RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXXXX CASE NUMBER: PD1201241 BRANCH OF SERVICE: ARMY BOARD DATE: 20130425 SEPARATION DATE: 20020430 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (71L30/Administrative NCOIC), medically separated for exertional shortness of breath (SOB) secondary to reactive airway disease (RAD). The CI developed dyspneal exertion while performing Mission Oriented Protective Posture (MOPP) training. Despite otolaryngology and pulmonary evaluations, pulmonary function testing (PFT), and a Methacholine Challenge Test (MCT), the CI failed to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded exertional SOB secondary to RAD to the Physical Evaluation Board (PEB). The MEB forwarded no other conditions for PEB adjudication. The PEB adjudicated the exertional SOB secondary to RAD condition as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals, and she was medically separated. CI CONTENTION: “This condition occurred after surgery to remove a cyst on the right thyroid.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The unfitting exertional SOB secondary to RAD condition meets the criteria prescribed in DoDI 6040.44 for Board purview and it is addressed below. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20020125 VA (~4 Mos. Post-Separation) – All Effective Date 20020501 Condition Code Rating Condition Code Rating Exam Exertional Shortness of Breath Secondary to Reactive Airway Disease 6602 10% Obstructive Ventilary Disease 6699-6600 Not Service Connected (NSC) 20020913 .No Additional MEB/PEB Entries. Total Abdominal Hysterectomy, Pelvic Abscess 7618 30% 20020913 0% X 2 20020913 Combined: 10% Combined: 30% ANALYSIS SUMMARY: The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Disability Evaluation System fitness determinations and rating decisions for disability at the time of separation. The Board utilizes service and VA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence. Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation. Exertional Shortness of Breath Secondary to Reactive Airway Disease Condition. The CI initially presented to otolaryngology for a right true vocal cord paralysis. During the workup, it was noted that the CI also had exertional dyspnea during MOPP training and needed a referral to pulmonary. The CI underwent an exercise study that revealed a decrease in oxygen consumption with decreased oxygen saturation to 88%. The CI terminated the study because she complained of muscular fatigue and some chest tightness. Because there was not a clear reason for the symptoms, a MCT was performed In November 2001 along with a PFT that showed a decrease to 67% in the Forced Expiratory Volume (FEV1) after administration of the methacholine. In addition, on the flow volume loop there was a consistent and reproducible partial obstruction that was suggestive of an obstruction from a combination of some RAD as well as a partial obstruction from the vocal cord paralysis. The pre-bronchodilator FEV1/FVC was 78% of predicted. The CI was placed on a permanent P3 Profile for obstructive ventilator defect with restrictions of no MOPP training with running and walking at her own pace and distance. The MEB narrative summary (NARSUM) exam approximately 4 months prior to separation indicated chronic SOB and that because the CI had true iatrogenic vocal cord paralysis, this made her symptoms significantly worse and prevented her from participating in MOPP training and required an alternate physical fitness test. According to the examiner, the November PFT MCT “clearly showed a decrease in her FEV1 of 33% from her baseline at 10mg per dl” of methacholine. A second PFT was completed in January 2002 and it noted a pre- bronchodilator FEV1 of 78% of predicted. The examiner opined the CI had exertional SOB due to RAD as indicated by the MCT as well as a true iatrogenic vocal cord paralysis that increased the severity of her symptoms. The examiner further opined that the CI would not respond to chronic use of inhaled steroids. The VA Compensation and Pension (C&P) examination approximately 4 months after separation documented SOB with exertion. The examiner noted a PFT performed at the VA found that the FEV1, although somewhat diminished, was better than the predicted and after bronchodilator use improved even more which caused the examiner to opine that the CI did not have any respiratory problem and her symptoms were a natural effect from exercise. However, this conclusion is incorrect and no PFT values were included so the Board cannot assess this PFT. A person with RAD will show improved values after the administration of a bronchodilator and in fact, this is considered diagnostic for RAD. Additionally, no MCT was performed by the VA examiner and he made no comment on the testing performed by the service. The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the exertional SOB secondary to RAD condition as 6602 asthma, bronchial (FEV-1 of 71- to 80% predicted or FEV-1/FVC of 71 to 80%) and rated 10%. The PEB based their determination on the PFT performed in January 2002, which included a pre-bronchodilator FEV1/FVC of 78% of predicted. No chronic therapy was indicated. The VA coded the obstructive ventilary disease 6699-6600 bronchitis, chronic and determined there was no clinically diagnosed obstructive ventilary disease and therefore, it was not service-connected. The C&P exam noted a somewhat diminished FEV1 that increased after administration of a bronchodilator. However, there was no documentation of any actual assigned FEV1 or FEV1/FVC values. Without these values, the Board cannot make a rating determination based on this examination. Therefore, the Board determined the MEB NARSUM examination findings had greater probative value. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 reasonable doubt, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the exertional SOB secondary to RAD condition. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the exertional SOB secondary to RAD condition and IAW VASRD §4.96a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Exertional Shortness of Breath Secondary to Reactive Airway Disease 6602 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120619, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxx, DAF Director of Operations Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130010764 (PD201201241) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)