RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01491
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060726

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Weather Forecaster, medically separated for “asthma,” with a disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  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 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 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 determinations 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 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 - 20060614	VARD - 20070720	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6620	10%	Asthma	6602	10%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Asthma.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI reported onset in September 2005 of worsening breathing symptoms with exercise.  At a 13 February 2006 encounter with a physician assistant (PA) for wrist pain, the CI reported a 6-month history of cough during, and after running.  The physical examination revealed the lungs were clear to auscultation with no wheezing, rales (abnormal respiratory sounds from fluid accumulation), or increased respiratory effort.  The assessment listed cough, and the PA started a trial of a bronchodilator (Albuterol), and ordered a chest X-ray, pulmonary function tests (PFTs), and placed a specialty consultation.  The 13 February 2006 chest X-ray was normal.  The 14 February 2006 PFTs revealed spirometry (measure of lung function in terms of volume and/or flow of air inhaled and exhaled) was within normal limits and the FEF25-75% increased by more than 20% post bronchodilator (Albuterol).  The FEV-1 was 108% predicted and the FEV-1/FVC was 77%.  At the 16 March 2006 follow-up, the assessment listed mild exercised-induced asthma.  The PA refilled the Albuterol and placed an allergy consultation.  The 5 May 2006 baseline PFTs recorded the FEV-1 was 96% predicted and the FEV-1/FVC was 79%.  The 5 May 2006 pharmacologic (Histamine) challenge (inhaled provocative agent to elicit bronchoconstriction to assess for asthma) produced a 34% drop in FEV-1 with Histamine 1mg/mL consistent with bronchial hyper-reactivity.  Bronchoconstriction was reversed with a bronchodilator.  The 5 May 2006 allergy/immunology consultation documented “Patient notes that over the past many months since September 2005, he noted the onset of worsening breathing symptoms with exercise.  Symptoms occur mostly with exercise, some symptoms with minimal exertion as well.  Symptoms include shortness of breath (SOB)/dyspnea on exertion (DOE), some chest tightness and wheezing.  Some coughing as well which produces some phlegm - does not know the color.  Symptoms occur within a minute or so with exercise - seems to improve with use of inhaler.  Symptoms resolve after 20 minutes on its own without treatment.  Some symptoms at rest to include cough and SOB, occurs only 1-2x/month or so.  Does use albuterol for the above symptoms, uses mostly related to exercise, a couple of times per week.  Does relate cough to some degree to phlegm in his throat, this has also occurred since September 2005.  He notes that these symptoms seemed to start after a deployment to Qatar.” 

The CI reported chronic rhinitis symptoms (nasal congestion, sneezing, runny nose, post nasal drip, and itchy nose, eyes, and ears) for many years and gastroesophageal reflux disease (GERD) symptoms a few times per month.  He denied chronic sinusitis, chronic pneumonias, eczema, rashes, emergency room visits, hospitalizations, intubations, or steroid bursts.  The active medication was an Albuterol metered dose inhaler (MDI) as needed (PRN), with the last use 1 week ago.  The physical examination documented a respiratory rate of 16 and pulse oximetry (measures peripheral arterial oxygen saturation as percentage of oxygenated hemoglobin with normal of 95-100%) oxygen saturation of 99% on room air.  The lung examination revealed the lungs were clear to auscultation, good air movement, normal respiratory effort, and no accessory muscle use.  The examiner recounted the findings of the normal chest X-ray and listed the findings from the serial PFTs and the Histamine challenge.  The assessment listed mild persistent asthma.  The allergist documented “I would recommend a trial of an inhaled steroid in an attempt to improve his symptoms.  If he lacks benefit after 1-2 months with this medication, I would then consider switching to Advair or the addition of Singulair to his regimen.  I would recommend performing allergy skin testing, and will attempt to perform this prior to my departure.”  The examiner opined “I would suspect that this patient has a good prognosis for continuing to be able to perform his military duties, assuming he is compliant with asthma medications and follow-up appointments.”  The plan documented “1. MEB for asthma per AFI A3.12.4.  2. Trial of AeroBid-M MDI (Flunisolide: 250 ug/puff) inhale 2 puffs twice a day using spacer as a trial of therapy for 2 months.  3. Albuterol MDI 2p q4-6 hours. prn and before exercise.”  

The 5 May 2006 MEB NARSUM, 3 months before separation, by allergy/immunology incorporated all the content of the same day consultation.  The allergist stated “I would suspect that this patient has a good prognosis for continuing to be able to perform his military duties, assuming he is compliant with asthma medications and follow-up appointments” but qualified for worldwide duty.   The 22 May 2006 commander’s statement documented “He has a medical condition that does not affect his ability to perform normal military duties or related tasks.  CI misses work occasionally to attend medical appointments, but does not miss work due to illness. … I believe CI is deployable to locations with a fixed Military Treatment Facility (MTF).”  The 23 May 2006 “Personal Statement on My Current Condition” documented “I don't have many symptoms of Asthma.  But when I participate in any physical activity, I am slowed down significantly due to the restrictive symptoms.  I believe that the best outcome that you could determine would be to dismiss me from military service.  I do not believe I am in any way deployable.”  On the 27 June 2006 report of medical assessment (DD FORM 2697), the CI stated he was currently taking Albuterol.  There was no VA examination in evidence within 12 month allowable window for adjudication.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 6602 code (asthma) citing asthma.  The VA assigned a 10% rating under the 6602 code (asthma) based on the Service medical records and noting the CI did not report for VA rating examination scheduled for March 9, 2007.  The VA cited mild asthma, PFTs which showed values of FEV-1/FVC of 71 to 80 percent, and need for intermittent inhalational or oral bronchodilator therapy.  The statements “I would suspect that this patient has a good prognosis for continuing to be able to perform his military duties, assuming he is compliant with asthma medications and follow-up appointments [allergist],” “He has a medical condition that does not affect his ability to perform normal military duties or related tasks [commander],” and “I don't have many symptoms of Asthma [CI],” do not suggest significant pathology.  In the 5 months from the initial prescription, the CPF and electronic medical record contain evidence of 2 Albuterol MDIs being prescribed with no refills written.  While the allergist proposed “recommendations” and associated “plans” in the allergy/immunology consultation and NARSUM, it is not evident from the CPF that these propositions were acted upon.  While the plan listed Albuterol MDI 2 puffs q4-6 hrs prn, and AeroBid-M MDI 2 puffs twice a day, it is not clear that these medications were prescribed or delivered.  In the report of medical assessment (DD FORM 2697) the CI only endorsed taking Albuterol.  Self-reports by the CI did not reflect AeroBid-M use, or suggest regular Albuterol use.

The panel agreed that only the criterion of “intermittent” use (as specified in the 10% rating description) was satisfied in this case.  The PFTs with FEV1/FVC ratios of 77% and 79%, and the overall clinical picture and medication use, were consistent with the 10% rating (FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 %, or; intermittent inhalational or oral bronchodilator therapy).  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 asthma condition.  

Contended PEB Condition:  Seasonal Allergic Rhinitis.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the asthma condition and IAW VASRD §4.100, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended allergic rhinitis condition, the panel unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150619, w/atchs
Exhibit B.  Service Treatment Record

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

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01491.

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,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings