RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-02808
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081222

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Motor Transport Operator, medically separated for “heat stroke” with a disability rating of 0%.  

CI CONTENTION:  The CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20081028	VARD - 20090625	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Heat Stroke	7999-7900	0%	Heat Injury	9399-9300	0%	20090226	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Heat Stroke.  According to the service treatment record and MEB narrative summary (NARSUM), the CI complained of a sudden onset headache and then fell over unresponsive on 18 July 2007 after he had been on the firing range for about 10 hours.  There was no known traumatic head injury during the incident.  He awoke in the ER, but only knew his last name.  He was able to move all extremities without any obvious deficits.  On examination it was unclear whether the CI even had a heat injury since his temperature was only 100 degrees Fahrenheit.  A dip stick (for glucose) was normal and a CT scan of the head was negative as was a lumbar puncture.  A drug screen was negative and laboratory studies were normal except low potassium, sodium and chloride.  Creatine kinase was 140 (normal 22-269) and the myoglobin level in the urine was negative but in the serum was 112.8 (normal 28-72).  A headache persisted despite narcotic pain medication (Dilaudid).  A non-contrast CT scan of the head was normal as were X-rays of the cervical spine and an ECG.  Treatment consisted of intravenous fluids, potassium supplementation, and monitoring.  The examiner’s impression was altered mental status, acute cephalgia (headache), hypokalemia, a syncopal event, and heat exhaustion.  The CI was admitted for observation for 2 days.  An echocardiogram revealed no significant abnormalities of structure or function of the heart.  The ejection fraction was 60% and there was a trace of tricuspid regurgitation.  At a neuropsychology evaluation in December 2007, the CI’s history indicated he was told he was “unconscious or incoherent for 45 minutes” on 18 July 2007 and had no recall of events until the morning of 19 July 2007.  With the exception of the increased headache, he denied any other antecedent symptoms.  He reported that he believed he had “over-hydrated” on that day.  He further related that he had a brief loss of consciousness in August 2004 when he was in close proximity to two explosive blasts on two consecutive days, the first of which he “blacked out,” and the second which “rang (his) bell.”  He was released from the hospital on a limited duty profile.  Thereafter, he had daily headaches and mild photosensitivity without impairment of his duties or persisting cognitive or emotional changes.  He reported treatment in the neurology clinic for the headaches, which he rated 4/10.  Mental status examination was normal.  Testing results did not show the presence of persisting marked cognitive impairment.  Serial testing of a comprehensive metabolic profile, thyroid stimulating hormone, creatine kinase, serum myoglobin and other laboratory tests were normal through May 2008.  

The 9 May 2008 MEB NARSUM examination, 7 months prior to separation, noted the complaint of heat stroke.  Since the incident, the CI reported hypersensitivity to light and exacerbation of occipital headaches that were not relieved without removing himself from the sun and going to a cool area.  The occipital headaches occurred weekly and could last for as long as 3 days.  He took over-the-counter BC powder (aspirin and caffeine) for relief.  He reported no significant intolerance to heat and denied forgetfulness and problems with memory, concentration and attention span.  He denied heat stress on the day prior to the episode of losing consciousness or a history of heat cramps, heat exhaustion, or heat stroke, or a multitude of other conditions that would cause or contribute susceptibility to heat exhaustion.  Physical examination was unremarkable.  The examiner noted the CI had one episode of heat stroke and was asymptomatic only at the cost of severely limited activity.  

At the 26 February 2009 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported a history of heat injury and headaches (not in the scope of review).  Physical examination including neurologic evaluation was normal, although it was noted that he had mild intermittent short-term memory loss.  Affect and mood were normal as was judgment.  Behavior and comprehension of commands was normal, and there was no obsessive behavior, hallucinations or delusions.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the heat injury 0%, analogously coded 7900 (hyperthyroidism), citing the Soldier has been asymptomatic, except for the headaches, since the heat stroke and enzymes and chemistries have been normal.  The VA also rated the heat injury 0%, analogously coded 9300 (delirium), based on the C&P examination, citing symptoms that were not severe enough to interfere with occupational and social functioning or require continuous medication.  Members noted the PEB and the VA rated the heat injury with different VASRD codes, one for hyperthyroidism (7900) and one for delirium (9300), neither of which are closely related to the laboratory abnormalities that are compatible with heat stroke or the clinical findings of elevated temperature, although delirium did encompass the CI’s acute findings. 

The panel first discussed whether a rating higher than 0% was possible IAW VASRD §4.119 using code 7900 for a 10% rating that requires “tachycardia (rapid heart rate), which may be intermittent, and tremor, or; continuous medication required for control.”  A 30% rating requires “tachycardia, tremor, and increased pulse pressure or blood pressure.”  However, at the time of separation, the CI had neither tachycardia, a tremor, continuous medication required for control, nor an increased pulse pressure or blood pressure.  Therefore, the 7900 code for hyperthyroidism, a state of increased thyroid activity does not offer a rating option higher than 0% with normal thyroid laboratory findings.  

The CI also did not have any abnormal laboratory findings suggestive of muscle or renal disease although he had headaches, which anteceded and followed the event and were controlled with medication and did not interfere with the performance of his duties.  He did have slight cognitive findings related to developmental learning limitations that do not justify a rating.  Therefore, there was no higher rating using code 7900, as noted previously or muscle injury or renal disease codes.  In regard to delirium, the event was temporary and code 9300 is rated IAW VASRD §4.130 (General Rating Formula for Mental Disorders) requires a mental condition to be formally diagnosed, but his symptoms were not sufficiently severe beyond the first 24 hours to interfere with occupational and social functioning or to require continuous medicine.  In this case a formal diagnosis of delirium was not made and the delirium symptoms were transient and resolved.  

Of interest was the CI’s statement that he was “overhydrated.”  The medical literature has reports related to over hydration with water during athletic events with disturbances resulting from low serum sodium, which the CI had along with low serum potassium and chloride.  He also had symptoms including headache, confusion, drowsiness and fatigue, which are also symptoms of heat exhaustion and heat stroke, but his temperature did not rise above 100.2 degrees and certainly was not greater than 104.0 degrees, which is compatible with the diagnosis of heat stroke.  Neither did he have dark urine or muscle involvement.  In the ER the examiner’s impression was heat exhaustion, while the NARSUM examiner indicated heat stroke.  However, there are no other applicable codes to use to warrant a higher rating.  After due deliberation, considering all 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 heat injury.  

BOARD FINDINGS:  In the matter of the heat injury and IAW VASRD §4.119, 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 20170428, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record  

AR20190009856, 

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 also been provided to the Department of Veterans Affairs.