RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01494
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040114

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Multiple Launch Rocket System Crewmember, medically separated for “exertional syncope” with a disability rating of 10%.  

CI CONTENTION:  His disability processing was rushed and he was told not to mention aches and pains.  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 - 20031209	VARD - 20040205	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Exertional Syncope 	8299-8210	10%	Exertional Syncope	8199-8108	NSC	20031231	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10% 	

ANALYSIS SUMMARY:  

Exertional Syncope.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s syncopal episodes condition began in May 2002 insidiously with an onset of mild dizziness, weakness, and lightheadedness three times a week. In June 2002 after running during a PT (physical training) test he experienced a syncopal episode and was revived in the field.   On 13 June 2002 he reported difficulty getting air in and was falling out of runs after two miles.  Exercise induced asthma versus deconditioning was considered.  A chest X-ray was normal.  Pulmonary function studies on 26 June 2002 were normal with an exercise challenge where the FEV1 at 15 minutes was 107% predicted, FVC 100.1% predicted, and the FEV1/FVC was 89.1%.  The CI exercised at target heart rate (162 beats per minute) for 6 minutes without incident and denied shortness of breath.  In August 2002 the CI had a graded exercise test (Bruce protocol at 14 minutes 30 seconds) and achieved 17 METS with a maximum heart rate of 192 bpm.  An echocardiogram in October 2002 showed left ventricular systolic function was normal and the ejection fraction was also normal, and there were no regional wall motion abnormalities.  Trivial aortic valve regurgitation and mild mitral valve regurgitation were present.  The CI had a near syncopal episode in December 2002 resulting in an emergency room (ER) visit.  In March 2003 he sustained a closed head injury after he raised up under the door of a tracked vehicle.  He was seen in follow-up with a post-concussive headache.  Treatment consisted of Naprosyn (naproxen, a nonsteroidal anti-inflammatory drug (NSAID)) and amitriptyline (for nerve pain).  

On 5 June 2003 the CI noted he had an increased heart rate with exertion.  A repeat stress test was performed in June 2003 and was normal, without evidence of exercise induced ischemia.   On 20 June 2003 the CI was brought to sick call for dizziness and weakness that developed while doing PT.  He had alert LOC (loss of consciousness) and was evaluated in the ER where laboratory results and an ECG (electrocardiogram) were normal.  He was seen in the ER again in July 2003 for dizziness while running and in August 2003 for syncope after running.  A neurological examination was normal on 15 September 2003 and the examiner opined that the episodic loss of consciousness was most likely a syncope and the CI’s history of tachycardia of over 200 triggered by exercise was probably the underlying mechanism.  MRI of the brain was unremarkable.  Awake and non-REM sleep electroencephalograms (EEG) were normal and no epileptiform discharges were noted.  However, the examiner noted a normal EEG did not exclude the diagnosis of a seizure disorder, and clinical coordination was recommended.  

During the 14 November 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported symptoms of dizziness or fainting spells since March 2002.  The examiner noted exertional syncope as a significant or disqualifying defect.  The 14 November 2003 MEB NARSUM examination noted complaints of difficulty with exerting himself while wearing a protective mask and difficulty keeping up with the formation on battery runs.  The CI noted he experienced syncope approximately six times with frank loss of consciousness at least five times over 18 months.  Physical examination was unremarkable. 

At the 31 December 2003 VA Compensation and Pension (C&P) evaluation, 2 weeks before separation, the CI reported that after running for about 2 miles he became light headed, fainted, and passed out.  He did not lose any time from work and took no medication.  Physical examination showed the CI was 70 inches and weighed 209 pounds.  His pulse was 84 and blood pressure was 118/66 three times.  The remainder of the examination was normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the exertional syncope condition 10%, coded 8299-8210 (tenth (pneumogastric, vagus) cranial nerve, paralysis of: incomplete, moderate), citing five episodes in 18 months.  The VA determined the exertional syncope condition was not service connected, coded 8199-8108 (narcolepsy), based on the C&P examination 2 weeks before separation, citing the examiner indicated there was no pathology to render a diagnosis.

Panel members noted the etiology of the CI’s exertional near syncopal and syncopal episodes was not determined despite an extensive workup.  However, the neurologist indicated the events occurred when the CI had a heart rate greater than 200.  The CI had a stress test where he performed 17 METS with a maximum heart beat rate of 193.  The use of code 7000 (valvular heart disease) would warrant a 0% rating.  The PEB used code 8210 to rate the exertional syncope.  The vagus nerve does mediate the lowering of the heart rate; however, there was no testing to confirm vagus nerve pathology or the extent thereof.  Therefore, panel members noted no route to a higher rating using analogous code 8210.  Members did note the VA used a code analogous to 8108, which is rated using code 8911.  However, the CI was not treated for narcolepsy and the CI had no neurological findings clinically or by EEG to suggest either narcolepsy or petit mal seizures.  Therefore, there was no route to a higher rating using any other code.  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 exertional syncope condition.  

BOARD FINDINGS:  In the matter of the exertional syncope condition and IAW VASRD §4.124a, the panel unanimously 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 20161012, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180003403, 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. 

A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXX. 

Sincerely,					      
						      					
Enclosure