RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02271
BRANCH OF SERVICE:  Army	BOARD DATE:  20150730
SEPARATION DATE:  20041110

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E-5 (Heavy Construction Equipment Operator) medically separated for Crohn’s disease.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent P3E2 profile and referred for a Medical Evaluation Board (MEB).  “Crohn’s disease” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded seven other conditions (see rating chart below) for PEB adjudication.  The Informal PEB adjudicated “Crohn’s disease” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting and therefore not ratable.  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:

Service IPEB – Dated 20041004	VA - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Crohn’s Disease	7399-7323	10%	Crohn’s Colitis	7399-7323	30%	20050118	
Depression	Not Unfitting	Major Depression	9434	50%	20050603	
Migraine Headaches	Not Unfitting	Migraines with Photophobia	8100	30%	20050118	
Pes Planus	Not Unfitting	Bilateral Pes Planus	5276	10%	20000617	
Temporomandibular Joint Dysfunction	Not Unfitting	Temporo-Mandibular Joint Condition	9999-9905	NSC	19991029	
Irregular Menstrual Periods	Not Unfitting	No VA Entry	
Vision Defect	Not Unfitting	No VA Entry	
Acne	Not Unfitting	No VA Entry	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 5	
Rating:  10%	Combined Rating:  90%	
Derived from VA Rating Decision (VARD) dated 20051026 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Crohn’s Disease.  The service treatment record (STR) detailed that the CI was hospitalized in November 2003 (14 months prior to separation) for a 1-week history of bloody diarrhea with some mucous and 20 stools a day.  Colonoscopy revealed patchy, irregular ulcerations, consistent with Crohn’s colitis.  The biopsy results were not diagnostic for, but were consistent with, Crohn’s disease.  She had some improvement with antibiotics (for coincidental Clostridium difficile colitis), steroids, and olsalazine (a salicylate, an anti-inflammatory drug used for Crohn’s disease); but was reevaluated in December 2003 due to persistent symptoms.  Repeat sigmoidoscopy and a small bowel follow-through X-ray showed “patchy colitis,” although biopsy results showed no evidence of Crohn’s disease.  The diagnosis was Crohn’s disease, and prednisone (an oral steroid) was added to her medical regimen.  In March 2004, the CI complained of on-and-off diarrhea for 6 months, dizziness, and stomach cramps (which were “likely” related to Crohn’s disease).  In June 2004 (7 months after hospitalization and 5 months prior to separation), the CI complained of four bowel movements per day, rectal bleeding, and anal pain; the gastroenterologist thought that the “mild increase” in symptoms were probably due to hemorrhoids and did not change the treatment regimen (an oral anti-inflammatory drug and steroids by mouth and enema).

The narrative summary (NARSUM) was completed on 19 August 2004, 9 months after hospitalization and 3 months prior to separation.  The examiner stated that the prednisone had been gradually tapered and discontinued, and that the CI was started on azathioprine (an immunosuppressive antimetabolite) for its steroid-sparing effects, but “still had incomplete control of her symptoms.”  She continued to have chronic abdominal pain and chronic loose stools that occurred approximately twice a day, occasionally with blood.  On examination there was generalized tenderness in the abdominal area, maximal over the right lower quadrant.  The examiner concluded that the Crohn’s disease was “not well controlled.”

At a VA Compensation and Pension (C&P) exam performed on 18 January 2005 (2 months after separation), the CI reported that she was on azathioprine and mesalamine (very similar to olsalazine) and a restricted diet.  She said that she was still having constant abdominal pain and dyspareunia (difficult or painful sexual intercourse) associated with the Crohn’s disease.  She had been diagnosed with borderline anemia and was taking iron supplements.  She still had blood in her stools about once a month.  On examination, there was mild tenderness about the umbilicus and in the lower quadrants bilaterally.

The CI was hospitalized (in a VA hospital) 2 weeks later (on 31 January 2005) with increased rectal bleeding, initially thought to be a possible flare of her Crohn’s disease.  Colonoscopy was normal throughout the colon and terminal ileum with no evidence of inflammation or colitis.  The provider stated, “In retrospect, her ‘bloody diarrhea’ may have been due to her hemorrhoids.”  Her medications for Crohn’s disease were azathioprine and mesalamine, and they were continued without any changes (the doctor mentioned specifically that no old records were available, and that the medications would be continued until the records could be obtained).

The CI had a second VA C&P examination on 5 July 2005 (8 months after separation) and complained of lower abdominal pain, more than two-thirds of the year.  The examiner stated, “For her intestinal condition, she has nausea and vomiting, chronic constipation, diarrhea and alternating diarrhea and constipation.  Specifically, the symptoms occur every day.  The symptoms described occur constantly.  The current treatment is Imuran (azathioprine) and Asacol and Cort enema [steroid enema].  There is no functional impairment resulting from the above condition.”  On examination there was tenderness in the suprapubic area.

At a VA appointment on 19 September 2005 (10 months after separation), the gastroenterologist stated that the CI had Crohn’s “flare-ups” every month, which initially seemed to be associated with menstrual periods.  Since her hospitalization in January 2005, she reported intermittent “flares” characterized by episodes of abdominal cramps with mild nausea (no vomiting) as often as every 3 to 4 days.  The physician concluded that the CI “has had negative w/u [work-up] and most likely has never had Crohns disease and had self-limited colitis at that time.”  Her medications were discontinued and the diagnosis was removed from her problem list.  She was also given a trial of an anti-spasmodic medication, “in case this is spasms.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition analogously with code 7323 (ulcerative colitis) at 10% (moderate), citing the continued abdominal pain and approximately two stools per day.  The VARD was dated 26 October 2005 (after the second C&P exam), and the condition was rated analogously with code 7323 at 30% (moderately severe), citing daily symptoms of abdominal distress with alternating diarrhea and constipation.  Although the CI had some persistent gastrointestinal symptoms, the available records did not indicate that she had “frequent” exacerbations of her Crohn’s disease (e.g., increased symptoms in  June 2004 was probably hemorrhoids, and what was initially thought to be flare in January 2005 was much more likely due to hemorrhoids).  Thus, member consensus was that the CI’s condition was best characterized as moderate, with infrequent exacerbations, which corresponded to a 10% rating.  The Board considered rating the condition under code 7336, hemorrhoids, but a higher rating was not supported as the STR did not indicate that the CI had persistent bleeding with secondary anemia, or with fissures.  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 Crohn’s disease condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the additional conditions listed by the MEB were not unfitting.  The Board’s threshold for countering fitness determinations is preponderance of evidence, which 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.

Depression.  A psychiatric MEB addendum was accomplished on 11 March 2004, 7 months prior to separation.  The addendum noted that the CI first presented to the mental health (MH) clinic 5 months earlier complaining of mood swings, at the urging of her unit.  She noted a number of life stressors including her mobilization.  She was being worked up for a possible demyelinating disorder because of possible white matter changes noted on magnetic resonance scanning (MRI).  The examiner stated, “Overall she stated that she felt emotionally more stable since more definitive treatment of her medical problems had been initiated.  She requested the reinitiation of supportive psychotherapy, but then missed her next clinic appointment.”  The diagnosis was mood disorder due to Crohn's Disease and possible demyelinating disorder, chronic, moderate.  The impairments for further military duty and social/industrial adaptability were judged to be mild, and the Global Assessment of Functioning (GAF, a numeric scale used by MH clinicians to rate subjectively the social, occupational, and psychological functioning of adults) was 60 (“Moderate symptoms OR moderate difficulty in social, occupational, or school functioning in social, occupational, or school functioning”).  The examiner discussed an S3 profile, stating that “definitive psychiatric care must be readily available,” but no such profile (DA Form 3349, Physical Profile) was found in available records.  The examiner also stated, “In any case, these problems in and of themselves are not felt to be unfitting for the military, nor likely to adversely impact social and industrial adaptability much.”

The CI was subsequently seen several times in MH clinic, with the GAF ranging from 55 to 58 (same clinical description as 60).  At a visit on 12 July 2004, the examiner stated, “After another long interval between appointments, [patient] returns. …  Most of the psychiatric difficulties she has are manifestations of her significant borderline personality disorder and childhood trauma.”  Her diagnoses were major depressive disorder and personality disorder with borderline traits.

In a performance statement to the PEB on 15 July 2004, the commander specifically mentioned the CI’s gastrointestinal diagnosis and a P3 profile, but not an S3 profile or any restrictions related to a mental health condition.  He stated that the CI was a “hard-working, knowledgeable, motivated soldier” whose chain of command reported that she was a “valuable member of their unit and made significant contributions.”  He also stated, “Her symptom's often include persistent diarrhea and bowl [sic] obstruction.  As a result she sometime appears depressed and embarrassed.”  On 19 August 2004, the writer of the primary NARSUM stated that depression did not cause her to fall below retention standards.

At the CI’s last visit to MH clinic on 1 November 2004 (9 days prior to separation), the provider stated, “Anxious Re:  reuniting and caring for 4 children.  [Patient] has increased coping skills, improved self-esteem & healthy relationship skills.  Sleeping is better.  [Anxiety] attacks have decreased.”  The recommended follow-up was ongoing medication management and individual therapy through the VA.

At a VA C&P MH exam performed on 3 June 2005 (7 months after separation), the CI reported that psychiatric symptoms began in 1993, and that “the mental condition has caused problems with sleeping for 12 years.”  Her current symptoms were constant and described as “suicidal thoughts, lack of interest in all areas and does not take care of herself.”  Continuous medication was still required to control her condition.  The examiner stated, “She is currently working in production since May 2005.  Her relationship with co-workers is good.”  The note also detailed changes in the CI’s daily activities and her social function:  she didn’t want to leave the house or go out with friends.  On mental status examination, her mood was depressed.  Her diagnosis was major depression and her GAF was 45 (serious symptoms or any serious impairment in social, occupational, or   school functioning.)  The examiner concluded that the CI “needs occasional interference in performing activities of daily living, she has fear of perpetrator following her.  She has difficulty establishing and maintaining effective work and social relationships.”  At a VA primary care appointment 3 weeks later on 23 June 2005, the provider stated the CI’s anxiety was well-managed with her antidepressant medication.

The Board directed attention to its recommendation based on the above evidence.  Although the psychiatric MEB addendum discussed an S3 profile and stated that definitive psychiatric care must be readily available, such a profile was never instituted, and the writer of the same note stated that the MH condition was not disqualifying for military service.  No other psychiatric notes in the STR commented on duty restrictions and they were not implicated in the commander’s statement.  The MH note most proximate to separation (9 days prior to separation) detailed increased coping skills, improved self-esteem, and healthy relationship skills.  The VA psychiatric C&P note reflected an inconsistent exam:  the CI was working (in production) and had a good relationship with her co-workers, but she didn’t want to leave the house or go out with friends, and had difficulty with work and social relationships.  Members agreed that there was insufficient performance based evidence from the record that depression 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 depression condition; thus no additional disability ratings can be recommended.

Migraine Headaches.  The STR detailed that the CI had headaches since 2003.  A clinic note on 2 July 2003 stated that she got debilitating headaches about once a month and that “Fortunately there does not seem to be indication for anything but abortive therapy.”  At a neurological evaluation for the MEB on 1 August 2004 (3 months prior to separation), the headaches were deemed to be stable, she was continued on the same medications, and there was no determination that the headaches were disqualifying for duty.  The NARSUM (later that month) reported that imaging of the brain (MRI) showed “bright spots that were non-enhancing,” while a brain wave study (EEG) and cerebrospinal fluid studies were normal.  No diagnosis of seizures or demyelinating disorder was made, and the final diagnosis was migraine headaches, stable on medications.  A note from the STR which was undated (but on/about 26 January 2005, 2 months after separation) stated that the CI had not had a headache for a month and that they were decreasing in frequency.  At the VA C&P exam on 5 July 2005 (6 months after separation), the CI stated that she thought she had stress headaches, not migraines.  The headaches averaged one a month and each one lasted 2 days.

Even though the CI had ongoing migraine headaches, they were never profiled; were not implicated in the commander’s statement; and were not judged to fail retention standards.  There was no performance based evidence from the record that the headaches 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 headache condition; thus no additional Service disability rating can be recommended.

Temporomandibular Joint Dysfunction, Irregular Menstrual Periods, Pes Planus, Vision Defect and Acne Conditions.  None of these conditions were profiled or implicated in the commander’s statement, and were not judged to fail retention standards.  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 these 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 Crohn’s disease condition, the Board recommends no change in the PEB adjudication.  In the matter of the multiple contended conditions (depression, migraine headaches, temporomandibular joint dysfunction, irregular menstrual periods, pes planus, vision defect, and acne), 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 20140520, 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 XXXXXXXXXXXXXXXXXX, AR20160000258 (PD201402271)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA