RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03520
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050126

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Infantryman, medically separated for “heat stroke with intermittent headaches and dizziness” with a disability rating of 0%.   

CI CONTENTION:  “More frequent short term memory loss, quicker loss of control of emotions, shorter temper and patience.”  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 - 20041214	VARD - 20050223	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Heat Stroke…	7999-7900	0%	Heat Stroke with Residual Headaches and Dizziness	8999-8911	10%	20040723	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Heat Stroke.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered heat stroke on 1 March 2004 after he completed a 5-mile run.  His temperature in the field was 107 degrees and upon reaching the hospital, it was 102.9 degrees.  He still had some altered mental status at the emergency room, but upon evaluation, his temperature was 98.9 degrees and he was “mentating” well.  Renal status laboratory measurements revealed creatinine of 2.0 mg/dL (normal 0.7-1.3) and BUN 16 mg/dL (normal 7-18).  Muscle breakdown indicators showed urine myoglobin was negative and creatine kinase was slightly elevated to 191 U/L (normal 26-174).  With intravenous hydration, laboratory results approached normal levels.  The CI’s 2-day course in the hospital was unremarkable, and he had been afebrile and felt well.  After hospital discharge, laboratory studies s a minimal elevation of creatinine to 1.5 mg/dL and a normal creatinine kinase of 59 U/L.  

At a neurology visit on 19 April 2004, 9 months before separation, the CI complained of frequent headaches triggered by prolonged exposure in the sun/heat and/or physical activity.  He occasionally found himself losing a random word or phrase during a conversation and felt his concentration was also affected, particularly when he tried to focus on reading.  Blood pressure was 146/74, heart rate was 91 beats/minute, and he was afebrile.  Neurologic examination was normal with no evidence of persistent cognitive or neurological sequelae; however, the CI continued to complain of heat intolerance, with frequent headaches and lightheadedness with exertion.  A trial of a nonsteroidal anti-inflammatory drug (naproxen) to treat the headaches was recommended.  By 29 April 2004, the creatinine was in the normal range of 1.3 mg/dL. 

During the 29 April 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported “heat stroke caused headaches, dizziness, memory loss, intolerance to heat, and [with] physical activity hand[s] sweat frequently.”  Physical examination revealed a blood pressure of 126/70 and pulse 57 beats/minute.  Each section of the clinical evaluation was checked normal except one part that was deferred. The examiner listed “heat stroke with residual problems (headaches and memory loss)” in the summary of defects.  At the 19 May 2004 MEB NARSUM examination, the CI stated “I had heat stroke,” and the examiner noted a well-developed and well-nourished individual, who seemed apprehensive and occasionally had problems expressing himself; vital signs and physical examination were normal.
 
At the 23 July 2004 VA Compensation and Pension (C&P) examination, 6 months before separation, the CI reported suffering non-migraine headaches after his heat stroke, which required him to stay in bed when attacks occurred.  Physical examination showed no acute distress and normal vital signs. He was alert and oriented, times three, and able to hear normal conversation across the room.  Neurological findings were normal as were behavior, comprehension and memory, with no signs of tension.

The 8 December 2004 MEB neurology evaluation, based on the 19 April 2004 examination, noted that since discharge, the CI experienced frequent headaches, which appeared to be triggered by prolonged exposure to the sun/heat and/or physical exertion.  They were described as bilateral dull pressure, rated at 7/10, and lasted for approximately 1 hour with occasionally associated mild nausea.  He continued to complain of heat intolerance, with frequent headaches and lightheadedness with exertion, and the examiner noted that transient headaches, dizziness and nausea could be experienced “for a period of time after a heat injury.” 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the heat stroke condition 0%, analogously coded 7999-7900 (hyperthyroidism), citing normal neurological findings and no evidence of persistent cognitive or neurological sequelae.  The VA rated the heat stroke condition 10%, analogously coded 8999-8911 (epilepsy, petit mal), based on the C&P examination, citing a documented history of heat stroke with chronic and persistent subjective symptoms of headache, lightheadedness, and heat intolerance.  Panel members noted that neither codes 7900 or 8911 are closely related to the symptomatology of heat stroke or the clinical finding of elevated temperature (although thyroid storm has several overlapping symptoms as heat stroke).   A 10% rating under code 7900 requires “tachycardia (rapid heart rate), which may be intermittent, and tremor, or; continuous medication required for control,” and a 30% rating requires “tachycardia, tremor, and increased pulse pressure or blood pressure.”  However, the CI only had a rapid heartbeat and elevated blood pressure at the neurology examination, where he complained of headaches.  Therefore, code 7900 did not offer a rating option higher than 0%, albeit there were no thyroid laboratory results in the STR to review.  Code 8999-8911 additionally p no reasonable rating options as there was no record of any petit mal symptoms noted at the neurology, NARSUM, or VA examinations.  While code 6204 (peripheral vestibular disorders) offered a 10% rating for occasional dizziness, there were no “objective findings supporting the diagnosis of vestibular disequilibrium” for use of that code.  

The panel also considered code 8100 (migraine), but the VA examiner noted only post-heat stroke headaches, not migraines.  Although the CI reported that his headaches required staying in bed and had caused lost time from work, he did not have a formal diagnosis of migraine headaches nor was he prescribed preventive or abortive migraine medications.  Additionally, there was no evidence of “prostrating” attacks (exhaustion, helpless, or powerless) objectively documented or recorded in the form of a headache log to warrant overcoming speculation related to determination of a rating under code 8100.  

Panel members finally considered analogous use of code 8099-8045 (brain disease due to trauma), noting that the CI had several symptoms consistent with a traumatic brain injury, which is defined as “a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury.”  The panel majority agreed that athough he did not suffer a classic traumatic injury to the brain, he did have transient and residual findings as a result of induced thermal trauma (temperature of 107 degrees) which were similar to a physically traumatic brain injury.  At the time of separation, the maximum allowable rating for purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, was 10% and no more under diagnostic code 9304 (dementia associated with brain trauma).  Therefore, IAW VASRD §4.7 (higher of two evaluations), a 10% rating using analogous code 8099-8045 is both reasonable and more appropriate compared to the ratings assigned by both the PEB and VA.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the heat stroke condition, analogously coded 8099-8045.  

BOARD FINDINGS:  In the matter of the heat stroke condition, the panel majority recommends a disability rating of 10%, coded 8099-8045 IAW VASRD §4.124a.  The single voter for dissent recommends no change and no re-characterization and did not elect to submit a minority opinion.  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	
Heat Stroke with Intermittent Headaches and Dizziness 	8099-8045	10%	

AR20190008434, 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 also been provided to the Department of Veterans Affairs.