RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01835
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20060922

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Aviation Operations Specialist, medically separated for “cognitive disorder” with a disability rating of 10%.

CI CONTENTION:  Review all conditions.  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 - 20060709	VARD - 20071101	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cognitive Disorder	9326	10%	Neurocognitive Deficits	9326	NSC	STR	
History of Major Depression Disorder	Not Unfitting	Mood Disorder	9435	10%	20070612	
History of Lymphocytic Thyroiditis 	Not Unfitting	Hashimoto's Disease or Hypothyroidism	7903	10%	20070717	
Post Ablative Hypothyroidism	Not Unfitting					
Metabolic Syndrome with History of Diastolic Hypertension	Not Unfitting	No VA Placement	
Hyperlipidemia with a History of Gestational Diabetes	Not Unfitting	No VA Placement	
PPD Convertor on INH Therapy	Not Unfitting	No VA Placement	
Papillary Thyroid Cancer	Not Unfitting	No VA Placement	
G1, P1 Status Post C-Section	Not Unfitting	No VA Placement	
Status Post Rhinoplasty, Thyroid Scar Revision and PRK	Not Unfitting	No VA Placement	
History of Urge Incontinence	Not Unfitting	Urge Incontinence	7599-7517	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Cognitive Disorder.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s cognitive disorder began in July 2002 associated with a thyroid condition.  She complained of fatigue, anxiety and depression; had difficulty remembering names and numbers and needed extra time to send e-mails.  She deployed to Afghanistan from May 2004-April 2005.  Upon her return she required frequent medical visits for depression and medication changes.  During the 23 June 2005 neuropsychology examination, the CI reported memory problems, difficulty performing some simple tasks and intermittent periods of disorientation.  Neuropsychological tests revealed deficits in attention, concentration, short-term memory and visual and verbal memory indicative of thyroid dysfunction.  She was diagnosed with cognitive disorder not otherwise specified (NOS), and anxiety disorder NOS with a Global Assessment of Functioning (GAF) score of 55 (moderate symptoms, impairment.)

The 18 October 2005 MEB psychiatry addendum noted the CI was “doing fine.”  The mental status examination was essentially normal.  Her psychiatric prognosis was “fairly good.”  The examiner opined the CI had “minor psychiatric limitations,” should be given an S2 profile and would probably require a moderate level of psychiatric care.  Indefinite antidepressant use was also recommended.  She was diagnosed with major depressive disorder, recurrent, in remission with a GAF score of 70 (mild symptoms, impairment.)  The 13 February 2006 commander’s statement attributed the CI’s frequent fatigue, anxiety, depression, memory loss, difficulty in focus, concentration, and multi-tasking to fluctuations in her thyroid hormone.  The commander asserted the CI’s symptoms conflicted with her military duties.  The CI required frequent supervision and retraining.  

The 7 March 2006 MEB NARSUM examination, 7 months prior to separation, noted complaints of thyroid dysfunction and neurocognitive deficit.  Psychological testing reflected situational stress, negative self-image, memory difficulty, anxiety, introversion, decreased self-esteem, depression and somatic preoccupation (pain and fatigue); indicative of patients with thyroid dysfunction.  The CI was taking Synthroid (thyroid replacement hormone,) INH (anti-tuberculosis) and Zoloft (anti-depression) medications daily.

Repeat neuropsychological testing on 11 April 2006 showed fatigue, difficulty with efficient expression, word-finding issues, difficulty with memory and decreased attention.  The examiner opined her current cognitive weaknesses and deficits were likely an expression of both her medical condition and psychological issues.  The CI was diagnosed with cognitive disorder NOS with a GAF score of 60 (moderate impairment).

During the 12 June 2007 Compensation and Pension (C&P) psychiatric evaluation, 9 months after separation, the CI reported continued periods of anxiety, depression, insomnia, hopelessness, but denied suicidal thoughts or plans.  The mental status examination revealed moderate to severe anxiety and depression, and moderate insomnia or excessive sleep.  The CI was diagnosed with mood disorder secondary to thyroid condition with a GAF score of 55 (serious symptoms).  

At the 17 July 2007 C&P General examination, the CI reported being tired, inability to lose weight (153 pounds at 5’3”) and had dry hair and skin.  Her most recent thyroid hormone test (3 April 2007) was normal.  She was in the midst of a divorce, had not worked since discharge from the Service and stayed home with her 5-year-old child.  She was taking Levothyroxine (thyroid replacement), Zoloft and Wellbutrin (two anti-depression) medications.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cognitive disorder 10%, coded 9326 (dementia due to other neurologic or general medical conditions), citing “industrial impairment rated as mild.”  The VA did not service-connect the cognitive disorder, but rated mood disorder secondary to thyroid condition at 10%, coded 9435 (mood order, not otherwise specified), based on the C&P evaluation 9 months after separation, citing moderate to severe anxiety and depression, with moderate sleep impairment due to insomnia or excessive sleep, and a GAF score of 55.

The MEB NARSUM examination noted the CI developed psychological and physical complaints after treatment for thyroiditis and thyroid cancer.  Neuropsychological testing confirmed the CI had cognitive deficits indicative of thyroid dysfunction, which had not been resolved by a thyroid replacement hormone.  Both the MEB NARSUM and repeat neuropsychological testing (April 2006) revealed anxiety, memory loss and depression.  The commander noted the CI’s symptoms conflicted with her military duties and the CI required frequent supervision and retraining.  The panel determined the CI had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the cognitive disorder, coded 9326.

Contended PEB Conditions: Metabolic Syndrome with History of Diastolic Hypertension; Hyperlipidemia with a History of Gestational Diabetes; PPD Convertor [Positive TB] on INH [Isoniazid] Therapy; History of Major Depressive Disorder; Status Post C-Section; Status Post Rhinoplasty [Nose Plastic Surgery], Thyroid Scar Revision and PRK [Laser Eye Surgery]; History of Urge Incontinence; History of Lymphocytic Thyroiditis and Hashimoto's Disease; Post Ablative Hypothyroidism; and Papillary Thyroid Cancer.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The commander’s statement noted the CI’s glucose intolerance, history of gestational diabetes and urge incontinence conditions, but did not endorse their impediment to satisfactory performance of duties.  The commander also noted the presence of anxiety and depression but asserted these conditions were a result of thyroid hormone fluctuation.  The March 2006 MEB psychiatric addendum diagnosed major depression in full remission.  The thyroid condition was profiled and the commander’s statement noted the residual effects (neurocognitive deficits of fatigue, anxiety, depression, memory loss difficulty in focus, concentration and multi-tasking) of thyroid treatment and continuing fluctuations of thyroid hormone.  The panel agreed these conditions were subsumed under the unfitting cognitive disorder to avoid pyramiding (VASRD 4.14), but did not impede the satisfactory performance of the CI’s military duties.  None of the contended conditions were judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the cognitive disorder, the panel recommends a disability rating of 30%, coded 9326 IAW VASRD §4.130.  In the matter of the contended history of lymphocytic thyroiditis and Hashimoto's disease; post-surgical, post ablative hypothyroidism; metabolic syndrome with history of diastolic hypertension; hyperlipidemia with a history of gestational diabetes; PPD convertor on INH therapy; papillary thyroid cancer; history of major depression disorder; status post C-section; status post rhinoplasty; thyroid scar revision; PRK and history of urge incontinence, the panel recommends no change from the PEB determinations as not unfitting.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Cognitive Disorder	9326	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170329, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180005422, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs [and to the counsel you listed on your application; [name and address]].

Sincerely,					      
Enclosure