RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02337
BRANCH OF SERVICE:  Army  	BOARD DATE:  20140912
SEPARATION DATE:  20090615

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (11B10/Infantryman) who was medically separated for syncope.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The syncope condition characterized as “recurrent syncopal episodes likely secondary to hyperventilation syndrome” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated syncope as unfitting rated at 20% citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Rated at 20% at time of discharge for two occurrences of syncope.  Not evaluated for the root cause of the heart conditions.”

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 CI.  The rating for the unfitting syncope condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  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 Board for Correction of Military Records.

RATING COMPARISON:  
   
Service IPEB – Dated 20090424 | VA C&P- (5 Mos. /Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam

Syncope

8999-8911

20%

Hyperventilation Syndrome With Syncope/Palpitation,
Claimed As A Heart Condition

8199-8108

NSC

20090804

Other x 0  (Not in Scope) | Other x 8 (Not in Scope) | 20090804
Combined:  20% | Combined:  10%
Derived from VA Rating Decision (VARD) dated 20091109 (most proximate to date of separation)

ANALYSIS SUMMARY:   

Syncope Condition.  The narrative summary (NARSUM) notes the CI reported he developed gradual random episodes of palpitations, shortness of breath (SOB), dizziness, blurred vision, and lightheadedness, starting in December 2005.  After that time, he had 12 episodes of associated syncope.  An emergency room (ER) note dated 8 July 2008 recorded the CI’s report of 3 to 4 months history of palpitations, described as beginning with a “jolt” and the feeling that his heart skips a beat, followed by the sensation that his heart is catching up for about 5 minutes before resolving.  He had presented to the ER with report of palpitations.  Electrocardiogram (ECGs) studies were borderline to abnormal, predominately notable for incomplete right bundle branch block; however, one recording was consistent with right bundle branch block.  The CI was prescribed medications to address the palpitations.  On 
14 August 2008, cardiology consultation revealed a normal physical examination.   Holter cardiac monitoring and stress echocardiogram test were ordered.  The results of the echocardiogram, dated 28 August 2008, demonstrated normal ejection fraction and mild mitral valve prolapse, and mild tricuspid and pulmonic valves regurgitation.  The CI presented to the ER on 4 September 2008 for report of chest pain and palpitations.  He reportedly stated he had passed out the day before for unknown reasons.  The CI underwent neurology consultation to rule out seizures on 2 October 2008.  At the neurological consult, the CI reported an approximate a year history of chest flutter accompanied by SOB, dizziness, blurred vision and cloudiness.  He also reported a year history of syncope and noted he had been able to abort other syncopal events by tucking his head between his knees whenever he felt “cloudy.”  The neurologist diagnosed syncope and hyperventilation syndrome.  Electroencephalogram (EEG) on 14 October 2008 was normal.  Magnetic resonance imaging (MRI) study of the brain on 18 November 2008 was unremarkable but noted a mild sinus condition.  An internal medicine clinic visit dated 1 December 2008 noted the CI reported less fainting episodes; however, he had anxiety and his palpitations had increased after his medication was discontinued.  His medication was re-started and the physician also prescribed medication to treat sinusitis.  The CI presented to the ER on 12 December 2008, with the report of syncopal and near syncopal events twice a week.  At the MEB exam on 27 March 2009, approximately 3 months prior to separation, the physician noted the CI had been diagnosed with hyperventilation syndrome, Gilbert’s Syndrome (a genetic liver disease problem) and right bundle branch block.  His palpitations were responsive to medication and the syncopal episodes occurred randomly without identifiable precipitating factors.  Physical examination was unremarkable.  The physician diagnosed recurrent syncopal episodes likely secondary to hyperventilation syndrome.  The CI underwent exercise stress test under the Bruce Protocol, and the results were normal (METS consistent with >10).

At the VA Compensation and Pension (C&P) examination on 4 August 2009, two months after separation, the CI noted he had been informed that his chest pain and SOB, syncope, and dizziness were caused by his hyperventilation disorder.   He reported that that he faints on occasion, with symptoms present as often as four times per day.  Physical examination of lungs and heart was unremarkable.  The examiner diagnosed hyperventilation syndrome with subjective factors of intermittent palpitation, hyperventilation and headache, and normal objective factors (normal lung exam, and pulmonary function test [PFT] test).  The condition of heart palpitation and syncope were noted as conditions related to the hyperventilation syndrome.  

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the condition of syncope, not otherwise specified, at 20% coded analogously 8999-8911 (petit mal seizures), for two minor seizures in the last six months.  The VA did not service connect the condition and therefore, did not rate it.  The higher rating of 40% requires demonstration of at least five to eight minor seizures weekly, which was not supported by the evidence.  The record in evidence demonstrated that the CI presented twice to the ER; once with the report of chest pain and palpitations and SOB, consistent with hyperventilation syndrome and the second visit, 3 months later, when the CI reported he had passed out earlier that day after feeling dizzy.  Each time syncope was diagnosed.  All board members agreed the evidence did not support the 40% rating criteria.  The Board next considered the 7015 code (atrioventricular [AV] block).  The higher rating of 30% under that code requires METs of less than 7, which was not supported by the evidence.  The Board discussed rating the condition under the analogous coding scheme 8299-8210 (tenth [vagus] cranial nerve), however concluded there was no benefit to the CI since the criteria for the higher rating of 30% (incomplete, severe paralysis) were not met. There were no other applicable codes to rate the condition.  After due deliberation in consideration of the totality of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB rating determination for the syncope 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 syncope condition and IAW VASRD §4.124a, 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.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131111, 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, AR20150003236 (PD201302337)

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

PD-2013-02337