RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW
NAME: BRANCH OF SERVICE: aIR FORCE
CASE NUMBER: PD201000563 SEPARATION DATE:
20090729
BOARD DATE: 20111006
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SUMMARY OF CASE: Data extracted from the available evidence of record
reflects that this covered individual (CI) was an active duty SrA/E-4
(1N251 /Signal Intel), medically separated from the Air Force in 2009 for
atypical chest pain. The CI had an extensive history of chest pain which
began after a viral illness in March, 2004. The pain was exacerbated by
exertion. She did not respond adequately to treatment and was unable to
participate in a physical fitness test; she was issued a permanent P2
profile and underwent a Medical Evaluation Board (MEB). She was returned
to duty with an Assignment Limitation Code C1 stratification which limited
duty assignments to military bases with a fixed medical treatment facility.
Chest pain was forwarded to the Physical Evaluation Board (PEB) as
medically unacceptable IAW AFI 48-123. The Informal PEB (IPEB) adjudicated
the atypical chest pain as unfitting, rated 10%; with application of the
AFI 48-123 and DoDI 1332.39, respectively. The CI made no appeals and was
medically separated with a 10% combined disability rating.
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CI CONTENTION: ‘’I was discharged from the Air Force with the VA
diagnostic code which was under Atypical Chest Pain, this was different
than that of what the VA rated me under. The VA gave me a rating of 60%
because they used the correct VA diagnostic code which shows that I have
Chronic Bilateral Pleurisy in which is my true diagnosed condition.”
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RATING COMPARISON:
|Service IPEB – Dated 20090506 |VA ( 7 Mos After Separation) – All |
| |Effective Date 20090730 |
|Condition |Code |
|Final Combined: 10% |Total Combined: 60% |
ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the
CI’s application, i.e., that there should be additional disability assigned
for the gravity of her condition and predictable consequences which merit
consideration for a higher separation rating. While the Medical Disability
Evaluation System considers all of the service member's medical records,
compensation can only be offered for those medical conditions that cut
short a service member's career, and then only to the degree of severity
present at the time of final disposition. However, the Department of
Veterans Affairs, operating under a different set of laws (Title 38, United
States Code), is empowered to periodically re-evaluate Veterans for the
purpose of adjusting the disability rating should his degree of impairment
vary over time.
Atypical Chest Pain. The CI complained of exertional chest pain beginning
with a viral bronchitis diagnosed on 13 September 2004. At that time, she
also complained of occasional shortness of breath (SOB) and had tenderness
to palpation in the left upper quadrant. She was treated with narcotics,
cough suppressants, and Albuterol. These were ineffective as were non-
steroidal medications. When seen again, two weeks later, she noted prior
episodes in 2001 (pre-enlistment). She had no shortness of breath and her
lungs were clear; the chest wall pain was reproduced with palpation. Over
the next year, she was evaluated by pulmonary medicine, cardiology and
cardiothoracic surgery. Testing included normal chest CT scans,
Echocardiograms, and pulmonary function tests (PFTs). She was noted to
have chronic, pleuritic chest pain of unknown etiology with an essentially
normal exam other than chest wall tenderness to palpation. Following a
pregnancy, she was found to remain symptomatic and unable to run more than
100 yards without chest pain. She was referred to MEB/PEB which returned
her to duty with the stipulation that she could only deploy to, or be
stationed at a location with a fixed military medical facility (Assignment
Limitation Code: C-1). A pulmonary consult dated 6 November 2007 noted
normal PFTs and a negative methacholine challenge test. Over the next one
one-half years, she continued to remain symptomatic with flares during
upper respiratory infections. At the 21 January 2009 review in lieu of MEB
(RILO) she was noted to have some improvement in her condition, but
remained unable to run 100 yards. Neurontin provided some relief of her
symptoms. An exacerbation in August 2008 (11+ months prior to separation),
required a steroid burst for relief. At the RILO exam, six months prior to
separation, she was noted to be less symptomatic than previously. At the
time of her 24 June 2009 Family Practice visit/separation physical (the
last while on active duty), she was noted to be on a trial of Lyrica which
did not result in significant benefit, but to be stable. A previous trial
of Flovent did not improve her symptoms. Medical separation was
recommended as she could not deploy nor was improvement in her symptoms
anticipated. The VA compensation and pension (C&P) examination performed
17 February 2010, almost six months after separation, was significant for
pain over the chest area and SOB while exercising. A new finding of a
faint pleural friction rub was heard. The examiner noted that the CI could
not sit or stand fully upright as this worsened the pleuritic pain. PFTs
were abnormal as documented in the chart below and consistent with a
restrictive defect. A good effort was documented. Chest x-ray was normal.
The Board notes that there was one episode when she was unable to perform
PFTs due to the chest pain, early in the course of her illness, 21 October
2004. There were four sets of PFTs in the record. The third set was two
months after the second, but unfortunately, poorly legible. Clear copies
were requested, but not available. However, the note by the pulmonologist
indicates that it was normal. The other three follow:
|Spirometry |Pulm |Pulm |C&P |
| |~4 years |~2 years |~7 Mos |
| |Pre Sep |Pre-Sep |Post Sep |
|Pre-Bronchod|FVC |3.67 (95%) |3.40 (96%) |1.68 (42%)|
|ilator | | | | |
| |FEV1 |3.65 (117%)|3.41 (110%)|1.51 (44%)|
| |FEV1/F|100% |98% |90% |
| |VC | | | |
|Post-Inhaled|FVC |- |- |1.76 (44%)|
|steroid | | | | |
| |FEV1 |- |- |0.84 (24%)|
| |FEV1/F|- |- |47% |
| |VC | | | |
|Comments |No Meds |No Meds |Flovent |
| | |PFTs two |was the |
| | |months |“bronchodi|
| | |later were |lator” |
| | |also NML | |
|§4.97 Rating |0% |0% |60% |
| | | |(VA 60%) |
The IPEB coded the atypical chest pain as 5399-5321 and awarded a
disability rating of 10%. The VA coded the condition as 6899-6845 (chronic
pleural effusion or fibrosis) and rated it at 60%. The Board considered
whether or not the VA or IPEB coding and rating better reflected the
disability at separation. The Board notes that her symptoms were
duplicated on several exams by chest wall and/or left upper quadrant
pressure; that PFTs were consistently normal until the C&P evaluation at
which time, as noted, she could not sit or stand upright due to discomfort;
and, that lung sounds were always clear other than at the C&P exam. At the
time of separation, she was on neither bronchodilators nor inhaled steroids
per the record. Rather, she was taking Lyrica and Celebrex for pain and
noted to be “stable” at her separation, exam one month prior to separation.
The Board noted that the findings on the C&P examination with worsening of
symptoms, the manifestation of a pleural rub, and a restrictive PFT reflect
post-separation worsening of her condition. The development of these signs
and symptoms are consistent with the diagnosis of pleurisy coded 6899-6845
by the VA. Rating under this code is also consistent with the VA findings
of 60%. One Board member considered that the VA C&P examination was
closest to separation and was appropriate to use for rating purposes;
however, due to the exacerbation of symptoms at the 7 month point the
actual PFT at the time of separation may not have been as abnormal and thus
advocated for a 30% rating under that code. The Board majority concluded
that under the 6899-6845 code, but based upon the PFT’s pre discharge and
the fact that the CI was somewhat stable before discharge, that the
appropriate rating under the 6899-6845 code would be 0%. Since Board
precedent is to not reduce PEB findings the majority considered no
recharacterization to be appropriate. After due deliberation, in
consideration of the totality of the evidence and §4.3 (reasonable doubt),
the Board concluded that there was insufficient cause to recommend a change
from the PEB fitness adjudication for the atypical chest pain condition.
Other PEB conditions and other contended conditions. None
Remaining Conditions. No other conditions were noted in the NARSUM,
identified by the CI on the MEB physical or found elsewhere in the DES
file. The Board does not have the authority under DoDI 6040.44 to render
fitness or rating recommendations for any conditions not considered by the
DES. No other conditions were considered to be service connected by the
VA. The Board thus has no basis for recommending any additional unfitting
conditions for separation rating.
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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. In matter of the atypical chest pain, the
Board recommends, by a 2:1 vote, no change in the PEB adjudication. The
minority voter who recommended that the condition be recharacterized to
pleurisy, coded 6899-6845 and rated at 30% disability elected not to submit
a minority opinion.
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RECOMMENDATION: The Board, therefore, recommends that there be no
recharacterization of the CI’s disability and separation determination.
|UNFITTING CONDITION |VASRD CODE |RATING |
|Atypical chest pain |5399-5321 |10% |
|COMBINED |10% |
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The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20100415, w/atchs.
Exhibit B. Service Treatment Record.
Exhibit C. Department of Veterans' Affairs Treatment Record.
President
Physical
Disability Board of Review
SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews MD 20762
Reference your application submitted under the provisions of DoDI
6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2010-00563.
After careful consideration of your application and treatment
records, the Physical Disability Board of Review determined that the
rating assigned at the time of final disposition of your disability
evaluation system processing was appropriate. Accordingly, the Board
recommended no re-characterization or modification of your separation
with severance pay.
I have carefully reviewed the evidence of record and the
recommendation of the Board. I concur with that finding and their
conclusion that re-characterization of your separation is not warranted.
Accordingly, I accept their recommendation that your application be denied.
Sincerely,
Director
Air Force Review Boards
Agency
Attachment:
Record of Proceedings
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