RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02134
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20041203

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated for “heat stroke” with a disability rating of 0%.

CI CONTENTION:  Struggles with work due to his heat stroke condition.  The CI made no specific contention.  The CI’s 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 - 20040816	VARD - 20041230	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Heat Stroke (One episode)	7999-7900	0%	Residuals of Heat Stroke	7999-7900	NSC	20040929	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Residuals of Heat Stroke.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s heat stroke occurred on 28 August 2003 while performing a road march at which time he collapsed with a loss of consciousness for greater than 30 minutes.  A hospital discharge summary dated 3 September 2004 indicated that at the Emergency Room his initial temperature was 107 degrees Fahrenheit (F), which was lowered to 101 degrees with ice packs, a fan, and intravenous fluids.  On examination he had hypotension (blood pressure 94/82), tachycardia (pulse 146), and tachypnea (32 breaths/minute).  His oral mucosa and skin were dry.   Laboratory data pertinent to kidney status revealed a creatinine of 2.1 mg/dL (normal 0.5-1.4) and BUN of 17 mg/dL (normal 7-25), and a white blood count of 14,300 (normal 4-10,000), hemoglobin 17.2 g/dL (normal 13-17), and hematocrit 49.2% (normal 40-52).  Laboratory studies indicative of muscle damage revealed the creatine kinase was 306 U/L (normal 25-200) and myoglobin 8.6 ng/ml (normal 10-95).  An EKG revealed normal sinus rhythm of 90 beats per minute with flipped (inverted) T waves in leads II, III, AVF, V5, and V6.  He was admitted to the hospital for heat stroke and acute renal failure, which were treated with aggressive fluid hydration with normal saline.  Serial laboratory studies were followed with an elevation of troponin (predominantly a measure of heart muscle damage) noted, which was diagnosed as a troponin leak.  At discharge his BUN was 11 mg/dL and creatinine 1.0 mg/dL.  EKG status was monitored and the T-wave inversions resolved.  An echocardiogram revealed an ejection fraction of approximately 60% with no wall motion abnormalities and no cardiac structural damage.  No medications were prescribed and the CI was advised not to do any physical exertion.  Heat injury prevention was reviewed in December 2003.  Despite treatment, the residuals of heat stroke condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  

During the 8 June 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported heat stroke in 2003 and heat stroke induced heart damage 2003.  The CI’s blood pressure was 129/69 and pulse was 74 beats/minute.  The examiner noted no findings related to the heat stroke, but did list it in the summary of defects and diagnoses.  At a medical evaluation on 25 June 2004, approximately 5 months prior to separation, the CI indicated he had no risk factors for heat stroke or prior serious illnesses.  The examiner noted the CI had one episode of heat stroke with documented rhabdomyolysis (muscle breakdown) and was asymptomatic, “but only at the cost of severely limited activity.”  The CI took no prescribed or over-the-counter medication.  The examiner noted the CI had “not improved and probably will not improve.  It is difficult to predict if another episode will occur.  Exposure to elevated temperatures and work in hot or even warm weather may cause another episode that could lead to serious sequelae and might be fatal.  This may be true for the rest of the service member’s life.”  The CI was unable to perform the duties required by his MOS since he was unable to participate in any vigorous activity or work in temperatures above 85 degrees F for more than 15 minutes per day.  He could not wear any protective gear or take or pass any Army physical fitness test aerobic event and was unable to improve his strength or stamina since the injury.  

At the 29 September 2004 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported he still could not tolerate excessive heat.  On examination his blood pressure was 100/75 three times and his pulse was 70 beats/minute.  He was well developed, well nourished, and in no acute distress.  Physical examination including neurological evaluation was essentially normal.  The CI was alert and oriented times three.  Behavior was normal.  Affect was appropriate.  Comprehension was normal and memory was intact and there were no signs of tension.  Laboratory studies on 29 September 2004 revealed a BUN of 20 mg/dL and creatinine 1.6 mg/dL.  The urinalysis showed a trace of protein, ketones, and leukocyte esterase (to determine the presence of white blood cells).  A chest X-ray on 29 September 2004 showed no active pulmonary disease.  The examiner indicated for the residuals of heat stroke, there was no diagnosis because there was no pathology to render a diagnosis.  Seven months post-separation on 5 July 2005, a note from the CI’s personal physician indicated he complained of intermittent chest pains and heat intolerance.  His place of employment was very hot from molten rock and he became overheated very quickly and often became exhausted and dizzy.  The CI was advised to get out of the heat, push fluids, and rest.  In a follow-up note dated 16 December 2005, 1 year post separation, nitroglycerin was again prescribed and studies were ordered to evaluate the chest pains.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the heat stroke condition 0%, analogously coded 7999-7900 (hyperthyroidism), citing the condition was asymptomatic.  The VA did not service-connect the residuals of heat stroke, coded 7999-7900, based on the C&P examination 2 months before separation, citing no permanent residual or chronic disability subject to service connection was shown by the STR or demonstrated by evidence following service.  Members discussed whether a rating higher than 0% was possible IAW VASRD §4.119 using code 7900 for a 10% rating that requires “tachycardia, which may be intermittent, and tremor, or; continuous medication required for control,” while a 30% rating requires “tachycardia, tremor, and increased pulse pressure or blood pressure.”  However, at the time of separation, the CI had neither tachycardia, a tremor, nor continuous medication required for control.  However, members noted that the 7900 code used by both the PEB and the VA was for hyperthyroidism, a state of increased thyroid activity.  Alternatively, members considered an analogous code 5099-5025 (fibromyalgia) since the CI had rhabdomyolysis, which involved muscle inflammation.  However, a 10% rating requires continuous medication for control, while a 20% rating requires musculoskeletal pain and tender points with episodic “exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time.”  While the CI became symptomatic when exposed to heat (environmental stress), his symptoms of nausea and dizziness were not congruent with musculoskeletal pain nor were the symptoms present more than one-third of the time.  Therefore, use of the 5025 code is not a viable option for rating.   Members also discussed whether other rating options were possible since the CI did have a history of EKG changes during the acute event with troponin elevations, which were attributed to troponin spillage.  The EKG normalized prior to hospital discharge and further evaluation did not note any heart abnormalities on an echocardiogram; however, the CI did complain of intermittent chest pains post-separation, but a work-up was not performed within the year following separation.  Therefore, no rating can be applied in the absence of a stress test with measurement of METs or symptoms reported during the test.  Additionally, the CI’s renal status normalized during hospitalization, although the creatinine was minimally elevated with trace protein in the urine at the VA examination.  Nevertheless, there was insufficient evidence of any significant renal abnormality to warrant an additional rating.  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 residuals of heat stroke condition.  

BOARD FINDINGS:  In the matter of the heat stroke condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  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 20150808, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010046 , XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,