RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 CASE:  PD1300892	
BRANCH OF SERVICE:  Army	 BOARD DATE:  20140103
SEPARATION DATE:  20060426		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (92F10/Petroleum Supply Specialist) medically separated for heat exhaustion.  The symptoms first occurred in 2004 and were exacerbated during a deployment to Iraq in 2005.  The CI was returned to home station early and the condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The condition, characterized as “heat exhaustion” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions as medically acceptable (see rating chart below) for PEB adjudication.  The PEB adjudicated “heat exhaustion, recurrent, recovered” as unfitting, rated at 0%.  The remaining conditions were determined to be not unfitting.  The CI made no appeals, and was medically separated.

CI CONTENTION:  “Heat intolerance due to heat stroke with kidney failure.  Left shoulder injury during basic training and lower back injury.  PTSD and Migraines.  However, I was told only the heat intolerance was used in my medical broad (Heat intolerance ARF/Heat Stroke).” 

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 IAW a Secretary of Defense directive for 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 heat exhaustion is addressed below, along with the contended post-traumatic stress disorder (PTSD).  The requested migraine and back conditions, which were determined to be not unfitting by the PEB, are addressed as well.  The requested shoulder condition was not identified by the PEB, and thus is not within the DoDI 6040.44 defined purview of the Board.

RATING COMPARISON:

Service IPEB – Dated 20060320	VA - (12 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Heat Exhaustion	7999-7900	0%	Isolated Episode of Heath Intolerance	7999-7900	NSC*	20070511	
Low Back Pain with L5 Mild Radiculopathy	Not Unfitting	Lumbar Strain	5237	10%	20070511	
Migraine Headaches	Not Unfitting	Migraines	8100	0%	20070511	
Antisocial Personality Disorder	Not Unfitting	PTSD and Antisocial Personality Disorder	9411	NSC**	20070529	
No Additional MEB/PEB Entries	Other x 2	20070529	
Rating:  0%	Combined Rating:  30%	
Derived from VA Rating Decision (VARD) dated 20070710 (most proximate to date of separation [DOS]).
*Changed to 30% effective at DOS (VARD dated 20120817 - DRO).
**Changed to 30% then 50% effective 20100608 (VARDs dated 20120125 and 20120817).

ANALYSIS SUMMARY:

Heat Exhaustion Condition.  The narrative summary (NARSUM) dated 2 March 2006 notes the CI had four episodes of heat intolerance while Iraq in July 2005 with episodes of loss of consciousness.  He was treated in theater with fluid resuscitation and medically evacuated from theater due to increased heat intolerance.  Treatment and hospitalization for heat exhaustion and acute renal failure led to normalization of renal function measures.  At the NARSUM exam, the CI stated “anytime his activity increases, his body starts getting hot, sweaty, he gets headaches, and the weather makes his symptoms worse.  Due to this, he is unable to do his MOS which includes working on the outside, lifting hoses, getting in and out of vehicles which increases his activity and the heat of his body.”  MEB Physical exam was unremarkable; noting normal skin.  The diagnosis was heat exhaustion.

The commander’s statement, dated 7 June 2006, indicated interference of performance due to “frequent Black Outs, Chemical Embalance, Severe Sweating, and Muscle Cramps. … Since his supervisors can never be sure when he will faint, his license has been revoked for the safety of himself and other drivers on the road ways.”  Treatment notes in the year prior to the NARSUM indicated diagnoses of heat exhaustion, heat stroke, inappropriate ADH syndrome, myalgias and myositis.  A treatment note on 27 July 2005 for ruling out a metabolic disorder was 9 months prior to the NARSUM.  The CI still had abnormal labs, symptoms of excessive sweating of hands and armpits 15-30 minutes after eating and muscle weakness.  Exam indicated “Skin: - Moisture was abnormal – Hyperhidrosis of skin – Showed hyperhidrosis generally.”

At the VA Compensation and Pension (C&P) exam performed 12 months after separation, the CI reported 8 weeks of hospitalization for his heat multiple injuries with rhabdomyolysis (muscle breakdown).  Current symptoms included “sweats without exertion and night sweats.”  Skin exam stated “No unusual findings.”  The examiner's clinical impression was isolated episode of heat intolerance, associated with weight loss, dehydration, rhabdomyolisis and acute renal failure, resolved without residual or sequelae.  VA exams in 2009 and 2010 did not note abnormal skin findings.  A C&P exam on 18 January 2011, over 4 years after separation, indicated the CI had severe hyperhidrosis at least as likely as not related to his residuals of heat stroke on active duty.  The CI complained of profuse sweating despite the use of clinical strength antiperspirant, the need to take two to three showers a day, inability to exercise vigorously or exercise at all in warm climates above 60 degrees due to severe sweating and inability to keep up with his fluid loss by oral replacement.  The CI “worked as a corrections officer in Arizona for 1 year after (an injury) working in a door shop that lasted for 2 months in 2007.  He last worked in March of 2008 and then had to move to the Northwest because he could not tolerate the warm weather in Arizona.”  Exam noted “He is currently having rivulets of perspiration from each axilla and from his groin area while seated on the table calmly undergoing a complete physical examination.”

The Board directs attention to its rating recommendation based on the above evidence.  The PEB and initial VA ratings all used coding of 7999-7900, analogous to hyperthyroidism for heat exhaustion or heat stroke without residuals.  The PEB rating of 0% IAW VASRD §4.31 was commensurate with the early VA not service-connected (NSC) rating for no permanent residual or chronic disability.  The VA change to a 30% rating coded 7832 (hyperhidrosis) was based on exam and medical opinion over 4 years remote from separation.  The CI was employed for at least 14 months after separation and there appeared to be post-separation worsening of hyperhidrosis.

The Board adjudged that the CI’s condition at the time of separation did not support hyperhidrosis to the level that he was unable to handle papers or tools because of moisture.  Given alternate coding under 7999-7832 (hyperhidrosis) would warrant only a 0% rating at the time of separation, the Board does not recommend changing the disability code.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 0% for the heat exhaustion condition was appropriately recommended in this case.

Contended (Low Back Pain with L5 Mild Radiculopathy; Migraine Headaches) Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the low back pain (LBP) with L5 mild radiculopathy and migraine headache (HA) conditions were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The LBP and HA conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any 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 the contended LBP and HA conditions and so no additional disability ratings are recommended.

Contended Mental Health Condition (Antisocial Personality Disorder; contended - PTSD):  The Board considered the MH condition regarding appropriateness of changes in diagnoses and fitness determination.  The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the fitness determinations based on a preponderance of evidence.  The serial physical profile report, dated 10 March 2006, initiating the MEB did not list an MH condition and indicated an S1 profile, no restrictions from an MH perspective.  The commander’s statement indicated interference of performance due to “frequent Black Outs” with his license having been revoked for possible fainting.

The NARSUM did not indicate an MH diagnosis; however, the 7 March 2006 memorandum from the Behavioral Health Clinic indicated a diagnosis of antisocial personality disorder.  The MEB forward an MH diagnosis of antisocial personality disorder as meeting retention standards for PEB consideration and the PEB adjudged the personality disorder as not unfitting.  The psychiatrist’s memo accompanying the NARSUM indicated initial MH clinic encounter in February 2005 (prior to deployment to Iraq in April 2005) with complaints of syncopal episodes and dissatisfaction with the Army.  The CI reported previous counseling as a child for his physical, sexual and verbal abuse, and was raised in a dysfunctional family.  Upon return from OIF 3 for his non-MH condition (heat exhaustion) the CI resumed MH services.  “He reported past intrusive memories of his physical and sexual abuse.  Also he reported past suicide attempts.  He has been hospitalized twice on the inpatient ward.  The first time was early February after he has assaulted his cat and the second time was after threatening the therapist in late February.  He shows limited insight and expresses little to no remorse for his behaviors.”  The diagnosis was antisocial personality disorder, meeting retention standards and the psychiatrist indicated “Mental health has recommended that the service member undergo a chapter 5-13 for his behavior.”

There was no diagnosis of PTSD prior to the CI’s date of separation; however, MH treatment records prior to separation were scant.  The VA C&P exam, dated 29 March 2007, 13 months after separation, made the diagnosis of PTSD based on childhood stressful events in addition to a diagnosis of antisocial personality disorder with a global assessment of functioning(GAF) of 55 (in the range of moderate symptoms).  The CI was employed as a corrections officer, divorced and living with his pregnant girlfriend.  The VA rating of this exam was NSC.  Later VA MH exams and records indicated “his lack of reliability has been noted by examiners in the past.”  The 6 December 2011 VA C&P exam was to obtain a medical opinion.  The CI was described as a forthright historian and described, “intrusive thoughts and recollections regarding traumatic events, which occurred in Iraq, as well as childhood, are interactive.”  Diagnoses were PTSD secondary to childhood traumas and military traumas, depressive disorder not otherwise specified, secondary to PTSD and migraine headaches.  The examiner opined that the symptoms of PTSD “meeting the DSM-IV criteria secondary equally and inseparably to childhood physical and sexual trauma, as well as traumas experienced while on active duty in the U.S. Army in Iraq.”  The GAF was 55-60 and described as moderated difficulties in social and occupational interaction.

The Board determined that no MH diagnoses were referred or changed to the applicant’s possible disadvantage in the disability evaluation.  The applicant therefore did not meet the inclusion criteria in the Terms of Reference of the Mental Health Diagnosis Review Project.  The Board next considered if MH symptoms at the time of separation rose to the level of being unfitting.  There was clear duty impairment from behavior with psychiatric hospitalizations and unreliability as noted in the psychiatric memo and the commander’s statement.  However, IAW DoDI 1332.38, E5.1, personality disorders do not constitute a physical disability and are not compensable.  The Board then considered if a compensable MH diagnosis was warranted at the time of separation.  The Board determined that there was not a preponderance of the evidence sufficient to recommend a change in MH diagnosis.

Ideally the PEB adjudication should be reworded to state that MEB diagnosis #4 (antisocial personality disorder) was not a compensable condition rather than being “not unfitting, not rated.”  However, this administrative change would provide no advantage to the CI.  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 MH diagnosis and not rated determination for the contended MH condition, therefore no additional disability rating can be 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the heat exhaustion condition, the Board unanimously agrees that it cannot be recommended for additional disability rating.  In the matter of the contended LBP and HA conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.
In the matter of the contended MH condition, the Board unanimously recommends no change from the PEB determinations as not ratable.  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, as follows:

UNFITTING CONDITION	VASRD CODE	RATING	
Heat Exhaustion 	7999-7900	0% 	
Low Back Pain with L5 Mild Radiculopathy	Not Unfitting	
Migraine Headaches	Not Unfitting	
Antisocial Personality Disorder	Not Unfitting	
RATING	0%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130611, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

	 

SFMR-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 XXXXXXXXXXXXXXXXXXXXXXXX, AR20140003438 (PD201300892)

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