RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02979
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a mobilized Army National Guard, E6, Armor Crewman, medically separated for “reactive airway disease syndrome” with a disability rating of 10%.

CI CONTENTION:  The CI requests the Board review all 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 - 20040522	VARD - 20060627	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Reactive Airway Disease	6699-6602	10%	Reactive Airway Dysfunction…	6699-6602	10%	20050922	
Posttraumatic Stress Disorder	Not Unfitting
	Post Traumatic Stress Disorder	9411	50%	20050824	
Hypercholesterolemia	Not Unfitting	Hypercholesterolemia	7199-7101	NSC	20050922	
Leukocytosis	Not Unfitting	Leukocytosis	6399-6350	0%	20050922	
Shoulder Region Disease	Not Unfitting	Separation, Right Shoulder	5202-5201	20%	20050922	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Reactive Airway Disease Syndrome.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI reported that his reactive airway disease syndrome (RADS) condition began after being exposed to toxic fumes from a fire during training in June of 2003.  Since that time he developed persistent chest pain both sides of chest and marked exercise limitation becoming short of breathe after one flight of stairs or walking 20-30 feet.  A formal diagnosis of asthma was never established.  Inhaled bronchodilators Advair (2x daily) and Albuterol (as needed) were prescribed.  There were no inhaled steroids prescribed or acute treatment with oral steroids.  Despite treatment, the asthma condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a Medical Evaluation Board (MEB).  The MEB forwarded “reactive airway disease syndrome” for PEB adjudication.

According to the pulmonary function analysis evaluation on 19 June 2003, (19 months prior to separation) the FEV1 (% Predicted) was 101 and the FEV1/FVC measurement was 79%. 

At the pulmonology clinic appointment on 29 August 2003 the CI was evaluated and the examiner noted that the CI was taking Singular (cpf.947).  His physical examination was normal, oxygen saturation was 98% and his lungs showed no anomalies.  The diagnosis was “reactive airway dysfunction syndrome.”

The CI had a flexible fiber optic bronchoscopy airway screening done on 2 February 2004 (1 year prior to separation).  The examination revealed a tracheal ring just below the vocal chords, with normal mucosa.  The remainder of the exam was normal with no endoscopic findings.  The CI was evaluated at the Clinical Pharmacology/Medical Toxicology consult service at Walter Reed Army Medical Center on 24 June 2004, 7 months prior to separation.  The examiner noted he was taking Advair, one puff three times per day and Albuterol, two puffs, three times per day.  The examiner noted that the nature and time course of the CI’s respiratory symptoms were consistent with inhalational exposure to hexavalent chromium, which can cause lung parenchymal injury, pulmonary fibrosis and emphysema. 

The NARSUM was accomplished in June 2004, approximately 7 months prior to separation.  The CI reported symptoms of cough and SOB most notably when he spend time outdoors and on hot days.  His symptoms were not improved with his inhaled medications which he took twice a day.  The physical exam was unremarkable with the exception of mild tenderness to palpation of the right lower chest more than on the left.  The examiner noted that the CI underwent PFTs in January 2004 that documented FEV1 at 78% predicted and FEV1/FVC of 80%.

At the MEB examination (recorded on DD Form 2807 and 2808) dated 3 November 2004 referred back to the Pulmonary Narrative Summary (NARSUM) dated 1 June 2004, the CI reported his diminished functional capabilities as being limited to climbing one flight of stairs or walking only 2-30 feet without being short of breath with symptoms worse outdoors and during hot weather.  There was no record of any hospitalizations or visits to the ER related to a pulmonary condition. There was mild improvement reported with the use of albuterol when taken as needed.  The examiner noted a limitation in exercise capability, even with use of medication though he could walk several blocks at night but with tightness and shortness of breath.  The examiner opined that is “seems unlikely that he will be able to perform sustained aerobic activity” and referred him to the PEB.  At the VA Compensation and Pension (C&P) evaluation on 22 September 2005, 8 months after to separation, the examiner noted that the CI was taking Advair 2 x day and Albuterol (4-5 puffs per day).  Pulmonary function testing (PFT) showed an FEV-1 of 58.1% of predicted and an FEV-1/FVC of 77%. (Standard study) and FEV-1 of 57.6% and FEV1/FVC of 80%. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma condition 10% coded 6699-6602, which differed from VASRD rating criteria.  The VA rated the asthma condition 10% (coded 6699-6602) citing the CI’s FEV-1 and FEV1/FVC results.   The Board noted that the STR and VA examinations reported current prescription and use of daily bronchodilators, one of which was an inhalational anti-inflammatory medication.  While there were no pharmacy records available, the medications are documented in multiple locations throughout the STR.  However, clinical objective evidence (PFTs) demonstrated improved respiratory function after bronchodilation, with spirometry values in the 10% disability range reflected on all three PFTs.  The Board concluded that the VASRD §4.97 threshold for a 10% rating was satisfied in this case based on the PFTs recorded in the STR, and the history.  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 reactive airway disease syndrome condition.  

Contended PEB Conditions.  PTSD; hypercholesterolemia, leukocytosis, and shoulder region disease, NEC.  The Board noted that the condition of PTSD was profiled; however, no mental health condition was implicated in the commander’s statement.  The psychiatric MEB noted that he received minimal treatment for his PTSD.  The psychiatric examination for the MEB dated July 2004 noted that the CI reported symptoms of avoidance, re-experiencing events from Desert Storm (1991), and hyperarousal.  The commander's statement dated October 2004 documented the CI’s pulmonary condition as the only condition which prevented him from performing the normal duties he would be required in any environment for the military.  

The hypercholesterolemia, leukocytosis, and shoulder region disease, NEC conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  There was no performance-based evidence from the record that any of the above conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 contended conditions and so no additional disability ratings are recommended.    

BOARD FINDINGS:  In the matter of the reactive airway disease syndrome condition and IAW VASRD §4.97, the Board majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  In the matter of the contended PTSD, hypercholesterolemia, leukocytosis, and shoulder region disease, NEC conditions, the Board recommends no change from the PEB determinations as not unfitting.  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 20140522, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MINORITY OPINION:  

The minority dissent with the majority recommendation is based on the totality of the evidence from the STR and the post-separation VA C&P examination.  Based on a preponderance of this evidence, the minority member opines that the CI met the criteria for a 30% rating. 

The majority vote favored a 10% rating for the “reactive airway disease syndrome” condition, however, the minority member opines that the CI meet the criteria for 30%.  The VASRD clearly states the use of “inhalational anti-inflammatory medication” as a criteria for the 30% rating. 

There was evidence throughout the CI’s record showing he was prescribed Advair, an anti-inflammatory medicine.  There was evidence in the MEB NARSUM examination, (8 months before separation) showing Advair being taking twice daily, the PEB’s DA Form 199 reported the use of Advair, and the VA C&P examination, (8 months after separation) reported the CI using Advair twice daily.

The minority member differs with the majority and offers that the §4.97 threshold for a 30% rating was reasonably satisfied in this case; since, there was evidence from multiple providers that inhaled anti-inflammatories, which are not specified as a daily requirement under the 30% rating provision, were prescribed.  Concession of prescribed inhaled steroids as a 30% criterion, provided with adequate evidence for regular (not necessarily daily) use, has been a consensus PDBR practice and has been applied in numerous prior cases.

Consistent with the DoDI 6040.44 standard of recommendations that are fair and equitable to both the Service and the CI, the Secretary is respectfully requested to consider the minority recommendation that the CI’s discharge with severance pay be re-characterized to reflect a permanent 30% disability retirement. 

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 
AR20160017028 (PD201402979)

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