RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05049
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060506

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Chemical Operations Specialist, medically separated for “syncopal episodes” with a disability rating of 0%.  

CI CONTENTION:  “Am unable to work or function normally due to condition.  VA rated as unemployable.”  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 - 20060328	VARD - 20061024	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Syncopal Episodes	8299-8210	0%	Neurocardiogenic Syncope 	8008-8108	20%	20060621	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Syncopal Episodes.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s syncope (loss of consciousness) began in August 2004 with frequent daily episodes of lightheadedness lasting 30-40 minutes.  These occurred while sitting or standing, and improved while lying down.  An April 2005 ECG (electrical activity of the heart test) was normal and the CI reported a heart monitor and stress test were normal.  A Florinef (fludrocortisone, a steroid) treatment trial was unsuccessful.  MRIs were unremarkable.  A neurologic evaluation on 27 July 2005 noted normal awake and sleeping brain activity.  An echocardiogram in October 2005 revealed a normal left ventricular ejection fraction and left ventricular dimensions.  Tilt-table testing on 26 October 2005 was positive for vasovagal (neurocardiogenic, loss of consciousness due to sudden heart rate and blood pressure drop).  Extensive laboratory testing was within normal limits except a liver enzyme (ALT), which was minimally elevated at 89 U/L (normal 21-72).  The CI had a limited response to treatment with midodrine (a vasopressor or antihypotensive agent) and Paxil (paroxetine, an antidepressant) with decreased syncope, but lightheadedness persisted and interfered with work and concentration.

The 30 November 2005 MEB NARSUM examination, 5 months prior to separation, noted complaints of uncontrolled pre-syncope and syncope despite medical therapy.  Physical examination showed a blood pressure of 105/62, pulse 72 beats/minute, respirations 12/minute, height 73 inches and weight 245 pounds.  The CI was alert with a flat affect.  There was no enlarged thyroid and no pulsing jugular vein.  Cardiac examination found a regular heart rate and rhythm without murmur.  Lungs were clear.  There was no lower extremity edema.  Gait and motor function was intact.  

During the 9 January 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported daily dizzy spells, and fainting spells once or twice a week.  Physical examination showed no abnormal findings.  The systolic blood pressure was unreadable, but not identified by the examiner as being abnormal.

At the 28 September 2006 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported passing out every 2 days and tended to get lightheaded every day.   Neurologic examination was normal and there were no bruits (heart murmur).  

At the 10 October C&P heart examination, 5 months after separation, the CI reported lying down when he felt lightheaded at home.  Physical examination showed a pulse of 76 beats/minute and blood pressure of 132/80, 139/79, and 128/82.  The heart had a normal sinus rhythm.  There were no carotid artery murmur or any evidence of congestive heart failure.  A transient ischemic attack (mini stroke) secondary to neurocardiogenic [hypotension] was diagnosed.  The examiner opined that the CI was almost asymptomatic without medication.  A stress test was recommended, but the CI declined.  The examiner estimated the CI’s METS (resting oxygen consumption while sitting) at 10 because he was able to do all daily activities, and seemed to be healthy, could jog, run and do normal strenuous activities.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the syncope 0%, analogously coded 8299-8210 (tenth (pneumogastric, vagus) cranial nerve paralysis), citing no etiology after a complete neurological and cardiac evaluation.  The VA rated the syncope 20%, dual coded 8008-8108 (brain, vessels, thrombosis-narcolepsy), based on the C&P examination, citing syncope episodes every 2 days.  

The panel agreed the STR evidence showed the CI had limited dizziness and neurocardiogenic syncope improvement with medication.  The VA cardiology examination documented the CI’s condition almost asymptomatic without medication.  While the PEB used an analogous code 8299-8210 rated a 0%, the panel agreed that the clinical findings of a positive tilt test and positional changes causing dizziness and syncope could suggest a 30% rating for incomplete, severe paralysis of the vagus nerve in the absence of medication.  However, proximal to separation, and while on medication, the condition was more consistent with an “incomplete, moderate” vagus nerve paralysis which supports a 10% rating.  The condition had improved 5 months after separation even without medication, as compared to the CI’s report of passing out every 2 days during the VA C&P examination.

The panel considered the VA’s use of codes 8008-8108 and the slight nodularity of a segment of the right anterior cerebral artery; however, there was no evidence of thrombosis of any vessels of the brain.  Furthermore, there was no evidence of narcolepsy in the absence of specific studies to make a reasonable assessment nor medication to treat it.  There was no petit mal type epilepsy (8911) recorded during awake and sleep brain activity testing, and the STR and VA showed the CI with persistent lightheadedness but no objective evidence of losing consciousness; albeit syncopal episodes do have brief losses of consciousness as do petit mal episodes.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the syncope, coded 8299-8210.

BOARD FINDINGS:  In the matter of the syncope, the panel recommends a disability rating of 10%, coded 8299-8210 IAW VASRD §4.124a.  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	
Syncopal Episodes	8299-8210	10%	

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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. 

Sincerely,				      
Enclosure