RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03911
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040419

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Motor Transport Operator, medically separated for “asthma” with a disability rating of 0%.

CI CONTENTION:  The CI contends for a higher rating for his asthma condition.  In addition he contends for ratings for back and mental health conditions identified by the PEB. 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 - 20040802	VARD - 20050211	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	0%	Asthma, Bronchial	6602**	0%**	20041120	
Major Depressive Disorder (In remission)	Not Unfitting	Dysthymia	9433	10%	20041120	
Functional Low Back Pain	Not Unfitting	Arthralgia, Thoracic & Cervical Pines	5237	NSC	20041120	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Asthma (and Nodule Left Lung).  A note in the service treatment (STR) record dated 4 February 2002 indicated the CI had a year-long history of dyspnea on exertion (DOE), also referred to as shortness of breath (SOB).  A chest X-ray showed a 1.9cm ill-defined nodule in the superior segment of the left lower lobe.  Treatment consisted of Proventil (albuterol, an inhaled bronchodilator).  Pulmonary function testing (PFT) on 19 February 2002 revealed an FVC (forced vital capacity) 93% predicted and FEV1 (forced expiratory volume at 1 second) 87% predicted, but FEF25-75% (forced expiratory flow) was 61% predicted.  The test results were interpreted as mild obstruction.  Along with the DOE the CI had atypical non-exertional chest pain in October 2002; and an electrocardiogram (EKG) was normal.  An exercise-induced bronchospasm study in November 2002 was terminated at 9.4 minutes; however there was good oxygen saturation with heavy exercise and the test was interpreted as no evidence of EIA (exercise-induced asthma).  A series of CT scans showed no change in the size of the nodule over time; and it was felt to be benign.  A methacholine challenge test was positive for asthma in February 2003.  Singulair (montelukast, an oral indirect-acting bronchodilator) and Flovent (fluticasone, an inhalation steroid) were added to the treatment regimen.  An EKG performed in March 2003 was normal.  A CT scan in April 2003 demonstrated a 12 x 18mm well-circumscribed pulmonary nodule of the left lower lobe that might have represented a granuloma rather than a vascular malformation and it was unchanged from prior examinations.  A chest X-ray series in August 2003 demonstrated a poorly defined nodular density in the left lower lung, which was less conspicuous than in prior examinations.  The CI’s asthma remained stable through 29 August 2003, although he was using the Proventil two to three times a day.  A follow-up CT examination in September 2003 demonstrated a stable 1.6cm nodule in the left upper lobe and small calcifications in the liver and spleen likely related to granulomatous disease.  Despite taking medications for asthma, the CI continued to have dyspnea and wheezing with running.  On examination his lungs were clear.  A chest X-ray in December 2003 revealed no active cardiopulmonary disease.  

The Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 30 September 2003, approximately 7 months before separation, indicated the CI reported wheezing and SOB over several years with running.  The CI diagnoses included asthma and a pulmonary nodule of the left lower lobe that remained stable over a year of observation.  It was felt by a thoracic surgeon to be benign and did not have to be removed.  Asthma interfered with the CI’s ability to pass his physical training test and his symptoms did not improve sufficiently despite conscientiously taking his medication.

At the December 2003 MEB examination (recorded on DD Forms 2807 and 2808), 4 months prior to separation, the CI reported he had asthma, experienced SOB with running, had wheezing two to three times a week, coughed at night, and used albuterol and Flovent.  The medical examiner checked off that the lungs were normal and listed moderate persistent asthma as the CI’s medical condition/diagnosis. The commander’s statement dated 13 December 2003 indicated the CI had been off and on some sort of physical profile for asthma and he did not improve after 8 months of observation.  As a result the CI was unable to do his occupational duties, take a physical fitness test, and could not deploy with his unit.  A permanent P3 profile was issued on 13 January 2004 for asthma with limitations of all physical testing as well as no running and stretching.  However, the CI was permitted to exercise at his own pace.  

At the VA Compensation and Pension (C&P) examination dated 20 November 2004, approximately 5 months after separation, the CI reported he initially had wheezing and SOB with chest tightness during exercise which then progressed to occurring without exercise.  He also reported smoking 10 cigarettes a day.  On examination his lungs were clear with bilateral breath sounds, but with occasional wheezing on the end of expiration noted in the lower bases.  The examiner opined the asthma was currently well controlled with albuterol, Singulair, and Flovent.  A chest X-ray was normal.  At a VA C&P examination dated 6 April 2005, 12 months after separation, the CI reported he wheezed 4-5 days per week.  On 20 November 2004, PFT results showed a very severe air flow obstruction with an FEV1 of 24% predicted and a moderate restriction with a FVC of 60% predicted and 92% oxygen saturation.  The CI had paradoxical worsening after use of a bronchodilator.  Residual volume was hyper-inflated consistent with gas trapping and there was a moderate reduction in DLCO (diffusing capacity of the lungs for carbon monoxide), which measures oxygen transfer from the lungs to the blood stream.  The CI stated his symptoms were stable if he took his medicines on a daily basis.  He had quit smoking a month earlier, but he became short of breath when exposed to chemicals while he worked as a barber and hair stylist.  On examination he had decreased expiratory excursion with decreased breath sounds of both lung fields.  There were a few crackles upon inspiration and expiration, but no wheezes were heard.  Pulmonary function studies dated 4 April 2005 revealed an FVC post-treatment 26% predicted, FEV1 12% predicted, and DLCO 57% predicted, which was interpreted as very severe airflow obstruction with paradoxical worsening after bronchodilator use.  

Pulmonary Exam	PFTs-Methacholine
~14 Mo. Pre-Sep
	NARSUM
~13 Mo. Pre-Sep
	Pulmonary
~7 Mo. Pre-Sep
	VA C&P
~7 Mo. Post-Sep
	VA C&P
~12 Mo. Post-Sep
	
FEV1 (% Predicted)	56% pre/93% post	76%	--	24%	12%	
FEV1/FVC	93.3 pre/93.9 post	84.4	--	40	26	
Meds	Proventil	Singular, Proventil (Albuterol) as needed	Singulair, Flovent, Proventil	Albuterol as needed, Singulair, Flovent	Albuterol as needed, Singulair	
§4.97 Rating	30%	30% (PEB 0%)	-	(VA100%)	 (VA100%)	

The Board directed attention to its rating recommendation based on the above evidence.  The Army PEB assigned a 0% rating using code 6602 for asthma and noted the CI was non-compliant with medical management.  The VA assigned a 0% rating using code 6602 for bronchial asthma based on non-compliance and continued smoking; however, the VA assigned a 100% rating retroactive to 20 April 2004 based on the FEV1 of 24% predicted in November 2004.  The Board members first examined DoDI 1332.39 6.1.3. (failure to comply with prescribed treatment) and DoDI 1332.39 6.1.3.2. (the Service member’s failure or refusal was willful or negligent, and not the result of mental disease or of physical inability to comply.)  The NARSUM dated 30 September 2003, however, indicated that “despite conscientiously taking medication, the symptoms are not sufficiently improved.”   Additionally, the CI was treated for a mental health condition (see below) during the time of the asthma treatment.  The CI warrants a rating of at least a minimum of 30% because he used a steroid inhaler (inhalational anti-inflammatory medication).  There were no PFT results in the STR proximate to separation; however, VA results were FEV1 24% predicted at 7 months post-separation and FEV1 12% at 12 months post-separation.  While those results support a 100% rating, which is congruent with the revised VA rating, albeit the code was changed to 6604 for chronic obstructive pulmonary disease, a 30% rating was more consistent with the findings prior to separation.  Additionally, other than chemical exposures as a barber post-separation and continued smoking, which did not help his condition and more likely exacerbated it, the record is silent on any additional inter-current events, illnesses, or exposures, which could have precipitated or exacerbated his condition after separation.   

The Board members then discussed whether the nodule of the left lung, which was a referred condition by a Navy MEB, but was not a referred condition by an Army MEB to the PEB and was not adjudicated by the Army PEB, was separately unfitting.  The Board members unanimously agreed the benign lung nodule, an incidental finding in the CI’s workup for asthma with no functional impairment or limitations that significantly interfered with performance, was not independently unfitting; and, therefore is non-compensable. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the asthma condition.  

Contended PEB Conditions. 

Mental Health.  The STR did not have any primary source documentation of the condition; however, a psychiatric NARSUM dated 10 February 2004 did provide details of the CI’s mental health prior to separation.  The CI reported having a history of chronic depression since childhood.  He was initially seen on 27 March 2003 with symptoms of sleep and appetite disturbance, low concentration and energy, a feeling of helplessness and hopelessness, and a depressed mood.  He denied any suicidal or homicidal ideation.  The chronic depression was continuous and he had one prior episode of medication overdose when he had difficulty coping with a particular life situation.  A mental health examination found the CI to be cooperative, alert and oriented to time, place and person.  He engaged in conversation and his speech was clear and of an adequate rate and volume.  There was no evidence of psychosis or mania and his thoughts appeared to be linear and goal-directed.  His mood had been irritable and depressed, but he demonstrated a full range of appropriate emotions including anger.  His concentration was good and his memory was intact as was his cognitive functioning.  He displayed good insight and judgment as well as voluntary control over his behavior.  The diagnosis of a major depressive disorder (in remission) was made.  Treatment consisted of increasing doses of Zoloft (sertraline, an antidepressant medication) which afforded significant improvement in his clinical depressive symptoms.  The CI planned to resume marital counseling and he was to return for follow-up, but the he failed to do so.  However, the CI called the examiner to report his symptoms were and remained in complete remission.  The psychiatrist noted the CI had the capacity for worldwide deployment and no longer required treatment for the depression.  A VA C&P examination for mental disorders was performed on 20 November 2004.  The CI reported he was depressed because he could not continue his military career and was treated with Celexa (citalopram, an antidepressant).  On examination his mood was low; affect was congruent with his mood and was mildly constricted; thought process was coherent and there was no suicidal or homicidal ideation.  Insight and judgment were adequate and higher cognitive functioning was intact.  His Axis I diagnosis was dysthymia and the GAF [Global Assessment of Functioning] was 69 (some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships.)  

Low Back Pain.  The CI was in a motor vehicle accident on 29 March 2002, developed neck strain, and was treated with Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug) and Skelaxin (metaxalone, a muscle relaxer).   In May 2002 the CI complained of stiffness and pain in the lower back; his neck had progressively gotten better since the accident.  X-rays of the lumbosacral spine showed no obvious fracture or dislocation.  The CI underwent chiropractic treatment and commenced physical therapy in June 2002.  The CI reported lower back pain for 2 months on 22 April 2003.  In July 2003 the CI reported he had received maximum benefit from a chiropractic stand point, but had intermittent pain of the mid and lower back.  On examination there was discomfort with full flexion.  At an orthopedic evaluation in January 2004, the CI noted he had recurring lower back pain, but he had been able to perform the duties of his MOS.  He claimed some relief with physical therapy, but the pain was aggravated by load-bearing equipment, his flak vest, and heavy lifting.  An orthopedic surgeon noted in January 2004 that the CI had “functional back pain which had not limited his ability to perform the duties of his current MOS.”  An addendum to the MEB dated 10 February 2004 indicated the CI developed chronic low back pain as a result of a motor vehicle accident. The CI denied radicular pain, paresthesias or weakness of the lower extremities as well as bowel or bladder dysfunction.  The pain was most severe in the morning and was aggravated by heavy lifting.  On examination he was able to reach ankle level on forward flexion.  He was able to laterally bend to the mid-thigh and hyperextend 20 degrees.  There was no evidence of kyphosis, lumbar lordosis or scoliosis and there was no paravertebral muscle tenderness or midline tenderness of the lumbosacral spine.  A neurological evaluation was unremarkable.  X-rays of the lumbosacral spine revealed normal disc spacing and no evidence of a degenerative process, spondylolysis (a defect in the vertebra, usually L-5) or spondylolisthesis (one vertebra overrides another vertebra).  At the VA C&P examination there was no tenderness to palpation over the cervical, thoracic or lumbar spine and the neck and back range of motion measurements were within normal limits.

The aforementioned conditions were reviewed and considered by the Board.   There was no 
satisfactory duty performance.  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 either of the contended conditions so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the asthma condition, the Board unanimously recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97.  In the matter of the contended mental health and low back pain 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 the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Asthma	6602	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140802, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160009408, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical
, separation minus the amount of severance pay you were previously paid at separation.

The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.   Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Deputy Assistant Secretary of the Army

Enclosure