RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00490
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030528

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Linguist in Training, medically separated for “vasovagal syncope” with a disability rating of 10%.  

CI CONTENTION:  The CI contends that he was not given a fair evaluation at discharge.  The applicant’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 - 20030409	VARD - 20040124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Vasovagal Syncope	8299-8210	10%	Left Ventricular Hypertrophy	7000	0%	20030721	
			Tachycardia	7010	NSC	20030721	
			Vasovagal Syncope	7020	NSC	20030721	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Vasovagal Syncope.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s syncope condition began in January 2002 after an episode of chest pain and syncope (loss of consciousness) led to an emergency room evaluation.  The CI had an episode of chest pain and near syncope and an additional syncope with chest pain event within the next month.  At the cardiology consultation in September 2002, the CI related a history of three to four episodes of syncope or near syncope, all of which had been associated with chest pain after exertion.  He typically noted that he becomes sweaty, and then lightheaded and had syncope or near syncope.  Cardiac evaluation documented normal cardiac electrical activity without arrhythmias, an enlarged heart (mild left ventricular hypertrophy) with normal pumping function, a normal exercise test (reaching a MET level of 17).  An echocardiogram and a cardiac angiogram indicated an ejection fraction of 65% (normal) with mild concentric ventricular hypertrophy and no other heart abnormalities.  Treatment, including medication, did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic chest pain, left ventricular hypertrophy” and “syncope with vasovagal etiology, cardiac workup negative” for PEB adjudication.  

According to the MEB examination (recorded on DD Form 2807 and 2808) dated January 2003, 3 months prior to separation, the CI reported chest pain and pressure on a chronic, recurring basis as well as dizziness and fainting spells associated with his heart condition.  He indicated that he fainted four times between March and July 2002 during strenuous exertion.  Clinical chest and heart examinations were normal.  The NARSUM dated March 2003, 3 months prior to separation, the CI reported summarized the MEB examination history and the cardiology consultation and record findings as above.  The diagnoses were chronic chest pain; syncope consistent with vasovagal etiology, as cardiac workup negative; and, left ventricular hypertrophy.  

At the VA Compensation and Pension (C&P) examination in July 2003, performed 2 months after separation, the CI reported having had multiple syncopal episodes starting in 2002 with a total of 5 blackouts and 50-70 near syncopal episodes and chest pain with any strenuous activity.  Physical examination showed normal blood pressure with normal chest and heart clinical exam.  The diagnosis was syncope of unknown etiology, and further workup from a requested cardiology consult was pending.  The examiner indicated that the CI’s presentation did not fit the pattern of a vasovagal response, and that multiple complex cardiology tests may be need to be interpreted for a final diagnosis.  The VA cardiology consultation dated August 2003 indicated that vasovagal syncope was only a presumptive diagnosis and there was no evidence to support the diagnosis of vasovagal syncope.  There was not any other medical evaluation or evidence following the January 2004 VARD.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the analogous 8210 code (paralysis of:  tenth (pneumogastric, vagus) cranial nerve), citing cardiac testing results and a moderate level under the vagus nerve.  The VA assigned a 0% rating for left ventricular hypertrophy using the 7000 code (valvular heart disease) as well as not service connected (NSC) findings for vasovagal syncope coded 7020 (cardiomyopathy) and tachycardia coded 7010 (supraventricular arrhythmias) based on the VA C&P examination 2 months after separation.  The VA cited the cardiology testing results of concentric hypertrophy with ejection fraction of 65% and exercise tolerance of 17 METS, no diagnosis of tachycardia and no VA examiner diagnosis of vasovagal syncope.  Syncope symptoms can be due to many different causes and when there is no clear etiology (underlying diagnosis), disability coding IAW VASRD criteria require judgment of which analogous coding (IAW VASRD §4.20) is most appropriate.  For rating analogously under code 8210 (vagus nerve), there was not sufficient evidence to support greater than the incomplete moderate (10%) rating awarded by the PEB.  There was some cardiac pathology (concentric hypertrophy) for possible rating under §4.104 (schedule of ratings–cardiovascular system), however, given the tested ejection fraction and greater than 10 METS there was no cardiac coding that would support greater than the 10% awarded by the PEB.  The Board next considered rating the syncopal episodes (loss of consciousness) analogously to 8108 (narcolepsy), as recommended in some tables of analogous codes for unspecified syncope.  The record supported at least two full syncope episodes within the 6 months prior to separation which justified the 20% rating.  The Board did not adjudge that the more frequent episodes of near syncope equated to either narcolepsy or a minor seizure (narcolepsy rating criteria) and there was insufficient evidence to support the criteria of “averaging at least 5 to 8 minor seizures weekly” for the next higher rating.  
After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the syncope condition, coded 8210-8108.  

BOARD FINDINGS:  In the matter of the syncope condition, the Board unanimously recommends a disability rating of 20%, coded 8210-8108 IAW VASRD §4.124a.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Vasovagal Syncope	8210-8108	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150530, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX AR20160014390 (PD201500490)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA