C&p service Clinician’s GuidE



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C&P Service Clinician’s Guide

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

Chapter 1 - INTRODUCTION TO COMPENSATION AND PENSION




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