RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01285
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20040430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Basic Marine, medically separated for “pneumonia, left lung with multiple parapneumonic effusion” with a disability rating of 10%.  

CI CONTENTION:  No specific contention made.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB – 20040310 	VARD-NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pneumonia, Left Lung with Multiple  Parapneumonic Effusions	6699-6600	10%	No VA Examination Proximate to Separation in Evidence	
Status Post (S/P) Multiple Chest Tube Placement	Cat II		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Pneumonia, Left Lung.  According to the service treatment record and MEB narrative summary (NARSUM), the CI recruit was admitted to the hospital on 10 December 2003 for a 3-day history of vomiting, fever, productive cough, and chest pain prior to admission.  Chest X-rays showed a well-defined density in the left upper lobe posteriorly suggestive of a retroperitoneal mass or abscess, a left sided pleural effusion, and a totally obscured hemidiaphragm with atelectasis (collapse) of the left lower lobe of the lung.  Culture grew out streptococcal pneumonia and treatment initially consisted of Levaquin (levofloxacin, an antibiotic).  Vancomycin (an antibiotic) was added to the treatment protocol, but was changed to Ceftin (cefuroxime, an antibiotic).  Chest tubes were placed and the left upper lobe density disappeared; however there was a large, left-sided pleural effusion (collection of fluid) obscuring the left hemidiaphragm.  After hospital transfer and consultation with cardiothoracic surgery and pulmonary medicine specialists, tPA (tissue plasminogen activator -- to dissolve clots) was added to the chest tubes to facilitate drainage of the parapneumonic effusions (pleural effusions that form in the pleural space adjacent to a bacterial pneumonia).  A hydropneumothorax (air and fluid within the pleural space) required the placement of a CT guided pigtail catheter that was flushed with tPA and left to suction to drain the effusion.  The CI required supplemental oxygen and he was treated by occupational therapy and physical therapy for weakness.  On the 13th hospital day the first chest tube was removed and the second was removed on 1 January 2004.  Daily chest X-rays showed improvement in the CI’s condition and he was titrated off the supplemental oxygen.  The examiners felt the CI would need multiple weeks of rehabilitation prior to resuming training as a Marine Corps recruit.  

During the 16 January 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported shortness of breath due to pneumonia.   Physical examination revealed three 1cm chest tube scars along the left upper back, left mid back and left chest that were tender.  

The 9 February 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of shortness of breath with rapid walking, and mild left chest pain at the chest tube scar sites.  Physical examination showed scars as noted above; the CI’s lungs were clear to auscultation bilaterally both anteriorly and posteriorly.  Pulmonary function studies on 5 March 2004, less than 2 months prior to separation, revealed an FEV1 of 74% predicted pre-bronchodilator and 66% predicted post-bronchodilator, and the FEV1/FVC was 84% pre-bronchodilator and 78% post-bronchodilator.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the pneumonia condition 10%, analogously coded 6699-6600 (bronchitis, chronic).  The Category II diagnosis of status post multiple chest tube placements is intrinsic to the rated condition and a separate rating cannot be supported without pyramiding (VASRD §4.14); thus, it is appropriately subsumed under the same rating.  

Panel members noted that for rating purposes the PEB used an analogous code 6699-6600 for chronic bronchitis since there was no code for status post pneumonia.  While the FEV1 of 74% predicted pre-bronchodilator was noted, the post-bronchodilator measurement was 66% predicted, while the FEV1/FVC was 84% pre-bronchodilator and 78% post-bronchodilator.  VASRD §4.96 (5) addresses those findings as follows:  “When evaluating based on PFT's, use post-bronchodilator results in applying the evaluation criteria in the rating schedule unless the post-bronchodilator results were poorer than the pre-bronchodilator results.  In those cases, use the pre-bronchodilator values for rating purposes.”  Therefore, IAW VASRD §4.97, which states “FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; DLCO (SB) 66- to 80-percent predicted,” only a 10% rating is warranted rather than a 30% rating, which requires an “FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56- to 65-percent predicted.”  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the pneumonia, left lung condition.  

BOARD FINDINGS:  In the matter of the pneumonia condition and IAW VASRD §§4.96 and 4.97, the panel recommends no change in the PEB adjudication.   There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends 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 20160913, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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 USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN