RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00432
BRANCH OF SERVICE: Army 	SEPARATION DATE:  20081002

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Trainee, medically separated for “asthma, primarily exercise induced” with a disability rating of 10%.   

CI CONTENTION:  “Review 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 based upon a 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 - 20080915	VARD - 20100405	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Asthma	6602	NSC	STR	
Bipolar Disorder	9432	EPTS	Bipolar Disorder	9432	NSC		
Mitral Valve Prolapse	Not Unfitting	Heart Condition	7005	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  --%	

ANALYSIS SUMMARY:  

Asthma.  According to service treatment records and the MEB narrative summary (NARSUM), the CI was seen in the medical clinic in June 2008 secondary to episodes of shortness of breath (SOB) and sensation of dyspnea.  She underwent pulmonary function tests without a confirmative diagnosis of asthma, but it was thought she may have asthma and should be treated for it.  The CI’s condition did not require oral steroid use on more than one occasion, or hospitalization for acute exacerbation.  Additionally, she did not require monthly visit to the physician for care of her condition.  Despite treatment, the asthma condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a Medical Evaluation Board (MEB).  The MEB forwarded “asthma, manifested by shortness of breath and exertional dyspnea, mild” for PEB adjudication.

The MEB NARSUM examination on 21 August 2008, 6 weeks before to separation, noted the CI was prescribed Flovent for daily use (inhaled anti-inflammatory).  The CI had a sensation of SOB, and chest pain.  She denied wheezing, cough, gasping and nocturnal symptoms.  The CI reported she was able to wear a helmet but was unable to wear the IBA, rucksack, or LBE due to her sensation of SOB, dyspnea, and her chest pain symptoms.  She also noted she was unable to run and if she walked greater than 1/2 mile, her symptoms worsen.  The physical examination noted normal respiratory vitals, and did not appear to be in acute distress, respiratory or otherwise.  The examiner noted the 7 July 2008 pulmonary test showed FVC of 84% predicted value, FEV1 at 83% and FEV1/FVC ratio of 87% “which was 100% of predicted.”  The VA Compensation and Pension (C&P) evaluation was performed 18 months after separation.  It was noted the CI was not taking any medication for asthma, and her PFTs were normal.  She had no current complaints of respiratory issues.  The examiner noted the CI’s methacholine test at the time of separation was negative.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the asthma condition 10% coded-6602, based on intermittent use of inhales and citing the NARSUM, July 2008 PFTs and medication profile.  The VA denied service connection, and noted the CI started on daily inhalation therapy in July 2008, but there was no current medical evidence of record that showed her disability was clinically diagnosed.

The Board noted in the last STR in evidence (3 weeks before the NARSUM the CI was prescribed inhaled bronchodilation therapy daily.  The C&P exam noted the CI had no respiratory issues.  The CI reported absence of symptoms and treatment since discharge.  While, evidence (before separation) of daily anti-inflammatory inhalation use was not clear, clinical objective evidence (PFTs) did not support a compensable rating.   At the C&P exam 18 months after separation, the CI noted she had not taken any asthma medications since discharge from the service and had no symptoms.  The examiner opined the CI’s asthma-like symptoms represented a post-inflammatory reactive airway following a “documented bout of bronchitis/upper respiratory infection.”

The record showed the CI underwent PFTs, 17 months after separation that were normal.  The examiner opined the CI did not suffer from asthma, and she had a negative methacholine test at the time of discharge.  The August 2008 medication profile reflects one inhaler was filled in July 2008 with no refills remaining, and no evidence of a new prescription.  Evidence of prescribed asthma medication beyond July was not present.  The Board considered the record in its totality and concluded, the CI’s condition at separation did not justify a rating higher than 10%.  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 reactive airway disease syndrome condition.  

BIPOLAR DISORDER.  According to the service treatment records (STR) and the MEB mental health narrative summary (NARSUM) the CI had 2 psychiatric hospitalizations secondary to suicidal ideation and gestures.  Her first documented encounter with MH was the result of a referral by her command in March 2008.  At that time, she had written a letter expressing suicidal thoughts, and reported symptoms of depression, irritability, loss of energy, and racing thoughts.  The CI was prescribed anti-depressant medication.  On the day of admission, 17 June 2008, the CI stated she made a “stupid decision” in her expressions and gesture of suicide.  The CI conveyed she engaged in several arguments with her boyfriend and was “stressed out” by her mother and from being away from home.  She also noted stress from the loss of her uncle who had committed suicide a few months earlier.  During the month of her loss, she made superficial cuts to her wrist out of frustration and anger.  Prior history of MH treatment or symptoms were not documented in the admission examination.  The examiner recorded a diagnosis of “rule out mood disorder, NOS [not otherwise specified]” and “history of bipolar disorder.”  The examiner noted her mood stabilizing medication would be continued and the admission would be brief.  The CI was discharged after 2 days of inpatient treatment.

The NARSUM was accomplished in July 2008, approximately 3 months before separation.  The examiner noted although the CI had notably improved in her mood symptoms with medication, compliance was an issue.  At the time of the NARSUM, the CI continued to report symptoms of insomnia, anhedonia, and lack of energy.  Bipolar symptoms were not recorded.  

The examiner noted the CI was seen by MH after the first hospitalization and reported she felt better and her mood stabilized with the medication; however, soon after discharge, she discontinued her medication, and mood lability returned with suicidal gestures.  At the NARSUM, the CI reported she had again discontinued her mood stabilizing medication.  A pre-military history of MH treatment or diagnosis was not documented.  The psychiatrist noted in summary, “The history of mood lability, irritability, and manic switch with Prozac suggest a diagnosis of bipolar disorder.”  The examiner diagnoses the CI with bipolar I disorder and dysthymic disorder.  The VA Compensation and Pension (C&P) mental examination was conducted 18 months after separation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB determined the bipolar disorder existed prior to service and was not service aggravated beyond natural disease progression.  The VA, used the STR and denied service connection based on medical evidence of record that failed to show the bipolar condition had been “clinically diagnosed.”  It was noted the STR demonstrated the bipolar disorder was well-controlled on medication and the evidence of record “does not show you have a current diagnosed mental health condition.  Therefore, service connection is denied.”

The Board first considered the PEB’s decision that her condition EPTS.  The Board referred to the 9 December 2009 memorandum to the PEBs regarding medical principles, presumption of soundness and permanent service aggravation.  The memorandum stated, the PEB must document all findings of EPTS, not service aggravated, IAW 10 USC§ 1222, by citing to all information upon which the PEB based its determination.  The Board noted DA FORM 199 recorded “There is compelling evidence to support a finding that the current condition EPTS and was not permanently aggravated beyond natural progression by such service.  The Soldier’s bipolar disorder existed prior to entry.  The psychiatrist estimates time of onset as 2004.”  The Board noted there was no documentation of a MH condition at the time of entry into the service and no mention of prior to entry MH treatment or diagnosis.  The Board acknowledged the NARSUM acknowledged the condition EPTS; however, there was no indication the CI was diagnosed with bipolar disorder prior to service. The DoDI notes the “PEB cannot rely on mere conclusory statements from the MEB regarding the issue of EPTS.  The MEB should ascertain whether the Soldier’s condition existed prior to military service and/or was permanently service aggravated by military service using this same method, i.e., using and citing well-established medical principles as applied to the Soldier’s specific presentation. When the MEB does not perform this detailed level of analysis, the PEB may supplement the record.”  The Board found no evidence this burden was met; therefore, a determination of EPTS could not be upheld.

Next, the Board noted there was no specific, highly stressful service related event to invoke §4.129 for a mental disorder due to traumatic stress.  The Board proceeded to rate under §4.130 and considered the NARSUM, the commander's statement (CS), and the C&P for historical data.  The NARSUM noted the CI’s condition had improved; and her mood was stable despite absence of medication use.  Treatment records were silent going forward.  The commander did not implicate a MH condition.  It was noted she worked an 8-hour duty, had no difficulty with memory, concentration, communication, or judgment. The C&P examination, noted the CI had not participated in MH treatment, including no psychotropic medication use since her discharge from the service (18 months after separation), and her mood was stable.  She was working full-time.  Her only complaint was related to her physical condition.  The examiner noted she did not meet criteria for a primary mental disorder.

Board members agreed her symptoms were stable at the time of separation, and did not require the continuous use of medication; therefore, her condition was best reflected in the 0% disability rating for “A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.  After due deliberation, and in consideration of all the evidence and VASRD §4.3 (reasonable doubt), the Board recommends a 0% rating for the bipolar I condition.

Contended PEB Condition-Mitral Valve Prolapse.  The mitral valve prolapse condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance based evidence from the record that the contended 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 contended condition and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the asthma, primarily exercise induced condition and IAW VASRD §4.97, the Board recommends no change in the PEB adjudication.  In the matter of bipolar disorder condition and IAW VASRD 4.130, the Board recommends a disability rating of 0%, coded 9432.  In the matter of the contended mitral valve prolapse condition, the Board agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Asthma	6602	10%	
Bipolar Disorder	9432	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150601, 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20160019848 (PD201500432)

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