RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01609
BRANCH OF SERVICE:  Army	BOARD DATE:  20150304
Separation Date:  20040607

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an ARMY National Guard SPC/E-4 (51R10/Interior Electrician) medically separated for abdominal pain and a mental health (MH) condition.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent P3/S3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic abdominal pain,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The “schizoaffective disorder, posttraumatic stress disorder (PTSD)” was forwarded to the PEB as existed prior to service (EPTS).  The MEB also identified and forwarded three other conditions (gastro esophageal reflux disease, peptic ulcer disease/antritis, and sliding hiatal hernia) for PEB adjudication.  The Informal PEB adjudicated “chronic abdominal pain, status post a cholecystectomy” and “schizoaffective disorder with PTSD, requiring psychotropic medications” as unfitting, rated 10% and ---% respectively, citing application of the US Army Physical Disability Agency (USAPDA) pain policy for the abdominal pain and EPTS without permanent service aggravation to the schizoaffective disorder.  The remaining conditions were determined to be not unfitting.  The CI submitted a written appeal.  The USAPDA affirmed the PEB findings and rating and the CI was medically separated.

CI CONTENTION:  “Schizoaffective disorder PTSD”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

IPEB – Dated 20040325	VA* - (~8 Mos. Post-Separation and Service Treatment Records (STR))	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Abdominal Pain	5099-5003	10%	Cholecystectomy, Residual of Chronic Abdominal Pain	7399-7307	0%	20050324	
Schizoaffective Disorder with PTSD	9211	--%	PTSD, Depression and Bipolar Disorder	9434	Not Service Connected (NSC)	STR	
Other x3 (Not In Scope)	Other x3 (Not In Scope)	
RATING:  10%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20050510 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Chronic Abdominal Pain Condition.  The CI developed abdominal pain in early 2000.  An endoscopy was performed on 22 May 2002 and demonstrated antritis (inflamed stomach lining) with erosions, reflux esophagitis and hiatal hernia.  A Clo-test (campylobacter-like organism test) done to diagnose a heliobacter pylori infection was negative.  The CI was started on medication to treat a peptic ulcer.  A gallbladder ultrasound was done on the same day and demonstrated gallstones.  The CI underwent a cholecystectomy (gallbladder removal) on 5 February 2003.  An abdominal ultrasound done for right upper quadrant tenderness was normal.  An abdominal CT scan was normal.  The GI (gastro-intestinal specialist) noted that the CI reported epigastric pain which occurred spontaneously and was relieved by bending forward.  The examiner noted physical exam findings of epigastric pain on palpation and recommended an esophagogastroduodenoscopy (EGD) (a test to examine the lining of the esophagus, stomach, and first part of the small intestine).  The CI underwent a colonoscopy which was normal on 11 July 2003 as well as an EGD which showed a small 3 cm hiatal hernia and a stomach biopsy was not performed because the CI became agitated.  The MEB narrative summary exam accomplished approximately 7 months prior to separation documented that the CI had a complete GI (gastro-intestinal) workup, including extensive laboratory testing, which was normal.  The examiner noted that the CI was currently stable though moderately limited by her chronic abdominal pain.  There were physical exam findings of moderate abdominal tenderness over the epigastric area and right upper quadrant.  The examiner opined that the CI’s prognosis for a complete and timely recovery was poor given the fact that she had failed to improve substantially despite cholecystectomy and maximal medical therapy for antritis and esophagitis.  The Primary Care provider noted constant heartburn and noted physical exam findings of hyperactive bowel sounds and mild epigastric tenderness.  An abdominal X-ray demonstrated questionable flattening of the mucosa near the greater curvature of the stomach which “may represent questionable atrophic gastritis.”  The General Surgeon noted that the CI reported a poor appetite, bowels that alternated with diarrhea and constipation and a 5-pound weight loss in a month, occasional vomiting and reflux with severe retrosternal burning.  The abdominal exam findings were normal, and the General Surgeon noted that the CI had a repeat colonoscopy, EGD, and biopsy which were all normal.  The VA Compensation and Pension (C&P) exam approximately 9 months after separation documented continued GI pain and heartburn on a daily basis which kept her awake at night.  She vomited one to two times per month and had such bad reflux that she was unable to drink water.  The CI rated her abdominal discomfort from 3-7/10 with food contents that would reflux up to the lower throat area.  The abdominal exam was normal.  The examiner diagnosed a hiatal hernia with gastro esophageal reflux disease.  The upper GI series showed no definitive hiatal hernia, reflux or ulcer and there was slight narrowing of the mid-dorsal thoracic esophagus.  The physical exam findings were some tenderness in the epigastric area and left upper quadrant.  The examiner diagnosed abdominal pain probably secondary to adhesions and gastritis.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the chronic abdominal pain condition as 5099 analogous to 5003, degenerative arthritis, and rated at 10% with application of the USAPDA pain policy.  The VA coded the cholecystectomy, residual of chronic abdominal pain condition as 7399 analogous to 7307, hypertrophic gastritis, and rated at 10%.  The CI did undergo removal of her gallbladder making the VA’s coding/rating option reasonable.  The CI underwent an extensive GI workup with the finding of a small to moderate sized hiatal hernia on two of the three studies.  The Board deliberated the application of several VASRD codes that could be appropriately applied to the CI’s abdominal pain condition.  Application of any of the VASRD codes considered by the Board would not lead to a rating greater than the 10% rating applied by the PEB.  Additionally, the VA’s coding/rating scheme would also confer no benefit to the CI.  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 chronic abdominal pain condition.

Schizoaffective Disorder with PTSD Condition:  The CI was given an S3 profile for the schizoaffective disorder and PTSD MH condition.  The commander’s statement noted that the CI was unable to perform her MOS duties because of her physical and MH conditions.  There was evidence in a VA Psychological Review performed on 29 April 2010 which was a comprehensive psychiatric review of the CI’s STR notes that the CI admitted to marijuana use and a suicide attempt by overdose in 1981 at age 17 prior to military experience.  This suicide attempt was documented on the SF-93 dated 17 August 1984.  There was further evidence that the CI developed PTSD as a result of a shooting incident in 1991 and a subsequent physically abusive relationship for several years which preceded her National Guard service.  The CI was followed by a MH social worker for the non-combat PTSD and schizoaffective disorder.  She had no psychiatric emergency room visits or hospitalizations for any MH condition.  The MEB Psychiatric Addendum diagnosed an Axis I schizoaffective disorder manifested by periods of depression and hypomania associated with psychotic symptoms which was EPTS and PTSD because she was physically abused by her ex-husband which was EPTS.  The CI was followed after separation by a VA MH provider who continued the diagnosis of non-combat PTSD from a gunshot wound as a civilian and schizoaffective disorder with paranoid ideations.  The CI did not undergo a VA C&P exam for a MH condition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the schizoaffective disorder with PTSD as 9211 with no rating applied.  This condition was deemed EPTS by the MEB and not service aggravated.  The VA coded the PTSD, depression and bipolar disorder condition as 9434 and determined it was NSC based on the STR.  The Board carefully reviewed the evidence in the STR regarding the schizoaffective disorder and PTSD and concluded that the MH conditions were EPTS and not service aggravated.  Additionally, the Board of Veterans Appeals considered the CI’s MH condition multiple times and was unable to establish service-connection with the available evidence.  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 schizoaffective disorder with PTSD 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the chronic abdominal pain condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic abdominal pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the schizoaffective disorder with PTSD condition, 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120925, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD 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 XXXXXXXXXXXXXXX, AR20150011084 (PD201301609)

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