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