RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		 CASE:  PD-2014-02785
BRANCH OF SERVICE:  Army	 SEPARATION DATE:  20010913

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Trainee) medically separated for Crohn’s disease.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “Crohn’s disease” and “erosive gastritis “was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions (mechanical low back pain, personality disorder, and hematuria) for PEB adjudication.  The Informal PEB adjudicated “Crohn’s disease” with “erosive gastritis” as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting and therefore, not rated.  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:  

IPEB – Dated 20010514	VA* - (~9 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Crohn’s Disease	7399-7323	10%	Crohn’s Disease	7323	30%	20020624	
Erosive Gastritis							
Mechanical Low Back Pain	Not Unfitting	Thoraco-lumbosacral Strain	5295-5292	40%		
Personality Disorder	Not Unfitting	PTSD	9411	30%		
Hematuria	Not Unfitting	No VA Placement	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING:  10%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20020812 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:   

Crohn’s Disease and Erosive Gastritis Condition.  The CI first sought care for gastrointestinal symptoms in mid-November (in the 12th week of basic training) 2000.  At the time he reported a 2-week history of abdominal pain, back pain and rectal bleeding.  He was admitted to the hospital for further workup and treatment.  He was found to have mild erosive gastritis and possibly ulcerative colitis.  The CI was prescribed Zantac to treat the gastritis.  It was recommended that the colonoscopy be repeated.  On 30 November 2000, the CI underwent a repeat colonoscopy with punch biopsies.  The results were consistent with the diagnosis of Crohn’s disease.  Appropriate treatment was initiated (prednisone and mesalamine [anti-inflammatory]); however, he had no response to treatment and continued to have bloody stool and abdominal pain.  In June 2001, the CI began treatment with Remicade IV infusion therapy and Imuran (Azathioprine).  The MEB/NARSUM was dictated on 1 May 2001; however, the examiner noted the NARSUM “is based on an examination performed on 14 December 2000 till present”.  At the NARSUM, the CI reported his abdominal pain was made worse with lying flat or standing up straight, and relieved by hunching over.  Pain intensity was at time 5/10.  The physical exam noted blood pressure, pulse and temperature were stable.  Abdominal exam noted tenderness and guarding with palpation, and no palpable mass.  The remainder of the clinical exam was unremarkable with no evidence of malnutrition.  Blood testing at the time of hospitalization (18 months before separation) revealed no evidence of anemia.  The physician opined that his condition was stable and that he has the ability to continue to perform his required duty; however, based on his “current subclinical flair of Crohn’s disease”, predicting whether the condition will interfere or preclude him from his required duty was not possible.  His pain was rated as “minimal to slight with occasional to frequent.”  The record noted that the CI was admitted to the hospital on 13 June 2001 to evaluate hematuria, and was transferred to GI service on 16 June for initiation of IV Remicade therapy.  He tolerated the therapy well, and was discharged to outpatient on 18 June 2001.  Nutritional consult dated 26 June 2001 recorded weight of 175 pounds and BMI of 27.  The CI reports he is currently having a flare up.  The consultant noted that the CI denied any recent weight changes despite having flare-up, and noted that he appears to be well nourished.  2 July treatment entry recorded weight of 180 pounds.     Treatment entry dated 11 July 2001, noted the report of stomach pain, and 2 watery stools without blood. Disposition is not clear (admitted to inpatient or ambulatory clinic).  Clinical entry dated 15 August 2001, 4 weeks before separation, recorded weight of 170 pounds and height of 68 inches.  The physician noted the CI has continued IV infusion therapy and immunosuppression drug (Imuran) and opined that he was “doing ok.”  

The VA Compensation and Pension (C&P) exam, 9 months after separation, documented the CI had been treated with immunosuppressive medications for about 4 months (May 2001-Sep 2001) and was prescribed prednisone from November 2000-January 2002.  It was noted he also had three infusion treatments with Ramicade in June 2001. The exam documented a January 2002 hospitalization after the CI reported symptoms he recognized as Crohn’s; however, the colonoscopy suggested irritable bowel syndrome.  The CI noted that on the night prior to hospitalization he had 7-8 watery stools that contained “a little bit of blood” and his abdomen was hurting.  At the time of the C&P exam, medications included mesalamine, and psyllium (Metamucil) as needed for constipation.  He was not taking steroids.  The CI reported abdominal pain that occurs more with physical activity.  He noted he had lost weight recently, and the examiner recorded that he had been hospitalized in January, June, and July 2001 for Crohn’s.  On physical examination vital signs (BP, pulse) were normal and the CI was not in distress.  He weighed 165 pounds (5 pounds decrease since separation).  The abdominal examination was unremarkable.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the condition under code 7323, colitis, but at different ratings.  The PEB rated 10% citing moderate.  The VA rated at 30% “based on frequent treatment for abdominal pain, constipation and diarrhea.”  The VARD recorded several hospitalizations: November 2000, January 2001, June 2001, July 2001, January 2002, and May 2002.  Under this code a 10% rating reflects moderate disease, with infrequent exacerbations.  A 30% rating considers the condition is moderately severe with frequent exacerbations.  The Board undertook a careful review of the record in evidence. The NARSUM presented documentation of his condition prior to and in the month after the November 2000 admission.  The VA indicated there had been three admissions beyond the initial November-December 2000 admission.  The Board could find only two admissions related to his Crohn’s condition.  The June admission appeared to have been prompted by the hematuria.  The admission diagnosis was Crohn’s; however, the condition was documented as stable.  During that admission, the CI received his first infusion treatment and the immunosuppressive medication was started.  The Board reviewed an encounter note written by a clinician, date not clearly identified, but may reflect the continuation of an 11 July 2001 encounter that recorded plan: admit APU (second floor).  It appeared the note was referencing an admission for the administration of IV infusion Remicade therapy, and not an admission related to an acute flare-up of the disease.  The Board found no entries documenting stool frequency greater than 7-8 per day during flare-ups.  Although IV infusion therapy for Crohn’s was initiated while the CI was admitted for investigation of a possible complication (hematuria) of his Crohn’s, that admission was not the result of a flare.  The Board noted the record to document no malnutrition, anemia, serious complications, sepsis or flares of the disease requiring hospitalization or treatment with additional steroid medications in the 10 months prior to separation.  After prolonged deliberation, Board members agreed that the documentation in the record of evidence at the time of separation reflect a pattern consistent with moderate disease with infrequent exacerbations.  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 condition.  

Contended PEB Conditions.  Erosive gastritis, mechanical low back pain, personality disorder not otherwise specified (NOS), hematuria, resolved.  The Board’s main charge is to assess the fairness of the PEB’s determination that the conditions of erosive gastritis, mechanical low back pain, personality disorder not otherwise specified (NOS), hematuria, resolved, were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board undertook a careful review of the record in evidence and noted that the CI was diagnosed with mild erosive gastritis that was treated with Zantac.  There was no indication in the record that other medical interventions were required or that his condition was not responsive to Zantac.  The Board next reviewed the low back pain condition.  The CI underwent radiographic evaluation of his back and the impression was normal lumbosacral spine.  He reported frequent back pain which was treated with medication. The CI also participated in mental health treatment and was admitted to psychiatry inpatient unit 9 months before separation for a possible medication overdose.  He was discharged with the diagnosis of adjustment disorder with mixed disturbance of emotions and conduct.  He was hospitalized a second time in April 2001 secondary to medication overdose at which time he indicated he was frustrated over several stressors related to legal issues.  At discharge, the diagnoses of adjustment disorder with mixed disturbance of emotions and conduct, and personality disorder NOS were documented.  The psychiatry addendum to the MEB conducted while CI was inpatient (April 2001), recorded a normal MSE, and the examiner wrote, “PV2’s overall presentation over the course of the past several months strongly supports a highly maladaptive personality style.”  The PEB noted that the CI’s psychiatric disorders (adjustment disorder and personality disorder), IAW DODI 1332.38, para E5.1.3, does not constitute physical disabilities and, therefore, are not compensable.  

The conditions of erosive gastritis, mechanical low back pain, and hematuria, resolved were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.   All were reviewed and considered by the Board.  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 the 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 and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended erosive gastritis, mechanical low back pain, personality disorder not otherwise specified (NOS), hematuria, resolved conditions, 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 20140529, 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 XXXXXXXXXX, AR20160003899 (PD2014-02785)

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