RECORD OF PROCEEDINGS 
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX		BRANCH OF SERVICE: Air Force  
CASE NUMBER:  PD0900550		BOARD DATE: 20100714
SEPARATION DATE: 20090629  
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SUMMARY OF CASE:  This covered individual (CI) was 0-3/Capt, Public Affairs medically separated from the Air Force in 2009 after 9.5 years of service.  The medical basis for the separation was Crohn’s Disease.  The Crohn’s Disease was determined to be medically unacceptable.  The CI was referred to the Physical Evaluation Board (PEB), determined unfit for the one condition, and separated at 10% disability using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Air Force and Department of Defense regulations.
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CI CONTENTION:  The CI states: ‘While still on active duty, as part of the Dept. of Veterans Affairs Benefits Delivery at Discharge program I was examined by a VA doctor for disability benefits in June, 2009.  I received a 50% disability rating from the VA in August, 2009. Based on a review of my military medical records and their exam, the VA rated my Crohn's disease at 30%, just a few months after the Air Force PEB gave me a rating of only 10%.  The VA assigned a 30% rating for diarrhea, intestinal pain, arthralgia and noted weight loss, all of which were observed and noted in both my military medical record and my VA medical exam, which occurred while I was still serving on active duty.  The VA determination of a 30% rating was based on the same information that was available to the PEB.  The Air Force should have used the same rating criteria when reviewing my records and given me at least 30% rating for my disease. However, I request that the board go one step further and completely re-assess my rating.  The VASRD lists the following for a 100% rating on Colitis (which is what Crohn's disease is rated under): "Pronounced; resulting in marked malnutrition, anemia, and general debility, or with serious complication as liver abscess."  I would argue that my condition meets the requirement for a 100% rating, in that I am markedly malnourished (check my history of blood work and weight loss), I have a history of anemia since being diagnosed (again, see lab work in my medical records), I have a repeatedly reported weakness and fatigue (general debility), and have had serious complications to include a peri-rectal abscess, which after 5 surgeries still acts up from time to time, and at least two documented occasions of a small bowel obstruction. (all reflected in my medical records).  This documented, serious illness impacts my quality of life on a daily basis.  The PEB 

rating of 10% was neither fair nor accurate.  The PDBR has the opportunity to correct this error by issuing a fair and accurate rating of at least 30%, and if fully applying the rating schedule as it should, a rating of 100%.’
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RATING COMPARISON:

Service PEB 20090331	VA (1  Month Prior to Separation)	
Condition	Code		Rating	Condition	Code	Rating	Exam	Effective	
Crohn’s Disease		7399-7323	IPEB (20090331)
	10%

	Crohn’s Disease, Anemia Hypochromic Microcytic, w/Arthralgia	7323	30%	20090527	20090630	
Crohn’s Disease Associated with Osteoporosis, Both Improving on Medication	7399-7323	AFPC (20040130) IPEB (20030828)	Not Unfitting

10%	Osteoporosis
(Normal DEXA Scan 20090415)	NSC		20090527		
Fibrous Dysplasia Status-Post Prophylactic Hip Pinning	5255	IPEB (20090331)
AFPC (20040130) IPEB (20030828)	Not Adjudicated

Not Unfitting

10%	Left Hip Strain with Fibrous Dysplasia	NSC		20090527		
		Not in DES	Cervical Strain	5237	10%	20090527	20090630	
		Not in DES	Thoracolumbar Spine	5237	10%	20090527	20090630	
		Not in DES	Tinnitus	6260	10%	20090604	20090630	
		Not in DES	Right Hand Thumb MCP Joint Degenerative Disease	5228	0%	20090527	20090630	
		Not in DES	Kidney Stone	7509	0%	20090527	20090630	
			NSC X 9 additional					
TOTAL Combined:  10%	TOTAL Combined (Includes Non-PEB Conditions):    
50%  from 20090630
 	
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ANALYSIS SUMMARY:

Crohn’s disease
In April 2002 the CI developed rectal pain with bright red blood per rectum (BRBPR) accompanied by intermittent fevers of 101-102 degrees F.  A peri-rectal abscess was identified and the CI was admitted to the hospital for percutaneous drainage of the abscess.  An upper GI series with small bowel follow-through revealed diffusely thickened and abnormal distal ileum with minor narrowing of the lumen.  A computed tomography (CT) scan showed multiple thick-walled loops of small bowel with associated mesenteric lymphadenopathy.  A diagnosis of Crohn's Disease was made and he was given levofloxacin, metronidazole, and Pentasa.  The CI was also diagnosed with fibrous dysplasia of the left hip and osteoporosis.  These conditions are discussed separately.

The CI’s post-operative course was complicated by continued fevers to 104F, a 30-lb weight-loss, and eventually recurrence of the abscess.  Over the next several months he underwent three additional incision and drainage procedures of his abscess, which had been confirmed (by both CT scan and magnetic resonance imaging (MRI)) to be loculated.  His condition was felt to be improving until 2 Jun 02, when he had a syncopal episode most likely caused by dehydration.  He continued to have intermittent fevers with persistent peri-anal discomfort and swelling.  A fistulagram on 25 Jun 02 showed a small residual cavity related to the original peri-rectal abscess.  No fistulas were identified.  A small bowel series on 26 Aug 02 showed evidence of Crohn’s disease involving a long section of ileum proximal to the terminal ileum and no fistulas.

In December 2002 the CI underwent an additional debridement procedure with placement of a seton to control two fistulous tracts.  Since then, his symptoms and clinical examination have improved remarkably.  The seton was removed on 14 July 03.  In February 2003, he was started on immunomodulator therapy, namely six (6) Mercaptopurine (50mg qd), to treat his underlying Crohn's disease.  At his most recent visit to the gastroenterologist on 5 Aug 03, he was noted to be ‘...stable in a clinical remission from the point of view of his Crohn's disease and will continue his current regimen but begin to taper the metronidazole...’  The CI reported having 2-3 formed stools per day with no abdominal or perineal pain and no bleeding. His weight was stable at 130 pounds. 

In October 2003, the CI’s Internist completed an addendum to the narrative summary (NARSUM) recommending the CI be allowed to remain on active duty.  He reported the CI had achieved clinical remission after the seton drain worked to allow the fistulous tracts to close.  He remained clinically stable on six (6) mercaptopurine and flagyl.  A taper of the flagyl had begun.  He was evaluated 23 Sep 03 and appeared thin but well and his weight was 135.  He reported having two to three formed stools per day.  He denied fever, abdominal pain, cramping, blood in his stool, joint pain, skin changes, or symptoms of iritis.  The CI had returned to a normal lifestyle with the exception that he avoided extended weight-bearing exercises as advised by his orthopedist secondary to the fibrous dysplasia of the left hip. He did participate regularly in low-impact aerobic and light weight-bearing activities; such as walking and short-duration jogging without difficulty.  He had always been completely asymptomatic with regard to his hip dysplasia and osteoporosis. His endocrinologist had increased his vitamin D dose to 50,000 units three times per week to be continued for six weeks. Malabsorption of vitamin D was likely a consequence of his Crohn's disease. 

The internist opined the CI’s medical problems were not interfering with his ability to perform his job as a Public Affairs Officer.  However, he was not confident the CI could perform more vigorous military duties without jeopardizing his safety or mission completion because of the increased risk of hip fracture.  He pointed out that if the CI’s hip was prophylactically pinned it would strengthen to the point where he could resume normal weight-bearing activities.

The Informal PEB 20030828 determined the CI was unfit due to Crohn’s Disease associated with Osteoporosis and Fibrous Dysplasia status post  Hip Pinning. Each condition was rated at 10%. However, there is no evidence any surgery was ever performed on the hip.  The CI appealed and in January 2004 the Air Force Personnel Council determined he was fit to return to duty with an assignment limitation code.  It appears that no Formal PEB was completed.

The CI’s Crohn’s disease remained under good control until January 2008.  A colonoscopy done in October 2007 showed severe terminal ileum ulceration but the CI remained symptom-free despite elevated ESR, CRP and mild iron deficiency anemia.  At that time he declined therapy and opted for vitamin supplementation and monitoring.  In January 2008 he was scheduled for a deployment to Washington DC which would involve multiple short trips to Guantanamo Bay, Cuba.  While driving from San Antonio TX to Washington DC he developed abdominal discomfort. Upon arrival went to National Naval Medical Center, Bethesda, MD for care and was found to have small bowel obstruction. He was admitted and responded rapidly to steroids.  He was discharged within three days and completed the TDY making multiple trips to Guantanamo without further Crohn’s flare-up. He followed-up in October 2008 with GI specialist upon return to Randolph AFB post-deployment.  At the time of the 2008 NARSUM he was taking Mercaptopurine (6MP) 75 mg daily and Calcium/Vitamin D 600 mg/400 mg BID.  His condition appeared to be under control and he was having one to two formed bowel movements per day.

An Informal PEB determined he was unfit for continued service due to Crohn’s Disease in March 2009.  He was considered a risk for recurrences with rapid incapacitation as well as potential life-threatening infection or bleeding as a possible side effect of mercaptopurine, an immunomodulator.  He also would require ongoing follow-up with a medical specialist.  He was separated with a 10% disability rating.

Endoscopy done in February 2009 documented moderate to severe activity endoscopically but had clinically tolerable disease with mild symptoms.  At the VA Compensation and Pension (C&P) examination in May 2009 he reported having diarrhea one to two days per week that occasionally was bloody and had occasional stomach cramps.  At that time he was taking mercaptopurine (6MP) 100 mg daily.  He had intermittent flares with remissions and during flares he experiences diffuse joint pains (different ones at different times), but mainly hips, knees, hands, ankles, neck & elbows.  His response to current treatments was considered good.

Frequency of Exacerbations
The December 2008 NARSUM documented one to two formed bowel movements per day and no other symptoms.

VA C&P exam done in May 2009 documented diarrhea one to two days per week which were occasionally bloody and occasionally accompanied by stomach cramps.  He had intermittent flares with remissions and during flares he would experience diffuse joint pains (different ones at different times) involving mainly his hips, knees, hands, ankles, neck, and elbows.

Anemia
The CI did have anemia when he was first diagnosed with Crohn’s Disease in 2002 and he intermittently required iron and vitamin B replacement.  His response to medication was good and he had no side effects from the treatment.  At the time of separation he was not on medication for anemia, had no signs or symptoms attributable to anemia but it did mildly affect his ability to exercise.  However this condition had no significant affect on his job as a Public Affairs specialist in the Department of Agriculture.

Multiple lab tests from 20080310 to 20081027 in service documented hemoglobin from 12.6 to 13.3.  After 20080505, all values were greater than 13.  A lab test from the VA 20090417 documented a hemoglobin of 13.5.  No disability rating is applied unless the hemoglobin is less than 10.  The VA exam documented no current significant effects of anemia.

Malnutrition
The CI had suffered weight loss secondary to Crohn’s disease and showed some signs of malnutrition on the VA C&P examination one month prior to separation--he looked thin and had bitemporal wasting. He was 74 inches tall and weighed 135 pounds, a 20% decrease from baseline.  This is not considered marked malnutrition.  At the NARSUM examination in December 2008 he weighed 150 pounds.  The original NARSUM documented a nadir of 125 pounds and a weight of 135 at the time of that exam in August 2003.  There were no signs of marked malnutrition.

Osteoporosis
In February 2003 the CI had bone mineral density scan performed and was diagnosed with osteoporosis.  It was believed that the osteoporosis was attributable to his history of Crohn's disease and 35-pound associated weight loss, both independent powerful risk factors for osteoporosis.  He was evaluated by endocrinology and did not require bisphosphonates.  It was anticipated that he would be able to achieve some return of bone mineral with good control of his Crohn’s and some weight gain. 

At the time of the second NARSUM in December 2008 he was taking Calcium supplements and riding a bike daily.  He weighed 150 pounds at that time.  His weight at the VA exam in May 2009 was 135.  A bone mineral density scan in April 2009 was normal and it appears the osteoporosis had resolved.

Rating
The VA rated the condition at 30% (Moderately Severe; with frequent exacerbations) for weekly symptoms of diarrhea, intestinal pain, arthralgia, and noted weight loss.  A 60% rating was not warranted because he did not have numerous attacks a year with malnutrition and health only fair during remissions.  The CI does have endoscopic evidence of moderate to severe Crohn’s and was having symptoms on a regular basis while on appropriate medication. 

Other Conditions
Fibrous Dysplasia Left Hip, Osteoporosis.  There is no evidence either of these conditions was unfitting at the time of separation from service.  At the VA C&P exam left hip X-rays were normal and there do not appear to be any duty restrictions related to his left hip or osteoporosis.  While the CI initially had documented osteoporosis, he had a normal DEXA scan in April 2009 and it had resolved.

Other Conditions Not in the Disability Evaluation System (DES)
Cervical Strain, Thoracolumbar Spine, Tinnitus, Right Hand Thumb MCP Joint Degenerative Disease, and Kidney Stone
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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 determined that the CI’s condition is most appropriately rated at 30% for 7399-7323 Crohn’s Disease.  The CI had weekly symptoms of diarrhea which was occasionally bloody, intestinal pain, arthralgia, and noted weight loss.  These symptoms occurred while he was on appropriate medications.  He was 74 inches tall and weighed 135 pounds in May 2009.  The maximum weight recorded was at the December 2008 NARSUM and was 150.  He also had endoscopic evidence of moderate to severe Crohn’s Disease.

The Board also considered the conditions of Fibrous Dysplasia Left Hip and Osteoporosis and unanimously determined that neither condition was unfitting at the time of separation from service and therefore no disability ratings are applied.  Neither condition prevented satisfactory performance of any required duties. 

The other diagnoses rated by the VA (Cervical Strain, Thoracolumbar Spine, Tinnitus, Right Hand Thumb MCP Joint Degenerative Disease, and Kidney Stone) were not mentioned in the Disability Evaluation System package and are therefore outside the scope of the Board.  The CI retains the right to request his service Board of Correction for Military Records (BCMR) to consider adding these conditions as unfitting.
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RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows and that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation.

UNFITTING CONDITION	VASRD CODE	RATING	
Crohn’s Disease		7399-7323	30%	
COMBINED	30%	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090910, 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-2010-00550.

	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 not appropriate under the guidelines of the Veterans Administration Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

	As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at 1-800-531-7502 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.  

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN
PDBR PD-2009-00550

MEMORANDUM FOR THE CHIEF OF STAFF

	Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Section 1554, Title 10, United States Code (122 Stat. 466) and Section 1552, Title 10, United States Code (70A Stat. 116) it is directed that:

	The pertinent military records of the Department of the Air Force relating to XXXXX, be corrected to show that:

		a.  The diagnosis in his finding of unfitness was Crohn’s Disease, VASRD Code 7399-7323, rated at 30% rather than 10%.

		b.  On 28 June 2009, he elected spouse-only SBP coverage based on the threshold amount in effect on the date of retirement.  

		c.  He was not discharged on 29 June 2009 with entitlement to disability severance pay; rather, on that date he was relieved from active duty and on 30 June 2009 his name was placed on the Permanent Disability Retired List.