RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00395
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071116

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

CI CONTENTION: The applicant believes his condition should be re-characterized under a different diagnosis.  The complete submission is at Exhibit A.”  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20071009	VARD- 20080229  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Exertional Heat Intolerance …	7999-7900	0%	Exertional Rhabdomyolysis	8999-8911	NSC 	20080111	
RATING:  0%	COMBINED RATING OF ALL VA CONDTIIONS:  N/A	

ANALYSIS SUMMARY:  

Exertional Heat Intolerance.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s heat intolerance condition began in June 2006 after an 8 mile ruck march and recurred in August 2006.  Both episodes included symptoms of vomiting, dizziness and lethargy; while the latter resulted in loss of consciousness.  Both episodes were reportedly treated in the field with intravenous (IV) fluid hydration with no STR documentation.  The CI did not go undergo further evaluation.  

On 2 separate visits on 22 August 2006 (after a ruck march) and 26 October 2006, increased CPK levels were noted.  Testing for blood glucose levels and kidney function (urinalysis) was normal. Oral rehydration and quarters was prescribed.  CPK levels normalized within one week on both occasions.  

At a February 2007 internal medicine consultation, other causes for abnormally elevated CPK levels (overwhelming infection, hyperthyroidism, stroke, seizure, drug withdrawal or toxicity) were not found.  The CI reported “multiple episodes” of abdominal discomfort, nausea, and vomiting, and denied sweating, loss of consciousness, and seizure activity.  The physical examination was unremarkable.  An electrocardiogram (heart tracing) was normal.  Blood and thyroid testing, and a urinalysis were normal.  The CI was diagnosed with “exertional heat stroke.”  

The February 2007 MEB examination (recorded on DD Forms 2697 and 2807-1), 9 months prior to separation showed a “mild” elevation in blood pressure, and a normal body temperature, respiratory and heart rate.  Physical examination showed a “mild” elevation in blood pressure, and a normal body temperature, respiratory and heart rate.  A partial blood count and urinalysis were normal.  

Two separate commander’s statements, dated 18 April 2007 and 11 September 2007, 7 and 2 months prior to separation, did not reference any mental disabilities or limitations that interfered with his safety and performance or with unit readiness.   At a 17 May 2007 psychiatric evaluation, 6 months prior to separation, no diagnosis was rendered.  

At the 21 August 2007 MEB NARSUM examination, 3 months prior to separation, the CI reported recurrent symptoms (dizziness, pallor, staggering gait) with walking more than 400 meters, running, carrying more than 15 pounds, and standing more than 15 minutes.  The examiner documented normal vital signs and an unremarkable physical examination.  

At the 11 January 2008 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI denied musculoskeletal problems, headache, and any knowledge of kidney damage, summarizing that he had been “fine since discharge.”  Physical examination showed no evidence of hypertensive retinopathy (retinal damage from high blood pressure), thyroid disease, or abnormal cardiopulmonary examination.  Blood testing documented no evidence of kidney or liver disease.  Electrocardiogram revealed a slow heart rate but was otherwise normal.  Chest radiographs were normal with no evidence of lung or cardiac disease.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated 0% for the exertional heat intolerance condition, analogously coded 7999-7900 (hyperthyroidism), citing “3 episodes of heat stroke and mild rhabdomyolysis” and no residual impairment  

After initially denying service connection, a 20 August 2009 VA rating decision rated the “exertional rhabdomyolysis” 0% from the date of separation, analogously coded 8999-8911 (epilepsy, petit mal), citing an elevated CPK level and based on the 4 August 2009 C&P examination 10 months after separation.  

The panel considered the evidence for rating and noted that there is no specific VASRD diagnostic code for the rhabdomyolysis condition and therefore considered the rating recommendation using several VASRD analogous codes in accordance with VASRD §4.20 (analogous ratings).  The episodes were characterized by nausea, abdominal cramping with dizziness consistent with “heat exhaustion.”  All symptoms resolved with oral or intravenous hydration.  There were no clinical findings that would qualify as “heat stroke,” in that there was no documentation of abnormal body temperatures, head trauma, or persistent “end organ” damage.  Although abnormal mental status was reported by non-medical personnel, no mental status changes were documented.  The commander’s statement did not reference any mental disabilities or limitations that interfered with his safety and performance or with unit readiness.  Although a referral to psychiatry was made, no diagnosis was rendered, therefore there were no cognitive findings in the record, no documentation of head injury, and therefore, no clinical documentation to support any neurocognitive deficits.  

There was no documentation of persistent sequellae at the time of separation in that there was no evidence of kidney disease, such as renal tubular disorders, nephropathy, or nephritis causing hypertension for rating under renal dysfunction (IAW VASRD §4.115a/b).  There was no evidence of long term drug therapy, one to two hospitalizations per year, or kidney disease requiring intermittent intensive management for a higher rating under analogous coding for urinary tract infections.  There was no evidence of heart disease resulting in dyspnea, fatigue, angina, dizziness, or syncope, and no evidence of continuous medication requirements for analogous coding under the cardiovascular codes 7001, 7006, 7007, or 7020 (IAW VASRD §4.104).  There was no evidence of tachycardia, tremor, increased pulse or blood pressure, or continuous medication for a higher rating under code 7900.  The panel concluded that there was no other more closely related option with regard to affected function, anatomic localization, and symptomatology, and that there were no residuals in evidence for a higher rating using alternative analogous codes.  There was no evidence in support of an alternate diagnosis that would be of benefit to the CI.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the exertional heat intolerance condition.  

BOARD FINDINGS:  In the matter of the exertional heat intolerance condition and IAW VASRD §4.119 and §4.124a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150531, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

17 Apr 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170005967 (PD-2015-00395)

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