RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03030
BRANCH OF SERVICE:  Army	 SEPARATION DATE:  20091227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Track Vehicle Repairer), medically separated by the Informal Physical Evaluation Board for “prinzmetal’s angina,” rated at 10%. 

CI CONTENTION:   The CI contends TBI, PTSD, Bilateral hearing loss (IED) attacks, left wrist, left shoulder, lumbar back pain (damage during IED attack).  The applicant’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 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:  

IPEB - Dated 20090921	VA* - (~2-5 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Prinzmetal’s Angina	7099-7005	10%	Prinzmetal’s Angina	7099-7005	30%	20100310	
Bilateral Hearing Loss	Not Unfitting 	Bilateral Hearing Loss	6100	0%	20100527	
Post-Traumatic Stress…	Not Unfitting	Posttraumatic Stress Disorder	9411	70%	20100216	
Left Wrist Pain	Not Unfitting	Left Wrist, Partial Tear…	5299-5215	10%	20100310	
Left Shoulder Pain	Not Unfitting	Rotator Cuff Derangement 	5299-5203	10%	20100310	
Lumbar Back Pain	Not Unfitting	Chronic Low Back Strain	5237	10%	20100310	
Other MEB/PEB Conditions x 5  (Not In Scope)	Other x 5  (equals SC, NSC & deferred)	
RATING:  10%	RATING:  100%	
*Derived from VA Rating Decision (VARD) dated 20100721 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Prinzmetal’s Angina Condition. The narrative summary (NARSUM) dated 16 March 2009 documented that the CI noted his chest pain begun during his second deployment (2006-2008). In October 2007, he had just completed eating food when he developed chest pain with associated shortness of breath (SOB), left arm numbness and pain radiation to the jaw.  He was diagnosed with a pinched nerve in the left shoulder.  After that episode, he noted he could not run without experiencing chest pain and SOB.  He was sent to the pulmonary clinic and diagnosed with asthma.  His pulmonary function tests were consistent with asthma, moderate type, and he was prescribed medication to treat his asthma.  However, he developed worsening chest pain that occurred even at rest.  In August 2008, he underwent cardiac catherization and was identified as having printzmetal angina.  He was followed by cardiology and was prescribed anti-angina medications.  At the time of the NARSUM, the CI rated his chest pain at 2/10 at rest accompanied by tightness.  His pain worsened with lifting over 50 pounds, and extended walking provoked SOB and chest pain.  The pain improved with rest and with the nitroglycerin patch.  Due to his inability to perform APFT activities, carry and fire an individual assigned weapon, move with a fighting load, wear chemical defense equipment, construct an individual fighting position, and not able to deploy, the CI was referred to the MEB.  Physical examination was unremarkable.  Chest X-ray obtained in July 2009 demonstrated normal heart size and normal vascularity.  The CI underwent exercise stress test in August 2009 that documented the CI achieved a work level of metabolic equivalent of 12.90.  The test was terminated secondary to the report of SOB; however, chest pain was present but not limiting, and arrhythmias and ST changes were absent.  The VA Compensation and Pension (C&P) exam was accomplished approximately 3 months post-separation.  The CI was not working but was attending school.  He noted he had chest pain with walking up one flight of stairs or walking one mile.  The examiner opined that the description of his limitation in activity suggested an “estimated METS of 5-8.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 10% coded analogously 7099-7005 (arteriosclerotic heart disease).  The VA, under the same coding scheme rated the condition at 30% based on the estimated METS recorded in the C&P exam.  The higher rating of 30% requires evidence of workload not exceeding METS of 7 that results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on EKG, echocardiogram or X-ray.  The Board considered the stress test in August 2009 conducted with recordings from echocardiogram, and the July 2009 chest X-ray with EKG, met the evidence standard of §4.100.  The Board acknowledged the C&P examiner’s opinion that the CI’s condition suggested METS of 5-8; however, IAW VASRD §4.100 METs testing is required in all cases except when there is medical contraindication.  The Board found no medical contraindication that would have precluded such testing at the time of the C&P exam.  The stress test, documented METS of 10.92, which is consistent with 10% rating.  Thereupon, 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 prinzmetal angina condition.  
 
Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions noted below 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.  

Bilateral hearing loss.  Audiology report in August 2008 noted normal hearing sensitivity in the left ear with a mild loss noted at 4000HZ.  Word recognition was 100% bilaterally.  The right ear demonstrated “a sloping moderately severe high frequency sensorineural hearing loss” and there was bilateral normal middle ear pressure and compliance on tympanometry.  Follow up recommendation was as needed and included annual hearing test and use of hearing protection when exposed to excessive loud noise.  Otorhinolaryngology exam in September 2008 recorded normal ear exam.  Although the hearing loss condition was profiled H2, the functional limitation restricted exposure to noise in excess of 85 decibels or weapon firing without use of properly fitted hearing protection.  The condition was not implicated in the commander’s statement and was not judged to fail retention standards.  

Left wrist pain.  The NARSUM dated 22 October 2002 noted this left-handed CI reported sudden onset of left wrist pain in October 2007 after catching a heavy chain above his head while wrist was in extended position.  MRI in April 2008 demonstrated partial tear of the triangulo-fibrocartilage.  His pain was reduced with the use of ice and wrist splint.  He was later treated with analgesic patches and reported significant pain reduction with increased wrist range of motion.  Occupational therapy entry 18 July 2008 recorded pain at rest of 0/10 and with use 2-3/10.  Treatment records were silent going forward.  The condition was not profiled or implicated in the commander’s statement.  

Left shoulder pain.  Treatment record dated 16 September 2005 recorded right shoulder pain onset after the CI fell.  Radiographs of the right shoulder recorded no evidence of fracture or acromioclavicular joint separation.  He was treated with Motrin and prescribed narcotic pain medication as needed.  Records were silent for this condition going forward until August 2007 when the CI presented to care with the report of neck and left shoulder pain after working on an 88 maintenance vehicle.  He was noted to respond immediately to the injection given for his pain.  Records again fell silent until the MEB.  The NARSUM recorded the condition as “left shoulder pain-unresolved-meets retention standards.”  The condition was not profiled or implicated in the commander’s statement.  

Lumbar back pain.  Treatment records for this condition were silent in the 5 years prior to separation.  The NARSUM noted the condition met retention standard.  The condition was not profiled or implicated in the commander’s statement.  

PTSD.  The psychiatric addendum to the MEB was accomplished in August 2009, 4 months before separation.  The examiner documented the CI’s last contact with mental health was December 2008, and that he his PTSD had been identified later as he was going through the MEB process for angina.  The CI noted while being evaluated at the MEB clinic, he was prescribed an antidepressant medication and his PTSD symptoms had reduced in severity to 4/10.  He reported he currently sleeps 3-4 hours per night because of combat related nightmares, and he had difficulty with leaving his home to shop and other activities due to concerns about being in large crowds.  His mental status examination was normal.  He endorsed other symptoms suggestive of PTSD, and the psychiatrist documented the diagnosis of PTSD with panic attacks.  A Global Assessment of Functioning (GAF) score of 60 (cusp of moderate-mild) was recorded.  The examiner noted that his condition met retention criteria.  The psychiatrist referenced the commander’s performance statement (CPS), noting that it reflected absence of deficits in industrial capacity; however, acknowledged that he had minimal duties while transitioning to the Warrior’s Transitional Unit.  The psychiatrist also wrote, “Given the patient’s inner strength, outpatient treatment for his PTSD would render SM to have mild difficulties from the psychiatric perspective…”  The examiner also noted favorable performance evaluations, confirmed by the CI, and that his military/industrial limitations related primarily to his angina condition.  A review of the medication log dated 26 March 2009, demonstrated absence of psychotropic medication prescriptions in the 5 year log history with the exception of one prescription for 60 tablets without a refill, dated 26 March 2009.  The Board reviewed the CPS which noted the CI was able to communicate effectively with others, relate civilly to supervisors and other workers, was able to sustain an ordinary routine without extra supervision, make basic work-related decisions, was able to respond appropriately to changes in routine, and able to be aware of safety hazards and take appropriate precautions.  The PTSD condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  

As noted above, all conditions 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 prinzmetal’s angina condition and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral hearing loss, left wrist pain, left shoulder pain, lumbar back pain, and PTSD 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.  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 20140528, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160005005 (PD201403030)

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