RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02513
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20041105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Motor Transport Operator, medically separated for “hypertension…,” “right wrist pain…“  and “migraine headaches…,” rated 10%, 0%, and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI contends Graves’ disease and a malfunctioning right kidney due to medications taken for her hypertension and migraine conditions.  The CI’s complete submission is at Exhibit A.

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 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 PEB - 20040714	VARD - 20050311	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Hypertension	7101	10%	Refractory Hypertension	7101	10%	20040908	
Right wrist pain…	5003	0%	Right Wrist…Osteoarthritis…	8515	10%	20040908	
			Scar, Right Wrist…	7804	10%	20040908	
Migraine Headache…	8100	0%	Migraine and Tension HAs	8100	10%	20040908	
Hyperthyroidism 	Not Unfitting	Hyperthyroidism	7900	0%	20040908	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Hypertension.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s hypertension (high blood pressure) condition began in January 2000, 3 months after accession.  She was treated with medications, life style changes, and weight reduction.  Control was problematic and her blood pressure exacerbated by stress such as deployment to the National Training Center from which she was evacuated after 1 day due to a marked increase in her blood pressure.  Her record noted she lost weight at a number of visits; however, the MEB separation physical recorded a weight of 192 which was 6 pounds less than her accession weight of 198.  Radiographic studies of the renal arteries were unremarkable.  A cardiac stress test showed no ischemia, but there was an exaggerated increase in the blood pressure response.  An echocardiogram was also normal per the NARSUM.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 7 April 2004, 7 months before separation, the CI reported ongoing issues with the control of her hypertension.  The physical examination did not show evidence of end organ damage.  During the NARSUM performed in May 2004, 6 months before separation, the CI again reported poor control of her hypertension.  She was on multiple medications, but reported difficulty adhering to a good diet due to eating food in the dining hall.  Her blood pressure was 160/93.  Evidence of end organ damage was not present on the examination or on testing.  A 5-day blood pressure evaluation ending in May 2004, showed an average blood pressure of less than 200 systolic and 110 diastolic in both arms.

At the VA Compensation and Pension (C&P) examination on 8 September 2004, 2 months before separation, the CI reported poorly controlled hypertension since April 2000.  Her blood pressure was noted to be 160/90 on medications.  Evidence of end organ damage was not recorded.  It was noted that two electrocardiograms (EKGs) had been normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 7101 code (hypertensive vascular disease), citing findings of blood pressure.  The VA also assigned a 10% rating coded 7101 based on the VA C&P examination 2 months before separation, citing findings of blood pressure.  The Board found no route to a higher rating.  After due deliberation, and in consideration of 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 hypertension condition.

Right Wrist Pain.  According to STR and the MEB NARSUM, the CI had a previous right wrist surgery, carpal tunnel release (CTR), performed in 1995, 4 years prior to accession.  In 2000, the CI fell onto her outstretched right hand after slipping on ice.  She subsequently had a second right wrist surgery.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated April 2004, 7 months before separation, the CI reported loss of feeling if she carried heavy objects and swelling with pushups.  The examination was checked “normal.”  The NARSUM noted tenderness over the previous incision site, but an examination which was otherwise normal.  Strength was noted to be normal, but the range of motion (ROM) was not recorded.

At the VA C&P examination in September 2004, performed 2 months before separation, the CI reported pain in the surgical site and that lifting was limited to 10 pounds.  X-rays from 23 April 2004 showed mild arthritis.  On examination, the scar was well-healed, but tender scar.  The wrist ROM was normal.  Strength was decreased due to pain and fatigue, but motion was not recorded as painful.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating coded 5003 (degenerative arthritis), citing based on the objective findings of decreased strength due to pain, fatigue, weakness, and lack of endurance.  The Board noted that this was reported by the CI and recorded on the VA C&P, but not documented on the MEB 2808 or on the NARSUM.  It was also noted that after the second surgery and post-operative treatment, the CI was not treated for the right wrist condition until seen again while in the MEB period, over 3 years later.  The evidence does not support a finding of painful motion (VASRD §4.59).  The Board considered functional loss (VASRD §4.40) and the Board majority found that the evidence does not support its application either.  The scar was noted as tender, but well healed.  There was no evidence that is separately impaired duty; a finding of a separately unfitting condition is not supported.  The VA assigned a 10% rating coded 8515 (paralysis of the median nerve) based on the VA C&P examination 2 months before separation, citing incomplete paralysis of hand movements which was mild.  The VA also assigned a 10% rating coded 7804 (scar(s), unstable or painful) for a tender scar.  After due deliberation, and in consideration of all 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 adjudication for the right wrist condition.

Migraine Headache.  According to STR and the MEB NARSUM, the CI’s had a history of headaches which preceded accession and worsened on active duty.  She reported that these were exacerbated by her hypertension.  Review of treatment records reveals 5 encounters of care for headaches in the 12 months before separation.  She was seen in the emergency room exactly 1 year before separation.  The other appointments were for management of a chronic condition.  At the MEB examination (recorded on DD Forms 2807 and 2808) in April 2004, 7 months before separation, the CI reported headaches exacerbated by hypertension.  The examiner noted that the CI had intermittent headaches, which were controlled on medications and dosage.  The commander’s statement, 26 April 2004, did not state that the CI missed any duty due to headache or acute treatment.  The NARSUM noted that the headaches were controlled with medications.

At the VA C&P examination, the CI reported that pounding headaches were occurring 3 times a month with nausea.  There was no vomiting or visual aura and the CI was able to stop the headaches within 2 hours with her medication.  The CI also reported she had chronic tension headaches in between and they were present almost daily; she reported being non-functional with the migraines.  This was not supported by the records available for review.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating coded 8100 (migraine), citing 3 documented episodes treated in an emergency room over a 1 year period.  The VA assigned a 10% rating also coded 8100 based on the VA C&P examination, citing there is evidence of 3 documented episodes treated in an emergency room over a 1 year period.  The Board did not find evidence in the records available for review to support this determination.  Rating guidance under diagnostic code 8100 is based on the frequency of “prostrating attacks” over the “last several months”.  The VASRD does not further define prostrating attacks however commonly accepted definitions include “utter physical exhaustion or helplessness” (Webster's New World Dictionary of American English), “complete physical or mental exhaustion” or “extreme exhaustion or powerlessness” (Dorland's Illustrated Medical Dictionary).  Review of service treatment records in the 12 months prior to separation does not show prostrating headaches occurring on average one in 2 months or more frequently to support a rating higher than the 0% adjudicated by the PEB.  Although the CI reported frequent headaches at the time of the VA C&P examination, the service treatment record did not support a finding that they constituted prostrating attacks.  The descriptions of the headaches did not differ from the time the CI was on active duty.  Then, repeated clinical observations noted the CI to be in no acute distress when seeking treatment for acute headaches.  During VA examination in September 2004, the CI reported that she was unable to work with her headaches, which occurred 3 times per month and lasted for 2 hours.  However, the record reflects that the CI had one prostrating attack (emergency care on 5 November 2003).  After due deliberation, and in consideration of all 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 migraine headache condition.

Contended Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the hyperthyroidism condition (contended as Graves Disease) was not unfitting.  The hyperthyroidism condition profiled or implicated in the commander’s statement and were not judged to fail retention standards.  It was diagnosed based on a slightly abnormal laboratory test which did not require treatment.  The VA assigned a non-compensable rating.  It was reviewed and considered by the Board.  There was no performance based evidence from the record that it 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 hyperthyroidism condition and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the hypertension, and migraine headache conditions and IAW VASRD §4.104 and §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right wrist condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  In the matter of the contended hyperthyroidism conditions, the Board unanimously recommends no change from the PEB determination as not unfitting.  The single voter for dissent recommended a modification and did not elect to submit a minority opinion.  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 20140531, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXXXX AR20160010946 (PD201402513)

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