RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02327
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20030812

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Dental Technician, medically separated “exercise induced 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 - 20030423	VARD - 20031112	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Exercise Induced Asthma	6602	10%	Asthma	6602	10%	20031112	
Mild/Moderate Asthma	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Asthma Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a history of reactive airway disease ([RAD] several conditions characterized by reversible bronchospasm, wheezing, and allergic reactions) as a child.  A 23 May 2001 sick call encounter reported the CI had a history of RAD as a child.  She complained of worsening shortness of breath with exercise and having difficulty taking a full breath.  “Here for waiver of PRT [physical readiness test] in lieu of symptoms.”  On 30 May 2001 internal medicine (IM) performed baseline pulmonary function tests (PFTs).  Flow-volume loops (plot of inspiratory and expiratory flow against volume during maximally forced inspiratory and expiratory maneuvers) and spirometry (measure of lung function in terms of volume and/or flow of air inhaled and exhaled) were normal.  The forced expiratory volume in 1 second (FEV-1)/forced vital capacity (FVC) was 95 percent, and the FEV-1 was 115 percent predicted.  On 4 June 2001 IM performed PFTs before and after exercise.  The baseline FEV-1 was 126 percent predicted, and the FEV-1/FVC was 99 percent.  After 15 minutes of jogging, the FEV-1 was 121 percent predicted, and the FEV-1/FVC was 96 percent.  The 5% change in FEV-1 was interpreted as within normal limits (WNL).  The 27 June 2001 normal baseline PFTs revealed the FEV-1 was 110 percent predicted, and the FEV-1/FVC was 85 percent.  The pharmacologic (Methacholine) challenge (inhaled provocative agent to elicit bronchoconstriction to assess for asthma) was positive and interpreted as consistent with a very marked response and RAD.  The 17 July 2001 IM assessment listed exercise induced asthma.  The CI was started on an inhalational anti-inflammatory (Intal [cromolyn sodium]) and an inhalational bronchodilator (Albuterol).  On 20 August 2001 IM performed an exercise PFT protocol with spirometry performed at baseline, and after exercising on a treadmill for 10 minutes at 85% of maximum predicted heart rate.  The pre-exercise FEV-1 was 124 percent predicted, and the FEV-1/FVC was 101 percent.  Serial PFTs were performed immediately after exercise, and at 5 and 10 minutes post-exercise.  The 1/5/10 minute post-exercise FEV-1 values were 125/124/126 percent predicted, and the FEV-1/FVC values were 105/102/102 percent.  The FEV-1 values were normal and there was no change in FEV-1 values and serial flow-volume loops.  The assessment listed exercise bronchoprovocation testing WNL.  “MBR [member] is fit for full duty.  MBR is fit for reenlistment.”  The 26 February 2002 family practice (FP) encounter documented the CI had been on Intal, and Albuterol as needed, for mainly exercise induced RAD.  The examiner continued the Albuterol, stopped the Intal, and started an inhalational steroid/bronchodilator combination (Advair [fluticasone/salmeterol]).  

At the 5 April 2002 FP encounter, the CI complained of chest pain/pressure and dyspnea (shortness of breath) with exercise.  She had been on Advair for 5 weeks, and Albuterol before exercise, without improvement.  “Here for PRT clearance … Pt has had (+) methacholine challenge test; Nl [normal] exercise PFTS.”  The examiner waived the CI for running the PRT and placed a pulmonary consult.  The 1 May 2002 pulmonary consultation documented “the pt has mild intermittent asthma on advair & albuterol prior to exercising and should be able to train adequately to take PRT.  If unable to pass PRT 2° wheezing, then she probably needs MEB.”  At the 13 May 2002 FP encounter the CI complained of still having chest pain and tightness with exercise and that Advair was not improving her symptoms.  The examiner continued the Albuterol, stopped the Advair, started an inhalational bronchodilator (Serevent [salmeterol]), and started an oral indirect-acting bronchodilator (Singulair [montelukast]).  The 9 September 2002 FP PRT screening impression listed asthma and the plan listed “(1) Waive from Swim and Run.  (2) Continue albuterol, singulair, and salmeterol.  (3) Continue to PT on your own in hopes of taking the PRT next spring.”  The 23 October 2002 IM encounter listed the medications as Albuterol, Serevent, Intal, and Singulair.  The assessment listed mild-moderate persistent asthma and the examiner started Advair and increased Ital from 2 to 4 times daily and before exercise.  For allergic rhinitis, the examiner started a nasal steroid (Flonase [fluticasone]) and continued an antihistamine (Zyrtec [cetirizine]).  

The 31 January 2003 MEB NARSUM examination, 6 months prior to separation, recounted the history and interventions.  The CI complained of dyspnea on exertion.  In the 14 May 2001  PRT screen “It was documented that she checked ‘yes’ to chest pain and shortness of breath, and that she noted worsening shortness of breath with running.  She told the provider that she had a history of reactive airway disease as a child (not noted on her enlistment physical), and now had difficulty taking complete breaths.”  The medications listed Albuterol, Montelukast, Advair, Cromolyn Sodium, and Fluticasone.  The physical examination revealed the lungs were clear to auscultation bilaterally with equal chest expansion.  The diagnoses listed exercise induced asthma and mild/moderate asthma, which both existed prior to enlistment, and were aggravated by service.  The examiner opined “Due to the fact that she has had multiple evaluations by at least two pulmonologists, two internists, and two family practitioners, and the fact that despite multiple medications and medication changes, she is unable to run more than one quarter mile before stopping secondary to dyspnea and wheezing, it is unlikely that she will ever be able to run.”  

On 17 June 2003, a new prescription for Intal was initiated.  The medication reconciliation also documented 17 June 2003 prescriptions for a nasal preparation (Flonase [fluticasone]), and an inhalational preparation (Flovent [fluticasone]), of the same steroid.  The CI had been historically taking Flonase for allergic rhinitis, but had not previously been prescribed Flovent.  This probably represented the wrong preparation of fluticasone being selected in the pulldown menu.  There were no STR encounters that documented a change from Advair to Flovent, and it is relatively contraindicated to be to be taking 2 inhalational steroids.  The 1 October 2003 PFTs impression listed normal spirometry with a FEV-1 of 121 percent predicted, and FEV-1/FVC of 84 percent.  

The 1 October 2003 VA compensation and pension (C&P) evaluation, 2 months after separation, regarding asthma documented “asthma, onset in 1987.  She also had it as a child, but outgrew it. … She currently takes Intal, Advair, albuterol, Singulair, and Flovent.  She reports some wheezing every two weeks for about 10 minutes when she takes the inhaler.  She does not relate it to activities or fumes.  It is triggered by weather or dust and air-conditioning.  She has never been to an emergency department, never been on oxygen, and never been on steroids.  She reports that she does not participate in sports because she is concerned about having an attack, but she has never had an attack with exercise.”  The physical examination revealed the lungs were clear to auscultation and percussion.  The examiner recounted the findings of the normal same day PFTs.  The impression listed asthma.  The 10 October 2003 chest X-rays were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 6602 code (asthma, bronchial) citing exercise induced asthma and preexisting condition reduced by 0%.  The listed Category II condition (mild/moderate asthma) was considered to contribute to the unfitting exercise induced asthma condition.  The VA assigned a 10% rating under the 6602 code (asthma, bronchial) based on the VA C&P examination 2 months after separation, citing asthma diagnosed as a child, existed prior to military service, permanently worsened as a result of service, since preservice percentage is 0, no deduction is necessary, medications, reported wheezing every two weeks for about 10 minutes when you take your inhaler, never treated at the emergency department, never placed on oxygen, never been on steroids, never experienced an attack with exercise, PFTs revealed an FEV-1/FVC of 84%, and rated for FEV-1 of 71 to 80 percent of predicted value, or FEV-1/FVC of 71 to 80 percent, or intermittent inhalational or oral bronchodilator therapy.  The panel noted, that with the exception of the methacholine challenge being consistent with a very marked response and RAD, the multiple (baseline and post-exercise) PFTs were normal.  The panel noted that the CI typically sought care for dyspnea on exertion in the context of a waiver for the PRT.  The STR contained 18 medical encounters, between 26 February 2002 and 22 July 2003, which captured the electronic medical record medication reconciliation.  The CI appeared to fill prescriptions only when medications were initially prescribed.  The last prescription for Intal, for a 6 week supply, was 17 June 2003.  The last prescription for Advair, for a 3 month supply, was 23 October 2002.  The only prescription for an Albuterol inhaler was filled on 13 May 2002.  The last prescription for Singulair, for a 3 month supply, was 20 May 2003.  The CI indicated she had been prescribed Intal, Advair, Albuterol, and Singulair in the VA C&P examination, 2 months after separation.  Had she been taking the medications as prescribed, she would have been out of the Intal, Advair, Albuterol, and Singulair for 2, 8, 13, and 1.5 months respectively, at the time of examination.  While the CI had been historically prescribed Intal, Advair, and Singulair for daily use, the evidence implies that she could not have been taking them at the time of the C&P examination.  

While the Albuterol was prescribed for use as needed before exercise, the evidence regarding prescriptions does not suggest regular use.  The panel agreed therefore, that only the criterion of “intermittent” use (as specified in the 10% rating description) was satisfied in this case.  The serial PFTs, apparent medication use, and overall clinical picture, 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.  

BOARD FINDINGS:  In the matter of the asthma 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 20150831, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

		
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