RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02253
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150324
SEPARATION DATE:  20011214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Storekeeper Second Class) medically separated for functional bowel disease.  The condition could not be adequately rehabilitated to meet the physical requirements of her Rating and she was referred for a Medical Evaluation Board (MEB).  The “functional bowel disease, diarrhea predominant” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded three other conditions for PEB adjudication.  The Informal PEB adjudicated “functional bowel disease, diarrhea predominant” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be Category III, conditions that are not separately unfitting and do not contribute to the unfitting condition.  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 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 2001029	VA* - (~14 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Functional Bowel Disease, Diarrhea Predominant	7319	10%	Irritable Bowel Syndrome (IBS)	7319	30%	20030115	
Major Depressive Disorder (MDD)	Cat III	MDD with Panic Disorder (to Include Claims for Anxiety Attacks and Sleep Disorder	9434	30%	20030205	
Panic Disorder without Agoraphobia	Cat III					
Extensive Surgical History …	Cat III	No VA Placement	
Other x 0 (Not In Scope)	Other x 10	
RATING:  10%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20030321(most proximate to date of separation [DOS]).
ANALYSIS SUMMARY:

Functional Bowel Disease.  The abdominal history for the CI dates to the age 15 when she had surgery for a ruptured appendix (this spills infected contents into the abdomen and can lead to adhesions later).  Per report by the CI, she underwent an operation for lysis of adhesions in the abdomen in 1988.  The records for this are not in evidence, but a discharge examination in 1987 noted that this had been in the spring of 1987.  She had chronic pelvic pain and underwent diagnostic laparoscopy (an examination of the abdomen through a fiber optic instrument, a laparoscope) on 23 March 1993.  This showed adhesions “to an old right paramedian incision on the abdomen,” the expected site of the previous appendectomy.  A gastrointestinal (GI) evaluation on 5 January 1994 noted that this had not been beneficial.  The possibility of an underlying inflammatory bowel disease, a more serious diagnosis than IBS, was raised as a possibility.  She had another surgery on 21 March 1994 for lysis of adhesions as well as removal of the right tube and ovary.  The records then fall silent until a re-enlistment history form dated 9 September 1999.  She noted the appendectomy and surgery in 1993, but current problems were not documented.  The CI then began counseling in mental health (MH) at some point after enlistment as documented in a 21 December 2000 note by the shipboard medical technician.  After this, she began to have recurrent right lower quadrant (RLQ) abdominal pain.  A radiological study for kidney stones was negative although suspected clinically.  A CT scan on 10 April 2001 showed free fluid in the pelvis.  She reported loose stool and vomiting.  A colonoscopy on 6 June 2001 was thought to be consistent with the diagnosis of IBS.  A primary care note dated 18 June 2001 noted that the CI wished to be administratively separated and that her ship was scheduled to be under way that day.  The clinician raised the concern of malingering to avoid military duty and recommended PEB consideration.  An ultrasound on 3 July 2001 was negative other than an absent right ovary.  She was evaluated on 23 July 2001 and reported sporadic unanticipated diarrhea and fecal urgency.  She reported stress fecal incontinence if she had no access to bathrooms.  Previously, her chief complaint had been chronic pelvic pain although loose stools up to 3 times a day had been noted.  The narrative summary was dated 25 July 2001.  It noted that the CI had been seen in GI on 3 May 2001 for a 2-to-3 month history of nausea, vomiting, and diarrhea.  She reported 3-to-4 foul smelling diarrhea episodes a day without blood.  She had significant abdominal pain and fatigue.  Her weight varied, but returned to baseline.  She endorsed a previous episode in 1994 which had resolved after lysis of her adhesions.  On examination, the CI was noted to be well nourished and in no acute distress.  The 67 inch CI weighed 135 pounds.  It recorded that the stress fecal incontinence reported to GI 2 days earlier occurred when she needed to stand watch and when on general quarters.  The CI was noted to have requested a Central PEB at that visit 2 days earlier.

The MH addendum for the PEB was dated 14 August 2001.  The CI had reported a significant history for anxiety and depression dating back to November 2000 related to her ongoing divorce and IBS symptoms.  She reported crying spells, increased sleep, loss of appetite, loss of pleasure, and depressed mood virtually every day.  She also reported recurrent panic attacks manifested by increased heart rate, nausea, and marked anxiety.  She had a prior history of anxiety 10 years earlier associated with family issues, but denied depression prior to November 2000.  She reported that she had separated from the USMC in 1987 due to the threat of divorce by her husband if she did not.  She reported repeated problems in her 18-year marriage and had filed for divorce.  As a consequence, she had had no contact with her children; this was a source of major stress for her.  On examination, she was depressed and anxious with congruent and tearful affect.  She reported difficulty with her duties including breaking into tears and having difficulty waking up due to her need for excessive sleep.  She also reported difficulty with concentration.  She reported that she had to leave work for a period of time until she recovered sufficiently to return to work.  She was diagnosed with MDD and panic disorder with agoraphobia.  It was noted that these symptoms had not responded to therapy and precluded her performing her duties.
On the medical assessment dated 17 August 2001, the CI reported pain in the right lower abdomen and that she could not be “a long way from a bathroom because the IBS hits w/o indication.”  An emergency room evaluation on 12 August 2001 noted RLQ pain and nausea.  At a gynecology evaluation on 30 August 2001, a history of a kidney stone was noted and the chronic pelvic pain; no GI symptoms were recorded.  Her pain was not thought to be of a gynecological origin.  A pain management evaluation on 20 September 2001 noted RLQ tenderness and chronic pelvic pain.  No GI symptoms were recorded although the diagnosis of IBS was noted.  She weighed 125 pounds.  An evaluation by general surgery on 25 September 2001, less than 3 months prior to separation, recorded that she had 3 loose stools per day, but incontinence was not documented.  Her weight was 130 pounds.

At the VA Compensation and Pension (C&P) examination performed 14 months after separation, the CI reported continued GI distress and bowel movements after meals.  She reported that for the previous 4 to 5 months, she had difficulty getting to the bathroom around 3 times a month.  She also reported 5 bowel movements a day which could be explosive and some were loosely formed.  She had been working as a security guard for the past 5 months.  She was divorced and living alone.  She reported drinking 7 cups of coffee and 20 ounces of caffeinated soda a day.  The Board noted that caffeine can aggravate symptoms in some individuals.  On examination, she was 67 inches and 131 pounds, essentially unchanged from the MEB examination.  She appeared well nourished.  There was mild diffuse widespread tenderness on deep palpation of the abdomen (this can be normal), but the examination was otherwise unremarkable.  Her mental status examination was unremarkable other than being drowsy with a flat affect.  She reported that she had worked 56 hours the previous 4 days.  Her laboratory values were normal.  Three weeks after the general C&P examination, on 5 February 2003, the CI was evaluated in MH.  She was followed in the VA MH clinic.  Broken appointments were noted and she had only been seen once on 15 July 2002, but the CI stated that she was compliant with medications.  At the time of that visit, she was unemployed, had recently filed for bankruptcy, and was in a long distance relationship, but did not think that it would work out.  Her depression was worsened by the fact that her children would not speak with her.  It noted that her depression and anxiety began in the context of her divorce and estrangement from her children.  She was working as a security guard and stated that it was stressful and had anxiety attacks as a consequence.  She socialized with her family and was looking on-line for a new boyfriend.  Her depression and anxiety did not appear to interfere very significantly with her ability to be employed and to function, but she was assigned a Global Assessment of Function of 60 to indicate significant impairment.

The Board directed its attention to its rating recommendation based on the above evidence.  It noted that the CI reported loose stools at most appointments, but incontinence only at the MEB GI evaluation.  Her weight was relatively stable at 130 pounds +/- 5 pounds.  She appeared well nourished on examination and her laboratory values were normal.  Her primary duty limitation prior to separation appeared to be duties in which she could not leave her station when she felt urgency.  The VA C&P examiner recorded that she was able to work at least 14 hours continuously though she had worked 56 hours over a 4-day period.  The PEB adjudicated the functional bowel disease condition as unfitting and rated it at 10% using the code 7319 (irritable bowel syndrome).  The VA rated the CI at 30% using the same code, relying on the history given at the VA C&P examination.  The criterion for a 30% rating is “severe; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress.”  The criterion for a 10% rating is “moderate; frequent episodes of bowel disturbance with abdominal distress.”  The Board determined that the objective evidence does not demonstrate an impact from the IBS on nutritional status.  Her subjective finds vary, but typically she reported loose stools 3 times a day.  The description for a severe condition was also thought to be inconsistent with were her reported ability to work 56 hours over a 4 day period.  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 functional bowel disease condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that MDD, panic disorder without agoraphobia and extensive surgical history in the past with adhesive disease were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  These conditions were all forwarded as additional diagnoses by the MEB.  None were specifically addressed by the commander.  Although seen for pelvic pain and MH issues, she was not referred into the PEB process until she reported that she could not stand watch or be on general quarters due to her stress incontinence.  All were reviewed and considered by the Board.  While the evidence from the record indicates that these conditions interfered with duty performance, the record does not support a finding that any prevented her from performing her duties.  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.  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 functional bowel disease condition and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended major depressive disorder, panic disorder without agoraphobia, and extensive surgical history in the past with adhesive disease 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 20140521, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd XX Sep 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC