RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00673
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060129 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Chemical Equipment Repairer) medically separated for a pulmonary condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic obstructive pulmonary disease secondary to asthma” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic obstructive pulmonary disease felt to be secondary to asthma” as unfitting, rated 10%.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The applicant claims she did not have asthma before joining the military.  Her complete submission is at Exhibit A. 

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

IPEB – Dated 20051118	VA* - Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Obstructive Pulmonary… 	6604	10%	Chronic Obstructive Pulmonary…	6604	10%	STR	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0 (Not in Scope)	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20061024 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY: 

Pulmonary Condition.  The service treatment record (STR) documented that the CI had dyspnea (shortness of breath) and chest pain during exercise beginning in Advanced Individual Training (AIT).  She was initially diagnosed with bronchitis and treated with an oral antibiotic.  The CI had persistent symptoms of dyspnea with exertion and presented to sick call.  In the 31 July 2004 troop medical clinic encounter, the CI complained of 2 weeks of shortness of breath with running, and a morning stuffy nose.  It documented that she was a nonsmoker with a history of pollen allergies.  The CI reported 10 days of congestion without a cough or purulent (containing pus) nasal discharge.  She was diagnoses with allergic rhinitis (hay fever) and prescribed a nasal corticosteroid (Flonase [fluticasone]) spray.  On 14 December 2004, the CI presented to the clinic complaining of dyspnea with heavy exertion for 4 months, and associated chest tightness with inspiration for 2 weeks.  The assessment listed dyspnea, possible asthma, and a plan to start inhalational bronchodilator (Proventil [albuterol]) therapy and a mast cell stabilizer (Intal [cromolyn sodium]).  The 4 January 2005 pulmonary function tests (PFTs) showed a forced expiratory volume in 1 second (FEV-1) of 73% and a ratio of forced expiratory volume in one second to forced vital capacity (FEV-1/FVC) of 66%.  The 28 March 2005 pulmonary evaluation recorded that the CI had dyspnea and chest pain during exercise only and did not have nocturnal symptoms consistent with asthma.  The PFTs showed an FEV-1 of 75% and an FEV-1/FVC of 79%.  The pulmonologist opined that “she may have mild asthma at best, but no true bronchodilator response with objective evidence of reversibility.”  The pulmonologist recommended spirometry (measuring of breath) at baseline and after 1, 5, 10, and 15 minutes of exercise to assess for exercise induced asthma.  Regarding her chest discomfort with exercise, a cardiology evaluation was recommended to see if there was a cardiac etiology to her chest tightness.  The 4 May 2005 PFTs showed a pre-bronchodilator FEV-1 of 69% and FEV-1/FVC of 61% and a post-bronchodilator FEV-1 of 69% and FEV-1/FVC of 61%.  The physician interpretation was obstructive airway disease present with no response to bronchodilator.  A 6 May 2005 chest X-ray showed nonspecific findings (breast shadow vs. infiltrate) in the left lung base.  A 10 May 2005 electrocardiogram was interpreted as a normal variant.  On 10 May 2005, the CI clinically performed well on an exercise stress test (EST) for atypical chest pain.  It was interpreted as an equivocal stress test because the machine failed to record all blood pressure values.  The 26 May 2005 transthoracic echocardiogram (heart ultrasound) was interpreted as normal.  The 12 August 2005 PFTs showed a pre-bronchodilator FEV-1 of 66% and FEV-1/FVC of 58% and a post-bronchodilator FEV-1 of 71% and FEV-1/FVC of 63%.  Post-exercise FEV-1/FVC values were:  1 minute of 62%; 5 minutes of 59%; 10 minutes of 59%; and 15 minutes of 59%.  The physician interpretation was mild obstruction present at baseline, no significant changes with exercise, possible small airway disease present, and no response to bronchodilator.  A 30 August 2005 chest X-ray showed a possible obstruction of a major airway (left main bronchus).  A 30 August 2005 CT of the chest and lower extremities showed no evidence for pulmonary embolism (obstruction of a lung artery).  The 6 September 2005 PFTs showed a pre-bronchodilator FEV-1 of 76% and FEV-1/FVC of 60%.  The 6 September 2005 pulmonary encounter listed the CI taking a nasal corticosteroid (Nasacort [triamcinolone]) and an inhaled anticholinergic agent (Atrovent [ipratropium]).  The pulmonologist started an oral corticosteroid (Prednisone 40mg) for 14 days and planned to repeat her spirometry.  He opined if she showed significant improvement in her FEV-1 after 14 days of steroids, she had atypical asthma.  If there is no improvement, he would look for some other lung process.  The 7 September 2005 pulmonary encounter recorded PFTs that showed a pre-bronchodilator FEV-1 of 71% and FEV-1/FVC of 64%.  The pulmonologist reported that all of her tests to date had been normal and could not explain why she had a fixed mild to moderate obstruction on spirometry.  The 20 September 2005 pulmonary encounter recorded PFTs that showed a pre-bronchodilator FEV-1 of 70% and FEV-1/FVC of 64%.  The pulmonologist reported a history of dyspnea on exertion since July of 2004 and that all of her tests (echocardiogram, EST, exercise spirometry) to date had been normal.  The CI had completed 2 weeks of an oral corticosteroid (Prednisone) with no change in the FEV-1.  The pulmonologist reported the CI had mild obstructive disease and opined this could be from long standing, untreated asthma, and now had a fixed obstruction from her asthma.  The 20 September 2005 PFTs showed a pre-bronchodilator FEV-1 of 72% and FEV-1/FVC of 57% and a post-bronchodilator FEV-1 of 73% and FEV-1/FVC of 59%.  The physician interpretation was mild obstruction present with no bronchodilator response.  The narrative summary (NARSUM), 3 months before separation, recounted the history of dyspnea, and chest pain, with exertion, and interventions to date.  The lung exam showed normal breath sounds with no expiratory or inspiratory wheezing.  The diagnosis listed chronic obstructive pulmonary disease (COPD) secondary to asthma.

The Board directed its attention to its rating recommendation based on the above evidence.  The Informal PEB, 2 months before separation, rated the COPD at 10% (VA code 6604; chronic obstructive pulmonary disease) citing PFTs and an FEV-1 of 76%.  The VA rating decision (VARD), 10 months after separation, rated the COPD at 10% (6604) citing PFTs, an FEV-1 of 76%, and failure to report to a 9 August 2006 compensation and pension (C&P) exam.  Review of the serial FEV-1 values showed 7 (5 pre-, 2 post-bronchodilator) of 14 were consistent with the 10% rating (71 to 80%) and 7 (3 pre-, 4 post-bronchodilator) of 14 were consistent with the 30% rating (56 to 70%).  Serial FEV-1/FVC values showed only one (1 pre-bronchodilator) of 12 was consistent with the 10% rating (71 to 80%) and 11 (4 pre-, 3 post-bronchodilator, 4 post-exercise) of 12 were consistent with the 30% rating (56 to 70%).  While the PFTs showed FEV-1 values intermittently consistent with a 10% rating, the majority of FEV-1/FVC values were consistent with a 30% rating.  The PFTs never approached the 50% rating (FEV-1 or FEV-1/FVC of 40-55%).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the pulmonary condition (6604).

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 pulmonary condition, the Board unanimously recommends a disability rating of 30%, coded 6604 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Obstructive Pulmonary Disease 	6604	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140201 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 XXXXXXXXXXXXXXXXXXXXXXXXXX, AR20160003063 (PD201400673)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

			      
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA