RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02583
BRANCH OF SERVICE:  Army	BOARD DATE:  20150609
SEPARATION DATE:  20080702

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Infantryman) medically separated for heat stroke with rhabdomyolysis.  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 L3 profile and referred for a Medical Evaluation Board (MEB).  The “heat stroke with residual heat intolerance” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “heat stroke with Rhabdomyolysis” as unfitting, rated 0%.  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 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:

IPEB – Dated 20080411	VA* - (~2 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Heat Stroke with Rhabdomyolysis	7999-7900	0%	Residuals Heat Stroke w/Rhabdomyolysis, residual of heat intolerance	7599-7540	NSC	20080905	
Other x 0 (Not In Scope)	Other x 0 (Not in Scope)	
RATING:  0%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20081015 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Heat Stroke with Rhabdomyolysis Condition.  The narrative summary notes that in August 2007 the CI suffered heatstroke during a 12 to 15-mile march.  The CI felt fatigued and vomited during the march and eventually he was unable to keep pace and fell to the ground.  The CI reported that the next thing he remembered was being in the back of a truck on his way to the emergency room (ER).  On admission his core temperature was 105.1 degrees Fahrenheit (F) (heatstroke is defined as core temperature of 106 degrees F or greater, however, if temperature first taken in ER, likely was higher).  A hospital discharge summary indicated diagnoses of dehydration, rhabdomyolysis (muscle injury) and acute kidney injury.  The CI spent 3 days in the intensive care unit and three additional days in the hospital.  No other information from the hospitalization is in the available record except for a few laboratory results, which showed very elevated muscle enzymes, (sensitive indicator of muscle injury) which slowly returned to normal.  Other abnormal findings included blood work that showed mild elevated liver enzymes and suggested impaired kidney function.  At a primary care visit on 10 December 2007, the examiner indicated he thought that recent follow-up tests, which noted possible persistent abnormal kidney function, were in error; repeat tests had been within normal.  The examiner thought that the CI did not have persistent kidney failure and planned to refer the CI to a kidney specialist.  There is no other evidence in record that the CI was seen by a kidney specialist or that there was any ongoing concern regarding the CI’s kidney function.  At a primary care visit on 3 January 2008 the CI was noted to have elevated blood pressure (BP) and was started on an antihypertensive medication.  The CI reported being off his medication for a week because he ran out, but subsequently restarted the medication and a primary care visit on 25 March 2008 noted the CI’s BP was well controlled on the medication.  Primary care visits in November 2007, the CI initially reported feeling fine and wanted to deploy with his unit.  The CI indicated that if he drank a lot of water he felt fine, but if he did not, he would get a headache.  But, later notes indicated that he continued to experience easy fatigability, headaches, and leg cramps provoked by walking for 15 minutes or standing for prolonged periods, and headaches and dizziness just from standing in formation in the sun for a few minutes.  At a primary care visit performed on 16 January 2008, the CI reported that he wished to be discharged from active duty by the MEB required by regulation following a heat injury.  At a primary care visit on 30 April 2008 the CI reported “feeling great” and that he was “staying inside a lot trying to keep cool,” and was staying well hydrated.

At the MEB examination performed on 8 March 2008 (4 months prior to separation), the CI reported continued heat intolerance as noted above.  The MEB physical exam was normal except for noted mild right side abdominal tenderness without any other abdominal findings.

Three VA Compensation and Pension (C&P) examinations were performed on 5 September 2008, (2 months after separation) the CI reported hypertension (high BP) for which he took medication from February 2008 to March 2008.  At the C&P General examination a complete physical exam was unremarkable and the examiner indicated there was no pathology to render a diagnosis.  A clarification of the CI’s BP condition was requested and the VA examiner responded that the CI had not been on medication for BP or a restricted diet since March 2008.  No follow-up was recommended because the high BP was thought to be stress related and there were no current signs or symptoms of hypertension.  At the genitourinary exam, the CI reported that his kidneys were fine now.  He reported no kidney dysfunction, but reported frequent urination, 8 to 10 times per day and twice at night and occasional urinary hesitancy.  Following receipt of a urine test and kidney function tests the VA C&P examiner reported all test results were within normal.  He opined that he did not think the CI was urinating as frequently as he reported and there were “no physical findings to render a diagnosis.”  At the VA C&P muscle examination the CI reported injury to his calf muscles with muscle tightness about once a week for 5 minutes, with severity of 7-8/10, but reported it resulted in no impairment.  Other than this the CI denied any pain, weakness or easy fatigability of his muscles.  The VA C&P examiner again indicated there was “no muscle involvement” and there was no “pathology to render a diagnosis.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the heat intolerance 0%, coded 7999-7900 (analogous to hyperthyroidism –analogous code for heat intolerance) and the VA did not service-connect the residual heat intolerance condition.  The evidence in record supports that the CI had a heatstroke complicated by muscle injury and acute kidney injury.  At the time of separation the CI reported occasional residual heat intolerance symptoms of headaches, dizziness, fatigue, and leg muscle cramps.  The CI’s symptoms recurred with heat exposures, but there were no persistent abnormalities noted on physical examination.  The Board first deliberated whether there was any evidence to support rating for residual kidney impairment IAW 4.115b (genitourinary system).  The laboratory results in record noted possible abnormal laboratory measures of kidney function after the heatstroke.  However, as noted above, there is no indication that the CI was diagnosed with residual kidney damage, following his recovery from the acute injury.  At the C&P examination the CI reported frequent urination, but the C&P examiner indicated screening tests for kidney injury were within normal.  The C&P examiner indicated he thought the CI was not urinating as frequently as he reported, however, it seemed entirely possible to the Board that it was a normal response to fluid intake, because the CI stayed well hydrated and felt well as long as he did so, a fact he repeatedly noted in the records.  Likewise, notes in the service treatment record indicated the CI was transiently noted to have elevated BP and was prescribed medication.  The Board discussed whether the BP issues could be related to persistent kidney damage, but the evidence does not provide sufficient support for that conclusion.  Furthermore, at the C&P exam the CI reported no BP medication use in 6 months, or dietary restrictions, and was noted to have normal BP.  Therefore, the Board noted that any effects of the heatstroke on the CI’s kidney function had apparently resolved.  Therefore, the Board abandoned this coding approach.

The PEB used analogous coding for heat injury based on analogy to hyperthyroidism symptoms.  The Board agreed that coded IAW §4.119 (endocrine system) as 7900, the 10% rating was achieved based on intermittent symptoms versus persistent symptoms.  Another frequently employed analogous code for heat injury is 8199-8100 for residual headaches IAW §4.124a (neurological conditions).  However, according to the rating criteria for migraines, the CI’s headaches were reported as frequent and not usually prostrating, but he reported he occasionally had to take over the counter medication or lay down.  Thus, the Board concluded that even with a generous interpretation of the intermittent headaches as occasionally prostrating, the 10% rating coded as 8100 was not exceeded, specified as “characteristic prostrating attacks averaging one in 2 months over the last several months.”  Members briefly discussed coding as 8999-8911 (analogous to minor seizure activity), but noted there was no evidence in the record of any seizure activity or episodes of altered mental status following the initial injury to support this coding approach.  Thus, the Board determined that the evidence in record supports a 10% rating of the heatstroke condition, coded 7999-7900 at the time of separation, and no higher evaluation was achieved with any applicable alternative code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the heatstroke condition.

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 heatstroke condition, the Board unanimously recommends a disability rating of 10%, coded 7999-7900 IAW VASRD §4.119.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Heat Stroke Condition	7999-7900	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140602, 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, AR20160002814 (PD201402583)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA