Prisoner of War (POW) Protocol

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

Narrative: This is the protocol for conducting initial examinations on former POWs. Approach these veterans with the greatest sensitivity because the POW experience likely resulted in a great deal of psychological and physical trauma. Details about beatings, torture, forced marches, forced labor, diet, disease, brainwashing, extremes of hot and cold, and anxiety may be significant parts of the veteran's history; eliciting these details requires that one establish a trusting relationship with the veteran. Examine veteran for each disability / disease / condition veteran is claiming as a consequence of the POW experience. A former POW may be entitled to service connection for presumptive POW diseases; the worksheet contains a list of these presumptive diseases. Based on veteran's claim(s) and your findings, please refer to and follow additional worksheets to assure the examination provides information adequate for rating purposes.

Presumptive POW disabilities:

Any of the anxiety states. Atherosclerotic heart disease, ischemic heart disease, coronary artery disease and beriberi heart disease to include complications e.g., myocardial infarction, congestive heart failure, arrhythmia. Avitaminosis. Beriberi including beriberi heart disease. Chronic dysentery. Cirrhosis of the liver. Dysthymic disorder or depressive neurosis. Helminthiasis. Hypertension and hypertensive vascular disease to include complications. Irritable bowel syndrome.

Ischemic heart disease Beriberi heart disease includes ischemic heart disease in a former prisoner of war who had experienced localized edema during captivity. Malnutrition including optic atrophy associated with malnutrition. Any other nutritional deficiency. Organic residuals of frostbite. Pellagra. Peptic ulcer disease. Peripheral neuropathy. Post-traumatic arthritis. Psychosis. Stroke ischemic stroke, hemorrhagic stroke and embolic stroke to include complications.

A. Review of Medical Records:

1. Include a review of VA Form 10-0048, Former POW Medical History, (If you do not have Adobe Acrobat software installed, you may download free viewer and reader software to view the form.) 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.

1. Describe initial symptoms, time of onset, and current symptoms of all presumptive POW disabilities found.
2. 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: 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: Indicate the dominant hand and how determined (i.e., writes, eats, combs hair, etc.).
3. Posture and gait: (If abnormal, describe.)
4. Skin, including appendages: (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 photographs of the affected area(s).
5. Hemic and Lymphatic: (Describe local or generalized adenopathy, tenderness, suppuration, etc.).
6. Head and face: Describe scars, deformities, etc.
7. Eyes: Describe external eye, pupil reaction, movements, field of vision, any uncorrectable refractive error or any retinopathy.
8. Ears: Describe canals, drums, perforations, discharge.
9. Nose, sinuses, mouth and throat: Include gross dental findings.
10. Neck: Describe lymph nodes, thyroid, etc.
11. Chest: 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: Comment on any masses palpated in breast parenchyma including axillary tail. Comment on any skin abnormalities. Comment on any discharge from nipples.
13. Cardiovascular: 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: Inspection, auscultation, palpation, percussion. If abnormal, describe (i.e., abdominal enlargement, masses, tenderness, etc.).
15. Genital/rectal (male): 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): 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: 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: Describe disease of thyroid, pituitary, adrenals, gonads, other body systems affected, etc.
19. Neurological: 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: 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 also 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, whether it is related to the period of confinement.