C&P Service Clinician’s Guide CLINICIAN’S GUIDE MARCH 2002 1 C&P Service Clinician’s Guide 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 1 C&P Service Clinician’s Guide 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 2 C&P Service Clinician’s Guide 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 3 C&P Service Clinician’s Guide 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 4 C&P Service Clinician’s Guide Chapter 1 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 5 C&P Service Clinician’s Guide 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). 6 C&P Service Clinician’s Guide 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