Citation Nr: 1142286 Decision Date: 11/15/11 Archive Date: 11/30/11 DOCKET NO. 09-34 648 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to disability compensation for a fungus infection in both lungs and blood stream with lung scarring and shortness of breath, pursuant to the provisions of 38 U.S.C.A. § 1151. 2. Entitlement to disability compensation for fluid drainage from the brain, pursuant to the provisions of 38 U.S.C.A. § 1151. 3. Entitlement to disability compensation for joint pain, pursuant to the provisions of 38 U.S.C.A. § 1151. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from February 1960 to January 1964. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In March 2011, the Veteran testified during a hearing at the RO before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Board notes that, in the July 2009 statement of the case, the RO said that it reviewed the Veteran's electronic Virtual VA records that did not reveal any medical evidence pertinent to this appeal. The Board has reviewed the contents of the Veteran's Virtual VA file and also found no medical or other evidence pertinent to this appeal that is not in his claims file. FINDING OF FACT Additional disability, including a fungus infection to both lungs and blood stream with lung scarring and shortness of breath, fluid drainage from the brain, and joint pain, is not the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing hospital care, medical or surgical treatment, or examination (including the prescription of Humira), and was not the result of an event not reasonably foreseeable. CONCLUSIONS OF LAW 1. The criteria for establishing benefits under the provisions of 38 U.S.C.A. § 1151 for additional disability characterized as fungus infection in both lungs and blood stream with lung scarring and shortness of breath, claimed to be the result of treatment at a VA medical facility in August 2006 and March 2007, are not met. 38 U.S.C.A. §§ 1151, 5103-5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.358, 3.361 (2011). 2. The criteria for establishing benefits under the provisions of 38 U.S.C.A. § 1151 for additional disability characterized as fluid drainage from the brain, claimed to be the result of treatment at a VA medical facility in August 2006 and March 2007, are not met. 38 U.S.C.A. §§ 1151, 5103-5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.358, 3.361. 3. The criteria for establishing benefits under the provisions of 38 U.S.C.A. § 1151 for additional disability characterized as joint pain, claimed to be the result of treatment at a VA medical facility in August 2006 and March 2007, are not met. 38 U.S.C.A. §§ 1151, 5103-5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.358, 3.361. REASONS AND BASES FOR FINDING AND CONCLUSIONS I. Duty to Notify and Assist In September, October, and December 2007 letters, the Agency of Original Jurisdiction (AOJ) satisfied its duty to notify the appellant under 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2011) and 38 C.F.R. § 3.159(b) (2011). The AOJ notified the Veteran of information and evidence necessary to substantiate his claims. He was notified of the information and evidence that VA would seek to provide and the information and evidence that he was expected to provide. In the October 2007 letter, the Veteran was informed of how VA determines disability ratings and effective dates, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In Bryant v. Shinseki, 23 Vet App 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) (2009) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the Veterans Law Judge outlined the issues on appeal and suggested that any evidence tending to show that pertinent disability was related to VA medical treatment would be helpful in establishing the claims. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2); they have not identified any prejudice in the conduct of the Board hearing. During his hearing, the Veteran requested that the record be held open for an additional 60-day period to allow him to obtain and submit additional evidence and/or argument in support of his case. The Veterans Law Judge granted the Veteran's request for an extension, but no additional evidence in support of his appeal was received by the Board. VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). His service treatment and personnel records and VA and private medical records have been associated with the claims file, to the extent available. All reasonably identified and available medical records have been secured. In June 2009, the RO obtained a VA medical opinion regarding the Veteran's claims and that report is of record. The Board finds the duties to notify and assist have been met. II. Factual Background and Legal Analysis The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). The Veteran contends that he has additional disability that he attributes to his taking Humira starting in August 2006, prescribed by medical personnel at the VA Daytona Beach, Florida, Community Based Outpatient Clinic (CBOC), and to his initial hospitalization at the VA medical center (VAMC) in Gainesville, Florida, in March 2007. In his November 2008 notice of disagreement, the Veteran said that he was misdiagnosed when initially hospitalized in March 2007 and that, while he was briefed or counseled as to the possible side effects of taking Humira, he "truly did not understand the consequences, side effects, or usage of the medication". He did not understand that it was an immunosuppressive medication or its possible side effects and medical personnel failed to adequately explain that information to him. The Veteran also said that, prior to being prescribed Humira in 2006 by Dr. R., his major problem was arthritis. Five months after taking the medication, he was hospitalized and his problems began. According to the Veteran, if Humira was not prescribed, he would not be suffering from conditions he currently had related to a lung condition, joint pain, and brain leakage. VA medical records from the Daytona Beach CBOC and VAMC Gainesville, dated from August 2006 to June 2009, are of record. When the Veteran was seen in the Dayton Beach CBOC in August 2006, a history of asbestos exposure in the 1960s was noted with negative chest x-ray results and he reported that he was told there was lung scarring in the past. He used an inhaler. These records indicate that the Veteran was diagnosed with rheumatoid arthritis, for which Humira, an immunosuppressive drug, was prescribed by Dr. N.E.R. The records further show that Dr. N.E.R. discussed inflammatory arthritis and the medications, as well as potential risks and benefits of the medications, specifically Humira. The clinical records reveal that Humira medication was discussed in detail with the Veteran when it was initially prescribed and he was advised of the risks that included lymphoma, serious or life threatening infection, liver failure, multiple sclerosis like illness, tuberculosis, and hematologic disorders, and received pamphlets on the effects of the medication. On March 7, 2007, the Veteran was admitted to the VAMC in Gainesville with complaints of shortness of breath, coughing, and malaise. At that time, the record indicates that there was concern for an upper respiratory tract infection or pneumonia because his immune system was suppressed as he was prescribed immunosuppressive medication. It was noted that he took Humira that morning despite being educated about the medication and directed not to. Results of a chest x-ray taken at the time showed pneumonia. The Humira medication was discussed again in detail with the Veteran, including the risk of lymphoma, serious or life threatening infection, liver failure, multiple sclerosis-like illness, tuberculosis, and hematologic disorders, and he was again directed in the future to hold the medication if he had an infection. The Veteran was placed on intravenous antibiotics for a bacterial pneumonia and placed in respiratory isolation because he was on medications that somewhat suppressed his immune system and could place him at risk for certain infections, including tuberculosis and fungal lung infections. He subsequently reported improvement in his symtoms with antibiotics and, on March 12, 2007, was discharged with levofloxacin for treatment of his pneumonia. A March 14, 2007 VA record indicates that the Veteran talked by telephone with Dr. N.E.R. who advised that he stop taking Humira. On March 22, 2007, the Veteran was readmitted to the VAMC in Gainesville with complaints of increasing shortness of breath. Results of a chest x-ray taken at the time showed progression of the pneumonia and a computed tomography (CT) scan showed findings consistent with an atypical pneumonia most consistent with a fungal infection. Results of a bronchoscopy with transbronchial biopsies confirmed a diagnosis of cryptococcal pneumonia that is a fungal type of pneumonia. The Veteran's treatment was changed to Fluconazole, used to treat fungal pneumonia. Records indicate that fungal pneumonias were usually associated with suppression of the immune system and that he was taking immunosuppressive medication for the treatment of his rheumatoid arthritis. On March 30, 2007, the Veteran was discharged and given Fluconazole to treat his cryptococcal pneumonia. On May 30, 2007, the Veteran was admitted to the VAMC in Gainesville with complaints of joint pain and shortness of breath. A chest x-ray and CT scan of his thorax showed significant improvement of the cryptococcal pneumonia that was seen in prior studies. He complained of headaches that were a new symptom, and a lumbar puncture was performed to evaluate cryptococcal organism. The record indicates that on May 31, 2007, the risks of that procedure, that included headache, were explained to the Veteran, and that he signed a statement indicating that he understood the procedure and risks involved. He was treated with pain medication as needed and given long acting, slow release, pain medication prior to discharge on June 5, 2007. The records further indicate that he was to take Fluconazole for one year for the treatment of his cryptococcal pneumonia. He was seen by a rheumatologist during this time and the addition of rheumatoid arthritis medication was not recommended while he was taking Fluconazole. Subsequent VA treatment records indicate that the Veteran continued to take Fluconazole and his cryptococcal pneumonia was improving. A February 2009 record indicates that results of a chest x-ray performed in October 2008 showed no evidence of active pulmonary disease. When seen in May 2009, results of a chest x-ray indicated that his lungs were clear with no evidence of acute pneumonia, congestive failure, or pleural effusion. The pneumonia/cryptococcus neoformans was considered resolved. In a February 2009 signed statement, J.B.H., M.D., a pulmonologist, said that he reviewed the Veteran's medical records with particular attention to his March 7-12, 2007 hospitalization. The physician noted the Veteran's medical history that included rheumatoid arthritis for which he was treated with immune modulators, including adalimumab injected subcutaneously every other week as well as methotrexate. It was also noted that he was evaluated in the rheumatology clinic on March 7, 2007 by Dr. N.E.R. for evaluation of an acute illness that included cough, upper respiratory symtoms, shortness of breath, and arthralgias. The Veteran's cough was non productive, but a chest x-ray showed bilateral infiltrates and he was admitted because of concerns of pneumonia. Further, Dr. J.B.H. said that the initial hospital note confirmed the concerns of bilateral pneumonia in a gentleman who was immunosuppressed specifically with the medications adalimumab and methotrexate. The initial records confirmed the concerns of pneumonia in an immunosuppressed patient and need to evaluate for unusual organisms including tuberculosis and possible fungal infections. According to Dr. J.B.H., despite the concerns, there was never any evaluation for fungal infections during the Veteran's hospitalization from March 7 to 12, 2007. He was evaluated for acute bacterial pneumonia and treated for such. He was placed in respiratory isolation for concern of possible tuberculosis and evaluated for this with negative AFB (acid-fast bacillus) smears. The Veteran was not allowed out of respiratory isolation until it was confirmed that he did not have tuberculosis. He was discharged on antibacterial treatment for community-acquired pneumonia and no fungal cultures or fungal serologies (were) sent during this hospitalization. His symtoms persisted and worsened and required readmission on March 22, 2007 with worsening x-ray findings, symptoms, and pulmonary functions. It was discovered at that time that the Veteran had a fungal infection of cryptococcus neoformans that was diagnosed via fiberoptic bronchoscopy and he was placed on proper treatment. Dr. J.B.H. opined that there was a delay in diagnosis of cryptococcal neoformans pneumonia in the Veteran, who had obvious risk factors for fungal pneumonia. The doctor said that, during the initial hospitalization, this was not evaluated or treated and, therefore, the Veteran's symtoms worsened over the ensuing time. According to a June 2009 VA medical report, a VA physician reviewed the Veteran's medical records and provided an opinion. In the VA examiner's opinion, the Veteran's claimed disabilities were not caused by, or aggravated by, VA medical treatment. The Veteran's treatment for rheumatoid arthritis did not indicate any departure from accepted levels of medical care and the performance of professional duties were as expected of a reasonable health care provider. The outcome of treatment with Humira was an ordinary risk or a reasonably foreseeable event of that type of treatment. The VA examiner explained that 1--[THE VETERAN] HAD SEVERE RHEUMATOID ARTHRITIS. TREATMENT WITH HUMIRA WAS GIVEN FOR A VALID AND APPROPRIATE INDICATION, IN APPROPRIATE DOSES. 2--POTENTIAL SERIOUS SIDE EFFECTS WERE EXPLAINED TO [THE VETERAN] IN PERSON AND IN THE FORM OF A PAMPHLET. HE WAS WILLINGLY TAKING THE TREATMENT. 3--"FLUID DRAINAGE FROM BRAIN"-THAT IS LUMBAR PUNCTURE-WAS DONE TO RULE OUT AN INTERCRANIAL OR SPINAL INFECTIONS, SINCE [THE VETERAN] HAD SEVERE HEADACHES. THIS WAS [THE] RIGHT THING TO DO. 4-[THE VETERAN] WAS PROPERLY DIAGNOSED AND TREATED FOR THE FUNGAL INFECTION IN LUNGS AND WITH CONTINUED TREATMENT, THERE SHOULD BE NO, PERMANENT DISABILITY FROM IT. 5-[THE VETERAN'S] JOINT PAINS ARE NOT CAUSED BY ANY VA TREATMENT. THEY ARE DUE TO HIS RHEUMATOID ARTHRITIS, FOR WHICH HE [IS] BEING TREATED PROPERLY. 6-[THE VETERAN] WAS NOT INCORRECTLY DIAGNOSED FOR A BACTERIAL PNEUMNIA, SINCE HE WAS RESPONDING WELL TO GIVEN ANTIBIOTICS. 7-[DR. J. B.H.'S] LETTER DOES NOT REFLECT ABOVE FACTS. During his March 2011 Board hearing, the Veteran and his representative clarified that he had a "back condition due to improper fluid drainage" because a proper procedure was not completed (see Board hearing transcript at page 2). He indicated that his fungus infection to the lungs caused spinal meningitis for which a lumbar puncture was performed during his second hospitalization (Id.). The Veteran said that if he was properly diagnosed at the outset, he could have been cured right away rather than hospitalized a second time (Id. at 12-13). He was no longer able to take typically prescribed medication for joint pain (Id. at 18). In pertinent part, 38 U.S.C.A. § 1151 provides for compensation for qualifying additional disability in the same manner as if such additional disability were service- connected. A qualifying additional disability is one in which the disability was not the result of the veteran's willful misconduct; and, the disability was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran; and, the proximate cause of the disability is the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination, or was the result of an event not reasonably foreseeable. Id. Thus, under the applicable law, VA fault or an event not reasonably foreseeable would be required for this claim to be granted, if the evidence were to establish additional disability which was caused by hospital care, or by medical or surgical treatment, rendered by the Department of Veterans Affairs. In determining whether a veteran has additional disability, VA compares his condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to his condition after such care or treatment. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the Veteran's additional disability. Merely showing that a veteran received care or treatment and that the Veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease or injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability, it must be shown that the hospital care or medical or surgical treatment caused the veteran's additional disability; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care or medical or surgical treatment without the veteran's informed consent. As for the merits of the Veteran's claim under 38 U.S.C.A. § 1151, the law, as noted above, provides that compensation may be awarded in the same manner as if the additional disability or death were service connected. The Court has consistently held that "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). The requisite link between a current disability and injury or disease incurred as a result of VA treatment may be established, in the absence of medical evidence that does so, by evidence that symptomatology attributable to an injury or disease which was "noted" during VA treatment has continued from then to the present. See e.g., Jones v. West, 12 Vet. App. 460, 463-4 (1999); see also Savage v. Gober, 10 Vet. App. 488, 498 (1997); 38 C.F.R. § 3.303(b) (2011). Thus, a claim for benefits under 38 U.S.C.A. § 1151 must be supported by medical evidence of additional disability that resulted from VA hospitalization or medical or surgical treatment. See Jimison v. West, 13 Vet. App. 75, 77-78 (1999). Moreover, and also consistent with the service connection analogy, since a section 1151 claim is a claim for disability compensation, a veteran who has made a showing of some type of injury due to VA medical care "must still submit sufficient evidence of a causal nexus between that . . . event and his or her current disability . . . to be ultimately successful on the merits of the claim." Wade v. West, 11 Vet. App. 302, 305 (1998). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent evidence to the effect that the claim is plausible. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d. 1372, 1377 (Fed. Cir. 2007). The Veteran does not meet the burden of presenting evidence as to medical cause and effect, or a diagnosis, merely by presenting his own statements, because as a layperson he is not competent to offer medical opinions. The Veteran can attest to factual matters of which he had first-hand knowledge, e.g., experiencing shortness of breath and joint pain. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the Veteran as a lay person has not been shown to be capable of making medical conclusions, thus his statements regarding causation are not competent. The VA medical records document that Humira was prescribed for treatment of the Veteran's rheumatoid arthritis in August 2006, and he was initially hospitalized on March 7, 2007, but it must still be shown that these events caused additional disability. The first complaints of lung infection were somewhat removed from the initial prescription according to the clinical records and, more recent VA medical records indicate that the Veteran took Fluconazole and his cryptococcal pneumonia was resolved. The Veteran asserts that he suffered a fungus infection of the lungs and blood stream and lung scarring and shortness of breath, fluid drainage from the brain, and joint pain, as a result of treatment administered by VA in August 2006, at which time he was prescribed Humira medication to treat his rheumatoid arthritis, and in March 2007 when initially hospitalized at the VAMC in Gainesville. The question on appeal, therefore, is whether the Humira medication prescribed by VA in August 2006, and the March 7-12, 2007 VAMC treatment, caused some additional disability due to VA fault or an event not reasonably foreseeable. Upon review of the medical evidence of record, it is the Board's conclusion that the Veteran has not presented competent medical evidence to support his claim for benefits, pursuant to the provisions of 38 U.S.C.A. § 1151, that fungus infection of the lungs and blood stream and lung scarring and shortness of breath, fluid drainage from the brain, and joint pain resulted from Humira medication prescribed to treat rheumatoid arthritis provided in August 2006 at a VA medical facility, and treatment provided from March7-12, 2007 at the VAMC in Gainesville. The Veteran claims that he did not fully understand the risks and consequences of taking Humira prescribed by the VA medical facility in August 2006 and, that when hospitalized at the VAMC in Gainesville from March 7-12, 2007, he was not properly diagnosed with a fungus infection in his lungs, and that he now has lung scarring, joint pain, and fluid drainage from the brain. Nevertheless, the fact that one event followed another does not mean that the first caused the second. More important, however, in order to establish entitlement to benefits under 38 U.S.C.A. § 1151, the evidence must show "additional disability" as a result of the treatment in question due to carelessness, negligence, lack of proper skill, error in judgment or an unforeseen event. This, at bottom, is a medical determination, and the competent medical evidence of record fails to show any causal relationship between current a fungus infection in both lungs and blood stream with lung scarring and shortness of breath, fluid drainage from the brain, and joint pain, and the treatment in question. Significantly, a VA examiner who reviewed the Veteran's medical records in June 2009 concluded that the Veteran's claimed disabilities were not caused by or aggravated by VA medical treatment. The VA examiner also said that the Veteran's treatment did not indicate any departure from accepted levels of medical care and that the performance of professional duties was as expected of a reasonable health care provider. As well, the VA examiner said that the outcome of treatment with Humira was an ordinary risk or a reasonable foreseeable event of that type of treatment. The opinion provided by a VA examiner in June 2009 was based upon a review of the Veteran's medical history and findings. Based upon a review of the aforementioned information, the VA examiner opined that the Veteran's claimed disabilities were not caused by or aggravated by VA medical treatment, that the Veteran's treatment for rheumatoid arthritis did not reflect any departure from accepted levels of medical care, and the outcome of treatment by Humira was an ordinary risk or a reasonably foreseeable event of that type of treatment. The VA medical specialist noted that the Veteran had severe rheumatoid arthritis and that treatment with Humira was given for a valid an appropriate indication in appropriate doses. The examiner said that potential serious side effects were explained to the Veteran in person and in the form of a pamphlet and that the Veteran willingly took the treatment. Further, the VA physician said that "fluid drainage from brain" (as claimed by the Veteran) was a lumbar puncture and was performed to rule out any intracranial or spinal infections and, as the Veteran had severe headaches, this was the right thing to do. The VA examiner also said that the Veteran was properly diagnosed and treated for the fungal infection in his lungs and with continued treatment there should be no permanent disability. The VA physician indicated that the Veteran's joint pains were not caused by VA treatment as they were due to his rheumatoid arthritis for which he was properly treated. The VA examiner said that the Veteran was not incorrectly diagnosed for a bacterial pneumonia, since he was responding well to given antibiotics. The Veteran's primary argument is apparently based upon his allegation that VA did not treat him in accordance with the prevailing standard of care and, therefore, was at fault/negligent in the prescribing the Humira medication for his rheumatoid arthritis in August 2006 and then misdiagnosing his fungal pneumonia during his March 7-12, 2007 VAMC hospitalization, that ultimately resulted in his fungus infection of the lungs and blood stream with lung scarring and shortness of breath, fluid drainage from the brain, and joint pain that the Veteran claims were due to the prescribed Humira medication and VAMC hospital treatment from March 7 to 12, 2007. In effect, the question is whether the August 2006 prescription for Humira medication and the March 7-12, 2007 VAMC treatment were the appropriate standard of care. As regards causation, the Board recognizes that the Veteran believes that treatment provided by VA in August 2006 when Humira was prescribed, and at the VAMC from March 7-12, 2007, resulted in his fungus infection of the lungs and blood stream with lung scarring and shortness of breath, fluid drainage to the brain, and joint pain. While the Veteran is certainly capable of providing evidence of symptomatology, a layperson is generally not capable of opining on matters requiring medical knowledge, such as the diagnosis of the disability produced by the symptoms or the underlying cause of the symptoms. See, e.g., Washington v. Nicholson; Jandreau v. Nicholson, supra, Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied 119 S. Ct. 404 (1998), and Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In the June 2009 VA opinion, a VA physician reviewed all of the Veteran's medical records and opined that the Veteran's claimed disabilities were not caused by or aggravated by VA medical treatment. This VA examiner said that the Veteran's treatment for rheumatoid arthritis did not indicate any departure from accepted levels of medical care and the performance of professional duties were as expected of a reasonable health care provider. The VA examiner further stated that the outcome of treatment with Humira was an ordinary risk or a reasonably foreseeable event of that type of treatment. Where a medical expert has fairly considered all the evidence, his opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion. Wray v. Brown, 7 Vet. App. 488, 493 (1995). The Board does, in fact, adopt the 2009 VA examiner's opinion on which it bases its determination that benefits pursuant to 38 U.S.C.A. § 1151 for tremors and uncontrolled salivation is not warranted. The 2009 VA medical examiner expressly based his opinion upon a review of the Veteran's medical records in his claims files. The physician explained that the Veteran had rheumatoid arthritis for which Humira was prescribed that was a valid and appropriate treatment given in appropriate doses. The VA examiner stated that the potential serious side effects of taking Humira were explained to the Veteran in person and in the form of a pamphlet and he willingly took it. According to the VA examiner "fluid drainage from brain" as claimed by the Veteran was a lumbar puncture that was done to rule out any intracranial or spinal infections, and since the veteran had severe headaches, this was the right thing to do. The VA examiner also said that the Veteran was properly diagnosed and treated for the fungal infection in his lungs and that, with continued treatment, there should be no permanent disability. The VA examiner stated that the Veteran's joint pains were not caused by VA medical treatment and were due to his rheumatoid arthritis. According to the VA examiner, the Veteran was not incorrectly diagnosed for a bacterial infection, as he was responding well to given antibiotics. Since the VA physician's opinion was based on a review of the pertinent medical history, and was supported by sound rationale, it provides compelling evidence against the appellant's claim. The Board emphasizes that the VA physician provided a valid medical analysis to the significant facts of this case in reaching his conclusion. In other words, the VA physician did not only provide data and conclusions, but also provided a clear and reasoned analysis that the Court has held is where most of the probative value of a medical opinion comes is derived. See Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008); see also Wray v. Brown, 7 Vet. App. at 493. The Board therefore places greater weight on the VA opinion that finds that the Veteran was not incorrectly diagnosed for a bacterial pneumonia when initially hospitalized at the VAMC in Gainesville form March 7-12, 2007, than on the February 2009 opinion rendered by Dr. J.B.H., the private physician, to the effect that there was a delay in diagnosis of cryptococcal neoformans pneumonia in the Veteran who had obvious risk factors for fungal pneumonia and that, during the initial hospitalization, this was not evaluated or treated and, therefore, his symtoms worsened over the ensuing time. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches"). But a medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. at 304. It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. at 433. But, we are mindful that we cannot make our own independent medical determinations, and that we must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. In evaluating the ultimate merit of this claim, the Board ascribes the greatest probative value to the medical opinion provided by the VA physician who provided the written opinion in June 2009. This physician had the opportunity to review all the Veteran's medical records regarding the initial prescription for Humira in 2006 and the hospitalizations in March 2007. This physician explained that the Veteran had rheumatoid arthritis for which Humira was prescribed that was a valid and appropriate treatment given in appropriate doses. The VA examiner noted that the potential serious side effects of taking Humira were explained to the Veteran in person and in the form of a pamphlet and he willingly took it. The VA examiner said that the Veteran was properly diagnosed and treated for the fungal infection in his lungs and that, with continued treatment, there should be no permanent disability. The VA examiner stated that the Veteran's joint pains were not caused by VA medical treatment and were due to his rheumatoid arthritis. According to the VA examiner, the Veteran was not incorrectly diagnosed for a bacterial infection, as he was responding well to given antibiotics. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). As to the February 2009 opinion of Dr. J.B.H., the private physician, who opined that there was an delay in diagnosis of cryptococcal neoformans pneumonia in the Veteran who had obvious risk factors for fungal infection and that, during the initial hospitalization, this was not evaluated nor treated and, therefore, his symtoms worsened over ensuing time, the Board finds that, given the scope and depth of the VA examiner's rationale, his opinion carries more weight than that of Dr. J.B.H. The Board is persuaded that the VA examiner's opinion is most persuasive in that this physician reviewed all the Veteran's medical records and provided a rationale for his opinion. See Prejean v. West, Wray v. Brown, supra. Thus, the probative and objective medical opinion of record demonstrates that the Veteran does not have additional disability due to VA medical treatment. While, in his September 2008 written statement, the Veteran asserts that he did not fully understand the risks of taking Humira , the VA examiner noted that the potential side effects were explained to the Veteran in person and in a written pamphlet and that he willingly took the treatment The Veteran himself is not shown to have the medical expertise to diagnose or determine the etiology of cryptococcal neoformans pneumonia and his argument that he was improperly prescribed Humira and misdiagnosed with bacterial pneumonia when initially hospitalized at the VAMC fails. Dr. J.B.H. commented that there was "a delay in diagnosis of cryptococcal neoformans pneumonia in [the Veteran]" who had "obvious risk factors for fungal pneumonia" and that, during the initial hospitalization, "this was not evaluated or treated and therefore his symtoms worsened over the ensuing time". The opinion is tenuous and based in part on what might have been present at the time, but has not been demonstrated in the record. Dr. J.B.H. assumes facts not in evidence, and his opinion is not accorded great weight by the Board. On the other hand, the VA examiner stated that he had reviewed all the evidence of record. This medical specialist explained that his review of the records revealed that the Veteran had rheumatoid arthritis for which Humira was prescribed that was a valid and appropriate treatment given in appropriate doses. The VA examiner noted that the potential serious side effects of taking Humira were explained to the Veteran in person and in the form of a pamphlet and he willingly took it. The VA examiner also said that the Veteran was properly diagnosed and treated for the fungal infection in his lungs and that, with continued treatment, there should be no permanent disability. According to the VA examiner, the Veteran was not incorrectly diagnosed for a bacterial infection, as he was responding well to given antibiotics. Thus, the opinion of Dr. J.B.H. is accorded less weight than that of the VA examiner. We recognize the Veteran's sincere belief that his fungal infection in the lungs and blood stream with lung scarring and shortness of breath, fluid drainage from the brain, and joint pain, are related in some way to his experience while taking Humira prescribed by VA personnel and during treatment at the VAMC in Gainesville. Nevertheless, in this case, the Veteran has not been shown to have the professional expertise necessary to provide meaningful evidence regarding the causal relationship between his fungal infection in the lungs and blood stream with lung scarring and shortness of breath, fluid drainage from the brain, and joint pain, and his prescription for Humira medication and hospital treatment from March 7 to 12, 2007, at the VAMC in Gainesville. See Washington v. Nicholson; Routen v. Brown, Jandreau v. Nicholson, Woehlaert v. Nicholson, supra. In summary, compensation is not warranted for additional disability claimed by the Veteran as due to VA medical treatment, because the weight of the evidence preponderates against a grant of these benefits under 38 U.S.C.A. § 1151. In reaching this conclusion, the Board has considered the applicability of our longstanding reasonable-doubt/benefit-of-the-doubt doctrine. However, the competent evidence of record does not place the Veteran's claim in relative equipoise. As the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to disability compensation for a fungus infection in both lungs and blood stream with lung scarring and shortness of breath, pursuant to the provisions of 38 U.S.C.A. § 1151 is denied. Entitlement to disability compensation for fluid drainage from the brain, pursuant to the provisions of 38 U.S.C.A. § 1151 is denied. Entitlement to disability compensation for joint pain, pursuant to the provisions of 38 U.S.C.A. § 1151 is denied. ____________________________________________ JOAQUIN AGUAYO-PERELES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs