RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02293
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040706

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Petroleum Supply Specialist, medically separated for “asthma,” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.

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 based upon a 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 – 20040310	VARD - 20120710	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Asthma	6602	10%	20120630	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Asthma.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), respiratory symptoms began approximately 5 months after affiliating with the Army.  On 14 August 2003, the CI presented to the emergency department complaining of fever, sinus congestion, nasal discharge, and productive cough since 23 July 2003.  The lung examination revealed bibasilar crackles and the CI was treated for an atypical pneumonia with an antibiotic, an inhalational bronchodilator (Albuterol), and quarters for 24 hours.  A 14 August 2003, chest X-ray was normal.  At a 9 September 2003 acute care clinic evaluation, the CI complained of not being able to run for 6 months because of trouble breathing.  The assessment listed shortness of breath and the examiner started Albuterol to be used 2 puffs, 4 times per day, and before running as needed.  At a 29 September 2003 family medicine encounter, the CI complained of 6 months of progressively worsening trouble with breathing.  The assessment listed possible asthma and the examiner started an inhalational corticosteroid (Flovent), an oral corticosteroid (Prednisone), ordered pulmonary function tests (PFTs), and consulted pulmonology.  The baseline PFTs documented a pre-drug (Albuterol) FEV-1 of 83% predicted, a pre-drug FEV-1/FVC of 77%, a post-drug FEV-1 of 77% predicted, and a post-drug FEV-1/FVC of 78%.  The pharmacologic (Methacholine) challenge (inhaled provocative agent to elicit bronchoconstriction to assess for asthma) was positive with a 60% decrease in FEV-1.  A 3 October 2003 pulmonology consultation request documented “… oral steroids were ordered for 29 Sept.  Soldier did not start them because she lost them.”  A 3 October 2003 pulmonology consultation documented that the CI had been taking Flovent for 1 week and that she was not using her Albuterol since starting the Flovent.  The pulmonologist recounted the findings of the PFTs and Methacholine challenge.  The assessment listed history consistent with mild to moderated persistent asthma and he recommended medication changes, observation in garrison, and not to deploy outside the continental United States (CONUS).  The examiner stopped the Flovent, started a combination inhalational corticosteroid/bronchodilator (Advair 250/50mcg), started an oral indirect-acting bronchodilator (Singulair), continued the Albuterol, and initiated a profile.  On 16 October 2003, the CI presented for care in Iraq complaining of chest tightness and difficulty breathing.  The CI stated “Battalion overlooked Asthma and deployed her knowing she had the dz [disease].”  Reported active medications listed Albuterol, Flovent, and Advair 250/50mcg.  The physical examination revealed breathing was a little labored with some wheezing and congestion in all lung lobes.  The CI was treated with an Albuterol metered dose inhaler (MDI), Albuterol nebulizer, and intravenous (IV) corticosteroid (Solumedrol).  The assessment listed asthma and the examiner documented the CI had been in country for 1 day and recommended redeployment to CONUS.  The discharge medications were an oral corticosteroid (Prednisone), Albuterol, Flovent, and Advair 250/50mcg.  Following medevac, the CI was reevaluated on 9 December 2003 by pulmonology.  Reported active medications listed Singulair, Albuterol, and Advair 250/50mcg.  The pulmonologist reported the CI had significant symptoms upon arriving in theater, was treated for about 1 month, and medically evacuated home.  The CI complained of persistent dyspnea on exertion and nasal and sinus complaints.  The assessment listed moderate, persistent asthma and Advair 250/50mcg was increased to 500/50mcg twice daily and the Singulair and Albuterol were continued.  In the 20 February 2004 NARSUM by pulmonology, 5 months before separation, the CI reported a long history of environmental allergies that were treated with over the counter medicines.  Since joining the Army, she had had persistent dyspnea on exertion with associated chest tightness and wheezing.  The CI reported that she fell out of most of the runs during basic and AIT, but was able to marginally pass the APFT.  She described significant difficulty with exertional activities wearing the chemical mask, but denied any nocturnal symptoms.  Following the initial evaluation, despite recommendations the CI be observed in garrison, the member's Command deployed her in support of Operation Iraqi Freedom.  Once deployed, she had significant asthma symptoms, and was treated for approximately 1 month.  The CI reported treatment with Albuterol, MDIs, nebulizers, and IV and oral steroids.  The examiner noted there was no significant documentation in her medical record to reveal further details of this treatment.  At the follow-up, she complained of persistent dyspnea on exertion and nasal and sinus complaints.  Reported active medications listed Singulair, Albuterol, and Advair 500/50mcg.  The physical examination revealed 96% oxygen saturation by pulse oximetry, lungs were clear to auscultation, and a normal inspiratory to expiratory ratio.  The examiner recounted the findings of the chest X-ray, baseline PFTs, and Methacholine challenge.  The PFTs were interpreted as normal and the Methacholine challenge as consistent with nonspecific bronchial hyperactivity.  The diagnosis listed moderate persistent asthma.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 6202 code (asthma, bronchial) citing FEV-1 of 77% after inhaled bronchodilator, aeromedically evacuated from Iraq, and medication profile reflects intermittent inhalational bronchodilator therapy.  The VA assigned a 10% rating under the 6202 code based on the VA C&P examination 8 years after separation.  The board assigned little probative value to the C&P examination because it occurred 8 years after separation.  The STR contained multiple medical encounters, which captured the medication reconciliation in the electronic medical record, between 14 August 2003 and 21 September 2004.  The only prescription for the increased Advair 500/50mcg dose was filled on 9 December 2003 for a 3 month supply.  The only prescription for Singulair was filled on 8 October 2003 for a 3 month supply.  The final prescription for Albuterol was filled on 9 September 2003 for a single MDI.  While the 20 February 2004 NARSUM listed Advair, Singulair, and Albuterol in the active medications, this occurred 2, 4, and 5 months respectively after the final prescriptions were filled.  A 5 August 2004 telephone consultation documented “req t-con to Dr Sigel/req allergy medication refill only.  Medication name: Zyrtec.”  The STR contained four medical encounters, which captured the electronic medical record medication reconciliation, in the 8 months following the NARSUM.  The only medication which was refilled after the NARSUM was the telephone consult requested Zyrtec on 9 September 2004.  An 11 December 2004 emergency department encounter documented no active medications.  The CI complained of 2 days of sore throat, cough, and congestion, but denied shortness of breath or dyspnea.  The baseline post-bronchodilator PFTs (FEV-1 of 77% predicted and FEV-1/FVC of 78%) were interpreted as “normal” and overall clinical picture and medication use were consistent with the 10% rating (FEV-1 of 71-80% predicted, or; FEV-1/FVC of 71-80%, or; intermittent inhalational or oral bronchodilator therapy).  The constellation of findings did not approach the 30% rating (FEV-1 of 56-70% predicted, or; FEV-1/FVC of 56-70%, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication).  Review of the STR revealed prescription medication loss, use outside of prescribed instructions, self-discontinuation, and inappropriate use of discontinued medications.  While the CI had been prescribed Advair and Singulair for daily use, the evidence makes clear that she did not engage in the daily use of these medications.  While Albuterol was prescribed for use as needed, the evidence regarding refills did not suggest daily or regular use.  Members agreed, therefore, that only the criterion of “intermittent” use (as specified in the 10% rating description) was satisfied in this case.  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 asthma condition.

BOARD FINDINGS:  In the matter of the asthma condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration. 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 20140527, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160013597 (PD201402293)

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