RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-01518
BRANCH OF SERVICE:  MARINE CORPS                                                  SEPARATION DATE:  20060131

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Corrections Specialist, medically separated for “persistent hypertension” with a disability rating of 20%.

CI CONTENTION:  The condition continues to worsen and negatively impact his daily activities.  The CI’s complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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:  

SERVICE PEB - 20051118	VARD -20070326	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Persistent Hypertension	7101	20%	Hypertension	7101	10%	20070112	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY: 

Hypertension.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), elevated blood pressure (BP) was noted approximately 7 years prior to referral for MEB.  Normal systolic BP (maximum arterial pressure during heart ventricular contraction) is less than 120 mmHg, and normal diastolic blood pressure (minimum arterial pressure during heart ventricular relaxation) is less than 80 mmHg.  An electrocardiogram (EKG) performed for uncontrolled hypertension (HTN) suggested left ventricular hypertrophy (left heart enlargement).  Diagnostic imaging (X-ray) of the chest showed mild cardiomegaly (heart enlargement).  Diagnostic imaging (ultrasound) of the kidneys was unremarkable.  On 5 October 2003, the CI was admitted to the intensive care unit (ICU) for uncontrolled HTN with a right arm BP of 238/136 and left arm BP of 208/140 mmHg.  
The impression listed resolved hypertensive emergency and uncontrolled HTN with evidence of end organ damage (EKG changes and slight cardiac enzyme elevation).  An echocardiogram (heart ultrasound) was unremarkable.  An ophthalmology assessment listed systemic HTN with a normal eye examination.  On 26 October 2004, the CI was readmitted to the ICU for hypertensive emergency with papilledema (retinal optic nerve swelling) concerning for malignant HTN.  Serial encounters by internal medicine did not reveal a secondary cause for the presumed primary (essential) HTN.  Antihypertensive medications were started, discontinued, and dose titrated without significant improvement.  The 5 October 2005 NARSUM, 4 months before separation, recounted the history of interventions and improved, but incompletely controlled BP.  The baseline minor renal insufficiency, noted at the first admission, had remained stable.  Imaging and lab studies revealed no secondary causes for his HTN or renal insufficiency.  Active medications were 4 antihypertensive agents.  The physical examination documented a BP of 154/100 mmHg, a normal eye (funduscopic) examination, and no edema.  The cardiac examination revealed normal heart sounds, a regular rhythm, and no murmurs, gallops or rubs.  The diagnosis listed persistent HTN.  The CI presented to the emergency room (ER), 8 months after separation, complaining of 2 weeks of shortness of breath, labored respirations (worse with exertion), productive cough with clear sputum, and left-sided chest pain.  A chest X-ray showed cardiomegaly with pulmonary edema (fluid in lungs).  The CI was admitted to the hospital where he reported he “was out of his medications for a couple of weeks but has been back on them for at least the last two weeks.”  His medications included three antihypertensive medications.  The admission diagnoses were acute congestive heart failure (CHF), history of cardiomyopathy (heart muscle [myocardium] disease), severe HTN, and renal insufficiency.  An echocardiogram showed severe dilatation of left ventricular cavity, severe left ventricular wall global hypokinesia (decreased motion), markedly depressed left ventricular systolic function with an ejection fraction (percent of blood ejected with heart contraction) of about 30% (normal 55-70%), and mild concentric left ventricular hypertrophy (wall thickening).  A cardiac catheterization (catheter introduced into heart for imaging, diagnosis, and interventions) showed no coronary artery disease, severe dilatation of left ventricular cavity, markedly depressed left ventricular systolic function with an ejection fraction (EF) of about 14%, and dilated cardiomyopathy, most likely hypertensive heart disease.  A cardiology consultation reported the CI started getting short of breath earlier this year, and was off his medications until October.  The active medications were the three pre-hospitalization anti-hypertensive agents at modified doses, and he now felt much better.  The BP was 148/94mmHg and the impression listed non-ischemic (heart muscle inadequate blood supply) dilated cardiomyopathy, likely secondary to HTN.  The HTN was not controlled and an additional antihypertensive agent and antianginal agent were started.  A cardiology follow-up listed a BP of 136/90mmHg and the impression listed labile BP, still poorly controlled.  The 12 January 2007 VA Compensation and Pension (C&P) examination recounted the history and interventions.  The CI complained of moderate shortness of breath on exertion, fatigue, weakness, angina (chest pain from reduced blood flow to heart muscle), and weight gain.  He reported a history of HTN and CHF but denied and history of heart trauma, cardiac neoplasm (mass), myocardial infarction, rheumatic heart disease, endocarditis (infection of endocardial surface or valve), or pericarditis (inflammation of fibroelastic sac around heart).  Active medications were 5 antihypertensive agents and an antianginal agent.  The physical examination recorded serial BPs of 198/130, 196/124, and 202/142 mmHg.  The cardiac examination revealed normal heart sounds, a regular rhythm, and no murmur, click, or pericardial friction rub.  The examiner recounted the findings of the abnormal EKG and the reduced EF and cardiomegaly by echocardiogram.  The chest X-ray showed cardiomegaly without pulmonary edema.  The diagnoses listed essential HTN, evidence of hypertensive heart disease (CHF), and dilated cardiomyopathy.  A subsequent cardiology encounter listed a BP of 159/100mmHg and the impression listed HTN, still poorly controlled.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 7101 code (hypertensive vascular disease) citing persistent HTN.  The VA assigned a 10% rating under the 7101 code (hypertensive vascular disease) based on the VA C&P examination 11 months before after separation,  citing uncontrolled HTN, placed on medication to manage BP, STR BPs of 166/102, 187/117, 177/108, 238/136, and 208/140, and current BPs of 198/130, 196/124, and 202/142.  The majority of the proximate BPs (NARSUM, C&P and cardiology) were consistent with the 40% rating (diastolic pressure predominantly 120 or more).  The higher 60% rating would require diastolic pressure predominantly 130 or more.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 40% for the HTN condition.  

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 HTN condition, the Board unanimously recommends a disability rating of 40%, coded 7101 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  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 his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Persistent Hypertension	7100	40%	
RATING	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131029, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX  
	(c) PDBR ltr dtd 21 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX 
	(e) PDBR ltr dtd 17 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 27 May 16 ICO XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 16 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (g) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:
     
     a. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXXXXXXX: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 20 percent) effective date of discharge. 

     e. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

		XXXXXXXXXXXXXXXXXXXX
		Assistant General Counsel
		(Manpower & Reserve Affairs)