RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-00843
BRANCH OF SERVICE:  Army	BOARD DATE:  20150113
SEPARATION DATE:  20040802

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve SPC/E-4 (75H/Personnel Services Specialist) medically separated for heat exhaustion with syncope and mild cognitive disorder (coded for disability purposes as a mental health [MH] disorder).  The CI deployed to Southwest Asia (Kuwait) from April 2003 – March 2004.  The CI was air-evacuated from theater in May 2003 following two heat-related injuries.  Despite follow-up treatment, the CI’s condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a P2/S4 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded cognitive disorder and adjustment disorder with anxiety to the Physical Evaluation Board (PEB) characterized as “unfitting” and “not unfitting,” respectively IAW AR 40-501.  In addition, the MEB forwarded “recurrent heat exhaustion with memory loss” as a non-MH condition deemed medically unacceptable.  The MEB also forwarded “left foot fracture” and “left wrist sprain” as medically acceptable, for further PEB consideration.  The PEB adjudicated “heat exhaustion with syncope and mild cognitive disorder” as unfitting, rated 10% with likely application of AR 635-40 or DODI 1332.39 (rescinded).  The PEB determined the adjustment disorder with anxiety, the left foot fracture, and the left wrist sprain to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “My rating should be changed I believe because, since the last time that I was fraudulently changed by the VA Doctor in Pittsburgh PA, I have had a broken left piggy toe and bruised foot.  I did speak to V-- T---, M.D. at Tri-State Orthopedics'; he said it was possible this was due to the opposite ankle having arthritis and that it never healed correctly.  Also, every winter, I must put on a brace during the day to walk, and a heating pad at night, take Extra Strength Excedrin, so I can walk the next day without a problem.  I also, believe again as many others due that the doctor that stated at the VA Hospital in Pittsburgh, PA was wrong in stating that I said I never had a problem with my ankle.  These types of statements as you, know have caused many Veteran's problems it the Past with this Hospital.  This problems with many of these VA doctors has made it hard to trust you doctor, and is unfortunate because it breaks down communication between doctors, patients', and our belief in the Veterans Administration to take care of use as veterans.” 

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB, when specifically requested by the applicant.  The ratings for conditions meeting the above criteria are addressed below.  In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The applicant was notified that he may meet the inclusion criteria of the Mental Health Review Terms of Reference.  The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20040426	VA - (3 weeks Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Heat Exhaustion With Syncope and Mild Cognitive Disorder	7999-7900-9304	10%	Residuals of Heat Stroke…	9399-9304	0%	20040821	
Adjustment Disorder	Not Unfitting	PTSD	9411	NSC	
Left Foot	Not Unfitting	Residuals Left Broken Ankle (Includes Claim for Left Foot Fracture)	5271	20%	20040821	
Other x “1” (not in scope)	Combined:  20%	
Combined:  10%		
Derived from VA Rating Decision (VARD) dated 20041006 (most proximate to date of separation [DOS]).  
VARD 20060325 decreased DC 5271 to 0% effective 20060601; then increased to 10% by VARD 20060720 effective 20060601.

ANALYSIS SUMMARY:

Heat Exhaustion with Syncope and Mild Cognitive Disorder Condition.  According to service treatment records (STR), the CI reported a history of heat illness that occurred in 2001, prior to entry on active duty.  No records are available from that event.  On 16 May 2003, while deployed to Kuwait, the CI presented to sick call with a report that she experienced an episode of syncope (loss of consciousness) while in a guard tower for 4-5 hours in the heat.  The examiner referred to two previous heat injuries for which original documentation is not available.  The CI’s temperature at the time of evaluation on 16 May was normal (98.9 degrees Fahrenheit), and the examination was otherwise unremarkable except for “slightly dry mucous membranes.”  The examiner rendered a diagnosis of heat injury and syncope by history.  A follow-up note the next day documented a normal temperature.  There were no clinical entries available which described evaluation and management of an acute syncopal episode.  The CI was subsequently medically evacuated from theater for further evaluation for heat–related illness.

At an internal medicine evaluation on 29 May 2003, the CI reported that a previous episode of heat stroke occurred in October 2002 while walking/running.  At a neurological examination on 4 June 2003, the CI reported that the first heat-related episode while deployed was in early May after she was on guard duty.  She subsequently felt “weazy,” [sic] went to eat, then went to sleep.  During the second heat–related episode in May her oral temperature was 110 degrees and she “passed out” and was placed on a stretcher, then taken by vehicle for medical care.  She also complained of memory loss for events preceding this episode.  The CI also reported a history of “heat strokes” at age 12 and in December 2002 while exercise-walking in a park.  The neurologist indicated the examination was normal but stated: “…pattern of memory loss does not follow (her) complaint.  No Neurological explanation for (loss of consciousness) consistent with history.”  It was also opined that the second heat illness episode while deployed was consistent with heat stroke.  Neuroimaging of the head was normal.

At neuropsychological testing in June 2003, it was confirmed that the second heat injury while deployed occurred on 16 May, and that the CI lost consciousness at that time.  She reported her temperature was 110 degrees, and stayed at that level the following day.  She complained of lasting confusion, memory loss for childhood and early life experiences and personality change since the first episode (of heat injury) in theater, but she could drive the streets of Maryland and Washington DC without difficulty.  Cognitive testing revealed mild impairment in complex attention, moderate impairment in learning, and variable impairments in verbal immediate and delayed memory.  Yet her recall of her deployment in Kuwait was clear and precise.  She had easy recall of events and details associated with her alleged heat injuries, but she reported severe amnesia for information concerning her childhood, education, and occupation experiences; and relationship history, interests and hobbies.  The examiner indicated this pattern of recall was highly atypical and suggested a psychogenic component.

On 14 August 2003 (a year prior to separation), the narrative summary (NARSUM) recorded a normal physical examination; blood pressure was 101/56, heart rate was 74 and no tremor was mentioned.  A mini mental status exam (a test of cognitive function) was normal (28/30), and thyroid laboratory tests were normal.  A diagnosis of recurrent heat exhaustion with memory loss was rendered.

The psychiatric NARSUM evaluation on 8 January 2004 was based on examinations performed on 23 July 2003 and 17 October 2003, and a review of medical records.  The CI reported a history of pre-menstrual irritability and crying spells diagnosed as pre-menstrual dysmorphic disorder (PMDD) since 1999.  Symptoms completely remitted with an anti-depressant, although she continued to take it.  She denied any mental symptoms during the visit in July.  She was referred to psychology in October 2003 with a diagnosis of adjustment disorder with anxiety, and individual and group therapy were recommended.  She cancelled a follow-up appointment and had not returned to Behavioral Health.  The examiner noted that she had a pattern of not showing or cancelling visits with therapists.  The CI reported she had lost all of her childhood memories, including not knowing her parents after she returned home, but when challenged by the examiner, she admitted she did know them “but I didn’t know some of my relatives.”  She was working at a sports complex without difficulty.  Mental status exam (MSE) during the October visit was normal.  Diagnoses of mild cognitive disorder NOS (not otherwise specified) and adjustment disorder with anxiety were rendered and a Global Assessment of Function (GAF) of 61-70 (connoting mild symptoms or impairment) was assigned.  The examiner opined that there was no evidence of posttraumatic stress disorder (PTSD), and that adjustment disorder was not unfitting.  An S4 profile was recommended for cognitive disorder.

The permanent P2 S4 profile for heat stroke/heat exhaustion on 25 February 2004 stipulated no assignment to a duty location with temperature greater than 100 degrees Fahrenheit for more than 15 minutes, no wear of heavy gear or helmets, no work outdoors in high heat and no engagement in outdoor formations.  An internal medicine addendum on 19 March 2004 noted there was no evidence of further heat related illness since returning from deployment and rendered a diagnosis of recurrent heat exhaustion with memory loss.

At the VA Compensation and Pension (C&P) examination for mental disorders on 24 July 2004 (a week prior to separation), the CI indicated that her worst memory in Kuwait, which was “heat stroke,” was the cause of her PTSD.  Although she reported “memory problems” after the heat stroke, she provided detailed information about her unit.  She was currently working but having trouble learning computers.  She came to the examination driving her own vehicle.  The examiner opined that the CI demonstrated excessive complaints about medical and emotional issues.  Social function appeared normal.  She had friends, worked in active reserve duties, and had not lost time from work.  She was not receiving psychotherapy.  The MSE was essentially normal.  Diagnosis of personality traits and coping style affecting medical conditions was rendered with a GAF of 70.  The examiner opined that CI’s report of PTSD and memory problems was not supported by objective clinical findings and current records.

At the VA C&P general medical exam on 21 August 2004 the CI re-iterated that her core body temperature reached 110 degrees while deployed.  She reported current “heat sensitivity.”  Exposure to extreme temperatures caused a “sense of weakness, even bordering on some confusion.”  Examination showed blood pressure of 98/64 and pulse of 70.  The examiner’s diagnosis was heat stroke (resolved) with some short term memory deficits related to the heat stroke.

At neuropsychological testing on 9 December 2004, the CI reported a number of neurocognitive complaints which began after the heat stroke in 2003, including a difficult time remembering directions; but she drove to her appointment and found the correct building with no difficulty.  She endorsed an active social life that included shopping, going to movies, watching television and performing all activities of daily function.  Observation noted the absence of tremors.  The examiner indicated that testing behavior “suggested an intention to exaggerate deficits or otherwise appear excessively impaired…or at the very least, the result of inconsistent effort.”  No Axis I diagnosis was rendered, although cognitive disorder “per medical record” was noted.  At a C&P exam on 4 August 2005 (a year after separation), the CI indicated that “the cognitive disorder has resolved…not having any problem with that at this time.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the condition as heat exhaustion with syncope and mild cognitive disorder, and rated it 10% coded analogously to 7900-9304 (hyperthyroidism; dementia due to head trauma).  The VA identified the condition as residuals of heat exhaustion and applied an analogous 9304 code with a 0% rating, noting no loss of cognitive function.

The Board noted that there is no VASRD code for heat illness, and that the only clinical manifestation of any disability in this case was cognitive disorder.  Therefore, the rating approach adopted by the VA and reflected in the PEB’s base code choice (9304) was the most appropriate.  Heat illness is thus properly subsumed under cognitive disorder.  The 9304 code requires rating IAW VASRD §4.130 criteria.  Application of VASRD §4.129 is considered by the Board for all cases of service-connected psychiatric conditions resulting in separation; but, all members agreed that the “highly stressful event” requisite for §4.129 was not satisfied in this case.  The Board therefore will consider only the VASRD §4.130 impairment present at separation for a single rating recommendation, and debated if the next higher 30% rating was justified.  This rating requires “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.”  Board members agreed that this rating was not described by the evidence, and therefore a rating higher than 10% was not justified.  Although a more accurate coding option (9399-9304) was considered, it was determined that there is no benefit to the CI in doing so.  Therefore, 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 heat exhaustion with syncope and mild cognitive disorder condition.

Mental Health Review.  At neuropsychological testing in June 2003, the CI stated that she had been diagnosed with PTSD that was a consequence of being traumatized by a lack of air conditioning and poor food quality while deployed to Kuwait.  She reported that she was seen by a social worker twice for counseling.  However, the social worker reported she was not providing counseling to the CI, had only seen her one time and was unaware of a PTSD diagnosis for the CI.  Results of the MMPI-2, a test of adult mental illness, did not suggest significant psychopathology.  The examiner did not render a diagnosis.

On the MEB DD Form 2807, dated 24 November 2003, the CI indicated she had anxiety, memory loss, difficulty with sleep, and depression; and had received counseling.  Her symptoms were reportedly due to PTSD.  Treatment did not include medications.  The profiling section of the DD Form 2808 listed a diagnosis of PTSD.  The examiner was silent about the criteria in support of a PTSD diagnosis.  The commander’s statement did not present specific information regarding the impact of medical conditions on duty performance, but only referred to “permanent profile.”  The psychiatric NARSUM evaluation on 8 January 2004 and VA C&P mental disorders exam on 24 July 2004 are described above in the heat exhaustion section.

The Board reviewed the records for evidence of inappropriate changes in diagnosis of the MH condition during processing through the DES.  The evidence of the available records showed a diagnosis of PTSD was rendered during the DES process (DD Form 2808).  The PTSD diagnosis was not forwarded by the MEB or adjudicated by the PEB; therefore the Board determined that this applicant did appear to meet the inclusion criteria in the Terms of Reference of the MH Review Project.  Board members concluded that the psychiatric NARSUM and C&P exams provided a preponderance of evidence that did not support a diagnosis of PTSD at the time of separation; and that the diagnosis of adjustment disorder was correct.

In considering whether a mental condition besides cognitive disorder was unfitting for continued military service, the Board concluded that the question is moot.  The disability associated with all psychiatric conditions, regardless of the diagnosis or presence of multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130. Therefore the applicant’s disability rating assigned by the PEB and recommended by the Board (above) for cognitive disorder already encompasses mental disability imposed by other psychiatric diagnoses.  Furthermore, the adjustment disorder condition adjudicated by the PEB is a condition not constituting a physical disability, IAW DoDI 1332.38.  Therefore, the Board has no basis for recommending another mental condition as unfitting.

Contended PEB Condition (Left Foot Fracture).  The Board’s main charge is to assess the fairness of the PEB’s determination that the left foot fracture was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

On the aeromedical evacuation record on 19 May 2003, a diagnosis of left foot or toe fracture was not listed.  The CI was noted to be ambulatory.  A summary progress note on 23 May 2003 possibly reported a left foot metatarsal fracture, but no further details were provided and the CI was ambulatory.  A note by internal medicine on 29 May 2003 indicated that during an episode of loss of consciousness, the CI sustained a left third toe fracture.  Examination showed wear of a hard-soled shoe.

In August 2003, the NARSUM examiner noted the CI had suffered a fractured left foot after passing out during the second heat injury episode in Kuwait, but further details were not provided.  Physical examination revealed a normal gait.  On the MEB DD Form 2807 the CI indicated that she suffered a “broke…left foot.”  However, the examiner specified the injury was a “left third toe fracture” that occurred in a fall during collapse from heat illness in May 2003, and that there were “no sequelae.”  On the DD Form 2697, Report of Medical Assessment, dated 2 August 2004, the CI wrote that since her last medical assessment, she had suffered a broken left foot and broken left ankle.  At the C&P general exam 3 weeks after separation, the CI reported that she suffered a left 4th toe fracture that healed, but caused pain with closed toe or high heeled shoes.

The Board notes that the STR is not clear if there was a foot fracture separate from a 3rd toe fracture, or if the term “left foot fracture” used by the MEB and adjudicated by the PEB referred only to a toe fracture.  Regardless, no fracture of the left toe or left foot was profiled, implicated in the commander’s statement or judged to fail retention standards.  The left foot fracture condition (to include toe fracture) was considered by the Board.  There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the left foot contended condition and so no additional disability rating is recommended.

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.  As discussed above, PEB reliance on AR 635-40 or DoDI 1332.39 for rating heat exhaustion with syncope and mild cognitive disorder was operant in this case and the condition was adjudicated independently of that regulation and instruction by this Board.  In the matter of the heat exhaustion with syncope and mild cognitive disorder condition, IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended adjustment disorder condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  In the matter of the contended left foot condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130430, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXX, AR20150006407 (PD201300843)

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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA