RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03243
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20060717

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3, Logistics Apprentice, medically separated for asthma, rated at 10%.

CI CONTENTION:  “Please consider all conditions.”  Her 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 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 20060530	VA - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Asthma	6602	10%	STR	
Allergic Rhinitis	Cat II	No VA Placement	
Other MEB/PEB Conditions x 0 	Other x 2	
RATING:  10%	RATING:  10%	

ANALYSIS SUMMARY:  

Asthma.  The service treatment record (STR) documents a history of dyspnea (shortness of breath) on exertion with chest tightness beginning in Technical School.  The initial pulmonary function tests (PFTs) showed normal spirometry (measuring lung function in terms of volume and/or flow of air inhaled and exhaled) without any significant degree of obstructive pulmonary impairment and/or restrictive ventilatory defect.  The FEV-1 was 93% predicted and the FEV-1/FVC was 101%.  A family practice assessment listed difficulty breathing (dyspnea).  The CI was started on an inhalational bronchodilator (Albuterol) and referred to allergy.  The subsequent PFTs showed normal baseline spirometry.  The FEV-1 was 88% predicted and the FEV-1/FVC was 88%.  The exercise challenge test (provocative test to trigger bronchoconstriction to assess for hyper-reactive airways and subset with asthma) was uninterpretable secondary to decreased effort.  The subsequent PFTs showed normal baseline spirometry with inadequate effort technique following bronchodilator.  The FEV-1 was 82% predicted and the FEV-1/FVC was 89%.  The pharmacologic (Methacholine) challenge (provocative test to trigger bronchoconstriction with inhaled provocative agents to assess for asthma) showed some airway hyper-reactivity but was negative per Air Force criteria for significant bronchial reactivity.  The examiner documented “If this patient is on inhaled steroids, may consider repeat methacholine challenge testing when off inhaled steroids for MEB purposes if asthma highly suspected.”  A family practice assessment listed exercised-induced asthma.  The CI was started on an inhalational anti-inflammatory medication (Advair) and referred to allergy.  At the allergy/immunology evaluation, the CI complained of chest tightness and difficulty breathing with running or exercising.  She indicated that the Albuterol seemed to help.  The assessment listed shortness of breath, allergic rhinitis (hay fever), and acute sinusitis.  The examiner documented that the exercise challenge reflected a poor effort and the Methacholine challenge was not consistent in effort, but showed no significant drop.  The CI was started on a nasal corticosteroid (Nasonex) and an antihistamine (Claritin) for the allergic rhinitis, and an antibiotic (Amoxil) for the sinusitis.  A chest X-ray was unremarkable.  The subsequent PFTs showed normal baseline spirometry.  The FEV-1 was 99% predicted and the FEV-1/FVC was 87%.  At the allergy/immunology follow-up, the CI complained of a rash within hours of her first dose of Amoxicillin.  She was converted to another antibiotic (Biaxin), but complained of “real bad chest pains.”  Though she had no hives or other symptoms, this antibiotic was also discontinued.  The CI reported she would awaken at night short of breath due to nasal symptoms, but not chest symptoms.  The CI complained of “a lot of coughing and difficulty breathing.”   She had been taking an inhalational corticosteroid (Advair) for the previous two weeks and reported it had not made any difference.  The Albuterol seemed to help with running.  The examiner documented that the CI had not limited her exercise, missed days from work, presented to the emergency room, been admitted to the hospital, been intubated, or taken steroids because of her dyspnea.  The assessment listed shortness of breath, chronic rhinitis, and allergy to cockroaches.  The examiner documented “She feels like she has improved since being on Advair.  Given this history, I recommended another Methacholinie challenge test … She may not have asthma … I have been suspicious for VCD [vocal cord dysfunction; a clinical phenomenon of paradoxical motion and inappropriate closing of the vocal folds].”  At a family practice encounter, the CI was diagnosed with oral candidiasis ([thrush] oropharyngeal yeast infection).  This was presumed secondary to improper rinsing of her mouth following administration of the inhalational corticosteroid (Advair).  The Advair was discontinued and the CI was started on an oral antifungal (Mycelex).  The subsequent PFTs showed normal baseline spirometry.  The FEV-1 was 93% predicted and the FEV-1/FVC was 87%.  The Methacholine challenge was positive.  The narrative summary (NARSUM), three months before separation, recounted the history and interventions.  The CI complained of regular shortness of breath with exercise.  She reported some symptomatic response to Albuterol, which she continued to use as needed.  The examiner documented “She has never been on inhaled steroids, and only has exertional symptoms, and I have not felt the need to initiate her on inhaled steroids.”  The pulmonary exam revealed good air entry bilaterally.  The lungs were clear to auscultation (listening to organ sounds, typically with a stethoscope) with no rhonchi (abnormal respiratory sounds from airway secretions), no crackles, and no wheezing.  The diagnosis listed mild to moderate persistent asthma.

The Board directed its attention to its rating recommendation based on the above evidence.  The Informal PEB, 2 months before separation, rated the asthma at 10% (VASRD code 6602; asthma, bronchial).  The VA rating decision (VARD), 11 months after separation, cited the STR as the CI did not report for the scheduled C&P exam.  The VARD rated the asthma at 10% (6602) and cited shortness of breath following exercise, mild to normal pulmonary testing, and treatment with Albuterol as needed.  The five baseline PFTs over the course of therapy were normal.  The measured FEV-1 values ranged from 82 to 99 percent predicted and FEV-1/FVC values ranged from 87 to 101 percent.  At the allergy/immunology follow-up, the CI reported the inhalational corticosteroid (anti-inflammatory) medication (Advair) had not made any difference.  While the CI had been prescribed Advair for approximately one month, it was discontinued because of the adverse effect of oral candidiasis.  The CI used the intermittent inhalational bronchodilator (Albuterol) as needed for symptomatic relief with exercise.  In that the serial baseline PFTs were normal, the overall clinical picture and medication use were consistent with the 10% rating (FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy).  The constellation of findings did not approach the 30% rating (FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication).  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 asthma condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the allergic rhinitis Category II condition was 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.  

Allergic Rhinitis.  At an allergy/immunology evaluation, the CI reported having allergy symptoms her whole life.  The assessment listed allergic rhinitis and the CI was started on a nasal corticosteroid (Nasonex) and an antihistamine (Claritin).  The NARSUM recorded a history of allergic rhinitis, but did not record any related symptoms or active medications.  The nasal exam revealed pale, boggy, enlarged, nasal turbinates ([nasal concha] scrolled spongy bones of the nasal passages) with a clear discharge.  While allergic rhinitis was listed in the past medical history, it was not listed under the final diagnoses.  The allergic rhinitis was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The allergic rhinitis was reviewed and considered by the Board.  There was no performance based evidence from the record that the allergic rhinitis condition 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 allergic rhinitis condition and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the asthma condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended allergic rhinitis condition, the Board unanimously recommends no change from the PEB determination 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 20140530, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03243.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings 

cc:
SAF/MRBR