RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXXXX CASE: PD1200022 

BRANCH OF SERVICE: ARMY BOARD DATE: 20130306 

SEPARATION DATE: 20090517 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SPC/E-4 (68W/Health Care Specialist) medically 
separated for anxiety disorder and bradycardia with pacemaker implantation. In September 
2007, the CI was experiencing numbness and tingling in both her upper and lower extremities. 
An electrocardiogram (EKG) in February 2008 showed sinus bradycardia. The CI underwent 
treatment but failed therapy and a pacemaker was inserted in April 2008. The CI was also 
diagnosed with anxiety disorder during this time. The anxiety disorder and bradycardia 
requiring a pacemaker 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). No other conditions were submitted by the 
MEB. The Physical Evaluation Board (PEB) adjudicated anxiety disorder and pacemaker 
implantation with symptomatic bradycardia as unfitting, rated 10% each, citing criteria of the 
Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The CI was then separated with a 
20% combined disability rating. 

 

 

CI CONTENTION: “Service member was rated for implantation of pacemaker and anxiety 
disorder due to medical condition. The pacemaker implantation has limited the individual's 
ability to pursue a career in desired field of nursing, and subsequently the individual has chosen 
a different field to complete her studies. Anxiety regarding the pacemaker is still continuous to 
this day, although noted that it resolved with implantation of pacemaker. The individual is seen 
at the Sandusky, OH, VA outpatient clinic for anxiety and is taking medication daily for these 
symptoms. (Please note at time of review, individual is pregnant and is not currently taking 
medications for anxiety, but will continue after the birth of child). The implantation of 
pacemaker and resulting anxiety has made it difficult for individual to acclimate to the school 
environment and has caused difficulties in her home life due to anxiety attacks. Individual is 
unable to complete certain tasks, such as heavy lifting and repetitive use of left arm due to pain 
and soreness that will result because of the area of implantation of pacemaker.” 

 

 

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 ratings for the unfitting anxiety disorder and 
bradycardia with pacemaker implantation are addressed below; and, 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 Army Board for Correction of Military Records. The 
Board acknowledges the CI’s information regarding the significant impairment with which his 
service-connected condition continues to burden her; but, must emphasize that the Disability 
Evaluation System has neither the role nor the authority to compensate members for 
anticipated future severity or potential complications of conditions resulting in medical 
separation. That role and authority is granted by Congress to the Department of Veteran 
Affairs, operating under a different set of laws. 

 


 

RATING COMPARISON: 

 

Service IPEB – Dated 20090324 

VA - (2 Months Pre- and 2 Month Post-Separation) 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Sinoatrial Node Dysfunction with 
Bradycardia and Pacemaker 

7018 

10% 

Sinus Node Dysfunction with 
Pacemaker 

7018 

10% 

20090318 

Anxiety Disorder 

9400 

10% 

Post Traumatic Stress Disorder 

9411 

30% 

20090720 

No Additional MEB/PEB Entries 

Other x 5 

20090318 

Combined: 20% 

Combined: 40% 



Derived from VA Rating Decision (VARD) dated 20090810 (most proximate to date of separation [DOS]). 

 

 

ANALYSIS SUMMARY: The Board’s authority as defined in DoDI 6040.44, resides in evaluating 
the fairness of DES fitness determinations and rating decisions for disability at the time of 
separation. The Board utilizes VA evidence proximal to separation in arriving at its 
recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to 
post-separation evidence. Post-separation evidence is probative only to the extent that it 
reasonably reflects the disability and fitness implications at the time of separation. 

 

Sinoatrial Node Dysfunction with Bradycardia and Pacemaker Condition. The MEB narrative 
summary (NARSUM) completed approximately 4 months prior to separation noted a diagnosis 
of sinoatrial node dysfunction (SND) that required the insertion of a pacemaker after treatment 
with theophylline failed. The CI’s symptoms of numbness and tingling in all four extremities 
began while she was deployed to Iraq and she was noted to have symptomatic sinus 
bradycardia at 30 beats per minute. The CI repeatedly denied any loss of consciousness 
although she did have lightheadedness and headaches noted in her service treatment record 
(STR). Electrophysiology studies at in April 2008 led to the diagnosis of SND and a pacemaker 
was inserted in April 2008. Cardiac stress testing completed prior to the pacemaker noted 
achievement of 18.2 metabolic equivalent of tasks (METS). Conclusions of the test were mild 
chronotropic incompetence manifest by inability to attain expected heart rate at various stages 
of exercise despite ability to attain approximately 80% of maximum predicted heart rate. 
Repeat testing completed in August 2008 noted achievement of 17.2 METs and her heart rate 
went from 37 to 150 beats per minute (76% of the maximal age predicted). Exercise was 
stopped due to the lightheadedness. At the time of the NARSUM, the CI reported minimal 
chest tightness and shortness of breath with overexertion and that her symptoms resolved with 
rest. This occurred less frequently after the pacemaker was inserted. The NARSUM examiner 
noted that the permanent pacemaker led to complete resolution of the previous fatigue and 
presyncope. No physical examination was included in the NARSUM and the examiner referred 
to a DD Form 2808 dated 9 January 2009. However, the only DD Form 2808 in the record was 
from August 2008 and it noted a normal heart exam and a pulse of 60 beats per minute. 

 

At the VA Compensation and Pension (C&P) exam performed approximately 2 months prior to 
separation, the CI also reported fatigue and dizziness prior to her diagnosis and pacemaker 
placement but again denied any syncopal episode. The clinical history reported is essentially 
the same as discussed above. The CI reported that although she felt tired around 11 AM, she 
was able to work an 8-hour day. She reported occasional lightheadedness with symptoms 
lasting 5 minutes and this occurred approximately twice a day. She continued to have 
shortness of breath when running but was able to use exercise equipment at the gym and walk 
without symptoms. She also reported pain at the pacemaker site. Her pulse was 60 beats per 
minute. Her cardiac examination was normal and she was noted to be NY Heart Association 
(NYHA) Class II. Class II is defined as: Mild symptoms (mild shortness of breath and/or angina) 
and slight limitation during ordinary activity. Her continued symptoms were noted to affect her 
occupational activities through lack of stamina, and weakness or fatigue. She was unable to 


play sports and her condition had a moderate effect on exercise and mild effects on shopping 
and traveling. She had no symptoms at rest. 

 

The Board directs attention to its rating recommendation based on the above evidence. Both 
the PEB and the VA rated the condition at 10% using VASRD 7018 implantable cardiac 
pacemakers. The PEB noted the CI’s symptoms had resolved after the placement of the 
pacemaker and the pacemaker was working properly. The VA noted response to treatment 
with the pacemaker was good although some symptoms remained. The 10% rating was 
assigned as the minimum rating following implantation of a pacemaker. The VASRD explains 
that after a pacemaker has been implanted, the condition will be rated as supraventricular 
arrhythmias (7010), ventricular arrhythmias (7011), or atrioventricular block (7015) and a 
minimum rating of 10% will be assigned. The CI’s sinoatrial node dysfunction with bradycardia 
could be rated as either 7010 or 7015; however, no rating greater than 10% would result. 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 sinoatrial node dysfunction with bradycardia and pacemaker condition. 

 

Anxiety Disorder due to a General Medical Condition Condition. 

The MEB psychiatric NARSUM completed approximately 4 months prior to separation noted the 
CI was first treated for anxiety at the time of her grandfather’s death just before she deployed. 
She was deployed to Iraq from 7 September 2007 until 25 February 2008 when she was 
evacuated out of theater for symptomatic bradycardia and significant anxiety. She initially 
went to Germany and then was at Walter Reed until July 2008 when she returned to Fort Drum. 
The examiner opined that life stressors and stress related to her medical condition lead to her 
anxiety disorder. The CI also reported there were several deaths in her immediate family 
during or around the time of her deployment. Specific dates and details are not included. 
However, the C&P examination for mental health discussed below noted the CI had lost many 
family members in the previous 5 years, with the death of her father just prior to deployment in 
September 2007 as the last event. The NARSUM reports the CI had symptoms about 3 to 5 
times per week and that she would need 0.5mg of Ativan once or twice a day when these 
symptoms occurred. Usually only one tablet was needed to control her anxiety. She was also 
receiving weekly therapy. Her current symptoms included restlessness or feeling keyed up, 
easily fatigued, difficulty concentrating, muscle tension, sleep disturbances all meeting the 
threshold for generalized anxiety disorder in the context of her general medical condition. 
However, the examiner noted that these symptoms did not prevent her from functioning fairly 
well in a military environment. The review of systems noted anxiety and sleep disturbance but 
a general overall feeling of “feeling fine,” normal enjoyment of activities, energy fair, no 
dangerous thoughts reported, no abnormal thoughts reported, no change in thought patterns, 
no sexual behavior complaints, no personality-related complaints, and no behavioral 
complaints. The psychiatric examination was completely normal and included a euthymic 
mood and a normal affect. Her symptoms were mild to moderate and only lasted an hour 
because of the effectiveness of the medication. The examiner speculated that only 10 to 20% 
of her missed duty was due to her mental health condition and the majority was a result of her 
cardiac problem. He diagnosed both anxiety disorder due to a medical condition and a 
generalized anxiety disorder and he estimated her Global Assessment of Functioning (GAF) was 
about 70 to 80. The examiner opined that without regular medication and therapy, the 
condition would immediately become worse and the CI would be a liability on the battlefield. 

 

There is one outpatient visit note from June 2008 that documents a referral to behavioral 
health at Walter Reed but there is no medical record available of any visit to mental health 
either at Walter Reed or at Fort Drum. Mental health conditions were included in the master 
problem list (MPL) at subsequent visits. An initial intake case management progress note from 
29 July 2008 noted the CI was being seen for depression and that she had her first appointment 
with behavioral health in Watertown that same day. However, no treatment notes are 


available for review. A medication profile covering early August 2008 to February 2009 noted 
four filled prescriptions for the anxiolytic Ativan (lorazepam). The first was dated 22 August 
2008 and the latest was dated 16 October 2008, while other medications had been filled as late 
as the end of January 2009. The medication profile does include narcotic and other pain 
medications dispensed from civilian pharmacies during this period so there is no evidence that 
any anxiolytics were dispensed from mid-October 2008 through February 2009. A total of 45 
1mg tablets and 60 0.5mg tablets were dispensed. If 0.5mg were taken daily, the amount 
dispensed would be enough for 150 days. Normal dosage for anxiety disorders is to two to six 
milligrams per day in divided doses. This implies either very sporadic use of medication or a 
complete halt to medication use after a period of more regular use. 

 

No permanent profile for any mental health disorder was ever issued. The commander’s 
statement does report behavioral health visits one to three times per week. However, the 
industrial capacity statement notes the CI could do everything except work an eight-hour duty 
day and perform without an unreasonable number and duration of rest periods and these 
limitations appear to be related to the fatigue she experienced from her cardiac condition. At 
the general medical C&P examination completed 4 months prior to the psychiatric C&P exam, 
the review of systems section included a history of depression, panic attacks, anxiety, and sleep 
impairment. However, the psychiatric examination included a normal affect, normal mood, 
normal judgment, and appropriate behavior, normal comprehension of commands, and no 
obsessive behavior or hallucinations/delusions. 

 

A C&P examination for mental health was completed approximately 2 months after the CI 
separated from service and had moved to Ohio. This exam reports that it was her father, not 
her grandfather, who died just before she deployed. This report included more details about 
when her other family members had passed away: her mother and grandmother in 2004, an 
aunt in 2005, her grandfather in February 2007, and her father in September 2007. This is a 
significant number of close family members to lose in a short time period but the dates and the 
fact that the CI did not redeploy for a funeral show that no family members died during her 
deployment. This exam also reports the CI had to identify the burned body of a squad leader 
she had been close too while deployed; however, this information is not mentioned anywhere 
else in the record. The description of the event and the cold injury in the C&P was significantly 
different than either was described in multiple other places in the record. While an event did 
occur and the CI did suffer a minor cold injury in January 2008, the story as described in the 
C&P appears to be significantly overdramatized. The record documents a minor cold injury that 
occurred during an Air Assault mission that was treated with warm fluids and monitoring. If the 
story had occurred as described there, there should be evidence of a more significant cold 
injury. However, there is no evidence of any significant cold injury and the CI’s cold hands and 
feet, which had first presented prior to deployment and were most likely related to her cardiac 
problem, improved significantly after her pacemaker was inserted. Additionally the VA did not 
service-connect a cold injury because there was no evidence of any residual or permanent 
disability from the mild hypothermia of her hands and toes. The CI also told the examiner she 
had to cut off her boot because it was stuck in the mud. She reportedly passed out during this 
episode and she had to be lifted onto a rescuing helicopter and then spent 4 to 5 months as an 
inpatient at Walter Reed. The CI denied ever having lost consciousness in every single other 
note in the record that addresses passing out. Some notes are silent on the matter, but none 
state she ever lost consciousness. This makes the reported nightmares about not being 
“rescued” and “being “found by Iraqis” to be less credible as a re-experiencing phenomenon. 
The CI did spend several months at Walter Reed but she was not an inpatient the entire time 
and she was hospitalized was for her cardiac problem and pacemaker insertion, not any injury 
related to the January 2008 event. Although the C&P examination was completed 
approximately 2 months after the CI separated from service, she reported she had been 
continuing counseling for “approximately one year following her release.” The VA examiner 
noted that VA electronic treatment notes documented a history of military sexual trauma (MST) 


but did not include any history related to this. These notes are not available for Board review. 
The diagnosis of MST is not mentioned anywhere else in the record except in two VA treatment 
notes from August 2011 and September 2012 discussed below. The VA examiner noted an 
anxious mood, a constricted affect, and slightly pressured speech. The examiner opined the 
CI’s symptoms were mild to moderate and did not significantly interfere with the CI’s ability to 
work. The examiner also opined the CI appeared to be “very resilient and optimistic despite 
numerous physical and psychiatric challenges.” The examiner opined the CI’s ability to remain 
free of addictive substances, her strong relationship with her current husband, and the regular 
counseling and medication she was receiving were the source for this higher than expected 
level of functioning. However, the examiner estimated the GAF as 55. 

 

No further C&P examinations were completed but review of two treatment notes from August 
2011 and September 2012 reveals diagnoses of generalized anxiety disorder, rule out 
obsessive-compulsive disorder, and military sexual trauma. There is no mention of PTSD but 
both notes state she had a “disability for Humanitarian emergency.” There is no evidence of 
any involvement in a humanitarian mission in the record available for Board review. At the 
time of both notes, the CI was attending graduate school earning a master’s in occupational 
therapy and the later note stated she was getting good grades. The September 2012 note 
stated the CI had not been seen in the intervening period and she had given birth to a baby that 
was 3 months old at the time of the second visit. She had stopped all of medications while 
pregnant and returned to restart them. Her mood was anxious at both visits and it was also 
depressed in September 2012. Her GAF was noted to be 50 in August 2011 and 60 in 
September 2012. 

 

The Board directs attention to its rating recommendation based on the above evidence. 
Despite the lack of any permanent profile or current occupational impairment due to mental 
illness, the PEB determined the anxiety disorder due to a general medical condition rendered 
the CI unfit for continued military service. Using VASRD 9400, they assigned a disability rating 
of 10% for transient or mild symptoms and occupational impairment only during periods of 
significant stress. With the clinical history provided by the CI, the VA determined a diagnosis of 
posttraumatic stress disorder (PTSD) and assigned a 30% rating for occupational and social 
impairment with occasional decrease in work efficiency and intermittent periods of inability to 
perform occupational tasks due to mental health symptoms. The VA rating decision (VARD) 
noted there was likelihood of improvement and a future review examination was planned for 
August 2011. Although the VA assigned a rating for PTSD, they did not assign an initial 50% 
rating as described in VASRD §4.129. 

 

The Board considered whether §4.129 should be applied in this case and determined it is not 
required. An initial 50% rating should be applied when a mental disorder that develops in 
service as a result of a highly stressful event is severe enough to bring about the veteran’s 
release from active military service. While the CI had many stressful events in her life near the 
time of separation that likely contributed to her mental illness, there is no evidence in the 
record that she experienced any particular event that can be considered outside the range of 
normal human experience. A majority of her stress was a result of her medical condition and 
the death of her father and multiple other family members in recent years and it is not clear 
that any highly stressful event brought about her release from active duty. After due 
deliberation, the Board concluded that there was insufficient cause to recommend the 
application of §4.129 in this case. 

 

It appears that despite significant mental health issues, the CI was resilient at the time of 
separation from service and remained so in the following three years. While there is no 
information regarding occupational function, the fact that the CI was successfully attending 
graduate school in 2011 and 2012 is evidence of a more limited impairment, either due to her 
personal coping mechanisms or medications, or both. This is congruent with the initial C&P 


examiner’s observation that near the time of separation the CI’s symptoms were “mild to 
moderate and [did] not interfere significantly with her ability to work; indeed, veteran could 
benefit from work or school and [had] plans to go back to school.” These observations by the 
VA examiner do not appear congruent with either a GAF of 55 or a disability rating of 30%. This 
coupled with the many historical inconsistencies, lack of any permanent profile for a psychiatric 
condition, minimal medication usage at the time of separation, and lack of any significant 
impairment despite substantial symptoms, does not support a rating greater than 10%. Neither 
the NARSUM nor the C&P examinations support 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 anxiety disorder 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 sinoatrial node dysfunction with bradycardia and 
pacemaker condition and IAW VASRD §4.104, the Board unanimously recommends no change 
in the PEB adjudication. In the matter of the anxiety disorder condition and IAW VASRD §4.130, 
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, as follows: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Sinoatrial Node Dysfunction with Bradycardia and Pacemaker 

7018 

10% 

Anxiety Disorder 

9400 

10% 

COMBINED 

20% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120702, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxxxxx, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / xxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 
for xxxxxxxxxxxxxxxxxxxxxxxx, AR20130007441 (PD201200022) 

 

 

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 xxxxxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)