RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-05623 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20071127

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty O3, Nurse, medically separated for “cognitive disorder secondary to intracranial hemorrhage” and “migraine headaches,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION: “They did not include the main injury, the intracranial hemorrhage into the rating factor.”  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 - 20070706	VARD - 20080818	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cognitive Disorder [DO] Secondary to Intracranial Hemorrhage	9399-9305	10%	Residuals of Cerebral Hemorrhage (Claimed as Head Injury and Cognitive DO)	8009	NSC	20080514	
Migraine Headaches	8100	0%	Migraine Headaches	8100	30%	20080515	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Cognitive Disorder Secondary to Intracranial Hemorrhage. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered an intracranial bleed after delivering her child in January 2006. A CT scan of the brain in the emergency room (ER) identified the bleed, and a brain MRI in September 2006 demonstrated findings in the left parietal  region

consistent with chronic hemorrhage. Surgery was not required, but after recovery from the bleed, the CI was left with some slurred speech, memory losses and visual problems.

At a neuropsychological (NP) evaluation on 9 March 2007, 8 months before separation, the CI complained of difficulty with memory as well as word finding and expressing thoughts. Also, she was not sleeping well, and her energy and sex drive were poor. Psychological test results demonstrated intellectual functioning in the high average range for intelligence (FSIQ=119) and general memory, and in the average to superior range for other aspects of cognitive functioning. The examiner concluded that overall test results showed the CI had “very mild” residual impairment secondary to the bleed. The diagnoses included “cognitive disorder, residual deficits secondary to stroke, and anxiety disorder NOS,” with a Global Assessment of Functioning (GAF) score of 62-65 (mild impairment/symptoms).

The 6 April 2007 MEB NARSUM examination, 7 months prior to separation, noted CI complaints of migraine headaches, slurred speech and memory problems. The examiner also documented treatment for hypertension and evaluation by ophthalmology for visual problems. Physical examination showed normal neurological findings with an assessment of a stable intracranial bleed with indefinite Coumadin (blood thinner) treatment and overall good prognosis.  At the  11 May 2007 MEB NARSUM psychiatric examination, 6 months before separation, the CI felt she was coping well, but had problems with focus and concentration and suffered some anxiety attacks. She was feeling less depressed than before, and continued to have problems with word finding. She worked more than 40 hours per week and was concerned about having 12 hours shifts due to possible stress. There was no documentation of chronic sleep impairment, depressed mood, irritability, impaired judgment, or panic attacks. The CI was not taking any psychotropic medication for treatment of mental health (MH) symptoms, and had not participated in any form of MH treatment. The mental status examination (MSE) was unremarkable with the exception of difficulty pronouncing or articulating words; however, speech was clear. The examiner diagnosed “cognitive disorder secondary to intracranial hemorrhage, and anxiety disorder NOS,” noting no impairment for military duty from the anxiety disorder.  A GAF score of 70 (mild symptoms or impairment) was assessed.

During the 14 May 2008 VA Compensation and Pension (C&P) MH examination, 6 months after separation, the CI reported her cognitive disorder had caused problems with memory and speech. She provided an extensive history of psychological problems prior to 2006, but noted no MH treatment since. She was not taking medication, and was married to her second husband of 7 years, and had two children. She was employed as a nursing director at a detention center, but had been on medical leave for 2 weeks due to an ectopic pregnancy. Psychiatric symptoms included some concern for the future because of her lost career in the military and health problems. She had occasional depressed mood and word-finding and memory problems. The MSE was unremarkable, with no impairment of thought processes, and no apparent difficulty with cognition or memory. The examiner concluded that she did “not have any apparent cognitive problems or disorder,” and determined that the occasional depressed mood (due to health problems) had a minimal and transient impact on occupational functioning.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the cognitive disorder 10% IAW VASRD §4.130, analogously coded 9399-9305 (vascular dementia), citing mild social/industrial impairment. The VA did not service connect the cognitive disorder. Panel members first agreed that the intracranial hemorrhage condition was an integral part of the cognitive disorder pathology and could not be recommended for additional rating IAW VASRD 4.14 (avoidance of pyramiding). The panel next considered whether a higher rating was justified under §4.130, and noted that a 30% rating criteria requires evidence of “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild

memory loss (such as forgetting names, directions, recent events).” Panel members observed that the MSEs during the MEB and C&P examinations were unremarkable, with no report of chronic sleep impairment, panic attacks, or significant memory problems. The NP evaluation documented “very mild” cognitive impairment secondary to the bleed, and the CI worked more than the 40-hour work week recommended by NP, despite reports of focus and concentration problems. The NARSUM examination documented mild social/industrial impairment, and the C&P recorded minimal or transient impairment which no longer met the criteria for a cognitive disorder. The commander’s statement did not implicate cognitive issues, noting CI was “an exceptional officer,” and that although her condition did not restrict the performance of duties as a nurse, it precluded her from performing critical field duties necessary in a deployed environment. The CI was employed in a supervisory position as a nurse, and had not received any MH treatment or prescribed psychotropic medication since 2006. The panel agreed that the CI’s condition was best characterized by a 10% level of disability for “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress.” 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 cognitive disorder secondary to intracranial hemorrhage condition.

Migraine Headaches. According to the STR and MEB narrative summary (NARSUM), the CI’s migraines worsened after the intracranial hemorrhage in January 2006. Prior to January 2006, the CI‘s headaches had been well-controlled with medication. During the MEB NARSUM examination, the CI reported a history of migraines about 4 times a month with photophobia, nausea and vomiting, and that she would need to leave work to “sleep off” the headaches. She also described daily headaches controlled with over-the-counter medication. The CI was seen by neurologist in December 2006, and was told that she had two kinds of headaches; her regular migraine headaches for which she took prescription medication for, and medication withdrawal headaches, which were the daily headaches. She was instructed to take Tylenol as needed for the medication withdrawal headaches. The examiner noted that the CI had 3-4 headaches a week, which were controlled with Tylenol, and that her migraine headaches occurred twice a month. The migraines occurred mostly when the CI was not working, and thus did not require he to miss days, and she had not sought treatment in the ER for the headaches. Physical examination was unremarkable, and the examiner opined that the headaches were incapacitating but not prostrating, and that the CI was able to do her required occupational duties.  The neurologist assessed migraine headaches without aura with intractable headaches.

At the 15 May 2008 VA C&P general medical examination, 6 months after separation, the CI reported about two headaches with aura twice a month that lasted 1-2 days per episode. She took Tylenol and rested to relieve the headaches. Physical examination was unremarkable. Prescription medications once prescribed for migraine treatment and prophylaxis were not among the medications noted during the examination.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the migraine headaches 0%, coded 8100 (migraine [headaches]), citing headaches averaging less than one prostrating attack in 2 months over the last several months. The VA rated the migraine headaches 30%, coded 8100, based on the VA C&P examination, citing the VASRD 30% criteria. The rating options under code 8100 for migraine headaches rely on the frequency of “prostrating” attacks, which are not defined by VASRD §4.124a. The panel’s precedence has relied on the English definition of prostrating to include extreme exhaustion, powerlessness, or reduced to extreme weakness, and members carefully considered the frequency and nature of the CI’s headaches including objective and corroborating subjective evidence. A 10% rating requires one prostrating headache in two months over the past several months, while a 30% requires once monthly prostrating attacks over the past several months. The MEB NARSUM noted the CI had regular migraine headaches twice a month, however these had not caused her

to leave work or seek treatment in the ER, and they were not prostrating. The neurologist also stated that the headaches had not interfered with her military occupational duties, and there was no evidence of modification of the work environment due to headaches. Panel members agreed that the STR did not show prostrating headaches occurring on average once every 2 months, or more frequently, over the last several months prior to separation to support a rating higher than the 0% adjudicated by the PEB. 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 migraine headache condition.

BOARD FINDINGS: In the matter of the cognitive disorder secondary to intracranial hemorrhage condition and IAW VASRD §4.130, the panel recommends no change in the PEB adjudication. In the matter of the migraine headaches and IAW VASRD §4.124a, 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.

PD-2017-05623 

ARXXXXXXXXXXX, XXXXXXXXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXX

	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.

Sincerely,					      

Enclosure

PD-2017-05623