RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02067
BRANCH OF SERVICE:  AIR FORCE 	SEPARATION DATE:  20061009

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Fire Protection Helper, medically separated for “chronic exertional dyspnea” with a disability rating of 0%.

CI CONTENTION:  “Reduced lung function and heart issues.  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 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 - 20060913	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Exertional Dyspnea	6699-6602	0%	No VA Exam in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Exertional Dyspnea.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic exertional dyspnea (shortness of breath) condition began in September 2005 after collapsing during training.  At a 28 September 2005 clinic evaluation for heat exhaustion, a chest X-ray showed a patchy airspace opacity that was presumed to be a right lower lobe (RLL) pneumonia.  The CI was treated empirically with an antibiotic (Z-Pak), corticosteroids (Prednisone) and an inhalational bronchodilator (Albuterol).  A 17 October 2005 chest X-ray showed an essentially stable appearing airspace density within the right middle lobe (RML).  The radiologist opined, “If this represents a pneumonia, would not expect this to have resolved radiographically since the prior film three weeks ago.”  

At the 3 November 2005 clinic follow-up, because of worsening productive cough, chest discomfort and sore throat, the CI was prescribed another antibiotic (Tequin) and an additional corticosteroid (Prednisone).  A 22 November 2005 chest computed tomography (CT) was normal.  The 5 December 2005 pulmonary function tests (PFTs) were interpreted as normal spirometry (measure of lung function in terms of volume and/or flow of air inhaled and exhaled).  The FEV-1 was 97% predicted and the FEV-1/FVC was 99%.  Because of persistent dyspnea on exertion (DOE) with normal PFTs, the CI was referred to cardiology.  A 1 February 2006 exercise stress echocardiogram was interpreted as normal with no evidence of myocardial ischemia or left ventricular dysfunction.  

Due to persistent DOE with normal PFTs and exercise stress echocardiogram, on 27 February 2006 the CI was referred to allergy.  Albuterol (inhalational bronchodilator) was refilled and a nasal steroid (Flonase) and antihistamine (Claritin) were prescribed.  The 29 March 2006 PFTs were interpreted as normal with no obstruction.  The FEV-1 was 90% predicted and the FEV-1/FVC was 83%.  The 29 March 2006 allergy consultation documented the CI “complains of shortness of breath if talking while walking.  Denies nocturnal symptoms.  He was given albuterol MDI at Goodfellow AFB during his course of pneumonia, which he used once without benefit.  Patient still complains of cough intermittently, with ‘coughing fits’ every few days and wheezing with these.”  The examiner recounted the findings of the normal PFTs and exercise stress echocardiogram.  The assessment listed “Bronchial hyper reactivity - patient's symptoms are not entirely consistent with asthma.  With a negative family history, negative personal history of atopy [genetic predisposition to develop immediate allergic reactions], and the additional features of his symptom complex that are not pulmonary in nature, do not feel patient warrants the diagnosis of asthma at this time.  After any upper respiratory infection, even non-asthmatics can exhibit bronchial hyper reactivity.”  The allergist refilled the inhalational bronchodilator (Albuterol).  In the pulmonology consultation, the CI complained of increased work of breathing with associated chest pain, chest tightness and intermittent wheezing with exertion.  He was taking no medications.  The pulmonologist performed a number of diagnostic studies.  The arterial blood gas (ABG) lab revealed a partial pressure of oxygen (PaO2) of 88 mmHg (75-100), and an oxygen saturation (SaO2) of 97% (94-100), on room air.  The PFTs revealed normal spirometry.  The electrocardiogram (EKG) showed normal sinus rhythm ([NSR] normal heart rate and rhythm) and evidence of early left ventricular hypertrophy (enlargement).  An echocardiogram revealed high right ventricular systolic pressure suggestive of severe pulmonary hypertension (high blood pressure in the pulmonary arteries and right heart).  The chest X-rays showed minimal bilateral hyperinflation, but was otherwise unremarkable.  Upper and lower extremity ultrasonography (US) revealed no evidence of deep vein thrombosis.  The physical examination documented a peak flow of 570 liters/minute (649 is normal for a 21-year-old, 70 inches tall) and an oxygen saturation of 98% (94-100) on room air.  The lungs were clear to auscultation with no wheezing, crackles or rhonchi (abnormal respiratory sounds from airway secretions).  The CI was started on an inhalational anti-inflammatory (QVAR) and an oral indirect-acting bronchodilator (Singulair).  

The 16 May 2008 chest X-ray was unremarkable and the pulmonary nuclear medicine ventilation/perfusion (V/Q) scan (assess for pulmonary embolism) was normal.  The 19 May 2006 pulmonology follow-up recounted the diagnostic studies and labs findings.  The pulmonologist documented “We had put him on QVAR and Singulair, did not seem to help much.  …We are going to stop these medications QVAR and Singulair from now. …The assessment of dyspnea is still undetermined.  …We are going to do six-minute walk and arrange the patient to have a limited echo again to check RVSP [right ventricular systolic pressure].”  The 5 June 2006 pulmonology follow-up recounted the diagnostic studies.  “He has no evidence of [oxygen] desaturation.  On six-minute walk, his saturation is 98%.  His echocardiogram revealed [normal] ejection fraction [% of blood ejected with heart contraction] of 52%. …Again, still undetermined etiology.  He has no evidence of reactive airway disease.  On his pulmonary function test, he had normal spirometry, normal lung volume and normal DLCO (diffusing capacity of lungs for carbon monoxide--measure of gas transfer from lungs to blood).”  Despite treatment, the dyspnea condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty.   

The 20 July 2006 MEB NARSUM examination, 3 months prior to separation, recounted the history and interventions.  The CI was taking no medications and complained of dyspnea and mild chest discomfort on exertion.  The examiner documented “Despite his extensive evaluations, he continues to experience dyspnea with minimal exertion.”  The physical examination revealed the lungs were clear to auscultation.  The examiner cited the allergy, cardiology and pulmonology consultations and recounted the various test findings.  The diagnosis listed “Despite extensive cardiopulmonary evaluation, this member continues to suffer from exertional dyspnea.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic exertional dyspnea 0%, coded 6602 (asthma, bronchial) citing chronic exertional dyspnea.  The next higher 10% rating stipulates “FEV-1 of 71 to 80 percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; intermittent inhalational or oral bronchodilator therapy.”  In this case, there were no medications prescribed.  The PFT results in this case showed an FEV-1 greater than 80 percent predicted and an FEV-1/FVC greater than 80 percent.  Therefore, a 10% rating was not supported.  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 chronic exertional dyspnea condition.  

BOARD FINDINGS:  In the matter of the chronic exertional dyspnea condition and IAW VASRD §4.97, 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 20150602, w/attachments
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-2015-02067.

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