RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00551
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020608

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Multichannel Transmission Systems Operator, medically separated for “chest pain with shortness of breath” with a disability rating of 10%.

CI CONTENTION:  Review all disabilities submitted to the PEB/MEB as well as asthma. 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 - 20020422	VARD - 20021015	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chest Pain with Shortness of Breath	5099-5003	10%	Shortness of Breath and Chest Pain, with History of Exposure to TB Prior to Service	6799-6731	NSC	STR	
Depressive Disorder, NOS	Not Unfitting	Depression	9434	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chest Pain with Shortness of Breath.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chest pain and shortness of breath began in 1989 before service entry with a history of tuberculosis (TB) exposure and antibiotic treatment from September 1985 to June 1986.  Symptoms worsened in 2000 and chest X-rays in November 2000 demonstrated a cardiac silhouette at the upper limits of normal.  
At a 2 February 2001 sick call visit, the CI complained of shortness of breath for 1-2 hours after a 5-mile run.  Physical examination showed clear lungs clear and no nasal flaring or accessory muscle use as well as a regular heart rate and rhythm without murmurs.  Oxygen saturation was 99% and treatment consisted of intravenous fluids.  During follow-up 3 days later, the CI was diagnosed with a viral syndrome and treated with an antihistamine and medication for a cough. 

On 2 March 2001, the CI was evaluated by primary care for a long history of intermittent episodes of shortness of breath related to exertional activities.  A 13 March 2001 graded exercise stress test was stopped secondary to shortness of breath with left-sided chest tightness, which resolved with rest.  At a 15 Mar 2001 emergency room (ER) visit for shortness of breath, the CI was treated with a nebulizer containing Atrovent (inhalation aerosol) and albuterol (bronchodilator) and given an albuterol inhaler.  A chest X-ray series on the same day was normal.

The CI had additional ER visits on 10 April 2001 and 16 April 2001 for shortness of breath, and an echocardiogram revealed a normal-sized left atrium and left ventricle with an ejection fraction of 60-65% and a trace to mild tricuspid regurgitation.   A 16 April 2001 pulmonary evaluation noted tenderness of the chest wall bilaterally with normal chest X-rays and pulmonary function tests (PFTs).  The examiner assessed the condition as chronic pain possibly caused by TB pleurisy and scarring.  A 23 April 2001 ventilation/perfusion lung scan was normal.  

On 28 June 2001, PFTs revealed an FVC (forced vital capacity) of 74% predicated, FEV1 (forced expiratory volume at 1 second) of 83% predicted, and FEV1/FVC of 111% predicted.  The results were interpreted as mild restrictive disease with normal single breath diffusion capacity.  A 13 July 2001 CT scan of the chest was normal.  At a 24 July 2001 pulmonology visit, the examiner was cognizant of the CI’s history of TB and opined that testing showed no objective evidence of a pulmonary process for the atypical chest pain or shortness of breath.

A 2 August 2001 myocardial perfusion study was normal with no evidence of decreased blood flow or infarction.  Left ventricle size and wall motion were normal with an ejection fraction of 59%.  A graded exercise stress test on the same day was also within normal limits.  During a 6 August 2001 ER visit, the CI complained of lateral wall chest pain lasting a few hours. An EKG indicated a normal sinus rhythm without any ST or T wave changes, and Percocet (narcotic pain reliever) was prescribed for pain.  Feldene (nonsteroidal anti-inflammatory drug) and Elavil (for nerve pain) were also prescribed in August 2001, with omeprazole (proton pump inhibitor) added for possible gastroesophageal reflux disease in September 2001.  

On 21 November 2001, PFTs revealed an FVC of 70% predicted, FEV1 76% predicted and FEV1/FVC of 80%, which were interpreted as mild restrictive disease.  Post bronchodilator, the FVC rose to 75% predicted, the FEV1 to 83%, the FEV1/FVC ratio to 111% predicted, and the FEF (forced expiratory flow) 25-75% increased by more than 20%.  Chest X-rays on 26 November 2001 were within normal limits.  
 
During the 6 November 2001 MEB examination (recorded on SF Forms 93 and 88), 7 months prior to separation, the CI reported a history of tuberculosis exposure and treatment in 1989, shortness of breath, and pain or pressure in the chest.  The examiner checked “normal” for the lungs and chest on the clinical evaluation and noted a history of left-sided chest pain for 3-4 years with all ancillary/diagnostic tests within normal limits.  The examiner noted chest pain, not reproducible, and that the heart had a regular rate and rhythm without murmurs.  

The 26 November 2001 MEB NARSUM examination, 7 months before separation, noted CI complaints of chronic chest pain and shortness of breath leading to a deconditioned state.  Physical examination showed a well-appearing man with lungs clear to auscultation bilaterally.  Cardiac examination revealed a regular rate and rhythm without any murmurs, rubs, or gallops. An EKG in January 2002 demonstrated sinus bradycardia and suggestion of a right ventricular conduction delay, but was otherwise normal.  
 
At the 30 June 2003 VA independent medical (pulmonary) evaluation, 13 months after separation, the CI reported he slept upright at night because of shortness of breath that occurred with lying down.  He had dyspnea on exertion along with chronic chest pain, mostly when resting and particularly after exercise.  He was using an albuterol inhaler and had taken steroids previously.  Physical examination demonstrated clear lungs and a normal heart.   PFTs revealed an FVC of 63% predicted, FEV1 of 68% predicted, and FEV1/FVC of 107%.  Post bronchodilator, the FVC was 68% predicted, FEV1 75% predicted, and FEV1/FVC 112%.   A handwritten note in the interpretation section of the report noted “mild obstructive defect with response to bronchodilator consistent with asthma.”  A note dated 8 August 2003 indicated PFTs for total lung capacity were 36% predicted, FRC (functional residual capacity) 32% predicted, vital capacity 43% predicted, and diffusion capacity 55% corrected for alveolar diffusion capacity, which when corrected for alveolar volume was normal.  The examiner opined that “the restrictive defect could be due to chest wall deformity rather than interstitial lung process.  However, it is certainly consistent with a restrictive ventilatory defect.” 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chest pain with shortness of breath of undetermined etiology 10%, coded 5099-5003 (arthritis, degenerative), citing no objective evidence of pulmonary or cardiac pathology and rated it as slight/frequent IAW the US Army Physical Disability Agency pain policy.  The VA determined the shortness of breath and chest pain condition was not service connected, based on the STR, citing mild restrictive airway disease without evidence to show it resulted from military service instead of prior exposure to tuberculosis.  Panel members noted a discrepancy in reporting of the 30 June 2003 PFT analyses in which the examiner first indicated a “mild obstructive defect” but later stated the PFT results were “consistent with a restrictive ventilatory defect” (which was similar to the “mild restrictive disease” interpretation in November 2001).  Nevertheless, neither the FEV1 nor the FEV1/FVC ratio on several examinations exceeded a 10% rating.  The panel also considered that while the diffusion capacity was reported as low when corrected for alveolar diffusion capacity, it was normal when corrected for alveolar volume.  Therefore a rating higher than 10%, using the examiner’s interpretation of the diffusion capacity as normal, would not be achieved using code 6899-6843 (traumatic chest wall defect, pneumothorax, hernia, etc.) under the general rating formula for restrictive lung disease despite the 55% corrected for alveolar diffusion capacity.  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 chest pain with shortness of breath condition, although code 6899-6843 at 10% is more applicable than code 5099-5003 at 10%.  

Contended PEB Condition:  Depressive Disorder, NOS.  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, implicated in the commander’s statement nor judged to fail retention standards.  The 19 November 2001 MEB NARSUM psychiatry addendum, 7 months before separation, documented CI reports of a 4-year history of worsening atypical chest pain and a tendency to be more socially withdrawn and easily irritated by others as well having sleep difficulties and significantly less energy.  On mental status examination, the CI was in no acute distress with normal speech rate and rhythm and no evidence of motor abnormality.  Eye contact was good and he was oriented to person, time and place.  Memory, concentration and thinking were intact and intelligence was average.  The CI’s mood was depressed and affect was somewhat blunted, but thought processes were linear and goal directed, and judgement and insight were good.  There was no evidence of hallucinations, delusions, or suicidal or homicidal ideation.  The examiner opined the “depressive symptoms have not been of sufficient severity to significantly interfere with his performance or active duty or with his social and industrial adaptability.”  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 chest pain with shortness of breath condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended depressive disorder, the panel unanimously recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends 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 20160909, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

AR20170016254  , 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,					      
						      					
Enclosure