RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01483
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041217

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Combat Engineer, medically separated for “syncopal attacks related to exertion” with a disability rating of 0%.  

CI CONTENTION:  No specific contention was 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 - 20041103	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Syncopal Attacks…	8299-8210	0%	No VA Examination in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Syncopal Attacks.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s syncopal attacks began in March 2004 after exertional activities including physical training.  The first episode was on 4 March 2004, which occurred after running.  An ER examiner noted the CI’s blood pressure was 121/46 with a pulse of 72 beats/minute and that he had not eaten that morning.  On 1 April 2004 the CI passed out while in formation, although he had eaten a power bar before formation.  Blood pressure was 127/49 with a pulse of 71 beats/minute.  An electrocardiogram revealed a normal sinus rhythm with a bradycardia (slow heart rate) and his blood sugar was 88 mg/dL (normal 70-100).  At a medical clinic visit on 1 April 2004 the CI indicated earlier in the day while performing physical training he felt a little dizzy, wobbly, and weird, and just blacked out.  He indicated those that observed him said he was rigid and shaking all over for about 20 seconds.  When he awakened he had a frontal headache, was very lethargic, confused, and wondered what had happened.  He was not incontinent. He was started on Dilantin (phenytoin, a seizure medication) while a seizure workup was conducted.  No specific abnormality was noted on an EEG (electroencephalogram) dated 8 April 2004.  Neurologic evaluation on 29 April 2004 noted the CI’s blood pressure was 147/50 lying down and 139/64 standing.  Further examination was unremarkable.  The neurologist noted the CI had two episodes of loss of consciousness with some seizure-like activity including tonic posturing and perhaps some clonic activity.  However, he did not bite or chew his tongue nor was he incontinent.  Both episodes were brief and occurred when standing.  The examiner opined the episodes could have represented seizures; however, they might have been seizures induced by a vasovagal episode of syncope.  He had another syncopal episode on 7 May 2004 where his blood pressure was recorded as 118/48 in the emergency room.  The CI had an asymptomatic, normal Holter monitor examination (to record heartbeat irregularities) on 12 May 2004 and a normal transthoracic echocardiogram on 13 May 2004 where the left ventricular fraction was estimated to be 65% (normal 55%-65%).  At a neurologic evaluation on 20 May 2004 the examiner doubted the CI had a seizure disorder and discontinued the Dilantin.  A sleep deprived EEG on 27 May 2004 was within normal limits.  At a medical clinic visit on 3 June 2004 the CI reported near-syncopal episodes with physical exertion, the most recent when he mowed his lawn.  At a cardiology visit on 23 July 2004 the examiner felt the CI’s symptoms were most likely neurocardiogenic syncope and he was scheduled for a tilt table test.  At a medical clinic visit on 1 October 2004 the neurocardiogenic workup was reported to be negative and the CI was started on Zestril (lisinopril, an ACE inhibitor) for hypertension of 159/72.  Follow-up blood pressure measurements were 124/60 on 7 October 2004 and 137/66 on 8 October 2004.  

The 8 October 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of episodes of passing out with activity.  Physical examination showed a blood pressure of 124/60, pulse 65 beats/minute, and respiration rate 18 breaths/minute.  Since May 2004 the CI had no syncopal episodes, but with exertional activity, he experienced significant pre-syncopal symptoms marked by a flushed, warm feeling with lightheadedness and vertigo (dizziness).  By sitting down and relaxing he was able to prevent an actual syncopal event. The CI was a well-developed, well-nourished male in no acute distress.  Head, eyes, ears, nose and throat were normal.  His neck was supple, without lymphadenopathy, thyromegaly, carotid bruits, or jugular venous distention.  His heart had a regular rate and rhythm without murmurs, and the lungs were clear.  The abdomen was benign and there was no peripheral edema.  Neurologically, he was awake, alert, and oriented times three.  There were no focal motor, sensory, cranial nerve, or cerebellar deficits noted.  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 syncope 0%, coded 8299-8210 (tenth [pneumogastric, vagus] cranial nerve), citing negative neurological and cardiac evaluations.  Panel members noted the CI did not have a stress test that would have determined the workload in METs, which is necessary for rating purposes when syncope is present.  While the electrocardiogram and echocardiogram were normal, although there was slight bradycardia, the CI was treated for hypertension prior to separation, but did have diastolic hypotension (diastole less than 60 mm Hg) on multiple occasions after a syncopal episode as well as at follow-up medical visits.  Because of the CI’s history of three syncopal episodes documented at emergency room visits and near syncopal episodes with exertion, a 10% rating using code 8299-8210 is reasonable for incomplete, moderate paralysis of the vagus nerve.  A 30% rating for incomplete, severe paralysis is not warranted since the CI did not have any additional documented syncopal episodes, although he had a near syncopal episode, but had negative neurologic and cardiologic testing.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the syncopal attacks condition, coded 8299-8210.  
BOARD FINDINGS:  In the matter of the syncopal attacks, the panel recommends a disability rating of 10%, coded 8299-8210 IAW VASRD §4.124a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Syncopal Attacks	8299-8210	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161013, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180005497, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure