RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02453
BRANCH OF SERVICE:  Army	BOARD DATE:  20150519
DATE OF PLACEMENT ONTO TDRL:  20030404
DATE OF REMOVAL FROM TDRL:  20070814

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Artillery Mechanic) medically separated for pneumonia.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “severe pneumonia with sepsis” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “severe pneumonia with sepsis, hypotensive and respirator dependent” as unfitting, rated 100% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  In 2007, the PEB re-adjudicated the pneumonia condition as resolved, rated at 0%, and the CI fit.  The CI appealed to the Formal PEB (FPEB).  The FPEB changed the rating from 100% to 0%, and the CI was medically separated.

CI CONTENTION:  The CI requested that the Board review all of his conditions.  His complete submission is at Exhibit A.

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:

FPEB – 20070628	VA Rating Decision1 - 20040127	
TDRL Placement – 20030403	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL2
Placement	TDRL3 Removal	
Pneumonia with Sepsis 	6899-6824	100%	0%	Obstructive Ventilatory Impairment; Status Post Septic Shock Due to Streptococcus Pneumonia…	6699-6604	10%	30%	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 1	
RATING:  100% → 0%	RATING:  10%	
1. Most proximate to TDRL placement
2. Rating derived from C&P exam dated 20030604, ~2 mos. post-TDRL placement 
3. Rating derived from C&P exam dated 20081118 ~15 mos. post-TDRL removal 

ANALYSIS SUMMARY:

Pneumonia Condition.  The service treatment record documents that the CI was diagnosed with community acquired pneumonia while in basic training.  A 19 January 2003 emergency department (ED) encounter diagnosed a left lower lobe (LLL) pneumonia by chest X-ray and the CI was started on an oral antibiotic.  Because of persistent symptoms, the CI returned to the ED on 20 January 2003, and was admitted to the hospital.  He improved over the 2-day hospitalization and was discharged to complete his antibiotic treatment.  A follow-up chest X-ray showed a LLL infiltrate (nonspecific, poorly defined opacity).  Symptoms failed to resolve completely and the CI was started on a different class of antibiotic.  On 2 April 2003, the CI returned to the ED for increased cough, fever, and chills.  He was found to hypoxic (low blood or tissue oxygen) and hypotensive (low blood pressure).  The CI was given oxygen, broad spectrum antibiotics, and a vasopressor (raises the blood pressure by constricting blood vessels), and fluids to support his blood pressure.  Because of the severity of illness, the CI was airlifted on 3 April 2003 to a tertiary care university hospital.  Upon arrival at the tertiary care hospital, the CI was in respiratory distress, rapidly intubated, and placed on a ventilator.  The chest X-ray confirmed a left lobar pneumonia.  On the morning of admission, an emergency code was called in response to hypoxia, hypotension, and a nonpalpable pulse.  The CI was in cardiac arrest and cardiopulmonary resuscitation (CPR) was initiated.  A normal (sinus) heart rhythm returned, blood pressure increased, and a bounding pulse was appreciated.  The overwhelming sepsis responded to antibiotics and fluids and the vasopressors were weaned as tolerated.  The 3 April 2003 narrative summary noted a blood culture was positive for bacteremia (bacteria in normally sterile blood).  It recounted the clinical course of pneumonia and septic (systemic manifestations of infection) shock (inadequate blood flow to tissues).  Based upon information from the medical records, and conversation with the attending ICU physician, the CI’s condition was deemed critical and death was expected within 72 hours.  The CI was referred to the PEB and placed on the Temporary Disability Retired List (TDRL).  A transthoracic echocardiogram (heart ultrasound) showed a decreased ejection fraction ([EF] % of blood ejected with heart contraction), but no evidence of endocarditis (bacterial growth/vegetation on heart valve).  The bacteria species (Streptococcus pneumoniae) in the blood culture was identified.  On 6 April 2003, the CI extubated (removed ventilator endotracheal tube) himself.  He improved to the point where he could be safely transferred to the general internal medicine floor.  Serial chest X-rays showed improving aeration of both lungs with residual infiltrates.  A 9 April 2003 transesophageal echocardiogram was normal, showed no evidence of endocarditis, and was significantly improved compared to the previous study.  The 11 April 2003 chest X-ray was improved but not yet completely clear.  The final inpatient progress note on 14 April 2003 listed the diagnosis of LLL pneumonia secondary to Streptococcus pneumoniae status post respiratory failure and septic shock.  On 14 April 2003, the CI was discharged to his unit with convalescence and administrative leave as necessary.  He was prescribed an antibiotic and mucus expectorant and given instructions to follow-up with his primary care manager as needed.  Two months after placement on the TDRL, the heart Compensation and Pension (C&P) exam recounted the medical history and treatment to date.  The examiner documented “Patient was slowly but surely improving and finally recovered.  Patient was referred back to Kentucky on the 04/14/03 and on the 18th he was discharged and returned to Puerto Rico.”  Here he has continued recovering, remaining feeling well except for of tiredness and weakness.  The physical exam documented “Examination of the heart shows, normal sinus rhythm, no murmurs, no gallops.  Examination of the chest shows, lungs clear to A&P.  Arterial pulses are normal.  There is no evidence of congestive heart failure today.  No lung rales, no edema and no hepatomegaly.”  The graded stress test reported 12 metabolic equivalents (METS; resting metabolic rate used to describe functional capacity or exercise tolerance).  The diagnoses were status post septic shock due to streptococcus pneumonia infection with sepsis and mild obstructive ventilatory impartment.  Pulmonary function tests (PFTs) showed a forced expiratory volume in 1 second (FEV-1) of 77% predicted.  The addendum to the heart C&P exam documented “In my opinion there is no specific heart condition present in this patient related to cardio-respiratory failure secondary to sepsis during the active military services.  Initial report of 12 METS was a mistake and the correct value is 5 METS.  This was associated to SOB [shortness of breath], but no chest pain.  PFT shows obstructive lung disease, this may explain these findings.”

The 12 April 2007 TDRL evaluation recounted the history of severe pneumonia and sepsis which resulted in TDRL placement.  It documented “Patient reports after resolution of his medical condition he was discharged home at the end of April 2003. … Patient reports sometimes he wakes up wheezing during the night with breathing problems during exercise or even at rest.  He also noticed at that time symptoms such as chest tightness, coughing, wheezing and shortness of breath.  He was placed on inhaled bronchodilators and steroids with control of his symptoms.  Patient reports today he is still incapacitated to do exercise due to shortness of breath and chest tightness.  Patient reports his asthma symptoms are also exacerbated by exposure to dust, paint fumes, mold, cigarette smoke, or pollen.”  The CI was taking no medications at the time of exam.  Physical exam showed normal respiratory movements with no use of accessory muscles of respiration or abdominal breathing.  Lung exam revealed normal breath sounds without wheezing or prolonged expiratory time.  Heart exam revealed a regular rate and rhythm without murmurs.  The balance of the exam was unremarkable and the chest X-ray was normal.  The 18 April 2007 PFTs documented “Good effort and cooperation, Oxygen saturation by pulse oxymeter 97%.” The spirometry values were:  FVC = 3.50 = 83% predicted; FEV1 = 2.89 = 83% predicted, and FEV1/FVC = 2.89/3.50 = 83%.  The interpretation listed “Normal Pulmonary Function study with normal airway resistance.”  Concerning present condition and current functional status, the examiner documented “The condition has resolved with adequate management and treatment. … Complete pulmonary disease evaluation confirmed the resolution of his condition, no evidence of pulmonary active disease at this moment.”  The 11 May 2007 IPEB found the CI fit for duty, but the CI did not concur and demanded a formal hearing.  The rebuttal of the PEB contained no new evidence which would warrant a change to the original findings.  The 28 June 2007 FPEB removed the CI from TDRL and discharged him rated at 0%.

The heart C&P exam, 15 months after removal from TDRL, documented the subjective complaints of fatigue and dyspnea on moderate exertion.  The heart exam was unremarkable with a regular rhythm and normal heat sounds.  Murmurs, clicks, rubs, and venous congestion were absent.  The lung exam was unremarkable with all fields clear to auscultation and normal percussion.  There was no chest deformity and edema was absent.  The graded stress test was interpreted as a submaximal exercise stress test for ischemia (inadequate blood supply to heart) with fair functional capacity for the patient age.  An electrocardiogram showed possible evidence of an old heart attack.  An echocardiogram was unremarkable (normal heart chamber, valve, and vessel anatomy, motion, and function) with a normal EF of 65%, and no evidence of effusion, clot, or valve vegetation.  The examiner opined “There is no objective evidence of any heart condition in this examination.  After reviewed all available evidence, I concurred with Dr. C---‘s opinion given in heart exam dated 12-29-03.”  In the respiratory C&P exam, 15 months after removal from TDRL, the CI reported he developed asthma after his pneumonia.  The report documented “According to veteran he had recurrent ER [emergency room] visits … where he was treated and then D/H [discharged home].  (No available evidence for reviewed by this examiner) refers is under treatment with Singulair which has help to control asthma attacks.”  Associated symptoms were occasional to frequent dyspnea with moderate to severe exertion and intermittent (less than daily) nonproductive cough.  He reported the one episode of respiratory failure and denied wheezing or hemoptysis (coughing blood).  Reported treatment was intermittent use of inhaled bronchodilators with good treatment response and relief of symptoms.  There was no history of treatment with steroids (oral or parenteral), antibiotics, or immunosuppressive medications.  The physical exam found no abnormal respiratory findings and there were no conditions that may be associated with pulmonary restrictive disease.  The chest X-ray was normal.  The 20 November 2008 PFTs were listed as “Abnormal … This study does not conform to ATS [American Thoracic Society] standards for interpretation.  ABGs [arterial blood gases] were not done for this study.  O2 saturation 97% at room air by pulse oximeter.”  The examiner opined the “veteran’s mild obstructive ventilatory impairment (asthma) is the same condition that was already service connected (rated as chronic obstructive pulmonary disease).”

The Board directed attention to its rating recommendation based on the above evidence.  The Board first considered its rating recommendation at the time of placement on TDRL.  The 3 April 2003 IPEB rated the pneumonia condition 100% (VA code 6899-6824, rating by analogy-chronic lung abscess).  The PEB cited severe pneumonia with sepsis, hypotensive, respirator dependent, and death was imminent within 72 hours.  All members agreed there was a severe active bacterial infection with life-threatening systemic symptoms consistent with the 100% rating (General Rating Formula for Bacterial Infections of the Lung [diagnostic codes 6822 through 6824]: Active infection with systemic symptoms such as fever, night sweats, weight loss, or hemoptysis).  The 100% rating adjudicated by the PEB is supported by the evidence.

The Board next considered its recommendation for permanent disability rating at the time of removal from the TDRL.  The VARD, 10 months after placement on TDRL, rated the pneumonia condition at 10% (VA code 6699-6604; rating by analogy-chronic obstructive pulmonary disease [COPD]).  The VARD cited the 3 June 2003 FEV-1 of 77% predicted, which is consistent with the 10% under 6604.  The FPEB, 2 months prior to removal from TDRL, rated the pneumonia condition at 0% (6899-6824; when obstructive lung disease is the major residual, rate residuals as chronic bronchitis [6600]).  The PEB cited the former disability, specifically pneumonia with sepsis, had resolved, there were no restrictions which would preclude returning to the military, and the 18 April 2007 FEV1 of 83% predicted.  The basis for the Board’s permanent disability recommendation is the optimal VASRD rating for disability at the time the CI is permanently separated at removal from TDRL.  The 18 April 2007 PFTs were interpreted as normal with normal airway resistance.  The clinical picture documented in the proximate TDRL evaluation and the heart and respiratory C&P exams (15 months after removal from TDRL) were consistent with resolution of the symptoms previously associated with the pneumonia and sepsis.  The CI was taking no medications at the time of the TDRL evaluation.  The examiner documented “The condition has resolved … Complete pulmonary disease evaluation confirmed the resolution … no evidence of pulmonary active disease.”  The heart C&P exam documented “There is no objective evidence of any heart condition.”  The respiratory C&P exam documented “mild obstructive ventilatory impairment.”  While the 20 November 2008 PFTs were listed as “Abnormal,” they were performed in a nonstandard fashion, did not list FEV-1 or FEV-1/FVC values, and were therefore assigned less probative value.  There was no objective evidence that the mild impairment would achieve a minimal rating under 6824, 6600, or 6604.  There was no VARD proximate to removal from TDRL.  The Board majority determined that the totality of evidence is consistent with the PEB adjudication of 0%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudications for the pneumonia condition at either TDRL placement or TDRL removal.

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 pneumonia condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication at both TDRL placement and TDRL removal.  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 20140423, 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 XXXXXXXXXXXXXXXXXXX, AR20150019286 (PD201402453)

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