RECORD OF PROCEEDINGS 
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX 		BRANCH OF SERVICE: AIR FORCE
CASE NUMBER:  PD0900474		BOARD DATE: 20100302
SEPARATION DATE: 20050701
______________________________________________________________________________

SUMMARY OF CASE:  This covered individual (CI) was a Staff Sergeant/E5 (Information Management) medically separated from the Air Force in 2005 after 9 years of combined service.  The medical basis for the separation was Ulcerative Colitis, Moderate with Infrequent Exacerbation.  The CI was referred to the Physical Evaluation Board (PEB), found unfit for continued military service, and separated with a 10% disability using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Air Force and Department of Defense regulations.
________________________________________________________________

CI CONTENTION:  “I feel that I should have been granted military retirement for my service to this country.  Being in the Air Force was my life; I gave all I had and then some to the service and this country.  My medical board was a total surprise to me; I was under the impression from my doctor at Travis AFB, that my disease would not put me in the position of going through a medical board because it did not prevent me from performing my (continued) daily duty.  It had also not prevented me from deploying, going TDY or even living overseas.  I had not missed excessive amounts of work due to medical appointments either, the most time I ever missed from work was during the year of finding the infected portion of my colon in August 2004 to going through my medical board process in May 2005.  Throughout this process I continued to produce exceptionally well on the job as noted by my then commander and supervisor in their letters of recommendation supporting my retention in the Air Force.  I feel that a simple change in my profile to a C-Code status would have been sufficient, but I was denied this during my appeal.  Even the board that I met with in May 2005 in Lackland were split 2 to 1 in my favor against separating me.  The officer who voted against my retention just happened to be the ranking officer on the board who told me flat out that I was “going to be separated with or without a severance package" whether I liked it or not.  After all that I’d gone through during my career, always trying to represent my service in a light of excellence and above-reproach, came crashing down around me at that moment.  Having to start my life over, leave my current home and return to a city that I no longer felt apart of was devastating to me.  I couldn't even find a job that paid me enough money to maintain my current life-style, so the severance package didn't last as long as it could have.  I feel that retiring me with at least 30% of my base pay and allowing me to maintain my base access, coupled with my severance, would have made this transition a lot easier.  Please reconsider my current status and medically retire me from service.”

RATING COMPARISON:

Service PEB	VA (VARD 3 Mo. after, then 12 Mo. Exam after Separation)	
Unfitting Conditions	Code	Rating	Date	Condition	Code	Rating	Exam	Effective	
Ulcerative Colitis, Moderate w/Infrequent Exacerbation	7323	10%	20050502	Left Sided Ulcerative Colitis

then

Left Sided Ulcerative Colitis & Irritable Bowel Syndrome w/Functional Constipation	7323

	10%

10%	CI missed VA Exam

20060718	20050702

20050702	
Constipation, Requiring Regular Use of Laxatives	CAT II	NARSUM Update & NARSUM	Irritable Bowel Syndrome w/Functional Constipation

then combined w/ Left Side Ulcerative Colitis above	7319	0%	CI missed VA Exam	20050702	
No PEB Entry	NARSUM Update	Hemorrhoids (Claimed as Internal & External Hemorrhoids)	7336	0%	CI missed VA Exam	20050702	
No PEB Entry	Not in DES	Chronic Adjustment Disorder (Claimed as Depression and Anxiety)	NSC
then 

9440	

30%	CI missed VA Exam

20060718 	

20050702	
No PEB Entry	Not in DES	Spider Veins, Right Lower Extremity	NSC
then 

7199-7120	

0%	CI missed VA Exam

20060718	

20050702	
No PEB Entry	Not in DES	Spider Veins, Left Lower Extremity	NSC
then 

7199-7120	

0%	CI missed VA Exam 

20060718	

20050702	
No PEB Entry	Not in DES	Chronic Headaches	NSC then

8100	

0%	CI missed VA Exam 

20060718	

20050702	
No PEB Entry	Not in DES	2 x Conditions (Left Hip Pain, Joint Inflammation;  Plantar Fasciitis)	NSC				
TOTAL Combined:  10%	TOTAL Combined (Includes Non-PEB Conditions):    
40%  from 20050702                                                         	

________________________________________________________________
ANALYSIS SUMMARY:

Condition 1: Ulcerative Colitis
On 20050328 the Informal Physical Evaluation Board (IPEB) determined that the CI’s medical condition prevented her from reasonably performing the duties of her office, grade, rank, or rating.  The member's conditions were not compatible with the rigors of military service and are subject to unpredictable flare-ups.  The Board opined the severity of the member's ulcerative colitis might be masked by her chronic constipation.  It recommended separation from service with a rating of 10% for 7323 Ulcerative Colitis.

The CI appealed the decision of the IPEB and contended she was fit to return to duty as she had been symptom-free since December 2004.  She was on medication but the gastroenterologist had noted she was in clinical remission.  She was medicated with Zelnorm, Prevacid, and Rowasa, and over-the-counter fiber pills. She stated she had four flares of bloody stools in her career (Feb 99, Ju1 99, Oct 00, and Aug 04) which, based on her research, may have been the result of taking over-the-counter fiber and laxatives (Psy1ium Husk Fiber and Cascara Sagrada). She believed, based on this same research that her bowel may return to normal after five years.  She also had strong command support for "Return to Duty" as evidenced by her supervisor's personal appearance and multiple letters of endorsement.  A Formal Physical Evaluation Board (FPEB) on 20050502 found her unfit and recommended Discharge with Severance Pay.  The board noted the member has a condition that has a high probability of frequent flare-ups especially in stressful situations.  The board opined it was not a reasonable risk to return her to duty as the stresses and rigors of military service may aggravate this condition.  The board opined the member's condition was appropriately rated at 10%.

The original Medical Evaluation Board (MEB) Narrative Summary (NARSUM) was completed in October 2004.  At that time she had been diagnosed with ulcerative colitis but it was difficult for the gastroenterologist to define the severity of her disease as her severe constipation was most likely masking symptoms.  He opined that once her constipation symptoms were better controlled, she would actually experience more symptoms of colitis such as diarrhea, increased stool frequency, and tenesmus.

At the time of an update to the NARSUM in February 2005 the CI was in remission and was not taking any medications for colitis. She was managing her constipation with Miralax and stimulant laxative as needed and her non-ulcer dyspepsia was controlled with Prevacid.  However, she would be expected to have symptoms of colitis in the future.

At an outpatient visit on 20050524 both sulfasalazine and folate were started.  The frequency or severity of current symptoms was not documented and her abdominal exam showed nonspecific tenderness.  A DD Form 2697 dated 20050601 listed her medications as Prilosec, Zelnorm, sulfasalazine, and oral contraceptive pills.

Her first VA evaluation was done in July 2006, 12 months after separation.  At that time she was on sulfadiazine daily as preventive therapy and Zelnorm as needed as well as meds to control constipation.  After a 25 pound weight gain when she first left service her weight remained stable.  There were no signs of anemia or malnutrition.  She reported three episodes a month of pain with bowel movements and straining.  She denied abdominal pain, bloating, or cramps but had had these symptoms while on active duty.  She also reported she was considered unfit for military service because of colitis, although she really wanted to stay in her military career.  She reported colitis was not affecting her current job but she was adjusting to less pay.  She reported colitis was not affecting her daily activities.  She was not on medications for acid reflux at time of VA exam.

Based on military and VA examinations, it appears that she had frequent (three times a month) flares of abdominal distress (pain but no diarrhea or bleeding) that appear to be more related to constipation than ulcerative colitis although both can cause abdominal pain.  Although frequent, these appear to be mild exacerbations of ulcerative colitis. 

The VA initially determined service connection for both left sided ulcerative colitis and irritable bowel syndrome (IBS) with functional constipation and separate evaluations of 10 percent for colitis and 0 percent for IBS were assigned.  Assigning separate evaluations for these two disabilities was an error as under the rating schedule for evaluating the digestive system ulcerative colitis and IBS are not to be evaluated separately, but rather a single evaluation is to be assigned under the diagnostic code which reflects the predominant disability picture.  This is considered a harmless error since the combined evaluation and compensation was not affected by the change.  A single 10 percent evaluation was assigned for left sided ulcerative colitis and irritable bowel syndrome with functional constipation effective from July 2, 2005.  The CI appealed the evaluation assigned for ulcerative colitis and irritable bowel syndrome but the VA did not adjust the rating.

The PEB listed constipation as a Category II condition (a condition that can be unfitting but is not currently compensable or ratable).  This condition cannot be added as a separately unfitting condition with a rating applied because doing so would violate VASRD §4.114 Schedule of ratings—digestive system.

Other Conditions: 
Hemorrhoids 
	Addressed in NARSUM Update 20050208
	No evidence this was unfitting

Additional Service Connected conditions:
None are mentioned in the Disability Evaluation System (DES) package and all are outside scope of PDBR:
Chronic Adjustment Disorder (Claimed as Depression and Anxiety)
Spider Veins, Right Lower Extremity
Spider Veins, Left Lower Extremity
Chronic Headaches
________________________________________________________________

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  After careful consideration of all available information the Board unanimously recommends that the CI’s condition be rated at 10% for 7323 Ulcerative Colitis, Moderate with Infrequent Exacerbation.

The CI had abdominal pain without diarrhea or bleeding about three times a month.  Her symptoms appeared to be more related to constipation rather than ulcerative colitis although both can cause abdominal pain.  This appears to have been mild exacerbations of ulcerative colitis.  Moderately severe symptoms were not present and her health was good during remissions.  Therefore, a rating greater than 10% is not warranted.

The VA initially rated ulcerative colitis at 10% and continued this rating after a subsequent evaluation in July 2006.  The VA also initially applied a separate rating of 0% for 7319 Irritable Bowel Syndrome with Functional Constipation but later removed this rating IAW with VASRD §4.114 Schedule of ratings—digestive system.  This paragraph states that ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other.  When this error was discovered, the VA assigned a single evaluation under the diagnostic code that represented the predominant disability picture and continued a 10% rating for 7323.

Hemorrhoids were the only other condition rated by the VA that was mentioned in the DES package.  The Board unanimously determined that this condition was not unfitting at the time of separation and therefore no rating is warranted.

The other diagnoses rated by the VA (Chronic Adjustment Disorder; Spider Veins, Right Lower Extremity; Spider Veins, Left Lower Extremity; and Chronic Headaches) were not mentioned in the DES package and are therefore outside the scope of the Board.  The CI retains the right to request her service Board of Correction for Military Records (BCMR) to consider adding these conditions as unfitting.
________________________________________________________________

RECOMMENDATION: 
The Board therefore recommends that there be no recharacterization of the CI’s disability and separation determination.

UNFITTING CONDITION	VASRD CODE	RATING	
Ulcerative Colitis, Moderate w/Infrequent Exacerbation	7323	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090802, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.

                  

SAF/MRB
1535 Command Drive, Suite E-302
Andrews AFB, MD  20762-7002

	Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2009-00474.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation with severance pay.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Attachment:
Record of Proceedings

cc:
SAF/MRBR