RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02444
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080828

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Calvary Scout, medically separated for “chronic fatigue as a residual of severe heat injury” and “mixed headache syndrome, including migraines as residual of severe heat injury” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI made no specific contention.  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 - 20080512	VARD - 20130717	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Fatigue 	7999-7903	10%	Symptoms of Chronic Fatigue	6399-6354	0%	20130717	
Mixed Headache Syndrome	8199-8100	10%	Migraine Headaches	8100	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Fatigue.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s fatigue condition began in August 2007 after collapsing at a “best squad” competition with heat stroke with rhabdomyolysis.  Since that time the soldier had extreme fatigue and severe headaches.  The 19 February 2008 MEB NARSUM examination, 6 months prior to separation, noted complaints of extreme fatigue with walking greater than 200 meters or lifting light weights.  He also complained of twice daily headaches with a varying pain level of 5-10/10.  Physical examination was completely normal including muscle strength, sensory and neurological examinations and a normal mini mental status examination.  The 17 July 2013 VA Compensation and Pension exam took place 5 years after the CI left the military and was too far from the date of separation to provide information relevant to the PEB rating.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic fatigue condition 10%, coded 7999-7903 (analogous to hypothyroidism), citing the CI continued to suffer from long-term fatigue with walking greater than 200 meters or lifting light weight.  The panel noted that the STR for review in this case was missing almost all records related to the CI following the initial heat stroke incident.  The panel’s decision is based primarily on the evidence in the NARSUM.  The panel agreed there was evidence of fatigability to justify the 10% rating adjudicated by the PEB.  There was no fatigability, constipation and mental sluggishness that supported an analogous 30% rating under the VASRD diagnostic codes for Hypothyroidism (7903).  There was no other VASRD §4.121 route to a higher rating under any applicable code for heat stroke residuals.  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 fatigue condition.  

Mixed Headache Syndrome.  According to the STR and the MEB NARSUM, the CI’s headache condition began in August 2007 after collapsing at a “best squad” competition with heat stroke with rhabdomyolysis.  Since that time the soldier had extreme fatigue and headaches.  The headaches symptoms included blurring of vision, photophobia, sonophobia, photopsia, short term memory loss and nausea.  His pain had been biparietal to temporal/frontal in location and described as pulsating and squeezing.  The headaches were daily and constant but with the medication tramadol, they were decreased to twice a day headaches lasting 1-12 hours.  The diagnosis of migraine headache was confirmed by a neurologist.  Lab work, brain MRI and EEG could not find a cause of the headaches.  The headaches which had not improved in the previous 6 months despite various medications resulted in the MEB which forwarded heat stroke with rhabdomyolysis with long term fatigue and headaches as sequelae for PEB adjudication.  The 19 February 2008 MEB NARSUM examination, 6 months prior to separation, noted complaints of extreme fatigue with walking greater than 200 meters or lifting light weights.  He also complained of twice daily migraine headaches with a varying pain level of 5-10/10.  Physical examination was completely normal including muscle strength, sensory and neurological examinations and a normal mini mental status examination.  In the 25 February 2008 Commander’s letter, 6 months prior to separation, the commander stated that although the CI had limited physical fitness he had “been performing his duties in garrison to a high level of proficiency”.  The 17 July 2013 VA Compensation and Pension exam took place 5 years after the CI left the military and was too far from the date of separation to provide information relevant to the PEB rating.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the mixed headache syndrome condition 10%, coded 8199-8100 (analogous to migraine), citing prostrating headaches averaging 1 every 2 months.  The panel noted that the STR for review in this case was missing possible records related to the CI following the initial heat stroke incident.  The panel’s decision is based primarily on the evidence in the NARSUM.  The rating options under 8100 for migraine headaches, which are open to consideration in this case, rely on the frequency of ‘prostrating’ attacks.  The DoDI 1332.39 para. E2.A1.4.1.4 (in effect at separation, but since rescinded) required that “the Service member must stop what he or she is doing and seek medical attention.”  However, VASRD §4.124a does not require seeking medical attention for an attack to be considered prostrating, and a common (court-sanctioned) approach is to apply the clear English definition of prostrating.  The panel carefully considered the frequency and nature of the CI’s headaches including objective evidence and corroborating subjective evidence.  It was clear from the NARSUM that the CI was having twice daily headaches since the initial heat stroke.  Yet the commander stated that the CI had “been performing his duties in garrison to a high level of proficiency” with no mention of reduced work days, leaving work early, of having to take frequent breaks due to his migraine headaches.  The panel majority concluded that there was no evidence in the STR or NARSUM that the CI’s headaches rose to the level of “prostrating” as defined above to justify a higher rating (8100).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the migraine headache condition.  

BOARD FINDINGS:  In the matter of the chronic fatigue condition and IAW VASRD §4. 121, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the mixed headache syndrome condition and IAW VASRD §4. 124a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommended re-characterization and did not elect to submit a minority opinion.  There are 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 20151012, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012917, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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,					      
						      					
Enclosure