RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX	CASE:  PD-2013-02746
BRANCH OF SERVICE:  Army	BOARD DATE:  20141212
SEPARATION DATE:  20070514

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Health Care Specialist) medically separated for psoriasis.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  “Psoriasis” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “psoriasis” as unfitting, rated at 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “I was a Nurse “Major Depression” Had 2 yrs. Intense R.E.M. treatment for PTSD.  During time of MRB was told unable to be diagnosed PTSD because I did not take direct fire.  I was in a CSH watching service members die daily, witnessed horrible wounds and was mortared on a daily basis.  I have continued counselling and therapy related to nightmares, flash backs and hypervigilance & provided immediate care and triage of injured Soldiers from Blackhawks and field evacuations.  Suffered intense survivors guilt as well as other mental issues related to my service during our invasion of Iraq.  During my deployment in Mosul we were mortared more time than I can account for, I saw more deaths of our comrades than I can account for and am still unable to care for adults in a nursing care setting due to my experiences.  I have a diagnosis of PTSD and would like the acknowledgement of the pain and traumatic events I experienced related to my military service.  I understand more has now been discovered related to PTSD that wasn’t available in 2007 and it was insulting to believe I am unable to suffer this diagnosis because as previously stated “I did not take direct fire” as a field nurse during a time of war.  I think it’s quite reasonable to think I have exceeded the “normal” expectation of the average nurse.  For 1yr I experienced traumatic events and feared for my life daily.  This experience has forever scarred and changed my view and ability to function normally from day to day.”

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 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:

Service IPEB – Dated 20070306 | VA - (1 Year Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Psoriasis | 7816 | 10% | Psoriasis | 7816 | 0%* | 20060505
Other x 0 (Not in Scope) | Other x 9
Rating:  10% | Combined Rating:  10%
Derived from VA Rating Decision (VARD) dated 20070809.  *VARD 20080105 increased the rating to 60%.

ANALYSIS SUMMARY:

Psoriasis Condition.  The narrative summary (NARSUM) which cites examination on 5 May 2006, notes the CI was diagnosed with psoriasis of the trunk, scalp, and extremities in 2003.  She was treated with light therapy and topical medications which improved but did not resolve the psoriasis.  The CI deployed and was unable to continue with the treatments and eventually was evacuated from theater in early 2004 due to frequent outbreaks.  The CI was evaluated by dermatology and placed on immunosuppressant medication, which cleared up the psoriasis after a few months.  Due to toxicity concerns, the medication was changed to daily oral therapy with a retinoid (not an immunosuppressant medication) by a civilian dermatologist in June or July 2005.  A dermatology consult on 6 April 2006 noted that the CI stopped the retinoid medication within 2 months of being prescribed and had not been on oral therapy for the prior 6 months.  The examination noted only two small lesions, one in a sun exposed area, one not.  The examiner recommended “risks of systemic medication outweigh any benefit…and clearly only topical therapy is indicated.”  The MEB physical exam on 5 May 2006 noted “Skin: currently clear except for some very mild plaques on her scalp.”  The MEB listed daily retinoid medication and the examiner noted that the CI was “taking immunosuppressant medication.”  A medication profile in the service treatment record (STR) documented use of methotrexate beginning in June 2004 and notes in the STR support that it was stopped in May or June 2005 and that the CI was prescribed oral retinoid medication instead.  The medication profile from 4 April 2005 to 15 February 2007 did not list any prescriptions for retinoid medication except one topical prescription.  A note in the record dated 7 February 2007 indicated the CI was prescribed oral retinoid medication daily but was not using it daily and preferred to use it as needed.

At the VA Compensation and Pension (C&P) examination on 5 May 2006, approximately 12 months prior to separation, the CI reported psoriasis.  The C&P examination report differed slightly from that of the MEB examination in that it documented there were no lesions present and the CI was taking medication listed as methotrexate (an immunosuppressant, not retinoid medication).  At a VA C&P skin examination on 10 January 2008, approximately 8 months after separation, the CI reported psoriasis controlled with constant use of methotrexate until February 2007 then oral retinoid therapy.  The examination noted “minor plaques in the scalp within hair line” and less than 5% of exposed areas and less than 5% total body area affected.  The examiner indicated the psoriasis was currently controlled with combined systemic and topical therapy.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the psoriasis condition 10%, coded 7816 (psoriasis) and the VA rated it 0% based upon the STRs and the prior to separation MEB/C&P examination on 5 May 2006, noting the CI did not attend a scheduled C&P examination.  The Board deliberated between the 7816 10% rating, specified as “at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period,” versus the 30% rating, specified as “20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy … required for six weeks or more, but not constantly, during the past 12-month period.”  No examination in the 12 months prior to separation noted involvement of at least 5% of the entire body or exposed areas.  Therefore, the Board agreed that the rating depended upon the medication use supported by the evidence in record and that either the oral immunosuppressant or oral retinoid medications satisfied the systemic medication criteria.  The Board noted that the available records were at multiple points in conflict with regard to the CI’s medication.  The 5 May 2006 examination for both the MEB and C&P indicated the CI was taking oral medication for psoriasis was in conflict with the cited contemporaneous notes in the STR.  A dermatology consultation a month earlier noted that the CI was not taking any medication for the previous 6 months and recommended use of only topical medication going forward.  The after separation C&P indicated that the CI was currently compliant with oral retinoid medication with good control, however noted that no records were obtained.  The CI reported that she was on methotrexate until February 2007 and then switched to oral retinoid therapy, which is not corroborated by the service medical records.  The Board also considered that the evidence at the after separation C&P was in conflict with a note in the STR dated 7 February 2007 that indicated the CI was not using her prescribed medications daily, including the retinoid, but preferred to use them as needed and medication profiles did not list any oral medication for psoriasis in the 12 months prior to separation.  Members concede the CI may have obtained medication off base, but there is no corroboration of this in the available records.  The Board concluded that there was insufficient evidence of “systemic therapy…required for a total duration of six weeks or more…” in the available record to support a recommendation for a rating greater than 10%.  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 psoriasis condition.

Contended Posttraumatic Stress Disorder (PTSD) Condition.  The CI deployed to the Iraq from February 2002-February 2003 as an ICU nurse.  There were no mental health (MH) treatment records.  On the MEB History and Physical DD Form 2807, dated 5 May 2006, the CI indicated she had anxiety and panic attacks, difficulty focusing, short-term memory loss, horrible nightmares (undescribed), stuttering, difficulty with sleep, depression, and counseling in association with PTSD.  On the DD Form 2697, Report of Medical Assessment, the CI reported she had been seen by MH and planned to seek disability for PTSD.

The commander’s statement (a year prior to separation) noted the CI was unable to perform her ICU duties and treat patients in a field hospital setting (due to) “stress induced condition flares up requiring medical evacuation out of theater…takes medication immunosuppressant placing soldier at risk for serious infections/disease” conditions as an impediment to performance of duty.  Her duty performance satisfactory and physical impairments prevented her from fulfilling the requirements of her MOS.  She received a S1 profile three months prior to separation.  The NARSUM, the MEB submission and the PEB Form 199 did not mention a MH condition.

The VA contract (Behavioral Health) examination for MH, dated 4 May 2007 (performed 10 days prior to separation), documented that no records related to a traumatic experience were provided for review.  However, the CI reported that as a nurse in a combat hospital and on field duty during combat, she was exposed to combat trauma that included exposure to death, body parts in boxes and amputees.  She saw her husband’s friend injured; this did not result in a consequence, but she felt threatened.  The CI reported she developed mental symptoms in May 2003 that included difficulty with sleep, frequent nightmares occurring 2-3 times per week, depressed mood, increased crying, and increased anger, an inability to control her emotions, panic attacks, social isolation, stomach problems, poor focus and feelings of guilt.  The symptoms were constant and escalated when her husband deployed, resulting in impairment in relationships due to increased irritability and decreased patience.  The CI reported she was taking an anti-depressant and anti-anxiety medication with a good response since August 2003.  In the past year she received psychotherapy as often as one time per week with a beneficial response.  She did not have a psychiatric hospitalization or a visit to an emergency room for psychiatric reasons.  Her relationship of 2 years with her spouse was excellent.  Mental status examination was notable impaired concentration with presence of forgetfulness and lack of focus, panic attacks more than once per week, obsessional rituals interfere with routine activities.  There was a mild degree of memory impairment.  A diagnosis of PTSD was rendered with a Global Assessment of Function score of 55 (moderate).  The examiner opined, “There was occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally the person is functioning satisfactorily.”  The VA assigned a 10% disability rating for major depression (claimed as PTSD).

All Board members agreed that evidence of the record reflected minimal occupational impairment on the basis of MH related symptoms.  The commander’s statement indicated her duty performance was satisfactory and that it was her physical impairments that prevented her from fulfilling the requirements of nursing.  At no time during the applicant’s military service did she require a psychiatric hospitalization or emergency care.  No MH condition was permanently profiled or was judged to fail retention standards.  The Board therefore concluded that there was insufficient evidence that any MH condition rose to the level of being unfitting at the time of separation.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a determination of unfit for any MH condition; and therefore, no disability rating can be 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.  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 psoriasis condition and IAW VASRD §4.118 the Board unanimously recommends no change in the PEB adjudication.  In the matter of any contended MH condition, the Board unanimously recommends no additional disability rating.  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 20131227, 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, AR20150008490 (PD201302746)

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

PD-2013-02746