in three or more
positions, it is intermittent in four or more positions, or it is
greater than 6^o^ per second. Positional nystagmus is abnormal if it is
enhanced with eyes open.

Direction-fixed nystagmus is usually caused by peripheral lesions.
Direction changing, particularly with eyes open, usually signifies a CNS
lesion. However, the examiner needs to rule out positional alcohol
nystagmus (PAN).

Positioning nystagmus is evaluated using the Hallpike maneuver in which
the patient in sitting position is moved suddenly to a supine position
with head hanging with right ear or left ear down. The eyes are observed
for evidence of jerk or rotary nystagmus. The presence of brief,
intense, delayed, fatigable nystagmus is characteristic of benign
paroxysmal positioning vertigo (BPPV), a very common condition thought
to be caused by dislodged otoconia in the cristae of the semicircular
canals. Some examiners define direction-fixed positional nystagmus as
spontaneous nystagmus. Spontaneous nystagmus is differentiated from
positional nystagmus by the fact that positional nystagmus is
characterized by differences in intensity between head positions whereas
spontaneous nystagmus is constant in all positions.

**c. Other examinations.** Head-shaking nystagmus may be evoked by
having the patient shake his/her head vigorously for 15-20 seconds. Eye
movements are observed by Frenzel lenses. If the patient has nystagmus
and did not have spontaneous nystagmus, an uncompensated lesion is
noted. Normally, the nystagmus beats away from the lesion side.

**d. Tests for postural vertigo.** Tests such as the Romberg,
Past-pointing, tandem walking, or the Fukuda Stepping Test are useful in
grossly assessing vestibular function.

> The **Romberg Test** involves having the patient stand with feet
> together and arms folded at the chest, eyes closed. Patients with
> unilateral peripheral lesions will sway or fall, usually toward the
> lesion side.
>
> **Past-pointing** involves having the patient place an index finger on
> the examiner's finger, extend the arm to vertical position, and return
> the index finger to the examiner's finger. Deviation is noted.
> Patients with peripheral lesions tend to past point toward the lesion
> side.
>
> **Tandem walking** involves having the patient walk heel to toe with
> eyes closed and open. In the eyes closed condition, swaying or
> deviation may indicate a peripheral vestibular lesion. In the eyes
> open condition, swaying or deviations may indicate a cerebellar
> disturbance.
>
> **The Fukuda Test** involves having the patient march in place (50
> steps) with eyes closed. The amount of rotation is noted. Usually, the
> patient rotates toward the lesion side. However, the direction of
> deviation or rotation in these tests is a poor indicator of the side
> of the lesion.

**e. Caloric stimulation.** This test should be performed only on those
patients with normal external auditory canals and intact tympanic
membranes. Using 2 ml of ice water in a syringe with a 14 or 16-gauge
needle, the examiner injects the water slowly into the ear canal. The
head is hyper-extended by 60^o^ from the vertical axis if the patient is
in the sitting position. If the patient is in supine position, the head
is flexed 30^o^ to bring the lateral semi-circular canal into the
vertical plane. The latency and duration of the nystagmus are measured
with a stopwatch. Nystagmus should be observed with the patient wearing
Frenzel lenses. The opposite ear is tested after a five-minute rest
period. The normal duration is 80-120 seconds. If a 30-second or greater
difference exists between ears, the side with the reduced duration has a
hypo-reactive response.

**f. Electronystagmography**. Non-electrical recordings must be
considered to be qualitative. Electronystagmography (ENG) is an
electrophysiologic test battery that provides a quantitative measure of
oculomotor and vestibular function and is usually performed by
audiologists.

ENG is usually obtained measuring eye position using the corneal-retinal
potential with electrodes or infrared video recordings. Eye movements
are displayed graphically on a strip chart or a video display.

The typical ENG battery consists of oculomotor tests (saccades, smooth
pursuit or pendular tracking, and optokinetic tests), positional and
positioning tests as described above, and caloric stimulation using cool
and warm water or air.

Oculomotor tests evaluate the oculomotor nuclei and/or
brainstem-cerebellar systems. Saccade tests involve having the patient
track a light target that jumps right, left, up and down. CNS lesions
may produce ocular dysmetria, saccadic slowing, or disconjugate eye
movements. Tracking or pursuit tests involve having the patient track a
light target moving across the visual field. Disorganized or saccadic
pursuit usually indicates a CNS lesion.

Positional tests evaluate the effect of movement or gravity on
vestibular responses. The diagnostic significance is the same for the
observation tests described above.

Caloric tests evaluate peripheral vestibular function. Failure to
suppress nystagmus with visual fixation is usually indicative of CNS
disease.

**g. Other objective measures** useful in the diagnosis of balance
disorders are sinusoidal vertical axis rotation testing (rotary chair),
and computerized dynamic posturography. The latter test provides
detailed analysis of vestibular, visual, and somatosensory integration.

## 5.14 What are important issues in examining for the sense of smell? 

**a. Anatomy**. The olfactory area includes the upper posterior part of
the nasal cavity where olfactory mucosa lines the superior turbinate and
upper septum. Most inspired air travels below the olfactory area, but
eddy currents are induced by sniffing, and the upward airflow makes
greater contact with the olfactory mucosa**.** Axons of the first
afferent neuron are grouped together as the olfactory nerves penetrate
the cribriform plate and synapse with the secondary neuron processes of
the olfactory bulbs intracranially. Proximally, from the bulbs, the
axons form the olfactory tracts centrally where some fibers cross the
midline to the reticular formation, anterior commissure, caudate
nucleus, internal capsule, hypothalamus, and hippocampal area of the
temporal lobes. There is also an efferent system by which the olfactory
bulbs receive impulses from the brain, which can lower the reception
threshold. The specific mechanism of the olfactory stimulus has not been
described. Regression of the sense of smell is commonly associated with
advancing age.

**b. Testing olfaction.** Substances used for testing olfaction should
have a common odor. Coffee, benzaldehyde, tar, and oil of lemon are
recom­mended. Each side of the nose should be tested separately, and the
odor should be named. The receptacles for the odors may be a test tube
or the barrel of a 10 cc. syringe. The examinee is asked to sniff as he
is exposed to the test substance.

Frequently, either all or none of the test odors are identified. Since
there is a marked deviation of threshold in normal individ­uals, the
qualitative tests of the presence or absence of the loss of smell
(anosmia) is practical. Quantitative testing is time consum­ing and of
equivocal diagnostic value. A suspected hysterical loss of smell can be
differentiated by presenting both irritating and pure odors. If neither
is identified, a suspicion of hysteria should be entertained

**c. Causes of anosmia.** The causes of anosmia may be extra or
intracranial. A genetic loss of olfaction in several generations of one
family has been described. The extracranial factors are related to nasal
obstruction from polypi, congested turbinates, and deviated septa. The
intracranial lesions include anterior cranial fossa fractures,
abscesses, tumors, and meningitis. Perversion of the sense of smell may
be caused by nasal foreign bodies, sinusitis, or the above intracranial
lesions.

## 5.15 What are important issues in examining for the sense of taste? 

**a. Anatomy.** The sites of origin of the sensation are the end organs
(taste buds) found mainly on the tongue; but also on the cheek, hard
palate, and faucial tonsillar pillars. The taste cells are thin fusiform
structures within the buds, and the peripheral end of the cell has a
delicate process which projects through the bud orifice. The mucosa of
the tongue is studded with small elevations, the lingual papillae. There
are three main types: filiform, fungi-form, and vallate. The filiform
papillae are minute conical projections covering the anterior two-thirds
of the tongue dorsum and rarely contain taste buds. The fungiform
papillae are considerably larger, round, and located mainly at the tip
and edges of the tongue. The vallate papillae are the largest, round
with a central elevation, a surrounding sulcus, and arranged in the form
of a "V" at the base of the tongue. The fungiform and vallate papillae
each contain 8 to 10 taste buds.

The principal nerves of taste are the chorda tympani branch of the
facial nerve and the glossopharyngeal nerve. The former supplies taste
buds over the anterior two-thirds of the tongue, and the latter is
distributed to the posterior one-third. The taste fibers of the chorda
tympani nerve arise in cells at the geniculate ganglion and end in the
sensory nucleus of the tractus solitarius. Secondary fibers arising from
there ascend to the thalamus. Tertiary neurons terminate in the
hippocampal gyrus cortex. The taste fibers of the glossopharyngeal
nerve, which arise in the petrosal ganglion, centrally, terminate in the
dorsal nucleus of the vagus and tractus solitarius. The central pathways
are similar to the chorda tympani nerve.

**b. Testing sense of taste.** The oral special sensory function of
taste is highly differentiated, and it can be evaluated accurately by
standardized tests. A substance must be in solution to stimulate the
taste cells, and its taste is related to the chemical composition.
Flavors are chiefly related to the sense of smell. The specific
character of orally ingested substances depends upon the stimulation of
tactile sensation as well as taste.

The basic taste modalities are sweet, sour, bitter, and salt. The tip
and sides of the tongue are most sensitive to sweet and sour, and the
base of the tongue is most sensitive to bitter. The acuity varies among
normal individuals, and in the time of day for one individual.

The recommended test substances are sugar, dilute acetic acid, quinine,
and common salt. A cotton-tipped applicator moistened with each
substance is applied to the lateral borders and vallate papillae of the
tongue. Responses from each side of the tongue are compared. The test
for the presence or absence of taste is considered to be of limited
value. In recent years, the more refined electrogustrometry has
permitted more accurate determination of impaired taste function. The
stimulating electrode incites an acid taste, and the threshold is
determined on each side of the tongue.

**c. Value of tests for taste.** The tests for taste have frequently
been used to establish a prognosis in patients with facial paralysis. A
disturbance in taste is believed to be an early indication of facial
nerve degeneration.

Taste tests on the base of the tongue may yield confirmatory evidence of
glossopharyngeal nerve paralysis. Taste sensation varies in endocrine
diseases being more acute in hypocorticoadrenalism and depressed in
hypercorticoadrenalism, hypogonadism, and pseudohypoparathyroidism. It
is also reduced in rickets and familial dysautonomia.

## Worksheet - AUDIO

Name: SSN:

Date of Exam: C-number:

Place of Exam:

[Narrative:]{.underline} An examination of hearing impairment must be
conducted by a state-licensed audiologist and must include a controlled
speech discrimination test (specifically, the Maryland CNC *recording*)
and a pure tone audiometry test in a sound isolated booth that meets
American National Standards Institute standards (ANSI S3.1. 1991) for
ambient noise. Measurements will be reported at the frequencies of 500,
1000, 2000, 3000, and 4000 Hz. The examination will include the
following tests: Pure tone audiometry by air conduction at 250, 500,
1000, 2000, 3000, 4000, and 8000 Hz, and by bone conduction at 250, 500,
1000, 2000, 3000, and 4000 Hz, spondee thresholds, speech recognition
using the recorded Maryland CNC Test, tympanometry and acoustic reflex
tests, and, when necessary, Stenger tests. Bone conduction thresholds
are measured when the air conduction thresholds are poorer than 15 dB
HL. A modified Hughson-Westlake procedure will be used with appropriate
masking. A Stenger must be administered whenever pure tone air
conduction thresholds at 500, 1000, 2000, 3000, and 4000 Hz differ by 20
dB or more between the two ears. Maximum speech recognition will be
reported with the 50 word VA approved recording of the Maryland CNC
test. When speech recognition is 92% or less, a performance intensity
function will be obtained with a starting presentation level 40 dB re
SRT. If necessary, the starting level will be adjusted upward to obtain
a level at least 5 dB above the threshold at 2000 Hz. The examination
will be conducted without the use of hearing aids. Both ears must be
examined for hearing impairment even if hearing loss in only one ear is
at issue.

A. **Review of Medical Records:** Indicate whether the C-file was
reviewed.

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Chief complaint.

2\. Situation of greatest difficulty.

3\. Pertinent service history.

4\. History of military, occupational, and recreational noise exposure.

5\. Tinnitus - If present, state:

a\. Date and circumstances of onset.

b\. Whether it is unilateral or bilateral.

c\. Whether it is recurrent (indicate frequency and duration).

d\. The most likely etiology of the tinnitus, and specifically, if
hearing loss is present, whether the tinnitus is due to the same
etiology (or causative factor) as the hearing loss.

C. **Physical Examination (Objective Findings):**

1\. Measure puretone thresholds in decibels at the indicated frequencies
(air conduction):

= = = = = = =RIGHT EAR= = = = = = = = = = = = = = = = = LEFT EAR = = = =
= = =

A\* B C D E \*\* A\* B C D E \*\*

500 \| 1000 \| 2000 \| 3000 \| 4000 \| average 500 \| 1000 \| 2000 \|
3000 \| 4000 \| average

\* The puretone threshold at 500 Hz is not used in determining the
evaluation but is used in determining whether or not a ratable hearing
loss exists.

\*\* The average of B, C, D, and E.

2\. Speech Recognition Score: Maryland CNC word list

\_\_\_\_\_\_\_% right ear \_\_\_\_\_\_% left ear.

3\. When only puretone results should be used to evaluate hearing loss,
the examiner, who must be a state-licensed audiologist, should certify
that language difficulties or other problems (specify what the problems
are) make the combined use of puretone average and speech discrimination
inappropriate.

**D. Diagnostic and Clinical Tests:**

1\. Report middle ear status, confirm type of loss, and indicate need
for medical follow-up. In cases where there is poor inter-test
reliability and/or positive Stenger test results, obtain and report
estimates of hearing thresholds using a combination of behavioral
testing, Stenger interference levels, and electrophysiological tests.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. Summary of audiologic test results. Indicate type and degree of
hearing loss for the frequency range from 500 to 4000 Hz. For type of
loss, indicate whether it is normal, conductive, sensorineural, central,
or mixed. For degree, indicate whether it is mild (26-40 HL), moderate
(41-54 HL), moderately severe (55-69HL), severe (70-89 HL), or profound
(90+HL).

\[For VA purposes, impaired hearing is considered to be a disability
when the auditory threshold in any of the frequencies 500, 1000, 2000,
3000, and 4000 Hz is 40 dB HL or greater; or when the auditory
thresholds for at least three of these frequencies are 26 dB HL or
greater; or when speech recognition scores are less than 94%.\]

2\. Note whether, based on audiologic results, medical follow-up is
needed for an ear or hearing problem, and whether there is a problem
which, if treated, might cause a change in hearing threshold levels.

Signature: Date:

## Worksheet - DENTAL AND ORAL

Name: SSN:

Date of Exam: C-number:

Place of Exam:

[Narrative:]{.underline} Regional Office action is required for all
dental treatment based on combat wounds, service trauma, prisoner of war
or extracted teeth under 38 CFR 17.123.

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe:

> 1\. Describe extent of functional impairment due to loss of motion and
> masticatory function loss.
>
> 2\. Describe the extent and number of missing teeth and whether the
> masticatory surface can be replaced by a prosthesis.
>
> 3\. If limitation of inter-incisal range of motion, provide actual
> range in mm (i.e., 0-Xmm) and also provide lateral excursion (i.e.,
> 0-Xmm).
>
> 4\. Describe the extent of any bone loss of mandible, maxilla, or hard
> palate. For hard palate and maxilla bone loss, state whether
> replaceable by prosthesis.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. X-ray to determine extent of bone tissue loss.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

> 1\. Give etiology where there is loss of teeth due to loss of
> substance of body of maxilla or mandible.

Signature: Date:

## Worksheet - EAR DISEASE

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:** Indicate whether the C-file was
reviewed.

B. **Medical History (Subjective Complaints):**

1\. Describe history of hearing loss, tinnitus, vertigo, balance or gait
problems, discharge, pain, pruritus. State onset and frequency and
duration of each, if not constant.

2\. Describe current or past treatment for ear conditions.

3\. If a malignant neoplasm of the ear is or was present:

> a\. State date of confirmed diagnosis.
>
> b\. State date of the last surgical, X-ray, antineoplastic
> chemotherapy, radiation, or other therapeutic procedure.
>
> c\. State expected date treatment regimen is to be completed.
>
> d\. If treatment is already completed, provide date of last treatment.

3\. If treatment is already completed, fully describe residuals.

C. **Physical Examination (Objective Findings):**

1\. Conduct an external and otoscopic examination. Address each of the
following and describe current findings, including abnormalities of
size, shape, or form:

> a\. Auricle. Any deformity? If there is tissue loss, state whether it
> is one-third or more of auricle.
>
> b\. External canal - describe any edema, scaling, discharge.
>
> c\. Tympanic membrane.
>
> d\. The tympanum.
>
> e\. Mastoids. Discharge? Evidence of cholesteatoma?
>
> f\. State all conditions secondary to ear disease, such as disturbance
> of balance, upper respiratory disease, hearing loss, etc.

2\. State whether an active ear disease is present.

3\. Infections of the middle or inner ear. Is there suppuration?
Effusion? Are aural polyps present?

4\. For peripheral vestibular disorders, state the specific diagnosis
and its basis, whether there is dizziness and how often, and whether a
staggering gait occurs and how often.

5\. For Meniere's syndrome, state the symptoms, including the frequency
of attacks of vertigo and cerebellar gait. Is tinnitus present? If so,
how frequently and what is its duration? Is there hearing loss? (See
audio worksheet.)

6\. Describe any complications of ear disease that are present.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - MOUTH, LIPS, AND TONGUE

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Disfigurement - if present, order [color photographs]{.underline}.

2\. Interference with mastication.

3\. Interference with speech - state extent.

4\. Absence of all or part of tongue - describe.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - NOSE, SINUS, LARYNX, AND PHARYNX

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Location and nature of the injury or disease.

2\. Interference with breathing through nose.

3\. Purulent discharge.

4\. Dyspnea at rest or on exertion?

5\. Treatments - type (surgery, medication, oxygen, respirator, etc.)
frequency, duration,

response, and side effects.

respirators, etc., response, and side effects.

6\. If speech impairment (ability to communicate by speech, ability to
speak above a

whisper, etc.).

7\. For chronic sinusitis, indicate which sinuses are affected and
whether pain and

headaches are present. Describe severity and frequency.

8\. If allergic attacks, frequency and baseline status between attacks.

9\. Other symptoms noted.

10\. Describe frequency and duration of periods of incapacitation
(defined as requiring

bedrest and treatment by a physician).

C. **Physical Examination (Objective Findings):**

Provide:

1\. If there is nasal obstruction, indicate percent each nostril.

2\. Sinusitis - Describe tenderness, purulent discharge, or crusting.

D. **Diagnostic and Clinical Tests:**

1\. If there is stenosis of larynx, order [FEV-1 with flow-volume
loop]{.underline}.

2\. If there is facial disfigurement, order [color
photographs]{.underline}.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Comment on whether the disease primarily involves or originates from the
nose, sinus,

larynx, or pharynx.

Signature: Date:

## Worksheet - SENSE OF SMELL AND TASTE

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

C. **Physical Examination (Objective Findings):**

D. **Diagnostic and Clinical Tests:**

> 1\. For [sense of smell]{.underline}, test each side of nose
> separately. State results with the following substances recommended
> for testing:

a\. Coffee.

b\. Soap.

c\. Oil of lemon.

d\. Other (state substance).

2\. For [sense of taste]{.underline}

a\. Using electrogustometry if available, test for:

\(1\) Sweet.

\(2\) Sour.

\(3\) Bitter.

\(4\) Salt.

b\. State results with the following substances recommended for testing:

\(1\) Sugar.

\(2\) Diluted acetic acid.

\(3\) Lemon or Orange.

\(4\) Salt.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Provide:

1\. State whether loss of sense of smell is partial or complete, and its
basis.

2\. State whether loss of sense of taste is partial or complete, and its
basis.

3\. If a psychiatric basis is suspected, a special psychiatric
examination should be ordered.

Signature: Date:

# Chapter 6 - RESPIRATORY

## 6.1 What are the basic elements of an examination for disease or injury of the respiratory system?

This chapter supplements the disability examination worksheets titled:

**[NOSE, SINUS, LARYNX AND PHARYNX;]{.smallcaps}**

**[RESPIRATORY (OBSTRUCTIVE, RESTRICTIVE, AND
INTERSTITIAL);]{.smallcaps}**

**[PULMONARY TUBERCULOSIS AND MYCOBACTERIAL DISEASES;]{.smallcaps}**

**[RESPIRATORY DISEASES, MISCELLANEOUS]{.smallcaps} (PVD, Neoplasms,
Bacterial Infections, Mycotic Lung Disease, Sarcoidosis, and Sleep
Apnea).**

**a. Initial examination**

1\) History of present illness - onset, frequency, and severity of
symptoms; past and current treatment; whether symptoms are controlled by
treatment; effects of condition on daily activities.

2\) General health information, as pertinent - including previous
surgery and illnesses; family history; military history.

3\) Respiratory history. Date of onset and course of shortness of
breath, cough, sputum, hemoptysis etc.

4\) Occupational and environmental history. Describe any exposure to
dusts, gases, toxins etc. both in the military and before and following
service, including occupational hazards.

**b. Review examination:** For a review examination, only an interval
history covering the period since the last examination is needed.

**c. Physical examination:** See worksheets for respiratory diseases and
additional information below.

**d. Usual laboratory studies**

> **1) Chest x-ray** is routine for lower respiratory conditions, unless
> report of an X-ray done within past 6 months is available in the
> record.
>
> **2) Pulmonary Function Tests** (unless carried out within past six
> months and the report is either in the claims folder or will be
> attached to this examination report). Most respiratory conditions are
> evaluated primarily on the basis of the results of pulmonary function
> tests. Spirometric pulmonary function testing should include FVC,
> FEV-1, and the FEV-1/FVC ratio (ratio of Forced Expiratory Volume in
> one second to Forced Vital Capacity). A DLCO (diffusion capacity of
> the lung for carbon monoxide by the single breath method) is included
> in a routine battery of pulmonary function tests in some medical
> facilities but not in all. Both pre- and post-bronchodilation test
> results should be reported. If post-bronchodilation is not done, an
> explanation of why it was not done should be given; otherwise, the
> examination will not be considered adequate for rating purposes.
>
> **3) Conditions that may be evaluated on the basis of PFT's** may
> alternatively be evaluated on the basis of maximum exercise capacity;
> presence of cor pulmonale, right ventricular hypertrophy, or pulmonary
> hypertension; or a requirement for outpatient oxygen therapy, so any
> of these findings that are present or known should be reported.
>
> **4) Need for DLCO or not**. If the DLCO test is not included as part
> of pulmonary function testing, the examiner should determine whether
> or not it would provide useful information about the severity of
> pulmonary functioning in a particular case. If it was not done as part
> of the routine testing, and would not be useful, the examiner should
> explain why, e.g., by explaining that the DLCO would not be valid in
> this particular case because of the decreased lung volumes. Unless an
> explanation for its omission is provided, the DLCO [should be
> done]{.underline}. It should also [always]{.underline} be done when
> requested by a BVA remand unless medically contraindicated.
>
> **5) Disparity in PFT's**: If there is a disparity between the results
> of different elements of the pulmonary function tests, e.g., if the
> FEV-1 indicates good functioning and the DLCO is very abnormal, the
> examiner should indicate which test or tests are more likely to
> accurately reflect the extent of impaired pulmonary functioning due to
> the condition and why. At times the tests may need to be repeated for
> clarification, for example, if there is doubt about the effort
> expended, or if there were technical difficulties during the test.

## 6.2 What specific information may be needed for the evaluation of certain upper respiratory conditions?

**a. Sinusitis**: Describe any previous surgery, current signs and
symptoms. Describe the frequency and duration of any incapacitating
episodes (defined as a period requiring bed rest and treatment by a
physician) during the past year and whether these episodes have required
antibiotic treatment and for how long. Describe any other
(non-incapacitating) episodes of sinusitis and their frequency and signs
and symptoms.

**b. Nasal septal deviation**: Report the percent of obstruction of
nasal passage on each side.

**c. Allergic or vasomotor rhinitis**: If diagnosis has been
established, report whether there are nasal polyps and the percent of
obstruction of nasal passage on each side.

**d. Chronic laryngitis**: Report any hoarseness, and describe laryngeal
findings, such as inflammation, nodules, polyps of cords, or any other
cord abnormalities.

**e. Stenosis of larynx**: Request an FEV-1 with flow-volume loop to see
if characteristic pattern of upper airway obstruction is present.

**f. Aphonia**: Report the extent to which the veteran can or cannot
communicate by speech or whether there is constant inability to
communicate by speech. Report whether the veteran cannot speak above a
whisper and whether this inability is constant.

## 6.3 What specific information should be provided in examinations of certain lower respiratory conditions?

**a. Bronchiectasis**: Report current signs and symptoms, and frequency
and duration of any courses of antibiotic treatment during the past
year. Describe the frequency and duration of any incapacitating episodes
(defined as a period requiring bed rest and treatment by a physician)
during the past year. PFT's may also be used to evaluate bronchiectasis.

**b. Asthma**: Provide PFT's. Although PFT's may be important in
evaluating asthma, the PFT's may be normal at some times and in some
patients. Other information may therefore also be used to evaluate
asthma, so the examiner should report the type of treatment, including
the use of systemic (oral or parenteral) corticosteroids, (state the
frequency of courses or whether used daily or intermittently and the
dosage), immunosuppressive medications, bronchodilators (oral or
inhalers), anti-inflammatory inhalers, or other medication.

**c. Chronic bronchitis, emphysema, COPD**: [Always]{.underline} provide
PFT's, specifically the FEV-1, FEV-1/FVC ratio, DLCO. Also report:

cor pulmonale

right ventricular hypertrophy

pulmonary hypertension

whether there have been episodes of respiratory failure

whether outpatient oxygen therapy is required

if available, the maximum exercise capacity.

**d. Interstitial lung diseases**: These include diffuse interstitial
fibrosis (interstitial pneumonitis, fibrosing alveolitis), desquamative
interstitial pneumonitis, pulmonary alveolar proteinosis, eosinophilic
granuloma of lung, drug-induced pulmonary pneumonitis and fibrosis,
radiation-induced pulmonary pneumonitis and fibrosis, hypersensitivity
pneumonitis (extrinsic allergic alveolitis), pneumoconiosis (silicosis,
anthracosis, etc.), and asbestosis. Provide PFT's, specifically the FVC
and DLCO. Also report:

cor pulmonale or pulmonary hypertension

whether outpatient oxygen therapy is required

if available, the maximum exercise capacity

**e. Restrictive lung diseases:** These include diaphragm paralysis or
paresis, spinal cord injury with respiratory insufficiency,
kyphoscoliosis, pectus excavatum, pectus carinatum, post-surgical
residual (lobectomy, pneumonectomy, etc.), chronic pleural effusion or
fibrosis, and traumatic chest wall defect are evaluated. Provide PFT's,
specifically the FEV-1, FEV-1/FVC ratio, DLCO. Also report:

cor pulmonale, right ventricular hypertrophy, or pulmonary hypertension

whether there have been episodes of respiratory failure

whether outpatient oxygen therapy is required

if available, the maximum exercise capacity.

**f. Sarcoidosis:** Report:

the extent of pulmonary and mediastinal disease and any associated signs
and symptoms

presence of cor pulmonale or congestive heart failure

type of treatment, frequency, and dosage

in detail all extra-pulmonary involvement (skin, eye, etc.) Use
additional worksheets, as appropriate.

PFT's as for chronic bronchitis.

**g. Mycotic lung diseases:** These include, among others,
histoplasmosis, coccidioidomycosis, blastomycosis, cryptococcosis,
aspergillosis, and mucormycosis. Report:

signs and symptoms of chronic pulmonary mycosis, such as fever, weight
loss, night sweats, cough, hemoptysis and their frequency and severity

need for suppressive therapy

whether mycotic lesions are healed or disease is active.

**h. Bacterial infections of the lung, including actinomycosis,
nocardiosis, and chronic lung abscess:** Report:

for active disease: signs and symptoms, such as fever, night sweats,
weight loss, hemoptysis

for inactive disease or residuals: PFT's and other findings listed above
for restrictive lung disease, interstitial lung disease, or obstructive
lung disease, as appropriate.

## 6.4 What specific information should be provided in examinations of pulmonary vascular disease?

a\. Describe the type of pulmonary vascular disease and its etiology.

b\. Discuss or describe, as appropriate:

chronic pulmonary thromboembolism

evidence of pulmonary hypertension, right ventricular hypertrophy, or
cor pulmonale

whether anticoagulant therapy is required

obstructive disease of pulmonary arteries or veins

history of inferior vena cava surgery

symptoms following resolution of acute pulmonary embolism

PFT's if residuals of pulmonary embolism include obstructive or
restrictive lung disease.

## 6.5 How should the diagnosis of cor pulmonale be confirmed?

Cor pulmonale, right ventricular hypertrophy, or pulmonary hypertension
should be confirmed by a cardiac Echo or cardiac catheterization. They
should not be diagnosed on clinical findings or X-rays only.

## 6.6 What should be provided for a disability examination of pulmonary neoplasms (benign and malignant)?

Benign and malignant neoplasms are evaluated on the basis of specific
residuals following treatment. If there has been a pulmonary resection,
provide PFT's and other elements listed for restrictive diseases (see
6.3 e). If treatment for malignant neoplasm has been completed, describe
the type of treatment and date of last treatment.

## 6.7 What is needed for an examination of pulmonary tuberculosis?

a\. See disability examination worksheet titled "PULMONARY TUBERCULOSIS
AND MYCOBACTERIAL DISEASES".

b\. The diagnosis of active pulmonary tuberculosis requires 3 sputum
smears and cultures.

c\. Classification of tuberculosis;

> 0\. No tuberculosis exposure, not infected (no history of exposure,
> negative reaction to tuberculin skin test).
>
> I. Tuberculosis exposure, no evidence of infection (history of
> exposure, negative reaction to tuberculin skin).
>
> II\. Tuberculous infection, without disease (positive tuberculin skin
> test, negative bacteriological studies (if done), no clinical and/or
> x-ray evidence of tuberculosis.) Give history of treatment.
>
> III\. Tuberculosis: current disease.
>
> 1\) Location of disease (pulmonary, pleural, lymphatic, bone and
> joint, genitourinary, meningeal, peritoneal, other)
>
> 2\) Type of lesion (cavitary, non-cavitary, miliary)
>
> 3\) Bacteriological status (microscopy and culture results and dates)
>
> 4\) X-rays (reports and dates)
>
> 5\) Treatment status (drugs - doses and dates)
>
> 6\) Condition (stable, worsening, improving)

## 6.8 What are the important elements of a disability examination for sleep apnea

a\. Sleep apnea includes intermittent cessation of airflow at the nose
and mouth during sleep, lasting 10 to 30 seconds and occurring 10 to 15
times per minute. Obstructive is due to collapse and occlusion of the
upper airway of the oropharynx, and snoring is a common symptom. Central
is due to a transient abolition of central ventilatory drive, which
causes a chronic alveolar hypoventilation. Mixed sleep apnea combines
features of both types.

b\. Report whether:

there is a tracheostomy;

there is chronic respiratory failure with carbon dioxide retention or
cor pulmonale;

breathing assistance device such as continuous airway pressure (CPAP) is
required;

there is persistent daytime hypersomnolence.

## Worksheet - RESPIRATORY (OBSTRUCTIVE, RESTRICTIVE, AND INTERSTITIAL)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Productive cough, sputum, hemoptysis, and/or anorexia.

2\. Extent of dyspnea on exertion.

3\. If veteran is asthmatic, report frequency of attacks and baseline
functional status

between attacks.

4\. Treatment (type, frequency and duration including a need for
oxygen), response, side

effects.

5\. Describe frequency and duration of any periods of incapacitation
(defined as requiring

bedrest and treatment by a physician).

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the condition being
examined and fully

describe current findings:

1\. Presence of cor pulmonale, RVH or pulmonary hypertension.

2\. Weight loss or gain.

3\. For restrictive disease, describe condition underlying restrictive
disease,

e.g., kyphoscoliosis, pectus excavatum, etc., unless already of record.

D. **Diagnostic and Clinical Tests:**

> Provide:
>
> 1\. [Pulmonary Function Tests]{.underline} (unless carried out within
> past six months and the report is either in the claims folder or will
> be attached to this examination report, e.g., PFT\'s were in VAMC
> records at your facility). Spirometric pulmonary function testing
> should include FVC, FEV-1, and the FEV-1/FVC ratio. Both pre- and
> post-bronchodilatation test results should be reported. If
> post-bronchodilatation testing is not conducted in a particular case,
> please provide an explanation of why not. A DLCO may or may not be
> done routinely as part of pulmonary function testing at a particular
> facility. If there is a disparity between the results of different
> tests, please indicate which tests are more likely to accurately
> reflect the severity of the condition.
>
> **DLCO note**: If the DLCO was not done as a routine part of pulmonary
> function testing, the examiner should use his or her judgment, based
> on the specific condition (e.g., whether it is obstructive,
> interstitial, etc.) and other available information about the
> condition, as to whether a DLCO test is needed, since it is not useful
> in all situations. If it may provide useful information about the
> severity of the condition, it should be requested and reviewed before
> the examination report is submitted. If the examiner determines that
> the DLCO test is not needed, a statement as to why not (e.g., there
> are decreased lung volumes that would not yield valid test results)
> should be included in the report. Such a statement could avoid a
> remand from BVA when the test is not done. However, in the case of a
> BVA remand in which the DLCO is requested, the DLCO MUST be done
> unless there is a medical contraindication.
>
> 2\. Chest X-ray (if no recent results available).
>
> 3\. Include results of all diagnostic and clinical tests conducted in
> the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - RESPIRATORY DISEASES, MISCELLANEOUS

(PVD, Neoplasms, Bacterial Infections, Mycotic Lung Disease,
Sarcoidosis, and Sleep Apnea)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Fever and/or night sweats.

2\. Weight loss or gain.

3\. Daytime hypersomnolence.

4\. Hemoptysis.

5\. Describe current treatment such as anticoagulant, tracheostomy,
CPAP, oxygen, or

antimicrobial therapy.

6\. If malignant disease, state initial treatment date, site of original
tumor, type of tumor,

types of treatment used, and date treatment is expected to end. If
treatment has been

completed, state date treatment was completed.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the condition being
examined and fully

describe current findings:

1\. Pulmonary Hypertension, RVH, cor pulmonale, or congestive heart
failure.

2\. Residuals of pulmonary embolism.

3\. Respiratory Failure.

4\. Evidence of chronic pulmonary thromboembolism.

5\. If ankylosing spondylitis, is there restriction of the chest
excursion and dyspnea on

minimal exertion?

6\. Describe all residuals of malignancy including those due to
treatment.

D. **Diagnostic and Clinical Tests:**

> 1\. Pulmonary Function Tests, if indicated. The FEV-1, FVC, and
> FEV-1/FVC should be included. Both pre- and post-bronchodilatation
> pulmonary function test results should be reported. If
> post-bronchodilatation testing is not conducted in a particular case,
> please provide an explanation of why not. A DLCO may or may not be
> done routinely as part of pulmonary function testing at a particular
> facility. If there is a disparity between the results of different
> tests, please indicate which tests are more likely to accurately
> reflect the severity of the condition.
>
> **DLCO note**: If the DLCO was not done as a routine part of pulmonary
> function testing, the examiner should use his or her judgment, based
> on the specific condition (e.g., whether it is obstructive,
> interstitial, etc.) and other available information about the
> condition, as to whether a DLCO test is needed. If it may provide
> useful information about the severity of the condition, it should be
> requested and reviewed before the examination report is submitted. If
> the examiner determines that the DLCO test is not needed, a statement
> as to why not (e.g., there are decreased lung volumes that would not
> yield valid test results) should be included in the report. Such a
> statement could avoid a remand from BVA when the test is not done.
> However, in the case of a BVA remand in which the DLCO is requested,
> the DLCO MUST be done unless there is a medical contraindication.
>
> 2\. If sleep apnea is suspected, order [Sleep Studies]{.underline}.
>
> 3\. Chest X-ray if necessary to document sarcoidosis or other
> parenchymal disease.
>
> 4\. Include results of all diagnostic and clinical tests conducted in
> the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - PULMONARY TUBERCULOSIS AND MYCOBACTERIAL DISEASES

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Activity of pulmonary tuberculosis or other mycobacterial disease.

2\. Date of inactivity if it is not active.

3\. Identity of organism (if possible).

C. **Physical examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Extent of structural damage to lungs.

2\. If patient was hospitalized for 6 months or more, what is the
condition at the end of

hospitalization?

3\. If patient was hospitalized for 12 months or more, what is the
condition at the end of

hospitalization?

D. **Diagnostic and Clinical Tests:**

> Provide:
>
> 1\. Pulmonary Function Tests, if indicated. If performed, include the
> results in the examination report. The FEV-1, FVC, and FEV-1/FVC
> should be included. Both pre- and post-bronchodilatation pulmonary
> function test results should be reported. If post-bronchodilatation
> testing is not conducted in a particular case, please provide an
> explanation of why not. A DLCO may or may not be done routinely as
> part of pulmonary function testing at a particular facility. If there
> is a disparity between the results of different tests, please indicate
> which tests are more likely to accurately reflect the severity of the
> condition.
>
> **DLCO note**: If the DLCO was not done as a routine part of pulmonary
> function testing, the examiner should use his or her judgment, based
> on the specific condition (e.g., whether it is obstructive,
> interstitial, etc.) and other available information about the
> condition, as to whether a DLCO test is needed, since it is not useful
> in all situations. If it may provide useful information about the
> severity of the condition, it should be requested and reviewed before
> the examination report is submitted. If the examiner determines that
> the DLCO test is not needed, a statement as to why not (e.g., there
> are decreased lung volumes that would not yield valid test results)
> should be included in the report. Such a statement could avoid a
> remand from BVA when the test is not done. However, in the case of a
> BVA remand in which the DLCO is requested, the DLCO MUST be done
> unless there is a medical contraindication.

E. **Diagnosis:**

> 1\. In reactivated cases, is this reactivation of the old disease or a
> separate and distinct new infection?
>
> [Additional note to the examiner:]{.underline}
>
> In all claims, if the disease is inactive and if the inactivity was
> confirmed at a non-VA facility, obtain the name and mailing address of
> the facility from the veteran so that the Regional Office may request
> the report.

Signature: Date:

# Chapter 7 - CARDIOVASCULAR SYSTEM

## 7.1 What are the important elements of a cardiovascular examination?

This chapter supplements the 5 examination worksheets titled: [HEART;
ARRHYTHMIAS; ARTERIES, VEINS, AND MISCELLANEOUS;
HYPERTENSION;]{.smallcaps} COLD INJURY PROTOCOL
EXAMINATION[.]{.smallcaps}

a\. What is needed in the history for an initial examination?

> 1\) History of present illness - onset, frequency, and severity of
> symptoms; past and current treatment; whether symptoms are controlled
> by treatment; effects of condition on daily activities.
>
> 2\) General health information - including previous surgery and
> illnesses; family history; military history.

b\. What is needed in the history for a review examination?

For a review examination, only an interval history covering the period
since the last examination is needed.

c\. What is needed for the physical examination?

Follow the appropriate cardiovascular examination worksheet.
Supplementary information is provided below.

d\. What laboratory studies may be needed?

> 1\) SMA-12, chest x-ray and ECG are routine; other tests such as
> cardiac enzymes, lipid profile, echocardiography, Doppler studies,
> cardiac stress tests, Holter monitor, electrophysiologic testing,
> computed tomography, magnetic resonance imaging, radionuclide imaging
> (or myocardial perfusion scan), cardiac catheterization, pulmonary
> artery catheterization, coronary angiography, or thallium stress test
> may be required.
>
> 2\) Most of the disability evaluations of cardiovascular disease are
> based on objective tests. Therefore, exercise stress testing, for
> example, is commonly needed (unless one done within the past year is
> of record) since it is a primary basis of evaluation for many types of
> heart disease.
>
> 3\) Stress testing and METS
>
> Meaning of METS: One MET is the energy cost of standing quietly at
> rest and represents an oxygen uptake of 3.5 milliliters per kilogram
> of body weight per minute. This is the resting energy requirement.
> With progressive activity, the number of METs required progressively
> increases. For example, a workload of three METs represents such
> activities as level walking, driving, and very light calisthenics, and
> a workload of between three and five METs represents such activities
> as walking two and a half miles per hour, social dancing, light
> carpentry, etc.
>
> Requirements for stress testing: Types of heart disease which require
> stress testing, and the exceptions for requirements, are listed on the
> examination worksheets (See B4 on HEART worksheet). Note that if left
> ventricular dysfunction is present and the ejection fraction is 50
> percent or less, or if there is chronic congestive heart failure or
> there has been more than one episode of acute congestive heart failure
> in the past year, stress testing is not needed. Many other conditions,
> especially during active infection or acute stages, such as valvular
> heart disease during active infection also do not require stress
> testing.
>
> If stress testing not done: However, when stress testing is needed, an
> examination will be returned for completion unless there is [a
> medical]{.underline} [reason]{.underline} why the stress testing
> cannot be done.
>
> Estimation of METS: When stress testing is medically contraindicated,
> the examiner must then provide an estimate of the level of activity
> expressed in METs that results in cardiac symptoms. Charts that
> associate METs levels with various activities and that may be used for
> estimates are available in standard medical and heart textbooks.

## 7.2 What is a standard way of reporting a diagnosis by NYHA criteria?

Nomenclature and Criteria established by the New York Heart Association
are commonly used to report a diagnosis and status of heart disease.
These include the etiological, anatomical, physiological and functional
capacity.

Example:

> I. Diagnosis: Arteriosclerotic heart disease.
>
> II\. Anatomy: 90% left circumflex coronary artery occlusion, EF = 60%.
>
> III\. Physiology: Atrial fibrillation, congestive heart failure.
>
> IV\. Functional Capacity: METS = 6.
>
> V. Prognosis: Good with therapy. (Use gradations such as excellent,
> good with therapy, fair with therapy or poor despite therapy.)

## 7.3 What information would be useful for valvular heart disease (including rheumatic heart disease), endocarditis, heart valve replacement, pericarditis, or pericardial adhesions?

a\. For all:

Report results of exercise testing in METs unless medically
contraindicated or otherwise not needed. (See B4 on HEART worksheet for
list of conditions/situations where exercise testing is not needed.)

Describe any episodes of congestive heart failure and whether the heart
failure has resolved.

Report current treatment

b\. Valvular heart disease or endocarditis

Diagnosis of either should be established (unless already of record) by
findings on physical examination and either echocardiogram, Doppler
echocardiogram, or cardiac catheterization.

For endocarditis: Bacterial, fungal, or nonbacterial vegetations may
form on the cardiac valves or endocardial surface of patients with
rheumatic fever, artificial heart valve, congenital heart disease,
heroin addiction involving intravenous self-medication, or dental
procedures. Emboli to the coronary, renal, cerebral, or peripheral
arteries may occur when vegetations break loose from the valves. Note
any petechiae, finger or toenail hemorrhages, Osler\'s nodes, or Roth
spots in the retina. Report residual effects of any emboli, using
appropriate worksheet.

c\. Rheumatic heart disease:

History: Record attacks prior to service, during service, and after
leaving the service, including results of throat cultures,
antistreptolysin titers, electrocardiographic findings, skin rashes,
migratory swollen joints, chorea, prolonged weakness, and fever.

Physical examination: Report mitral or aortic murmurs, accentuation of
the mitral component of the first heart sound, decreased intensity of
second aortic sound, prolongation of the P-R interval.

d\. Some causes of pericarditis:

infection, such as AIDS or other virus

cancer from an adjacent area

myocardial infarction

trauma

rheumatoid arthritis

lupus erythematosus

renal failure.

## 7.4 What information would be useful for arteriosclerotic heart disease, myocardial infarction, hypertensive heart disease, coronary bypass surgery, cardiomyopathy, or syphilitic heart disease?

a\. The diagnosis: requires documentation. For example, the diagnosis of
coronary artery disease may be established by ECG, treadmill exercise
testing (with or without a thallium scan), or cardiac catheterization
and angiography - the "gold standard".

b\. If the diagnosis has already been established:

Report results of exercise testing in METs unless medically
contraindicated or otherwise not needed. (See B4 on HEART worksheet for
list of conditions/situations where exercise testing is not needed.)

Describe any episodes of congestive heart failure and whether the heart
failure has resolved.

Report current treatment.

c\. If arteriosclerotic heart disease has been superimposed upon another
type of heart disease that is related to service, explain which current
signs and symptoms are attributable to each type of heart disease. If it
is impossible to separate the findings due to each condition, explain
why.

d\. Untreated tertiary syphilis may be associated with aortic
insufficiency, coronary artery ostial occlusion, angina pectoris, or
aortic aneurysm. Any aortic regurgitation, capillary pulsation, or
Duroziez\'s sign should be recorded. Valvular malfunction should be
documented by echocardiography or cardiac catheterization.

e\. If asked to give an opinion about the etiology of coronary artery
disease in a particular veteran, be sure you take into consideration all
risk factors for CAD that are present and explain the rationale for your
opinion.

## 7.5 What is important about a diagnosis of ischemic heart disease in former prisoners of war?

Beriberi heart disease is a condition that is presumptively service
connected for former prisoners of war. A regulation has established that
beriberi heart disease includes ischemic heart disease if the former
prisoner experienced edema of the feet or legs during captivity. There
is no requirement that there was ever an actual diagnosis of beriberi.

Therefore you may be asked to determine whether ischemic heart disease
is present in a former prisoner of war. You need not determine the
etiology in these cases, only whether ischemic heart disease is present,
and the current findings. The ischemic heart disease may be either
absolute (e.g., coronary artery disease) or relative (e.g.,
cardiomyopathy with a greatly enlarged heart).

An exam for ischemic heart disease should use the HEART worksheet and
the inform in section 7.4.

## 7.6 What additional information would be useful in a disability examination for arrhythmias?

Arrhythmias may occur as part of a primary heart disease or secondary to
pulmonary or metabolic disease. Record the time of onset of the
arrhythmia, precipitating conditions, and responses to past and present
therapy. Although an ECG is essential, it may often be necessary to
record long rhythm strips or Holter monitors to document intermittent
abnormalities. The diagnosis of conduction block is usually established
by ECG, but it may require special conduction studies such as HIS bundle
tests.

Supraventricular arrhythmias: Report number of documented (by ECG or
Holter monitor) episodes per year. State whether paroxysmal or
permanent. Report treatment, including pacemaker

Sustained ventricular arrhythmias: Report results of exercise testing in
METs unless medically contraindicated or otherwise not needed (See B4 on
HEART worksheet for list of conditions/situations where exercise testing
is not needed). Report any periods of hospitalization for diagnosis or
treatment. State whether there is an AICD in place. Report current
treatment and results, including pacemaker. Describe any episodes of
congestive heart failure and whether the heart failure has resolved.

Atrioventricular block: Report results of exercise testing in METs
unless medically contraindicated or otherwise not needed. (See B4 on
HEART worksheet for list of conditions/situations where exercise testing
is not needed.) Describe any episodes of congestive heart failure and
whether the heart failure has resolved. Report current treatment,
including pacemaker.

## 7.7 What additional information would be useful in a disability examination for cardiac transplantation?

Report results of exercise testing in METs unless medically
contraindicated or otherwise not needed. (See B4 on HEART worksheet for
list of conditions/situations where exercise testing is not needed.)

Describe any episodes of congestive heart failure and whether the heart
failure has resolved.

## 7.8 What additional information would be useful in a disability examination for cor pulmonale?

a\. Diagnosis of cor pulmonale:

clinical examination

ECG

echocardiography showing increased right ventricular size and wall
thickness

right heart catheterization showing elevated right atrial, ventricular,
and pulmonary artery pressures

b\. Exam

Record any underlying chronic lung disease as well as the cardiac
symptoms and signs. Include any hypertrophy of the right ventricle,
dilation of the right atrium or ventricle, and venous or hepatic
congestion. Evaluation is based on the underlying pulmonary disease.

## 7.9 What additional information would be useful in a disability examination for endocrinopathic heart disease?

Record both endocrine and cardiac functions and past and present
response to therapy. Any signs of congestive heart failure, emaciation,
obesity, myxedema, circulatory insufficiency, paroxysmal atrial
fibrillation, flutter, tachycardia, or mediastinal obstruction should be
noted. Report heart disease findings as stated on HEART worksheet.

## 7.10 What additional information would be useful in a disability examination for traumatic heart disease?

Blunt trauma to the chest such as a motor vehicle accident, crush, blow
or fall injury, a high velocity missile, or a stab wound may injure the
heart. Record any aortic regurgitation, pericardial tamponade,
pericardial fibrosis, or calcification. Chest x-ray, ECG, or serum
enzymes may be useful. Follow guidelines on HEART worksheet.

## 7.11 What additional information would be useful in a disability examination for other heart disease?

Amyloid disease, sarcoidosis, metastatic neoplasm, infections such as
diphtheria, typhoid fever, malaria, meningitis, melioidosis,
arteriovenous fistula, renal disease, and cardiac poisons, such as
herbicides, insecticides, and solvents may cause heart disease. Follow
guidelines on HEART worksheet.

## 7.12 What additional information would be useful in a disability examination for hypertension and isolated systolic hypertension?

a\. Diagnosis

Multiple BP readings are required to establish the diagnosis of
hypertension. There must be 2 or more readings on at least 3 different
days.

However, once hypertension has been [properly]{.underline} diagnosed,
readings on multiple days are not required for follow-up examinations.

If the veteran is on treatment for hypertension at the initial exam,
multiple readings on different days are not necessary because they would
not be useful.

b\. Classification

Current classification of hypertension (Sixth Report of the Joint
National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure - 1997)

Stage 1 - 140 mm Hg to 159 mm Hg systolic or 90 mm Hg to 99 mm Hg
diastolic

Stage 2 - 160-179 systolic or 100-109 diastolic

Stage 3 - \>180 systolic or \>110 diastolic

The Committee considers a systolic pressure of \<120 and diastolic
pressure of \<80 to be optimal, systolic pressure of \<130 and diastolic
of \<85 to be normal, and systolic pressure of 130-139 and diastolic of
85 to 89 to be high normal.

c\. Examination needs once diagnosis has been established:

Carefully record the blood pressure, preferably at least three times,
spread throughout the examination, because the blood pressure reading is
the primary basis of evaluation.

Describe in detail any complications that are present - eye, renal,
cerebral, cardiac, etc - following the appropriate worksheets.

If isolated systolic hypertension is present, indicate underlying
condition, if any.

Report treatment and side effects.

## 7.13 What additional information would be useful in a disability examination for aneurysms?

a\. For aortic aneurysms:

Diagnosis may be made on the signs and symptoms on a routine
examination, but may require abdominal x-ray, ultrasound scan, computed
tomography (CT) scan, MRI scan, or aortography.

Record size, location, related symptoms, etiology (arteriosclerosis,
syphilis, hypertension, trauma, etc.). Give history of any grafting or
other surgery and residuals. State any restrictions on activity.
Describe any other organs affected.

b\. Aneurysms of other large arteries:

Report location, symptoms (including claudication), history of surgical
correction and residuals, ankle/brachial index (See 7.15b).

c\. Aneurysms of small arteries:

Berry aneurysm - small (\<1.5 cm diameter), congenital aneurysm of
brain. Rupture leads to subarachnoid hemorrhage. Can be cured by being
clipped.

Mycotic aneurysm - from infection. A typical complication of bacterial
endocarditis. Involves any artery, especially the cerebral, mesenteric,
renal, or splenic arteries. Tend to rupture when small (\< 1 cm
diameter).

For any small aneurysm, report any symptoms in body part affected. If
surgically corrected, report residuals.

## 7.14 What additional information would be useful in a disability examination for arterial embolism?

Report residual effects of embolus or emboli on particular area of body
affected.

Emboli arising from the cardiac atria, ventricles, valves, or the aorta
can produce anoxia, devascularization, paresthesia, anesthesia,
hyperesthesia, loss of motor function, gangrene, or even
auto-amputation.

Arterial pulmonary embolism (paradoxical embolus) may arise from the
peripheral veins if congenital heart disease, trauma, infarction, or
endocarditis has caused an abnormal communication between the right and
left sides of the heart.

## 7.15 What additional information would be useful in a disability examination for arteriosclerosis obliterans and thromboangiitis obliterans?

a\. Diagnosis: Angiography is required for precise localization of the
obstructed vascular segments. During claudication attacks there may be
coldness and pallor of the foot (particularly just following exercise),
cyanosis on dependency, and altered or diminished sensation. Rest pain
of the most distal parts of the involved extremity is a sign indicative
of poor prognosis. In advanced cases muscle atrophy, osteoporosis,
terminal ulceration, and gangrene may follow.

b\. Examination:

> 1\) Record the ankle/brachial index (using Doppler) for each affected
> lower extremity. Divide the ankle systolic blood pressure by the
> brachial systolic pressure to determine the ankle/brachial index. The
> ankle pressure is normally 90% of the arm pressure, or 0.9 or greater.
>
> 0.7 to 0.9 = mild arterial insufficiency or obstruction.
>
> 0.5 to 0.7 = moderate disease.
>
> less than 0.5 = severe arterial occlusive disease.
>
> 2\) Report how many yards of walking on level ground at 2 miles per
> hour a person is able to cover before claudication develops.
>
> 3\) Report color, temperature (if cool or cold, whether this is
> persistent), trophic changes (skin thinning, hair loss, dystrophic
> nails), ulceration, whether there is pain at rest.

c\. Additional information about thromboangiitis obliterans (Buerger\'s
disease)

Obstruction of small and medium-sized arteries and veins by
inflammation. Mostly (95%) in men who smoke cigarettes. Not a type of
arteriosclerosis, but an inflammatory response in the arteries, veins,
and nerves, which leads to a thickening of the blood vessel walls.
Symptoms begin at fingertips or toes and progress up the arms or legs.
About 40% also have episodes of phlebitis. Some have Raynaud\'s
phenomenon. Additional residuals may include muscle atrophy in affected
areas, osteoporosis of the bones of the leg and foot, regional
hyperkeratosis, callus formation.

## 7.16 What additional information would be useful in a disability examination for arteriovenous fistulae?

a\. Background and diagnosis:

Arteriovenous fistulae are connections between an artery and vein, often
due to trauma such as a gunshot or stab wound.

The missile need not penetrate the vessel wall, and blunt trauma can
sufficiently weaken the wall so that arterial pulsation will create a
fistula through the damaged elastic and muscle layers.

Fistulae may cause delayed manifestations such as hypervolemic
hypertensive heart failure with dilation of the chambers, edema,
ischemia, ulcers, and even gangrene of the affected extremities.

Record any palpable thrill or bruit with pronounced accentuation in
systole. When the fistula is closed by pressure, the fast heart rate and
the systolic blood pressure elevation fall. Arteriography and Doppler
sonography provide a precise diagnosis.

b\. Examination

Record blood pressure, pulse, heart size, and whether there is heart
failure.

Record edema, stasis dermatitis, ulceration, or cellulitis of affected
extremity.

## 7.17 What additional information would be useful in a disability examination for Raynaud\'s phenomenon and Raynaud\'s disease? 

a\. Characteristics of Raynaud\'s:

Raynaud\'s disease and Raynaud\'s phenomenon or syndrome are conditions
in which arterioles, usually in the fingers and toes, go into spasm,
causing a characteristic attack lasting minutes to hours.

It may also affect the nose, earlobes, or lips.

Color changes in the digits of white, red, and blue occur, not
necessarily in a particular order.

There is no underlying cause for Raynaud\'s disease. Raynaud\'s
phenomenon or syndrome may be associated with scleroderma, rheumatoid
arthritis, lupus erythematosus, atherosclerosis, nerve disorders, or
reactions to certain drugs.

b\. Exam:

Describe a characteristic attack and report frequency and duration of
characteristic attacks. Report ulcers or autoamputation of fingers.

## 7.18 What additional information would be useful in a disability examination for erythromelalgia?

a\. Diagnosis: Erythromelalgia is a pain syndrome of the skin with 5
main signs:

> 1\) intense burning and tingling pain of the hands and feet
>
> 2\) erythema
>
> 3\) increased skin temperature at affected sites
>
> 4\) aggravation of symptoms by warmth
>
> 5\) there is symptomatic relief by cooling or aspirin.
>
> It may be idiopathic, congenital, or due to myeloproliferative
> disorder, rheumatoid arthritis or other collagen vascular disorder,
> diabetes mellitus, cancer, or pernicious anemia.

b\. Exam: Report frequency and duration of attacks and their responses
to treatment, plus any effects on daily activities.

## 7.19 What additional information would be useful in a disability examination for varicose veins or post-phlebitic syndrome?

a\. Background:

Varicosities are dilated segments of veins with thin walls, and
inflammation, thrombosis, and infection may occur. The cause of varices
is not known, but is probably a hereditary weakness in the walls of the
superficial veins. Some are due to phlebitis. Varices are often more
cosmetically disturbing than disabling; however, there may be severe and
even fatal complications at times. Some experience symptoms of tired,
heavy, or aching legs, and a few develop dermatitis, phlebitis,
bleeding, induration, ulceration, edema (post-phlebitic syndrome.

The causes of thrombophlebitis include injury to the lining of the vein;
an increased tendency for blood to clot, as can happen with some cancers
and rarely with oral contraceptive use; slowing of the blood flow in the
veins, as happens during prolonged bed rest, long flights or drives,
etc. Acute thrombophlebitis will not normally present for disability
examination. It is the chronic residuals, such as post-phlebitic
syndrome, that will be seen.

The post-phlebitic syndrome may itself lead to the development of
varicosities because of chronic venous insufficiency, and varicosities
can lead to post-phlebitic syndrome, a chronic form of venous
insufficiency due either to varicose veins or thrombophlebitis.

b\. Exam for either varices or post-phlebitic syndrome:

> Report any visible or palpable varicose veins, level of activity that
> leads to symptoms, level of activity that leads to it, and whether it
> is relieved by elevation or compression hosiery. Report other skin
> changes - pigmentation, eczema, ulceration and whether there is
> subcutaneous induration or board-like edema.

## 7.20 What additional information would be useful in a disability examination for residuals of cold injury?

Follow the COLD INJURY PROTOCOL worksheets. They offer a detailed
examination protocol. See VHA IL 10-96-030 and 10-98-008 for further
information for examiners of cold injury residuals. Additional detailed
clinical information about the late effects of cold injury is available
on the VA cold injury website at http://www.va.gov/oph/cold.

## Worksheet - ARRHYTHMIAS

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

> 1\. Type of arrhythmia, onset of disorder, frequency and duration of
> attacks. Attacks confirmed by EKG or Holter monitor.
>
> 2\. Pacemaker present? If so, when was it inserted, effectiveness,
> side effects?
>
> 3\. Other treatment? If so, type, effectiveness, side effects?
>
> 4\. For sustained ventricular arrhythmias, atrioventricular block, and
> implantable cardiac pacemakers (if ventricular arrhythmia or
> atrioventricular block was the reason for the pacemaker), the examiner
> must [provide the METs level, determined by exercise
> testing]{.underline}, at which symptoms of dyspnea, fatigue, angina,
> dizziness, or syncope result.
>
> 5\. Exercise testing is [not]{.underline} required for the above
> listed conditions in the following circumstances:
>
> a\. If exercise testing is medically contraindicated:
>
> 1\. In that case, provide the medical reason exercise testing cannot
> be conducted, and
>
> [2. Provide an estimate of the level of activity (expressed in METs
> and supported by specific examples]{.underline}, such as slow stair
> climbing, or shoveling snow) that results in dyspnea, fatigue, angina,
> dizziness, or syncope.
>
> b\. For sustained ventricular arrhythmia---from date of hospital
> admission for initial evaluation and medical therapy for a sustained
> ventricular arrhythmia or for ventricular aneurysmectomy, and for six
> months following discharge.
>
> c\. With an automatic implantable Cardioverter-Defibrillator (AICD) in
> place.
>
> d\. For two months following hospital admission for implantation or
> reimplantation of an implantable cardiac pacemaker.
>
> e\. If an exercise test has been done within the past year, the
> results are of record, and there is no indication that there has been
> a change in the cardiac status of the veteran since.
>
> 6\. For implantable cardiac pacemakers---if [supraventricular
> arrhythmia]{.underline} was the reason
>
> for the pacemaker---describe any attacks of atrial fibrillation or
> other symptoms.
>
> 7\. Describe the effects of the condition on the veteran\'s usual
> occupation and daily
>
> activities.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

> 1\. Heart size and method of determination, heart rate and rhythm,
> blood pressure.
>
> 2\. Status of cardiac function - evidence of congestive heart failure.
>
> 3\. Cardiac arrhythmia - type. Confirmed by EKG or Holter monitor?

D **Diagnostic and Clinical Tests:**

1\. EKG.

2\. Holter monitor, other tests as indicated.

> 3\. Chest X-ray, exercise stress test, echocardiogram, Holter monitor,
> thallium study, angiography, etc., as appropriate, and as required or
> indicated.
>
> 4\. Include results of all diagnostic and clinical tests conducted in
> the examination report, including status of left ventricular function,
> if measured.

E. **Diagnosis:**

Signature: Date:

## Worksheet - ARTERIES, VEINS, and Miscellaneous

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

For all conditions, comment on:

> 1\. Course, including onset of disorder, and any treatment, including
> surgery (type and when carried out).
>
> 2\. SDymptoms.
>
> 3\. Is exercise and exertion precluded by the condition?
>
> 4\. Current treatment - type, effectiveness, side effects.
>
> 5\. If surgery has been done, report effectiveness and any residual or
> recurrent symptoms.
>
> 6\. Describe the effects of the condition on the veteran\'s usual
> occupation and daily activities.

For aortic aneurysm, aneurysm of any large artery, aneurysm of any small
artery, arteriovenous fistula, arteriosclerosis obliterans and
thromboangiitis obliterans, additionally comment on:

> 1\. If lower extremities are affected, is there claudication, and, if
> so, after how many yards of walking on level ground at 2 miles per
> hour does it develop?
>
> 2\. Is there pain at rest?

For Raynaud's phenomenon, angioneurotic edema, and erythromelalgia,
additionally comment on:

> 1\. Describe a characteristic attack.
>
> 2\. Record the frequency, duration, and severity of characteristic
> attacks.
>
> 3\. Describe which parts of the body are affected. For angioneurotic
> edema,
>
> state whether laryngeal edema occurs and how frequently.
>
> 4\. What is the current treatment - type, dose, effectiveness, side
> effects?
>
> 5\. Describe the effects of the condition on the veteran\'s usual
> occupation and
>
> daily activities.

For Varicose veins and Post-phlebitic syndrome of any etiology,
additionally comment on:

> 1\. Describe symptoms, noting particularly whether aching, fatigue, or
>
> abnormal sensations are present in the leg at rest or after prolonged
>
> standing or walking.
>
> 2\. Are symptoms or edema relieved by elevation of the extremity,
>
> compression hosiery, or other measures?
>
> 3\. What is the current treatment - type, dose, effectiveness, side
> effects.
>
> 4\. What are the effects of the condition on the veteran's usual
> occupation
>
> and daily activities?

For soft tissue sarcoma or other malignant neoplasms of vascular origin:

> 1\. Record date of diagnosis and pathologic diagnosis.
>
> 2\. Record type and dates of treatment. If treatment has been
> completed, state date of last treatment.
>
> 3\. Describe current symptoms. If treatment has been completed,
> describe residual or recurrent symptoms.
>
> 4\. What are the effects of the condition on the veteran's usual
> occupation and daily activities?

C. **Physical Examination (Objective Findings):**

For aortic aneurysm, aneurysm of any large artery, aneurysm of any small
artery, or arteriovenous fistula:

> 1\. State size of aneurysm, cardiac status, including heart size and
> rate, pulse pressure, and whether there is evidence of high output
> failure.
>
> 2\. If extremities are affected, describe temperature and color,
> pulses, trophic changes, ulcers (deep or superficial?), edema,
> dermatitis, cellulitis.
>
> 3\. If lower extremities are affected, record ankle/brachial index
> (using Doppler).
>
> 4\. If surgery has been carried out, describe residual findings, using
> appropriate worksheet for the affected body system or organ.

For arteriosclerosis obliterans and thromboangiitis obliterans:

> 1\. Describe each affected extremity separately.
>
> 2\. record ankle/brachial index (using Doppler).
>
> 3\. Describe temperature and color of extremities, pulses, trophic
> changes, ulcers (deep or superficial?).
>
> 4\. If surgery has been carried out, describe any residuals or side
> effects of surgery.

For Raynaud's phenomenon, angioneurotic edema, and erythromelalgia:

> 1\. Describe ulcers, autoamputations, and any other current findings.

For Varicose veins and Post-phlebitic syndrome of any etiology:

> 1\. Describe any visible or palpable varicose veins.
>
> 2\. Describe extent of any ulcers, edema, stasis pigmentation, and
> eczema. If edema is present, is it boardlike? Is it persistent?
>
> 3\. Describe each affected extremity separately.

For soft tissue sarcoma or other malignant neoplasms of vascular origin:

I.  Describe all current findings, whether pre- or post-treatment,
    including any residuals of treatment.

Use other worksheets, if necessary, specific to the affected body system
or organs.

D. **Diagnostic and Clinical Tests:**

1\. X-rays, Doppler vascular studies, angiogram, etc., as appropriate,
and if indicated.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - HEART 

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

1\. Past history - describe onset of disorder and frequency of cardiac
symptoms, including angina, dyspnea, fatigue, dizziness, and syncope.
Record dates and severity of episodes of acute cardiac illness,
including myocardial infarction, congestive heart failure, and acute
rheumatic heart disease. Describe all cardiac surgery, including
coronary artery bypass, valvular surgery, cardiac transplant, and
angioplasty.

2\. Current treatment - type, dosage, response, and side effects.

3\. With the exceptions given below, examinations for valvular heart
disease, endocarditis, pericarditis, pericardial adhesions, syphilitic
heart disease,, arteriosclerotic heart disease, myocardial infarction,
hypertensive heart disease, heart valve replacement, coronary bypass
surgery, cardiac transplantation, and cardiomyopathy, require the
examiner [to provide the METs level, determined by exercise
testing]{.underline}, at which symptoms of dyspnea, fatigue, angina,
dizziness, or syncope result.

4\. Exercise testing is [not]{.underline} required for the above listed
conditions in the following circumstances:

> a\. If exercise testing is medically contraindicated:
>
> 1\) In that case, provide the medical reason exercise testing cannot
> be conducted, and
>
> [2) Provide an estimate of the level of activity (expressed in METs
> and supported by specific examples]{.underline}, such as slow stair
> climbing, or shoveling snow) that results in dyspnea, fatigue, angina,
> dizziness, or syncope.
>
> b\. If left ventricular dysfunction is present, and the ejection
> fraction is 50 percent or less.
>
> c\. If there is chronic congestive heart failure or there has been
> more than one episode of acute congestive heart failure in the past
> year.
>
> d\. With valvular heart disease---during active infection with
> valvular heart damage and for three months following cessation of
> therapy for the active infection.
>
> e\. With endocarditis---for three months following cessation of
> therapy for active infection with cardiac involvement.
>
> f\. With pericarditis---for three months following cessation of
> therapy for active infection with cardiac involvement.
>
> g\. With myocardial infarction---for three months following myocardial
> infarction.
>
> h\. With valve replacement---for six months following date of hospital
> admission for valve replacement.
>
> i\. With coronary bypass surgery---for three months following hospital
> admission for surgery.
>
> j\. For cardiac transplantation---for indefinite period from date of
> hospital admission for cardiac transplantation.
>
> k\. If an exercise test has been done within the past year, the
> results are of record, and there is no indication that there has been
> a change in the cardiac status of the veteran since.

5\. For hyperthyroid heart disease, if atrial fibrillation is present,
use arrhythmia worksheet. Also use endocrine worksheet if examining for
hyperthyroidism.

6\. Describe the effects of the condition on the veteran\'s usual
occupation and daily activities.

7\. Even when special examinations and tests (e.g., exercise testing)
are not [required]{.underline}

under the worksheet guidelines, they may be requested or conducted at
the discretion

of the examiner, when the examiner believes that the available
information does not

fully reflect the severity of the veteran's cardiovascular disability.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

> 1\. Heart size and method of determination, heart rhythm and rate,
> heart sounds, blood pressure.
>
> 2\. Evidence of congestive heart failure - rales, edema, liver
> enlargement, etc.

D. **Diagnostic and Clinical Tests:**

> 1\. Chest X-ray, EKG, exercise stress test, echocardiogram, Holter
> monitor, thallium study, angiography, etc., as appropriate, and as
> required or indicated.
>
> 2\. Include results of all diagnostic and clinical tests conducted in
> the examination
>
> report, including status of left ventricular function, if measured.
>
> 3\. Valvular heart disease and endocarditis require documentation of
> diagnosis by
>
> physical findings and either echocardiogram, Doppler echocardiogram,
> or cardiac
>
> catheterization, if not already of record.
>
> 4\. Other types of heart disease must be documented by appropriate
> objective diagnostic
>
> tests.

E. **Diagnosis and Opinion:**

> 1\. Type of heart disease and etiology, if known.
>
> 2\. Type of surgery, if any, and results.
>
> 3\. If the veteran is service-connected for rheumatic heart disease
> and later develops non-service-connected arteriosclerotic heart
> disease, state, if possible, which cardiac findings can be attributed
> to each condition. If it is not possible to separate the signs and
> symptoms of one from the other, so state, and explain.

Signature: Date:

## Worksheet - HYPERTENSION

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

> 1\. Date of diagnosis.
>
> 2\. Symptoms, if any.

3\. Treatment - type, dosage, side effects.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

> 1\. Blood pressure - If the diagnosis of hypertension has not been
> previously established, readings must be taken two or more times on at
> least three different days. If hypertension has been previously
> diagnosed, take three blood pressure readings on the day of
> examination.
>
> 2\. Cardiac status - size, function. If there is evidence of
> hypertensive heart disease, use Heart Worksheet.
>
> 3\. If arteriosclerotic complications of hypertension are present, use
> worksheet for the specific condition(s) found.

D. **Diagnostic and Clinical Tests:**

> 1\. X-rays or other tests, as indicated.
>
> 2\. Include results of all diagnostic and clinical tests conducted in
> the examination report.

E. **Diagnosis:**

Signature: Date:

# Chapter 8 - DISEASES OF THE DIGESTIVE SYSTEM

## SECTION I. ESOPHAGUS

## 8.1 General

Among the diagnostic procedures that may be useful are: cineradiographic
studies of the esophagus for motor disorders or to demonstrate
gastroesophageal reflux; the use of constantly perfused, open-tipped
catheters to study disorders of esophageal motility in diffuse
esophageal spasm, gastroesophageal sphincter incompetence, and achalasia
(cardiospasm); esophagoscopy with flexible fiberoptic instruments for
direct visualization with biopsy and cytology; the acid barium swallow
to study the activity of the esophagus in response to the direct
presence of acid; and manometry of the esophagus to distinguish among
diffuse esophageal spasm, achalasia, and malignant disease.

**Primary symptoms of esophageal disease**:

*Dysphagia* (difficulty in swallowing) with accompanying pain or
discomfort usually located at the lower end of the sternum

*"Heartburn"* (usually a consequence of acid gastroesophageal reflux
into the esophagus) which is generally an unmistakably distinct burning
sensation most likely to occur 10-20 minutes to an hour after eating.
Describe the specificity and frequency of heartburn**,** whether it
occurs while eating or afterwards, and, if afterwards, how long
afterwards.

*Regurgitation* may be a prominent symptom of achalasia and consists of
the appearance of esophageal or gastric contents in the mouth from below
without the effort of vomiting. Report whether regurgitation is lessened
in the upright position.

*Weight loss* and *cough* are other possible symptoms.

## 8.2 What are the usual findings in stricture of the esophagus?

There may be a history of previously swallowing a caustic substance
resulting in scarring and contraction of the esophagus. Stricture may
also result from severe reflux esophagitis.

Exam: Describe the cause of the stricture and the forms of therapy used,
including frequency of dilation. Report any difficulty of liquid or food
passage through the esophagus and the weight curve.

## 8.3 What are the main features of carcinoma of the esophagus?

Dysphagia is the most important symptom of carcinoma of the esophagus.
At first, there is progressive difficulty swallowing solid foods. As the
lumen is progressively encroached upon, (usually over no more than a
6-month period) food must be increasingly soft to be swallowed. Finally
only liquids can be taken. Raising of blood or mucus may occur. Weight
loss is progressive as food intake lessens. The X-ray is often
diagnostic, but biopsies are indicated to make the diagnosis of
esophageal malignancy conclusive.

Exam: Report type of treatment, residuals or side effects of treatment,
and current signs and symptoms due to residual or recurrent tumor.
Report date of last treatment, if completed.

## 8.4 What are the notable findings about achalasia?

**a. Symptoms.** The primary symptom is chronic dysphagia gradually
progressive over months to years. Achalasia is characterized by massive
dilatation in the lower two-thirds of the esophagus and consequent
collection of swallowed liquids and food in the dilated portion. There
is also an accompanying spastic esophagogastric sphincter. If the
patient lies down before emptying of the esophagus, regurgitation of
esophageal contents occurs, with the swallowed material moving
effortlessly back into the pharynx and mouth. Weight loss may be
progressive over the years.

**b. Cause.** The condition is caused by absence of peristaltic waves in
the lower two-thirds of the esophagus. Accompanying this is greatly
increased gastrin induced tone of the esophagogastric sphincter with its
consequent inability to relax after swallowing.

**c. Diagnosis.** X-ray study with barium is characteristic, showing a
smooth marked dilatation of the esophageal wall with a conically shaped
or beak-like narrowing of the distal portion of the esophagus. Endoscopy
confirms the esophageal dilatation, but the diagnosis usually requires
confirmation by esophageal manometry to show absence of peristalsis and
other findings.

**d. Complications**. Achalasia may be complicated by aspiration
pneumonia caused by regurgitation of the food into the trachea and
bronchi.

**e. Treatment.** Current major treatments are pneumatic dilatation (via
endoscopy), injection of botulinum toxin (also by endoscopy), and
surgery (mainly myotomy, sometimes via laparoscopy). Medications such as
nitrates and calcium channel blockers, once commonly used, are now used
mainly if dilatation or injections fail or are not feasible.

**f. Exam:** Report current signs and symptoms, any diet restriction,
and details of current treatment or residuals of past treatment, plus
any complications, such as aspiration.

## 8.5 What are the characteristic findings of GERD (gastroesophageal reflux disease)?

**a. Cause of GERD:**

Gastroesophageal reflux disease results from a greater than normal
degree of reflux of acid contents of the stomach upward through the
esophagogastric sphincter, which can lead to inflammation of the
esophagus (reflux esophagitis).

**b. Symptoms of GERD:**

The symptoms include heartburn, indigestion, chest pain, coughing or
choking while lying down, increased salivation, regurgitation,
difficulty sleeping after eating, and asthma-like symptoms while
sleeping. Less common are noncardiac chest pain, dysphagia (without
evidence of esophageal obstruction), hoarseness, sore throat, frequent
clearing of the throat, and gingivitis.

Smoking, caffeine, and alcohol may exacerbate heartburn.

Long-term complications include bleeding, stricture, and even
malignancy.

**c. Diagnosis of GERD:**

Some patients can be diagnosed on the basis of history and response to
appropriate treatment. Others, especially when there are severe or
longstanding symptoms, may require endoscopic studies. A 24-hour pH
probe study (a small catheter with an acid sensitive probe is placed in
the lower esophagus for 24 hours to measure the acid that is present)
may be useful in some cases to confirm the diagnosis or to correlate
symptoms with episodes of acid reflux.

**d. Treatment of GERD:**

The purpose is to reduce the acidity of the refluxed material. Antacids
help in mild cases. Acid-reducing medications such as histamine H2
receptor antagonists (such as Zantac, Pepcid, Tagamet) are the mainstay
of treatment. Lifestyle modifications, such as weight reduction and
nocturnal postural drainage, facilitated by elevating the head of the
bed on 15 cm blocks, are often helpful. More severe disease may require
proton pump inhibitors (Omeprazole or Lansoprazole) alone or combined
with agents that improve emptying of the esophagus and stomach and
increase the tone of the lower esophageal sphincter.

Surgical treatment consists of various techniques that reinforce the
lower esophageal sphincter and correct anatomical abnormalities (for
example, hiatal hernias) to prevent reflux, such as by creating a
valve-like mechanism by wrapping a gastric pouch around the distal
esophagus. This is sometimes done laparoscopically (laparoscopic Nissen
fundoplication).

**e. How does GERD relate to hiatal hernia?**

Most patients with GERD have a hiatal hernia, but the hernia may not be
the cause of heartburn. The exact role of hiatal hernia in the
pathogenesis of gastroesophageal reflux has not been defined.

**f. Exam:** Report symptoms and describe any complications and their
effects on functioning.

## 8.6 What are the characteristics of hiatal hernia?

**a. Types of hiatal hernia:**

Direct or sliding - herniation of a portion of the stomach into the
thorax through the esophageal hiatus of the diaphragm

Paraesophageal - the hernia occurs adjacent to the hiatus.

**b. Symptoms**:

May be totally asymptomatic or present as a dull substernal or
precordial distress or fullness usually appearing soon after eating and
generally disappearing after a few minutes to an hour or with other
symptoms, as described under 8.5b. Oozing of blood or even acute
bleeding with hematemesis are said to originate as a result of peptic
ulcer of the esophagus with erosion of the mucosa and esophagitis.

**c. Diagnosis:**

The diagnosis is usually made by X-ray. It may also be seen on
endoscopy.

In pure esophageal reflux without hiatal hernia, X-ray studies
demonstrate the reflux in less than 50 percent of the cases.

**d. Significance of hiatal hernia.**

Since 20 to 50 percent of persons over age 50 have a demonstrable hiatus
hernia, the question of origin of symptoms becomes important, i.e.,
whether or not the symptoms are referable to the hernia or to associated
gastroesophageal reflux.

Asymptomatic hiatal hernias do not require treatment. If the hernia
contributes to GERD, the treatment is usually the same as for GERD.

**e. Test for incompetent sphincter with acid reflux:**

To establish whether or not reflux or the presence of the hiatal hernia
alone is producing the pain, it is necessary to show that the pain can
be reproduced and, therefore, that the esophagus is sensitive to the
refluxed material from the stomach. To determine this, a test may be
performed in which HCl is introduced into the stomach. If the
esophagogastric sphincter is functioning properly, the pH in the
esophagus will remain at or above 5 or 6. With an incompetent sphincter
and consequent acid reflux into the lower esophagus, the pH will fall to
1.5 to 2, similar to the pH of the gastric contents.

**f. Exam:** Describe basis of diagnosis, symptoms, any episodes of
bleeding, and effects on functioning.

## 8.7 What are the characteristics of esophageal diverticula?

**a. How they are found**.

Diverticula are occasionally discovered, especially in the aged, during
the course of routine radiographic examinations. Rarely are they the
cause of specific symptoms.

**b. Zenker's diverticulum**

**Located** in the pharyngeal esophagus, can be large, and may be
symptomatic due to regurgitation of material swallowed earlier. It is
always posterior. Diagnosis is made by barium swallow.

**Exam:** Describe the symptoms, treatment, and results.

**c. Traction diverticula**.

**Located** in the lower part of the esophagus, usually due to traction
on its wall by old inflammatory pulmonary or mediastinal lesions, such
as tuberculosis.

**Treatment.** None is needed unless regurgitation results in pulmonary
aspiration. In those cases, surgery may be carried out.

**Exam:** Describe the symptoms, treatment, and results, including any
post-surgical residuals.

## 8.8 What are the characteristics of esophageal and gastric varices?

**a. What are varices and what causes them?**

Varices are submucosal venous collaterals, usually in the esophagus, but
also occurring in the upper stomach, and are due to elevated portal
venous pressure. Usually, but not always, they are caused by cirrhosis
of the liver.

**b. Diagnosis:** Varices may be diagnosed by upper gastrointestinal
X-ray, but should be confirmed by fiberoptic endoscopy**.**

**c. Treatment:** No treatment of varices is necessary unless they
bleed.

**d. Exam:** Report cause, any episodes of bleeding, frequency, and
treatment.

## 8.9 What are the findings in esophageal spastic motility disorders?

**a. Symptoms. C**ontraction abnormalities of the esophagus usually
produce intermittent or slowly progressive dysphagia that rarely causes
weight loss. Sometimes they result in excruciating substernal chest pain
resembling the pain of coronary artery disease, with or without
dysphagia.

**b. Diagnosis.** Esophageal manometry, especially with a provocative
test to elicit chest pain symptoms, is the primary means of diagnosis.
Barium swallow may show diffuse esophageal spasm.

**c. Treatment.** Treatment is symptomatic, plus specific treatment for
any associated gastric reflux.

**d. Exam:** Report how diagnosis was established and current symptoms
and treatment, including any dietary restrictions, weight loss.

## SECTION II. STOMACH

## 8.10 What are the types and characteristics of gastritis?

**a. types**. Gastritis means an inflammation of the lining of the
stomach, but the term "gastritis" is frequently a "catch-all" or "waste
basket" diagnosis for a number of gastric complaints. It can be
classified as acute or chronic, as erosive or nonerosive, and as
atrophic or hypertrophic.

**b. Symptoms.** Symptoms may include epigastric pain, tenderness,
anorexia, nausea, and vomiting, but hemorrhage is of most concern and
may be the only finding in acute gastritis. In some cases, there are no
symptoms at all.

**c. Erosive gastritis.** [Acute]{.underline} erosive gastritis may be
due to acute stress such as severe burns, sepsis, shock, etc.; to
corticosteroids, aspirin, or other anti-inflammatory agents; or to
toxins. Diagnosis is by endoscopy. [Chronic]{.underline} erosive
gastritis may be idiopathic or caused by drugs (especially aspirin and
other NSAIDs). Multiple ulcers are seen on endoscopy. Symptoms, if
any**,** are the same as for acute gastritis. Medical treatment is
similar to that for GERD.

**d. Nonerosive gastritis.** Often due to Helicobacter pylori infection.
May be few or no symptoms. Definitive diagnosis is by endoscopy and
biopsy, but serologic tests for antibodies to H. pylori may also suggest
the diagnosis. Treatment is to eradicate H. pylori infection if present
and otherwise is symptomatic (and similar to GERD treatment).

**e. Chronic atrophic gastritis.** Seen in 80-90% of those with gastric
cancer. All must be investigated for presence of carcinoma. Chronic
atrophic gastritis is found in nearly all cases of pernicious anemia.
The diagnosis should be based on gastroscopic examination and biopsy. Is
also associated with gastric polyps and gastric ulcer. May follow
chronic antral gastritis. May be symptom-free.

**f. Exam:** Report how diagnosis of gastritis was established, any
episodes of bleeding, and current symptoms and treatment.

## 8.11 What is prolapse of the gastric mucosa (antral prolapse)?

Prolapse of loose, redundant gastric mucosal folds through the pylorus
into the duodenal lumen may be found during radiologic observation of a
barium meal. There are no clearly defined symptoms**,** but hemorrhage,
incarceration, and obstruction may occur. Often this condition is
mistaken for duodenal ulcer and gallbladder disease.

## 8.12 What are the notable findings in ulcer disease?

**a. General. "**Peptic" ulcer is a loosely used term, which is not
acceptable as a complete diagnosis. Ulcers may be found in the stomach,
duodenum, lower end of the esophagus, Meckel's diverticulum, and in the
small intestine adjacent to a gastroenterostomy.

**b. Cause.** Alcohol, tobacco, aspirin and other NSAIDS, and
physiologic stresses are predisposing factors, but, excluding those with
Zollinger-Ellison syndrome or NSAID-related ulcer disease, up to 95% of
duodenal ulcers and 80% of gastric ulcers are associated with infection
due to the Helicobacter pylori organism. It is believed the H. pylori
infection makes the mucosa more susceptible to an attack by acid.

**c. Diagnosis.** Ulcer disease can be diagnosed by a combination of
history plus either X-ray barium study or endoscopy. H. pylori infection
can be diagnosed by endoscopy and biopsy or by non-invasive procedures
(serologic test, breath test for urease activity).

**d. Treatment.** Antibiotic treatment is still evolving, but current
treatment if H. pylori infection is present is 2 weeks of treatment with
two antibiotics to eradicate the Helicobacter infection plus a longer
period of treatment with an acid inhibitor. Surgery has greatly
decreased as treatment for ulcer disease in recent years except for the
complications of perforation, hemorrhage, or obstruction.

**e. Exam:** Record: (a) the detailed history, including sites of pain,
rhythmicity, periodicity, and chronicity; (b) any recurrences with the
disability's frequency, duration, response to medical or surgical
management, and influence upon employment; (c) complications of the
ulcer such as hemorrhage, perforation, or pyloric obstruction; (d)
nutritional status; (e**)** frequency and duration of any incapacitating
episodes, and (f) current treatment.

## 8.13 What are the significant findings of postgastrectomy syndrome (dumping syndrome)?

**a. Cause.** After partial gastrectomy or gastroenterostomy, ingested
food may enter the jejunum rapidly and set up a symptom complex known as
the "dumping syndrome."

**b. Symptoms.** Postcibal warmth, sweating, tightness or pain in the
epigastrium, nausea, vomiting, weakness, abdominal cramps, palpitation,
vertigo, or collapse. These complaints may occur during or immediately
after eating and resemble hypoglycemia. This is the early dumping
syndrome. However, a delayed or late type of dumping syndrome, with
weakness, sweating, and dizziness occurring one to three hours after
eating, may also occur. Both types may occur in the same person.
Symptoms may be mild or incapacitating, and the duration is variable.

**c. Exam:** Describe the symptoms, their duration and intensity, time
of onset after eating, the response to therapy or reconstructive
surgery. Describe nutritional status, weight prior to surgery, present
weight, and any loss of strength and appetite.

## 8.14 What are the significant findings of marginal (gastrojejunal or gastroduodenal) ulcer?

**a. Symptoms**. Similar to duodenal ulcer. Pain may be referred to the
left midabdomen, to the left lower quadrant, or to the back. Massive
hemorrhage may occur; however, perforation is not uncommon.
Gastrojejuno**c**olic fistula is a serious complication that causes
severe malnutrition, weight loss, anemia, and diarrhea.

**b. Diagnosis**. The diagnosis should be made by radiologic and
gastroscopic studies.

**c. Exam**: Describe symptoms and their duration, treatment, (such as
efforts at closure and vagotomy), and weight changes.

## 8.15 What are the findings in postvagotomy syndrome?

Vagotomy with such drainage procedures as gastroenterostomy,
pyloroplasty, or partial gastrectomy may give rise to abdominal
distention, belching of foul smelling gas, diarrhea, nausea, vomiting,
and evidence of gastric stasis. Though symptoms may disappear with time,
gastric emptying time may be prolonged indefinitely.

**Exam:** Report symptoms due to the vagotomy and any medication needed.

## 8.16 What are the findings in benign neoplasms of the stomach?

**a. General**. These are rare. May be inside the stomach or
extragastric. Polypoid and papillary adenomas are the most common.
Intramural lesions may be due to invasion by lymphomas. Polyps occur
infrequently and are considered to be precursors of carcinoma.

**b. Symptoms.** Are nonspecific. Hemorrhage with or without anemia may
be an initial symptom.

**c. Diagnosis**. Should be made by radiologic and gastroscopic studies.

**d. Exam**: Describe all post-operative residuals.

## 8.17 What are the findings in malignant neoplasms of the stomach?

**a. Symptoms.** Usually nonspecific. A history of "indigestion" in a
middle-aged individual without previous gastrointestinal symptoms must
arouse suspicion. Weight loss, pallor, tenderness, a palpable abdominal
mass, enlarged supraclavicular node, or metastatic hepatic nodules are
late manifestations.

**b. Diagnosis**. Hypochlorhydria or achlorhydria is present in
approximately 50%. The diagnosis should be made by repeated cytologic
study of gastric washings, radiologic study, and gastroscopic
examination.

**c. Exam**: Report type of treatment, date of last treatment if
treatment completed, and residuals after treatment, or signs and
symptoms of residual or recurrent tumor.

## SECTION III. INTESTINE

## 8.18 What are the notable findings about regional enteritis (Crohn's syndrome)?

**a. Location.** Granulomas may involve the terminal ileum alone, or the
thickened, edematous, and hyperemic process also may be noted in any
part of the gastrointestinal tract from the mouth to the anus. Multiple
adhesions may bind together numerous portions of the intestine and other
peritoneal-covered viscera.

**b. Symptoms.** Intermittent or continuous diarrhea and abdominal pain
are the most common symptoms. Rectal bleeding, tenesmus, fever, weight
loss, anemia, and edema may also occur.

**c. Laboratory studies**. Complete blood count, serum protein, albumin:
globulin ratio, prothrombin time (especially with any history of
bleeding) may be useful, and a small and large bowel radiological study
unless diagnosis is already established.

**d. Complications**. Look for an anal fistula, abscess, stricture.
Fistulous connections between small and large bowel, abdominal wall,
urinary bladder, or other structures may develop in advanced cases.
Malabsorption may be a complication.

**e. Extra-intestinal findings.** Arthritis, erythema nodosum, pyoderma
gangrenosum, uveitis, episcleritis, aphthous stomatitis, kidney stones,
gallstones, or other diseases of the liver and biliary system, and other
extra-intestinal complications may occur.

**f. Exam:** Report current symptoms of primary disease and
complications, describe treatment and side effects or residuals. Report
details, frequency, and duration of any incapacitating episodes.

## 8.19 What are the notable findings about irritable bowel syndrome (IBS)?

**a. General.** Formerly also known as functional bowel disease, spastic
colitis or mucous colitis, but the term "colitis" is a misnomer since
both inflammation and an organic component are lacking.

**b. Symptoms**. Symptoms are crampy abdominal pain, abdominal
distention, constipation, diarrhea, or constipation alternating with
diarrhea, excessive mucous secretion, and neuromuscular instability.
Certain types of food and emotional stress may precipitate symptoms.

**c. Diagnosis.** Usually there is a well-nourished appearance despite a
history of frequent loose stools daily. Physical examination is often
completely normal. May be tenderness in the left lower quadrant where a
tender and spastic descending and sigmoid colon may be felt. Barium
enema may reveal a spastic, irritable descending and sigmoid colon,
which may resemble a narrow tube devoid of haustral markings.
Sigmoidoscopic examination is negative. The diagnosis of parasitic
disease must be eliminated by examination of the stool for ova, cysts,
and parasites. IBS is usually diagnosed after other diseases have been
excluded.

**d. Exam:** Report symptoms, frequency of bowel disturbances, effects
on activities.

## 8.20 What are the notable findings about ulcerative colitis?

**a. General.** A relatively uncommon disease characterized by a diffuse
inflammation of the colon of unknown etiology. Most often involves the
rectum, but may extend to involve the entire colon, always in continuity
without skip segments.

**b. Symptoms.** A history of frequent liquid stools containing blood,
mucus, and pus should arouse suspicion. Fever, weight loss, dehydration,
anorexia, and malnutrition are common in advanced or acute fulminating
forms of the disease. Nausea, emesis, abdominal cramps, and passage of
gas may occur.

**c. Diagnosis.** Made by sigmoidoscopic examination, culture of fresh
warm stools and rectal swabs for pathogens, examination for entamoeba
histolytica, and barium enema. A rectal biopsy may provide a definitive
diagnosis.

**d. Complications.** Bleeding is the most common complication, and
toxic colitis and toxic megacolon are very serious complications. Skin
lesions (erythema nodosum, pyoderma gangrenosum), arthropathies
(including ankylosing spondylitis), uveitis, episcleritis,
thrombophlebitis, malnutrition, liver disease (fatty liver, autoimmune
hepatitis, cirrhosis, primary sclerosing cholangitis), and anal fissure,
fistula, abscess, or stricture may occur. Carcinoma is reported in 30 to
100 percent of prolonged smoldering cases. When present, the prognosis
is poor regardless of resection.

**e. Exam:** Report current symptoms of primary disease and
complications (as described in b and d). Report details, frequency, and
duration of any incapacitating episodes. Barium enema is usually
unnecessary if the diagnosis has been established.

## 8.21 What are the implications of diverticulosis and diverticulitis?

**Diverticula** are small outpouchings through weakened areas of the
wall of the large intestine, usually found in the aged person.

**Diverticulosis** may be asymptomatic or may present symptoms similar
to those of an irritable bowel syndrome.

**Acute diverticulitis** presents with fever, leukocytosis, localized
tenderness, and muscle spasm, usually in the left lower abdomen. This
may progress to perforation, peritonitis, abscess, fistulous formation,
or intestinal obstruction.

**Diagnosis** is by X-ray.

**Exam:** Report current symptoms and treatment or residuals of past
treatment, and any complications.

## 8.22 What are the notable findings about bacillary dysentery (shigellosis)?

**a. Symptoms.** Acutely, severe abdominal pain, fever, nausea,
vomiting, diarrhea (usually with blood, pus, and mucous), dehydration,
and exhaustion. Stools are green in color, irritating, contain flecks of
blood, and have shreds of mucus and pus.

**b. Diagnosis.** Sigmoidoscopic examination reveals diffuse hyperemia,
shallow ulcers, and yellow mucous discharge. It usually resolves in 4 to
8 days or up to 3 to 6 weeks for severe cases.

**c. Diagnosis and Treatment.** Is an infection of the bowel due to one
of four species of Shigella bacteria. Microscopic study of the stool and
culture for *Shigella* are the diagnostic tests. Treatment is
maintenance of hydration and sometimes antibiotics.

**d. Complications.** Complications include secondary bacterial
infections and perforation, and rarely toxic neuritis, arthritis, or
myocarditis.

**e. Exam:** Describe the signs and symptoms due to the primary disease
or complications.

## 8.23 What are the notable findings about amebiasis?

**a. Cause.** Amebiasis (including the symptomless carrier state or cyst
passers and cases of chronic amebic diarrhea) is caused *by Entamoeba
histolytica***.** It involves the colon primarily and invades other
organs secondarily.

**b. Symptoms.** May be asymptomatic in the carrier state. Clinical
manifestations are persistent or intermittent diarrhea, alternating
constipation and diarrhea, tenesmus, fever in acute cases, blood and
mucus in stools, weight loss**,** and anemia.

**c. Diagnosis.** Examination for motile amebae should be made from a
warm, fresh stool or rectal swab and of scrapings from undermined edges
of ulcers at the time of sigmoidoscopy. Culture and staining for cysts
should also be performed. A barium enema should be studied in chronic
cases to exclude amebomas or masses, usually around the cecum, due to
reaction around slow perforation and abscess formation.

**d. Exam:** Describe the character and frequency of stools, tenesmus,
nutritional status, weight, complications, and treatment. Serologic
testing for amebiasis of the liver (and also for amebic dysentery) is of
value, unless already part of the medical record. It is useful in
excluding amebiasis as a possible diagnosis rather than in telling
whether it is currently an active disease process. Ordinarily the
diagnosis will already be established at the time of exam.

## 8.24 What are the notable findings about malabsorption syndromes?

**a. Causes.** Malabsorption syndromes may be associated with many
conditions that affect absorption of nutrients from the small bowel, for
example, diseases of the gall bladder, liver, and pancreas, short bowel
syndrome, gastric surgery, Crohn's syndrome, celiac disease, and
tropical sprue.

**b. Symptoms.** Depend partly on the cause but may include steatorrhea
with passage of frequent, soft, bulky, greasy and foul stools, abdominal
distention, cramps, diarrhea, edema, muscle cramps or muscle wasting,
progressive weight loss, weakness, anemia, dehydration,
hypoprothrombinemia, cardiac arrhythmias, and a number of nutritional
disturbances that may resemble pellagra and beriberi.

**c. Diagnosis**. Extensive testing may be needed to establish the
diagnosis, with the particular tests done depending on the likely cause.
Tests may include fecal fat measurements, small intestine biopsy, and
many types of blood tests.

**d. Exam**: Describe the underlying cause, and report the signs and
symptoms, treatment, and any secondary complications, such as
malnutrition and anemia.

## 8.25 What are the significant findings in benign neoplasms of the intestines?

**a. Types of neoplasms**. Include polyps (most common type in the large
bowel), fibromas, myomas, teratomas, carcinoids, leiomyoma, and vascular
tumors.

**b. Symptoms.** Non-specific abdominal pain, intestinal bleeding,
unexplained anemia or partial obstruction. Polyps may be asymptomatic or
may bleed. Although initially or locally of benign nature, these
neoplasms may be multiple and some of them, especially sessile polyps,
large adenomatous polyps, and villous adenomas of the large bowel, may
become malignant.

**c. Exam:** It is the residuals of bowel surgery that will ordinarily
be the basis of disability evaluation. Describe effects of adhesions or
other complications.

## 8.26 What are the significant findings in carcinoma of the colon?

**a. General**. Adenocarcinoma is one of the most common cancers of the
colon. More than one-half are within range of the sigmoidoscope.

**b. Symptoms.** Due to the mechanical effect of the carcinoma's growth
on intestinal function or to complications. Include changes in bowel
habit in middle-aged or older individuals, alternating constipation and
diarrhea, unexplained anemia, or weight loss. Carcinoma of the rectum
may give rise to local pain.

**c. Diagnosis.** Should be based on sigmoidoscopy, biopsy, and barium
enema.

**d. Exam:** Residuals after treatment are the usual basis of disability
evaluation. Colostomy, resections, or intestinal external fistula
formation should be described as to location, size, control with
prosthetic devices, offensive aroma or other residual disabling
features, continence or lack of continence of colostomy, and skin
irritation or infection in area of colostomy.

## 8.27 What should be reported in peritoneal adhesions?

**Exam:** Include cause (surgery, trauma, infections, radiation, etc.),
as well as current manifestations such as cramps, obstipation, vomiting,
or episodes of obstruction, their frequency and duration, and whether
episodes of obstruction are confirmed by X-ray.

## 8.28 What should be reported about inguinal, ventral, and femoral hernias?

**Exam**: Describe symptoms, how well the hernia is controlled by
surgery, trusses, or abdominal belts, the exact size of the hernia,
history of incarceration or recurrence, and whether the hernias are
bilateral or multiple.

## SECTION IV. RECTUM AND ANUS

## 8.29 What are the significant findings in diseases of the rectum? 

**a. General examination**. Should include careful visual inspection of
the exposed area by anoscopy, digital rectal examination, and culture or
biopsy when indicated. When the examination is done for fresh bleeding,
sigmoidoscopy should be done even though hemorrhoids are found.

**Exam:** Report current signs and symptoms and frequency and severity
of symptoms.

**b. Proctitis**. May be part of ulcerative colitis or Crohn's disease
but also may be due to sexually transmitted disease or other infection,
and in some cases, is of unknown cause. Rectal bleeding, mucous, and
anorectal pain may occur. Diagnosis is by proctoscopy or sigmoidoscopy,
smear and culture for infection, and biopsy in some cases.

**c. Prolapse**. Prolapse may be partial or complete. There may be fecal
or mucous leakage, persistent pain, bleeding, and incontinence.

**d. Anal or rectal stricture**. May be due to radiation therapy for
prostate cancer, infection by chlamydia, lymphogranuloma venereum,
herpes simplex, rectal tuberculosis, Crohn's disease, or trauma to the
anus. Causes painful or difficult defecation.

**e. Impaired sphincter control with fecal incontinence**. Causes
include nerve damage (due to trauma, stroke, radiation therapy), muscle
damage (as in childbirth injury), pelvic or perineal surgery, anorectal
surgery or inflammation, and sometimes rectal prolapse.

**Exam:** Describe the extent of loss of bowel control in terms of
whether absorbent material is needed, how often, and how often it must
be changed, also whether there is leakage only with liquid stool or with
both liquid and formed stool. Mechanical means of control or medication
used should also be reported.

**f. Carcinoma of the rectum** often causes pain, tenesmus, bleeding,
and ribbon-like stools. It may present as a cauliflower-like mass or an
area of induration and narrowing.

## 8.30 What information would be useful to report in examinations for diseases of the anal canal?

**a. Hemorrhoids.** **Exam:** Differentiate between internal and
external types, and describe whether prolapsing, ulcerated, or
thrombotic. Differentiate hemorrhoids from simple anal skin tags.
Describe their location and complications such as pain, bleeding, or
tenesmus.

**b. Fistula-in-ano**. **Exam:** Note the location and recurrence of the
fistulous tract(s) between the anal mucosa and perineal skin. Report
current symptoms and treatment.

**c. Fissure-in-ano**. **Exam:** Note the location and extent of this
fissure or groove between the anal mucosa and exterior. It is often
extremely painful and tender and may form an abscess. Report current
symptoms and treatment or residuals of past treatment.

**d. Cryptitis.** This inflammation of the crypts inside the anal canal
leads to severe tenesmus or obstruction. **Exam:** Report symptoms,
including frequency and severity.

**e. Papillitis.** **Exam:** Note size of hypertrophied papillae and
their inflammation and report symptoms, including frequency and
severity.

**f. Lymphogranuloma venereum with stenosis**. **Exam:** Describe the
ulceration and stricture of this chronic lesion. Report current symptoms
and treatment or residuals of past treatment.

**g. Abscess**. **Exam:** Differentiate between perianal or perirectal
abscesses. Describe whether persistent and symptoms.

**h. Impaired anal sphincter**. **Exam:** Describe any tenesmus or fecal
leaking.

**i. Anal scar**. **Exam:** Report cause, extent of any constriction or
deformity, loss of sphincter tone, and fecal leakage.

**j. Tuberculous lesion.** **Exam**: Describe anal ulceration or
proctitis; confirm by culture when possible. Describe any tuberculous
pulmonary or other findings (chest film, barium enema, and small bowel
series may be needed).

## 8.31 What information would be useful to report in examinations for perianal diseases?

**a. Benign lesions.** **Exam:** Indicate type (cysts, lipomata, and
condylomata).

**b. Pilonidal cysts**. **Exam:** Report any operations, scars,
abscesses, and the presence of redness, tenderness, swelling, drainage,
or a sinus orifice. Report current symptoms and treatment or residuals
of past treatment.

## 8.32 What information would be useful to report in examinations for pruritus ani?

**Exam:** Report the underlying cause of the condition, and describe the
severity and persistence of perineal itching, bleeding, and spasm of the
anal sphincter as well as other manifestations. Perianal examination
should be described.

## SECTION V. ALIMENTARY APPENDAGES

## 8.33 What are the significant findings in gallbladder diseases?

**a. Types of gallbladder disease.** These include cholecystitis,
cholelithiasis, choledocholithiasis, choledochal polyps, and carcinoma.

**b. Signs and symptoms**. Recurrent episodes of fever, upper right
abdominal colic-like pain, nausea, distention, and low-grade jaundice.
With stones, the pain often radiates to the right scapula.

**Post cholecystectomy:** Relief is usually permanent, and there is
seldom permanent disability unless there are retained stones or other
associated disease.

**Polyps in the gallbladder** produce symptoms when they cause
intermittent obstruction.

**c. Exam:** Report frequency and duration of attacks of colic, whether
associated with jaundice, results of imaging studies, and past and
current treatment and results.

## 8.34 What are the significant findings in pancreatic diseases?

**a. Chronic Pancreatitis**. This seldom manifests itself until very far
advanced; steatorrhea is the most common manifestation. Very severe
malnutrition, emaciation, and weakness follow. Recurrent or constant
epigastric pain may radiate to the lumbar back. Diabetes mellitus may be
a complication. Multiple calcifications throughout the pancreas may be
seen on X-ray. Serial changes of the serum amylase, lipase, calcium,
blood sugar, and glucose tolerance should be recorded. CT scans and
ultrasound examinations may be useful. At times, the more sophisticated
procedures of ERCP (endoscopic retrograde cholangiopancretography), EUS
(endoscopic ultrasound), or MRI (magnetic resonance imaging) may be
needed. A history of chronic alcoholism is commonly present, but may
also be due to hemochromatosis or to unknown factors.

**Exam**: Report current symptoms, complications, and treatment or
residuals of past treatment.

**b. Acute Pancreatitis**. Almost half is due to gallstones, and chronic
alcoholism is the second most common cause. Symptoms include anorexia,
nausea, vomiting, and mild to severe upper abdominal pain, nonspecific
in nature. There may or may not be epigastric tenderness. Shock may
occur. Acute pancreatitis should be considered in the differential
diagnosis of any acute abdominal emergency. Elevated serum and urinary
amylase and serum lipase are of great diagnostic value. If pain and
other manifestations persist beyond several days, hemorrhagic
pancreatitis, pancreatic abscess, or pseudocyst of the pancreas should
be suspected. Long-term complications may include chronic pancreatitis,
pancreatic pseudocyst, pleural fistula, and ascites.

**Exam**: Will ordinarily be seen for disability examination purposes
only for examination of long-term complications. Report signs and
symptoms of complications, effects on functioning.

**c. Tumors of the Pancreas.** May be benign or malignant --
adenocarcinoma is most common. When in the head of the pancreas, it is
clinically obscure and usually painless. Obstruction to the common bile
duct is marked by the appearance of jaundice. Carcinoma arising in or
extending to the body of the pancreas is usually quite painful**.**
Ultrasonography, CT (computed tomography), ERCP, endoscopic ultrasound,
MRI, and percutaneous transhepatic cholangiography (PTC) may all be used
for diagnosis.

**Exam**: Will usually be made following the completion of treatment, to
report signs and symptoms that are the residuals of treatment or are due
to residual or recurrent tumor. Report type of treatment, date of last
treatment if completed, loss of weight or strength, anemia, etc.

**d. Adenoma of the Islet Cells**. Periodically, islet cell adenomas
produce excessive insulin with associated episodes of hypoglycemia,
nervousness, tremors, convulsions, hunger, coma, or shock. These tumors
present the classical Whipple's triad (spontaneous hypoglycemia, central
nervous or vasomotor system symptoms, and relief of the symptoms by the
oral or intravenous administration of glucose). Are usually benign, but
may become malignant and metastasize. Rarely, the islet cell tumor may
be derived from the alpha cells instead of the beta cells and manifests
itself by episodes of hyperglycemia instead of hypoglycemia. Either type
may initially label the patient as having only psychoneurosis or
functional complaints.

**Exam**: Report signs and symptoms, or post-surgical residuals, if any.
State how diagnosis was made.

## 8.35 What are the significant findings in salivary gland diseases?

**a. Causes.** May result from inflammation, ductal obstruction, stones,
fistula, benign or malignant tumors, or crushing or penetrating trauma.

**b. Exam:** Report dry mouth, dental caries, tooth loss, halitosis,
decreased sense of taste, difficulty chewing or swallowing, weight loss,
enlargement and tenderness of gland.

## 8.36 What are the significant findings in hepatitis?

**a. Causes.** The most common cause is viral infection, followed
closely by drug-induced liver disease. Hepatitis may be acute or
chronic, with each having a different prognosis. The commonest viruses
are hepatitis A, B, and C. Others include the Epstein-Barr virus
(infectious mononucleosis), cytomegalovirus, and rarely, the viruses of
yellow fever, herpes simplex, coxsackie B, varicella, and rubeola. Among
the many drugs that are associated with acute or chronic hepatitis are
alpha-methyldopa, INH, nitrofurantoin, halothane, phenylbutazone, etc.

**b. Hepatitis A infection**. Viral A hepatitis is spread via the
oral-fecal route, and most commonly affects children and young adults.
Diagnosis is made by a specific serologic test (IgM anti-HAV). The
disease is usually mild, with minimal mortality and no long-term
sequelae.

**c. Hepatitis B and C infection.** Viral B and C hepatitis are spread
through contact with contaminated blood, blood products, or body
secretions. Higher risk levels for hepatitis C are found in injecting
drug users, individuals with hemophilia treated with clotting factor
concentrate before 1987, and recipients of blood transfusions from
HCV-positive donors (mainly occurred prior to 1993). Moderate prevalence
is found among long-term hemodialysis recipients. Lower levels of
prevalence occur in those with inapparent percutaneous or mucosal
exposures, e.g., persons with evidence of high-risk sexual practices, or
those with small, sporadic percutaneous exposures, e.g., medical worker,
including those involved in combat casualty care or who suffered a
needle stick injury. Other risk factors include tattoo or repeated body
piercing, intranasal cocaine use, and having multiple sexual partners,
past or present. The risk factors for hepatitis B infection are similar.
Chronic hepatitis results in approximately 10 percent of those with type
B hepatitis and 60 to 80 percent of those with hepatitis C. Both
diseases are associated with a carrier state. Both hepatitis B and C
infections may culminate in the development of cirrhosis or
hepatocellular carcinoma.

**d. Signs and symptoms.** Acute hepatitis most commonly is
asymptomatic. When symptomatic, the disease usually presents with mild
fever, arthralgias, malaise, nausea, vomiting, jaundice, and right upper
quadrant discomfort. Chronic hepatitis also is most frequently
asymptomatic for many years or decades, and may be discovered because of
abnormalities found in routine blood tests. When symptomatic, it may
simulate acute hepatitis or may manifest with features of portal
hypertension because of the development of cirrhosis in the late stages.
Hepatocellular carcinoma is associated with hepatitis B and C. Hence,
all those with chronic hepatitis B or C should be tested for alpha
fetoprotein.

**e. Laboratory tests.** Useful biochemical tests include serum
bilirubin, AST, ALT, alkaline phosphatase, prothrombin time, total
protein, and protein electrophoresis. They may need to be performed
periodically. Specific diagnostic serologic tests are also of the
greatest importance. If done, results of a liver biopsy should be
incorporated in the report.

**f. Treatment.** Specific therapy for chronic hepatitis B and C is
available with interferon, ribavirin, lamirudine. The hepatitis A and B
vaccines are highly effective.

**g. Exam for hepatitis C infection:**

**Diagnosis:** For C&P purposes, there must be [a record of]{.underline}
either 1) both a positive EIA (or ELISA) test and a RIBA confirmatory
test, or 2) a positive HCV RNA test to establish the diagnosis of
hepatitis C. These are required even when they are not clinically
necessary, so unless the report of either 1) or 2) are in the record,
the examiner will need to obtain them.

**Opinions:** The examiner will frequently be asked to determine whether
a current hepatitis C infection is related to hepatitis of known or
unknown type during active service. In these cases, a battery of
hepatitis serologic tests may be needed, because clarifying this issue
is critical to determining the relationship to service. An examiner may
also be asked to provide an opinion as to whether hepatitis C is related
to service, in the absence of any indication of hepatitis in service. In
such cases, the examiner should consider and fully discuss all pertinent
risk factors before, during, and after service, and should give an
opinion as to whether it is at least as likely as not that a risk factor
related to service is the cause.

**General information**: Report current symptoms of hepatitis and its
complications, and describe treatment and side effects or residuals of
treatment. Report details, frequency, and duration of any incapacitating
episodes.

## 8.37 What are the significant findings in Cirrhosis?

**a. Causes**. The end result of various diseases, it is fibrosis of the
liver leading to architectural distortion, and manifests as portal
hypertension and/or hepatocellular failure. In the United States, the
commonest cause by far is alcohol. The hepatic consequences of chronic
alcoholism include fatty liver, alcoholic hepatitis, cirrhosis, and
hepatocellular carcinoma. Other causes include viral hepatitis (types B
and C) certain drugs (INH, alphamethyldopa, methotrexate,
chlorpromazine, etc.), iron overload, long-standing right-sided
congestive cardiac failure (cardiac cirrhosis), long-standing
obstructive biliary tree disease (secondary biliary cirrhosis), and
diseases of unclear pathogenesis (primary biliary cirrhosis, Wilson's
disease, alpha 1 antitrypsin deficiency).

**b. Signs and symptoms**. There are often no symptoms, and the disease
is discovered simply because of the identification of an abnormal
biochemical or serologic test. In the later stages, regardless of
etiology, clinical features may include malnutrition, muscle atrophy,
glossitis, jaundice, spider angioma, prominent collateral veins in the
abdomen, ascites, peripheral edema, esophageal varices, hepatomegaly,
and splenomegaly. As with hepatitis, biochemical tests should be
carefully appraised serially. Liver biopsy is useful for confirmation of
diagnosis and determination of progress of disease. The diagnosis is
aided by radioisotope scanning or by visualization of the liver at
laparoscopy. Portal pressure measurements are also useful.

**c. Exam:** Report current signs and symptoms of liver disease, as well
as the type and frequency of any complications, such as ascites,
encephalopathy, and gastrointestinal bleeding. Describe treatment and
side effects or residuals of treatment. A diagnosis of cirrhosis should
be confirmed by biopsy or imaging and abnormal liver function tests.

## Worksheet - ESOPHAGUS AND HIATAL HERNIA

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Dysphagia - for solids, liquids (frequency and extent).

> 2\. Pyrosis, epigastric or other pain, including associated substernal
> or arm pain (frequency and severity).

3\. Hematemesis or melena (describe any episodes).

4\. Reflux or regurgitation (frequency); for regurgitation, contents.

5\. Nausea, vomiting (frequency, precipitants).

6\. Current treatment - if dilatation, give frequency.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. General state of health, anemia.

2\. Nutrition, weight gain or loss.

D. **Diagnostic and Clinical Tests:**

1\. X-ray or endoscopic confirmation of obstruction, abnormal motility,
esophagitis,

reflux, etc.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. With obstruction or spasm, amenable to dilatation?

Signature: Date:

## Worksheet - DIGESTIVE CONDITIONS, MISCELLANEOUS

**(Tuberculous Peritonitis, Inguinal Hernia, Ventral Hernia, Femoral
Hernia,**

**Visceroptosis, and Benign and Malignant New Growths)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

1\. Describe all hernia surgery and results.

2\. For malignancy, state type of treatment, dates of treatment,
including last date of

treatment if it has ended.

3\. For peritoneal tuberculosis, state date of diagnosis, treatment, and
date on which

inactivity was established.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. For inguinal or ventral hernia, state whether reducible, how well
supported by truss or

belt, and whether irremediable or inoperable.

2\. For ventral hernia, state size of hernia, extent of diastasis of
recti muscles, status of

muscles and fascia of abdominal wall.

3\. All residuals of malignancy, including residuals from treatment.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - INTESTINES (LARGE AND SMALL)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Weight gain or loss.

2\. Nausea and/or vomiting.

3\. Constipation, diarrhea (frequency, severity, duration, and episodic
or not?).

4\. For fistula - frequency, duration, and amount of fecal discharge.

.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Malnutrition, anemia, other evidence of debility.

2\. Abdominal pain - location, type, frequency, and duration.

3\. Current treatment - type, duration, response, and side effects.

4\. For fistula - location.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - LIVER, GALL BLADDER, AND PANCREAS

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:** This may be of particular importance
when hepatitis C or chronic liver disease is claimed as related to
service.

B. **Medical History (Subjective Complaints):**

Comment on:

> 1\. Vomiting, hematemesis, or melena.
>
> 2\. Current treatment - type (medication, diet, enzymes, etc.),
> duration, response, side effects.
>
> 3\. Episodes of colic or other abdominal pain, distention, nausea,
> vomiting duration, frequency, severity, treatment, and response to
> treatment.
>
> 4\. Fatigue, weakness, depression, or anxiety.
>
> 5\. When chronic liver disease is claimed, record history of any risk
> factors for liver disease, including transfusions, hepatitis (and what
> type), intravenous drug use, occupational blood exposure, high-risk
> sexual activity, etc. When did they take place? Describe current
> symptoms of liver disease and onset of symptoms.
>
> 6\. Provide history of alcohol use/abuse, both current and past.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate, and fully describe current
findings:

1\. Ascites.

2\. Weight gain or loss, steatorrhea, malabsorption, malnutrition.

3\. Hematemesis or melena (describe any episodes).

4\. Pain or tenderness - location, type, precipitating factors.

5\. Liver size, superficial abdominal veins.

> 6\. Muscle strength and wasting.
>
> 7\. Any other signs of liver disease, e.g., palmar erythema, spider
> angiomata, etc.

D. **Diagnostic and Clinical Tests:**

1\. For esophageal varices, X-ray, endoscopy, etc.

2\. For adhesions, X-ray to show partial obstruction, delayed motility.

3\. For gall bladder disease, X-ray or other objective confirmation.

> 4\. For liver disease: liver function tests (albumin, prothrombin
> time, bilirubin, AST, ALT, WBC, platelets); serologic tests for
> hepatitis (HBsAg, anti-HCV, anti-HBc, ferritin, alpha-fetoprotein);
> and liver imaging (ultrasound or abdominal CT scan), as appropriate.
> If hepatitis C is the diagnosis, a positive EIA (enzyme immunoassay)
> test for hepatitis C should be confirmed by a RIBA (recombinant
> immunoblot assay) test.
>
> a\. With a diagnosis of hepatitis, name the specific type (A, B, C, or
> other), and for hepatitis B and C, provide an opinion as to which risk
> factor is the most likely cause. Support the opinion by discussing all
> risk factors in the individual and the rationale for your opinion. If
> you can not determine which risk factor is the likely cause, state
> that there is no risk factor that is more likely than another to be
> the cause, and explain.
>
> b\. With a diagnosis of cirrhosis, chronic hepatitis, liver
> malignancy, or other chronic liver disease, state the most likely
> etiology. Address the relationship of the disease to active service,
> including any hepatitis that occurred in service. If you cannot
> determine the most likely etiology, cannot determine whether it is
> more likely than not that one of multiple risk factors is the cause,
> or cannot determine whether it is at least as likely as not that the
> liver disease is related to service, so state and explain.
>
> 5\. Include results of all diagnostic and clinical tests conducted in
> the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - RECTUM AND ANUS

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Degree of sphincter control.

2\. Extent and frequency of fecal leakage or involuntary bowel
movements- is a pad

needed?

3\. Bleeding or thrombosis of hemorrhoids - frequency and extent.

4\. Current treatment.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Colostomy.

2\. Evidence of fecal leakage.

3\. Size of lumen - rectum and anus.

4\. Signs of anemia.

5\. Fissures.

6\. If hemorrhoids - location, size, and if thrombosed.

7\. Evidence of bleeding.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - STOMACH, DUODENUM, AND PERITONEAL ADHESIONS

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Vomiting.

2\. Hematemesis or melena (describe any episodes).

3\. Treatment - type, duration, response, side effects.

4\. Circulatory disturbance after meals, hypoglycemic reactions (state
time of onset

in relation to meals, frequency).

5\. Diarrhea, constipation.

6\. Episodes of colic, distention, nausea, and/or vomiting - frequency,
duration, and

severity.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Specific site of any ulcer disease.

2\. Weight gain or loss.

3\. Signs of anemia.

4\. Pain or tenderness - location, type, precipitating factors.

D. **Diagnostic and Clinical Tests:**

1\. For gastritis, endoscopic evidence - describe hemorrhage, ulcerated
or eroded areas.

2\. For adhesions, X-ray to show partial obstruction, delayed motility.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

# Chapter 9 - GENITOURINARY SYSTEM

## 9.1 What should an examination include?

**History**

**a. Initial examinations**. A complete chronological history of the
onset of the conditions(s) claimed, its course, including treatment, and
relevant family history, history of nephrotoxic drug use, etc., should
be recorded.

**b. Review examinations**. Only an interim history since the last
disability examination is required.

**c. All examinations.** Current symptoms of genitourinary disability
should be reported. In addition, the effects of the condition(s) on
daily and occupational activities should be reported. When pain, for
example, is a symptom, its origin, frequency, severity, duration, and
response to treatment should be reported, as well as its effects on
activities.

**Physical examination**

A detailed examination of the pertinent area(s) should be conducted.
Local and related remote findings should be reported in detail. This
might require assessment of other organ systems, such as the
cardiovascular system, if affected by renal disease.

**Laboratory studies**

Request laboratory studies as indicated for diagnosis or assessment,
based on the particular condition and what tests have already been done.
The regional office should be consulted before any invasive or expensive
testing is undertaken.

## 9.2 What is the basis of disability evaluation of genitourinary conditions?

Most, but not all, genitourinary disabilities are evaluated by the
Veterans Benefits Administration on the basis of renal dysfunction,
urinary tract infection, voiding dysfunction, or some combination. The
examiner should assess the condition being examined as to whether it has
resulted in renal dysfunction, urinary tract infection, voiding
dysfunction, or some combination, and report the information pertinent
to that category described below. For example, when the condition is
associated with renal dysfunction, the examination should include
information (as shown in "a") about the urinalysis, presence of edema or
hypertension, creatinine, etc. If the same condition is also associated
with urinary tract infection, the findings under "b" should be reported
as well.

**a. Renal dysfunction**: With renal dysfunction**,** evaluation depends
on the presence or severity of the following findings, as well as any
other pertinent signs and symptoms of the condition, all of which should
be reported:

> urinalysis - albuminuria, casts, hematuria
>
> edema
>
> hypertension
>
> decreased renal function - creatinine, BUN
>
> generalized symptoms such as weakness, lethargy, anorexia, weight loss
>
> need for restriction of activities, such as limited to sedentary
> activities
>
> secondary effects on the cardiovascular system or other organ systems
>
> need for hemodialysis

**b. Urinary tract infection:** With urinary tract infection**,**
evaluation depends on the presence or severity of the following
findings, as well as any other pertinent signs and symptoms of the
condition, all of which should be reported:

> evidence of renal dysfunction (see 9.2 a)
>
> whether recurrent infection requires:
>
> \- hospitalization one or more times a year
>
> \- long-term drug therapy
>
> \- intermittent or continuous intensive management
>
> \- drainage one or more times per year

**c. Voiding dysfunction:** With voiding dysfunction, evaluation depends
on the presence or severity of the following findings, as well as any
other pertinent signs and symptoms of the condition, all of which should
be reported:

> **1) Urine leakage** - continual urine leakage, post surgical urinary
> diversion, urinary incontinence, or stress incontinence
>
> whether wearing of an appliance (what type?) or absorbent materials is
> needed
>
> how many times per day absorbent materials must be changed.
>
> **2) Urinary frequency**
>
> duration of the daytime voiding interval
>
> how often there is wakening to void at night.
>
> **3) Obstructed voiding**
>
> whether dilatation is required and how often it must be done
>
> whether intermittent catheterization is required (frequency?)
>
> whether there are obstructive symptoms (such as hesitancy and a weak
> stream) [plus:]{.underline}
>
> post-void residuals greater than 150cc.
>
> decreased flow rate on uroflowmetry
>
> recurrent secondary urinary tract infections.

## 9.3 What should the examination include for disabilities rated on other criteria?

**1. Residuals of trauma: Record** the history and course of the injury,
its residuals, and the relationship of current genitourinary
condition(s) to the original injury. Record findings according to 9.2
when appropriate.

**2. Following nephrectomy**:

> residuals of the surgery.
>
> renal function (*see* 9.2 a)
>
> whether there is nephritis, infection, or other pathology in the
> remaining kidney.

**3. Nephrolithiasis, ureterolithiasis, ureteral stricture:**

> how the diagnosis was established
>
> the number, size, location of stones
>
> frequency of episodes of colic
>
> type of stones if known
>
> whether there has been associated infection
>
> past and current treatment, including drug therapy
>
> whether a special diet has been prescribed
>
> whether invasive or noninvasive procedures are used and how often
>
> renal function (*see* 9.2 a)

**4. Hydronephrosis or hydroureter:**

> frequency of attacks of colic with infection
>
> type of treatment, including catheter drainage
>
> renal function (*see* 9.2 a)

**5. Neurogenic bladder:**

> cause, frequency, and severity of such symptoms as incontinence,
> dribbling, or retention of urine.
>
> with incontinence, report extent of voiding dysfunction (*see* 9.2 c).
>
> renal function (*see* 9.2 a).
>
> in exceptional cases - urodynamic studies, cystoscopic, radiographic,
> or isotopic scanning of the genitourinary system may be needed.

**6. Fistula of the bladder or urethra:**

> the location and extent of the fistulous tract
>
> associated symptoms
>
> treatment
>
> findings under 9.2 b and c.

**7. Carcinoma of the prostate:**

a\. history and physical examination including a digital rectal
examination.

b\. PSA and alkaline phosphatase tests.

c\. if post treatment:

> Describe the type of treatment(s) used - radical prostatectomy,
> external radiation, brachytherapy, hormone therapy, etc.
>
> Give date of the last treatment (or report current treatment).
>
> State residuals of treatment, such as incontinence (*see* 9.2 c) or
> other urinary symptoms, impotence, retrograde ejaculation, sterility,
> feminizing signs, etc. (s*ee* 9.3).
>
> Indicate if current treatment is palliative, adjuvant, etc., and if
> there is residual cancer.
>
> If there are metastases, describe their location and signs, symptoms,
> and complications.
>
> If no treatment is being used or was used, explain why.

## 9.4 What needs to be reported about anatomical loss or loss of use of a creative organ and why?

The examination must include the following information:

> a\. The details of loss of a creative organ may be in the medical
> records, but the examiner should still describe lost and remaining
> portions of the penis, scrotum, and testes.
>
> b\. Impotence, sterility, or retrograde ejaculation should always be
> described and the cause named (e.g., Peyronie's disease causing
> impotence or TURP for BPH causing retrograde ejaculation). If a
> vasectomy was performed, the examiner should report when it was done
> and the reason.
>
> c\. With impotence, the report should indicate whether it is constant,
> whether it is permanent, what treatment is used, and the effectiveness
> of treatment in allowing intercourse.
>
> d\. With penile deformity, whether erectile function is wholly or
> partially lost should be reported.
>
> e\. Examination for testicular atrophy must be conducted by **at least
> two** **examiners.** The size and consistency of the testis should be
> recorded. Reduction in size should be described as reduction to
> one-third or one-half normal size, or even less, for example. If only
> one testis is affected, the size of the unaffected testis should be
> recorded. The etiology of the atrophy should be reported.

## Worksheet - GENITOURINARY EXAMINATION

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Lethargy, weakness, anorexia, weight loss or gain.

2\. Frequency (day or night, indicate voiding intervals), hesitancy,
stream, dysuria.

3\. Incontinence - if present, describe required frequency of absorbent
material and

whether an appliance is needed.

4\. Provide details of any history of:

a\. Surgery on any part of the urinary tract. Residuals? Impotence?

b\. Recurrent urinary tract infections.

c\. Renal colic or bladder stones.

d\. Acute nephritis.

e\. Hospitalization for urinary tract disease, if so, how many in the
past year?

f\. Treatment for malignancy, including type and date of last treatment.

5\. Treatments.

a\. Is catheterization needed? Intermittent or continuous?

b\. Frequency of dilations?

c\. Drainage procedures.

d\. Diet therapy - specify.

e\. Medications.

f\. Frequency per year of invasive and noninvasive procedures.

6\. Describe the effects of the condition(s) on the veteran\'s usual
occupation and daily

activities.

For Male Loss of Use of a Creative Organ

Comment on:

1\. Trauma/surgery affecting penis/testicles (e.g. vasectomy?)

2\. Local and/or systemic diseases affecting sexual function.

a\. Endocrine.

b\. Neurologic.

c\. Infections.

d\. Vascular.

e\. Psychological.

3\. Symptoms: Vaginal penetration with ejaculation possible?

4\. Past treatment:

a\. Medications, injections, implants, pump, counseling

b\. Effectiveness in allowing intercourse.

C. **Physical Examination (Objective Findings):**

Address each of the following, as appropriate, to the condition being
examined and fully

describe current findings:

1\. Blood pressure, cardiovascular examination, if indicated, describe
edema, to include

persistence.

2\. If on dialysis, type, where done, and how often?

3\. Inspection and palpation of penis, testicles, epididymis, and
spermatic cord. If there is

penis deformity, state whether there is loss of erectile power.
Inspection of anus and

digital exam of rectal walls, prostate, and seminal vesicles.

4\. Fistula.

5\. Specific residuals of genitourinary disease, including
post-treatment residuals of

malignancy.

6\. Testicular atrophy - size and consistency.

7\. Sensation and reflexes

8\. Peripheral pulses

D. **Diagnostic and Clinical Tests:**

1\. CBC.

2\. UA.

3\. Creatinine, BUN, albumin, electrolytes.

4\. Uroflowmetry, if indicated.

5\. Measurement of post-void residual, if indicated.

6\. Semen analysis, including sperm count and interpretation of results,
if applicable.

7\. Endocrine evaluation (glucose, TSH, testosterone, LH, FSH,
prolactin), if applicable.

8\. Psychiatric evaluation, if applicable.

9\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

# Chapter 10 - GYNECOLOGICAL CONDITIONS AND DISORDERS OF THE BREAST

## 10.1 What are the elements of a good gynecologic and breast examination?

This chapter supplements the examination worksheet.

**a. What is needed in the history for an initial examination?**

**1) History of present illness -** onset, frequency, and severity of
symptoms; past and current treatment; whether symptoms are controlled by
treatment; effects of condition on daily activities.

**2) General health information -** including previous surgery and
illnesses; family history; military history.

**3) Menstrual history**. Date of onset, date of last menstrual period,
interval between menstrual periods (regular or irregular), duration of
menstrual periods, premonitory or associated symptoms, amount of flow
(pads or tampons per day), degree and type of pain or cramps, passage of
clots or bright red blood, bleeding between menstrual periods, degree
and type of vaginal discharge and relation to sexual activity, and
symptoms and timing of any menopausal changes.

**4) Sexual history of significance and pregnancy history**. Number of
pregnancies**,** types and complications of deliveries, number and dates
of abortions or miscarriages. Complications of contraceptives used.

**5) Urinary tract history**. Past infections or surgery. Current
symptoms and treatment.

**b. What is needed in the history for a review examination?**

For a review examination, only an history covering the period since the
last examination is needed.

**c. What is needed for the physical examination?**

1\) The results of any general physical examination should be
coordinated with the breast and gynecologic examination. A complete
breast and pelvic examination is needed unless only a particular
condition is requested for examination, e.g., if the examination request
specifies breast disease, a pelvic examination is not needed. For a
review examination, only the specific area or areas of concern need be
examined.

2\) Describe findings on examination of

**external genitalia** - glands, outlet, mucosa, and presence of a
discharge.

**vagina** - inspection and description of mucosa, characteristics of
discharge, depth, pelvic-supporting tissue, and presence of urethrocele,
cystocele, or rectocele.

**cervix** - position, size, consistency, presence of erosions,
eversion, tumors or suspicious areas, mobility, and tenderness. The
speculum will always be used unless specific contraindications exist, if
so explain.

**uterus** - position (retroverted, retroflexed, retrocessed), size,
shape (regularity), consistency, mobility, tenderness, and degree of
decensus with moderate traction.

**fallopian tubes** - if palpated, any thickening, mobility, swelling,
or tenderness.

**ovaries** - if palpated, their position, size, mobility, and
consistency. If enlarged, estimate size in centimeters (as 3 x 5 cm.)

**cul-de-sac** - free, tender, obliterated, or other condition.

**rectal and rectovaginal** - to confirm the pelvic findings.

**breast** - *see* paragraph 10.11.

## 10.2 What laboratory studies may be needed?

CBC and urinalysis are routine; request other studies as indicated. Pap
smear and mammogram may be indicated if not done within the recommended
time period. Culture and stained smears should be used for any
discharge. Specialized tests may be needed at times, such as
laparoscopy, diagnostic curettage, cervical biopsy, and ultrasound.
Consult with the Veterans Service Center before requesting or scheduling
any specialized or invasive test.

## 10.3 What is needed for a breast examination?

**a. For a radical mastectomy or modified radical mastectomy**, describe
the extent of edema of the involved arm, presence of aching or pain,
whether there is limited use of the upper extremity, tenderness or
fixation of the scar, and any neurologic signs or symptoms.

**b. For a** **simple or partial mastectomy or excision of a lesion**,
report the size and contour, and tenderness or fixation of the scar.
Describe size, contour, and symmetry in comparison with the opposite
breast.

**c. Note history of** **augmentation mammoplasty** with a prosthetic
implant or **reduction mammoplasty** and any complications, such as
tender or painful scar or muscle weakness or herniation of a flap-donor
site.

## 10.4 What is needed for an examination for endometriosis?

Describe pelvic pain, heavy or irregular bleeding, and bowel or bladder
symptoms, and indicate whether they are due to endometriosis. State
whether or not the symptoms require continuous (regular, on going)
treatment, and if they do, whether the symptoms are controlled by
treatment. The initial diagnosis and any diagnosis of bowel or bladder
involvement require confirmation by laparoscopy.

## 10.5 What is needed for an examination of benign neoplasms of the gynecological system or breast?

**a. For uterine fibroids**, describe gynecological or urinary symptoms
and if operated, post-surgical residuals.

**b. For benign breast neoplasms**, e.g., fibroadenoma, intraductal
papilloma, lipoma, describe any post-operative residuals, including
scar.

## 10.6 What is needed for an examination of malignant neoplasms of gynecological system or breast?

a\. Provide the date of confirmed diagnosis, date of the last treatment
(surgical, X-ray, antineoplastic chemotherapy, radiation, or other
therapeutic procedure), and the date the treatment regimen was, or is
expected to be, completed.

b\. If post treatment, describe any local recurrence or metastases as
well as any residuals of the cancer or its treatment. Describe type of
surgery.

c\. If on Tamoxifen, state reason, i.e. prophylactic, therapeutic,
palliative.

## 10.7 What is needed for an examination if atrophy of both ovaries is suspected prior to the climacteric?

Tests to determine whether there is complete atrophy of both ovaries
will be needed. Complete atrophy should be confirmed by laparoscopy,
examination of the vaginal epithelial smear for the mid-cycle maturation
index, absence of urinary progesterone, or measurement of the urinary
24-hour gonadotrophin level. Describe changes in hair, voice,
fatigability, breast or skin turgor, sexual activity, \"hot flashes,\"
etc., as well as the response to hormone replacement therapy.

## 10.8 What is needed for relaxation of pelvic support due to surgical complication of pregnancy, trauma, or other?

Report any cystocele, rectocele, or urethrocele, its extent and cause.
Describe symptoms such as incontinence with coughing, sneezing,
evacuation, standing upright, walking, coitus; need for use of absorbent
pads (and how often they need to be changed daily) or appliances to
prevent soiling; and any \"pulling\" sensation in the lower back.

## 10.9 What is needed for an examination of displacement of the uterus?

Report the position of the uterus, whether the fundus leans to the
right, left, forward, backward, or bends upon the long axis of the
uterus. Describe associated symptoms such as discomfort in the back or
lower abdomen, interference with menstrual flow, interference with
coitus, or menstrual disturbances.

## 10.10 What is needed for an examination after uterine or ovarian surgery?

Describe residuals, including menopausal changes. Describe any ongoing
treatment, including hormone replacement therapy. The exact extent of
surgery must be made clear. If only part of an ovary is removed, the
amount removed should be reported if known.

## 10.11 What is needed for an examination of prolapse of the uterus?

a\. Describe whether the prolapse is complete, through the vaginal
orifice (presenting as a mass about the size of a grapefruit lodged
between the thighs), or partial (if only the cervix or the cervix and
part of the body of the uterus protrudes through the vaginal orifice).
In either case, report whether the prolapse is constant or occurs only
upon standing.

b\. Describe symptoms - interference with walking, urination,
defecation, rest, coitus, or pregnancy.

## 10.12 What is needed for an examination for vesicovaginal, urethrovaginal, ureterovaginal, enterovaginal, or rectovaginal fistula?

Describe any leakage of urine, feces, or greenish bowel discharge from
the vagina, fistulous tract location, need for absorbent pads (and
frequency of changing daily) or use of an appliance. Report likely
etiology - past surgery, infection, radiation, etc.

## 10.13 What is needed in examinations for vulvovaginitis, vaginitis, cervicitis, salpingitis, and oophoritis?

Describe duration, cause, and interference with daily activities. State
whether or not the symptoms require continuous (regular, on going)
treatment, and if they do, whether the symptoms are controlled by
treatment.

## Worksheet - GYNECOLOGICAL CONDITIONS AND DISORDERS OF THE BREAST

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Provide:

1\. Date of onset of symptoms.

2\. Describe symptoms, e.g., abnormal bleeding, vaginal discharge,
fever, pain, bowel or

bladder symptoms, etc.

3\. Treatments:

a\. Detail all breast and pelvic surgery.

b\. If a malignant process has been identified, provide:

1\) Date of confirmed diagnosis.

2\) Date of the last surgical, X-ray, antineoplastic chemotherapy,

radiation, or other therapeutic procedure.

3\) Expected date treatment regimen is to be completed.

4\) If already completed, provide date.

5\) Fully describe residuals.

c\. Detail hormonal and other medications and whether continuous
medication is

required, response, and side effects.

4\. Include complete menstrual history, pregnancy history, and urinary
tract history.

C. **Physical Examination (Objective Findings):**

Provide a full gynecological and breast examination (*unless only a
particular*

*condition or portion of the examination is requested*).

Address each of the following and fully describe current findings:

1\. Uterus.

a\. If post operative, state extent of surgery.

b\. If prolapse is present, is it through the introitus?

c\. If displaced, are there adhesions and/or menstrual disturbances.

2\. If rectovaginal fistula is present, describe extent and frequency of
leakage and

whether a pad is required.

3\. If urethrovaginal fistula is present, describe whether absorbent
material is required and

how often it must be changed.

4\. If rectocele, cystocele, or perineal relaxation is present, is it
due to pregnancy?

5\. Breasts.

If post-operative, Identify the type of surgery using the following
definitions:

a\. [Radical mastectomy]{.underline} - removal of the entire breast,
underlying pectoral muscles,

and regional lymph nodes up to the coracoclavicular ligament.

b\. [Modified radical mastectomy]{.underline} - removal of the entire
breast and axillary lymph

nodes (in continuity with the breast). Pectoral muscles are left intact.

c\. [Simple (or total) mastectomy]{.underline} - removal of all the
breast tissue, nipple, and a

small portion of the overlying skin, but lymph nodes and muscles are
left intact.

d\. [Wide local incision]{.underline} - includes partial mastectomy,
lumpectomy,

tylectomy, segmentectomy, and quadrantectomy. This means removal of a

portion of the breast tissue.

e\. Describe any alteration of size and form.

D. **Diagnostic and Clinical Tests:**

1\. CBC.

2\. Urinalysis.

3\. Laparoscopy is required to establish diagnosis of endometriosis and
to confirm bowel

or bladder involvement.

4\. Ultrasound, mammography, if indicated.

5\. Pap smear (if none within past year).

6\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

# Chapter 11 - MUSCULOSKELETAL

## 11.1 What are the basic elements of a musculoskeletal examination for disability evaluation purposes?

**a. Initial examination:** Follow the specific worksheet(s) for the
area(s) to be examined. This chapter supplements the following
examination worksheets: **BONES (FRACTURES AND BONE DISEASE);
FIBROMYALGIA; RESIDUALS OF AMPUTATIONS; JOINTS (SHOULDER, ELBOW, WRIST,
HIP, KNEE AND ANKLE); HAND, THUMB AND FINGERS; FEET; SPINE (CERVICAL,
THORACIC AND LUMBAR); AND MUSCLES.**

**b. Review/follow-up examination:** Only an interval history covering
the period since the last examination is needed. In addition, no
diagnostic studies are needed on a review examination if the diagnosis
has been previously well established. Otherwise, follow the specific
worksheet for the area to be examined.

## 11.2 What are the important factors in range-of-motion testing?

a\. Accurate assessment of joint range-of-motion (ROM) is extremely
important. See worksheets for standardized descriptions of "average
normal" joint motion measurements for the upper and lower extremities.

b\. Use a **goniometer** to measure both passive and active ROM,
including movement against gravity and strong resistance. **Provide ROM
[in degrees]{.underline};** it is **not acceptable** simply to note that
range of motion is "normal" or "within normal limits."

c\. It is good practice to include ROM of the contralateral joint
whenever possible. This is particularly true if joint ROM is felt to be
"normal," but the measured ROM in degrees is different from the
**average** normal ROM shown in the worksheets.

d\. Report the joint range of motion with reference to the anatomic
position, e.g., state that "elbow flexion **is** 0 to 120 degrees",
rather than "elbow flexion is **limited by** 25 degrees" or "elbow
flexion is **limited to** 120 degrees" or "the elbow **lacks** 25
degrees of full flexion". Reporting range of motion any other way than
by referring to the anatomic position leads to confusion among raters
and may result in incorrect disability evaluations.

e\. The \"anatomic position\" is defined as the patient standing erect
with feet flat on the floor, heels together, arms at the sides, palms
facing forward, fingers and thumbs extended parallel to hands, and chin
straight forward.

## 11.3 How is functional assessment of joints conducted?

Because the CAVC found that the traditional VA method of assessing
disabilities for rating purposes -- one-time measurement of active and
passive ROM -- was inadequate under VA regulations, as **functional
impairment** may be **underestimated,** additional factors must be
considered for **each joint** examined. See Deluca v. Brown, 6 Vet. App.
321, 324 (1993).

These include:

> **1) pain** with joint movement
>
> **2) weakened movement** against varying resistance
>
> **3) lack of endurance** following repetitive use
>
> **4) effects of episodic exacerbations** (**flare-ups**) on functional
> ability.

b\. Each of these issues should be assessed and the amount the joint is
[additionally limited]{.underline} (if any) resulting from one or more
of these factors should -- if possible --be reported **in degrees of
additional loss of motion**. The **absence** of any (or all) of these
factors should also be noted. You must be specific as to
[where]{.underline} (i.e., from [flexion]{.underline} or
[extension]{.underline}) any additional losses should be subtracted. For
example, if knee pain on ROM testing prevents full flexion and an
additional ROM loss for pain of 20 degrees is warranted, you must
specifically state the additional limitation of flexion due to pain
(e.g., "An additional 20 degrees loss of knee flexion is warranted
because of pain on movement" or, better and clearer, "Because of pain on
movement, the ROM is estimated to be 0 to X rather than 0 to Y found on
range of motion without taking pain into consideration."). At present
there are no guidelines as to which tests should be used to determine
the strength and endurance for the various joints. These tests should be
individualized, keeping in mind patient safety.

**[Example]{.underline}:** If shoulder abduction is 0 to 180 degrees
against gravity, but there is evidence of pain (verbal complaint, facial
grimace, etc.) between 120 degrees and 180 degrees, this should be
documented. If further testing for endurance against resistance (e.g.,
10 repetitions using a 5-pound dumbbell) reduces shoulder abduction to
90 degrees, this should be reported. If more than one factor is
contributing to loss of ROM, state -- if possible -- which has the major
functional impact. This can be done as a **comment**. For the above
example, this might read: "[Comment]{.underline}: While shoulder
abduction against gravity is full, 0 to 180 degrees, because of the
combined effects of pain and lack of endurance, the veteran's functional
ROM is best estimated to be 0 to 90 degrees."

c\. Describe the patient\'s functional disability as to effects on daily
activities (eating, dressing, walking, breathing, etc.) and employment.

## 11.4 What are the important elements of a disability examination for disease or injury of the spine?

**a. History:** State type and date of injury or date of onset of
infection or arthritis. Describe treatment and response, plus any side
effects of treatment. Report pain, inflammation, morning stiffness,
fatigue, frequency, severity, and duration of flare-ups, and any effects
on daily activities and employment.

**b. Range of motion**: Rating criteria (and associated examination
requirements) for the spine are currently under review and
[no]{.underline} average normal ranges of motion for the spine are
included in the **Spine Worksheet. Examiners should state the normal
range of motion when providing spine range of motion measured by a
goniometer**, e.g., forward flexion of the lumbar spine is 80 out of 90
degrees, and backward extension is 20 out of 35 degrees. This is
necessary until a regulation (pending) standardizes normal ranges of
motion of the spine for VA disability examination purposes, since both
the range of motion of the spine considered to be normal and the method
by which it is determined vary in different standard medical textbooks
and books on disability evaluation. Until the regulation is in effect,
it is currently up to the examiner to provide the particular baseline
range of motion he or she considers normal (and to refer to the source
of that normal ROM) so that the rater has a good basis on which to make
a disability evaluation. For example, the following is the normal spine
range of motion that was given in the American Medical Association
[Guides to the Evaluation of Permanent Impairment]{.underline}, 2nd ed.
(1984), which is the last edition of the [Guides]{.underline} that
measured range of motion of the spine using a goniometer. It could be
used as a reference for normal ROM, although it is not the only
acceptable reference at present.

**Cervical spine**

0 to 45 degrees flexion

0 to 45 degrees extension

0 to 45 degrees left and right lateral flexion

0 to 80 degrees left and right lateral rotation

**Thoracolumbar (or lumbar) spine**

0 to 90 degrees forward flexion

0 to 30 degrees extension

0 to 30 degrees, left and right lateral flexion

0 to 30 degrees left and right lateral rotation

**c. If the range of motion** in a particular individual is limited by
factors other than disease or injury of the spine, such as age, body
habitus, or neurologic disease, the examiner should explain and give an
approximation, if possible, of the normal ROM for that individual based
on those factors.

**d. Thoracic spine** use [either]{.underline} the cervical spine ROM
[in degrees]{.underline} or the lumbosacral spine ROM [in
degrees]{.underline}, depending on whether the thoracic spine
symptoms/findings are predominantly in the upper (i.e., use cervical
ROM) or lower (i.e., use lumbosacral ROM) portion of the thoracic spine.

**e. Ankylosis**: Describe each segment of the spine affected by
ankylosis and report whether the entire segment or only part of the
segment is ankylosed. Indicate whether the ankylosis is in favorable or
unfavorable position, and if unfavorable, what functions are affected.
In general, favorable ankylosis of a segment of the spine means
ankylosis is fixed in a neutral position. Unfavorable ankylosis of a
segment of the spine means there is fixation in flexion or extension,
and there is functional impairment because of the ankylosis, such as
difficulty walking because of a limited line of vision, restricted
opening of the mouth and chewing, dyspnea, dysphagia, atlantoaxial or
cervical subluxation or dislocation, neurologic symptoms, etc.

## 11.5 What are the important elements of a disability examination for disc disease (intervertebral disc syndrome)?

**a. Spine examination**: A complete examination of the pertinent areas
of the spine, as described in 11.4, should be conducted, whether or not
there has been surgery.

**b. Neurologic examination**: A thorough neurologic examination, both
motor and sensory, of all potentially affected areas, should also be
conducted. Include any effects on bowel or bladder functioning.

**c. Incapacitating episodes**. Describe the duration of any
incapacitating episodes (an incapacitating episode is a period of acute
signs and symptoms due to intervertebral disc syndrome that requires bed
rest and treatment by a physician) during the past year.

## 11.6 When are imaging studies usually needed?

a\. In general, the least invasive and least expensive means of
objectively documenting pathology, such as arthritic changes and/or
structural defects, is preferred.

b\. The **diagnosis of degenerative or post-traumatic arthritis of a
joint requires x-ray confirmation one time only**. Once the diagnosis of
arthritis has been confirmed in a joint, further imaging studies of that
joint are generally **not** required because benefits are determined by
the amount of functional impairment and not by the severity of x-ray or
other imaging study findings. For example, if the examination request
specifies a veteran's left knee for examination, and the request notes
that the veteran is already service-connected (SC) for "left knee
degenerative arthritis," then additional x-rays are not required. On the
other hand, if the veteran is only **claiming** service-connection for
left knee degenerative arthritis and is not yet service-connected, and
no past imaging studies are available documenting arthritic changes,
then appropriate x-ray studies should be obtained and the results
included with the final examination report. Consult with the regional
office before requesting or scheduling any specialized or invasive test.

c\. Review all requested imaging tests, include them in the examination
report, and correlate them with clinical findings before finalizing the
diagnosis and returning the report to VBA.

## 11.7 What are the important elements of a disability examination for muscle disease or injury?

**a. History:** type and date of injury or infection, treatment and
response, pain, inflammation, stiffness, fatigue, and frequency and
severity of flare-ups. For residuals of wounds, describe both entrance
and exit wounds, the history of the initial injury, whether or not
hospitalization was required, whether there was debridement or other
surgery, etc.

**b. Physical:**

1\) Identify each specific muscle affected by tissue loss, penetrating
injuries, scar formation, adhesions, damage to tendons.

2\) When there is muscle atrophy, record the circumference of the
atrophic muscle and the comparison muscle on the opposite side.

3\) If the injured muscle acts upon a joint or joints, record the range
of motion of the affected joint(s) as described in 11.3.

4\) Report any effects on gait, posture, or functions of adjacent
joints, muscles, or nerves, and interference with sitting, standing,
walking, weight-bearing, balance and working.

**c. Reference:**

"Emergency War Surgery NATO Handbook", 2^nd^ ed., 1988. It is also
available on the Internet at http://www.vnh.org/.

## 11.8 What is the standard muscle strength grading system?

**0 = Absent** No muscle movement felt.

**1 = Trace** Muscle can be felt to tighten, but no movement produced.

**2 = Poor** Muscle movement produced only with gravity eliminated.

**3 = Fair** Muscle movement produced against gravity, but cannot
overcome any resistance.

**4 = Good** Muscle movement produced against some resistance, but not
against "normal" resistance.

**5 = Normal** Muscle movement can overcome "normal" resistance.

## 11.9 What are the major muscle groups and what is their significance?

a\. The rating schedule lists the following 23 muscle groups, provided
for your reference, and the rating percentage evaluations to be assigned
for different degrees of muscle injury (slight, moderate, etc.) vary
depending upon which muscle group is affected. Therefore, specify each
individual muscle affected so that the rater can select the appropriate
group(s) under which to evaluate.

b\. For the sake of clarity, and to avoid returned exams or questions,
use muscle terminology as it is given below (e.g., "adductor of thumb"
instead of "adductor pollicis," but "extensor hallucis longus" instead
of "long extensor of the great toe"), because this is the terminology
used in the rating schedule regulations.

c\. With penetrating wounds, including chest and abdominal wounds,
identify each muscle traversed by the projectile.

d\. Unless the report is precise, it may be returned, especially in
complex cases, to clarify the exact muscles or muscle group(s) involved
in an injury.

**Group I.** Extrinsic muscles of shoulder girdle, which rotate scapula
upward and elevate the arm above shoulder level. (1) trapezium (2)
levator scapulae (3) serratus magnus.

**Group II.** Extrinsic muscles of shoulder girdle, which lower the arm
from a vertical overhead position to hanging at side and act with Group
III in forward and backward swing of the arm. (1) pectoralis major,
costosternal origin; (2) latissimus dorsi and teres major; (3)
pectoralis minor; (4) rhomboid, major and minor.

**Group III.** Intrinsic muscles of shoulder girdle, which elevate and
abduct arm to level of shoulder and act with Group II in forward and
backward swing of the arm. (1) pectoralis major, clavicular origin (2)
deltoid.

**Group IV.** Intrinsic muscles of shoulder girdle, which stabilize
shoulder against injury in strong movements, hold head of humerus in
socket, and abduct, outwardly rotate, and inwardly rotate arm. (1)
supraspinatus; (2) infraspinatus and teres minor; (3) subscapularis; (4)
coracobrachialis.

**Group V.** Flexor muscles of the elbow, which flex and supinate the
elbow and help stabilize the shoulder joint. (1) biceps (2) brachial (3)
brachioradialis.

**Group VI.** Extensor muscles of the elbow, which extend the elbow and
help stabilize the shoulder joint. (1) triceps (2) anconeus.

**Group VII.** Muscles arising from medial condyle of humerus, which
flex wrist and fingers. Flexors of the carpus and long flexors of
fingers and thumb; pronator teres and quadratus.

**Group VIII.** Muscles arising mainly from lateral condyle of humerus,
which extend wrist, fingers and thumb and abduct thumb. Extensor of
carpus, fingers and thumb; supinator.

**Group IX.** Intrinsic muscles of the hand, which perform the delicate
manipulative movements of the hand. Thenar eminence; short flexor,
opponens, abductor, and adductor of the thumb; hypothenar eminence;
short flexor, opponens, and abductor of the little finger; 4 lumbricales
and 4 dorsal and 3 palmar interrossei.

**Group X.** Intrinsic muscles of the foot, for movement of forefoot and
toes, propulsive thrust in walking. [Plantar]{.underline}: (1) flexor
digitorum brevis; (2) abductor hallucis; (3) abductor digiti minimi; (4)
quadratus plantae; (5) lumbricales; (6) flexor hallucis brevis; (7)
adductor hallucis; (8) flexor digiti minimi brevis; (9) dorsal and
plantar interossei. Other important plantar structures include the
plantar aponeurosis, long plantar and calcaneonavicular ligament,
tendons of posterior tibial, peroneus longus, and long flexors of great
and little toes. [Dorsal:]{.underline} (1) extensor hallucis brevis (2)
extensor digitorum brevis. Other important dorsal structures include the
cruciate, crural, deltoid and other ligaments, tendons of long extensors
of toes and peroneal muscles.

**Group XI.** Posterior and lateral crural muscles and muscles of the
calf, which produce propulsion, plantar flexion of foot, stabilization
of the arch, flexion of toes, and flexion of knee. (1) triceps surae
(gastrocnemius and soleus); (2) tibialis posterior; (3) peroneus longus;
(4) peroneus brevis; (5) flexor hallucis longus; (6) flexor digitorum
longus; (7) popliteus; (8) plantaris.

**Group XII.** Anterior muscles of the leg, which dorsiflex the foot,
extend the toes, and stabilize the arch. (1) tibialis anterior (2)
extensor digitorum longus; (3) extensor hallucis longus; (4) peroneus
tertius.

**Group XIII.** Posterior thigh group, hamstring complex, which extend
the hip, flex the knee, and outwardly and inwardly rotate the flexed
knee, help synchronize simultaneous flexion or extension of hip and
knee. (1) biceps femoris (2) semimembranous (3) semitendinosus.

**Group XIV.** Anterior thigh group, which extends knee, aids
simultaneous flexion of hip and knee, produces tension of fascia lata
and iliotibial band, acting with Group XVII in postural support of the
body, helps synchronize hip and knee. (1) sartorius (2) rectus femoris
(3) vastus externus; (4) vastus intermedius (5) vastus internus (6)
tensor vaginae femoris (tensor fasciae latae).

**Group XV.** Mesial thigh group, which adducts hip, flexes hip, and
flexes knee. (1) adductor longus; (2) adductor brevis; (3) adductor
magnus; (4) gracilis.

**Group XVI.** Pelvic girdle group 1, which flexes hip. (1) psoas (2)
iliacus (3) pectineus.

**Group XVII.** Pelvic girdle group 2, which extends hip, abducts thigh,
elevates opposite side of pelvis, and produces tension of fascia lata
and iliotibial band, aiding postural support by steadying pelvis. (1)
gluteus maximus (2) gluteus medius (3) gluteus minimus.

**Group XVIII.** Pelvic girdle group 3, which outwardly rotates thigh
and stabilizes hip joint. (1) piriformis (2) gemellus, superior or
inferior (3) obturator, external or internal (4) quadratus femoris.

**Group XIX.** Muscles of the abdominal wall, which support and compress
abdominal wall and lower thorax, produce flexion and lateral motions of
spine, act as synergists in strong downward motion of arm. (1) rectus
abdominis (2) external oblique (3) internal oblique (4) transversalis
(5) quadratus lumborum.

**Group XX.** Spinal muscles, which produce postural support of body,
extension and lateral movements of spine. Sacrospinalis (erector spinae
and its prolongations in thoracic and cervical regions).

**Group XXI.** Muscles of respiration. Thoracic muscle group.

**Group XXII.** Muscles of the front of the neck, which produce rotary
and forward movements of the head, respiration, deglutition. Lateral,
suprahyoid and infrahyoid group, which rotates and moves head forward;
respiration; deglutition. (1.) trapezius 1 (clavicular insertion) (2)
sternocleidomastoid (3) the \"hyoid\" muscles (4) sternothyroid (5)
digastric.

**Group XXIII.** Muscles of the side and back of the neck, which produce
movements of the head, fixation of shoulder movements. Suboccipital,
lateral vertebral and anterior vertebral muscles.

## 11.10 What are some key elements of a disability examination for scars? 

a\. See also "**Scars" Worksheet**.

b\. Always report the **presence** or **absence of tenderness on direct
palpation**.

c\. As compensation for **burn scars** is dependent on **size** and
whether the scar is a residual of a **second degree** or **third degree
burn**, each burn scar must include information on size (cm x cm) and
the type of burn scar (i.e., second degree or third degree). In general,
second-degree burn scars retain normal appearance under usual
circumstances, but may lack normal hair growth, lack normal sweating,
and/or appear different when exposed to sun.

d\. With disfigurement or disfiguring scars of the head, face or neck,
submit unretouched color prints.

## 11.11 How should a Final Diagnosis of musculoskeletal disease be expressed and supported?

a\. After review of any requested studies, the examiner should include a
Final Diagnosis for each musculoskeletal condition, complaint, or
symptom listed on the examination request, or -- if a complete general
medical examination was requested -- all musculoskeletal complaints
and/or findings noted at the time of the examination.

b\. Pay particular attention that the body part is correctly identified
(left vs. right vs. bilateral) throughout the history, physical
examination and Final Diagnosis.

c\. For VA rating purposes, Final Diagnoses should **not** be expressed
in ambiguous or equivocal terms. Avoid qualifiers such as "possible,"
"may be due to," or "rule out."

d\. Be sure that Final Diagnoses are supported by appropriate diagnostic
studies. For example, if the lumbosacral spine x-ray does not show
degenerative changes, then a Final Diagnosis of "degenerative arthritis"
is not acceptable because this diagnosis requires X-ray confirmation.

e\. Also, be sure that the Final Diagnosis identifies a pathologic
process. Thus, "lumbosacral **pain**" is [not]{.underline} acceptable,
while "lumbosacral **strain**" is an acceptable Final Diagnosis. A Final
Diagnosis of "arthralgia" is also unacceptable unless it is part of a
systemic condition, such as rheumatoid arthritis, or an "undiagnosed
illness" in a Gulf War veteran (See examination worksheet titled
"**Guidelines for Disability Examinations in Gulf War Veterans").**

## Worksheet - BONES (FRACTURES AND BONE DISEASE)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Describe details of any injury, episodes of osteomyelitis, or
surgery.

2\. Symptoms of pain, weakness, stiffness, swelling, heat, redness,
drainage, instability or

giving way, \"locking,\" abnormal motion, etc.

3\. Treatment: medication type, dose, frequency, response, and side
effects; other

treatment.

4\. If there are periods of flare-up of bone disease:

a\. State their severity, frequency, and duration.

b\. Name the precipitating and alleviating factors.

c\. Estimate to what extent, if any, they affect functional impairment
during the

flare-up.

5\. Is there current active infection? If not, when was the last active
infection? How was

it determined?

6\. Describe whether crutches, brace, cane, corrective shoes, etc., are
needed.

7\. Are there constitutional symptoms of bone disease?

8\. Describe the effects of the condition on the veteran\'s usual
occupation and daily

activities.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the disability being
examined and fully

describe current findings:

1\. Describe objective evidence of deformity, angulation, false motion,
shortening, intra-

articular involvement, etc.

2\. Malunion, nonunion, any loose motion, false joint.

3\. Tenderness, drainage, edema, painful motion, weakness, redness,
heat.

> 4\. For weight bearing joints (hip, knee, ankle), describe gait and
> functional limitations on standing and walking. Describe any
> callosities, breakdown, or unusual shoe wear

pattern that would indicate abnormal weight bearing.

5\. If ankylosis is present, describe the position of the bones of the
joint in relationship to

one another (in degrees of flexion, external rotation, etc.), and state
whether the

ankylosis is stable and pain free.

6\. With joint involvement, [a detailed assessment of each affected
joint is required]{.underline}.

**Note:** See worksheet on Shoulder, Elbow, Wrist, Hip, Knee, and Ankle
for normal

range of motion of those joints.

a\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance.

b\. If the joint is painful on motion, state at what point in the range
of motion pain

begins and ends.

c\. State to what extent, if any, the range of motion or function is
[additionally]{.underline}

[limited]{.underline} by pain, fatigue, weakness, or lack of endurance.
If more than one of

these is present, state, if possible, which has the major functional
impact.

7\. If shortening of the leg may be present, measure the leg length from
the anterior

superior iliac spine to the medial malleolus.

8\. Are there constitutional signs of bone disease - anemia, weight
loss, fever, debility,

amyloid liver, etc.?

D. **Diagnostic and Clinical Tests:**

1\. As indicated: X-rays, including special views or weight bearing
films, MRI,

arthrogram, diagnostic arthroscopy. **Note:** The diagnosis of
degenerative arthritis or

post-traumatic arthritis of a joint requires X-ray confirmation. Once
the diagnosis has

been confirmed in a joint, further X-rays of that joint are not
required.

2\. For osteomyelitis, state whether there is an involucrum, sequestrum,
or draining sinus.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

**E. Diagnosis:**

Signature: Date:

## Worksheet - CHRONIC FATIGUE SYNDROME

Name: SSN:

Date of Exam: C-number:

Place of Exam:

Narrative: Chronic fatigue syndrome (CFS) is an illness characterized by
debilitating fatigue and several flu-like symptoms. It may have both
physical and psychiatric manifestations and closely resembles
neurasthenia, neurocirculatory asthenia, fibrositis, or fibromyalgia.

**For VA purposes, a diagnosis of CFS must meet both of the following
criteria:**

1\. New onset of debilitating fatigue that is severe enough to reduce or
impair average

daily activity below 50 percent of the patient\'s pre-illness activity
level for a period

of 6 months, and

2\. Other clinical conditions that may produce similar symptoms must be
excluded

by thorough evaluation, based on history, physical examination, and
appropriate

laboratory tests.

**It must also meet six or more of the following ten criteria:**

1\. Describe in detail:

a\. Acute onset of the condition.

b\. Low grade fever.

c\. Nonexudative pharyngitis.

d\. Palpable or tender cervical or axillary lymph nodes.

e\. Generalized muscle aches or weakness.

f\. Fatigue following lasting 24 hours or longer after exercise.

g\. Headaches (of a type, severity or pattern that is different from
headaches in the

premorbid state.

h\. Migratory joint pains.

i\. Neuropsychologic symptoms.

j\. Sleep disturbance.

A. **Review of Medical Records:**

Comment on:

1\. Date diagnosis established.

2\. Does it meet the requirements outlined above?

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Estimate the amount of routine daily activities that are restricted
due to CFS. Give

specific examples.

2\. If there are incapacitating episodes (requiring bed rest and
treatment by a physician),

what is their frequency and duration?.

3\. Does the patient require continuous medication for CFS?

C. **Physical Examination (Objective Findings):**

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - FEET

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Pain, weakness, stiffness, swelling, heat, redness, fatigability,
lack of endurance, etc.

Describe symptoms at rest and on standing and walking.

2\. Treatment - type, dose, frequency, response, side effects.

3\. If there are periods of flare-up of joint disease:

a\. State their severity, frequency, and duration.

b\. Name the precipitating and alleviating factors.

c\. Estimate to what extent, if any, they result in additional
limitation of motion or

functional impairment during the flare-up.

4\. Describe whether crutches, brace, cane, corrective shoes, etc., are
needed.

5\. Describe details of any surgery or injury.

6\. Describe corrective shoes, shoe inserts, or braces used and their
efficacy.

7\. Describe effects of the condition(s) on the veteran\'s usual
occupation and daily

activities.

C. **Physical Examination (Objective Findings)**

Address each of the following as appropriate to the condition being
examined and fully describe current findings: [A detailed assessment of
each affected joint is required]{.underline}.

1\. Describe each foot separately. For nomenclature of toes use: great
toe, second, third,

fourth, and fifth. The functional loss should be related to the
anatomical condition.

2\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance.

3\. If the joint is painful on motion, state at what point in the range
of motion pain begins

and ends.

4\. State to what extent (if any) and in which degrees (if possible) the
range of motion or

function is [additionally limited]{.underline} by pain, fatigue,
weakness, or lack of endurance

following repetitive use or during flare-ups. If more than one of these
is present, state,

if possible, which has the major functional impact.

5\. Describe objective evidence of painful motion, edema, instability,
weakness,

tenderness, etc.

6\. Describe gait and functional limitations on standing and walking.

7\. Describe any callosities, breakdown, or unusual shoe wear pattern
that would indicate

abnormal weight bearing.

8\. Describe any skin and vascular changes.

9\. Posture on standing, squatting, supination, pronation, and rising on
toes and heels.

10\. Describe hammertoes, high arch, clawfoot, or other deformity -
actively or passively

correctable?

11\. For flatfoot

a\. Describe weight bearing and non-weight bearing alignment of the
Achilles

tendon.

b\. Describe whether the Achilles tendon alignment can be corrected by

manipulation and whether there is pain on manipulation.

c\. Describe degrees of valgus and whether correctable by manipulation.

d\. Describe extent of forefoot and midfoot malalignment and whether
correctable

by manipulation.

12\. For hallux valgus, describe angulation and dorsiflexion at first
metatarso-phalangeal

joints.

D. **Diagnostic and Clinical Tests:**

Comment on:

1\. X-rays for flatfoot and clawfoot - weight bearing AP and lateral
views and non-weight

bearing AP, lateral, and oblique views.

2\. For other conditions, AP lateral and oblique of entire foot as
applicable.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - FIBROMYALGIA

Name: SSN:

Date of Exam: C-number:

Place of Exam:

Narrative: For VA compensation purposes, the diagnosis of fibromyalgia
(sometimes called fibrositis, primary fibromyalgia syndrome, or
myofascial pain syndrome) requires the presence of widespread
musculoskeletal pain and tender points. Additional findings may also be
present: fatigue, sleep disturbance, stiffness, paresthesias, headache,
irritable bowel symptoms, depression, anxiety, or Raynaud\'s-like
symptoms. Widespread pain is defined as pain in both the left and right
sides of the body, that is both above and below the waist, and that
affects both the axial skeleton (i.e., cervical spine, anterior chest,
thoracic spine, or low back) and the extremities. Rule out other
diagnostic entities that may be responsible for the symptomatology
presented.

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Date of onset of symptoms, date of diagnosis (if known).

2\. What precipitates and alleviates symptoms?

3\. Location, severity, frequency of any musculoskeletal pain,
stiffness, or muscle

weakness, whether episodic or constant, and their effects on daily
activities

4\. Unexplained fatigue, sleep disturbances.

5\. GI symptoms.

6\. Treatment, (type, duration, response). Has treatment been
continuous?

7\. Is there depression or anxiety?

8\. Lost time from work?

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:
(Please incorporate all

ancillary study results into the final diagnosis.)

1\. Is the condition currently active or in remission?

2\. Musculoskeletal areas involved.

3\. Trigger or tender points.

4\. Muscle strength in involved areas.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - JOINTS (SHOULDER, ELBOW, WRIST, HIP, KNEE, AND ANKLE)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Pain, weakness, stiffness, swelling, heat and redness, instability
or giving way,

\"locking,\" fatigability, lack of endurance, etc.

2\. Treatment - type, dose, frequency, response, side effects.

3\. If there are periods of flare-up of joint disease:

a\. State their severity, frequency, and duration.

b\. Name the precipitating and alleviating factors.

c\. Estimate to what extent, if any, they result in additional
limitation of motion or

functional impairment during the flare-up.

4\. Describe whether crutches, brace, cane, corrective shoes, etc., are
needed.

5\. Describe details of any surgery or injury.

6\. Describe any episodes of dislocation or recurrent subluxation.

7\. For inflammatory arthritis, describe any constitutional symptoms.

8\. Describe the effects of the condition on the veteran\'s usual
occupation and daily

activities.

9\. Dominance of extremity and means used to identify dominant
extremity.

10\. If there is a prosthesis, provide date of prosthetic implant and
describe any complaint

of pain, weakness, or limitation of motion. State whether crutches,
brace, etc., are

needed.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the condition being
examined and fully

describe current findings: [A detailed assessment of each affected joint
is required,]{.underline}

[including joints with prostheses]{.underline}.

1\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance. Provide range of
motion in

degrees.

2\. If the joint is painful on motion, state at what point in the range
of motion pain begins

and ends.

3\. State to what extent (if any) and in which degrees (if possible) the
range of motion or

joint function is [additionally limited]{.underline} by pain, fatigue,
weakness, or lack of endurance

following repetitive use or during flare-ups. If more than one of these
is present, state,

if possible, which has the major functional impact.

4\. Describe objective evidence of painful motion, edema, effusion,
instability, weakness,

tenderness, redness, heat, abnormal movement, guarding of movement, etc.

> 5\. For weight bearing joints (hip, knee, ankle), describe gait and
> functional limitations on standing and walking. Describe any
> callosities, breakdown, or unusual shoe wear

pattern that would indicate abnormal weight bearing.

6\. If ankylosis is present, describe the position of the bones of the
joint in relationship to

one another (in degrees of flexion, external rotation, etc.), and state
whether the

ankylosis is stable and pain free.

7\. If indicated, measure the leg length from the anterior superior
iliac spine to the medial

malleolus.

8\. For [inflammatory arthritis]{.underline}, describe any
constitutional signs.

9\. Describe range of motion with prosthesis in same detail as described
above for

nonprosthetic joints.

D. **Normal Range of Motion:** All joint Range of Motion measurements
must be made using a **[goniometer]{.underline}**. Show each measured
range of motion separately rather than as a continuum. For example, if
the veteran lacks 10 degrees of full knee extension and has normal
flexion, show the range of motion as extension to minus 10 degrees (or
lacks 10 degrees of extension) and flexion

0 to 140 degrees.

1\. [Hip range of motion:]{.underline} (Movement of femur as it rotates
in the acetabulum.)

a\. Normal range of motion, using the anatomical position as zero
degrees.

[Flexion]{.underline} = 0 to 125 degrees (To gain a true picture of hip
flexion, i.e.,

movement between the pelvis and femur in the hip joint, the opposite
thigh

should be extended to minimize motion between the pelvis and spine.)

[Extension]{.underline} = 0 to 30 degrees.

[Adduction]{.underline} = 0 to 25 degrees.

[Abduction]{.underline} = 0 to 45 degrees.

[External rotation]{.underline} = 0 to 60 degrees.

[Internal rotation]{.underline} = 0 to 40 degrees.

2\. [Knee range of motion:]{.underline}

a\. Normal range of motion, using the anatomical position as zero
degrees.

[Flexion]{.underline} = 0 to 140 degrees.

> [Extension]{.underline} - zero degrees = full extension. Show loss of
> extension by describing the degrees in which extension is not
> possible. (e.g., Show range of motion as extension to minus 10 degrees
> and flexion 0 to 140 degrees when full extension is limited by 10
> degrees and full flexion is possible.)

b\. Stability.

[Medial and Lateral Collateral Ligaments:]{.underline}
[Varus/valgus]{.underline} in neutral and in 30

degrees of flexion - normal is no motion.

[Anterior and Posterior Cruciate Ligaments:]{.underline}
[Anterior/posterior]{.underline} in 30 degrees of

flexion with foot stabilized - normal is less than 5 mm. of motion (1/4
inch -

Lachman\'s test) or in 90 degrees of flexion with foot stabilized -
normal is less

than 5mm. of motion (1/4 inch - anterior and posterior drawer test).

[Medial and Lateral Meniscus:]{.underline} Perform McMurray\'s test.

3\. [Ankle range of motion:]{.underline}

a\. Neutral position is with foot at 90 degrees to ankle. From that
position,

dorsiflexion is 0 to 20 degrees; plantar flexion is 0 to 45 degrees.

b\. Describe any varus or valgus angulation of the os calcis in
relationship to the

long axis of the tibia and fibula.

4\. [Shoulder, elbow, forearm, and wrist range of motion:]{.underline}

a\. Normal range of motion is measured with zero degrees the anatomical
position

[except]{.underline} for 2 situations:

\(1\) Supination and pronation of the forearm is measured with the arm

against the body, the elbow flexed to 90 degrees, and the forearm in

mid position (zero degrees) between supination and pronation.

> \(2\) Shoulder rotation is measured with the arm abducted to 90
> degrees, the elbow flexed to 90 degrees, and the forearm reflecting
> the midpoint (zero degrees) between internal and external rotation of
> the shoulder.

b\. [Shoulder forward flexion]{.underline} = zero to 180 degrees.

c\. [Shoulder abduction]{.underline} = zero to 180 degrees.

d\. [Shoulder external rotation]{.underline} = zero to 90 degrees.

e\. [Shoulder internal rotation]{.underline} = zero to 90 degrees.

f\. [Elbow flexion]{.underline} = zero to 145 degrees.

g\. [Forearm supination]{.underline} = zero to 85 degrees.

h\. [Forearm pronation]{.underline} = zero to 80 degrees.

i\. [Wrist dorsiflexion]{.underline} (extension) = zero to 70 degrees.

j\. [Wrist palmar flexion]{.underline} = zero to 80 degrees.

k\. [Wrist radial deviation]{.underline} = zero to 20 degrees.

l\. [Wrist ulnar deviation]{.underline} = zero to 45 degrees.

E. **Diagnostic and Clinical Tests:**

> 1\. As indicated: X-rays, including special views or weight bearing
> films, MRI, arthrogram, diagnostic arthroscopy.
>
> **Note:** The diagnosis of degenerative arthritis or post-traumatic
> arthritis of a joint requires X-ray confirmation.
>
> 2\. Include results of all diagnostic and clinical tests in the
> examination report.
>
> Once the diagnosis has been confirmed in a joint, further X-rays of
> that joint are not required.

F. **Diagnosis:**

Signature: Date:

## Worksheet - HAND, THUMB, AND FINGERS

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. If there are periods of flare-up of joint disease:

a\. State their severity, frequency, and duration.

b\. Name the precipitating and alleviating factors.

c\. Estimate to what extent, if any, they result in additional
limitation of motion or

functional impairment during the flare-up.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the condition being
examined and fully

describe current findings:

1\. Anatomical defects.

> 2\. Functional defects (motion of thumb and fingers should be
> described as to how near, in inches, the tip of thumb can approximate
> the fingers, or how near the tips of fingers can approximate the
> median transverse fold of the palm.

3\. Grasping objects (strength and dexterity).

> The hand should be evaluated as a unit intricately adapted for
> grasping, pushing, pulling, twisting, probing, writing, touching, and
> expression. Do not designate fingers numerically; use thumb, index,
> middle (or long), ring, and little. Specify which hand is involved and
> state whether the individual is right- or left-handed. Designate the
> joints as wrist, MP (metacarpophalangeal), PIP (proximal
> interphalangeal), or DIP (distal interphalangeal). Designate phalanges
> as proximal, middle or distal.

4\. [A detailed assessment of each affected joint is
required]{.underline}.

> a\. Using a goniometer, measure the [passive]{.underline} and
> [active]{.underline} range of motion, including movement against
> gravity and against strong resistance.
>
> b\. State to what extent (if any) and in which degrees (if possible)
> the range of motion or joint function is [additionally
> limited]{.underline} by pain, fatigue, weakness, or lack of endurance
> following repetitive use or during flare-ups. If more than one of
> these is present, state, if possible, which has the major functional
> impact.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - MUSCLES

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. If there are periods of flare-up of residuals of muscle injury:

a\. State their severity, frequency, and duration.

b\. Name the precipitating and alleviating factors.

> c\. Estimate to what extent, if any, they result in additional
> limitation of motion or functional impairment during the flare-up.
>
> 2\. If injury is due to a missile: initial treatment in the field,
> length of initial hospitalization and any surgeries or other repairs
> undertaken, time for return to duty or limited duty or determination
> that duty could not be resumed.

3\. Record exact muscles injured or destroyed and describe.

> 4\. Record any associated injuries, particularly those affecting bony
> structures, nerves or vascular structures and specify the nature of
> treatment required.
>
> 5\. Describe present symptoms of muscle pain, activity limited by
> fatigue or inability to move joint through a portion of its range; and
> the degree to which this interferes with activities of daily living.
>
> 6\. For tumors of muscle, describe onset of symptoms, date(s) of
> biopsy and/or surgical excision and residual defects. If malignant
> neoplasm, need date of diagnosis, dates and type of treatment, and
> date of last treatment.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Entry and exit wound scars as well as dimensions.

2\. Tissue loss comparison, and specify muscle group(s) penetrated.

3\. Scar formation measurement (sensitivity, tenderness, etc.)

4\. Adhesions.

5\. Tendon damage.

6\. Bone, joint or nerve damage.

7\. Muscle strength.

8\. Muscle herniation and, if any, if supported by a truss or belt.

> 9\. Loss of muscle function. Can muscle group move joint through
> normal range with sufficient comfort, endurance and strength to
> accomplish activities of daily living? Can muscle group move joint
> independently through useful ranges of motion but with limitation by
> pain or easy fatigability or weakness? Can muscle group move joint
> only with assistance or with gravity eliminated? Is there no ability
> of muscle group to move joint even with gravity eliminated and joint
> passively moveable? Is any muscle contraction felt?

10\. If joint function is affected:

a\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance

> b\. State to what extent (if any) and in which degrees (if possible)
> the range of motion or function is [additionally limited]{.underline}
> by pain, fatigue, weakness, or lack of endurance following repetitive
> use or during flare-ups. If more than one of these is present, state,
> if possible, which has the major functional impact.

D. **Diagnostic and Clinical Tests:**

1\. If applicable, x-rays of joint(s) involved in two planes or anatomic
area involved if not

recorded in past (once taken, the x-rays do not need to be repeated).

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - RESIDUALS OF AMPUTATIONS

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. The location of the amputation site.

2\. If symptoms exist, describe precipitating factors, aggravating
factors, alleviating

factors, alleviating medications, frequency, severity, and duration.

**C. Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Swelling, deformity, tenderness of stump.

2\. Skin, including scar.

3\. Circulation.

4\. Muscles

5\. Describe any limited motion or instability in the joint above the
amputation site.

6\. [A detailed assessment of each affected joint is
required]{.underline}.

a\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance.

b\. If the joint is painful on motion, state at what point in the range
of motion pain

begins and ends.

c\. State to what extent, if any, the range of motion or function is
[additionally]{.underline}

limited by pain, fatigue, weakness, or lack of endurance. If more than
one of

these is present, state, if possible, which has the major functional
impact.

7\. Bones

8\. Length of stump

9\. Neuroma, if present

10\. Is amputation of lower extremity improvable by prosthesis
controlled by natural knee

action?

**Measurement of the Stump:**

The stump of an amputated [thigh]{.underline} will be measured from the
perineum, at the origin of the adductor tendons, to the bony end of the
stump, with the claimant recumbent and the stump lying parallel with the
other lower limb. It is to be kept in mind that if the limb is abducted,
flexed, rotated or adducted, its length will be altered. The effective
length of a thigh stump is governed by its inside dimension. Measure
length of normal thigh if present and indicate whether amputation is in
upper, middle, or lower third. When amputation is bilateral, estimate
the same for a person of similar height.

The stump of an amputated [leg below the knee]{.underline} must be
measured from the insertion of the internal hamstring muscles to the
bony end of the stump with the patient recumbent and the leg flexed at
90 degrees.

The stump of an amputated [arm]{.underline} should be measured from the
anterior axillary fold to the bony end of the stump, with the stump
hanging parallel to the chest wall. Indicate whether the amputation site
is above or below the insertion of the deltoid muscle. A statement of
the remaining function is the best indicator of a disability\'s
severity.

The stump of an amputated [forearm]{.underline} should be measured from
the insertion of the biceps tendon to the bony end, with the elbow
flexed at 90 degrees. Indicate if the amputation site is above or below
the attachment of the pronator teres.

Amputations of [fingers]{.underline} should be described as through the
distal, middle, or proximal phalanx or as disarticulations through the
distal interphalangeal, proximal interphalangeal, or metacarpophalangeal
joint. Resection of the head of the metacarpal will always be reported
if shown. Complete or partial loss or resection of bones of the hand
will described in terms of the fraction of each remaining. If surgery
has altered the usefulness of remaining or transplanted digits, this
will be described.

Complete or partial loss of [toes]{.underline} or [metatarsal or tarsal
bones]{.underline} should be described as in the subparagraph above.
Always report loss of metatarsal head or other defects. Indicate if
amputation is through the tarsal-metatarsal joint and if any other
portions of the bones of the foot remain.

D. **Diagnostic and Clinical Tests:**

1\. X-ray if exact amputation level is not of record.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Amputations must be described in accordance with the following levels:

1\. ARM:

a\. Disarticulation

b\. Amputation above insertion of deltoid muscle.

c\. Amputation below insertion of deltoid muscle.

2\. FOREARM:

> a\. Above radial insertion of pronator teres (function is best
> indicator of disability).

b\. Below insertion of pronator teres.

3\. THIGH:

a\. Disarticulation, with loss of extrinsic pelvic girdle muscles.

> b\. Amputation of upper, middle or lower third, always measured from
> perineum to the bony end of the stump with the claimant recumbent and
> stump lying parallel with the other lower limb.
>
> State whether this level permits satisfactory prosthesis.

4\. LEG:

a\. Give level of amputation and condition of stump.

b\. State whether this level permits a satisfactory prosthesis.

c\. Describe any stump defects (e.g., painful neuroma or circulatory
disturbance).

Signature: Date:

## Worksheet - SPINE (CERVICAL, THORACIC, AND LUMBAR)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Present Medical History (Subjective Complaints):**

Comment on:

1\. Complaints of pain, weakness, stiffness, fatigability, lack of
endurance, etc.

2\. Treatment - type, dose, frequency, response, side effects

3\. If there are periods of flare-up:

a\. State their severity, frequency, and duration.

b\. Name the precipitating and alleviating factors.

c\. Estimate to what extent, if any, they result in additional
limitation of motion or

functional impairment during the flare-up.

4\. Describe whether crutches, brace, cane, etc., are needed.

5\. Describe details of any surgery or injury.

> 6\. Functional Assessment - Describe effects of the condition(s) on
> the veteran\'s usual occupation and daily activities.

C. **Physical Examination (Objective Findings):**

> Address each of the following as appropriate to the condition being
> examined and fully describe current findings:
>
> 1\. Using a goniometer, measure the [passive]{.underline} and
> [active]{.underline} range of motion, including movement against
> gravity and against strong resistance. Provide range of motion in
> degrees.
>
> 2\. If the spine is painful on motion, state at what point in the
> range of motion pain begins and ends.
>
> 3\. State to what extent (if any) and in which degrees (if possible)
> the range of motion or spinal function is [additionally
> limited]{.underline} by pain, fatigue, weakness, or lack of endurance
> following repetitive use or during flare-ups. If more than one of
> these is present, state, if possible, which has the major functional
> impact.

4\. Describe objective evidence of painful motion, spasm, weakness,
tenderness, etc.

5\. Postural abnormalities, fixed deformity.

6\. Musculature of back.

7\. Neurological abnormalities - if present, see appropriate worksheet.

D. **Normal Range of Motion:** All joint Range of Motion measurements
must be made using a **[goniometer]{.underline}**. Show each measured
range of motion separately rather than as a continuum.

E. **Diagnostic and Clinical Tests:**

Obtain the following and comment on them, as indicated:

1\. X-rays, MRI, as indicated.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

F. **Diagnosis:**

Signature: Date:

# Chapter 12 - NEUROLOGIC EXAMINATION

## 12.1 What are general considerations in conducting a neurologic examination for compensation and pension purposes?

**a. Purpose.** The disability evaluation examination serves as the
basis for **confirming (or establishing) the diagnosis** and for the
**determination of disability**. Neurologic disability is ordinarily
rated in proportion to the degree of impairment of motor, sensory, or
mental dysfunction. A major goal of the examination, then, is to
determine the presence and degree of such impairments since they cannot
be predicted from the diagnosis alone. This is obviously the case when
the diagnostic label merely defines the etiology or specifies the site
of abnormal anatomy. It is also true when the diagnosis does neither but
is a summary descriptor of the impairment itself. Such generic labels
(e.g., hemiplegia) seldom define the actual degrees of impair­ment in
specific patients.

**b. Diagnosis.** Nevertheless, a specific and accurate diagnosis is
necessary in every case. It is critical to adjudications related to
eligibility and forms a partial basis for rating decisions. By defining
the general spectrum of any disorder, the diagnosis suggests the major
types of impairment that may be present and which should be sought for
and evaluated. In addition, the prognosis for change is primarily
defined by an accurate diagnosis. Most applicants will present with an
established diagnosis. In a few it will be incorrect. In others new
signs and symptoms will have developed, accompanied by change in the
types and degree of impairment. In rare cases the applicant will be
undiagnosed. Thus, in all cases it is critical to carry out a thorough
examination in order to establish and confirm the correct diagnosis.

**c. Multiple diagnoses**. Every effort should be made to arrive at a
single unifying diagnosis whenever possible. Multiple diagnoses,
particularly one neurologic or "organic" and one psychiatric, cause
significant problems for the raters that are trying to evaluate the
disability. This will necessitate a complete general physical
examination and a psychiatric study as well as a detailed neurologic
examination. Some examinees will, however, clearly have two (or more)
separate and unrelated disorders and should be so diagnosed.

**d. Integration of findings**. Diagnosis of neurologic disease, like
the diagnosis of all disease, depends upon an integration of the
findings from the history, the physical examination, and laboratory
testing. Each has a somewhat unique contribution to make. The
neurological examination gives a static or cross-sectional view of the
current pattern of normal and abnormal findings from which one can often
infer the locus and extent of anatomic disturbances. The findings
themselves, however, do not necessarily reveal the etiology, nor the
history of how they came to be. For instance, the changes in strength,
tone, and reflexes can be much the same in a hemiplegia whether it is
due to a tumor or an infarct. On the other hand, the sequence of events
leading up to the current findings (the history) can often clearly
distinguish between the two. For many neurologic disorders, the
historical course of the symptoms and the findings on examination are so
characteristic that both an anatomic (localization) and etiologic
diagnosis can be made with reasonable certainty. In others only a
presumptive or differential diagnosis can be made, and laboratory
testing is needed. In a few cases definitive diagnosis can be difficult,
even for the experienced neurologist. This is particularly the case for
the uncommon or complicated problems. When the diagnosis cannot be made
with reasonable clinical certainty, it is better to simply report the
pertinent history and findings than to force them into an
unsubstantiated diagnostic conclusion.

**e. Need to report motor, sensory, and mental function**. In all cases
it is necessary to describe the impairments of motor, sensory, and
mental function as they form the major basis for rating determinations.
The methodology of the neurologic history and examination has been
developed primarily to establish etiologic and anatomic diagnoses, but
does not necessarily lend itself well to determining the degree of
functional impairment. For example, the presence of a Babinski sign may
be crucial to the diagnosis, yet no necessary direct functional
impairment can be attributed to this finding. Much the same can be said
for most laboratory tests. With few exceptions then, the degree of
motor, sensory or mental impairment can only be established by
observations more specifically designed for that purpose.

**f. Need for neurologic references**. It is beyond the scope of this
guide to review the methodology of the formal neurologic history and
physical examination, or the diagnostic criteria for the various
neurologic disorders. Reference should be made, when needed, to any of
several standard contemporary texts for these purposes. Rather, this
section focuses on several aspects of the evaluation process that may
assist the examiner in determining the degree of impairment, and that
are not generally addressed in standard neurologic texts.

## 12.2 What are the history requirements?

**a. Overall impression and chronology**. The pattern of symptom
development is often crucial for the diagnosis, regardless of the
findings on examination. Significant disturbances of function in many
neurologic disorders can be episodic. Unless performed during an
episode, the examination may be completely silent as to their presence.
Thus, it is important to gain an overall impression of the presenting
complaints and the chronology of their development. This should be done
before the details are sought, as this can distract both the patient and
the examiner.

**b. Guiding the history**. It is always desirable to permit the patient
to give his/her history of the illness without too much interruption,
except to redirect his/her conversation when it tends to drift too far a
field. Interjection of a brief question, such as "What happened next?"
helps to maintain chronological development of the course of events.
When possible, the patient's own words should be recorded to describe
his/her symptoms, but his/her meaning for the terms he/she uses must be
made clear. When complaints such as being *"dizzy,"* "confused," or
"weak" are made, care must be taken to specifically describe the
patient's exact meaning. Every safeguard should be used not to suggest
symptoms to the patient. The use of the question "Was there anything
else?" or "Did anything else bother you?" should always be used before
direct questioning for possible associated symptoms such as nausea or
vomiting in a patient with headache. When complaints are only obtained
after direct questioning, this fact should be noted in the record. A
specific statement should be made as to what parts of the history were
obtained from the patient and what parts, if any, from someone else. The
apparent reliability of the informants should be noted.

**c. Social/vocational history.** This is paramount for disability
evaluation examinations. Significant limitations in vocational
adaptability occasioned by neurologic disease will usually be
accompanied by similar limitations in comparable avocational activities
and daily living. A reliable history will usually document both types of
limitation. In most cases, a *validated* history of what the patient can
and cannot do, as well as the observations made by the physician during
the examination, will form the basis for the disability evaluation
granted by raters.

## 12.3 What are the examination requirements?

**a. Systematic survey desirable.** The neurologic examination utilizes
a diversity of often-unrelated techniques that must be applied to every
major portion of the body and to the body as a whole. Abnormal findings
in any area require more specific exploration in detail, so that any
branch of the examination must be expanded when necessary. Subsequent
findings may modify the interpretation of previous findings and may even
necessitate their reevaluation. Certain components of the examination
will be preselected for special interest, usually by the history or the
diagnosis itself. But these needs must not distract the examiner from
completing a systematic survey of neurologic functions. As with the
history, it is best to complete the general survey first. This prevents
overlooking significant findings in areas other than those preselected
for special attention and allows for a more complete integration of all
the findings. It is most important to employ a predetermined plan or
system for at least the general survey. The examiner can then return to
specific areas of interest for a more detailed evaluation.

**b. Minimum needs.** Any of the schemes recommended in standard texts
can be used as long as it is comprehensive. Whatever scheme is used, it
should minimally include a general inspection, testing of the cranial
nerves and special senses, general sensory and motor testing, a survey
of the "higher brain functions," and an estimation of the mental status.

**c. Report of examination**. The report should summarize all
significant positive findings, particularly those relating to limitation
of function. For facilitating comparison of serial examinations,
particularly when reported by different examiners, it is more helpful to
describe the actual observations than to summarize them as "mild,"
"moderate," or "severe," etc.

**d. Need for specific guidance for disability examinations**. The
formal neurologic examination, however, particularly as reported on
standardized forms, has been designed more to serve as a basis for
anatomic diagnosis than to determine the degree of disability. The
following comments are intended to assist the examiner in this most
important part of a disability evaluation examination.

## 12.4 What elements can be seen by general inspection?

**a. Disturbances of function**. Although a formal examination is needed
to define the precise nature of most deficits, their meaning or
significance is more defined by disturbances or limitations of
performance. Significant abnormalities on the formal examination will
usually be accompanied by disturbances of function in daily living, and
general inspection is often the best way to detect this. Since general
inspection begins with the first contact with the applicant, and does
not cease until the applicant leaves the presence of the examiner, the
applicant is often unaware that the examination has begun or is still in
progress. Thus, it can serve to predict abnormalities to be found or
validate those that are present on the "formal" examination.

**b. Assessment during history taking interview**. An observant
physician is able to gain considerable information concerning the
neurological status of the patient during the history-taking interview.
The state of the muscular system can be evaluated to some extent by
observing the gait as he/she walks into the consulting room. The nature
of spontaneous movements, the presence or absence of involuntary
movements, and the presence or absence of normal associated movements
will be revealed, at least in part, as the applicant sits through the
inter­view. The facial expression, hearing acuity, quality of voice, type
of speech, and the status of the eye movements should be noted. A fair
idea of the intellectual and emotional capacity of the patient, as well
as his/her motivation, may be gained during the taking of this history.
The ease or clumsiness with which the patient handles buttoning or
unbuttoning clothes, disrobing, tying shoelaces, removing articles from
pockets or other simple routine movements may be most revealing of the
presence or absence of disturbed function in the central or peripheral
nervous system.

## 12.5 Should all cranial nerves be examined?

All cranial nerves and special senses should be evaluated, although
tests of smell and taste can be omitted unless there are specific
indications to do them. When they are tested, the guidelines given in
sections 5.14 and 5.15, should be followed.

## 12.6 How should motor function (dysfunction) be examined?

**a. Need to assess performance criteria**. Many measures of motor
status traditionally employed in the neurological examination (reflexes,
bulk, tone of muscles, fasiculations, etc.) are crucial for localization
and diagnosis. They do not, however, necessarily define the type or
degree of functional impairment. Thus, a reliable and equitable rating
decision cannot be made on the basis of such findings alone. Such
decisions must depend upon performance criteria, such as strength and
endurance, ease and range of motion, and skill and dex­terity. Ideally,
the performance evaluated should define the degree and type of
impairment related to occupational adaptability, and to performance of
the activities of daily living. Test results would be standardized and
quantifiable.

**b. Formal assessment techniques**. The tests usually performed on the
neurologic examination (finger-to-nose, grip strength, etc.) may be
adequate for diagnostic purposes, but are poorly quantifiable, if at
all. They are often insensitive to milder degrees of dysfunction that
can be significant for vocational adaptability. Assessment techniques
that approach the needed goal have been developed by physical and
occupational therapy and by vocational rehabilitation programs. While
such formal testing is not needed in every case, it can be invaluable in
many. When available, such resources should be used, particularly in the
complicated or unusual case, or when­ever more routine clinical
assessment does not clearly establish the degrees of impairment.

**c. Information from verified history**. In many cases, however, a
reliable determination can be made from a *verified* history, focusing
on recent vocational and avocational performances, coupled with the
observation of relevant performances during the evaluation. The ease and
skill with which the examinee robes and disrobes, writes, or picks up
small items (coins, paper clips, etc.), one at a time as fast as
possible, are examples. The ability to sustain a posture or simple
repetitive motor performance is important. Conversely, the ability to
rapidly change from one posture or performance to another is just as
important. Fatigue is another important consideration that is poorly
evaluated by the usual neurologic examination. There are a number of
disorders, besides myasthenia gravis, in which strength on initial
effort may be normal (or only slightly decreased) but declines rapidly
on sustained or repeated effort.

**d. Report of direct observations.** The actual results of such
observations should be briefly reported. Illustrative examples might be
"Examinee can perform gross movements (such as shaking hands) but cannot
manipulate small items in the hand," or "An intention tremor prevents
examinee from performing such tasks as tying shoes without assistance."
Such objective reports are far more reliable than the use of summary
judgmental descriptors (often idiosyncratically applied) such as "mild,"
"moderate," or "severe."

**e. Voluntary influences on motor function**. However the evaluation of
motor function is done, it must be remembered that voluntary movements
are under the control of the patient. They are thus subject to
influences other than the type and degree of neurologic disease. This
applies to performance reported by history as well as to that observed
during the examination. In most cases, the history of those activities
the patient can and cannot perform is as important as the observations
made during the examination, provided that the history is reliable and
validated. Limitations in vocational adaptability due to neurologic
disease will usually, if not always, be accomplished by similar
limitations in comparable avocational and daily-living activities. A
reliable history will document both types of limitations.

**f. Reporting discrepancies**. Abnormalities in motor performance
observed on examination, particularly incoordination, weakness, and
decreased range of motion, not associated with supporting or
confirmatory signs (atrophy, reflex changes, abnormal tone, automatic
compensatory actions, etc.) require special consideration. Often such
abnormalities will be present when the patient perceives the performance
is being specifically tested but absent when the performance is part of
a larger, more spontaneous action, or when the patient's attention is
distracted. A common example is the patient who, while standing with
heels together, sways wildly when asked to close his/her eyes (Romberg
sign). Yet the patient does not sway when asked to close the eyes in the
same standing posture but is distracted by doing rapid alternating
finger-to-nose movements. Another common example is the patient who
demonstrates marked weakness of some muscles (or muscle groups) when
they are tested individually, yet shows no dysfunction in using the same
muscles during other parts of the examination, or in dressing, etc.,
when the examination is "over." Such performances strongly suggest
hysteria or malingering but by themselves alone do not warrant a
diagnosis of either. Unless such diagnoses are confirmed by more
positive and definitive findings, it is best not to speculate but simply
to report the observed discrepancies.

**g. Apraxia.** Hysterical weakness (or malingering), however, should
not be confused with apraxia. Associated with disease of one or both
cerebral hemispheres, apraxia is the loss of ability to perform complex,
often symbolic, acts at will or on command, without specific paralysis
of the invoked parts. Generally the apractic patient will attempt the
movement, but cannot complete it and appears perplexed and frustrated.
It is as if he/she has "forgotten" how to do the act. Simpler voluntary
and associated move­ments may be normal, and individual muscles (or
muscle groups) are not affected. As with aphasia, apraxia is worsened by
fatigue and improved by the presence of environmental clues. Also as
with aphasia, the type and degree of apraxia observed depends in part on
the methods by which it is sought.

**h. Summary.** In summary, while a formal examination of reflexes,
tone, etc., must be done to establish or confirm the diagnosis, the
functional significance of motor disturbances is determined by
observation of performance. A detailed and *verified* history of what
activities the patient can and cannot do, both in the vocational and
avocational spheres, is as objective and reliable an indicator of
vocational adaptability as are the observations made during the physical
examination.

## 12.7 How should sensory function (dysfunction) be examined?

**a. Formal testing**. As with motor function, formal testing of sensory
function (dysfunction) to identify the modalities affected and the
topography of deficits is necessary to establish (or confirm) the
diagnosis. At a minimum, the distal extremities should be tested for
light touch, pain, position sense, and vibration. The hands should also
be tested for graphesthesia and stereognosis. The trunk should be
screened for light touch and pain. Abnormalities suggested by the
history, or detected on the examination, should be more completely
tested and mapped out in detail. However, the formal sensory
examination, with few exceptions, is entirely subjective; that is, the
examiner applies a stimulus, and the examinee reports his/her response.
The examiner must be careful to be consistent in applying stimuli and
even well intentioned, conscientious patients may show some
inconsistencies in response, particularly when tired or fatigued. In
addition, the topography of sensory changes after even complete lesions
of individual spinal roots or peripheral nerves rarely match exactly
those illustrated in standard references. Thus, performance of the
sensory examination and interpretation of the results require
considerable skill and patience. Yet it is traditionally the most poorly
performed part of the neurologic examination.

**b. Relationship of sensory deficits to functioning**. Significant
sensory deficits, however, are always accompanied by disturbances in
function. The patient who reports marked loss of touch and/or position
sense in the fingers and hand will not be able to perform skilled
movements normally (buttoning, unbuttoning, manipulating small objects,
etc.), particularly when not looking directly at the hand. When major
sensory deficits reported on the formal sensory examination are not
associated with the expected functional deficits, suspicion of hysteria
or malingering should be raised.

**c. Summary.** In summary, the sensory examination is the most
subjective and thus most often abused part of the neurologic
examination. While formal sensory testing is necessary, it is the least
reliable part of the examination. The significance of sensory
abnormalities is more determined by the disturbances in function which
they occasion. These are better determined by observing performance, in
a manner similar to the evaluation of motor disturbances.

## 12.8 How should mental function (dysfunction) be evaluated?

**a. What is included**. Here we are concerned with those mental
activities which have clearly been shown to depend upon the organic
integrity of the brain, i.e., the so-called higher order cortical or
brain functions. Such activities include perception, cognition, language
function, general intellect and problem solving, memory, orientation,
concentration, and attention. Disturbances in language function, apart
from that as part of a general intellectual decline, are reported as any
of the several varieties of aphasia. Disturbances in the other functions
(usually occurring in various combinations) are reported under the
psychiatric disorders as "organic brain syndromes."

**b. Diagnosis of organic brain syndrome**. The presence of an organic
lesion or neurologic disease of the brain is a necessary but not
sufficient condition to establish a diagnosis, as such lesions can be
present without having any significant effect upon mental functions. The
diagnosis of an organic brain syndrome is only warranted when the
examinee shows findings on examination that document disturbances or
deficits in higher order brain functions.

**c. Need for neuropsychologic tests**. Most test procedures used in
routine clinical assessment are relatively insensitive, detecting only
major or obvious degrees of impairment. They are poorly quantifiable at
best and have seldom been standardized. These deficiencies render them
poorly suited for rating purposes. Standard, quantifiable
neuropsychologic test batteries can overcome most of these limitations.
Their use is desirable in all cases, except the most classical or
severe, and is mandatory whenever the picture is not clear or easily
defined. No single psychometric test is adequate for the purpose of
diagnosing or grading severity of the loss of integrity of the "higher
brain functions." Rather, a coordinated battery of tests is needed,
preferably administered and interpreted by an experienced
neuropsychologist.

## 12.9 How should epilepsy and other paroxysmal disorders be examined?

**a. Types of paroxysmal disorders.** There are a number of diseases
whose major if not exclusive clinical manifestations are the result of
brief, reversible but recurrent alterations in function of the nervous
system. Epilepsy, narcolepsy, cataplexy, periodic paralysis, trigeminal
neuralgia, and "hemiplegic" migraine are typical examples. TIA's
(transient cerebral ischemic attacks), cluster or histamine headache,
and even common migraine could be examples but are more often considered
under cerebrovascular diseases or headache syndromes. Because the
individual attacks generally develop suddenly and unpredictably, these
diseases are often referred to collectively as the "paroxysmal
disorders." In some cases the periodic neuronal dysfunction is secondary
to anatomic lesions within the nervous system itself. In other cases it
can be triggered by periodic disturbances in extracerebral (e.g.,
cardiorespiratory) or metabolic functions. In many cases, similar if not
identical symptoms appear to be "primary" since no "lesion" can be
identified. The diagnostic evaluation must not only identify the type
(and subclassification) of the paroxysmal disorder but must determine
whether it is primary or secondary. If secondary, the etiology must be
determined.

**b. Features of paroxysmal disorders**. Several characteristic features
of the paroxysmal disorders affect the value or weight of the usual
components of the diagnostic triad (i.e., the history, physical
examination, and laboratory testing). First, the patients are usually
asymptomatic between attacks. Second, there are few if any physical
findings (particularly between attacks) that reliably differentiate
between patients who do and do not have a paroxysmal disorder, or
between the subclassifications in those who do. Finally, there are no
known laboratory abnormalities in some types (e.g., trigeminal
neuralgia). Abnormalities may be present in some cases even when tested
between attacks (e.g., spike or spike-and-wave discharges in the EEG in
some cases of epilepsy). But similar abnormalities can, on rare
occasions, be present in normal subjects. Even when present, the
abnormalities are usually intermittent and may be missed. Thus, neither
positive nor negative (normal) findings on routine testing, by
themselves, are a sufficient basis for confirming or excluding the
diagnosis.

**c. History of paroxysmal disorders** Almost by default the history
becomes the major data base from which the diagnosis can be made. This
is not a real disad­vantage as a thorough and reliable history by itself
will allow a diagnosis with reasonable clinical certainty in the
majority of cases. The physical examination and laboratory tests are
nevertheless important, but more to distinguish between primary and
secondary cases and determine the etiology in secondary cases.

**d. Corroboration of history**. Ordinarily the patient is the best
source of the history and is the expert on his/her own symptoms. But
many paroxysmal attacks, particularly epileptic seizures, alter the
patient's consciousness and memory for the attack. Thus, it is always
advisable to corroborate or verify the history from others who have
witnessed one or more of the patient's attacks.

**e. Directly monitoring a paroxysm**. When the history and routine
laboratory testing will not permit a diagnosis with any certainty,
direct observations and/or polygraphic and audiovisual recording of
actual attacks is necessary. When an attack is "captured" such
procedures are usually definitive. Because attacks are often
unpredictable and may be infrequent, even prolonged monitoring
occasionally fails to capture an attack. This may result from the
"therapeutic effect" of hospitalization itself, which decreases the
probability of occurrence of attacks. Thus, failure to observe or record
an attack cannot be taken by itself as definitive evidence that a
paroxysmal disorder is not present.

**f. Inability to diagnose**. When the examiner cannot make a diagnosis
with reasonable certainty from the information available during the
disability evaluation examination, he/she should so state in the report.
The types of information that are lacking, and the examiner's opinion/
recommendation as to the procedures needed to obtain the necessary data
also should be briefly indicated.

**g. Frequency and effects of attacks**. The examiner should determine
and report the type and frequency of attacks as accurately as possible
in every case, since severity of disability (for rating purposes) is
determined according to type (grand or petit mal, Jacksonian, focal
motor or sensory, etc.), frequency, duration, and sequelae of seizures.
At least one detailed description of a typical seizure, preferably one
observed (or at least verified) and reported by a physician, is
required. The examination report should include the number and average
frequency of attacks over the past 1-2 years and whether they were
wholly or principally nocturnal or diurnal. The description should also
include reference to the following: the presence or absence of aura;
evidence of old or recent tongue biting; anal and bladder sphincter
control; injuries associated with seizures; and postictal phenomena.
Documentation of epilepsy should include at least one EEC test. The
frequency of seizures as they occur in everyday life (not while in the
hospital) is the issue of concern. This can only be determined by the
history. Unless there is reason to doubt the reliability or veracity of
the patient and/or family (or surrogates), they are the best source of
this information. Although reports from others can be helpful, few will
be able to give reliable first-hand reports on actual frequency unless
they maintain a close and continual contact with the patient.

**h. Determining consequences of epilepsy**. In addition, the examiner
should be sensitive to the existence of the many possible direct
consequences of epilepsy (and other paroxysmal disorders) that often
cause significant morbidity. It is seldom necessary to obtain a full
psychological and Social Service workup: rather, a brief
social/vocational history and mental status examination usually
suffices, at least as a screening device. The examiner should be careful
not to "lead the witness" and create problems where they do not exist.
When significant problems are identified, they should be reported,
preferably as specific diagnoses whenever possible (e.g., depressive
reaction, neurosis, organic brain syndrome, etc.).

## Worksheet - BRAIN AND SPINAL CORD

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. If flare-ups exist, describe precipitating factors, aggravating
factors, alleviating factors,

alleviating medications, frequency, severity, duration and whether the
flare-ups include

pain, weakness, fatigue or functional loss.

2\. Current treatment, response, and side effects.

3\. State whether condition has stabilized.

4\. Seizures - type, frequency.

5\. Headache, dizziness, etc.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. If a tumor is or was present, note location, type, and whether or
not it is malignant. If

a malignancy is present but is now cured or in remission, report the
date of last

surgery, radiation therapy, chemotherapy or other treatment.

2\. Describe in detail the motor and sensory impairment of all affected
nerves.

3\. Describe in detail any functional impairment of the peripheral and
autonomic systems.

4\. [A detailed assessment of each affected joint is
required]{.underline}.

a\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance.

b\. If the joint is painful on motion, state at what point in the range
of motion pain

begins and ends.

c\. State to what extent, if any, the range of motion or function is
[additionally]{.underline}

limited by pain, fatigue, weakness, or lack of endurance. If more than
one of

these is present, state, if possible, which has the major functional
impact.

5\. Describe any psychiatric manifestations in detail - see worksheets
for mental disorders.

6\. Eye examination.

7\. State if the veteran has bladder or bowel functional impairment. If
present, state

whether partial or total, intermittent or constant and what measures are
taken as a

result of the impairment.

8\. State if the veteran is capable of managing his or her benefit
payments in his or her own

best interest without restriction. (A physical disability which prevents
the veteran from

attending to financial matters in person is not a proper basis for a
finding of

incompetency unless the veteran is, by reason of that disability,
incapable of directing

someone else in handling the individual\'s financial affairs.)

9\. If smell or taste is affected, also complete the appropriate
worksheet.

D. **Diagnostic and Clinical Tests:**

1\. Skull X-rays to measure bony defect, if there was surgery; spine
X-rays if there was

spinal cord surgery.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - COLD INJURY PROTOCOL EXAMINATION

Name: SSN:

Date of Exam: C-number:

Place of Exam:

**Narration:** Veterans during World War II, the Korean War, and in
smaller numbers during other campaigns, have suffered cold injuries,
including frostbite (freezing cold injury or FCI) and immersion foot
(nonfreezing cold injury or NCI). Documentation of such injuries may be
lacking because of battlefield conditions. A number of long-term and
delayed sequelae to cold injuries are recognized, including peripheral
neuropathy, skin cancer in frostbite scars, and arthritis in involved
limbs.

**Review Examination:** Any veteran examined for residuals of cold
injury should undergo a cold injury protocol examination **if** it has
not already been carried out. If the veteran has already had a cold
injury protocol examination, only an interval history is required, and
the extent of the examination, laboratory tests performed, etc., will be
determined by the examiner based on the history, and as requested.

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

**[History of Cold Injury:]{.underline}** If the cold injury protocol
form has been filled out by the veteran, most details about the
circumstances of the acute cold injury and its subsequent course will be
recorded. Review for any needed expansion or clarification by the
veteran. If the protocol history form has not been completed, obtain the
following history and comment on each:

1\. Description of the circumstances of the cold injury.

2\. Parts of the body affected.

3\. Signs and symptoms - at time of acute injury.

4\. The type of treatment and where it was administered.

*5.* Any treatment since service - where and what type.

6\. Current symptoms - specifically inquire about:

a\. Amputations or other tissue loss.

b\. Cold sensitization.

c\. Raynaud\'s phenomenon.

d\. Hyperhidrosis.

e\. Paresthesias, numbness.

f\. Chronic pain resembling causalgia or reflex sympathetic dystrophy.

g\. Recurrent fungal infections.

h\. Breakdown or ulceration of frostbite scars.

i\. Disturbances of nail growth.

j\. Skin cancer in chronic ulcers or scars.

k\. Arthritis or joint stiffness, including limitation of motion of
affected areas.

l\. Edema.

m\. Changes in skin color.

n\. Skin thickening or thinning.

o\. Any sleep disturbance due to associated symptoms.

p\. Cold feeling (relationship to season or not).

q\. Numbness, tingling, burning.

r\. Excess sweating.

s\. Pain - location, intensity, constancy, precipitating factors (cold,
walking,

standing, night pain); type (sharp burning, etc.).

7\. Current treatment, including nonmedical measures taken - moving to
warmer climate,

wearing multiple pairs of socks, etc.

**[Other Medical History:]{.underline}**

1\. Major illnesses, surgery, current medical conditions and their
treatment, including

diabetes mellitus or hypertension.

2\. Smoking history, other risk factors for vascular disease, history of
skin cancer.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. **General:** Carriage, gait, posture.

2\. **Skin:**

a\. Color.

b\. Edema.

c\. Temperature.

d\. Atrophy.

e\. Dry or moist.

f\. Texture.

g\. Ulceration.

h\. Hair growth.

i\. Evidence of fungus or other infection.

3\. **Scars:**

a\. Location.

b\. Length.

c\. Width.

d\. Color.

e\. Tenderness.

f\. Raised or depressed.

g\. If of head or neck, any disfigurement.

4\. **Nails:**

a\. All or part missing

b\. Evidence of fungus infection

c\. Deformed or atrophic

5\. **Neurological:**

a\. Reflexes.

b\. Sensory - subjective complaints of pain, numbness, etc., Objective
sensory

changes - pinprick, touch.

c\. Motor - weakness, atrophy.

6\. **Orthopedic:**

a\. Pain or stiffness of any joints affected by cold injury.

b\. Deformity or swelling of any joints.

c\. Measure range of motion of all affected joints.

d\. Strength of ligaments in affected areas.

e\. Pes planus.

f\. Callus.

g\. Pain on manipulation of joints.

h\. Loss of tissue of digits or other affected parts.

7\. **Vascular:**

a\. Status of peripheral pulses.

b\. Doppler study to confirm vascular compromise, if indicated.

c\. Evidence of vascular insufficiency - edema, hair loss, shiny
atrophic skin, etc.

d\. Blood pressure in arms and legs (is ratio normal?).

e\. Evidence of Raynaud\'s phenomenon.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. X-rays of affected areas of extremities if never done or if not done
in past five years.

2\. Doppler study of blood vessels, if indicated.

3\. Nerve conduction studies, if indicated.

4\. Biopsy of any area suspicious for malignancy.

5\. Scrapings to confirm fungus infection.

6\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. List each diagnosis and state whether related to cold injury (if
that can be determined).

2\. Specialty exams that might be needed:

a\. Neurology.

b\. Podiatry.

c\. Dermatology.

d\. Rheumatology.

e\. Others as needed.

Signature: Date:

## Worksheet - CRANIAL NERVES

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. If flare-ups exist, describe precipitating factors, aggravating
factors, alleviating factors,

alleviating medications, frequency, severity, duration and whether the
flare-ups include

pain, weakness, fatigue or functional loss.

2\. Current treatment, response, side effects.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Identify the nerve and the side.

2\. Identify the disorder (i.e., paralysis, neuritis, neuralgia).

3\. Describe in detail specific motor and sensory impairment,
quantifying as much as

possible.

4\. If smell or taste is affected, please also complete the appropriate
worksheet.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. State etiology.

Signature: Date:

## Worksheet - EPILEPSY AND NARCOLEPSY

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Discuss precipitating factors, aggravating factors, alleviating
factors.

2\. Current treatment, response, side effects.

3\. State the frequency and type of seizures or episodes of narcolepsy
during the past 12

months, including any change in frequency pattern. If possible, record
the actual

number of seizures in each calendar month. If the veteran keeps a
seizure diary, record

dates of seizures.

4\. Discuss the effect of epilepsy or narcolepsy on daily activities,
including the effects of

medications.

C. **Physical Examination (Objective Findings):**

1\. Order a psychiatric examination if there are indications of a mental
disorder associated

with epilepsy.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. If the diagnosis is NOT established or is questioned, schedule any
necessary special

studies, including admission for a period of examination and
observation, as

appropriate to provide a definitive diagnosis.

Signature: Date:

## Worksheet - NEUROLOGICAL DISORDERS, MISCELLANEOUS

**(Migraine, Tic, Paramyoclonus Multiplex,**

**Sydenham\'s and Huntington\'s Chorea, and Athetosis)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Onset and course - If flare-ups exist, describe precipitating
factors, aggravating factors,

alleviating factors, alleviating medications, frequency, severity,
duration, and whether

the flare-ups include pain, weakness, fatigue or functional loss.

2\. Current treatment, response, side effects.

C. **Physical Examination (Objective Findings):**

1\. If [Migraine:]{.underline} - Obtain the history of frequency and
duration of attacks and description

of level of activity the veteran can maintain during the attacks. For
example, state if

the attacks are prostrating in nature or if ordinary activity is
possible.

2\. If [Tics and Paramyoclonus Complex:]{.underline} - Ascertain the
muscle group(s) involved and

obtain the best possible history of frequency and severity of attacks.
State the effects

on daily activities.

3\. If [Chorea, Choreiform Disorders, etc.:]{.underline} - Describe
manifestations by impairment of

strength, coordination, tremor, etc., with particular attention to the
effects of the

performance of ordinary activities of daily living.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - PERIPHERAL NERVES

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Onset and course - If flare-ups exist, describe precipitating
factors, aggravating factors,

alleviating factors, alleviating medications, frequency, severity,
duration and whether

the flare-ups include pain, weakness, fatigue or functional loss.

2\. Current treatment, response, and side effects.

3\. Paresthesias, dysesthesias, other sensory abnormalities.

4\. Describe extent to which condition interferes with daily activity.

5\. Specify nerves involved.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. If the disability is the result of brain disease or injury, spinal
cord disease or injury,

cervical disc disease, or trauma to the nerve roots themselves:

a\. Report sensory and motor impairment by reference to the distribution
of the

affected groups as paralysis, neuritis or neuralgia.

b\. Report each affected extremity separately.

2\. If disability is NOT from the above:

a\. Identify the specific major nerve involved, localize the lesion and
describe

specific impairment of motor and sensory function, fine motor control,
etc.

b\. Characterize as paralysis, neuritis or neuralgia, and indicate
whether any muscle

wasting or atrophy represents direct effect of nerve damage or merely
disuse.

c\. Report each affected extremity separately.

3\. For each joint that is affected:

a\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance.

b\. If the joint is painful on motion, state at what point in the range
of motion pain

begins and ends.

c\. State to what extent, if any, the range of motion or function is
[additionally]{.underline}

[limited]{.underline} by pain, fatigue, weakness, or lack of endurance.
If more than one of

these is present, state, if possible, which has the major functional
impact.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:** State etiology.

Signature: Date:

# Chapter 13 - MENTAL DISORDERS

## 13.1 What general information should be provided in examinations for mental disorders?

Information required for a disability evaluation of a psychiatric
disorder (or an alleged psychiatric disorder) is essentially no more
extensive than a discerning examiner would want for his/her own use in
an adequate understanding of a patient. The evaluation requires a report
that sets forth a clear and complete word picture of the patient as a
whole person, what he/she is like, and how able he/she is to take care
of himself/herself and earn a living. The examination worksheets
describe the specific requirements for a disability examination for
mental disorders. This material supplements them. Specifically, the
examination report should include:

a\. Complaints in a veteran's own words, recorded between quotation
marks. The presenting problems, when symptoms began, their course
(chronological evolution).

b\. Information covering behavior, attitudes, and general health prior
to onset of present illness.

c\. A detailed military history: Where served, combat, when, wounds,
decorations, names of units where served.

d\. A description of the symptoms, subjective and objective, upon which
the diagnosis is based.

e\. An occupational history as it relates to the veteran's adjustment to
his/her work: Pre-service social, employment, and educational history.

f\. A definitive diagnosis or diagnoses, based on whole history and
current examination. (If the diagnosis of a psychosis is made, always
qualify by stating "active," "in full remission", or "in partial
remission.") Terminology and the basis of the diagnosis must conform to
the 4th edition of the Diagnostic and Statistical Manual of Mental
Disorders of the American Psychiatric Association (DSM-IV); otherwise
the report will be returned. The report should explain how the veteran
meets the DSM-IV diagnostic criteria for the mental disorder(s)
diagnosed.

g\. An opinion as to mental competency.

h\. A discussion of social functioning.

i\. A complete multiaxial assessment should be provided in all cases.

## 13.2 What constitutes a good longitudinal psychiatric history?

a\. A detailed history is essential in psychiatric disorders. It should
be developed and recorded in full if the examination is an initial one,
and in re-examinations it should bridge the period since the preceding
examination.

b\. It is sometimes insufficient to rely entirely upon the history given
by the veteran. A study by a social worker should be requested, if
necessary. The problem involved, and the period or area requiring
clarification, should be clearly indicated

c\. The examiner should not be tempted into making a spot diagnosis on
impressions of the moment. Determining whether a disability is
developmental or not cannot be made without a longitudinal study.

d\. The examiner must have a fair estimate of the personality
development, knowledge of all previous illnesses, injuries, residual
conditions, other impairments, and a chronological picture of the
evolution of the current psychiatric disorder; so that the present
condition and disability can be viewed in its proper perspective.

## 13.3 What indicates the level of social and occupational functioning? 

a\. Of first importance in the consideration of social and occupational
functioning is a chronological social and occupational history covering
the period since the most recent of any previous reports.

b\. Taking into account the economic conditions generally prevailing in
the veteran's community, indicators of adequate social and occupational
functioning, partial or complete, include the ability to hold employment
continuously; the showing of efforts to advance one's self; satisfactory
adjustment to superiors and fellow workers; conformance to social
standards of the environment; the absence of eccentricities of behavior
or gross errors in judgment; and freedom from the necessity of
supervision.

c\. On the other hand, a history of no real attempt to secure available
employment, or a history of frequently interrupted employment plus
evidence of defective judgment, abnormalities in behavior, emotional
lability, poor community adjustment, or antisocial tendencies, are
evidences of poor social and occupational functioning and should be
recorded.

d\. Social integration is one of the best evidences of mental health and
reflects the ability to establish (together with the desire to
establish) healthy and effective interpersonal relationships. Poor
contact with other human beings may be an index of emo­tional illness.

## 13.4 What are disability evaluations based on?

a\. Disability evaluations by raters in the VBA regional offices are
based primarily on a combination of the signs and symptoms of the mental
health disorder and their effects on social and occupational
functioning.

b\. Raters consider the extent of social impairment, but do not assign
an evaluation solely on the basis of social impairment. Impaired social
functioning is important for rating purposes primarily as it affects
occupational functioning.

c\. Unemployment because of such extrinsic factors as economic
depression, dissatisfaction with work environment, or domestic
difficulties is not an indication of occupational impairment.

## 13.5 What information should be provided to support the diagnosis?

A disability evaluation cannot be made merely on the basis of the
diagnosis. The diagnosis must be supported by the history and
examination findings. For adequate justification for the diagnosis, the
examiner should consider the following and record all information of
importance concerning them:

a\. Chronological historical medical, social, occupational, and military
data.

b\. Clearly and fully detailed symptomatology. The examiner will usually
need to include in the examination report a statement covering the
following main topics:

Appearance, attitude, and behavior.

Stream of talk and mental activity.

Emotional reactions and mood tendencies.

Content of special preoccupations.

Sensorium and intellectual resources.

c\. Sufficient data upon which the differential diagnosis can be made.

d\. Hospital study in cases where indicated.

e\. The existence of an underlying organic condition that may cause the
psychiatric symptoms.

f\. Resolution of any inconsistencies between findings of specialists.

g\. Necessity for social work service study.

h\. Indication for psychological evaluation and results of any
psychological tests conducted, to be correlated with other findings.

i\. Conference with other examiners in the examining unit, if needed.

j\. A diagnosis must never be made solely by exclusion. In other words
the absence of physical findings is not in itself sufficient to justify
a psychiatric diagnosis, nor does the mere suspicion on the part of the
physician that the symptoms are functional warrant a positive
psychiatric diagnosis.

## 13.6 How should the current diagnosis be related to previous diagnoses?

In the interpretation of the veteran's history and behavior, the
examiner should be familiar with previous diagnostic interpretations.
One cannot presume that the initial diagnosis, for example in the
service medical records, is correct.

a\. Care is required before changing a diagnosis previously established,
especially on more than one occasion, by the same or different
psychiatrists.

b\. Whenever the history and findings of the examination do not confirm
a diagnosis that has been previously made, the examiner should record
the diagnosis which, in his/her opinion is justified on the basis of all
the evidence, but should relate a current diagnosis to a former one, so
that the rating boards may clearly understand whether:

> A current diagnosis corrects an old (erroneous) one.
>
> A current diagnosis represents a mere change in nomenclature. Include
> diagnosis from the old and new Diagnostic Statistical Manuals.
>
> A current diagnosis reflects a new phase or later development of a
> condition formerly diagnosed differently.
>
> A current diagnosis represents a new clinical entity not related to an
> earlier diagnostic entity.

c\. An examination report which is the basis for a diagnostic conclusion
of "No disease, following observation (or careful examination) for
psychiatric disorder" should reflect the same careful consideration and
thorough examination as required for the diagnosis of a psychiatric
disease.

d\. The examiner is frequently confronted with the absence of any
present findings attributable to a disorder previously reported. If
he/she is of the opinion that the subsequent course disproves the
earlier diagnosis, he/she should so state. If the examiner reaches the
conclusion that the formerly diagnosed condition actually existed at
some earlier date but that the veteran has recovered, he/she should so
state. In either case, reasons for such a conclusion must be recorded.

e\. A previously recorded diagnosis, if different from the currently
accepted terminology, will be parenthesized after the current diagnosis.
If the current diagnosis represents an entirely different category of
disorder, you will need to provide a summary of the pertinent evidence
to support it.

## 13.7 How should developmental or congenital conditions be reported?

Distinction must be made between conditions due to disease or injury and
conditions which are of developmental or congenital origin. Primary
personality disorders and disorders of intelligence should be fully
described and classified.

## 13.8 How and why should an examiner consider mental incompetency?

a\. Incompetence for VA purposes is defined in section 3.353(a) of title
38, Code of Federal Regulations, as follows: "A mentally incompetent
person is one who because of injury or disease lacks the mental capacity
to contract or to manage his or her own affairs, including disbursement
of funds without limitation." This is a determination ultimately to be
made by the VBA rater based on all evidence of record. However, the
examiner's assessment regarding incompetency is important and should be
reported for two reasons:

as a factor in measuring the relative disability.

to assist in determining the propriety of payments of monetary awards
directly to the veteran or to a guardian appointed by a court.

b\. While an opinion of incompetency frequently follows a determination
that a veteran is psychotic, this is not always true, so a distinction
should be recognized between a psychosis as a mental disorder and
incompetency as an existing fact.

c\. A determination of incompetency will be based upon affirmative
answers to these questions:

Is the individual incapable of administering his/her personal affairs?

Is there definite evidence of a more or less prolonged departure from
normal behavior as compared with the social standards of the community
indicated by such things as dissipation of funds, irresponsibility
toward personal and financial obligations, and lack of appreciation of
values?

## 13.9 What pertinent information is available in the claim file and medical folder?

The claim file and medical folder may be useful to show:

> chronological medical, social, and occupational history (including
> social study, if made).
>
> the basis for previous diagnoses.
>
> previous ratings.

## 13.10 What constitutes a good psychiatric examination?

a\. A review of the physical status, particularly with somatic
complaints (including a brief neurological survey) is not only of value
to the examiner but reassures the veteran that he/ she has had complete
medical attention, even if a physical examination, including
neurological examination, is already of record.

b\. A detailed history as described in paragraph 13.2.

c\. The examiner does two things at the same time---participates in the
interview, and observes general appearance, behavior, and speech
production (noting emotional, intellectual, and physiological
reactions). The quality of the patient-doctor relationship established
and the extent to which the veteran feels accepted and understood will
markedly affect his/her feeling toward the final rating decision.

d\. Knowledge of pertinent data in the claim file and medical record
file and skill in interviewing and understanding the objectives are both
essential to an examination.

e\. The following psychiatric interview technique is offered as a
suggestion only, since most examiners have their own methods of
eliciting information to be used as a basis for diagnostic
classification and evaluation:

> 1\) Begin by asking the veteran to relate everything that is troubling
> him/her. Permit the veteran to give a full spontaneous account of the
> symptoms and difficulties. Ask no leading questions except in
> instances where it is apparent that a psychotic process is present.
> Record verbatim a few representative statements and all complaints.
>
> 2\) After the veteran has finished an uninterrupted story, inquire
> what else troubles him/her.
>
> 3\) Probe each symptom and how long it is present. Note the severity
> and whether it is persistent or intermittent. Describe its influence
> or effect upon total functioning, including relationship with others,
> work, and financial security.
>
> 4\) Inquire what the veteran has done about his/her symptoms. What
> factors aggravate and what factors diminish the symptoms?
>
> 5\) Has the veteran been thoroughly examined previously? What has
> he/she been told?
>
> 6\) Inquire what the veteran thinks is behind the symptoms---the cause
> of them. Did they follow some stress? (Precipitating factors.)
>
> 7\) Determine how the veteran felt about him/herself before the onset
> of the present trouble.
>
> 8\) While the veteran is relating the story, formulate your impression
> concerning the following points:
>
> \(a\) How much discomfort or trouble does the veteran seem to be
> having as a result of the symptoms?
>
> \(b\) Is the emotional display consistent with the symptoms?
>
> \(c\) Does the veteran seem to be exaggerating?
>
> \(d\) Is the veteran apprehensive or anxious? (Note objective signs of
> anxiety.)
>
> \(e\) Consider the question of emotional immaturity, a pathological
> personality, or a disorder of intelligence. (Request psychological
> consultation if certain tests may be expected to contribute to an
> understanding of the disorder).
>
> \(f\) The extent of impairment of insight and judgment.

f\. The eliciting of information through the interview, plus an
interpretation of the material contained in the claim file and medical
record file, an evaluation of a social study (if one has been made), and
an assessment of special tests, should furnish the examiner with
sufficient facts to provide a comprehensive report.

## 13.11 What is the value of and best way to use the Social Work Service?

a\. A study by the social work service examines significant experiences
related to family interrelationships, education, psychosexual
development, employment, military history, and the onset of medical or
psychiatric problems. They are examined in terms of their effect on the
veteran's psychosocial development and functioning.

b\. The social study will assist the examiner in developing an
appro­priate diagnosis; in evaluating the degree of social,
psychological, and industrial impairment; and in assessing the veteran's
potential for improved social functioning and employment.

c\. A social study can help to clarify:

> The nature and sequence of events that may have affected the veteran's
> life.
>
> The physical and social situation, and especially the interpersonal
> relationships, past and present, that have perceptibly affected
> him/her.
>
> Social and psychological situations that may have brought out abnormal
> functioning which has a bearing on the cause and nature of the
> veteran's maladjustment.
>
> Information about the veteran's behavior patterns.
>
> Response to stressful situations.
>
> Competency .

d\. Social data are particularly useful in helping the examiner solve
diagnostic problems such as differentiating between a transient
personality reaction to an acute or special stress and an anxiety or
other type psychiatric disorder; determining the significance of
addiction to alcohol or drugs; indicating the existence of delusional
trends, and determining what continuity of symptoms has existed over
periods during which there have been conflicting diagnoses.

e\. A social study may focus on the psychogenic factors in an illness
where the obvious symptoms may be the disordered function of an organ or
system of the body.

f\. Finally, the social study may provide additional information
concerning the veteran's readiness for treatment and potential for
response to treatment.

## 13.12 How can psychological tests help?

The use of some of the many objective and projective psychological tests
can aid the examiner materially in making a complete diagnostic
evaluation. Although the test findings are not a substitute for a
psychiatric examination, they can provide many corroborative facts
through investigating the presence, extent, and severity of symptoms.
Further insight into sources of anxiety and unconscious conflicts as
well as descriptions of characteristic defense reactions to stress and
frustration can be secured. Additional facts concerning the veteran's
motivation, goals, aspirations, needs, and attitudes can also be
obtained.

a\. Psychological tests can aid in the differential diagnosis of

> psychiatric and neurological disorders and reactions
>
> psychoses and anxiety and personality disorders
>
> psychotic and anxiety disorders
>
> mental retardation and schizophrenia
>
> mental retardation and organic brain disease.

b\. Various tests can be used to delineate some of the veteran's
outstanding personality traits and modes of expressions, such as:

> emotional responsiveness and control
>
> the degree and quality of ideational activity
>
> the degree to which he/she functions within the limits of capacity
> without undue inner tension or stress.

c\. Tests can determine the differential effects of organic brain damage
and psychiatric illness upon the psychological functions, such as
memory, perception, and reasoning, as well as the degree of impairment.

d\. Facts concerning the potential and resources of the veteran which
are useful in judging the likelihood of improvement or recovery can also
be provided.

## 13.13 Consultations

An examination by an appropriate consultant may be required in cases
where there is the possibility of an organic condition being either a
cause or a result of a psychiatric disorder.

## Worksheet - EATING DISORDERS (Mental Disorders)

Name: SSN:

Date of Exam: C-number:

Place of Exam

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. [Past Medical History:]{.underline}

a\. Previous hospitalizations and outpatient care for parenteral
nutrition or tube

feeding.

b\. Medical and occupational history from the time between the last such
rating

examination and the present needs to be accounted for, UNLESS the
purpose

of this examination is to ESTABLISH service connection, then a complete

medical history since discharge from military service is required.

c\. Periods of incapacitation (during which bedrest and treatment by a
physician

are required due to the eating disorder). Describe the frequency and
duration.

d\. Current treatment, response, side effects.

2\. [Present Medical, Occupational and Social History]{.underline} -
over the past one year.

a\. History of onset of eating disorder.

b\. Its course, treatment, and current status to include symptoms.

c\. Extent of time lost from work over the past 12 month period and
social

impairment. If employed, identify current occupation and length of time
at this

job.

3\. [Subjective Complaints:]{.underline}

a\. Describe fully.

C. **Examination (Objective Findings):**

Address each of the following and fully describe:

1\. Mental status exam to confirm or establish diagnosis in accordance
with DSM-IV.

2\. Additionally, please provide this specific information: a. Current
weight.

b\. Expected minimum weight based on age, height, and body build.

c\. Obtain weight history.

3\. Additionally, to allow evaluation by the rating specialist, describe
and fully explain the

existence, frequency, and extent of the following signs and symptoms and
relate how

they interfere with employment:

a\. Binge eating.

b\. Self-induced vomiting or other measure to prevent weight gain when
weight is

already below expected minimum normal weight.

D. **Diagnostic Tests** (including psychological testing if deemed
necessary):

1\. Provide specific evaluation information required by the rating board
or on a BVA

Remand. Diagnostic Tests (See the examination request remarks for
specifics.):

a\. **Competency:** State whether the veteran is capable of managing his
or her

benefit payments in the individual\'s own best interests (a physical
disability

which prevents the veteran from attending to financial matters in person
is not a

proper basis for a finding of incompetency unless the veteran is, by
reason of

that disability, incapable of directing someone else in handling the
individual\'s

financial affairs).

b\. **Other Opinion:** Furnish any other specific opinion requested by
the

rating board or BVA Remand furnishing the complete rationale and
citation

of medical texts or treatise supporting opinion, if medical literature
review was

undertaken. If the requested opinion is medically not ascertainable on
exam or

testing please state why. If the requested opinion can not be expressed

without resorting to speculation or making improbable assumptions say
so, and

explain why. If the opinion asks \"\...is it at least as likely as
not\...\", fully explain

the clinical findings and rationale for the opinion.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - MENTAL DISORDERS (except PTSD and Eating Disorders)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A: **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. [Past Medical History:]{.underline}

a\. Previous hospitalizations and outpatient care.

> b\. Medical and occupational history from the time between last rating
> examination and the present, unless the purpose of this examination is
> to ESTABLISH service connection, then the complete medical history
> since discharge from military service is required.

2\. [Present Medical, Occupational, and Social History]{.underline} -
over the past one year.

a\. Frequency, severity and duration of psychiatric symptoms.

b\. Length of remissions, to include capacity for adjustment during
periods of

remissions.

> c\. Extent of time lost from work over the past 12 month period and
> social impairment. If employed, identify current occupation and length
> of time at this job. If unemployed, note in [Complaints]{.underline}
> whether veteran contends it is due to the effects of a mental
> disorder. Further indicate following [**DIAGNOSIS**]{.smallcaps} what
> factors, and objective findings support or rebut that contention.

d\. Treatments including statement on effectiveness and side effects
experienced.

3\. [Subjective Complaints]{.underline}:

a\. Describe fully.

C. **Examination (Objective Findings):**

Address each of the following and fully describe:

1\. Mental status exam to confirm or establish diagnosis in accordance
with DSM-IV.

2\. Additionally, to allow evaluation by the rating specialist, describe
and fully

explain the existence, frequency, and extent of the following signs and
symptoms, or

any others present, and relate how they interfere with employment and
social

functioning:

a\. Impairment of thought process or communication.

b\. Delusions, hallucinations and their persistence.

c\. Inappropriate behavior cited with examples.

d\. Suicidal or homicidal thoughts, ideations or plans or intent.

e\. Ability to maintain minimal personal hygiene and other basic
activities of daily

living.

f\. Orientation to person, place and time.

g\. Memory loss or impairment (both short and/or long term).

h\. Obsessive or ritualistic behavior which interferes with routine
activities

(describe with examples).

i\. Rate and flow of speech and note irrelevant, illogical, or obscure
speech

patterns and whether constant or intermittent.

> j\. Panic attacks noting the severity, duration, frequency and effect
> on independent functioning and whether clinically observed or good
> evidence of prior clinical or equivalent observation.

k\. Depression, depressed mood or anxiety.

l\. Impaired impulse control and its effect on motivation or mood.

m\. Sleep impairment and describe extent it interferes with daytime
activities.

n\. Other symptoms and the extent to which they interfere with
activities.

D. **Diagnostic Tests:**

1\. Provide psychological testing if deemed necessary.

2\. If testing is requested, the results must be reported and considered
in arriving at the

diagnosis.

3\. Provide any specific evaluation information required by the rating
board or on

**BVA Remand** (in claims folder).

> a\. Capacity to Manage Financial Affairs
>
> Mental competency, for VA benefits purposes, refers only to the
> ability of the veteran to manage VA benefit payments in his or her own
> best interest, and not to any other subject. Mental incompetency, for
> VA benefits purposes, means that the veteran, because of injury or
> disease, is not capable of managing benefit payments in his or her
> best interest. In order to assist raters in making a legal
> determination as to competency, please address the following:

What is the impact of injury or disease on the veteran\'s ability to
manage his or her financial affairs, including consideration of such
things as knowing the amount of his or her VA benefit payment, knowing
the amounts and types of bills owed monthly, and handling the payment
prudently? Does the veteran handle the money and pay the bills himself
or herself?

Based on your examination, do you believe that the veteran is capable of
managing his or her financial affairs? Please provide examples to
support your conclusion.

If you believe a Social Work Service assessment is needed before you can
give your opinion on the veteran\'s ability to manage his or her
financial affairs, please explain why.

b\. **Other Opinion:** Furnish any other specific opinion requested by
the

rating board or BVA Remand furnishing the complete rationale and
citation of

medical texts or treatise supporting opinion, if medical literature
review was

undertaken. If the requested opinion is medically not ascertainable on
exam or

testing, please indicate **why.** If the requested opinion can not be
expressed

without resorting to speculation or making improbable assumptions say
so, and

explain why. If the opinion asks \"\...is it at least as likely as
not\...?\", fully

explain the clinical findings and rationale for the opinion.

4\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Provide:

1\. The Diagnosis must conform to DSM-IV and be supported by the
findings on the

examination report.

2\. If the diagnosis is changed, explain fully whether the new diagnosis
represents a

progression of the prior diagnosis or development of a new and separate
condition.

3\. If there are multiple mental disorders, delineate to the extent
possible the symptoms

associated with each and a discussion of relationship.

4\. Evaluation is based on the effects of the signs and symptoms on
occupational and

social functioning.

NOTE: VA is prohibited by statute, 38 U.S.C. § 1110, from paying
compensation for a disability that is a result of the veteran's own
ALCOHOL OR DRUG ABUSE. However, when a veteran's alcohol or drug abuse
disability is secondary to or is caused or aggravated by a primary
service-connected disorder, the veteran may be entitled to compensation.
See [Allen v. Principi]{.underline}, 237 F.3d 1368, 1381 (Fed. Cir.
2001). Therefore, it is important to determine the relationship, if any,
between a service-connected disorder and a disability resulting from the
veteran's alcohol or drug abuse.

F. **Global Assessment of Functioning (GAF):**

**NOTE:** The complete multi-axial format as specified by DSM-IV may be
required by BVA REMAND or specifically requested by the rating
specialist. If so, include the GAF score and note whether it refers to
current functioning. A BVA REMAND may also request, in addition to an
overall GAF score, that a separate GAF score be provided for each mental
disorder present when there are multiple Axis I or Axis II diagnoses and
not all are service-connected. If separate GAF scores can be given, an
explanation and discussion of the rationale is needed. If it is not
possible, an explanation as to why not is needed. (See the above note
pertaining to alcohol or drug abuse, the effects of which cannot be used
to assess the effects of a service-connected condition.)

Signature: Date:

# Chapter 14 - POST-TRAUMATIC STRESS DISORDER (PTSD)

## 14.1 What is PTSD?

PTSD is a mental disorder that is a specific type of anxiety disorder
that may result from a traumatic event such as combat, rape or other
personal assault, natural disaster, accident, or other traumatic
experience.

DSM-III established the diagnosis of PTSD and set forth clear diagnostic
criteria. DSM-IV provided revised diagnostic criteria. While this
chapter plus the examination worksheets for PTSD provide considerable
guidance on the diagnosis and assessment of PTSD, for more comprehensive
information, see the booklet: "VA Practice Guideline for Post-Traumatic
Stress Disorder Compensation and Pension Examinations."

## 14.2 What causes PTSD?

Research and clinical observations have demonstrated that the etiology
is complex. The most relevant etiologic variables in the delayed and
chronic forms are:

> a\. Quantity and quality of traumatic stressors encountered.
>
> b\. General psychosocial conditions prevailing in a war zone, e.g.,
> unit integrity, tactical and strategic coherence of military
> operations, and clarity of purpose in the war.
>
> c\. Homecoming experiences post-war, particularly adequacy of
> military, family, and community opportunities for debriefing and
> readjustment.
>
> d\. Pre-existing traumatic incidents (make people more vulnerable to
> PTSD).
>
> e\. Inherited biological factors

## 14.3 Why is establishing rapport at the onset of the interview critical? 

Since accurate diagnosis requires extended discussion of experiences,
which may have been extremely traumatic, veterans, whether they have had
little or no treatment or extensive treatment, may react strongly to the
history taking and review of memories of the war or other stressor.
Sensitivity, tact, and on-going assessment of the level of arousal are
required. Opportunities for therapeutic interview may need to be
assured.

Repression, denial, and general haziness of memories are often hurdles
in obtaining an adequate military history many years after service.
Because of cultural and individual factors, some veterans may find it
difficult to be forthcoming with the examiner.

For these reasons, and the inherently painful quality of the traumatic
material, it is crucial that the examiner place emphasis on avoiding an
authoritarian role, avoiding judgmental interventions, and establishing
rapport through an initial focus on current life experiences or other
discussion which encourages comfort in the interview.

It is often useful for both parties to discuss and become comfortable
with the fact that the examiner may not have experienced the events
lived through by the veteran. Such clarification of the initial status
of both parties, though time-consuming, may ultimately produce the most
accurate clinical data.

## 14.4 What are recommended guidelines for assessing trauma exposure?

a\. Objective.

The objective of trauma assessment is to document whether the veteran
was exposed to a traumatic event, during military service, of sufficient
magnitude to meet the DSM-IV stressor criterion, described below.

DSM-IV Stressor Criterion (A)

The person has been exposed to a traumatic event in which both of the
following have been present:

> 1\. The person experienced, witnessed, or was confronted with an event
> or events that involved actual or threatened death or serious injury,
> or a threat to the physical integrity of self or others
>
> 2\. The person\'s response involved intense fear, helplessness, or
> horror.

Compensation and pension examinations routinely address PTSD resulting
from combat exposure. However, many other forms of military-related
stress are sufficient to induce PTSD and should be reviewed among
veterans applying for service-connected disability benefits. Non-combat
forms of military-related trauma that are not uncommon include sexual
assault or severe harassment; non-sexual physical assault, duties
involved in graves registration or morgue assignment; accidents
involving injury, death, or near death experiences; and experiences
associated with peace-keeping deployments that meet the DSM-IV stressor
criterion described above.

[Note]{.underline}*.* Adverse psychological reactions are often
associated with stressful events that have the quality of being
unpredictable and uncontrollable. Additionally, stressors that result in
bodily injury, threat to life, tragic loss of a significant other, or
involvement with brutality or the grotesque heighten risk for subsequent
PTSD. Exposure to assaultive violence, particularly of a criminal
nature, is more likely to induce PTSD than random \"acts of God.\" It is
known that severity of the stressor, in terms of intensity, frequency,
and duration, is the most important trauma characteristic associated
with subsequent development of PTSD. Factors surrounding the trauma
incident, such as absence of social support for the victim, may also
influence the degree to which a stressful event is experienced as
psychologically traumatic, and may contribute to its potential for
inducing psychiatric symptoms.

b\. Sources of information used in trauma assessment include:

> 1\. VA Claims File
>
> 2\. DD-214
>
> 3\. medical records from VA, Department of Defense, and other health
> care facilities
>
> 4\. statements from collaterals or others who have information about
> the veteran\'s trauma exposure and its behavioral sequelae
>
> 5\. evidence of behavior changes that occurred shortly after the
> trauma incident
>
> 6\. statements derived from interview of the claimant.

c\. Guidelines for interview assessment of trauma exposure. Initial
examinations conducted for purposes of establishing a diagnosis of PTSD
require clinician assessment of trauma exposure and documentation of
findings. Provided below are guidelines:

> 1\. Orientation of the claimant to trauma assessment. For initial
> examinations, explain to the claimant that it is necessary to obtain a
> detailed description of one or more traumatic events related to
> military service. Further, it is helpful to orient him/her to the fact
> that, although trauma assessment is brief (20-30 minutes), it is
> likely to cause some distress. The veteran should be advised that
> trauma assessment is a mutual and collaborative process, and that
> he/she is not required to answer in depth some questions, if it is too
> distressing to do so.
>
> 2\. Documentation of trauma-related information*.* A detailed
> narrative description of the traumatic episode must be recorded in the
> report, including:
>
> a\) the objective features of the traumatic event
>
> b\) date and location of the stressor(s)
>
> c\) names of individuals who witnessed or were involved in the
> traumatic incident
>
> d\) individual decorations or medals received
>
> e\) the veteran\'s subjective emotional reaction during and after the
> trauma and his/her behavioral response
>
> f\) the veteran\'s perception of perceived consequences of the
> traumatic event, including abrupt changes in behavior
>
> g\) names of health care facilities where trauma-related injuries were
> treated.
>
> 3\. Suggested interview queries. Assessment of one or more personally
> relevant traumas proceeds after sufficient rapport has developed and
> some cursory details regarding the context of the trauma situation(s)
> have been gathered (e.g., branch of the military served in; events
> leading up to the traumatic situation). Provided below are questions
> that may then be asked of the veteran, if appropriate to the context
> of the trauma situation:
>
> [Stem or lead inquiry]{.underline}: The Clinician Administered PTSD
> Scale (CAPS) strategy for assessing the stressor criterion is
> recommended for the initial inquiry about trauma exposure. This
> strategy involves the following sequence of orienting procedures and
> questions:
>
> *Orienting statement*: *\"I\'m going to be asking you about some
> difficult or stressful things that sometimes happen to people. Some
> examples of this are being in some type of serious accident; being in
> a fire, a hurricane, or an earthquake; being mugged or beaten up or
> attacked with a weapon; or being forced to have sex when you didn\'t
> want to. I\'ll start by asking you to look over a list of experiences
> like this and check any that apply to you. Then, if any of them do
> apply to you, I\'ll ask you to briefly describe what happened and how
> you felt at the time.*
>
> *Some of these experiences may be hard to remember or may bring back
> uncomfortable memories or feelings. People often find that talking
> about them can be helpful, but it\'s up to you to decide how much you
> want to tell me. As we go along, if you find yourself becoming upset,
> let me know and we can slow down and talk about it. Do you have any
> questions before we start?"*
>
> [Administration of trauma exposure checklist]{.underline}: The CAPS
> 17-item trauma exposure checklist may be administered as a preliminary
> means of identifying exposure to different traumatic events. Detailed
> inquiry should follow positive endorsement of traumatic events, in
> order to clarify objective features of the stressor, using questions
> suggested below as appropriate:
>
> Were you wounded or injured?
>
> Did you witness others being killed, injured or wounded?
>
> Were you exposed to bodies that had been dismembered?
>
> About how many times were you exposed to \[the traumatic event\]?
>
> Was somebody important to you killed or seriously hurt during this
> situation?
>
> During the trauma, did the perpetrator coerce you into doing something
> against your will? (sexual assault)
>
> During the trauma, did the perpetrator threaten to injure you or kill
> you if you did not comply with their wishes? Did you believe there
> would be any other negative consequences to you if you did not comply
> with their intentions? (sexual assault)
>
> What did other people notice about your emotional response?
>
> What were the consequences or outcomes of this event?
>
> Did you receive any help, or talk to anyone, after this event
> occurred?
>
> [Questions assessing subjective response to the stressor]{.underline}:
> Suggested inquiries for assessing subjective reactions to trauma
> exposure (DSM-IV criterion A.2) include:
>
> At the time the trauma was occurring, did you believe your life was
> threatened? Did you think you could be physically injured in this
> situation?
>
> At the time this occurred, how did you feel emotionally (fearful,
> horrified, helpless)?
>
> Were you stunned or in shock so that you didn\'t feel anything at all?
>
> Did you disconnect from the situation, like feeling that things
> weren\'t real or feeling like you were in a daze?
>
> Can you recall any bodily sensations you may have had at the time?
>
> [Suggested inquiries if no events are endorsed on the CAPS trauma
> exposure checklist]{.underline}:
>
> Has there ever been a time in the military when your life was in
> danger or you were seriously injured or harmed?
>
> What about a time when you were threatened with death or serious
> injury, even if you weren\'t actually injured or harmed?
>
> What about witnessing something like this happen to someone else or
> finding out that it happened to someone close to you?
>
> What would you say are some of the most stressful experiences you had
> during the military which still upset you today?
>
> 4\. Recommended Instruments for Trauma Assessment. The following
> instruments are useful in assessing objective features of trauma
> exposure. They should be administered only to clients who resemble the
> appropriate criterion group on which the instruments were developed.
> Responses to these instruments may be used as a stimulus for further
> interview inquiry or to guide the interview. Some instruments (e.g.,
> the Combat Exposure Scale) provide sufficient information to make
> gross assessments of whether the individual was exposed to a \"high,\"
> \"moderate,\" or \"low\" degree of trauma. While helpful, use of these
> instruments is never sufficient, and must be accompanied by a
> narrative description of unique details of the veteran\'s traumatic
> experience.
>
> a\) For infantryman and other ground troop personnel: Combat Exposure
> Scale
>
> b\) For females serving in a war zone: Women's Wartime Stressor Scale
>
> c\) For Gulf War veterans: Desert Storm Trauma Exposure
>
> d\) For veterans exposed to sexual assault: Brief Screening
> Questionnaire for Sexual Assault

## 14.5 How is PTSD assessed?

a\. Objective. Assessment of PTSD for compensation and pension purposes
should:

> 1\. establish the presence or absence of a diagnosis of PTSD
>
> 2\. determine the severity of PTSD symptoms
>
> 3\. establish a logical relationship between exposure to military
> stressors and current PTSD symptomatology.
>
> Thorough assessment of PTSD requires inquiry into the presence/absence
> of all 17 symptoms of the disorder, together with associated features
> articulated in DSM-IV. Objective and standardized assessment of PTSD
> will be enhanced by using a structured diagnostic interview schedule,
> as well as psychometric tests specially designed for PTSD assessment.
> Below is a recommended minimum core battery of PTSD measures to be
> used in compensation and pension settings, based on their established
> reliability and validity, ease of administration, and the fact that no
> fee is charged for their use.

DSM-IV Diagnostic Criteria for PTSD

> A. The person has been exposed to a traumatic event.
>
> B. The traumatic event is persistently re-experienced in one (or more)
> of the following ways:
>
> 1\. Recurrent and intrusive distressing recollections of the event,
> including images, thoughts, or perceptions.
>
> 2\. Recurrent distressing dreams of the event.
>
> 3\. Acting or feeling as if the traumatic event were recurring
> (includes a sense of reliving the experience, illusions,
> hallucinations, and dissociative flashback episodes, including those
> that occur on awakening or when intoxicated).
>
> 4\. Intense psychological distress at exposure to internal or external
> cues that symbolize or resemble an aspect of the traumatic event.
>
> 5\. Physiological reactivity on exposure to internal or external cues
> that symbolize or resemble an aspect of the traumatic event.
>
> C. Persistent avoidance of stimuli associated with the trauma and
> numbing of general responsiveness (not present before the trauma), as
> indicated by three (or more) of the following:
>
> 1\. Efforts to avoid thoughts, feelings, or conversations associated
> with the trauma.
>
> 2\. Efforts to avoid activities, places, or people that arouse
> recollections of the trauma.
>
> 3\. Inability to recall an important aspect of the trauma.
>
> 4\. Markedly diminished interest or participation in significant
> activities.
>
> 5\. Feeling of detachment or estrangement from others.
>
> 6\. Restricted range of affect (e.g., unable to have loving feelings).
>
> 7\. Sense of a foreshortened future (e.g., does not expect to have a
> career, marriage, children, or a normal life span).
>
> D. Persistent symptoms of increased arousal (not present before the
> trauma), as indicated by two (or more) of the following:
>
> 1\. Difficulty falling or staying asleep.
>
> 2\. Irritability or outbursts of anger.
>
> 3\. Difficulty concentrating.
>
> 4\. Hypervigilance.
>
> 5\. Exaggerated startle response.
>
> E. Duration of the disturbance (symptoms in Criteria B, C, and D) is
> more than 1 month.
>
> F. The disturbance causes clinically significant distress or
> impairment in social, occupational, or other important areas of
> functioning.
>
> *Specify if:*
>
> Acute: if duration of symptoms is less than 3 months
>
> Chronic: if duration of symptoms is 3 months or more
>
> *Specify if:*
>
> With Delayed Onset: if onset of symptoms is at least 6 months after
> the stressor.

b\. Diagnostic interview assessment of PTSD. The CAPS is a structured
clinical interview designed to assess the 17 symptoms of PTSD
corresponding to DSM-IV criteria. The CAPS has a number of advantages
over other diagnostic interview methods for PTSD, including

> 1\. the use of explicit behavioral anchors as the basis for clinician
> ratings
>
> 2\. separate scoring of frequency and intensity dimensions for each
> PTSD symptom
>
> 3\. measurement of associated clinical features
>
> 4\. assessment of the impact of PTSD symptoms on social and
> occupational functioning
>
> 5\. ratings of the validity of information obtained.

The CAPS requires approximately one hour to administer, although it can
be customized and abbreviated by eliminating less relevant components.
However, sites with limited clinical resources may consider using other
interview-based diagnostic instruments for PTSD, which are somewhat
briefer. These instruments include

PTSD symptom Scale

Structured Interview for PTSD

Structured Clinical Interview for DSM-IV

Anxiety Disorders Interview---Revised

PTSD Interview.

Although a modest amount of timesaving may result from using these
alternative instruments, the information gleaned from them is typically
not as comprehensive and, unlike the CAPS, there may be a charge
associated with their use.

## 14.6 What is the recommended time allotment for completing examination?

This guideline is designed to enhance the objectivity, reliability, and
accuracy of PTSD examinations conducted in compensation and pension
settings. Although the administration of the recommended assessment
instruments requires additional clinician time, it is expected to result
in improved quality and increased veteran satisfaction.

Approximately three to four hours are required to conduct a
comprehensive initial compensation and pension examination for PTSD.
This includes 90 minutes for interview assessment of trauma stress
exposure and PTSD symptoms plus an additional hour to complete other
portions of the examination. An additional 1.5 hours is required for
review of psychological testing materials and preparation of a report of
findings. (These time estimates may be adjusted downward, depending on
the availability of an independent social-industrial survey completed by
a social worker.)

## 14.7 What mental health professionals are qualified to conduct Compensation and Pension examinations for PTSD?

Professionals qualified to perform PTSD examinations should have
doctoral-level training in psychopathology, diagnostic methods, and
clinical interview methods. They should have a working knowledge of
DSM-IV, as well as extensive clinical experience in diagnosing and
treating veterans with PTSD. Ideally, examiners should be proficient in
the use of structured clinical interview schedules for assessing PTSD
and other disorders, as well as psychometric methods for assessing PTSD.

Board certified psychiatrists and licensed psychologists have the
requisite professional qualifications to conduct compensation and
pension examinations for PTSD. Psychiatric residents and psychology
interns are also qualified to perform these examinations, under close
supervision of attending psychiatrists or psychologists.

## 14.8 What standardized psychometric tests are useful in PTSD?

Psychometric assessment of PTSD provides quantitative assessment of
degree of PTSD symptom severity. Judgments about symptom severity can be
made by comparing an individual's scores against norms established on
reference samples of individuals who are known to have or not have PTSD.
Cutting scores have been established for the psychometric measures of
PTSD recommended here, based on their high sensitivity and specificity
in discriminating individuals with PTSD from those without PTSD. Data
from psychometric tests never serve as a "stand alone" means for
diagnosing PTSD. Rather, the psychometric measures recommended here
should be used to supplement and substantiate findings gleaned from
interview assessment and other sources of data. The following
psychometric instruments are recommended for inclusion in disability
evaluations for PTSD:

1\. Mississippi Scale for Combat-Related PTSD - for combat-exposed
populations

2\. PTSD Checklist - for individuals exposed to combat and non-combat
trauma

Alternatives include:

1\. MMPI PTSD subscales

2\. Impact of Event Scale---Revised

3\. Penn Inventory

4\. PTSD Stress Diagnostic Scale

5\. Trauma Symptom Inventory.

Additionally, many instruments (e.g., MMPI) exist for quantifying extent
of symptoms of other disorders that often co-occur with PTSD, and should
be considered for use as resources permit. The MMPI and MMPI-2 include
scales known as "validity scales" that are elevated in people who are
trying to exaggerate their symptoms. Use of the MMPI and MMPI-2 may help
the evaluator determine test-taking style of the veteran (i.e.,
defensive, overendorsing, underendorsing). Cutoff scores for utilizing
the MMPI-2 to assess validity of PTSD diagnosis have been reported in a
number of research studies. In addition, MMPI-2 cutoff scores for
specific PTSD scales (i.e., PK, PS) have been shown to be effective at
assessing PTSD.

## 14.9 What is the differential diagnosis of PTSD?

a\. Personality Disorders. These disorders do not usually emerge without
early signs in adolescence, and are rare in individuals with successful
military careers. Therefore, the diagnosis of primary personality
disorder requires the usual evidence of existence of these pathological
traits prior to military duty. Certain features may be due either to
personality disorder or to PTSD. These include:

> General alienation.
>
> Reluctance to talk to professionals.
>
> Violent outbursts and assaults.
>
> Intolerance or distrust of authority.
>
> Dysfunctional patterns of living.

PTSD sometimes occurs concomitantly with a personality disorder. In this
case careful assessment must be made of the etiology of specific
symptoms and behaviors recorded. The more severe cases of PTSD may be
confused with borderline personality because of regression to splitting
mechanisms and severity of behavioral disruptions. Clear assessment of
the childhood, adolescent, and pre-military young adult histories will
indicate whether or not the pre-military picture is consistent with
borderline problems.

b\. Substance Abuse. Substance abuse may pre-exist PTSD or may occur as
a result of PTSD. Only a detailed examination of the history of the
substance abuse, its relation or non-relation to PTSD symptoms and
stressors, and an adequate examination of the history for such
stressors, will permit a differentiation.

c\. Depression. However, depression may also be an associated feature of
PTSD. Clinical reports and research suggest that depression is prominent
in some cases as a manifestation of the stress disorder or as a result
of impacted grief and mourning. Major depressive disorder, especially in
women, can be a risk factor for increasing likelihood for PTSD.

d\. Schizophrenia. It is not uncommon to find cases of PTSD misdiagnosed
as schizophrenia during the period prior to 1980. Presence or absence of
formal thought disorder is often a helpful distinguishing feature. In
severe cases of PTSD, the re-experiencing of traumatic events
(flashbacks) seems to have hallucinatory quality. However, these may be
distinguished from schizophrenic hallucinations by determining the
content and noting whether it involves a repetition of the traumatic
experiences. The constriction of affect sometimes seen in PTSD may
resemble the flattened affect of schizophrenics. One distinguishing
feature is that PTSD patients usually express considerable pain over
their constricted affect and contrast it to their pre-war state, whereas
schizophrenics manifest less dissatisfaction with the lack of emotions.

## 14.10 How can a stressor be documented?

a\. Validity of history. The diagnosis of PTSD is contingent on the
experiencing of traumatic stressors. At times, the examiner may have
questions about the degree of distortion or fabrication in the
interview. The clinical picture of PTSD is relatively easy to fabricate
on a superficial level but very difficult to fabricate in depth. Thus,
the more detailed the history taking, the greater the validity.

b\. Documentation of traumatic experiences.

> 1\. A study by the Social Work Service may assist in gathering
> information about a buddy or officer who might be contacted to help
> confirm or deny crucial statements about military operations or other
> events in specific localities.
>
> 2\. Documentation from family, friends, and teachers concerning
> changes in the individual from pre- to post-service status may be
> helpful.

## Worksheet - INITIAL EVALUATION FOR POST-TRAUMATIC STRESS DISORDER (PTSD)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. Identifying Information

> age
>
> ethnic background
>
> era of military service
>
> reason for referral (original exam to establish PTSD diagnosis and
> related psychosocial impairment; re-evaluation of status of existing
> service-connected PTSD condition)

B. Sources of Information

> records reviewed (C-file, DD-214, medical records, other
> documentation)
>
> review of social-industrial survey completed by social worker
>
> statements from collaterals
>
> administration of psychometric tests and questionnaires (identify
> here)

C. Review of Medical Records:

> 1\. Past Medical History:
>
> a\. Previous hospitalizations and outpatient care.
>
> b\. Complete medical history is required, including history since
> discharge from military service.
>
> c\. Review of Claims Folder is required on initial exams to establish
> or rule out the diagnosis.
>
> 2\. Present Medical History - over the past one year.
>
> a\. Frequency, severity and duration of medical and psychiatric
> symptoms.
>
> b\. Length of remissions, to include capacity for adjustment during
> periods of remissions.

D. Examination (Objective Findings):

> Address each of the following and fully describe:

History (Subjective Complaints):

> Comment on:
>
> Preliminary History (refer to social-industrial survey if completed)
>
> \* describe family structure and environment where raised (identify
> constellation of family members and quality of relationships)
>
> \* quality of peer relationships and social adjustment (e.g.,
> activities, achievements, athletic and/or extracurricular involvement,
> sexual involvements, etc.)
>
> \* education obtained and performance in school
>
> \* employment
>
> \* legal infractions
>
> \* delinquency or behavior conduct disturbances
>
> \* substance use patterns
>
> \* significant medical problems and treatments obtained
>
> \* family psychiatric history
>
> \* exposure to traumatic stressors (see CAPS trauma assessment
> checklist)
>
> \* summary assessment of psychosocial adjustment and progression
> through developmental milestones (performance in employment or
> schooling, routine responsibilities of self-care, family role
> functioning, physical health, social/interpersonal relationships,
> recreation/leisure pursuits).
>
> Military History
>
> \* branch of service (enlisted or drafted)
>
> \* dates of service
>
> \* dates and location of war zone duty and number of months stationed
> in war zone
>
> \* Military Occupational Specialty (describe nature and duration of
> job(s) in war zone
>
> \* highest rank obtained during service (rank at discharge if
> different)
>
> \* type of discharge from military
>
> \* describe routine combat stressors veterans was exposed to (refer to
> Combat Scale)
>
> \* combat wounds sustained (describe)
>
> \* CLEARLY DESCRIBE SPECIFIC STRESSOR EVENT(S) VETERAN CONSIDERED
> PARTICULARLY TRAUMATIC.
>
> clearly describe the stressor. Particularly if the stressor is a type
> of personal assault, including sexual assault, provide information,
> with examples, if possible.
>
> \* indicate overall level of traumatic stress exposure (high,
> moderate, low) based on frequency and severity of incident exposure
> (refer to trauma assessment scale scores described in Appendix B).
>
> \* citations or medals received
>
> \* disciplinary infractions or other adjustment problems during
> military

**NOTE**: Service connection for post-traumatic stress disorder (PTSD)
requires medical evidence establishing a diagnosis of the condition that
conforms to the diagnostic criteria of DSM-IV, credible supporting
evidence that the claimed in-service stressor actually occurred, and a
link, established by medical evidence, between current symptomatology
and the claimed in-service stressor. It is the responsibility of the
examiner to indicate the traumatic stressor leading to PTSD, if he or
she makes the diagnosis of PTSD. *Crucial in this description are
specific details of the stressor, with names, dates, and places linked
to the stressor, so that the rating specialist can confirm that the
cited stressor occurred during active duty.*

A diagnosis of PTSD cannot be adequately documented or ruled out without
obtaining a detailed military history and reviewing the claims folder.
This means that initial review of the folder prior to examination, the
history and examination itself, and the dictation for an examination
initially establishing PTSD will often require more time than for
examinations of other disorders. Ninety minutes to two hours on an
initial exam is normal.

Post-Military Trauma History (refer to social-industrial survey if
completed)

> \* describe post-military traumatic events (see CAPS trauma assessment
> checklist)
>
> \* describe psychosocial consequences of post-military trauma
> exposure(s) (treatment received, disruption to work, adverse health
> consequences)

Post-Military Psychosocial Adjustment (refer to social-industrial survey
if completed)

> \* legal history (DWIs, arrests, time spent in jail)
>
> \* educational accomplishment
>
> \* employment history (describe periods of employment and reasons)
>
> \* marital and family relationships (including quality of
> relationships with children)
>
> \* degree and quality of social relationships
>
> \* activities and leisure pursuits
>
> \* problematic substance abuse (lifetime and current)
>
> \* significant medical disorders (resulting pain or disability;
> current medications)
>
> \* treatment history for significant medical conditions, including
> hospitalizations
>
> \* history of inpatient and/or outpatient psychiatric care (dates and
> conditions treated)
>
> \* history of assaultiveness
>
> \* history of suicide attempts
>
> \* summary statement of current psychosocial functional status
> (performance in employment or schooling, routine responsibilities of
> self care, family role functioning, physical health,
> social/interpersonal relationships, recreation/leisure pursuits)

**E. Mental Status Examination**

Conduct a [brief]{.underline} mental status examination aimed at
screening for DSM-IV mental disorders. Describe and fully explain the
existence, frequency and extent of the following signs and symptoms, or
any others present, and relate how they interfere with employment and
social functioning:

> \* Impairment of thought process or communication.
>
> \* Delusions, hallucinations and their persistence.
>
> \* Eye Contact, interaction in session, and inappropriate behavior
> cited with examples.
>
> \* Suicidal or homicidal thoughts, ideations or plans or intent.
>
> \* Ability to maintain minimal personal hygiene and other basic
> activities of daily living.
>
> \* Orientation to person, place and time.
>
> \* Memory loss, or impairment (both short and long-term).
>
> \* Obsessive or ritualistic behavior which interferes with routine
> activities and describe any found.
>
> \* Rate and flow of speech and note any irrelevant, illogical, or
> obscure speech patterns and whether constant or intermittent.
>
> \* Panic attacks noting the severity, duration, frequency and effect
> on independent functioning and whether clinically observed or good
> evidence of prior clinical or equivalent observation is shown.
>
> \* Depression, depressed mood or anxiety.
>
> Impaired impulse control and its effect on motivation or mood.
>
> \* Sleep impairment and describe extent it interferes with daytime
> activities.
>
> \* Other disorders or symptoms and the extent they interfere with
> activities, particularly:
>
> mood disorders (especially major depression and dysthymia)
>
> substance use disorders (especially alcohol use disorders)
>
> anxiety disorders (especially panic disorder, obsessive-compulsive
> disorder, generalized anxiety disorder)
>
> somatoform disorders
>
> personality disorders (especially antisocial personality disorder and
> borderline personality disorder)

Specify onset and duration of symptoms as acute, chronic, or with
delayed onset.

F. Assessment of PTSD

> \* state whether or not the veteran meets the DSM-IV stressor
> criterion
>
> \* identify behavioral, cognitive, social, affective, or somatic
> change veteran attributes to stress exposure
>
> \* describe specific PTSD symptoms present (symptoms of trauma
> re-experiencing, avoidance/numbing, heightened physiological arousal,
> and associated features \[e.g., disillusionment and demoralization\])
>
> \* specify onset, duration, typical frequency, and severity of
> symptoms

G. Psychometric Testing Results

> \* provide psychological testing if deemed necessary
>
> \* provide specific evaluation information required by the rating
> board or on a **BVA Remand**.
>
> \* comment on validity of psychological test results
>
> \* provide scores for PTSD psychometric assessments administered
>
> \* state whether PTSD psychometric measures are consistent or
> inconsistent with a diagnosis of PTSD, based on normative data and
> established \"cutting scores\" (cutting scores that are consistent
> with or supportive of a PTSD diagnosis are as follows: PCL
> [\>]{.underline} 50; Mississippi Scale [\>]{.underline} 107; MMPI PTSD
> subscale a score \> 28; MMPI code type: 2-8 or 2-7-8)
>
> \* state degree of severity of PTSD symptoms based on psychometric
> data (mild, moderate, or severe)
>
> \* describe findings from psychological tests measuring problems other
> than PTSD (MMPI, etc.)

H. Diagnosis

> 1\. The Diagnosis must conform to DSM-IV and be supported by the
> findings on the examination report.
>
> 2\. If there are multiple mental disorders, delineate to the extent
> possible the symptoms associated with each and a discussion of
> relationship.
>
> 3\. Evaluation is based on the effects of the signs and symptoms on
> occupational and social functioning.

NOTE: VA is prohibited by statute, 38 U.S.C. § 1110, from paying
compensation for a disability that is a result of the veteran's own
ALCOHOL OR DRUG ABUSE. However, when a veteran's alcohol or drug abuse
disability is secondary to or is caused or aggravated by a primary
service-connected disorder, the veteran may be entitled to compensation.
See [Allen v. Principi]{.underline}, 237 F.3d 1368, 1381 (Fed. Cir.
2001). Therefore, it is important to determine the relationship, if any,
between a service-connected disorder and a disability resulting from the
veteran's alcohol or drug abuse.

I. Diagnostic Status

> Axis I disorders
>
> Axis II disorders
>
> Axis III disorders
>
> Axis IV (psychosocial and environmental problems)
>
> Axis V (GAF score - current)

J. Global Assessment of Functioning (GAF):

NOTE: The complete multi-axial format as specified by DSM-IV may be
required by BVA REMAND or specifically requested by the rating
specialist. If so, include the GAF score and note whether it refers to
current functioning. A BVA REMAND may also request, in addition to an
overall GAF score, that a separate GAF score be provided for each mental
disorder present when there are multiple Axis I or Axis II diagnoses and
not all are service-connected. If separate GAF scores can be given, an
explanation and discussion of the rationale is needed. If it is not
possible, an explanation as to why not is needed. (See the above note
pertaining to alcohol or drug abuse, the effects of which cannot be used
to assess the effects of a service-connected condition.)

DSM-IV is only for application from 11/7/96 on. Therefore, when
applicable note whether the diagnosis of PTSD was supportable under
DSM-III-R prior to that date. The prior criteria under DSM-III-R are
provided as an attachment.

K. Capacity to Manage Financial Affairs

Mental competency, for VA benefits purposes, refers only to the ability
of the veteran to manage VA benefit payments in his or her own best
interest, and not to any other subject. Mental incompetency, for VA
benefits purposes, means that the veteran, because of injury or disease,
is not capable of managing benefit payments in his or her best interest.
In order to assist raters in making a legal determination as to
competency, please address the following:

> What is the impact of injury or disease on the veteran\'s ability to
> manage his or her financial affairs, including consideration of such
> things as knowing the amount of his or her VA benefit payment, knowing
> the amounts and types of bills owed monthly, and handling the payment
> prudently? Does the veteran handle the money and pay the bills himself
> or herself?
>
> Based on your examination, do you believe that the veteran is capable
> of managing his or her financial affairs? Please provide examples to
> support your conclusion.
>
> If you believe a Social Work Service assessment is needed before you
> can give your opinion on the veteran\'s ability to manage his or her
> financial affairs, please explain why.

L. Other Opinion:

Furnish any other specific opinion requested by the rating

board or BVA remand (furnish the complete rationale and citation of
medical

texts or treatise supporting opinion, if medical literature review was

undertaken). If the requested opinion is medically not ascertainable

on exam or testing please state WHY. If the requested opinion can not be

expressed without resorting to speculation or making improbable
assumptions

say so, and explain why. If the opinion asks \"\... is it at least as
likely

as not..\", fully explain the clinical findings and rationale for the
opinion.

M. Integrated Summary and Conclusions

\- Describe changes in PSYCHOSOCIAL FUNCTIONAL STATUS and QUALITY of
LIFE

following trauma exposure (performance in employment or schooling,

routine responsibilities of self care, family role functioning, physical

health, social/interpersonal relationships, recreation/leisure pursuits)

\- Describe linkage between PTSD symptoms and aforementioned changes in

impairment in functional status and quality of life.

Particularly in cases where a veteran is unemployed, specific

details about the effects of PTSD and its symptoms on employment

are especially important.

\- If possible, describe extent to which disorders other than PTSD

(e.g., substance use disorders) are independently responsible for

impairment in psychosocial adjustment and quality of life. If this is

not possible, explain why (e.g., substance use had onset after PTSD

and clearly is a means of coping with PTSD symptoms).

\- If possible, describe pre-trauma risk factors or characteristics that

may have rendered the veteran vulnerable to developing PTSD subsequent

to trauma exposure.

\- If possible, state prognosis for improvement of psychiatric condition

and impairments in functional status.

\- Comment on whether veteran is capable of managing his or her
financial affairs.

Signature: Date:

## Worksheet - REVIEW EXAMINATION FOR POST-TRAUMATIC STRESS DISORDER (PTSD)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. Review of Medical Records

B. Medical History since last exam:

Comments on:

1\. Hospitalizations and outpatient care from the time between last

rating examination to the present, UNLESS the purpose of this

examination is to ESTABLISH service connection, then the complete

medical history since discharge from military service is required.

2\. Frequency, severity and duration of psychiatric symptoms.

3\. Length of remissions from psychiatric symptoms, to include capacity

for adjustment during periods of remissions.

4\. Treatments including statement on effectiveness and side effects

experienced.

5\. SUBJECTIVE COMPLAINTS: Describe fully.

C. Psychosocial Adjustment since the last exam

1\. legal history (DWIs, arrests, time spent in jail)

2\. educational accomplishment

3\. extent of time lost from work over the past 12 month period and
social

impairment. If employed, identify current occupation and length of time

at this job.

If unemployed, note in COMPLAINTS whether veteran contends it is due to

the effects of a mental disorder. Further indicate following DIAGNOSIS

what factors, and objective findings support or rebut that contention.

4\. marital and family relationships ( including quality of
relationships with

spouse and children)

5\. degree and quality of social relationships

6\. activities and leisure pursuits

7\. problematic substance abuse

8\. significant medical disorders (resulting pain or disability; current

medications)

9\. history of violence/assaultiveness

10\. history of suicide attempts

11\. summary statement of current psychosocial functional status
(performance

in employment or schooling, routine responsibilities of self care,

family role functioning, physical health, social/interpersonal

relationship, recreation/leisure pursuits)

D. Mental Status Examination

Conduct a BRIEF mental status examination aimed at screening for DSM-IV

mental disorders. Describe and fully explain the existence, frequency
and

extent of the following signs and symptoms, or any others present, and

relate how they interfere with employment and social functioning:

1\. Impairment of thought process or communication.

2\. Delusions, hallucinations and their persistence.

3\. Eye Contact, interaction in session, and inappropriate behavior
cited

with examples.

4\. Suicidal or homicidal thoughts, ideations or plans or intent.

5\. Ability to maintain minimal personal hygiene and other basic
activities

of daily living.

6\. Orientation to person, place, and time.

7\. Memory loss, or impairment (both short and long-term).

8\. Obsessive or ritualistic behavior which interferes with routine
activities

and describe any found.

9\. Rate and flow of speech and note any irrelevant, illogical, or
obscure

speech patterns and whether constant or intermittent.

10\. Panic attacks noting the severity, duration, frequency, and effect
on

independent functioning and whether clinically observed or good evidence

of prior clinical or equivalent observation is shown.

11\. Depression, depressed mood or anxiety.

12\. Impaired impulse control and its effect on motivation or mood.

13\. Sleep impairment and describe extent it interferes with daytime
activities

14\. Other disorders or symptoms and the extent they interfere with
activities,

particularly:

a\. mood disorders (especially major depression and dysthymia)

b\. substance use disorders (especially alcohol use disorders)

c\. anxiety disorders (especially panic disorder, obsessive-compulsive

disorder, generalized anxiety disorder)

d\. somatoform disorders

e\. personality disorders (especially antisocial personality disorder

and borderline personality disorder)

E. Assessment of PTSD

1\. state whether or not the veteran meets the DSM-IV stressor criterion

2\. identify behavioral, cognitive, social, affective, or somatic
symptoms

veteran attributes to PTSD

3\. describe specific PTSD symptoms present (symptoms of trauma

re-experiencing, avoidance/numbing, heightened physiological arousal,

and associated features \[e.g., disillusionment and demoralization\])

4\. specify typical frequency, and severity of symptoms

F. Psychometric Testing Results

1\. provide psychological testing if deemed necessary.

2\. provide specific evaluation information required by the rating board
or

on a BVA Remand.

3\. comment on validity of psychological test results

4\. provide scores for PTSD psychometric assessments administered

5\. state whether PTSD psychometric measures are consistent or
inconsistent

with a diagnosis of PTSD, based on normative data and established

\"cutting scores\" (cutting scores that are consistent with or
supportive

of a PTSD diagnosis are as follows: PCL - not less than 50;

Mississippi Scale - not less than 107; MMPI PTSD subscale a score

greater than 28; MMPI code type: 2-8 or 2-7-8)

6\. state degree of severity of PTSD symptoms based on psychometric data

(mild, moderate, or severe)

7\. describe findings from psychological tests measuring other than

PTSD (MMPI, etc.)

G. Diagnosis:

1\. The Diagnosis must conform to DSM-IV and be supported by the
findings

on the examination report.

2\. If there are multiple mental disorders, delineate to the extent
possible

the symptoms associated with each and a discussion of relationship.

3\. Evaluation is based on the effects of the signs and symptoms on

occupational and social functioning.

NOTE: VA is prohibited by statute, 38 U.S.C. 1110, from paying
compensation

for a disability that is a result of the veteran\'s own ALCOHOL OR DRUG
ABUSE.

However, when a veteran\'s alcohol or drug abuse disability is secondary
to

or is caused or aggravated by a primary service-connected disorder, the

veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d

1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the

relationship, if any, between a service-connected disorder and a
disability

resulting from the veteran\'s alcohol or drug abuse. Unless alcohol or
drug

abuse is secondary to or is caused or aggravated by another mental
disorder,

you should separate, to the extent possible, the effects of the alcohol
or

drug abuse from the effects of the other mental disorder(s). If it is
not

possible to separate the effects in such cases, please explain why.

H. Diagnostic Status

Axis I disorders

Axis II disorders

Axis III disorders

Axis IV (psychosocial and environmental problems)

Axis V (GAF score - current)

I. Global Assessment of Functioning (GAF):

NOTE: The complete multi-axial format as specified by DSM-IV may be
required

by BVA REMAND or specifically requested by the rating specialist. If so,

include the GAF score and note whether it refers to current functioning.

A BVA REMAND may also request, in addition to an overall GAF score,

that a separate GAF score be provided for each mental disorder present
when

there are multiple Axis I or Axis II diagnoses and not all are service-

connected. If separate GAF scores can be given, an explanation and

discussion of the rationale is needed. If it is not possible, an
explanation

as to why not is needed. (See the above note pertaining to alcohol or
drug

abuse.)

J. Capacity to Manage Financial Affairs

> Mental competency, for VA benefits purposes, refers only to the
> ability of the veteran to manage VA benefit payments in his or her own
> best interest, and not to any other subject. Mental incompetency, for
> VA benefits purposes, means that the veteran, because of injury or
> disease, is not capable of managing benefit payments in his or her
> best interest. In order to assist raters in making a legal
> determination as to competency, please address the following:
>
> What is the impact of injury or disease on the veteran\'s ability to
> manage his or her financial affairs, including consideration of such
> things as knowing the amount of his or her VA benefit payment, knowing
> the amounts and types of bills owed monthly, and handling the payment
> prudently? Does the veteran handle the money and pay the bills himself
> or herself?
>
> Based on your examination, do you believe that the veteran is capable
> of managing his or her financial affairs? Please provide examples to
> support your conclusion.
>
> If you believe a Social Work Service assessment is needed before you
> can give your opinion on the veteran\'s ability to manage his or her
> financial affairs, please explain why.

K. Other Opinion:

Furnish any other specific opinion requested by the rating board or BVA
remand (i.e., furnish the complete rationale and citation of medical
texts or treatise supporting opinion, if medical literature review was
undertaken). If the requested opinion is medically not ascertainable on
exam or testing please state WHY. If the requested opinion can not be
expressed without resorting to speculation or making improbable
assumptions say so, and explain why. If the opinion asks \"\... is it at
least as likely as not..\", fully explain the clinical findings and
rationale for the opinion.

L. Integrated Summary and Conclusions

1\. Describe changes in PSYCHOSOCIAL FUNCTIONAL STATUS and QUALITY of
LIFE

since the last exam (performance in employment or schooling, routine

responsibilities of self care, family role functioning, physical health,

social/interpersonal relationships, recreation/leisure pursuits)

2\. Describe linkage between PTSD symptoms and aforementioned changes in

impairment in functional status and quality of life.

Particularly in cases where a veteran is unemployed, specific details

about the effects of PTSD and its symptoms on employment are especially
important.

3\. If possible, describe extent to which disorders other than PTSD

(e.g., substance use disorders) are independently responsible for

impairment in psychosocial adjustment and quality of life. If this is
not

possible, explain why (e.g., substance use had onset after PTSD

and clearly is a means of coping with PTSD symptoms).

4\. If possible, state prognosis for improvement of psychiatric
condition

and impairments in functional status.

5\. Comment on whether veteran is capable of managing his or her
financial affairs.

Signature: Date:

# Chapter 15 - INFECTIOUS DISEASES, IMMUNE DISORDERS, AND NUTRITIONAL DEFICIENCIES

## 15.1 What are the basic elements of an examination for Infectious Diseases, Immune Disorders, and Nutritional Deficiencies?

This chapter supplements the disability examination worksheets.
Generally, the veteran presents with a history of infectious disease in
the past with recurring exacerbations, chronic infection, or residuals.

a\. Initial examination

> 1\) History of present illness - onset, frequency, and severity of
> symptoms; past and current treatment; whether symptoms are controlled
> by treatment; effects of condition on daily activities.
>
> 2\) General health information, as pertinent - including previous
> surgery and illnesses; family history; military history.
>
> 3\) Infectious history. Date of onset and course of infection,
> including exacerbations, response to therapy, and residuals.
>
> 4\) Immune disorder history. Date of onset and course of immune
> disorder, including exacerbations, response to therapy, and residuals.
>
> 5\) Nutritional deficiency history. Date of onset and conditions of
> nutritional deficiency, including exacerbations, response to therapy,
> and residuals.
>
> 6\) Occupational and environmental history. Describe any similar
> exposure both in the military and before and following service,
> including occupational hazards.

b\. Review examination: For a review examination, only an interval
history covering the period since the last examination is needed.

c\. Physical examination: See worksheets for additional information.

d\. Usual laboratory studies

CBC with differential for infections, autoimmune studies for immune
deficiencies and serum protein for nutritional deficiencies.

## 15.2 What are the characteristics of Avitaminosis?

Describe any residuals of malnutrition.

Include the date of onset of symptoms, clinical manifestations, weight
curve (average, highest, lowest, and present weight), and any treatment
received.

## 15.3 What are the characteristics of Bartonellosis or Oroya Fever?

Describe any abrupt febrile illness with muscle and joint pain or cherry
red cutaneous nodules on the face, limbs, genitalia, scalp, pharynx, or
mouth as well as any severe anemia. The red blood cell count drops
precipitously and stained smears reveal large number of *Bartenella
bacillifonnis* in the erythrocytes. Convalescence is prolonged and blood
cultures may be positive long after recovery. Search for other
parasites, blood borne or intestinal, is in order.

## 15.4 What are the characteristics of Beriberi?

Describe any nutritional polyneuritis, cardiac findings (palpitation,
tachycardia, cardiac irregularities, dyspnea, murmurs, ECG changes,
inversion of T-waves, prolongation of Q-T intervals), enlarged heart or
cardiac failure. The diagnosis depends upon a history of thiamin
deficiency and findings of peripheral neuritis, foot drop, impaired
vibratory and position sense, enlarged heart, edema or tenderness and
atrophy of muscles. Response to replacement therapy may not be
satisfactory in relieving residuals after manifestations have progressed
to an advanced degree of severity. On the other hand, it is essential to
recall that with very rare exceptions patients with beriberi heart
disease either die quickly after the acute fulminating phase of heart
failure or recover entirely.

## 15.5 What are the characteristics of Brucellosis (undulant fever, Malta fever)?

Record any history of abrupt febrile illness or prolonged symptoms of
weakness, depression or an incapacitating illness. Extreme fatigue and
exhaustion often occur with the slightest physical exertion despite
comfort at rest. Fever is intermittent with diurnal variations from 98.0
to 104 degrees F (38.50 to 40.0C). Profuse nocturnal sweats, adenopathy,
hepatomegaly, splenomegaly, and abdominal tenderness may be present.

Complications are encephalitis, meningitis, spondylitis involving the
thoracolumbar region, vegetative endocarditis, myocarditis,
pericarditis, uveitis, orchitis, bone infarcts or abscess, nephritis,
cystitis, and hepatitis. Jaundice may occur. Laboratory tests may
include agglutination reaction, blood culture or culture of aspirated
sternal bone marrow.

## 15.6 What are the characteristics of Cholera?

Record any history of copious emesis, frequent, large watery stools
containing little or no pus, dehydration, electrolyte imbalance, severe
thirst, weight loss, anuria, uremia (in severe cases), and finding the
causative organism on stool culture. Usually with present day treatment,
the patient survives with little or no residual disability. Include any
residuals such as renal impairment.

## 15.7 What are the characteristics of Filariasis?

Record any history of swelling of the scrotum, penis, or labia, swelling
of the arm or leg after physical exertion. Diagnosis is dependent upon
demonstration of microfilariae in the blood stream. Eosinophilia occurs
in two-thirds of cases. Describe any residuals such as elephantiasis.

## 15.8 What are the characteristics of Kala-azar (Visceral Leishmaniasis)?

Record any history of irregular bouts of fever with daily double spikes,
hepatomegaly, splenomegaly, lymphadenopathy, leukopenia, weight loss,
debility, anemia, edema or hyperpigmentation of the skin. There may be a
reversal of albumen globulin (A/G) ratio with marked hyperglobulinemia.
Diagnosis is dependent upon demonstration of parasites in peripheral
blood, sternal bone marrow, biopsy of lymph nodes, skin lesions, liver
or spleen. Animal inoculation or culture may be required for diagnosis.
About 98 percent of cases are cured with good treatment.

## 15.9 What are the characteristics of Malaria?

Extreme care must be used to evaluate this condition in a veteran who
was in an endemic area and left service during recent months. The
disease is often not diagnosed while in service or in endemic areas
because of suppressive control measures but later becomes evident after
return to civilian life. Rarely, a period of years may occur between the
time malaria is acquired and the time it is recognized clinically. Onset
of malarial reactivation often occurs with exposure to cold, trauma,
alcohol, infections, unusual exertions, debilitating conditions, or
other situations affecting the immune system. Diagnoses of acute or
relapsing malaria must be based on identification of malarial parasites
in blood smears. A diagnosis of chronic malaria should include any
residuals such as liver or spleen damage.

## 15.10 What are the characteristics of Lupus Erythematosus?

The report should include date of onset and a clinical description of
the extent of the disease in the particular organs involved. Note any
butterfly erythema of face, arthralgias, recurrent pneumonitis, serous
membrane involvement with pleurisy or pericarditis, diffuse myocarditis,
atypical verrucous endocarditis (Libman-Sachs disease), central nervous
system involvement (epilepsy), or renal involvement.

The report should include results of abnormal laboratory findings such
as anemia, leukopenia, thrombocytopenia, positive Coombs test, positive
tests for antinuclear antibodies, and a positive rheumatoid factors.

Describe frequency of exacerbations and whether or not they cause severe
impairment of health.

## 15.11 What are the characteristics of Melioidosis?

Record any history of an acute upper respiratory illness, followed by an
abrupt onset of localized or widespread pulmonary abscesses. This phase
may resemble miliary tuberculosis or subacute bacterial endocarditis.
The illness may be devastating or fatal, with pulmonary, meningeal,
cardiac, or other findings. Cultures of appropriate material are
essential for diagnosis.

## 15.12 What are the characteristics of Pellagra?

The diagnosis depends upon a history of inadequate niacin in the diet
(high in carbohydrate and fat, low in animal proteins), dermatitis, and
stomatitis. Describe any diarrhea or skin lesions on hands, wrists,
elbows, neck, knees, feet, under breasts, and in the perineal region,
glossitis or stomatitis. Include any residuals such as subacute combined
degeneration of the spinal cord with spasticity and ataxia, peripheral
neuritis, depression, apprehension, hallucinations or disorientation.
Lab tests should include CBC with differential (microcytic or macrocytic
anemia).

## 15.13 What are the characteristics of Plague?

Describe any high fever, lymphangitis with tender enlarged lymph nodes
or buboes, overwhelming septicemia, or patchy pneumonia. Include any
residuals such as infected buboes or primary plague pneumonia. Diagnosis
is dependent upon a demonstration of *Yersinia pestis* in material
aspirated from buboes, blood or sputum.

## 15.14 What are the characteristics of Relapsing Fever (Recurrent Fever, Famine Fever, Tick Fever)?

Describe any chills, fever, headache, erythematous rash, rose-colored
spots on trunk or limbs, severe muscle pain or involvement of the
central nervous system. Fever generally subsides in 3 to 10 days with
later relapses similar to the original complaints. Diagnosis is
demonstrated by *Borrelia recurrentis* in peripheral blood or by animal
inoculation.

## 15.15 What are the characteristics of Rheumatic Fever?

Record any history of an upper respiratory infection due to Group A beta
hemolytic streptococci, acute migratory polyarthritis primarily
involving the larger joints and accompanied by a febrile illness, signs
of myocarditis, pericarditis, valvular disease, erythema marginatum,
subcutaneous nodules, or chorea minor (Sydenham\'s Chorea). Include any
frequent nosebleeds, \"heart murmurs,\" nodules along extensor tendons,
long terms of bed rest, and restriction from sports. The episodes of
active rheumatic fever must clearly detail cardiac findings, fever,
rash, and involvement of joints or the central nervous system. A mitral
presystolic rumble, suggesting mitral stenosis or atrial myxoma, may
require a cardiology consultation.

The laboratory findings include ECG, elevated serum antistreptolysin 0
titre, anemia, leukocytosis, elevated sedimentation rate, and positive
C-reactive protein.

Describe any residuals such as chronic heart disease.

## 15.16 What are the characteristics of Schistosomiasis?

Authenticated, positive diagnosis during military service in the tropics
should be obtained. Other tropical diseases sometimes produce some of
the findings of schistosomiasis. Any disease of the central nervous
system, or gastrointestinal tract should be fully documented. The date
of the last positive stool and date of completion of treatment, as well
as drug and amount, should be noted. Any eosinophilia should be noted.
Careful stool examination should be done and a skin test or rectal
biopsy may be useful.

## 15.17 What are the characteristics of Scrub Typhus (Tsutsugamushi fever or Tropical Typhus)?

Record any history of eschar at the site of the bite, ulcer, lymphatic
enlargement, high fever, and red macular rash, parotitis, melena, coma,
mania, heart failure, or pulmonary edema. Weil-Felix Reaction test may
be useful.

## 15.18 What are the characteristics of Extra-Pulmonary Tuberculosis? (See also the Respiratory Chapter)

Describe any symptoms such as fatigue, anorexia, weight loss, fever of
unknown origin or unexplained hematuria. Record any abnormalities in
lymph nodes, pleura, genitourinary tract, bone, pericardium or
peritoneum. Although tuberculosis usually presents with symptoms, many
patients have insidious symptoms which they ignore. Describe any
residuals such as joint involvement, ankylosis or surgical removal of a
part of an extremity.

Classification of Tuberculosis:

> 0\. No tuberculosis exposure, not infected (no history of exposure,
> reaction to tuberculin skin test not significant).
>
> I. Tuberculosis exposure, no evidence of infection (history of
> exposure, reaction to tuberculin skin test not significant).
>
> II\. Tuberculous infection, without disease (significant reaction to
> tuberculin skin test, negative bacteriological studies (if done), no
> clinical and/or x-ray evidence of tuberculosis.)
>
> Chemotherapy status (preventive therapy);
>
> A. None
>
> B. On chemotherapy since (date)
>
> C. Chemotherapy terminated (date)
>
> 1\. Complete (prescribed course of therapy)
>
> 2\. Incomplete
>
> III\. Tuberculosis: current disease.
>
> A. Location of disease (predominant site; other sites if significant)
>
> B. Bacteriological status
>
> C. Chemotherapy status
>
> D. Roentgenogram findings
>
> E. Tuberculin skin test
>
> IV\. Tuberculosis: no current disease.

## 15.19 What are the characteristics of Syphilis?

Describe any residuals of the nervous system such as tabes dorsalis,
Charcot's joints, or foot ulcerations; residuals of the cardiovascular
system such as aortitis; residuals of the eye such as iritis, optic
neuritis, retinitis pigmentosa, or uveitis; gummas of the skin; skeletal
system; upper respiratory tract; liver; or stomach. Lab tests may
include RPR, VDRL, FTA-ABS, MHA-TP, cerebrospinal evaluation.

## 15.20 What are the characteristics of Leprosy?

Describe any symptoms of pain, difficulty seeing, nasal stuffiness,
epistaxis, laryngitis, or hoarseness. Describe any signs of skin
lesions, neurologic abnormalities, or joint abnormalities. Include any
residuals such as skin lesions, peripheral neuropathy, hand deformity,
traumatic lesions, chronic infections, or blindness. State whether or
not the disease is active or inactive.

## 15.21 What are the characteristics of Miliary Tuberculosis?

Describe all organs involved and the extent of involvement. Include past
and present treatment and the response to that treatment. Tests should
include chest x-ray and CBC with differential. Other tests which may be
helpful include transbronchial biopsy, liver biopsy, or bone marrow
biopsy. State whether or not the disease is active or inactive.

## 15.22 What are the characteristics of Lyme Disease?

Describe any skin lesions, meningitis, cranial or peripheral neuritis,
carditis or migratory musculoskeletal pain. Include any residuals such
as arthritis, skin conditions, or chronic neurologic disease. Laboratory
tests include serology and may include rheumatoid factor and antinuclear
antibodies to exclude other forms of arthritis.

## 15.23 What are the characteristics of Other Parasitic Infections?

Describe where and when the infection was acquired, past and present
treatment, and response to treatment. Include any residuals such as
spleen or liver damage.

## 15.24 What are the characteristics of HIV -- Related Illness?

Describe risk factors, onset and progression of the disease, all the
body systems affected, memory loss, and the degree of disability,
including what the veteran can and cannot do and its effects on
employment. List the number and frequency of exacerbations, all
opportunistic infections such as oral candidiasis, neoplasms, Hairy cell
leukoplakia, and any neurologic or psychiatric conditions. Include any
weight loss, debility, and refractory symptoms such as chronic diarrhea
and any lymphadenopathy. Indicate current CBC with differential and most
recent T4 cell count.

## 15.25 What are the characteristics of Chronic Fatigue Syndrome?

Chronic Fatigue Syndrome (CFS) is an illness characterized by
debilitating fatigue and flu-like symptoms. Usually it begins with a
sudden onset of flu-like symptoms which do not fully resolve, lasting
months to years and accompanied by debilitating fatigue and malaise
lasting more than 6 months. Since the diagnosis is one of exclusion, the
clinician must rule out malignancy, autoimmune disease, infection,
chronic inflammatory disease, endocrine disorders, allergic reactions to
drugs or toxic agents, chronic mental conditions, and drug dependency.

Report fever, sore throat, painful lymph nodes, muscle weakness,
myalgia, prolonged generalized fatigue following exercise, headaches and
frequency, migratory arthralgia, photophobia, scotomas, sleep
disturbances, or neurologic symptoms such as forgetfulness,
irritability, confusion, difficulty thinking, inability to concentrate
or depression. Report fever, non-exudative pharyngitis, or palpable
cervical or axillary lymph nodes.

Indicate what the veteran can and cannot due and the effect on
activities of daily living and employment.

For VA purposes, the diagnosis of chronic fatigue syndrome requires all
of the following:

\(1\) New onset of debilitating fatigue severe enough to reduce daily
activity to less than 50 percent of the usual level for at least six
months; and

\(2\) The exclusion, by history, physical examination, and laboratory
tests of all other clinical conditions that may produce similar
symptoms; and

\(3\) Six or more of the following:

> \(a\) Acute onset of the condition
>
> \(b\) Low grade fever
>
> \(c\) Nonexudative pharyngitis
>
> \(d\) Palpable or tender cervical or axillary lymph nodes
>
> \(e\) Generalized muscle aches or weakness
>
> \(f\) Fatigue lasting 24 hours or longer after exercise
>
> \(g\) Headaches (of a type, severity, or pattern that is different
> from headaches in the pre-morbid state)
>
> \(h\) Migratory joint pains
>
> \(i\) Neuropsychologic symptoms
>
> \(j\) Sleep disturbance

## Worksheet - HIV-RELATED ILLNESS

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment On:

1\. Recurrent opportunistic infections.

2\. Recurrent constitutional symptoms.

3\. Diarrhea.

4\. Debility.

5\. Progressive weight loss.

6\. Remissions in any symptomatology.

7\. Depression or memory loss.

8\. Treatment - Is this an approved medication?

9\. Describe the effects of the condition on the veteran\'s usual
occupation and daily

activities.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe:

1\. Definitive diagnosis of AIDS. (Use CDC Definition.)

2\. Secondary diseases affecting multiple body systems - describe.

3\. HIV-related illnesses - describe.

4\. Neoplasm related to HIV-related illness. Describe.

5\. T4 cell counts.

6\. Hairy cell leukoplakia.

7\. Oral candidiasis.

8\. Use of HIV-related medications.

9\. Lymphadenopathy.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. T4 Cell counts.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - INFECTIOUS, IMMUNE, AND NUTRITIONAL DISABILITIES 

Name: SSN:

Date of Exam: C-number:

Place of Exam:

Narrative: Many infectious diseases, immune disorders, and nutritional
deficiencies have acute phases at onset and accompanying recurrences but
leave little or no residual disability beyond the acute phase. Other
such conditions may have slow progression and show significant residual
disability. The examiner must diligently search for residual
disabilities upon which adjudication of the case may be made.

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Date of symptom onset.

2\. Date of diagnosis.

3\. Clinical manifestations.

4\. Treatment (type, frequency, duration, response, side effects).

5\. Disease activity (exacerbations and/or remissions)? If there were
exacerbations,

what was the state of the veteran\'s health between exacerbations?
Frequency and

duration of exacerbations.

6\. Current symptoms

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Is the condition still present?

2\. Current weight, nutrition. Any residuals of malnutrition, vitamin
deficiency?

3\. General appearance.

4\. Describe findings of all organ systems involved. See appropriate
examination

worksheets - respiratory, joints, cardiovascular, etc.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

**Note:** If an infectious etiology is documented, specify the organism.

E. **Diagnosis:**

Signature: Date:

# Chapter 16 - ENDOCRINE CONDITIONS

## 16.1 What are the basic elements of an examination for disease of the endocrine system?

This chapter supplements the examination worksheet.

**a. Initial examination**

1\) History of present illness - onset, frequency, and severity of
symptoms; past and current treatment; whether symptoms are controlled by
treatment; effects of condition on daily activities.

2\) General health information, as pertinent - including previous
surgery and illnesses; family history; military history.

3\) Endocrine history. Date of onset and course of endocrine disorder.

4\) Occupational and environmental history. Describe any exposure to
dusts, gases, toxins, etc., both in the military and before and
following service, including occupational hazards.

**b. Review examination:** For a review examination, only an interval
history covering the period since the last examination is needed.

**c. Physical examination:** See worksheets for endocrine diseases and
additional information below.

**d. Usual laboratory studies:** Appropriate tests for the endocrine
disease claimed. Specialized tests may be needed at times, such as
endocrine stimulation tests or ultrasound. A consultation with the
regional office is suggested before any specialized or invasive test is
requested or scheduled.

## 16.2 What specific information may be needed for the evaluation of Addison\'s Disease?

Record any history of tuberculosis or previous treatment with ACTH or
corticosteroids, an adrenalectomy for another condition, associated
autoimmune diseases in the patient or family members, symptoms of
weakness or fatigability, weight loss. Appropriate treatment with
adrenocortical steroids results in remarkable subjective and objective
improvement with restoration of appetite, weight, muscular strength, and
the ability to withstand infection, trauma, or other stress. Include the
number of crises (hypotension and shock) or episodes (orthostatic
hypotension and dehydration) per year. Serum sodium, potassium, and
glucose readings must be obtained. KUB x-ray for adrenal calcification
and ECG\'s may be indicated. Secondary adrenocortical insufficiency
associated with pituitary or hypothalamic disease should be
differentiated from primary Addison\'s disease by plasma ACTH assay.

## 16.3 What specific information may be needed for the evaluation of Benign New Growths of the Endocrine System?

Describe the treatment and interference with specific endocrine
functions. If the patient cannot be accurately evaluated by techniques
available on an outpatient basis, hospitalization for further studies
and/or treatment is indicated.

## 16.4 What specific information may be needed for the evaluation of Cushing\'s Syndrome?

State whether there has been a change in appearance or weight, weakness,
easy bruisability, current infection, change in personality, or a
history compatible with bone disease, such as loss in height or
pathologic fractures. Describe any moon face, buffalo hump, pigmented
striae, abnormal fat distribution (centripetal obesity), or muscle
weakness. Report any restrictions in daily activities and the frequency
of visits to a diabetic care provider. Examine the fundi and test the
visual fields. Overnight dexamethasone test may also be abnormal in
depression, uremia, or morbid obesity. The best confirmatory test is a
24-hour urinary free cortisol determination. Skull films and CT scans of
the head and abdomen may be indicated.

## 16.5 What specific information may be needed for the evaluation of Diabetes Mellitus?

Report the circumstances under which diabetes mellitus was discovered
(routine urinalysis, acidosis, trauma, surgery, or during some other
illness). Give the approximate frequency and dates of hospitalizations
and record whether hospitalizations were for ketoacidosis, insulin
reactions, hypoglycemia, or specific complications of diabetes. Record
the number and types of daily insulin taken, the number of units needed
daily, and the time of day injected. If other hypoglycemic agents are
being used, specify. Include any restrictions of diet or physical
activities and any weight loss. Describe any microvascular or
macrovascular complications such as coronary artery disease,
atherosclerotic peripheral vascular disease, renal disease, retinopathy,
etc.

## 16.6 What specific information may be needed for the evaluation of Hyperthyroidism (with Diffuse Goiter or Nodular Goiter)?

Record a history of treatment with surgery, radioactive iodine, or
anti-thyroid drugs. Note any visible tumor or palpable nodule(s),
increase in neck size, prominent eyeballs, double vision, lid lag, or
any other ocular signs. Report excessive feeling of warmth, weight loss
despite excellent appetite, and easy fatigability, including muscular
weakness especially when climbing or descending stairs. When these
symptoms interfere with normal daily activities or job efficiency it is
essential that the extent of such handicaps be described. Record the
presence of diarrhea, tachycardia, nocturnal heart awareness, dyspnea,
palpitations, or other cardiac symptoms. Record irregularities of
menstruation. Serum thyroxin (T4) by (radioimmunoassay) is usually, but
not always, elevated in thyrotoxicosis. If the results seem at variance
with the clinical picture, then the diagnosis of T3-thyrotoxicosis
should be considered, particularly in elderly subjects or patients from
iodine-deficient areas. Since greater than 99 percent of circulating T4
and T3 are bound to plasma protein, which will be affected by a variety
of drugs or disease states, tests for TBG (thyroid hormone binding
globulin), such as the T3 resin uptake test, should be performed. From
this and the serum T4 concentration, a calculated value for free T4
(PTI) can be obtained. Elevations of TBG and T4 are seen in patients on
estrogen therapy, during pregnancy, and in patients with acute
hepatitis. A false decrease in T4, due to decreased TBG production, is
seen in patients on androgen or prolonged high-dose glucocorticosteroid
therapy, and also in patients with chronic disease, particularly liver
disease. Radioactive uptake and scanning procedures may be needed.
Although the plasma cholesterol is frequently low, it is not invariably
so and is therefore not a reliable diagnostic procedure. Routine tests
to be ordered include ECG\'s and X-rays of the chest and cervical area
for substernal thyroid and tracheal deviation.

## 16.7 What specific information may be needed for the evaluation of Hyperparathyroidism?

This diagnosis should be suggested by repeated genitourinary stones,
pathological fractures, pancreatitis, or hypercalcemia found in routine
laboratory screening. Symptoms are anorexia, nausea, vomiting,
occasional severe dehydration, weakness, weight loss, constipation,
abdominal pain, loss of muscular tone, neurotic and psychotic symptoms,
polydipsia and polyuria occasionally simulating diabetes insipidus,
repeated ureteral colic from lithiasis, and fever and pain from
secondary urinary tract infections. The serum calcium may be elevated.
Repeated fasting calcium determinations should be obtained for
reliability and blood should be drawn with the tourniquet off. The serum
phosphorus is usually below normal. The serum albumin should be
determined with each serum calcium since hypoalbuminemic disorders will
lower the total calcium even though the serum dializable calcium remains
elevated. The serum alkaline phosphatase may be somewhat elevated but is
often normal. Renal function tests may be desirable if nephrocalcinosis
is suspected. A urinalysis should be performed for evidence of renal
gravel, hypercalciuria, and secondary infections. If indicated, the
urine should be cultured. X-rays of the hands and wrists as well as a
lateral view of the skull are indicated. X-rays should be taken of all
bones, deformed or tender, or otherwise suspect on physical examination.
Perform KUB for calcinosis. Urograms may be indicated. The teeth should
be X-rayed for disappearance of lamina dura. The CT scan is occasionally
helpful in locating the adenoma. Serum parathormone levels can be
ordered in difficult diagnostic cases.

## 16.8 What specific information may be needed for the evaluation of Hypothyroidism?

State whether or not there has been a surgical thyroidectomy or other
treatment such as I131. Report any history of low anterior cervical
pain, sore throat, and fever, consistent with thyroiditis. Report
slowness of thought and speech, inability to concentrate, loss of
memory, lethargy, or drowsiness. Record symptoms of weakness and
fatigability. The degree to which symptoms interfere with daily
activities and job efficiency should be stated. Indicate any history of
chronic anemia. In women record a history of menstrual disturbances.
Chest pain, dyspnea, and other cardiovascular symptoms should be
reported. Is the patient taking thyroid extract or some of its
modifications? If so, record daily dose and duration of treatment. Does
the patient have a good clinical response to relatively small doses?
Inquire as to symptoms of other glandular deficiencies. The best
screening test for hypothyroidism is the serum T4 concentration. The
free T4 index and T3 resin uptake should also be obtained in screening
for this disease. Serum T3 concentration (RIA) is not helpful in the
diagnosis of hypothyroidism since such values may be within normal
limits in patients with decreased thyroid function. If the T4 is
borderline, then order a serum TSH. The TSH should be elevated in
patients with primary hypothyroidism. If the TSH value is borderline, a
TRH (thyrotropin releasing hormone) test, measuring TSH levels, should
be diagnostic, since the TSH response is exaggerated in patients with
decreased thyroid function. The basal metabolic rate should not be
ordered routinely. The serum cholesterol, while elevated, is
nonspecific. If hypothyroidism is thought to be on the basis of
autoimmune (Hashimoto\'s) thyroiditis, then tests for antibodies to
thyroidal tissue should be ordered.

## 16.9 What specific information may be needed for the evaluation of Hypoparathyroidism?

Record any previous thyroidectomy or parathyroid surgery and the date of
onset of symptoms after surgery, paresthesia of the extremities,
numbness and stiffness about the mouth, muscular twitchings, cramps,
tetany, painful muscular spasms, carpopedal spasm, or diminished vision
associated with cataracts. Record medications, regularity and dosage of
medications, diet (Vitamin D, aluminum hydroxide gels, calcium salts,
low phosphorus diet.) If the patient is receiving treatment, record how
well the symptoms are controlled and do they interfere with daily
activities? Is there a history of mental deterioration? The serum
calcium determination is low (between 4 and 8 mg %) and should be
repeated as noted under \"hyperparathyroidism.\" The skull should be
X-rayed with an anteroposterior view for possible calcification of the
basal ganglia. An anteroposterior view of lower limbs for possible
sclerosis of bones is also indicated.

## 16.10 What is MEN (Multiple Endocrine Neoplasia) Syndromes (Types I, II, III)?

Type I - Pituitary adenoma, hyperparathyroidism (usually hyperplasia),
and islet cell tumors (gastrinomas, insulinomas, and glucagonomas).

Type II - Medullary carcinoma of the thyroid, pheochromocytoma
(frequently bilateral), and hyperparathyroidism.

Type III - Medullary carcinoma of the thyroid, pheochromocytoma,
multiple neuromas of the conjunctiva, tongue, buccal mucosa, and
abnormalities of the gastrointestinal tract; no hyperparathyroidism.

## 16.11 What specific information may be needed for the evaluation of Malignant New Growths of the Endocrine System?

Record the dates and amounts of treatment, plus evidence of recurrence,
metastases, endocrine complications, or residuals, as appropriate.

## 16.12 What specific information may be needed for the evaluation of Pituitary Tumors (Acromegaly, Prolactinoma)?

Record frequency and location of headaches, changes in vision, and
neurological symptoms. In male patients, prolactinoma is suggested by a
long-standing history of infertility and impotence. In female patients a
history of secondary amenorrhea, infertility, and galactorrhea should be
noted. Visual fields and X-rays of the skull are essential. A CT scan of
the skull with contrast is frequently diagnostic. Acromegaly is
diagnosed by an elevated fasting plasma growth hormone level. In cases
of borderline elevations, lack of suppression by glucose during a
glucose tolerance test may confirm the diagnosis. The most useful
confirmatory test for prolactinoma is the basal serum prolactin level.

## 16.13 What specific information may be needed for the evaluation of Posterior Hypopituitarism (Diabetes lnsipidus)?

a\. Diagnosis:

Record date of onset, history of head trauma, surgical injury, infection
(such as syphilis or encephalitis), or tumor in the pituitary or
hypothalamic region, if the pituitary or pituitary stalk was destroyed
in the treatment of some other disease, and any neurological symptoms,
polydipsia, nocturia, polyuria, weakness, episodes of dehydration, and
excessive weight loss. A 24-hour output of urine may be over four
liters. Measure the 24-hour urine volume. The urine should be negative
for glucose and protein. Plasma and urinary ADH measurements can be
helpful in selected cases. A skull X-ray with lateral and
posteroanterior views for distortion of the sella turcica, erosion of
the clinoid processes, or displacement of the calcified pineal should be
obtained. The possibility of a brain tumor or cyst should be kept in
mind.

b\. Assessment:

Describe number of episodes of dehydration over the past year and the
type of treatment required.

## 16.14 What specific information may be needed for the evaluation of Toxic Adenoma?

The examination is essentially the same as described under
"Hyperthyroidism." However, in \"toxic adenoma,\" examination usually
reveals an adenomatous, irregular, and multi-nodular goiter. Single or
isolated toxic nodules may be present. Important tests are T3 uptake and
especially thyroid suppression and scanning tests. Exophthalmos and
other ocular signs rarely occur and are not required for the diagnosis.

## 16.15 What specific information may be needed for the evaluation of Non-Toxic Adenoma?

The history is usually negative for symptoms or signs of toxicity.
However, there may be neck pressure symptoms and disfigurement. If so,
describe cough, dysphonia, dysphagia and any neck mass deformity of face
or neck. If not, state that no pressure symptoms were found. It may be
necessary to rule out toxicity using studies similar to those described
under "Hyperthyroidism." If a \"hot\" or a \"cold\" nodule is suspected,
the patient should be referred for scanning procedures, T3 uptake, and
surgical consultation. Note that the finding of a single \"cold\" nodule
is compatible with malignancy in from 10 to 25 percent of cases. The
importance of careful studies to rule out malignancies in these
situations is very important. Ultrasound examination to determine
whether or not the lesion is cystic may be helpful in such cases. Serum
thyroglobulin determinations, elevated in thyroid cancer, are helpful
only if extremely high since falsely elevated values may be seen in
benign nodular goiter. They are helpful in following patients after
therapy in determining progression of disease.

## Worksheet - ACROMEGALY

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B**. Medical History (Subjective Complaints):**

Comment on:

1\. Date diagnosis established.

2\. Joint pains.

3\. Changes in vision.

4\. Headaches (severity and frequency).

5\. Cardiac symptoms.

6\. Change in shoe, glove, or hat size.

7\. Symptoms of glucose intolerance.

8\. Treatments.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Arthropathy.

2\. Vascular fragility.

3\. Evidence of increased intracranial pressure.

4\. Size of acral parts, long bones.

5\. Visual impairment, including visual fields.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. CT of brain or X-ray of sella turcica.

2\. Glucose tolerance test.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Comment on:

1\. Is the disease active or in remission?

Signature: Date:

## Worksheet - CUSHING\'S SYNDROME

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B**. Medical History (Subjective Complaints):**

Comment on:

1\. Date diagnosis established.

2\. Weakness.

3\. Etiology ? Iatrogenic?

4\. Treatments (surgery, medication, etc.), dose, frequency, response,
side effects.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Muscle strength.

2\. Vascular fragility.

3\. Gastrointestinal.

4\. Blood Pressure.

5\. Striae.

6\. Weight gain or loss.

7\. Moonface.

8\. Glucose metabolism.

9\. After control, describe adrenal insufficiency, cardiovascular,
psychiatric, skin, or

skeletal complications or residuals.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. CT of brain or X-ray of sella turcica.

2\. Serum and urine cortisol levels.

3\. High and low dose dexamethasone suppression test.

4\. X-rays if osteoporosis suspected.

5\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Comment on:

1\. Is the disease active or in remission?

Signature: Date:

## Worksheet - DIABETES MELLITUS

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Age of onset.

2\. Frequency of ketoacidosis or hypoglycemic reactions (hospitalization
required?).

3\. Restricted diet, weight loss or gain since last exam.

4\. Describe any restriction of activities.

5\. Visual problems.

6\. Vascular or cardiac symptoms.

7\. Neurologic symptoms.

8\. Treatment - oral hypoglycemic, insulin (frequency of injections).

9\. Frequency of visits to diabetic care provider.

10\. Other symptoms, such as anal pruritus, loss of strength.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Blood pressure, other cardiovascular findings, including status of
peripheral vessels.

2\. Neurologic examination.

3\. Eye examination.

4\. Skin examination.

5\. Examination of extremities, including feet.

6\. State if the veteran has bladder or bowel functional impairment. If
present, state

whether partial or total, intermittent or constant and what measures are
taken as a

result of the impairment.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. Renal function tests, including 24 hour urine test for protein if
renal involvement is

uncertain.

2\. Blood sugar.

3\. Urinalysis.

4\. Glucose tolerance test, if necessary to establish the diagnosis.

5\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Comment on:

1\. All complications noted - visual, cardiac, vascular, nephrologic,
neurologic (including

both peripheral neuropathy and cerebral effects), amputations. See
examination

worksheets for the conditions found.

Signature: Date:

## Worksheet - ENDOCRINE DISEASES, MISCELLANEOUS

**(Benign and Malignant Neoplasms, Hyperpituitarism,**

**Hyperaldosteronism, and Pheochromocytoma)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B**. Medical History (Subjective Complaints):**

Comment on:

1\. Date of diagnosis and how established.

2\. Fatigability.

3\. Headaches.

4\. Changes in vision.

5\. Neurologic, cardiovascular, or gastrointestinal symptoms.

6\. Treatments (surgery, medications, hormones), including dose,
frequency, response,

side effects. For malignancy, provide date of completion of treatment
for malignancy.

7\. Weight gain or loss.

8\. Excessive thirst, frequency of urination.

9\. Describe the effects of the condition(s) on the veteran\'s usual
occupation and daily

activities.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. For hypoparathyroidism, thyroid surgery scar?

2\. For diabetes insipidus, signs of dehydration?

3\. For Addison\'s disease, muscle strength, blood pressure, skin
pigmentary changes.

Number of crises (with peripheral vascular collapse) or episodes (less
acute and severe

than crisis - no peripheral vascular collapse).

4\. For pluriglandular syndromes, see examinations for glands affected.

5\. Describe all residuals of benign or malignant neoplasm, including
those related to

treatment.

6\. Is the disease active or in remission?

7\. For hyperparathyroidism, history of kidney stones. History of
demineralization of

skeleton.

D. **Diagnostic and Clinical Tests:**

Provide, as appropriate:

1\. Blood and urinary calcium.

2\. X-ray of bones to confirm decalcification.

3\. Glucose tolerance test, if necessary.

4\. Antidiuretic hormone level.

5\. Serum and urine electrolytes.

6\. Urine specific gravity.

7\. Serum cortisol.

8\. Serum creatinine.

9\. Serum glucose.

10\. ACTH test.

11\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

## Worksheet - THYROID AND PARATHYROID DISEASES

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Date diagnosis established.

2\. Fatigability.

3\. Mental assessment.

4\. Neurologic, cardiovascular, or gastrointestinal symptoms.

5\. Treatments (surgery, medications, hormones), including dose,
frequency, response,

side effects. For C-cell hyperplasia, provide date of completion of any
treatment for

malignancy.

6\. Symptoms due to pressure (on larynx, esophagus, etc.).

7\. Cold or heat intolerance.

8\. Constipation.

9\. Weight gain or loss.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Thyroid size.

2\. Pulse and blood pressure.

3\. Eye and vision abnormalities.

4\. Muscle strength.

5\. Tremor.

6\. Myxedema.

7\. All other residuals of thyroid disease or its treatment.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. T4, T3, TSH, and/or other thyroid function tests, if needed.

2\. If thyroidectomy scar is disfiguring, order [color
photograph]{.underline}.

3\. Thyroid scan, if indicated.

4\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Comment on:

1\. Is the disease active or in remission?

Signature: Date:

# Chapter 17 - HEMIC AND LYMPHATIC SYSTEMS

## 17.1 What specific information may be needed for a hematologic examination?

This chapter supplements the examination worksheet.

a\. What is needed in the history for an initial examination?

1\) History of present illness - onset, frequency, and severity of
symptoms; past and current treatment; whether symptoms are controlled by
treatment; effects of condition on daily activities.

2\) General health information - including previous surgery and
illnesses; family history; military history.

3\) Treatment in past. Medication, dosage and effect on disease.

4\) Include details of treatment and its side effects or residuals post
treatment.

b\. What is needed in the history for a review examination?

For a review examination, only an interval history covering the period
since the last examination is needed.

c\. What is needed for the physical examination?

1\) The results of any general physical examination should be
coordinated with the hematologic examination. For a review examination,
only the specific area or areas of concern need be examined.

2\) Describe findings on examination of

vital signs - blood pressure, pulse

skin -- pale nail beds or conjunctiva

general - weight loss

d\. What laboratory studies may be needed?

CBC with differential is routine; request other studies as indicated. A
consultation with the regional office is suggested before any
specialized or invasive test is requested or scheduled.

## 17.2 What specific information may be needed for an agranulocytosis examination?

Describe any tiredness, easy fatigability, chills, high fever,
pharyngitis, stomatitis, gingivitis with ulcerations, weakness,
prostration, purpura, sepsis, exposure to benzene, anticonvulsive
agents, sulfonamides, arsenicals, butazolidin, gold, chlorproniazine,
chemotherapeutic agents, or irradiation. Include details of treatment
and its side effects or residuals post treatment. Laboratory tests
should include CBC with differential. Bone marrow study may be needed.

## 17.3 What specific information may be needed for an aplastic anemia examination?

Describe any tiredness, easy fatigability, severe infections, bleeding,
and drug use such as chloramphenicol or immunologic depressants. Include
blood pressure, pulse pale nail beds or conjunctiva or bleeding. Include
details of treatment and its side effects or residuals post treatment.
Laboratory tests should include CBC with differential and sometimes a
bone marrow examination.

## 17.4 What specific information may be needed for a Hodgkin\'s and Non Hodgkin's disease examination? 

**a. Hodgkin's Disease:**

Describe any pruritus, fever, weight loss, present therapy, response,
number of relapses, and complications of the disease. Include the exact
locations of enlarged discrete firm lymph nodes in the cervical,
axillary or inguinal regions, hepatomegaly or splenomegaly and any brain
involvement. Include details of treatment and its side effects or
residuals post treatment. Describe completely all manifestations of the
disease, all complications, and all residuals of treatment, as well as
their effects on functioning. Laboratory tests should include CBC with
differential. Tests that may be required are lymph node biopsy,
lymphangiogram, CAT scan, liver biopsy or exploratory laparotomy.

**b. Non-Hodgkin's Disease:**

Non-Hodgkin\'s Lymphoma represents a heterogenous group of tumors, which
are similar to Hodgkin\'s disease except that extranodal involvement
including blood involvement is more common. Because lymph tissue is
found in many parts of the body, non-Hodgkin\'s lymphoma can start in
almost any part of the body. The cancer can spread to almost any organ
or tissue in the body, including the liver, bone marrow (the spongy
tissue inside the large bones of the body that makes blood cells),
spleen, and nose. The diagnosis must be supported by lymph node or other
tissue biopsy which should be classified as to pathologic type. Stage,
response to therapy, relapses and complications of therapy should be
included. Include the exact locations of all tumor involvement. Include
details of treatment and its side effects or residuals post treatment.
Describe completely all manifestations of the disease, all
complications, and all residuals of treatment, as well as their effects
on functioning. Laboratory tests should include CBC with differential.
Tests that may be required are lymph node biopsy, lymphangiogram, CAT
scan, liver biopsy or exploratory laparotomy.

## 17.5 What specific information may be needed for a hypochromic microcytic anemia examination?

Describe any tiredness, easy fatigability, external or internal blood
loss, interference with the absorption of iron in the diet, an
inadequate diet in the face of accelerated growth, lactation, multiple
pregnancies, chronic infections, inflammatory diseases or malignancy.
Include details of treatment and its side effects or residuals post
treatment. Laboratory tests should include CBC with differential. Tests
that may be required are serum iron, serum ferritin, serum iron binding
capacity, x-rays for potential bleeding sites, absent hemosiderin or
ringed sideroblasts in the bone marrow smear.

## 17.6 What specific information may be needed for a leukemia examination?

Describe any fever, adenopathy, skin lesions, hemorrhage from the
gastrointestinal or genitourinary tract, sepsis, exposure to irradiation
or toxic agents such as benzene or past chemotherapy. Include details of
treatment and its side effects or residuals post treatment. Laboratory
tests should include CBC with differential. Tests that may be required
are bone marrow biopsy.

## 17.7 What specific information may be needed for a megaloblastic anemia examination? 

Describe any tiredness, easy fatigability, autoimmune diseases, atrophic
gastritis, achlorhydria, gastric carcinoma, paresthesias, total
gastrectomy, overgrowth of enteric organisms in blind loops, diverticuli
of the small intestine, fish tapeworm infections, alcoholism,
malnutrition, pregnancy, malabsorption secondary to sprue or other
intestinal disorders, or treatment with drugs such as dilantin.
Laboratory tests that should be ordered include CBC with differential.
Laboratory tests that may be required include lactic dehydrogenase,
intrinsic factor, Schilling test, bilirubin or endoscopy.

## 17.8 What specific information may be needed for a plasma cell dyscrasias examination?

Describe any purpura, hemorrhage, amyloidosis, congestive heart failure,
cardiac arrhythmias, orthostatic hypotension, peripheral neuropathy,
nephrotic syndrome, or malabsorption. Include details of treatment and
its side effects or residuals post treatment. Laboratory tests that
should be ordered include CBC with differential. Laboratory tests that
may be required include immunoglobulin in serum and urine, serum
viscosity, serum calcium, creatinine, bone marrow biopsy, or bone
x-rays.

## 17.9 What specific information may be needed for a polycythemia rubra vera examination?

Describe any redness of skin, headaches, epistaxes, dizziness,
hemorrhage, venous thrombosis, hemorrhage from esophageal varices (due
to portal vein thrombosis), cerebrovascular accidents, or duodenal
ulceration. Include any treatment with myelosuppressants and when,
whether phlebotomies are required and how often, and whether medication
is required. Include details of treatment and its side effects or
residuals post treatment.

Laboratory tests that should be ordered include CBC with differential.
Laboratory test that may be required include red cell mass, blood
volume, renal function tests, chest x-ray to differentiate from
secondary polycythemia which may result from cardiac or pulmonary
disease, or autonomous erythropoietin production due to tumors or renal
disease.

## 17.10 What specific information may be needed for a sickle cell anemia examination?

Describe any recurrent painful \"crises,\" vasocclusion with resulting
damage to various tissues and organs including lung, retina, brain,
bone, and joints, pneumococcal sepsis, or salmonella osteomyelitis.
Include details of treatment and its side effects or residuals post
treatment and frequency of crises and their effects of work activities.
Laboratory tests that should be ordered include CBC with differential.
Laboratory tests that may be required include smear for sickling of red
blood cells, blood viscosity, urinalysis, or hemoglobin type.

## 17.11 What specific information may be needed for a thrombocytopenic purpura examination?

Describe any easy bruisability, bleeding, quinidine drug use, underlying
systemic illness, purpura, splinter hemorrhages, or bleeding into mucous
membranes of the gastrointestinal, urinary, or genital tract. Include
details of treatment and its side effects or residuals post treatment.
Laboratory tests that should be ordered include CBC with differential.
Laboratory tests that may be required include immunoglobulin, bleeding
time, clot retraction, or platelet aggregation.

## Worksheet - HEMIC DISORDERS

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Frequency and duration of crisis if sickle cell disease.

2\. Fatigability and/or weakness? (Is light manual labor precluded?)

3\. Headaches?

4\. History of infections? If yes, frequency and response to therapy?

5\. Shortness of breath? If yes, with what degree of exertion?

6\. Chest pain? Symptoms of claudication?

7\. History and frequency of transfusions, phlebotomy, bone marrow
transplant, myelo-

suppressant therapy.

8\. Symptoms of other end organ pathology?

9\. Disease activity (exacerbations/remission)? If there were
exacerbations, what was the

state of the veteran\'s health between exacerbations?

10\. Current and past treatment history including date and type of last
treatment?

11\. Syncope, lightheadedness.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the condition being
examined and fully

describe current findings:

1\. Swelling of hands and/or feet (edema)?

2\. Presence of pallor (nail beds, mucosal surfaces, and skin)?

3\. Any other significant physical exam findings?

4\. Residuals of bone or other vascular infarction.

5\. Congestive heart failure?

D. **Diagnostic and Clinical Tests:**

1\. Hemoglobin level, platelet count, CBC.

2\. X-rays of bones or joints as indicated.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. Is the disease active?

Signature: Date:

## Worksheet - LYMPHATIC DISORDERS

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Disease activity (exacerbations/remission)? If there were
exacerbations, what was

the state of the veteran\'s health between exacerbations?

2\. Current and past treatment history including date and type of last
treatment, response,

side effects.

3\. If malignant neoplasm need date of diagnosis, date of treatment, or
if treatment

stopped when did it end.

4\. Location of disease.

5\. Current symptoms.

C. **Physical Examination (Objective Findings):**

Describe the residuals of each body system affected.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

# Chapter 18 - RADIATION EXPOSURE

## 18.1 Why does VA conduct examinations in radiation exposure cases?

a\. to help the Veterans Benefits Administration (VBA) determine whether
a veteran has a disability that will entitle him or her to VA benefits

b\. to provide VBA with information about the degree of disability in
order to determine appropriate benefit levels.

## 18.2 Are there unique requirements for examinations of radiation-related disabilities?

a\. In general, adjudicators in VBA, sometimes with the assistance of
the Department of Defense and the Under Secretaries for Health and
Benefits, gather information about the extent of radiation exposure and
make the determination as to whether a particular condition warrants
service connection on the basis of radiation exposure.

b\. The examiner will be asked to examine a specific condition or
conditions. Depending on the body system involved, the appropriate
worksheet for the condition(s) should be followed.

c\. There are no unique requirements for a disability examination for
radiation-related conditions because a disease process resulting from
radiation exposure is indistinguishable from the same disease process
arising from another etiology. However, a careful history that includes
family history, occupational history, and information about other
possible risk factors for the condition being examined is particularly
important.

## 18.3 How does VBA determine whether a condition is related to radiation exposure?

There are 2 different complex regulations that govern the adjudication
of radiation-related disabilities. The regulation that applies depends
on the particular in-service circumstances of the veteran and the
condition claimed. The type of examination to be conducted does not
differ depending under which regulation the conditions falls. This
material is provided only as background. The lists of conditions are
subject to change with new regulations.

Regulation one: 38 CFR 3.309 (d) for presumptive service connection for
radiation-related conditions.

a\. This regulation provides a list of malignancies that shall be
service-connected if they develop in a radiation-exposed veteran (as
defined in this regulation).

b\. A radiation-exposed veteran means a veteran who participated in a
radiation risk activity, which is defined as onsite participation in a
test involving the detonation of a nuclear device, the occupation of
Hiroshima or Nagasaki during the period August 6, 1945 to July 1, 1946,
or internment as a POW in Japan during WWII or active duty in Japan
immediately following such internment.

c\. These conditions will be service-connected as long as an
intercurrent cause is not established.

d\. No radiation dosage estimate is required.

e\. Conditions that fall under this regulation are:

> Leukemia (other than chronic lymphocytic leukemia).
>
> Cancer of the thyroid
>
> Cancer of the breast
>
> Cancer of the pharynx
>
> Cancer of the esophagus
>
> Cancer of the stomach
>
> Cancer of the small intestine
>
> Cancer of the pancreas
>
> Multiple myeloma
>
> Lymphomas (except Hodgkin's disease)
>
> Cancer of the bile ducts
>
> Cancer of the gall bladder
>
> Primary liver cancer (except if cirrhosis or hepatitis B is
> indicated).
>
> Cancer of the salivary gland
>
> Cancer of the urinary tract
>
> Bronchiolor-alveolar carcinoma

Regulation two: 38 CFR 3.311 for other claims based on exposure to
radiation.

a\. This regulation allows service connection for a different list of
conditions and also for any condition claimed to be due to any type of
in-service radiation exposure, as long as the requirements of the
regulation are met. Any other potential in-service exposure that is not
named under the first regulation falls under this regulation. For
example, veterans who had nasopharyngeal radium irradiation therapy
(NRI) are adjudicated under this regulation, as are veterans who were
exposed to ionizing radiation during the performance of their normal
military duties as radiologists, x-ray technicians, etc.

b\. There must be competent scientific or medical evidence that the
claimed condition is a radiogenic disease, if the condition is not on
the list.

c\. There must be a radiation dose estimate, an advisory opinion from
the Under Secretary for Health about the relationship of the claimed
condition to radiation exposure in view of the reported radiation dose,
and a determination by the Under Secretary for Benefits as to whether it
is at least as likely as not that the veteran's claimed condition
resulted from exposure to radiation in service.

d\. There are also time limitations for certain conditions under this
regulation: bone cancer must become manifest within 30 years after
exposure, leukemia may become manifest at any time after exposure,
posterior subcapsular cataracts must become manifest 6 months or more
after exposure, and all other specified diseases must become manifest 5
years or more after exposure.

e\. Conditions that fall under this regulation are:

> All forms of leukemia except chronic lymphatic (lymphocytic) leukemia;
>
> Thyroid cancer
>
> Breast cancer
>
> Lung cancer
>
> Bone cancer
>
> Liver cancer
>
> Skin cancer
>
> Esophageal cancer
>
> Stomach cancer
>
> Colon cancer
>
> Pancreatic cancer
>
> Kidney cancer
>
> Urinary bladder cancer
>
> Salivary gland cancer
>
> Multiple myeloma
>
> Posterior subcapsular cataracts
>
> Non-malignant thyroid nodular disease
>
> Ovarian cancer
>
> Parathyroid adenoma
>
> Tumors of the brain and central nervous system
>
> Cancer of the rectum
>
> Lymphomas other than Hodgkin's disease
>
> Prostate cancer
>
> Any other cancer

# Chapter 19 - FORMER PRISONERS OF WAR (POWS)

## 19.1 What are unique problems in former POWs?

There is a need for examiners to have compassion for former POWs and
sensitivity to the POW experience. It has been estimated that more than
88,000 former POWs from World War I, World War II, the Korean Conflict,
and Vietnam Era are still living. Studies in this country and abroad
have shown that the physical deprivation and psychological stress
endured as a captive have lifelong effects on subsequent health, as well
as on social and vocational adjustment. Former POWs have a significantly
higher incidence for illnesses in many body systems, and longer hospital
stays and vulnerability to psychological stress are also markedly
increased.

## 19.2 What were some of the conditions experienced by former POWs? (As told by Ex-POWs)

### a. WORLD WAR II -- PACIFIC (Prisoners of the Japanese)

Of the 34,648 American prisoners, 40% died in captivity.

Reasons for the high death rate:

> a\. Most were captured early in the War, and the average incarceration
> lasted more than 3 years. Most of the American prisoners were regular
> Army with an average age of 27.
>
> b\. The Japanese had signed, but never ratified, the Geneva Convention
> regarding treatment of POWs.
>
> c\. To the Japanese, dying in battle was a sign of honor, and
> surrendering was a sign of cowardliness. Thus they treated their
> prisoners with contempt and brutality, rather than compassion.
>
> d\. Since the Japanese assumed that conquered soldiers would die
> rather than surrender, they had made no provisions for housing or
> feeding large numbers of prisoners.
>
> e\. Inadequate food and water was provided, and movement was via foot
> rather than via vehicle.
>
> f\. Many prisoners were enslaved and forced to work at hard labor,
> while being malnourished and beaten.

History given by former POWs:

> a\. The Japanese had long wanted to rid their land of Occidentals, and
> the bombing of Pearl Harbor was part of their plan.
>
> b\. Following Pearl Harbor, the U.S. deployed many troops to the
> Philippine Islands to fight the Japanese.
>
> c\. In January 1942, due to the escalating war with Germany, General
> MacArthur was ordered to leave the Philippines for duty in Europe.
> Since he did not have time to remove his troops, he ordered all
> American soldiers to the peninsula of Bataan, placed Major General
> Edward King in command, gave them a 30 day supply of food, and he
> promised he would return and remove them within a month.
>
> d\. When MacArthur had not returned by February and no new supplies
> had arrived, all soldiers were placed on half rations.
>
> e\. By March, they had eaten all the cavalry horses and mules, the
> local pigs, water buffalo and monkeys, and they were reduced to
> quarter rations. The soldiers began to loss weight and become weaker,
> and dysentery and malaria weakened them further.
>
> f\. On April 9, 1942, Major General Edward King surrendered all 13,000
> American troops and 25,000 Philippine Army Scouts to the Japanese
> 14^th^ Army commander, General Homma.
>
> g\. Since the Japanese had no plans for moving or feeding so many
> prisoners, they began the infamous 100-mile Bataan Death March via
> foot northward to Camp O'Donnell and Cabanatuan.
>
> h\. The soldiers were ordered to remove their boots and helmets and
> begin marching in the hot sun without food or water.
>
> i\. Whenever a prisoner strayed from the line to get water from
> artesian wells along the way or to help a fellow prisoner, they would
> be bayoneted and killed, requiring the remaining prisoners to step
> over the dead bodies as they marched.
>
> j\. If the March were not moving fast enough, one prisoner would be
> singled out and decapitated to set an example for the other prisoners.
> They were constantly beaten with bamboo sticks, kicked, and hit with
> rifle butts.
>
> k\. All stragglers were hit on the head, and when they fell alongside
> the road they were buried alive.
>
> l\. At one point, the Japanese became so angry at the Philippine Army
> Scouts because they had helped the Americans, they tied one hundred
> officers together by their necks in four columns of 25 and began
> cutting their heads off with swords. It took eight hours to finish
> decapitating all 100 prisoners amid the screams and cries of the dying
> and soon-to-die. After the remaining prisoners had witnessed this
> ordeal, they were forced to continue the march. It was obvious that
> prisoners were a burden to the Japanese and allowing them to died
> simplified their job.
>
> m\. When they reached the town of Balanga, they were placed into
> small, crowded warehouses and made to lie beside dead and dying
> comrades awaiting arrival of a train. Several days later when the
> train arrived, the prisoners were packed so tightly into the boxcars
> that when they arrived at Camp O'Donnell, the dead were standing up
> alongside the living.
>
> n\. During the March, over 17,000 prisoners died, most from beheadings
> and shootings, but some from dysentery and dehydration.
>
> o\. At Camp O'Donnell, all prisoners were stripped of their rank and
> clothes, made to wear loincloths, and they were required to bow to
> their captors.
>
> p\. Food consisted of a small ball of insect-infested, dirty rice each
> day. The food given to prisoners had been determined to be unfit for
> the Japanese soldiers and generally would have been discarded.
>
> q\. Grave detail consisted of digging a large pit each day, carrying
> the dead into the pit and straightening out their rigor mortis twisted
> limbs, so more bodies could be stacked into the pit.
>
> r\. When the Japanese decided to use the prisoners as slave labor
> rebuilding bridges and railroads and manufacturing war supplies, they
> packed them into holes of animal cargo ships called "hell ships" for
> transportation back to Japan. Often, the prisoners were forced to
> remain in the crowded, rodent infested holes with dying and dead
> comrades, without food, water or toilet facilities until the harbor
> was safe from American submarines so the cargo ships could sail.
>
> s\. Often, the cargo ships were torpedoed and sunk by American
> submarines, killing all the prisoners on board.
>
> t\. In April 1943, three Americans escaped and made it back to an
> American submarine with the help of Philippine nationals, and they
> finally had a meeting with General MacArthur. The General and top
> administration in the United States decided to do nothing about it,
> because they later said, "they feared for the lives of the remaining
> prisoners." When the news media got the story and the American people
> realized the atrocities being perpetrated on American soldiers,
> pressure was placed on MacArthur to invade the Philippines and rescue
> the POWs.

### b. WORLD WAR II -- EUROPE (Prisoners of the Germans)

Of the 93,941 American prisoners, 1% died in captivity.

Reasons for the low death rate:

> a\. The Germans had signed and ratified the Geneva Convention
> regarding treatment of POWs, and they frequently allowed the Red Cross
> to bring supplies to the prisoners. The camps were true POW camps and
> not concentration camps.
>
> b\. To the Germans, surrender when all hope was lost was reasonable.
>
> c\. Since America had many German prisoners, it was in their best
> interest to treat Americans humanely, since they could be used for
> prisoner exchanges.

History given by former POWs:

> a\. The first prisoners captured early in the War were airplane
> pilots, who were officers. Since the German POW camps were run by
> Herman Goehring, Chief of the Luftwaffe, American pilots were treated
> fairly humanely by their captors, since all pilots have a common
> kinship and the German pilots always had a chance of being captured
> themselves by the Allied Forces.
>
> b\. The second group of prisoners captured late in the War was
> draftees with an average age of 25, and their average incarceration
> lasted less than 1 year. Although they were not treated as well as the
> officers, they generally were not tortured. Since they were
> non-officers, they often were forced to sleep in cold barracks or walk
> with tattered shoes during the winter months.
>
> c\. Food was provided, although it often consisted only of potato soup
> and black bread.
>
> d\. Transportation was via truck or train until the end of the war,
> when forced marches were common to keep the American prisoners from
> rejoining the advancing forces. During these marches in the winter of
> 1944-45, cold exposure and frostbite were common.

### c. KOREA (Prisoners of the North Koreans)

Of the 7,140 American prisoners, 38% died in captivity.

Reasons for the high death rate:

> a\. Most were captured early in the War, and the average incarceration
> lasted more than 3 years. Most of the American prisoners were regular
> Army with an average age of 27.
>
> b\. The North Koreans had not signed the Geneva Convention regarding
> treatment of POWs.
>
> c\. Like the Japanese, they did not believe in surrendering during war
> or in taking prisoners.
>
> d\. They felt that all enemies should be treated harshly.
>
> e\. Executions and starvation were used as solutions to overcrowded
> POW problems.
>
> f\. The primary causes of death were executions, starvation, vitamin
> deficiency diseases, and infectious diseases.

History given by former POWs:

> a\. The first prisoners captured during the late 1950s endured the
> most severe torture. Out of 700, 500 were either executed or died of
> cold exposure.
>
> b\. Since no medical care was provided, many died of complications of
> their wounds.
>
> c\. Many were captured during the summer months, so their only clothes
> were light summer fatigues. The Koreans had not yet built barracks, so
> prisoners slept in the fields. When winter came, many froze to death.
>
> d\. Often as punishment, a POW was stripped, made to stand at
> attention, and had cold water poured over his body until he froze.
>
> e\. Food was scarce, and many died of starvation.
>
> f\. The second group was captured during the hot summer of 1951. They
> were crammed into small farmhouses with little food and water. Many
> died of starvation or infectious diseases.
>
> g\. The North Koreans used propaganda brainwashing, unlike the
> Japanese or the Germans. Since this war was directed against
> communism, the North Koreans attempted to change world opinion by
> indoctrinating prisoners to embrace communism and denounce capitalism.
> They tortured prisoners via beatings, deprivation of food and water,
> and exposure to cold in an effort to break their spirits and have them
> sign statements favorable to the Communist cause. They rewarded
> prisoners who cooperated with them with food and warmth.
>
> h\. The third phase of capture occurred from 1952-53 after armistice
> talks had begun and permanent camps had been built. Torture and abuse
> decreased, and food became more plentiful, although it generally
> consisted only of corn and millet with small amounts of green
> vegetables.

I.  Although their brainwashing did result in 21 American POWs choosing
    to remain in North Korea following the War, over a million North
    Korean POWs in our hands chose to remain in the United States.

### d. VIETNAM (Prisoners of the Vietnamese)

Of the 772 American prisoners, 15% died in captivity.

Reasons for the high death rate:

> a\. The Vietnamese people were generally poorly fed, and POWs were fed
> even less.
>
> b\. Infectious diseases and lack of sanitation and medical supplies
> killed many.

History given by former POWs:

> a\. The prisoners captured in South Vietnam by the Viet Cong were
> generally infantry soldiers, and 25% of these died of starvation,
> complications of vitamin deficiencies, or infectious diseases. Torture
> and interrogations were less common than in the north.
>
> b\. Prisoners captured in North Vietnam were pilots, who were
> officers. The North Vietnamese wanted these prisoners for propaganda
> purposes, so they used physical and psychological torture to try to
> get them to renounce their country and speak positively about
> communism.
>
> c\. The pilots were kept in solitary confinement at the "Hanoi
> Hilton", a cement barracks in downtown Hanoi. A single light bulb
> burned 24 hours a day in each cell.
>
> d\. Often, they were tied up in various contortions, and arms and legs
> were broken and dislocated. Beating while being tied up was common.
>
> e\. Since they were not allowed to see or speak to other prisoners,
> they developed a sophisticated set of codes, which allowed them to
> communicate with a prisoner in the next cell by tapping on the wall.
> Messages would be conveyed from one cell to the next via this system.
> Survivors say that this communication helped keep them alive.

## 19.3 What should an examiner consider in examining a former POW?

Physicians should thoroughly review all POW experiences with the
veteran, including all claimed and potential injuries and diseases which
may be associated with confinement, deprivation, malnutrition,
avitaminosis, cold or wet exposure, and physical and mental abuse. Many
former POWs have coped with their incarceration experiences by
suppressing memories or avoiding talking about them even with friends
and family. Discussions of these traumatic experiences may rekindle
unpleasant memories or reactions during the examination process.

## 19.4 What conditions are presumed to be due to former POW experiences?

These conditions will be service-connected even though there is no
record of them during service because they are presumed to be related to
the POW experience unless there is an intervening cause for the
condition or other reason to rebut the presumption.

> Avitaminosis.
>
> Beriberi (including beriberi heart disease, which includes ischemic
> heart disease in a former prisoner of war who had experienced
> localized edema during captivity).
>
> Chronic dysentery.
>
> Helminthiasis.
>
> Malnutrition (including optic atrophy associated with malnutrition).
>
> Pellagra.
>
> Any other nutritional deficiency.
>
> Psychosis.
>
> Any of the anxiety states.
>
> Dysthymic disorder (or depressive neurosis).
>
> Organic residuals of frostbite, if it is determined that the veteran
> was interned in climatic conditions consistent with the occurrence of
> frostbite.
>
> Post-traumatic osteoarthritis.
>
> Irritable bowel syndrome.
>
> Peptic ulcer disease.
>
> Peripheral neuropathy except where directly related to infectious
> causes.

## 19.5 What is a former POW protocol examination?

VA has developed a special POW Medical History Questionnaire and a
Physical Examination Package (See POW Examination Worksheet), which is
to be used by all VA health care facilities. This evaluation is
conducted only once in a veteran's life to determine the baseline
medical condition of the veteran from his/her incarceration to this
point in time. It is also used as a comprehensive examination for
disability compensation purposes.

a\. The former POW fills out the first portion of the history and then
presents it to the examining physician, who checks its contents for
completeness and any required amplification.

b\. The examining physician completes the second part of the history,
the physical and the summary forms.

c\. A copy of the entire packet is sent to Washington, D.C. for future
reference.

## Worksheet - PRISONER OF WAR PROTOCOL EXAMINATION

Name: SSN:

Date of Exam: C-number:

Place of Exam:

Narrative: This is the protocol for conducting initial full examinations
on former POWs. It should be faxed in its entirety to the regional
office. Bear in mind that the POW experience likely resulted in a great
deal of psychological and physical trauma. Approach these veterans with
the greatest sensitivity. Details about diet, beatings, torture, forced
marches, forced labor, disease, brainwashing, extremes of hot and cold,
and anxiety may be significant parts of the veteran\'s history, and
eliciting them requires that a trusting relationship with the veteran
first be established.

[Presumptive POW disabilities:]{.underline}

Avitaminosis.

Beriberi (including beriberi heart disease).

Chronic dysentery.

Helminthiasis.

Malnutrition (including optic atrophy associated with malnutrition).

Pellagra.

Any other nutritional deficiency.

Psychosis.

Any of the anxiety states.

Dysthymic disorder (or depressive neurosis).

Organic residuals of frostbite.

Post-traumatic arthritis.

Irritable bowel syndrome.

Peptic ulcer disease.

Peripheral neuropathy.

Ischemic heart disease (Beriberi heart disease includes ischemic heart
disease in a former prisoner of war who had experienced localized edema
during captivity.)

A. **Review of Medical Records:**

1\. Include a review of VA Form 10-0048, [Former POW Medical
History]{.underline}, which the

veteran should have completed, prior to conducting the examination.

2\. Review the Social Survey.

B. **Medical History (Subjective Complaints):**

**NOTE**: If the veteran has had a previous protocol examination, only
an interval history is

required. Comment on:

1\. Past medical history, including childhood and adult illnesses and
surgery.

2\. Family history.

3\. Social history - state civilian and military occupations, including
dates and locations.

Describe use of alcohol, tobacco, and drugs.

4\. Complete system review, commenting on all positive symptoms.

a\. Describe initial symptoms, time of onset, and current symptoms of
all

presumptive POW disabilities found.

b\. Comment on amount of weight lost as a prisoner. Record initial and
release

weights.

5\. Describe current treatment (specify type, frequency, duration,
response, side effects).

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings: The
examiner should

incorporate all ancillary study results into the final diagnoses.

1\. [VS]{.underline}: Heart rate, blood pressure (sitting, standing, a
total of at least three BP's if in

abnormal or if hypertension claimed ), respirations, height, weight,
maximum weight in

past year, weight change in past year, body build, and state of
nutrition.

2\. [Dominant hand]{.underline}: Indicate the dominant hand and how
determined (i.e., writes, eats,

combs hair, etc.).

3\. [Posture and gait:]{.underline} (If abnormal, describe.)

4\. [Skin, including appendages:]{.underline} (If abnormal, describe
appearance, location, extent of

lesions, and limitations to daily activity.) If there are laceration or
burn scars, describe

the location, measurements (cm. x cm.), shape, depression, type of
tissue loss,

adherence, disfigurement, and tenderness. For each burn scar, state if
due to a 2nd or

3rd degree burn. **(NOTE:** If the skin condition or scars are
disfiguring, obtain [color]{.underline}

[photographs]{.underline} of the affected area(s).

5\. [Hemic and Lymphatic:]{.underline} (Describe local or generalized
adenopathy, tenderness,

suppuration, etc.).

6\. [Head and face]{.underline}: Describe scars, deformities, etc.

7\. [Eyes]{.underline}: Describe external eye, pupil reaction,
movements, field of vision**,** any

uncorrectable refractive error or any retinopathy.

8\. [Ears]{.underline}: Describe canals, drums, perforations, discharge.

9\. [Nose, sinuses, mouth and throat]{.underline}: Include gross dental
findings.

10\. [Neck]{.underline}: Describe lymph nodes, thyroid, etc.

11\. [Chest]{.underline}: Inspection, palpation, percussion,
auscultation. If abnormal, describe

limitations of daily living (i.e., How far can the veteran walk, how
many flights of

stairs can he or she climb, etc.).

12\. [Breast]{.underline}: Comment on any masses palpated in breast
parenchyma including axillary tail.

Comment on any skin abnormalities. Comment on any discharge from
nipples.

13\. [Cardiovascular]{.underline}: Record pulse, heart sounds,
abnormalities (i.e., arrhythmias,

murmurs, etc.), and status of peripheral vessels. Note edema. Describe
varicose veins

including location, size, extent, ulcers, scars, and competency of deep
circulation.

Examine for evidence of residuals of frostbite when indicated. See cold

injuries examination worksheet. **(NOTE:** Cardiovascular signs and
symptoms should

be graded using NYHA scale.)

14\. [Abdomen]{.underline}: Inspection, auscultation, palpation,
percussion. If abnormal, describe (i.e.,

abdominal enlargement, masses, tenderness, etc.).

15\. [Genital/rectal (male)]{.underline}: Inspection and palpation of
penis, testicles, epididymis, and

spermatic cord. (If hernia, describe type, location, size, whether
complete, reducible,

recurrent, supported by truss or belt, and whether or not operable).
Inspection of anus

for fissures, hemorrhoids, ulcerations, etc. and digital exam of rectal
walls, and

prostate.

16\. [Genital/rectal (female)]{.underline}: Pelvic exam should include
inspection of introitus, vagina,

and cervix, palpation of labia, vagina, cervix, uterus, adnexa, and
ovaries. . Pap smear

(if none within past year). Any severe abnormalities may be referred to
a specialist.

17\. [Musculoskeletal]{.underline}: For joint or muscle defects,
describe location, swelling, atrophy,

tenderness, active and passive motion in degrees using a goniometer,
angle of fixation,

fracture, fibrous or bony residual, and mechanical aids used by veteran.
Provide an

assessment of the effect on range of motion and joint function of pain,
weakness, fatigue,

or incoordination following repetitive use or during flare-ups. (See the
appropriate worksheet

for more detail.) If foot problems exist, perform above exam and also
include

objective evidence of pain at rest and on manipulation, rigidity, spasm,
circulatory

disturbance, swelling, callus, loss of strength, mobility of ankles and
feet, and whether

acquired or congenital.

18\. [Endocrine]{.underline}: Disease of thyroid, pituitary, adrenals,
gonads, other body systems affected.

19\. [Neurological]{.underline}: Cerebrum - orientation and memory.
Cerebellum - gait, stance,

and coordination. Spinal Cord - deep tendon reflexes, pain, touch,
temperature,

vibration, and position. Cranial nerves - I-XII. If abnormalities are
found, describe

region of CNS affected.

20\. [Psychiatric]{.underline}: Describe behavior, comprehension,
coherence of response, emotional

reaction, signs of tension and response to social and occupational
capacity. State

whether the veteran is capable of managing his or her benefit payments
in his or her

own best interests without restriction. (A physical disability which
prevents the

veteran from attending to financial matters in person is not a proper
basis for a finding

of incompetency unless the veteran is, by reason of that disability,
incapable of

directing someone else in handling the individual\'s financial affairs.)

D. **Diagnostic and Clinical Tests:**

1\. As indicated - e.g., parasite studies, X-rays of joints, etc.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. All laboratory and diagnostic tests should be completed and reviewed

prior to completing the summary of findings.

2\. The POW Physician Coordinator should complete summary of findings,
diagnoses, and

recommendations. The Coordinator should express an opinion, with
supporting

reasons, concerning the relationship between the veteran\'s experiences
as a POW and

each current medical condition. If osteoarthritis is diagnosed, it
should be clarified

> whether this is post-traumatic osteoarthritis, and, if so, is it
> related to the period of confinement.

Signature: Date:

# Chapter 20 - GULF WAR VETERANS

## 20.1 What kinds of hazards may Gulf War veterans have been exposed to?

According to the Department of Defense (DOD) the approximately 690,000
American servicemen and women who served in the Gulf War may have been
exposed to many hazards such as:

> oil and other petrochemical agents
>
> smoke from the sabotage of Kuwaiti oil wells by retreating Iraqi
> forces
>
> Leishmaniasis (Sand flies)
>
> pyridostigmine bromide, malaria prophylaxis, and other prophylactic
> drug treatments
>
> depleted Uranium (DU)
>
> inoculations (Anthrax, botulism, etc.)
>
> pesticides
>
> diesel and jet fuels and other petrochemicals and solvents
>
> chemical Agent Resistant Compound (CARC) paint
>
> chemical and/or biological warfare agents
>
> contaminated food and water obtained in the Persian Gulf
>
> air pollutants (carbon monoxide, sulfur oxide, hydrocarbons,
> particulate matter, and nitrogen oxide)
>
> psychological stressors

## 20.2 What is unique about examinations of Gulf War veterans?

Gulf War veterans may claim, and require an examination for, any
condition resulting from a disease or injury that was incurred in or
aggravated by military service, as other veterans do. In such cases, the
regional office may request an examination of one or more specific
conditions, e.g., residuals of a knee injury, and will refer to the
appropriate worksheet(s). However, what is unique about Gulf War
veterans is that some veterans will need instead, or in addition, a
comprehensive examination that will allow the examiner to distinguish
between a clearly diagnosable condition (like asthma) and an
"undiagnosed illness" (like a cough that cannot be attributed to a
specific diagnosis). An undiagnosed illness is established when findings
are present that cannot be attributed to a known, clearly defined
diagnosis, after all likely diagnostic possibilities for such
abnormalities have been ruled out. Examiners should follow the worksheet
titled "Guidelines for Disability Examination in Gulf War Veterans,"
which provides detailed instructions for examinations in Gulf War
veterans.

## 20.3 What are the some signs and symptoms that may be manifestations of undiagnosed illnesses in Gulf War veterans? (38 CFR 3.317)

> fatigue
>
> signs or symptoms involving the skin
>
> headache
>
> muscle pain
>
> joint pain
>
> neurologic signs and symptoms
>
> neuropsychological signs and symptoms
>
> signs or symptoms involving the respiratory system (upper or lower)
>
> sleep disturbances
>
> gastrointestinal signs or symptoms
>
> cardiovascular signs or symptoms
>
> abnormal weight loss
>
> menstrual disorders

## Worksheet - GUIDELINES FOR DISABILITY EXAMINATIONS IN GULF WAR VETERANS

Name: SSN:

Date of Exam: C-number:

Place of Exam:

[Introduction]{.underline}

Disability examinations of Gulf War veterans have unique requirements
because this group of veterans is eligible for compensation not only for
disability due to diagnosed illnesses, but also for disability due to
[undiagnosed]{.underline} illnesses. An undiagnosed illness is
established when findings are present that cannot be attributed to a
known, clearly defined diagnosis, after all likely diagnostic
possibilities for such abnormalities have been ruled out. Examiners
should follow the guidelines in the "Handout of Instructions for
Compensation and Pension Examinations" but will also need to request
more laboratory tests and specialists' examinations than average in
these cases*.*

[Guidelines]{.underline}

1\. Thoroughly review the claims file.

2\. Address all conditions and symptoms specified on the examination
request [and]{.underline} also address all additional conditions and
symptoms that you can elicit from the veteran during the examination,
[even if not specified on the request form]{.underline}.

3\. Conduct a comprehensive general medical examination, following the
AMIE General Medical Examination worksheet. For all conditions and
symptoms which the General Medical Examination worksheet does not
address in detail, follow the appropriate additional AMIE worksheets,
and request specialists' examinations as indicated. Provide details
about the onset, frequency, duration, and severity of [all]{.underline}
complaints and state what precipitates and what relieves them.

4\. List all diagnosed conditions and state which symptoms, abnormal
physical findings, and abnormal laboratory test results are associated
with [each]{.underline}. If all symptoms, abnormal physical findings,
and abnormal laboratory test results are associated with a diagnosed
condition, additional specialist examinations for diagnostic purposes
are not needed. Diagnosed conditions will be handled as standard claims
for service connection. Symptom-based "diagnoses" such as (but not
limited to) myalgia, arthralgia, headache, and diarrhea, are not
considered as diagnosed conditions for compensation purposes.

5\. However, if there [are]{.underline} symptoms, abnormal physical
findings, or abnormal laboratory test results that have
[not]{.underline} been determined to be part of a known clinical
diagnosis, [further specialist examinations]{.underline} will be
required to address these findings.

6\. Provide the specialist with all examination reports and test
results. Specify the symptoms, abnormal physical findings, and abnormal
laboratory test results that have [not]{.underline} been attributed to a
known clinical diagnosis. Request that the specialist determine which of
these, if any, can be attributed in this veteran to a known clinical
diagnosis and which, if any, [cannot]{.underline} be attributed in this
veteran to a known clinical diagnosis.

7\. After the specialists' examinations have been completed, and all
laboratory test results received, make a final report providing a list
of diagnosed conditions. Separately list all symptoms, abnormal physical
findings, and abnormal laboratory test results that cannot be attributed
to a known clinical diagnosis. Reconcile all differences among the
examiners, by consultation or workgroup as necessary, before the
examination is returned to the regional office.

Signature: Date:

# Chapter 21 - HERBICIDE EXPOSURE/AGENT ORANGE

## 21.1 How did herbicide/Agent Orange exposure come about and when?

**a.** **Background.** From 1962 to 1971, the military sprayed millions
of gallons of herbicides in Vietnam to destroy crops and protective
cover and to clear perimeters around US positions. Agent Orange was a
commonly used type of herbicide. Toxic chemicals in the herbicides
included 2, 4-D; 2, 4, 5-T and its contaminant TCDD; cacodylic acid; and
picloram. In 1969, a scientific study concluded that 2, 4-5T caused
birth defects in animals. Later studies indicated dangers from exposure
to dioxins, such as TCDD, found in the herbicides.

**b.** **Veterans presumed to have been exposed**. Veterans who served
in the Republic of Vietnam during the period beginning on January 9,
1962 and ending on May 7, 1975, and who have one of the conditions
listed in 21.2, are presumed to have been exposed to an herbicide agent.

## 21.2 What medical conditions have been determined by VA to be associated with herbicide exposure?

a\. Role of NAS. The National Academy of Sciences (NAS) periodically
reviews and summarizes the worldwide scientific literature concerning a
possible association between exposure to herbicides and diseases, and
reports to VA's Secretary.

b\. Role of Secretary. The Secretary then determines whether a positive
association exists between exposure to a herbicide agent (i.e., a
chemical in a herbicide used in support of the United States and allied
military operations in the Republic of Vietnam during the Vietnam era)
and a disease. When a positive association is found, the Secretary
establishes presumptive service connection for that disease.

c\. Presumptive service connection. This means that a disease will be
service-connected even though there is no record of such disease during
service, if a veteran had the requisite service in Vietnam, as stated in
21.1b, and there is not an intervening cause for the condition or other
reason to rebut the presumption.

d\. Presumptive diseases for service connection and examination needed.
These are the diseases that have been recognized by VA as associated
with herbicide exposure as of March 2001. The examination to be
conducted will depend on the conditions(s) claimed by the veteran, as
indicated by the regional office examination request. The examiner
should base the examination on the appropriate worksheet(s).

> 1\) chloracne, or other acneform disease consistent with chloracne
>
> 2\) Hodgkin's disease
>
> 3\) multiple myeloma
>
> 4\) non-Hodgkin's lymphoma
>
> 5\) acute and subacute peripheral neuropathy (transient peripheral
> neuropathy that appears within weeks or months of exposure to a
> herbicide agent and resolves within two years of the date of onset)
>
> 6\) porphyria cutanea tarda
>
> 7\) diabetes
>
> 8\) prostate cancer
>
> 9\) respiratory cancers (cancers of the lung, bronchus, larynx, or
> trachea)
>
> 10\) soft-tissue sarcoma (adult fibrosarcoma, dermatofibrosarcoma
> protuberans, malignant fibrous histiocytoma, liposarcoma;
> leiomyosarcoma, epithelioid leiomyosarcoma, malignant leiomyoblastoma,
> rhabdomyosarcoma, ectomesenchymoma, angiosarcoma, hemangiosarcoma,
> lymphangiosarcoma, proliferating (systemic) angioendotheliomatosis,
> malignant glomus tumor, malignant hemangiopericytoma, synovial sarcoma
> (malignant synovioma), malignant giant cell tumor of tendon sheath,
> malignant schwannoma, malignant schwannoma with rhabdomyoblastic
> differentiation (malignant Triton tumor), glandular and epithelioid
> malignant schwannomas, malignant mesenchymoma, malignant granular cell
> tumor, alveolar soft part sarcoma, epithelioid sarcoma, clear cell
> sarcoma of tendons and aponeuroses, extraskeletal Ewing\'s sarcoma,
> congenital and infantile fibrosarcoma, and malignant ganglioneuroma.

## 21.3 Can a veteran establish service connection for an herbicide-related disease in any other way?

If a veteran does not have one of the diseases listed in 21.2, there is
no presumption of herbicide exposure. Service connection may, however,
be established on a direct, rather than a presumptive, basis if the
veteran is found on a factual basis to have had contact with herbicides
during military service (for example, in their transport or manufacture)
and there is medical or scientific evidence supporting an etiological
relationship between the claimed condition and herbicide exposure. The
examination(s) required will depend on the claimed condition(s).

## 21.4 For claims concerning spina bifida in a child of a Vietnam veteran, see Chapter 3 -- Birth Defects.