RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04028
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Security Forces Journeyman, medically separated for “abdominal pain” 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 - 20071210	VARD - 20080606	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Abdominal Pain	7399-7301	10%	Status Post Splenectomy	7706	20%	20080311	
Paroxysmal Atrial Fibrillation (PAF)	7010	Cat II	PAF	7010	10%		
History of Bleeding Gastric Ulcers	7304		History of Ulcers 	7304 	NSC 		
Mechanical Low Back Pain	5299-5237		Lumbar Spine Strain	5237	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Abdominal Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s abdominal condition began in March 2006 with a fever of unknown origin, drenching night sweats, severe headaches, nosebleeds, nausea, vomiting and sharp epigastric abdominal pain.  Extensive laboratory workup showed a drop in hemoglobin over 2 weeks.  A CT scan of the head was negative.  An abdominal CT scan revealed splenomegaly and some prominent abdominal lymph nodes.  The stomach and duodenum were normal.  No infectious or hematologic etiology was determined.  An esophagogastroduodenoscopy (EGD) study on 27 April 2006 showed a large hiatal hernia and grade C esophagitis (mucosal breaks that are continuous between the tops of two or more mucosal folds, but which involve less than 75% of the esophageal circumference) in the lower third of the esophagus and gastroesophageal junction with no bleeding.  The stomach and duodenum were normal.  A CT/PET scan in May 2006 showed no lymphoma, but splenomegaly was present.  A bone marrow biopsy was negative except for low iron stores likely due to gastrointestinal bleeding.  He underwent a splenectomy on 22 January 2007.  No malignancy was noted, but the spleen was larger than normal, possibly due to a viral infection.  A primary care examination on 13 April 2007 revealed a non-distended soft abdomen and normal bowel sounds without guarding, rebound tenderness or palpable mass, but there was tenderness at the incision sites and right upper and lower quadrants.  An EGD on 15 July 2007 again revealed Grade C esophagitis.    

The 7 October 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of abdominal pain and tenderness, which limited running and wearing of protective gear.  Physical examination showed normal bowel sounds and a soft non-distended abdomen, but there was tenderness in the bilateral upper quadrants.  No rebound, guarding or hepatomegaly was noted.  

At the 11 March 2008 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported daily sharp pain characteristic of cramps.  The examiner found tenderness of the abdomen without liver enlargement, distension of the superficial veins, striae (stretch marks) on the abdominal wall, ascites or fistula.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the abdominal condition 10%, analogously coded 7399-7301 (moderate adhesions of peritoneum).  The VA rated the abdominal condition 20%, coded 7706 (splenectomy), based on the STR and C&P examination, citing loss of spleen.  Panel members noted that a 30% rating under code 7301 requires a “moderately severe; partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain.”  However, there was no evidence of obstruction.  The CI did, however, undergo a splenectomy for an enlarged spleen probably due to a viral infection, which left him with pain from either residuals of the viral infection and/or adhesions post splenectomy.  Therefore, a dual code of 7301-7706 with a 20% rating is both appropriate and reasonable.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the abdominal condition, coded 7301-7706.  

Contended PEB Condition:  PAF.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The condition was not explicitly profiled, although a P4 was issued.  The PAF was referred to as a “fluttering heart” and “heart issues” in the commander’s statement.  Although the CI had a long history of intermittent tachycardia (rapid heartbeat) and palpitations associated with occasional chest pain, there was no shortness of breath.  A cardiology workup including a stress echocardiogram was negative.  His elevated heart rate was confirmed to be atrial fibrillation and was effectively treated with Cardizem (diltiazem, a calcium channel blocker) when he was compliant.  An electrocardiogram on 22 March 2007 showed normal sinus rhythm and conduction intervals with no evidence of pre-excitation or ischemic changes.  The MEB NARSUM examination showed lungs clear to auscultation bilaterally without wheezes, rales or rhonchi and his heart had a regular rate and rhythm without any murmurs, jugular venous distension or bruits (high pitched sounds in the neck arteries).  There was no peripheral edema present.  The VA C&P examination revealed a regular sinus rhythm with no heaves, thrills, murmurs, gallops or evidence of congestive heart failure, cardiomegaly or cor pulmonale.  Although an electrocardiogram was abnormal and showed ST elevations diffusely, particularly in V2-V6, the CI had a normal stress test and achieved 12.9 METS on 16 April 2008, 4 months after separation.  The panel majority could find no performance-based evidence to show that the PAF significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel majority concluded there was insufficient cause to recommend a change in the PEB fitness determination for the paroxysmal atrial fibrillation, so no additional disability rating is recommended.

Contended PEB Conditions:  History of Gastric Ulcers and Mechanical Low Back Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  Neither of the conditions were explicitly profiled or implicated in the commander’s statement.  The CI was prescribed an antacid and Nexium.  The MEB NARSUM examiner noted the CI had no recurring hematemesis and complete resolution of his symptoms as he long as he took his Nexium.  The examiner opined the condition did not affect his activities.  The CI reported the back condition did not limit his activities, as he was able to work through the pain.  X-rays showed six lumbar vertebrae, but was otherwise normal.  The NARSUM showed a normal gait with normal strength.  The examiner noted the CI was able to function with moderate activity despite the pain.  There was no performance-based evidence from the record that either the gastric ulcers or back condition 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 determinations for either the gastric ulcers or back condition, so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the abdominal condition, the panel recommends a disability rating of 20%, coded 7301-7706 IAW VASRD §4.117.  In the matter of the contended paroxysmal atrial fibrillation, the panel majority recommends no change from the PEB determination as not unfitting.  The single voter for dissent submitted the appended minority opinion.  In the matter of the contended gastric ulcers and back condition, 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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Abdominal Pain	7301-7706	20%	

	

Minority Opinion.  The minority voter recommends the PAF be found unfitting since although cardiology studies found no evidence of it when the CI was taking his medication, there were instances when he did not take his medication and he felt mild chest pain and palpitations.  While he is able to function with the medication, without it the aforementioned symptoms as well as other symptoms including lightheadedness, dizziness, confusion, shortness of breath, weakness, and exercise limitations, may require additional medical visits and/or cardiology evaluations that can take the CI away from work and create a burden for his unit as well as the Air Force.  There was performance-based evidence from the record that PAF condition did interfere with satisfactory duty performance when and if no medication is taken inadvertently or if is not available for any reason.  Therefore, the minority voter notes the preponderance of the evidence with regard to the functional impairment of PAF condition when medication is not taken favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 7010 (supraventricular arrhythmias) and meets the VASRD §4.104 criteria for a 0% rating since at the time of separation there was no clinical evidence of the PAF.  

The minority voter recommends the ROP be modified as follows:

In the matter of the contended paroxysmal atrial fibrillation condition, the panel agrees it was unfitting and recommends a disability rating of 0% coded 7010 IAW VASRD §4.104.  

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

CONDITION	VASRD CODE	PERMANENT RATING	
Abdominal Pain	7301-7706	20%	
Paroxysmal Atrial Fibrillation 	7010	0%	
COMBINED	20%	

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

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Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-04028.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.