RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX.	CASE:  PD-2017-04595
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080421

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty, Infantryman, medically separated for “gunshot wound to pleural cavity with discomfort on exertion” with a disability rating of 20%.  

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 - 20080507	VARD - 20080722	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Gunshot Wound to Pleural Cavity with Discomfort on Exertion	6899-6844	20%	Status Post (S/P) Gunshot Wound with Thoracotomy and Hemothorax	6844-6843	20%	20080407	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Gunshot Wound to Pleural Cavity with Discomfort on Exertion.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s pleural cavity discomfort began in September 2006 after sustaining a gunshot wound to the posterior left chest.  He underwent emergency left thoracotomy with repair to the left pulmonary artery and lung.  He required a chest tube due to a hemopneumothorax.  In January 2007, he developed left-sided chest pain, which was a dull pressure at rest, worse with any skin contact or activity.  He noted a lump on his left antero-lateral chest wall.  Neurontin mildly improved the pain.  A second opinion resulted in a diagnosis of post-thoracotomy syndrome/intercostal neuralgia.  There were no surgical options and recommended treatment included avoidance of aggravating factors and long term pain control.  The 10 May 2007 chest scan showed extensive left thoracic shrapnel without pleural effusion or pneumothorax.  A small to moderate area of the left lower lobe airspace was probably due to combined atelectasis and contusion.  A focused physical examination on 10 October 2007, by Physical Medicine and Rehabilitation, was significant for tenderness and parethesias along the thoracotomy scar.  The CI was able to do one hour per week of cardiovascular exercise and a home exercise program (HEP).  He was unable to do the run, walk or swim events of the APFT, but was able to do the bike event.  The December 2007 chest X-ray showed interval healing of an old rib fracture on the left sixth rib with stable multiple metallic fragments overlying the left lateral chest wall.  

The 12 December 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of left-sided chest pain with constant pressure at rest and sharp pain followed by tingling and then numbness.  Precipitating and exacerbating factors included twisting, bending and overhead activities.  Pressure, touching or using the left arm also provoked symptoms as did anything that increased the work of breathing or chest wall expansion.  Nothing relieved the pain and it interfered with sleep.  He was able to do 1 hour of cardiovascular exercise and the HEP.  The general physical examination showed a 3 cm bullet entry wound just left of T4-T5 with a large curving thoracotomy scar just inferior to the left scapula.  The CI was markedly tender to left anterior chest wall pressure at T9-13.  There was lateral wall tenderness with a small lump resembling scar tissue, approximately 2x3 cm, non-mobile over the 8th left rib.  The thoracotomy scar was also tender with areas of numbness.  Pulmonary function testing was normal.  

At the 7 April 2008 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported a number of symptoms that mainly involved a kind of tingling pain that existed in the left axilla and if the area was touched, he experienced tingling and discomfort in the left arm.  There was pain when he took a deep breath mainly in the area of the left axilla which was also associated with shortness of breath (SOB).  There was some stiffness in the left shoulder area, pain with lifting weights and tenderness around the left axilla.  Physical examination showed three small scars that were reddish, level and tender, each about 2x1 cm, with hyperpigmentation, but no instability, adherence, burn, ulceration, abnormal texture or loss of underlying tissue and they didn’t limit motion.  There was a scar that extended from the left axilla to the posterior lung on the left side, measuring 20x1 cm and another very tender, slightly depressed, irregular scar on the thoracic spine at about T6, which measured 2x3 cm without hyperpigmentation, instability or abnormal texture.  Although there was loss of underlying tissue, it was less than six square inches and there was no limitation of motion due to the scar. There was tenderness of the lower anterior ribs on the left side due to the skin sensitivity.  The left shoulder joint showed full range of motion and normal appearance.  The lungs were clear and there was a healed surgical scar over the posterior aspect of the left lung.  The left shoulder joint appeared normal but there was pain at the extremes of flexion and abduction and some pain in the left upper back.  Strength was 5/5 in the bilateral upper extremities.  The examiner noted radicular pain related to injury of the nerve roots of the thoracic spine, manifested by hypersensitivity in the area of dermatomes T4, T5 and T6 on the left side.  This was treated with Gabapentin.  The examiner noted the bullet struck very near the spine and landed somewhere on the left anterior ribs after striking the left lung.  There were several tender scars in the left axilla and tenderness in the area of the left axilla due to pain when taking a deep breath.  Pulmonary function testing was normal.  The examiner indicated the CI was limited in working with his left upper extremity above his head, couldn’t do frequent pushing and pulling due to thoracic neuropathy in the axillary region and might have limitations of extremely heavy lifting with left upper extremity due to subjective pain in the left axilla.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the pleural cavity discomfort 20%, analogously coded as 6844 (post-surgical residual (lobectomy, pneumonectomy, etc.)), citing the General Rating Formula for Restrictive Lung Disease.  The VA rated the condition 20%, dual coded 6844-6843 (traumatic chest wall defect – post-surgical residual), based on the C&P examination, citing “radiodense foreign bodies in the soft tissue of [the] left chest wall and pain when taking a deep breath.” 

A lengthy and detailed discussion occurred among panel members with particular attention to objective clinical findings.  The NARSUM examination noted chest pain post-gunshot wound and thoracotomy associated with chest cavity discomfort (pain and SOB) while the C&P examination noted a post-thorax condition.  The PEB adopted VASRD language under 6844 note 3, to identify the condition to be adjudicated, and noted assignment of a 20% disability rating.  The panel consideration including separate ratings for the scars and for neuropathy.  However, this would not render a rating higher than the 20% assigned by the PEB.  Furthermore, the panel determined the other conditions rated by the VA (including scars and neuropathy), could not be rated separately, as this would violate VASRD rules regarding pyramiding.  

The panel then considered rating under code 5319 to capture the clinical findings of muscle disability due to tenderness in the chest and axillary areas, entry level scar on the posterior chest, tenderness over the lower anterior ribs, SOB that occurred with a deep breath and evidence of remaining fragments over the left lateral chest wall.  However, the panel majority concluded there was no evidence of muscle involvement and therefore disallowed the use of the 5319 code.  Panel members noted the 6844 code allowed rating consideration under restrictive lung disease but the results of the December 2008 spirometry were normal and examination of the lungs on both the NARSUM and the C&P examinations was negative, despite reported SOB on exertion.  Panel majority agreed there was no path to a higher rating than the 20% assigned by the PEB under code 6844.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the pleural cavity discomfort.  

BOARD FINDINGS:  In the matter of the pleural cavity discomfort and IAW VASRD §4.97, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  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:

 
[AR Number], XXXXXXXXXX. 

Dear XXXXXXXXXX:

	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.