RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00870
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20030616

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Communications Computer Systems Operator, medically separated for “localization related epilepsy,” with a disability rating of 20%.

CI CONTENTION:  The CI contends her condition continues to worsen and negatively impact her daily activities.  Her 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 - 20030221	VARD - 20031201	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Localization Related Epilepsy	8910	20%	Epilepsy	8910	20%	20031009	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Localization Related Epilepsy.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the seizure condition began approximately 14 months prior to referral for MEB.  On 9 December 2001, the CI presented to the emergency department with a chief complaint of possible “amnesia” from 7:30 pm until 2:30 am.  She awoke shaking and disoriented at 2:30 am, went back to sleep, and awoke with sores on the tip of her tongue.  According to an 8 January 2002 neurology encounter, the CI awoke on 9 December 2002, and per her spouse was awake, "white as a ghost," and shaking.  “The morning of the 9th, around 0800, the front edge of her tongue was "purplish-black," and she had blood on the collar of her sweatshirt.  She also had diffuse myalgias [muscle aches].  She had no incontinence.  She did not fall off the bed.  She had no headache, vision changes, or focal sensory symptoms, but noted some dyesqulibrium [disequilibrium].”  The mental status examination revealed normal orientation, cognitive function, comprehension, and fluency.  The neurological examination was unremarkable.  The 3 and 8 January 2003 electroencephalograms ([EEGs] diagnostic test to assess for epilepsy) were abnormal but showed no obvious epileptiform abnormalities.  The examiner recounted the normal 8 December 2002 brain CT.  The neurologist documented “suspected GTC [generalized tonic-clonic] seizure …, but unfortunately no spell was witnessed. … I cannot say for sure whether or not she indeed had a seizure.  Further, because there is not any more convincing evidence of having multiple spells, I would not want to start her on any AED's [antiepileptic drugs] at this time.  Even if there was more convincing historical evidence for a seizure, I would not start an AED at this time due to her newly-diagnosed pregnancy.”  A 16 April 2002 neurology consultation documented “Single episode of loss of consciousness, etiology unclear:  Episode is suspicious for seizure activity, especially given muscle soreness and tongue biting.  However, while EEG's were abnormal, they were not diagnostic.  Given the fact that the patient has had no further episodes since Dec and that she is pregnant, agree with withholding treatment with AED's for now.”  On 8 January 2003, the CI was transported to the emergency department following a “seizure” in class.  “Her teacher noticed her eyes widened, then she cocked her head back.  After a few minutes, she started to shake all of her body with all four limbs jerking.  + [positive] urinary incontinence.  As per observers lasted 8 minutes.  After the GTC, patient had post-ictal confusion for 1/2 hour and was drowsy for a few hours afterward.”  She was loaded with an AED (Dilantin) and admitted to the hospital under the neurology service.  The CI was transitioned to another AED (Trileptal) prior to discharge.  A 9 January 2003 head CT was unremarkable except for two small areas of hypodensity.  A 9 January 2003 brain diagnostic imaging (MRI) study was unremarkable except for an old left frontal lobe infarct of indeterminate age.  A 9 January 2003 EEG showed evidence to support the clinical diagnosis of a localization-related epilepsy and suggested seizures might emanate from the left mid and posterior temporal regions.  A 10 January 2003 sleep deprived EEG showed evidence to support the clinical diagnosis of a localization-related epilepsy and suggested seizures might emanate from the left mid temporal region.  

The 16 January 2003 NARSUM by neurology, 5 months before separation, recounted the history and interventions.  The physical examination noted a severely macerated tongue with no broken teeth.  The mental status examination revealed normal mood, affect, orientation, comprehension, and fluency.  The neurological examination was unremarkable.  The examiner recounted the findings of the head CT, brain MRI, and January 2003 EEGs.  The diagnosis listed cryptogenic localization-related epilepsy (localization-related epilepsy of unknown cause).  The neurologist opined “This patient shows evidence of cryptogenic, localization-related epilepsy.  She apparently had partial seizures (manifested by "panic attacks") followed by a single GTC seizure.  There is a strong likelihood that she had a seizure one year ago, but without a witnessed event, that can never be fully determined.  The patient had no recurrent seizures during the period of her observation.  Two abnormal EEGs and an abnormal MRI makes it very likely that she would seize again without medication.  The patient should remain on medication lifelong as her MRI indicates she has a potential seizure focus.”  The 9 October 2003 VA Compensation and Pension (C&P) examination, 4 months after separation, recounted the history and interventions.  “She was initially treated with Dilantin and that was switched over to Trileptal, but because of side-effects she now is on Lamictal 100 mg b.i.d. [twice daily] and is doing well.  She has had no recurrent seizures.  She was medically separated from the military because of her seizure disorder.  She denies any previous history of head trauma, although she states she had a dog bite over the scalp area of her forehead when she was one year of age.”  The mental status and speech were intact and the neurological examination was unremarkable.  The diagnosis listed epilepsy.  The neurologist documented “Her neurologic examination is normal at this time.  She is doing well on Lamictal 100 mg b.i.d., concerning control of her seizures.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 8910 code (epilepsy, grand mal) citing localization related epilepsy.  The VA assigned a 20% rating under the 8910 code (epilepsy, grand mal) based on the VA C&P examination 4 months after separation, citing epilepsy,  single episode seizure of tonic clonic convulsion in January 2003, evidence of suspected seizure in December 2001, taking Lamictal for control of seizures, and no evidence of recurrent seizures since January 2003.  The board concurred the seizure in January 2003 was consistent with a major seizure (characterized by the generalized tonic-clonic convulsion with unconsciousness).  The Board established the overall clinical picture was consistent with the 20% rating under the 8910 code.  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 seizure condition.  

BOARD FINDINGS:  In the matter of the epilepsy condition and IAW VASRD §4.71a, the Board unanimously or majority 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 20150605, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00870.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXXXX

Attachment:
Record of Proceedings