P

PANCREAS

The pancreas is an elongated gland located in the upper abdomen behind
the stomach. The primary functions are to produce pancreatic juices used
as an aid to digestion and to manufacture insulin needed in supplying
heat and energy to the body through utilization of carbohydrates. Some
of the more common symptoms with acute pancreatitis are epigastric pain
radiating to back, jaundice, weight loss, anorexia, nausea, vomiting,
constipation and various other gastro-intestinal disturbances. In most
chronic cases, diagnosis is difficult and is only detected by abdominal
surgery. Associated conditions include hemorrhage, calculi, cyst or
tumor, and sometimes cancer.

Underwriting Requirements

An APS (VA Form 29-8158) is required.

  ------------------------------------------------ ----------------------
  Abscess                                          Rate as Cyst

                                                   

  Cyst or pseudocyst                               

  Single                                           

  Present                                          

  Less than 6 months                               Refer to Section Chief

  Thereafter                                       50

  Operated, no sequelae                            0

  Multiple                                         

  Present                                          

  Less than 6 months                               Refer to Section Chief

  Thereafter                                       100

  Operated, no sequelae                            0
  ------------------------------------------------ ----------------------

[Pancreatitis]{.underline}

Pancreatitis may be acute or chronic and attacks are usually manifested
by severe abdominal pain. While stones in the bile duct may cause acute
pancreatitis, the most common cause of chronic pancreatitis is
alcoholism.

Underwriting Requirements

An APS (VA Form 29-8158) is required.

  ----------------------------------------------------- -----------------
  Acute -- single episode                               

  Within 1 year of recovery                             330

  2^nd^ year                                            230

  3^rd^ year                                            130

  4^th^ year                                            30

  After 4 years                                         0

  Chronic -- recurrent episodes or prolonged course     
  with complications such as diabetes, cyst formation   
  or malabsorption                                      

  Within 1 year of recovery                             400

  2^nd^ year                                            300

  3^rd^ year                                            200

  4^th^ year                                            100

  5^th^ year                                            50

  After 5 years                                         0

  Due to alcoholism                                     Rate as Cirrhosis
  ----------------------------------------------------- -----------------

PANNICULITIS

Panniculitis or subcutaneous fibrositis is an inflammation of the
fascial layer of the subcutaneous tissue noticeable in the fat layer.
This in some instances is secondary to some other disease and in other
cases, primary in the panniculus adiposus. Although there are many
etiologic factors, the fat reacts about the same way in all of these
diseases. With the atrophy of the subcutaneous fat, nodular lesions
appear in the skin. There are mild to severe vascular changes. Some
forms are relapsing, febrile, nodular and nonsuppurative, while others
are nonfebrile, liquefying or migratory. Most of the cases occur in
obese, middle-aged or older women who suffer from diabetes, arthritis,
pancreatitis or nephritis. Treatment is usually ineffectual.

Underwriting Requirements

An APS (VA Form 29-8158) is required.

  ----------------------------------------------------- -----------------
  Without involvement of other structures               

  Present                                               

  Mild                                                  100

  Moderate                                              200

  Severe                                                400

  With involvement of other structures                  

  Present                                               

  Mild                                                  200

  Moderate                                              300

  Severe                                                500
  ----------------------------------------------------- -----------------

PAPILLOMA AND POLYP

(Polypus)

A polyp or papilloma is a tumor which is an outgrowth of either skin or
mucous membrane. Polyps may be either broad-based (sessile) or
pedunculated (on a stalk). Although these lesions are usually benign,
they may be precancerous, or if they are not removed, they may
subsequently undergo malignant change. This is particularly true of
papillomatous lesions of the colon, rectum, urinary bladder and larynx.

Papillomata or polyps may occur in the nose, paranasal sinuses, the
larynx and vocal cords or the bronchial tree. They are particularly
common in the gastrointestinal tract, where they may occur in virtually
any location, from the esophagus to the ano-rectal area. They may also
be found in many locations of the genitourinary tract, including the
uterers, the bladder, and the urethra. In females, polyps may also be
found in the uterus or cervix.

Underwriting Requirements

An APS (VA Form 29-8158) is required.

  -------------------------------------------------------- --------------
  Nasal, paranasal, uterine, urethral, or anal             

  Present, depending on extent and nature                  30-0

  History, no suggestion of malignancy                     0

                                                           

  Larynx                                                   

  Singer's Nodule -- not a true tumor, commonly found in   
  singers or those involved in occupations requiring       
  frequent public speaking                                 

  Present or history                                       0

  Others                                                   Refer to
                                                           Section Chief
  -------------------------------------------------------- --------------

###### [Bladder]{.underline}

Although completely benign lesions occasionally do occur in the bladder,
the great majority are carcinomas occurring either singly or as multiple
growths which are primarily papillary in nature. Tumors of the
transitional cell epithelium of the bladder account for approximately
90% of all bladder tumors. Squamous cell carcinomas (8%) and
adenocarcinomas (2%) make up the balance of bladder tumors.

Underwriting Requirements

An APS (VA Form 29-8158) is required.

  ----------------------------------------------------- -----------------
  Present                                               R

  History (normal current urine, adequate follow-up,    
  return to normal duties)                              

  1-2 polyps with 1 operation (including fulguration)   

  Within 1 year                                         350

  2^nd^ year                                            250

  3^rd^ year                                            150

  4^th^ year                                            50

  After 4 years                                         0

  3 or more polyps or more than one operation           

  Within 1 year                                         400

  2^nd^ year                                            300

  3^rd^ year                                            155

  4^th^ and 5^th^ year                                  55

  After 5 years                                         0

  If urine is abnormal                                  

  Debit for RBC's is 55                                 R

  Albumin, casts or WBC's                               See Urine section
  ----------------------------------------------------- -----------------

###### [Colon and Rectum]{.underline}

####### Selection of risks involving polyps of the colon and rectum depends on the following factors:

1.  Number -- Risk of cancer rises in proportion to number of polyps
    found.

2.  Size -- Small polyps (under 1 cm.) are usually benign. Polyps of
    1-2 cm. have approximately a 10% incidence of malignancy and the
    rate of increase with increasing size.

3.  Pathology -- Hyperplastic "polyps" are uniformly benign. Those
    described as pedunculated or adenomatous have a better prognosis in
    general tan those described as sessile or villous.

4.  Follow-up -- Once a polyp has been found, the development of
    additional polyps is common, thus adequate follow-up is essential.

# **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

+-------------------------------------+-----------------+--------------+
|                                     | Known to be not | ###          |
|                                     | more than 1 cm. | # [Others\*] |
|                                     | in              | {.underline} |
|                                     | [diameter       |              |
|                                     | \*]{.underline} |              |
+-------------------------------------+-----------------+--------------+
| Present                             |                 |              |
+-------------------------------------+-----------------+--------------+
| 1 or 2 polyps                       | 0               | 100-55       |
+-------------------------------------+-----------------+--------------+
| 3 or more polyps                    | 100-55          | R-200        |
+-------------------------------------+-----------------+--------------+
|                                     |                 |              |
+-------------------------------------+-----------------+--------------+
| History -- (if removed by           |                 |              |
| fulguration small size can be       |                 |              |
| assumed)                            |                 |              |
+-------------------------------------+-----------------+--------------+
| Up to 3 adenomatous or              |                 |              |
| pedunculated, negative biopsy       |                 |              |
+-------------------------------------+-----------------+--------------+
| Within 1 year                       | 0               | 20           |
+-------------------------------------+-----------------+--------------+
| 2^nd^ year                          | 0               | 10           |
+-------------------------------------+-----------------+--------------+
| After 2 years                       | 0               | 0            |
+-------------------------------------+-----------------+--------------+
| More than 3 polyps or more than 1   |                 |              |
| operation                           |                 |              |
+-------------------------------------+-----------------+--------------+
| Within 1 year                       | 20              | 100-55       |
+-------------------------------------+-----------------+--------------+
| 2^nd^ year                          | 10              | 55-30        |
+-------------------------------------+-----------------+--------------+
| 3^rd^ -- 5^th^ year                 | 0               | 30-0         |
+-------------------------------------+-----------------+--------------+
| After 5 years                       | 0               | 0            |
+-------------------------------------+-----------------+--------------+
| \*Select appropriate rating in each |                 |              |
| instance depending on size and      |                 |              |
| number of polyps if known. If       |                 |              |
| described as villous, use higher    |                 |              |
| rating in the ranges shown above.   |                 |              |
+-------------------------------------+-----------------+--------------+
|                                     |                 |              |
+-------------------------------------+-----------------+--------------+
| Negative biopsy for cancer          | 0               |              |
+-------------------------------------+-----------------+--------------+
| Cancer present on biopsy            | See Cancer      |              |
|                                     | schedule        |              |
+-------------------------------------+-----------------+--------------+
| Malignant any site                  | See Cancer      |              |
|                                     | schedule        |              |
+-------------------------------------+-----------------+--------------+
| Polyposis, complete colectomy       |                 |              |
+-------------------------------------+-----------------+--------------+
| Within 2 years                      | R               |              |
+-------------------------------------+-----------------+--------------+
| 3^rd^ -- 5^th^ year                 | 100             |              |
+-------------------------------------+-----------------+--------------+
| 6^th^ -- 10^th^ year                | 80-30           |              |
+-------------------------------------+-----------------+--------------+
| After 10 years                      | 0               |              |
+-------------------------------------+-----------------+--------------+

##### PARAPLEGIA/QUADRIPLEGIA

Paraplegia is paralysis of both lower extremities, often including the
lower trunk with loss of normal bowel and bladder function. The usual
cause is trauma; occasionally a spinal cord tumor or other disease will
lead to paraplegia. When the spinal cord in the upper neck is affected,
all four limbs may be paralyzed. This is called quadriplegia.

  ------------------------------------------------- ---------------------
  Paraplegia                                        

  Urine clear or mildly abnormal                    125

  Chronic urinary tract infection or definite       Usually R
  kidney impairment                                 

  Quadriplegia                                      Usually R
  ------------------------------------------------- ---------------------

# **PARASITIC INFECTIONS**

Human infections with parasites and worms account for a major portion of
the diseases caused by infectious agents. These infections are less
common in the U.S. and other highly developed industrial nations than
they are in the less developed countries. Worldwide travel has increased
their frequency.

All of these parasites are capable of producing severe disability, both
acute and chronic in character.

Following diagnosis, most if not all of these conditions can be treated
effectively, with few lasting effects. If they are not discovered
promptly, however, serious residual organ damage may result.

# **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ----------------------------------------------- -----------------------
  Present                                         Refer to Section Chief

  After recovery                                  0
  ----------------------------------------------- -----------------------

# **PARKINSON'S DISEASE** 

# **(Paralysis Agitans)**

Parkinson's Disease is a progressive neurological disorder. It is
characterized by tremor, slowness of movement, muscle rigidity and loss
of normal postural reflexes. Various medical and surgical treatments are
used, but none is entirely satisfactory. Onset is most common in the
50's and 60's, and progression to disability is slow, on average 10 to
15 years. Mortality occurs from injuries, aspiration or infections.

Parkinsonian symptoms may occur secondary to other toxic, vascular and
infectious disorders. Some of these may either stabilize or pursue a
more prolonged course than Parkinson's Disease.

# **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ----------------------------------------------------- -----------------
  Non-progressive, or very slowly progressive,          
  apparently under good control                         

  Within 1 year of onset                                175

  2^nd^ year                                            125

  3^rd^ year                                            75

  After 3 years                                         50

  Progressive with apparent disability                  R
  ----------------------------------------------------- -----------------

**PAROTID GLAND**

This gland is one of the salivary glands and is situated just in front
of the ear. Inflammation of the glands may be associated with
infections, such as typhoid and scarlet fever, and with mumps. Tumors,
usually benign, appear in the gland, and malignant degeneration is
possible.

# **Underwriting Requirements**

An APS (VA Form 29-8158) is required within 5 years.

  ----------------------------------------------- -----------------------
  Present                                         Refer to Section Chief

  History                                         

  Single, after recovery from operation           0
  ----------------------------------------------- -----------------------

# **PEPTIC ULCER**

Originally ulcers were felt to be due to the action of hydrochloric acid
and pepsin (thus "peptic") on the lining of the stomach or duodenum
where most occur. There are, in fact, numerous contributing causes to
ulcers, both endogenous and exogenous. Among the latter are cigarette
smoking, the use of adrenocroticosteroids and the use of aspirin and
other nonsteroidal, anti-inflammatory drugs.

The major complications of ulcers are bleeding, obstruction due to
scarring and perforation. Surgery is usually reserved for cases with
complications. It commonly involves vagotomy (severing the nerve which
stimulates gastric secretion) and procedures to enlarge the pylorus,
remove acid secreting cells from the stomach or to create an opening
from the stomach to the intestines.

Even after surgery, ulcers may recur and other complications such as
dumping syndrome, diarrhea and weight loss are not uncommon.

######## **[Duodenal Ulcer]{.underline}** 

Duodenal ulcer is a benign condition which is diagnosed by x-ray or
endoscopy. Most heal with medication. Because of the tendency to recur,
treatment is usually continued for months or years after healing is
presumed.

######### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ----------------------- ----------------------- -----------------------
                          [One                    [Multiple
                          Episode]{.underline}    Episodes]{.underline}

  Within 1 year           20                      40

  2^nd^ year              10                      30

  3^rd^ year              0                       20

  4^th^ year              0                       10

  5^th^ year              0                       0

  After 5 years           0                       0
  ----------------------- ----------------------- -----------------------

**[Gastric Ulcer (and Peptic Ulcers, Site Unspecified)]{.underline}**

Gastric ulcers are occasionally malignant. Because of this, after the
original diagnosis endoscopy and biopsy should be done, and the ulcer
followed to insure complete healing. Ulcers that show no healing after
12 weeks may require surgery.

######### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ----------------------- ----------------------- -----------------------
                          [One                    [Multiple
                          Episode]{.underline}    Episodes]{.underline}

  Within 1 year           20                      50

  2^nd^ year              10                      40

  3^rd^ year              0                       30

  4^th^ year              0                       20

  5^th^ year              0                       10

  After 5 years           0                       0
  ----------------------- ----------------------- -----------------------

**[Dumping Syndrome]{.underline}**

An assortment of symptoms which may occur following surgery for peptic
ulcer and includes palpitations, tachycardia, light-headedness,
diaphoresis, postural hypotension, abdominal discomfort and vomiting.

  ----------------------------------- -----------------------------------
  Dumping Syndrome                    Add +50 to appropriate ulcer rating

  ----------------------------------- -----------------------------------

**[Pyloric Stenosis and Pylorospasm]{.underline}**

The pylorus is a valve-like opening between the lower end of the stomach
and the duodenum. Pylorospasm and less severe cases of pyloric stenosis
usually respond to proper diet and medication. Severe cases often
require a corrective operation (pyloroplasty). An obstruction at the
pylorus, occurring in adults, is usually due to a spasm of the muscle or
fibrosis, and scarring produced by an ulcer, carcinoma, etc. Vomiting is
a prominent symptom. An x-ray study showing gastric retention is
necessary for a positive diagnosis.

The term pylorospasm is occasionally used to designate indigestion,
which may be of emotional origin and manifested by nausea, vomiting, and
vague upper abdominal distress. Care is required to differentiate this
condition from ulcer, carcinoma, or other organic disease, especially in
those over 40 years of age.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  --------------------------------- -------------------------------------
  Cause determined -- operated      RFC

  Unoperated                        Refer to Section Chief
  --------------------------------- -------------------------------------

**PERIOSTITIS**

Periostitis is an inflammation of the fibrous membrane (periosteum)
surrounding a bone. Infection or injury are the usual causes.

**Underwriting Requirements**

Obtain an APS (VA Form 29-8158) within 2 years.

  ------------------------------------------ ----------------------------
  Not associated with Osteomyelitis, after   0
  recovery, symptomless                      

  Associated with Osteomyelitis              Apply rating for
                                             Osteomyelitis
  ------------------------------------------ ----------------------------

**PERIPHERAL NEUROPATHIES**

Peripheral neuropathies have multiple causes including arsenic
poisoning, drug induced neuropathies, diabetes mellitus, trauma and
alcohol abuse. The significance is that of the underlying disease.

  ------------------------------------------------------- ---------------
  Present or history                                      RFC

  ------------------------------------------------------- ---------------

**PERITONITIS**

Peritonitis is an inflammation of the serous membrane (peritoneum),
which lines the abdominal wall and envelops the abdominal organs.
Usually it is secondary to other diseases and may be acute or chronic,
localized or generalized. The more common causes for acute peritonitis
are ruptured appendix, perforated ulcer, intestinal obstruction,
strangulated hernia, abdominal operations, abortions and pelvic
diseases. Chronic peritonitis is usually of tuberculosis origin.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required within 2 years of onset.

  ------------------------------------------------------ ----------------
  Present                                                RFC

  ------------------------------------------------------ ----------------

**PERONEAL MUSCULAR ATROPHY**

**(Charcot-Marie-Tooth)**

This is a disease characterized by peripheral wasting and usually has
its onset in adolescence. The atrophy remains confined to the lower legs
and distal arms, including the hands, and progresses very slowly.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------------ ----------------
  Ambulatory, disease stable for 2 years                 0

  Others                                                 75
  ------------------------------------------------------ ----------------

**PERSONALITY DISORDERS**

Personality disorders describe behavior that is odd or eccentric
(schizoid, paranoid, schizotypical), dramatic, emotional and erratic
(histrionic, narcissistic, antisocial, borderline), anxious, fearful and
extroverted (avoidant, dependent, compulsive, passive-aggressive).

These conditions include borderline personality disorder and antisocial
personality disorder, among others. All these conditions may be
associated with personality clashes a tendency to drug and alcohol
abuse, self-destructive behavior, sexual deviance and criminal activity.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------------ ----------------
  All personality disorders                              R-100

  ------------------------------------------------------ ----------------

**PHARYNGITIS**

Pharyngitis is an inflammation of the mucous membrane and underlying
tissues of the pharynx (throat). If an acute form, it may accompany
upper respiratory infections, tonsillitis, grippe, scarlet fever, etc.
Chronic Pharyngitis may result from prolonged irritation by chronic
sinusitis, neglected adenoids, and excessive use of the voice.

**Underwriting Requirements**

An APS (VA Form 29-8158) may be required if not adequately explained.

  -------------------------------------------------- --------------------
  Present                                            RFC

  Otherwise                                          Disregard
  -------------------------------------------------- --------------------

##### 

##### PHEOCHROMOCYTOMA

Pheochromocytoma is a tumor that produces adrenalin-like substances. It
can be benign or malignant, and is most often found in the adrenal
gland. Symptoms include sudden, severe hypertension, headaches,
perspiration, palpitations, and tachycardia.

# Underwriting Requirements

An APS (VA Form 29-8158) is required.

  ------------------------------------------------ ----------------------
  Unoperated                                       Refer to Section Chief

  Operated                                         

  Benign                                           

  Within 1 year                                    75

  Within 2 years                                   50

  After 2 years                                    0

  Malignant                                        See Tumor Rating Chart
                                                   A
  ------------------------------------------------ ----------------------

**PITUITARY GLAND**

The pituitary gland, situated within the skull, is composed of two
lobes. It is a gland of internal secretion and produces important
hormones, which go directly into the circulation. These hormones control
the growth of the body and influence other internal glands. Disturbances
in function of this gland (frequently due to tumor) may result in
acromegaly, diabetes insipidus, or Frohlich\'s syndrome, which are
covered under stated disorders; as well as the following:

**[Acromegaly]{.underline}**

Acromegaly is a condition produced by excess growth hormone. It is
characterized by hypertrophy and swelling of the soft tissues of the
face and extremities, increased hair growth, sweating, and skin
pigmentation and bony hypertrophy. Hypertension and diabetes or
carbohydrate intolerance is common. Surgery for growth hormone producing
tumors is the treatment of choice. Radiation and bromocriptine therapy
are less satisfactory alternatives. Excess mortality is associated with
cardiovascular, cerebrovascular and respiratory causes.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------- ---------------------
  Untreated, incomplete recovery or abnormal growth R-80
  hormone levels                                    

  Medical, surgical or radiation treatment, stable, 0
  normal growth hormone levels                      
  ------------------------------------------------- ---------------------

[Diabetes Insipidus]{.underline}

Pituitary diabetes insipidus is a disorder of excess water loss through
the kidneys due to a deficiency of antidiuretic hormone (ADH). The most
common cause of this disorder is pituitary surgery or trauma. It may
also result from a pituitary tumor or from metastatic carcinoma. It has
no relation to diabetes mellitus.

The most common treatment is synthetic ADH nasal spray (DDAVP). Small
doses of cholorpropamide (an oral hypoglycemic agent) or a thiazide
diuretic may also be used.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  --------------------------------------------------------- -------------
  Cause known                                               RFC

  Cause unknown                                             

  Present                                                   400

  Full recovery                                             

  Within 1 year                                             300

  Within 2 to 3 years                                       55
  --------------------------------------------------------- -------------

**[Panypopituitarism]{.underline}**

Complete or partial reduction may be the result of pituitary or
hypothalamic tumors, craniopharyngioma, metastitic carcinoma,
sarcoidosis, histiocystosis, CNS syphilis, skull trauma or postpartum
pituitary necrosis. It may also result from treatment of pituitary
tumors by surgery or radiation. Replacement therapy with thyroid hormone
and Cortisone is unnecessary in all cases of complete
panhypopituitarism.

  -------------------------------------------- --------------------------
  Panhypopituitarism                           Rate as Adrenal
                                               Insufficiency

  -------------------------------------------- --------------------------

**[Prolactinomas]{.underline}**

Hyperprolactinemia may be due to a pituitary tumor or may be of unknown
cause. Hyperprolactinemia is associated with galactorrhea (inappropriate
milk production by the breast), amenorrhea, and infertility in women and
galactorrhea in men.

Many prolactinomas can be treated effectively by medical therapy as by
surgery, and only 5-10% of microadenomas become macroadenomas. Therapy
with bromocriptine may reduce the size of macroadenomas for many years
and be useful in reducing tumor size prior to surgery.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------- --------------------------
  Hyperprolactinemia of unknown cause          Refer to Section Chief

  Due to tumor                                 Rate as Pituitary Tumor
  -------------------------------------------- --------------------------

**[Tumors]{.underline}**

Pituitary tumors may be associated with the symptoms of excess
production of a pituitary hormone (e.g., acromegaly) or with complaints
of loss of visual field or headaches. Evaluation for endocrine disorders
before and after treatment is therefore as important as treatment of the
tumor itself. Pituitary tumors may be treated surgically or with
radiation therapy. Radiation therapy may be used after surgery for
residual tumors.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------- --------------------------
  With surgery, complete recovery              

  Within 1 year                                20

  2^nd^ year                                   10

  After 2 years                                0

                                               

  Others                                       

  Within 1 year                                100

  2^nd^ and 3^rd^ year                         55

  After 3 years                                0
  -------------------------------------------- --------------------------

**PLATELETS**

**[Thrombocytopenia, Idiopathic Thrombocytopenic Purpura
(ITP)]{.underline}**

Thrombocytopenia is defined as a platelet count below 100,000 (normal
150-400,000). Post traumatic bleeding may occur at counts below 60,000
and spontaneous hemorrhage may occur at 20,000.

Acute ITP occurs in young children, usually following a viral infection.
Life-threatening bleeding may occur. Spontaneous recovery occurs in 85%
of cases but for those who do not recover, splenectomy may be done with
favorable results.

ITP in adults is a chronic condition requiring intermittent therapy when
the platelet count is dangerously low. Corticosteroid therapy often
results in prompt recovery of platelet levels but relapse is expected.
Splenectomy results in cure for most people but platelet count may
continue to be low.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------- ---------------------
  Acute, recovered, operated or unoperated          

  Within 1 year                                     75

  Thereafter                                        0

  Chronic                                           

  Operated (splenectomy)                            

  Without recurrence                                0

  Others                                            R

  Unoperated                                        

  Within 1 year of recovery                         Refer to Section
                                                    Chief

  2^nd^ and 3^rd^ year                              100

  4^th^ and 5^th^ year                              55

  After 5 years                                     0
  ------------------------------------------------- ---------------------

**[Thrombocytosis, Thrombocythemia]{.underline}**

High platelet count (over 500,000) may predispose to either clotting or
hemorrhage. Primary (essential) thrombocytosis is one of the
myeloproliferative diseases.

  ------------------------------------------------- ---------------------
  Present or history                                R

  ------------------------------------------------- ---------------------

**PLEURISY**

An accumulation of fluid in the pleural space which may be caused by
malignant tumors, infection, trauma, collagen vascular disease,
pulmonary infarction or congestive heart failure.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------- ---------------------
  Cause known                                       RFC

  Cause unknown                                     0
  ------------------------------------------------- ---------------------

**PNEUMOCYSTIS CARINII PNEUMONIA**

Pneumocystis Carinii Pneumonia is a protozoan infection mostly found
among patients with immunologic deficiencies or are undergoing
immunosuppressive therapy. The disease is highly fatal and is a common
opportunistic infection among AIDS patients. The presence of this
disease together with a positive test for HIV (HTLV-III) has been
determined by the CDC as sufficient evidence for a diagnosis of AIDS.

  ------------------------------------------------- ---------------------
  Pneumocystis carinii pneumonia                    See AIDS

  ------------------------------------------------- ---------------------

**PNEUMONIA**

Pneumonia may be viral or bacterial. In normal individuals it is cured
without residual. Those with chronic lung, heart, and immune system
diseases present with pneumonias caused by unusual organisms leading to
more complicated and prolonged courses. Suspect immune deficiency with
pneumonia caused by pneumocystis organisms.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------- ---------------------
  Complications                                     See specific disorder

  Uncomplicated, recovered                          0
  ------------------------------------------------- ---------------------

**PNEUMOTHORAX**

Pneumothorax is an accumulation of air or gas in the pleural cavity,
resulting in varying degrees of collapse of the lung. It may occur
following spontaneous rupture of blebs or bullae, secondary to chronic
obstructive pulmonary disease, or following injury.

Pneumothorax may resolve uneventfully, but recurrences are common.
Surgery may occasionally be necessary.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------------- --------------------
  Cause known                                        RFC

  Otherwise                                          0
  -------------------------------------------------- --------------------

**POLIOMYELITIS**

Poliomyelitis is an acute infectious disease which may result in
paralysis. Due to wide-spread use of effective vaccination it is seldom
seen in its acute phase. Applicants with residuals from the epidemics of
the 1950s are not uncommon. The main concern today is development of the
"Post-polio Syndrome", a late complication characterized by pain,
fatigue, and increasing weakness of previously affected muscles.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

+--------------------------------------------------+-------------------+
| History, no residuals or minimal to moderate     | 0                 |
| residuals with good adjustment                   |                   |
+--------------------------------------------------+-------------------+
| Marked impairment, wheelchair-bound, etc.        | R-55              |
|                                                  |                   |
|                                                  | Refer to Section  |
|                                                  | Chief             |
+--------------------------------------------------+-------------------+

**POLYCYTHEMIA, ERYTHROCYTOSIS**

The hemoglobin concentration, the hematocrit of the red cell count is
above normal. Polycythemia rubra vera is a malignancy. On the other
hand, a normal bone marrow may be stimulated to produce more red cells
than normal when there is inadequate oxygen in the blood.

**[Polycythemia Rubra Vera (PCV), Primary Polycythemia]{.underline}**

PCV is one of the myeloproliferative disorders. It is characterized by
excessive production of red cells and in half the cases an abnormally
high white cell or platelet count. Later, as the "burned out" or
terminal phase is reached, the bone marrow may become scarred
(myelofibrosis) with decreasing cell counts. Acute leukemia may result.

Treatment consists of a combination of regular phlebotomy, radioactive
phosphorus or chemotherapy.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ---------------------------------------------------- ------------------
  Recent hemoglobin over 20 mgm%, hematocrit over 55%, R-200
  platelet count over 750,000                          

  Others                                               125
  ---------------------------------------------------- ------------------

**[Secondary, Stress, Relative Polycythemia]{.underline}**

Polycythemia may occur as a reaction to inadequate oxygen. Individuals
living at high altitudes, those with chronic lung disease, congenital
heart disease, obesity and heavy smokers may all be found to have a
reactive form of polycythemia. The white cell and platelet counts are
normal and the risk of thrombosis and hemorrhage is minimal.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ---------------------------------------------------- ------------------
  Present or history                                   0

  ---------------------------------------------------- ------------------

**POLYMYALGIA RHEUMATICA**

This is a syndrome characterized by pain and stiffness in the pelvic and
shoulder muscles, elevated sedimentation rate and dramatic response to
small doses of steroids. It is usually limited to people over age 50.

  ------------------------------------------- ---------------------------
  Present or history                          Rate as Rheumatoid
                                              Arthritis

  ------------------------------------------- ---------------------------

**POLYMYOSITIS/DERMATOMYOSITIS**

These disorders of unknown etiology are characterized by inflammation
and weakness of the proximal muscles. Dermatomyositis is associated with
a variety of cutaneous manifestations. Either disorder may be
accompanied by arthritis, myocarditis, pulmonary interstitial fibrosis
or an esophageal motility disorder. Especially in older males, there is
an association between these disorders, particularly dermatomyositis,
and malignancy.

  ------------------------------------------- ---------------------------
  Polymyositis and Dermatomyositis            Rate as Rheumatoid
                                              Arthritis

  ------------------------------------------- ---------------------------

**PROSTATIC DISORDERS**

The prostate is a gland which surrounds the neck of the urinary bladder
and the urethra.

Acute prostatitis is common and usually caused from nonspecific
organisms. Chronic prostatitis includes low grade infections and
abscesses, which commonly are treated by antibiotics or rarely by
incision and drainage.

Benign prostatic hypertrophy (BPH) is frequently after age 55, and
causes symptoms of obstruction and urinary retention. Enlargement of the
prostate is a common disorder, but carcinoma must be ruled out
especially in the older age groups.

**Underwriting Requirements**

APS (VA Form 29-8158) is required.

  ------------------------------------------- ---------------------------
  Prostatitis                                 

  Acute (not related to benign hypertrophy)   0

  Chronic                                     0

  Benign prostatic hypertrophy (BPH)          

  Present                                     0

  History, treated by surgery                 0

  Urine abnormal                              Rate for urinary
                                              abnormality using +55 for
                                              ratable WBC

  Malignant lesion                            See Tumors and Cancer
                                              section
  ------------------------------------------- ---------------------------

**PSITTACOSIS**

Psittacosis or Parrot Fever is a rare virus disease transmitted from
parrots and other birds. It is sudden in onset and characterized by
chills, high fever, headache, nausea, nosebleed, acute toxemia and
pulmonary disorders.

**Underwriting Requirements**

APS (VA Form 29-8158) if recovery is doubtful.

  ----------------------------------------------------------- -----------
  Present                                                     50

  Complete recovery                                           0
  ----------------------------------------------------------- -----------

**PSYCHIATRIC DISORDERS**

In underwriting psychiatric disorders, the main distinction to be made
is whether the illness is psychotic or non-psychotic. Psychotic
disorders are major illnesses which are associated with disturbances in
thinking, perception and behavior. Non-psychotic illnesses, on the other
hand, may produce uncomfortable symptoms or interfere with an
individual's adjustment but generally do not lead to profound regression
or inability to function in society.

**[Non-Psychotic Disorders, Psychoneurosis]{.underline}**

These conditions are common and are not associated with any noteworthy
increase in mortality. An exception may be increased suicide with severe
depression, or accidents with panic disorder. They can be categorized as
follows:

1.  Mood disorders include depression (unipolar) or depression
    alternating with elevated mood (bipolar). Depression may be a
    response to an obvious life stress or may occur without being
    precipitated by any apparent event. Mood disorders may be either
    non-psychotic or psychotic. In the latter case rate under Psychotic
    Disorders.

2.  Anxiety disorders are characterized by a persistent irrational fear
    of a particular entity or activity. These include such things as
    panic disorders, claustrophobia and obsessive-compulsive conditions.

3.  Somatoform disorders are multiple, recurrent physical symptoms not
    identifiable to a specific disorder and include such things as
    hysteria and hypochondriasis.

4.  Dissociative disorders include depersonalization disorder, multiple
    personality, psychogenic amnesia and fugue. These are characterized
    by sudden temporary disruptions of consciousness and identity or
    motor behavior without a physical basis.

5.  Other conditions include sexual disorders (exhibitionism), sleep
    disorders (primarily insomnia), impulse control disorders
    (kleptomanias) and factitious disorders.

The grades of severity can be defined as follows:

Mild: No disability, able to carry on normal activities.

Moderate: Disability of not more than 3 months, with or without
hospitalization.

Severe: Disability of more than 3 months duration, with or without
hospitalization.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  --------------------------------------- -------------------- ------------------------ ----------------------
                                          [Mild]{.underline}   [Moderate]{.underline}   [Severe]{.underline}

  One Episode                                                                           

  Present or within                                                                     

  1 year of recovery                      0                    30                       175

  2^nd^ -- 3^rd^ year of recovery         0                    0                        55

  After 3 years                           0                    0                        0

                                                                                        

  Recurrent or chronic                                                                  

  Present or within                                                                     

                                          [Mild]{.underline}   [Moderate]{.underline}   [Severe]{.underline}

  1 year of recovery                      0                    50                       225

  2^nd^ -- 3^rd^ year                     0                    50                       80

  4^th^ -- 5^th^ year                     0                    0                        0
  --------------------------------------- -------------------- ------------------------ ----------------------

**[Psychotic Disorders]{.underline}**

These are major psychiatric illnesses associated with disturbances of
thinking, perception, and behavior. Most are considered to have
biological origins related to hereditary factors and disruption in
chemical processes of the central nervous system.

They include such conditions as:

1.  Schizophrenia

2.  Mood disorders (such as major depression, or bipolar-manic
    depression illness)

Excess mortality is experienced with the major mood disorders such as
bipolar disorders (manic depressive disorder) and major depressions.

Excess mortality with the other conditions such as schizophrenia, is
generally associated with social factors (such as homelessness), rather
than with the primary disorder itself.

**[Schizophrenia]{.underline}**

There are various types of schizophrenia including Disorganized
(Hebephrenia), Catatonic, Schiziod, and Undifferentiated. The
classifications depend on predominant clinical manifestation.

The treatment is psychopharmacy, and the most commonly used agents are
phenothiazines. When the phenothiazines are prescribed, the underwriter
is usually dealing with a significant psychotic disorder.

Prognosis is favorable when the onset is abrupt and the response to
medication is rapid. Recurrent episodes or a chronic course are
unfavorable features.

In most cases the individual may be judged recovered when able to resume
usual duties, even though on maintenance medication or under follow-up
psychiatric care.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ---------------------------------------------------- ------------------
  Single episode, fully recovered, no nervous or       
  mental symptoms                                      

  Within 1 year of recovery                            R

  2^nd^ -- 4^th^ year                                  400-225

  5^th^ -- 7^th^ year                                  175-80

  After 7 years                                        55-0

  Two or more episodes, fully recovered, etc.          Add 1 year to R
                                                       and +75 to other
                                                       durations
  ---------------------------------------------------- ------------------

**[Mood Disorders]{.underline}**

Mood disorders are characterized as unipolar, usually a sustained
depression, or bipolar, a sustained depression alternating with at least
one period in which elation (mania) predominates.

**Major depressive episode** -- Depression is a common psychiatric
illness. While most depressions are mild or moderate (see non-psychotic
disorders) they can be severe and reach psychotic proportions. In
addition to the mood change, lack of self-esteem, negative expectations,
anorexia, fatigue and insomnia, major depressive episodes may be
accompanied by delusions and hallucinations. Recurrent thoughts of death
and suicide are not uncommon and hospitalization for treatment,
including electroconvulsive therapy may be required.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ---------------------------------------------------- ------------------
  Single episode, fully recovered, no nervous or       
  mental symptoms                                      

  Within 1 year of recovery                            R

  2^nd^ -- 5^th^ year                                  225-80

  6^th^ -- 10^th^ year                                 80-30

  Two or more episodes                                 Add 1 year to R
                                                       and +75 to other
                                                       durations
  ---------------------------------------------------- ------------------

**Manic Depression, Bipolar Mood Disorder --** In the depressed phase,
bipolar disorders resemble major depressive episodes. In the manic
phase, there is a feeling of elation and expansive mood, a reduced need
for sleep, mild flights of ideas, and there may be involvement in
gambling, alcohol and drugs, reckless driving or foolish investments.
The inordinate capacity for activity may lead to intrusive and
aggressive behavior. In spite of this, the patient may believe he is in
his best mental state and resist attempts to help.

  ----------------------------------------- -----------------------------
  Manic Depression                          Rate as Major Depressive
                                            episode

  ----------------------------------------- -----------------------------

**PULMONARY FIBROSIS**

**(Idiopathic, Interstitial, Progressive Diffuse Interstitial Fibrosing
Pneumonia and Alveolar -- Capillary Block Syndrome)**

Alveolar-Capillary block is a clinical syndrome, which occurs, in
certain types of pulmonary fibrosis due to impaired oxygen diffusing
capacity of the lungs with thickening of the alveolar walls. It is
associated with a variety of diseases (e.g., Sarcoidosis, berylliosis,
asbestosis, rheumatoid arthritis, scleroderma, radiation fibrosis,
fungus infection of lungs, lymphatic spread of carcinoma, obstruction of
pulmonary veins, etc., and sometimes from unknown etiology).

The fibrosis may occur as an acute or chronic illness. The acute form
(Hamman-Rich syndrome) often follows a very short and rapid course but
is not always fatal as was once believed, and in recently reported cases
of the disease some appeared to have existed for a number of years. The
duration of the disease from onset of symptoms is from 1 to 12 years.

All types of pulmonary fibrosis are not associated with the
alveolar-capillary block syndrome. Extensive pulmonary fibrosis may
occur following inflammatory diseases of the lung such as pulmonary
tuberculosis, fungal diseases and bronchiectasis. The diffusing capacity
for oxygen and carbon dioxide is characteristically reduced. The
symptoms are fatigue, dyspnea, and weight loss. Later with right-sided
heart failure there is cyanosis, marked edema of the extremities in the
advanced stage. The lungs become shrunken, cirrhotic or liver-like in
consistency and present a hob-nailed or cobblestone appearance. There is
diffuse emphysema, bronchiolectasis and gross bronchiectasis, which give
the organ a honeycomb appearance.

X-rays are quite diagnostic, e.g.,

1)  Early cases show a faint haze to fine granules.

2)  Moderately advanced cases show localized increased ring shadows
    especially in apices.

3)  In the far advanced or late stage there is a generalized honeycomb
    appearance throughout the lungs and is often called cystic lung
    disease.

Where there is a honeycomb appearance throughout the lungs the prognosis
is very poor. Without treatment most of the cases will show a more or
less deterioration. If treatment (steroid) is to be successful it should
be started before reaching the advanced stage. If this is reversible,
improvement can be anticipated, e.g. Miliary Tuberculosis, some forms of
pulmonary edema, sarcoidosis in its acute form and some types of
nonspecific granulomas. When fibrosis is well established, improvement
usually does not occur.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------- ---------------------
  Where cause known                                 RFC

  Others, acute, or early stage (x-ray)             

  Under treatment and control                       100

  Not under treatment and questionable control      500 - 300

  Chronic or moderately advanced (x-ray)            

  Under treatment, questionable control             400

  Not under treatment, doubtful control             400

  Far advanced -- honeycomb appearance by x-ray     Refer to Section
                                                    Chief
  ------------------------------------------------- ---------------------

**PYORRHEA**

Pyorrhea, pyorrhea alveolaris, or Rigg\'s Disease, is an inflammation
with pus, involving the membranes lining the sockets of the teeth. It is
characterized by shrinkage of the gums, tooth decay and loosening of the
teeth.

  ------------------------------------------ ----------------------------
  No complications                           Disregard

  Complications                              Apply rules for complication
  ------------------------------------------ ----------------------------