RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	  CASE:  PD-2014-03996
BRANCH OF SERVICE:  Army                                                              SEPARATION DATE:  20090910  	

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E2, Basic Trainee, medically separated for “post pneumonia with empyema drainage, decortication, residual parenchymal scarring,” with a disability rating of 0%.

CI CONTENTION:  The CI requests the Board consider 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 - 20090829	VARD - 20110112	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Pneumonia with Empyema Drainage, Decortication, Residual Parenchymal Scarring.	6899-6844	0%	Scars, Residual of Thoracoscopy	7804	0%	20100907	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Post Pneumonia with Empyema Drainage, Decortication, Residual Parenchymal Scarring.  The service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 5 August 2009 indicated the CI complained of chest pain on 4 February 2009 along with a cough and chest congestion.  Although his temperature was normal, he had tachycardia (increased heart rate), decreased breath sounds on the left, an elevated white blood count (WBC) to 24,900 (Normal 4500-10,000) and chest X-ray findings of bilateral basilar pneumonia and a small to moderate left-sided pleural effusion.  Treatment consisted intravenous antibiotics for culture positive streptococcus.  Despite the antibiotics, vancomycin, Rocephin (ceftriaxone), and Zithromax (azithromycin), the WBC remained elevated.  Repeat serial chest X-rays showed an extensive pneumonia in the left base with atelectasis (collapse or closure of the lung) with bilateral effusions tracking to the apices (tops of the lungs).  On 8 February 2009 the CI underwent thoracocentesis (drainage of fluid from the lung) with removal of approximately 350 cc of yellow-cloudy fluid.  A CT [computed tomography] scan showed moderate-size bilateral effusions.  On 11 February 2009 he underwent a left video-assisted thoracoscopy (VATS) with decortication (removal of the surface layer) of the left lung.  A follow-up CT (computed axial tomography) scan on 14 February 2009 showed a new infiltrate in the right lower lobe consistent with pneumonia.  On discharge from the hospital, the CI’s medications included Levaquin (levofloxacin, an antibiotic), Mucinex (guaifenesin, a mucolytic medication) and Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever).   

During convalescent leave, the CI was followed with regular examinations and follow-up chest X-rays.  Upon return to duty he noted exercise intolerance and reported substantial pain on deep breathing, left-sided chest pain when lifting, and a sharp left-sided chest pain when he bent to the right.  Chest X-rays on 29 May 2009 showed pleural thickening/fluid at the left lung base and scarring at the left lower lobe with no active infiltrates.  A CT scan of the chest on 31 July 2009 demonstrated biapical pleural-parenchymal (lung lining and lung tissue) scarring, opacities at the left lung base likely representing scarring with minimal pleural thickening in the costophrenic angle (base of the lung), and opacities in the left lower lobe, which were felt to be infectious sequelae.  The NARSUM examiner noted surgical scars on the CI’s chest and decreased breath sounds in the left lung base and diagnosed the condition as status post pneumonia with empyema (abscess) drainage, decortication, and residual parenchymal scarring with pain on exercise and exercise intolerance.

At the MEB examination dated 11 June 2009 the CI reported a history of pneumonia and surgery on the left side of the chest, a cough at night and chest pain, trouble sleeping because of chest pain and trouble breathing.  The physical examiner noted a few surgical scars of the left chest that were stable and tender.  At the left lung base there was “decreased air.”  A permanent P3 profile was issued on 10 August 2009 for “1) chest pain post procedur[e] 2) post pneumonia” with limitations of physical fitness testing and all military functional activities except carrying and firing an individual assigned weapon.  The commander’s statement dated 15 November 2009 indicated the CI “needs more time to recover from pneumonia.  He is making progress and should be retained!”   

The CI established care at the VA in December 2009 at which time he noted shortness of breath.  On examination there was no dullness to percussion, rales or wheezes in the lungs.  A CT scan of the lung was unremarkable in January 2010 and at a pulmonary evaluation his lungs were clear and the thoracoscopy scars were well healed.  Pulmonary function studies in January 2010 revealed an FVC [forced vital capacity] 89% predicted and FEV1 [forced expiratory volume at 1 second] 96% predicted and a repeat study 4 days later revealed an FVC 75% predicted and FEV1 84% predicted; however, it was noted that the spirometry tests were not acceptable due to a variable effort.  A thoracic surgery consult in February 2010 for dyspnea (shortness of breath) that occurred after walking a few blocks or a few flights of stairs in the absence of pain found no anatomic basis for the dyspnea and indicated there was no surgical intervention to be taken.  In June 2010 the CI underwent a stress test for chest pain and performed 13.5 METS (metabolic equivalents), which was limited by chest pain that resolved in recovery.  An exercise myocardial perfusion SPECT [single photon emission computed tomography] study was normal with no evidence of stress induced ischemia and the left ventricular ejection fraction was 53%.

At the VA Compensation and Pension (C&P) examination dated 7 September 2010, performed 12 months after separation, the CI reported he coughed a lot, but only sometimes he coughed up some yellow-greenish mucus and noted the “more physical I get, the more it hurts” in the left upper substernal area.  On examination, the CI was very thin, bordering on emaciation and did not appear well.  His breath sounds were with good air movement.  He did not have any peripheral cyanosis (blue/gray color due to low oxygen).  Pulmonary function tests at the time of the examination could not be continued or completed due to a strong gag reflex.  The examiner opined that objective evidence was negative for a respiratory condition and that the CI had not been able to complete pulmonary function testing adequately.  Examination of the skin of the chest revealed thoracoscopy scars ranging in size 1.1 x 0.7 cm to 3.7 x 0.2 cm with two scars on the left lateral chest, one on the left mid chest, and one on the left lateral upper back.  They were well-healed without tenderness, elevation, depression, inflammation, edema, keloid (thickened scar) formation, limitation of motion, adherence, skin breakdown, skin surface changes, or inflexibility.  A remote chest X-ray in May 2012 showed unchanged mild blunting of the left costophrenic angle, which was likely scarring and there were no findings to suggest acute pulmonary disease.  Pain management with medication was instituted and left rib blocks were scheduled.  

Pulmonary Exam	PFTs ~1 Mo. Pre-Sep	PFTs ~4 Mo. Post-Sep	PFTs ~4 Mo. Post-Sep	VA C&P ~ 12 Mo. Post-Sep	
FEV1 (% Predicted)	108	96	84	35	
FEV1/FVC	103	108	112		
Meds	-	
-	
-	Not able to continue or complete testing due to a strong gag reflex	
§4.97 Rating	0%	0%	0%	-	

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 0% rating using code 6899-6844 (Post-surgical residual) for post pneumonia.  The VA assigned a 0% rating using code 7804 for scars, residual of thoracoscopy.  The Board sought a route to a higher rating, but in the absence of an active infection, use of the General Rating Formula for Restrictive Lung Disease does not offer any higher rating options based on the pulmonary function studies.  Post-separation studies were not considered adequate due to a variable effort and the CI was unable continue an additional VA study due to a strong gag reflex.  While the CI had 4 scars of the skin of the chest post VATS, they were neither unstable nor painful; therefore, a rating greater than 0% is not possible.  Rating for dyspnea is not an option since the CI had a workload of 13.5 METS.  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 post pneumonia condition.  

BOARD FINDINGS:  In the matter of the post pneumonia condition and IAW VASRD §4.97, the Board unanimously recommends no change in the PEB adjudication.  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 20140806, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

21SEP2016

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 XXXXXXXXXXXXXXXXXXXX, AR20160009449 (PD201403996)

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