Citation Nr: 0122095 Decision Date: 09/06/01 Archive Date: 09/12/01 DOCKET NO. 01-02 261 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for Augmentin induced meningitis. 2. Entitlement to service connection for hysterectomy due to chronic pelvic adhesive disease. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD C. Trueba-Sessing, Associate Counsel INTRODUCTION The veteran served on active duty from December 1992 to July 1998. The case arises from a July 1999 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which denied the benefits sought. The veteran filed a timely appeal, and the case has been referred to the Board of Veterans' Appeals (Board) for resolution. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable resolution of the issues on appeal has been obtained by the RO. 2. The record includes competent medical evidence showing the veteran has residuals of Augmentin induced meningitis, and of a nexus between such residuals and in-service use of Augmentin. 3. The record includes competent medical evidence showing the veteran underwent a hysterectomy due to chronic pelvic adhesive disease, and of a nexus between her hysterectomy and in-service pelvic inflammatory disease. CONCLUSIONS OF LAW 1. Augmentin induced meningitis was incurred during the veteran's active service. 38 U.S.C.A. §§ 1110, 5107 (West 1991 & Supp. 2000); 38 C.F.R. §§ 3.102, 3.303 (2000); Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000). 2. Hysterectomy due to chronic pelvic adhesive disease is linked to the veteran's active service. 38 U.S.C.A. §§ 1110, 5107 (West 1991 & Supp 2000); 38 C.F.R. §§ 3.102, 3.303 (2000); Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As a preliminary matter, the Board notes that on November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), which applies to all pending claims for VA benefits, and which provides that the VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate his or her claim for benefits under the laws administered by the VA. Among other things, this law eliminates the concept of a well-grounded claim, redefines the obligations of the VA with respect to the duty to assist, and supersedes the decision of the United States Court of Appeals for Veterans Claims (Court) in Morton v. West, 112 Vet. App. 477 (1999), withdrawn sub nom, Morton v. Gober, No. 96-1517 (U.S. Vet. App. Nov. 6, 2000) (per curiam order), which had held that the VA cannot assist in the development of a claim that is well grounded. The VCAA is applicable to all claims filed on or after the date of enactment, November 9, 2000, or filed before the date of enactment and not yet final as of that date. See VCAA, Pub. L. No. 106-475, § 7, subpart (a), 114 Stat. 2096, 2099 (2000). See Karnas v. Derwinski, 1 Vet. App. 308 (1991). First, the VA has a duty to notify the veteran and his/her representative of any information and evidence necessary to substantiate and complete a claim for VA benefits. See VCAA, § 3(a), 114 Stat. 2096, 2096-97 (2000) (to be codified as amended at 38 U.S.C. §§ 5102 and 5103). Second, the VA has a duty to assist the veteran in obtaining evidence necessary to substantiate his/her claim. See VCAA, § 3(a), 114 Stat. 2096, 2097-98 (2000) (to be codified as amended at 38 U.S.C. § 5103A). In the present case, although the RO did not have the benefit of the explicit provisions of the VCAA, the VA's redefined duty to assist has been fulfilled. The Board finds that the veteran has been provided adequate notice as to the evidence needed to substantiate her claims for service connection. The Board concludes that discussions, as contained in the rating decisions, in the subsequent statement of the case, and in correspondence to the veteran, have provided her with sufficient information regarding the applicable regulations and regarding the evidence necessary to substantiate her claims. The Board finds, therefore, that such documents are essentially in compliance with the VA's revised notice requirements. The Board finds that the VA does not have any further outstanding duty to inform the veteran that any additional information or evidence is needed. The Board also finds that all relevant facts have been properly developed, and that all evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, particularly in view of the Board's grant of benefits in this case. The evidence of record includes the veteran's service medical records, records of treatment following service, reports of VA examinations, and personal statements made by the veteran advancing her contentions. The veteran was given the opportunity to present testimony during an appeal hearing, but she declined such opportunity. The Board is aware that the veteran's April 2000 VA examination rating the claimed hysterectomy due to chronic pelvic adhesive disease does not appear to provide a definite conclusion as to its etiology, given the wording included in the report. However, in light of the clinical evidence presented below, and in light of the Board's ultimate decision to grant this claim, the Board finds that it is not necessary to schedule the veteran for a rating examination in connection with the claim. Therefore, no further assistance to the veteran regarding the development of evidence is required. See generally VCAA. Generally, service connection may be granted for a disability resulting from a disease or injury that was incurred in or aggravated by service. See 38 U.S.C.A. § 1110 (West 1991 & Supp. 2000); 38 C.F.R. §§ 3.102, 3.303 (2000). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2000). In the present case, while a showing of a "well-grounded claim" is no longer a valid basis for establishment of service connection, see VCAA, supra, the basic elements for establishing service connection, irrespective of the "well- grounded" doctrine, have remained unchanged. There must be medical evidence of a present disability, evidence of an injury or disease in service, and competent medical evidence of a nexus or link between the currently diagnosed disorder and the veteran's active service. I. Augmentin Induced Meningitis. The veteran claims that she currently suffers from the residuals of meningitis incurred as a result of her in- service use of Augmentin prescribed as treatment for a sinusitis infection. Her service medical records confirm that she was diagnosed with probable sinusitis and was treated with Augmentin 250 milligrams, as per July 1997 notations. Additional July 1997 notations indicate the veteran reported she was told she had Augmentin induced meningitis and that she should be considered allergic to Augmentin. Lastly, the veteran's March 1998 report of medical history and discharge examination report indicate she had meningitis in 1997 and a history of headaches since her meningitis. With respect to the post service medical history, medical records from the Yakima Valley Memorial Hospital indicate the veteran was hospitalized from July 9, 1997 to July 12, 1997 for complaints of severe headache for several days. Upon admission, she reported that she had sinusitis for a week and had been taking Augmentin 250 milligrams up until the day of her admission. She also had a prior history of meningitis in 1989 without sequelae. The veteran's entrance diagnosis was meningitis, aseptic versus partially treated bacterial meningitis. However, upon discharge, her diagnosis was meningitis, likely secondary to medication (Augmentin) versus aseptic. The hospitalization report further noted that most of the evidence pointed towards aseptic meningitis but also some evidence pointed towards early bacterial meningitis. Given the veteran's recovery within two days and after consulting with local internists, the Ears-Nose-Throat department, and Infections Disease care, it was the opinion of the veteran's treating physician that her meningitis was most likely drug induced, probably secondary to Augmentin, as opposed to aseptic. Lastly, a February 1998 VA examination report indicates the veteran had Augmentin induced meningitis with residuals. She was noted to continue to suffer from ongoing congestion and earache, and that her headaches had resolved. Given the above described medical evidence, the Board finds that the evidence supports a grant of service connection for Augmentin induced meningitis. The veteran's service medical records show she was in fact treated with Augmentin for probable sinusitis, and the July 1997 hospitalization summary from the Yakima Valley Memorial Hospital conclusively diagnoses the veteran with meningitis likely secondary to medication (Augmentin). These facts, in conjunction with all other relevant evidence of record, provide a sufficient basis to conclude that the claimed Augmentin induced meningitis is related to her active service. As such, the Board finds that the evidence is at least in relative equipoise, that the benefit of the doubt rule is applicable to this claim, and that, resolving all reasonable doubt in the veteran's favor, a grant of service connection for Augmentin induced meningitis is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 1991 & Supp 2000); 38 C.F.R. §§ 3.102, 3.303 (2000); Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000). II. Hysterectomy Due to Chronic Pelvic Adhesive Disease. In May 1999, the veteran underwent a hysterectomy due to pelvic pain and bleeding, and chronic pelvic adhesive disease. She contends that she was treated during her active service for pelvic inflammatory disease (PID), which in turn led to her chronic pelvic adhesive disease and eventually to her hysterectomy. In this regard, the service medical records show the veteran was treated for various gynecological problems during her active service. Specifically, May 1993 notations indicate she had a 2 week history of abdominal pain, and July 1993 notations show she was diagnosed with Trichomonas. Additionally, September 1995 notations indicate she had acute abdominal/pelvic pain secondary to probable PID, and October 1995 notations revealing she was diagnosed with rule out endometriosis and had completed empiric therapy for PID. Lastly, September 1998 notations show the veteran was again suffering from acute abdominal/pelvic pain with a probable diagnosis of PID. The post service medical evidence includes medical records from various private health care providers including, but not limited to the Yakima Valley Memorial Hospital, the Grant/Riverside Methodist Hospital, the Cornerstone Medical Clinic and Donald K. Bryan, M.D. These records describe the treatment the veteran received over time for various gynecological problems. Specifically, the Board notes that a May 1999 hospitalization report from the Grant/Riverside Methodist Hospital indicates the veteran was diagnosed with pelvic pain, pelvic bleeding, and chronic pelvic adhesive disease. As a result, the veteran underwent lysis of pelvic adhesions, a total abdominal hysterectomy, right salpingo- oophorectomy and suspension of the left ovary. Additionally, a September 1999 statement from Dr. Bryan notes that it is his opinion that the veteran underwent a hysterectomy for chronic pelvic inflammatory disease (PID). He further explained that the veteran had developed chronic pelvic adhesive disease as a result of having chronic PID with an initial episode of acute PID while in the service, and that it was well recognized that chronic PID is a sequela of acute PID. Lastly, the Board notes the veteran underwent a VA examination in April 2000, which indicates that she was told she was having dysfunctional uterine bleeding not related to PID and that, at the time of her hysterectomy, multiple adhesions were taken down which could account for her ongoing pelvic pain. In this respect, it was the examiner's opinion that if the pathologic findings on the operative report revealed a fibroid uterus, that in fact was the cause for the dysfunctional uterine bleeding and subsequent hysterectomy. However, following the examination, the veteran was diagnosed with status post total abdominal hysterectomy for dysfunctional uterine bleeding and pelvic adhesive disease which was dictated post-operatively to be secondary to pelvic inflammatory disease (PID). The Board has evaluated the foregoing, and concludes that the evidence supports a grant of service connection for hysterectomy due to chronic pelvic adhesive disease. The veteran contends that her hysterectomy was secondary to pelvic adhesive disease, which in turn was caused by her in- service PID. And, as noted above, her service medical records in fact show she was treated for acute abdominal/pelvic pain and was diagnosed with probable PID on at least two occasions during her active service. The record further reflects, as indicated in Dr. Bryan's September 1999 statement, that chronic PID is a known sequelae of acute PID, and that the veteran developed chronic adhesive disease as a result of having chronic PID which began during the veteran's active service. The Board finds that the medical evidence described, in conjunction with all other relevant evidence of record, provides a sufficient basis to conclude that her hysterectomy was secondary to pelvic adhesive disease, which in turn is related to her in-service episodes of pelvic inflammatory disease. As such, the Board finds that the evidence is at least in relative equipoise, that the benefit of the doubt rule is applicable to this claim, and that, resolving all reasonable doubt in the veteran's favor, a grant of service connection for hysterectomy due to chronic pelvic adhesive disease is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 1991 & Supp 2000); 38 C.F.R. §§ 3.102, 3.303 (2000); Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000). ORDER Service connection for Augmentin induced meningitis is granted. Service connection for hysterectomy due to chronic pelvic adhesive disease is granted. WARREN W. RICE, JR. Member, Board of Veterans' Appeals