RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1300867
BRANCH OF SERVICE:  Army	BOARD DATE:  20140401
SEPARATION DATE:  20070220

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (94E20/35E Radio and COMSEC Repair) medically separated for angioedema and headache conditions.  After returning from his deployment to Iraq in 2003, the CI reported experiencing exercised-induced shortness of breath (SOB) attributing the condition to being out of shape.  In 2005, he sought medical attention for swelling of lips, headaches, wheezing, eye tingling and irritation.  He received pulmonary, cardiology, allergist and neurology consultations followed by a sleep study in 2006.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P3/L2/S3 profile and referred for a Medical Evaluation Board (MEB).  The following four diagnoses were forwarded to Physical Evaluation Board (PEB) as not meeting medical standards IAW AR 40-501: angioedema with severe dyspnea, Axis I: psychological factors affecting medical condition (DSM IV 316), migraine headaches and sleep apnea.  No other conditions were submitted by the MEB.  The PEB adjudicated angioedema with dyspnea on exertion and migraine headaches conditions as unfitting, each rated 0% respectfully, citing Department of Defense Instruction (DoDI) 1332.39 and application of VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “First, Asthma/Angioedema/Exercised induced Asthma is obviously an issue. I deal with.  I took Numerous trips to Augusta to figure out what was wrong.  I had multiple emergency room visits for this when the Board said I didn’t.  Secondly, I definitely have PTSD and Sleep Apnea.  1. Multiple Emergency Room visits for Asthma/Angioedema.  The Board said there weren’t any but there are.  One visit was said to be Allergic reaction, it wasn’t, it was Asthma Attack.  I notified a counselor immediately return from Iraq that I was having issues.  I had social impairments.  I struggled to function and work daily.  I hated coming on post.  I just lost another job and recently due to PTSD and my sleep apnea.  Documentation shows that I have at least 65 obstructive airway events a night.  I was diagnosed with sleep apnea from the Army and VA.  It affects my job, my driving and my focus.  I have lost 2 jobs to these medical issues.  Lastly, migraines are an issue.  I have prostrating migraines often.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  In addition, the CI was notified by the Army that his case may be eligible for review of the military disability evaluation of his mental health (MH) condition in accordance with Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose MH diagnoses were changed during that process.  The CI is also eligible for PDBR review of other conditions evaluated by the PEB and has elected review by the PDBR.  The rating for the unfitting angioedema with dyspnea and migraine headaches are addressed below.  Additionally, the contended and not unfitting, psychological factors and sleep apnea will also be addressed.

RATING COMPARISON:

Service IPEB – Dated 20061220	VA* - (8 Mo. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Angioedema w/Dyspnea...	7118	0%	Angioedema Anaphylaxis	7118	20%	20070723	
Migraine Headaches	8100	0%	Migraine Headaches	8100	10%	20070723	
Psychological Factors...	Not Unfitting	No VA Entry4	20070723	
Sleep Apnea	Not Unfitting	Obstructive Sleep Apnea	6847	50%	20070723	
No Additional MEB/PEB Entries	Other x 5	20070723	
Combined:  0%	Combined:  80%	
* Derived from VA Rating Decision (VARD) dated 20071016 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:  The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force.  While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career and then only to the degree of severity present at the time of final disposition.  The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation nor for conditions determined to be service-connected by the Department of Veterans Affairs (DVA) but not determined to be unfitting by the PEB.  However, the DVA operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time.  This Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation.  The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of DES fitness determinations and rating decisions for disability at the time of separation.  The Board utilizes service and DVA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence.  Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.

Angioedema with Dyspnea on Exertion.  Although a former long distance runner, the CI began to experience, upon his return from Operation Iraqi Freedom in 2003, difficulty breathing (dyspnea) with exercise.  With a well-documented history of shellfish allergy, he was first evaluated by pulmonary medicine in May 2005, with swelling of the lips and dyspnea at rest, occurring several times per day.  An initial pulmonary function test dated 1 April 2005, documenting that the CI did smoke tobacco, noted some “decreased lung capacity.”  Additionally, a chest X-ray dated 30 September 2005, noted some “bronchial wall thickening…consistent with a bronchitic type process.”  (These two objective findings verified the presence, at that time, of a mild pulmonary pathology which later resolved, temporally related to cessation of smoking).

Examination of the service treatment records (STRs) reveals two well documented emergency room visits (26 September and 24 December 2005) for SOB, with normal vital signs (blood pressure and pulse) and without symptoms either of asthma or of laryngeal (throat) involvement, such as difficulty speaking and which, according to hospital records, resolved spontaneously without treatment within 20 minutes of the CI’s arrival.  The CI underwent thorough evaluation by cardiology, pulmonology, allergists and MH (for psychological factors that may be exacerbating the condition).  Allergists noted that he was allergic to many common environmental allergens, noting that he was “atopic,” or prone to allergic reactions.  He was diagnosed with angioedema with anaphylaxis, an allergic condition manifested by swelling of soft tissues that can include the skin and lips, tongue and throat.  More systemic involvement (anaphylaxis) can be cause severe reactions that may be life threatening (such as from a fall in blood pressure or respiratory symptoms).  Intermittently, during the initial evaluation of this condition, the diagnosis of asthma had been entertained.  However, repeated pulmonary function tests, including a methacholine bronchoprovocation test (to check for asthma), exercise stress test (for exercise induced asthma) and bronchoscopy were all interpreted as normal, effectively ruling out asthma or other pulmonary pathology as a cause for this condition.  Cardiology evaluation including echocardiogram and stress testing were negative for heart disease.  The CI attained 15.4 METS (metabolic equivalent of tasks) on exercise stress testing, indicating an excellent level of cardiopulmonary fitness.  A permanent profile dated 5 December 2006 listed him as P3 for the dyspnea condition and he was referred for an MEB.

The MEB narrative summary (NARSUM) dated 24 November 2006 noted “Severe shortness of breath” caused by “any strenuous activity,” [treated with Singulair, Benadryl and Albuterol], which was diagnosed as “angioedema [swelling like hives under skin, tongue, lips or face] with severe dyspnea on exertion.”  The MEB recommended that this condition did not meet retention standards.  The PEB found this condition unfitting and noted that the medical evaluation had been negative for asthma.  The PEB rated this condition at 0% under VASRD code 7118 (angioneurotic edema) but without laryngeal involvement.

At a VA Compensation and Pension (C&P) examination completed on 23 July 2007, 5 months after separation, the CI noted his history of angioedema symptoms after “running and exercise,” with a history of non-incapacitating flares, three to four times weekly, lasting approximately 30 minutes, with swelling of lips and around the eyes.  At the time of the C&P examination, no flare was occurring and his physical examination for this condition was entirely normal.  The VARD dated 16 October 2007, 8 months after separation, awarded a rating of 20% under VASRD code 7118 (angioneurotic edema) for “attacks without laryngeal edema, lasting one to seven days and occurring five to eight times per year.”

The Board directs attention to its rating recommendation based on the above evidence.  Both the military medical providers and the VA examiners agreed on the diagnosis of angioedema.  Additionally, both the PEB and the VARD rated this condition under VASRD code 7118 for angioneurotic edema.  The PEB rated the angioedema condition at 0%, noting that there was no evidence of vocal cord (laryngeal) dysfunction and that there were “no documented episodes lasting one to seven days.”  The VARD, noted that the CI’s condition was not incapacitating and occurred “3-4 times per week and lasts about 30 minutes”.  The VARD rated this condition at 20% based upon “attacks without laryngeal involvement lasting one to seven days and occurring five to eight times a year; or, attacks with laryngeal involvement of any duration which occur once or twice a year.”  The Board noted the CI reported that exacerbations of the condition resolved spontaneously within 30 minutes, far less than a day and of such a short time as to not significantly interfere with daily activities.  Treatment records did not show the episodes involved the larynx.  The Board found no other VASRD rating codes that better approximated the condition for rating consideration and no other route to a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the angioedema with dyspnea on exertion condition.

Migraine Headaches.  In a clinic visit dated 18 October 2005, the CI reported headaches, without previous head injury, after returning from Iraq in 2003.  At one time the headaches were constant, but ultimately became intermittent, approximately three per week, often but not exclusively left sided, throbbing, associated with photophobia but no nausea, vomiting or aura.  STRs dated 6 February 2006 noted head CT scan as normal.  Evaluation by neurology, dated 9 May 2006, notes that the CI lost 5 days of work in the previous year due to headaches, which occur on either side of the head, and for which he had never gone for emergent care nor received any parenteral (injected) medications.  At this occasion the neurological examination was normal, resulting in a diagnosis of “common migraine (without aura).”  The neurologist noted that the headaches were not prostrating.  On 29 August 2006, neurology notes document that the headaches had improved and, subsequent to Topamax and Imitrex, were less frequent.  Severe headaches occurred twice monthly, however the CI had been out of the Topamax for over 2 months.  Permanent profile on 5 December 2006, 3 months prior to separation, included migraine headaches.  The MEB NARSUM, dated 4 December 2006, 2 months prior to separation, briefly describes migraine headaches, noting six “regular” headaches per week and three migraine headaches per week, at least one of which requires him to leave work and go home.  The MEB forwarded the migraine headaches to the PEB as not meeting retention standards.  A 24 January 2007 clinic record entry reflected the CI reported medication was working well for his headaches but had recurred when he ran out of medication.  At a VA C&P examination, dated 23 July 2007, 5 months after separation, the CI reported two headaches per week, but added that he was not incapacitated by headaches, and had lost “no time from work due to headache.”

The Board directs attention to its rating recommendation based on the above evidence.  The PEB found the headaches unfitting for continued military service, and rated the condition at 0% under VASRD code 8100, noting no emergency department visits for headaches during the previous year, and an absence of prostrating attacks requiring the CI to seek medical attention.  The VARD, dated 16 October 2007, awarded 10% under VASRD code 8100, citing that a 10% evaluation was indicated, with two headaches per week, since the headaches were “not incapacitating and do not cause you [sic] to lose time from your job.”  The VARD added that a higher rating of 30% was not warranted since prostrating headaches had not been documented to occur “on an average of once a month over the last several months.”  The Board concluded the service treatment records indicated a good response to medication treatment and did not reflect prostrating episodes that warranted a rating higher than that adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the common migraine headache condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that psychological factors affecting medical condition and sleep apnea were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence.

Contended Mental Health Condition:  At the time of return from deployment, the CI completed the post-deployment health assessment form on 12 June 2003.  He checked “yes” to seeing enemy and civilian wounded killed or dead (not Coalition) and having felt in great danger.  He indicated he was not involved in direct combat.  He indicated experiencing some feeling down, depressed or hopeless, but not loss of interest or thoughts of self-harm.  He indicated feeling constantly on guard, watchful or easily startled but not having experienced nightmares, feeling numb or detached, or avoidance symptoms.  He indicated he did not have concerns about having serious conflicts with family or friends or that he might lose control.  He checked “no” to question 10 inquiring whether he was interested in receiving help for a stress, emotional, alcohol, or family problem.  In the final section of the form, the CI checked no to having sought or intending to seek mental health counselling.  On the form, the CI wrote that he had marked “yes” but was told to indicate “no,” contending it happened to a lot of soldiers.  The CI’s correction and comments on the form are undated.

A second health care provider review is annotated at the bottom dated 7 July 2003 indicating “no changes.”  The Non-Commissioned Officer Evaluation Report (NCOER) for the period of November 2002 to October 2003 which covered the time the CI was deployed reflected excellent duty performance (repair of COMSEC equipment, daily resupply missions, and squad leader).  The NCOER for the period of November 2003 to July 2004, covering the period of time following return from deployment reflected excellent duty performance.  Following return from deployment, STRs were silent with regard to complaints or treatment for psychological symptoms until an October 2005 clinic entry.  At the time of a clinic evaluation on 18 October 2005, the CI reported that after initially returning from deployment, he had bad dreams, twitching in his sleep, and dreams of dead bodies.  He was not attacked in Iraq and never saw anyone killed but did see a lot of dead bodies.  A 28 October 2005 allergy note indicated concern for an underlying anxiety disorder contributing to angioedema symptoms.  At the time of evaluation by a civilian sleep specialist on 13 February 2006, the CI denied depression or anxiety symptoms.  The MEB physical examination on 18 April 2006 listed a diagnosis of anxiety disorder treated with medication, however there are no specific clinic entries confirming this.  A medication was prescribed for insomnia.  The commander’s statement on 25 April 2006 noted the CI’s back and SOB conditions interfered with his ability to perform critical field duties and perform heavy lifting but that he was otherwise a good soldier.  At an 8 May 2006 neurology evaluation, the examiner indicated there were no psychological symptoms, no sleep complaints, and normal mood.

The CI was referred to MH on 30 May 2006, 9 months prior to separation, “to assess if level of anxiety contributed” to his angioedema condition.  At this occasion, the CI recalled having difficulty sleeping and some problems with nightmares for the first few months upon return from deployment in 2003 but denied having problems sleeping any longer after he learned to avoid sleeping on his back.  He reported being “happily married” for 5 years, denied “feeling stressed” and denied suicidal thoughts or ideations.  He stated he was well connected to his community and active in his church.  On 9 June 2006, the CI underwent psychological testing as a part of this evaluation, testing which found that the CI exhibited “somatic reactivity under stress;” that is, he may have been converting psychological symptoms into physical symptoms.  On this occasion, the CI was diagnosed with “psychological factors affecting physical condition” (Axis I: 316; Diagnostic and Statistical Manual of Mental Disorders, VI, Text Revision).  The psychologist thought the CI was minimizing his symptoms and the CI declined counseling.  No medications were prescribed at this time.  A 20 June 2006 entry by the psychologist noted that the CI did “not easily agree” with the diagnosis and felt that he coped well with stress and cited his good duty performance.  His wife had remarked that he was aloof.

A MEB NARSUM noted an S3 profile with “marked” impairment for further military duty but no impairment for social or industrial adaptability (“none”).  On 3 December 2006, 2 months prior to separation, the MEB forwarded to the PEB this diagnosis as not meeting retention standards.  On 20 December 2006, the PEB found this condition “not independently unfitting.”

The CI’s original claim with the VA dated 26 January 2007 does not list a MH condition but did list sleep apnea (in the comments section, the CI noted sleep problems while deployed and dreams after returning).  At the time of a VA primary care clinic appointment on 16 July 2007, 5 months after separation, the CI responded “yes” to screening questions for posttraumatic stress disorder (PTSD).  The examining provider noted the positive screen but stated “patient does not have PTSD based on my assessment.”  On 26 November 2007, a VA primary care telephone encounter recorded CI complaint of “some depression” without suicidal thoughts.  He reported he had difficulty with his mood and nightmares when in the service.  A prescription for an antidepressant was issued and a follow-up appointment was scheduled.  At a VA psychiatry evaluation on 20 December 2007, 10 months after separation, the CI endorsed symptoms of PTSD including nightmares, easily startled, hypervigilance, avoidance of reminders, detachment of emotions and isolation.  He denied intrusive recollections and flashbacks, irritability or anger outbursts.  He denied life threatening situations but witnessed dead bodies, feared for his life and was in a Humvee accident.  He denied other anxiety symptoms including panic.  He denied any prior MH diagnoses and denied depressive symptoms or any history of depression.  He reported that previous medication treatment for sleep was beneficial.  He had stopped taking the medication recently prescribed by his VA primary provider after taking two doses.  At the time of the examination he was employed fulltime as a data monitor (data entry).  On mental status examination, his affect was normal (euthymic) with normal behavior, speech and thought processes.  There were no suicidal thoughts.  The examiner diagnosed PTSD and advised resuming medication.

The CI filed a VA disability compensation claim for PTSD dated 20 December 2007, 10 months after separation.  During the VA C&P examination for PTSD, on 19 July 2008, 17 months after separation, the CI noted that, while in the military, “the only time he saw a psychologist was for the psychological evaluation as part of his medical board exam.”  The CI added that he had “never been admitted to a psychiatric ward or hospital” and had “received psychiatric care after he became a civilian.”  He stated he was not injured in combat but cut his leg while clearing a building.  Stressors included seeing dead bodies and body parts.  The CI reported that the memory from Iraq which bothered him the most was “latrine duty he had to do for a month,” in which the “stench was unbearable.”  He reported witnessing dead enemy soldiers and a motor vehicle accident when his HumVee had been struck by another vehicle.  He endorsed symptoms that were not recorded in service treatment records prior to separation.  The VA diagnosis was PTSD.

The Board considered the appropriateness of any changes in the MH diagnoses along with the PEB fitness determination; and if unfitting, whether the provisions of VASRD §4.129 were applicable, with a disability rating recommendation in accordance with VASRD §4.130.  The Board first considered the appropriateness of any changes in the MH diagnoses.  The diagnosis of psychological factors affecting medical condition (Axis I: 316; DSM IV-TR) was referred into the DES and remained unchanged throughout the DES processing.  The Board determined that no MH diagnoses were changed to the applicant's possible disadvantage in the disability evaluation process.  This applicant therefore did not meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The Board considered whether the CI’s MH condition, diagnosed as “psychological factors affecting medical condition” (DSM-IV-TR Axis I: 319), or any other MH condition, was unfitting for continued military service, based on a preponderance of evidence.  The commander’s memorandum to the MEB, 10 months prior to separation, noted only the CI’s physical limitations and did not include any observations of behavior which indicated impaired psychological functioning.  A permanent profile, dated 5 December 2006, 2 months prior to separation, included the diagnosis of “psychological factors” and listed the profile as S3; however, no specific duty or mobility restrictions pertaining to this condition were listed.  There was no documentation of lost work due to this condition.  The MEB recommended that this MH condition did not meet retention standards.  However, the PEB concluded that this condition reflected “symptoms related to the diagnosis of angioedema” and was itself “manifested by…no social/industrial impairment” and therefore, was “not independently unfitting.”  There was no performance based evidence from the record that the psychological factors affecting physical condition separately significantly interfered with satisfactory duty performance.  Therefore, the Board concluded there was not a separately unfitting mental health condition at, or prior to, the date of separation.

Sleep Apnea.  The Board considered whether the sleep apnea condition was unfitting for continued military service.  STRs reveal that the CI first presented with sleep disturbance on 24 October 2005, noting “poor sleep habits and feeling of chronic sleep deprivation.”  Physical examination revealed normal a nose, pharynx and lungs.  A sleep study performed on 8 March 2006 revealed mild obstructive sleep apnea (OSA) and another on 23 May 2006 revealed borderline OSA.  A follow-up visit on 22 September 2006 documented that the CI “now has continuous positive airway pressure (CPAP) and loves it” and “can tell a big difference in the way he feels.”  His spouse reported that he was no longer snoring.  He was prescribed ProVigil to use on duty days at work when he could not use the CPAP.  The commander’s memorandum, dated 25 April 2006, did not include reference to sleep apnea and did not record any observations, such as daytime sleepiness, which might indicate impairment due to this condition.  The permanent profile, dated 5 December 2006, noted sleep apnea as a diagnosis but included no duty or mobility restrictions due to this condition.  The MEB NARSUM, dated 4 December 2006, included sleep apnea as a diagnosis, noting that the CI, despite “some sleepiness in the afternoon,” is “well controlled with his CPAP machine.”  The MEB forwarded the sleep apnea condition as failing to meet retention standards.  The PEB, noting no evidence that the diagnosis of sleep apnea significantly interfered with duty performance, found this condition “not unfitting.”

On 23 July 2007, 5 months after separation, the CI was evaluated by the VA for sleep apnea, which found “no daytime hypersomnolence [excessive sleepiness] with CPAP.”  Routinely OSA is not considered unfitting solely on the basis of field and operational impediments to the use of CPAP.  There is no evidence in this case that OSA was associated with any functional impairment that were not corrected by CPAP.  Accordingly, Board members concurred that the PEB’s fitness determination was reasonable; and, after due deliberation, the Board finds insufficient cause to recommend a change in the PEB adjudication of the OSA condition.

The diagnoses of psychological factors affecting medical condition and sleep apnea were both profiled on 4 December 2006.  Both conditions were forwarded to the PEB, which found both conditions “not unfitting” for continued military service.  Both conditions were reviewed and considered by the Board.  There was no performance based evidence from the record that either of these conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either  psychological factors affecting medical condition or for sleep apnea, and so no additional disability ratings are recommended.

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.  In the matter of the angioedema with dyspnea, and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the common migraine headache condition, and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended psychological factors affecting medical condition or for sleep apnea conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130603, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				

SAMR-RB							

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20140013374 (PD201300867)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     

CF: 
(  ) DoD PDBR
(  ) DVA