RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01767
BRANCH OF SERVICE:  Army	BOARD DATE:  20140912
SEPARATION DATE:  20040407

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-4 (Motor Transport Operator) medically separated for recurrent heat injuries.  The condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty or satisfy physical fitness standards.  The CI was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The heat injury condition, characterized as “recurrent history of heat injuries…” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions (gastroesophageal reflux disease (GERD), depression, tobacco dependency and history of benign cyst removal to right breast) to the PEB as medical acceptable.  The Informal PEB (IPEB) adjudicated the heat injury condition as unfitting, rated at 10%.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please Consider All Conditions.”

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:

Service IPEB – Dated 20040315	VA - (1 Wk. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Heat Injuries	7999-7900	10%	Residuals Of Heat Exhaustion	6399-6354	20%	20040412	
Gastroesophageal Reflux Disease	Not Unfitting	Gastroesophageal Reflux Disease	7346	NSC	20040412	
Depression	Not Unfitting	Depression	9434	NSC	20040412	
Tobacco Dependency 	Not Unfitting	No VA Entry	
History of Benign Cyst Removal to Right Breast	Not Unfitting	No VA Entry	
Other x 0 (Not in Scope)	Other x 1	20040412	
Rating:  10%	Combined:  20%	
*Derived from VA Rating Decision (VARD) dated 20040521
ANALYSIS SUMMARY:  

Heat Exhaustion Condition.  A Pre-Deployment Health Assessment dated 29 January 2003 documented that the CI was in good health and deployable.  The CI deployed to Kuwait on 27 April 2003.  He presented to theater clinic on 26 May 2003 and was diagnosed with heat exhaustion.  He developed recurrent episodes of heat intolerance, vomiting, diarrhea, leg and back cramps, dehydration and renal insufficiency.  He was treated with intravenous fluids and activity modification.  He was medically evacuated to CONUS in July 2003.  He was issued permanent P3 profile for recurrent episodes of heat exhaustion and referred to an MEB.  The narrative summary (NARSUM) dated 14 November 2003, noted the CI had a family practice consultation for heat exhaustion.  The evaluation was negative for diabetes and renal problems.  Bilirubin presence was secondary to Lexapro medication and he was asymptomatic regarding heat injuries.  He had five [heat exhaustion] episodes within 2 months.  The physical examination was normal except for several scars.  The diagnosis of recurrent history of heat injuries, specifically heat exhaustion, was continued.

During the VA Compensation and Pension (C&P) examination (performed a month after separation), the CI stated after the fifth episode of heat exhaustion, they ceased.  He reported he was medically discharged because of his heat exhaustion, which has had a negative effect on his daily activities.  He had stopped performing domestic chores, limited his ability to play with his children; became exhausted easily, sweats while standing and had subjective cold sensation easily.  The CI reported that he was employed in a meat packing plant and stated that he was easily fatigued, which was not present prior to his heat stokes episodes.  The physical examination was normal.  The examiner diagnosed heat exhaustion, giving rise to medical discharge.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the heat injury condition as unfitting.  The PEB identified the condition as recurrent heat injury, coded 7999-7900 (analogously to hyperthyroidism) and rated at 10% based on recurrent heat injuries.  The VA identified the condition as residuals of heat exhaustion coded 6399-6354, analogous to chronic fatigue syndrome and rated at 20%.  The Board considered whether there was evidence for a rating higher than 10%.  The Board noted that the PEB coding, analogous to hyperthyroidism, approximated acute heat exhaustion symptomatology and VA coding, analogous to chronic fatigue syndrome, approximated residual symptomatology.  A 20% rating analogous to chronic fatigue syndrome would require nearly constant symptoms, which restrict routine daily activities by less than 25% of the pre-illness level or; which wax and wane, resulting in periods of incapacitation of at least 2, but less than 4 weeks total duration per year.  The Board noted that there were five heat exhaustion episodes in a 60-day period while deployed to Kuwait.  The NARSUM examination (5 months prior to separation), noted that the CI had been asymptomatic for 5 months with restriction of outside activity in the heat.  The IPEB dated 15 March 2004 (a month prior to separation), noted that there were “no apparent residuals found.”  At the VA examination (a month post-separation), the CI reported he had no further episodes of heat exhaustion and was able to resume employment at the meat packing plant, but was not able to perform chores at home and limited the type playing he did with his kids.  He reported cold sensitivity, excessive sweating, and fatigue on “some days” would make him feel like he was ready for bed after work.  The Board determined that the evidence did not meet the criteria of nearly constant symptoms or waxing and waning symptoms resulting in incapacitation for a 20% 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 heat injury condition.  Although coding analogous to chronic fatigue syndrome reflects the functions affected and symptomatology for the residuals of heat exhaustion, specifically easy fatigability with minimal exertion and heat sensitivity, the Board does not recommend a change in the PEB coding of the condition because it would not provide any benefit to the CI.  The Board concluded therefore that this condition could not be recommended for additional disability rating.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that GERD disease, tobacco dependency, a problem with snoring, depression, and a history of benign cyst removal to right breast 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 GERD disease, tobacco dependency, a problem with snoring, depression and a history of benign cyst removal to right breast conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  The CI had an upper endoscopy, which showed Stage II reflux problems.  The NARSUM noted that the GERD was under good control with Prevacid.  Available treatment records document that the CI first presented to MH care in October 2001 after the death of his daughter.  He was treated for depression with Lexapro by a civilian provider.  The military treatment records were silent for depression until a February 2003 request for a pre-deployment refill for Lexapro.  The MEB history and physical examination documented that the depression was controlled by Lexapro.  At the C&P examination, CI reported he developed a clinical depression after the loss of his 3-year-old daughter.  He reported he continued to take his anti-depressant medication and had no functional impairment with regards to his depression.  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 any of the contended conditions 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 heat injury condition and IAW VASRD §4.119a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended GERD, tobacco dependency, snoring problem, depression and benign cyst removal to right breast 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140413, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150009534 (PD201401767)

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			     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA