RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX		CASE: PD-2017-05744
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20090527

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Motor Transport Operator, medically separated for “syncope, vasovagal” with a disability rating of 20%.

CI CONTENTION: “The only unfitting condition is the most severe…” 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 - 20030903	VARD - 20090824	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Syncope, Vasovagal	8999-8911	20%	Neurocardiogenic Syncope	8199-8108	40%	20090625	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 70%	

ANALYSIS SUMMARY:

Vasovagal Syncope. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s syncope (loss of consciousness) condition was noted in December 2006 during a deployment, and was related to mental and physical stress, heat exposure, and sleep deprivation; however, he had episodes since childhood. On 22 June 2007, he developed shortness of breath, lightheadedness, tunnel vision, paresthesias, and syncope in between wind sprints and vomited twice. He required four liters of intravenous fluids before voiding, which suggested an underlying volume depletion. On 11 July 2007, he was seen for the same symptoms, and further history indicated he had recurrent episodes for years, which had become

more frequent. At a cardiology visit on 20 July 2007 the CI had an electrocardiogram that was normal with a normal sinus rhythm, and no ischemic changes, Brugada syndrome (abnormal electrical activity), right ventricle dysplasia (a rare type of cardiomyopathy where muscle tissue of the right ventricle is replaced with scar tissue), or delta waves (indicative of Wolff-Parkinson- White). He was noted to have a 10-year history of syncope that the examiner indicated was classic for vasovagal syncope. An echocardiogram on 23 July 2007 was normal and a head CT scan on 10 August 2007 was negative. Brain MRIs on 20 August 2007 and 14 September 2007 were normal.

On 17 October 2007, the CI reported an episode of syncope 2 weeks earlier. The neurologist indicated the episodes did not sound like epilepsy and noted merely 5% of syncope has a neurological cause, while 40% has no clear etiology. An awake and asleep electroencephalogram (EEG) was normal on 25 October 2007. On 29 October 2007, a trial of Lopressor (metoprolol, a beta blocker) was instituted. A stress test dated 26 November 2007 was normal with a maximum workload of 13.20 METS with no chest pain or syncope. A note dated 29 May 2008 indicated a 12 lead electrocardiogram was normal. A cardiac MRI revealed no left ventricular hypertrophy, myocarditis, aortic root abnormality, or arrhythmogenic right ventricular dysplasia. A gated exercise test with the CI on a beta blocker revealed good exercise tolerance with a workload  of
11.2 METS into late stage 4. A tilt test was consistent with neurocardiogenic syncope. An event monitor and night time telemetric study revealed no arrhythmia or transient QT abnormality. The examiner noted the recurrent syncope most certainly was neurocardiogenic in nature with no objective evidence to suggest underlying high risk cardiac disease.

During the 24 June 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 11 months prior to separation, the CI reported a history of fainting. Physical examination was essentially normal. A note dated 18 November 2008 indicated the CI went 1 week without an episode of syncope. The 13 January 2009 MEB NARSUM examination, 4 months prior to separation, noted complaints of multiple episodes of loss of consciousness, but no syncopal episodes per se since January 2008, but did endorse frequent dizzy spells. Physical examination showed a regular heart rate and rhythm with no murmurs, rubs, or gallops. Lungs were clear, and the abdomen was soft, nontender, and non-distended.  Neurological evaluation was unremarkable.

At the 25 June 2009 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported syncope approximately once a month. Physical examination showed he was 70 inches tall and weighed 247 pounds. Blood pressure was 122/86 on the right and 126/86 on the left.  Lung and heart examinations were within normal limits.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the vasovagal syncope 20%, analogously coded 8999-8911 (epilepsy, petit mal), citing “rated for two episodes in past six months.” The VA rated neurocardiogenic syncope 40%, analogously coded 8199-8108 (narcolepsy), based on the C&P examination, citing approximately one episode a month, which affected activities of daily living and resulted in the CI not seeking employment as a truck driver. The VA also noted that although the frequency of episodes did not meet the requirements of 5-8 episodes per week, it exceeded the requirement of a 20% evaluation and more closely approximated a 40% disabling condition.

Panel members noted the CI had syncopal episodes since childhood, although they were worse when he was deployed. Therefore, although the condition existed prior to enlistment, there is justification for consideration of service aggravation. However, with treatment and stress reduction, the episodes were reported to have decreased. Although the CI reported at the VA examination he was not able to work as a truck driver, neither was he able to work in his military specialty as a motor transport operator. Nevertheless, proximate to separation as noted in the NARSUM, he had no syncopal episodes in the prior year, albeit he did endorse frequent dizzy spells.  Since the condition is rated analogously to petit mal epilepsy, the absence of a brief loss

of consciousness for an extended period does not favor a rating higher than 20% at the time of separation since a 40% rating requires “[a]t least 1 major seizure in the last 6 months or 2 in the last year; or averaging at least 5 to 8 minor seizures weekly.” 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 vasovagal syncope.

BOARD FINDINGS: In the matter of the syncope condition 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-2017-05744

AR20190009695, XXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXX

	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.

PD-2017-05744