Citation Nr: 1234912 Decision Date: 10/09/12 Archive Date: 10/17/12 DOCKET NO. 07-27 826 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of hypertension claimed to be the result of being prescribed an improper dosage of thyroid medication at the Department of Veteran's Affairs (VA) Community Based Outpatient Clinic (CBOC) in Logan, West Virginia. 2. Entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of vision problems claimed to be the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia. 3. Entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of tinnitus claimed to be the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia. 4. Entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of depression claimed to be the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1964 to June 1967. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a July 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia, which denied the benefits sought on appeal. A hearing was held at the RO in July 2008, conducted by a Decision Review Officer. A Travel Board hearing was also held on June 29, 2010 at the RO before the undersigned Veterans Law Judge. Transcripts of the hearings are in the claims file. In September 2010, the Board remanded the issues on appeal for further development. Pursuant to the remand directives, available private treatment records from Dr. T. dated from March 2005 to January 2006 were obtained and VA medical opinions were obtained in October and November 2010. Given the foregoing, the Board finds that VA has substantially complied with the Board's September 2010 remand with regard to the issue decided herein. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). The issues of entitlement to compensation under 38 U.S.C.A. § 1151 for additional disabilities of hypertension, vision problems, and tinnitus claimed to be the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The probative and persuasive evidence of record does not show that the Veteran has an additional disability of depression as the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia. CONCLUSION OF LAW The requirements for entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of depression claimed to be the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia have not been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.361 (2011). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2011). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his/her representative, if applicable, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Further, in Dingess v. Nicholson, the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. 19 Vet. App. 473 (2006); see also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. With respect to the issue decided herein, the Board finds that the VCAA duty to notify was satisfied by a letter sent to the Veteran in December 2006 with regard to the claim. The letter addressed all of the notice elements and was sent prior to the initial unfavorable decision by the RO in December 2006. In this case, the fact that the notice did not address either the relevant rating criteria or effective date provisions, was harmless error because service connection is being denied, and therefore no rating or effective date is being assigned. Therefore, the Board finds that VA has fulfilled its duty to notify under the VCAA. VA has also satisfied its duty to assist the Veteran at every stage of this case with regard to the claim. The Veteran's service treatment records, and all available identified VA and private treatment records pertinent to the claim are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. In this regard, in the September 2010 remand, the Board requested all private treatment records from Dr. T. pertaining to treatments afforded the Veteran. In December 2010 and March 2011, the RO requested the records from Dr. T., which were received in April 2011. 38 C.F.R. § 3.159(c)(1). Pursuant to the Board's September 2010 remand, a VA examination was obtained in October 2010. 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). With respect to the issue decided herein, the Board finds that the VA opinion obtained in this case is adequate, as it is predicated on a reading of relevant medical records in the Veteran's claims file. It considered all of the pertinent evidence of record, to include the Veteran's medical records and statements, and provides a complete rationale for the opinions stated. There is adequate medical evidence of record to make a determination with regard to the issue of depression. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to this issue has been met. 38 C.F.R. § 3.159(c)(4). The Board observes the Veteran's representative's arguments made in June 2012 that the October 2010 VA psychiatric examination and opinion are not adequate. The representative asserts that the examiner noted varying dates of the onset of the improper dosage, initially stating the improper dosage was first reflected in May 2004, and later stating it was shown to have started in December 2004, and the examiner did not have a clear understanding of when the problems began. The representative also contends that the same examiner failed to comment on the question of aggravation if the Veteran did have depression and/or anxiety prior to the improper dosage. Despite the representative's contentions, the examiner did address the aggravation of the Veteran's depression as the result of the improper dosage in that he indicated that there was no relationship between improper dosage of thyroid hormone and depression. Further, the examiner explained that hyperthyroidism, either by itself or due to overdose of thyroid hormone, does not relate to depression, but hypothyroidism may cause depression. In essence, this statement indicates that the overdose of thyroid medication did not aggravate any pre-existing depression. Additionally, the Board finds that although the examiner once mistakenly noted that the improper dosage occurred on May 22, 2004, it appears to be a harmless typographical error. The examiner later correctly noted that the Veteran was prescribed Levothyroxine at a dose of 0.2 mg on December 22, 2004, which was not adjusted to 0.2 mg until May 25, 2005. To that end, the examiner concluded that the Veteran did not suffer disability relating to depression attributable to the VA's failure to properly prescribe Levothyroxine from December 22, 2004 to May 25, 2005. Thus, the Board concludes that the VA examiner provided an adequate rationale for his conclusion that is supported by the evidence of record, as will be discussed more fully below. VA has also assisted the Veteran and his representative throughout the course of this appeal by providing them with a Statement of the Case and Supplemental Statement of the Case, which informed them of the laws and regulations relevant to his claims. For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). 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. 38 C.F.R. § 3.303(d). Under certain circumstances 38 U.S.C.A. § 1151(a) grants compensation and DIC for a qualifying disability or death of a veteran in the same manner as if such disability or death were service-connected. See also 38 C.F.R. § 3.361. For claims filed after October 1, 1997, the disability or death must be caused by hospital care, medical or surgical treatment, or examination furnished the veteran by VA, and the proximate cause of the disability or death was (a) 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 (b) an event that was not reasonably foreseeable. 38 U.S.C.A. § 1151(a)(1); 38 C.F.R. § 3.361(d). 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 or death, it must be shown that the hospital care or medical or surgical treatment caused the veteran's additional disability or death; 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. See 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. See 38 C.F.R. § 3.361(d)(2). Second, there must be evidence of additional disability, as shown by comparing the veteran's condition before and after the VA medical care in question. 38 C.F.R. § 3.361(b). In determining whether disability or death resulted from disease or injury or aggravation of an existing disease or injury suffered as a result of VA care, the evidence must show actual causation rather than coincidental occurrence. 38 C.F.R. § 3.361(c)(1). Finally, the disability or death must not be the result of the veteran's failure to follow properly given medical instructions. 38 U.S.C.A. § 1151(a); 38 C.F.R. § 3.301(c)(3). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("Although interest may affect the credibility of testimony, it does not affect competency to testify."). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to compensation under 38 U.S.C.A. § 1151 for additional disability of hypertension, vision problems or depression claimed to be the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia. The Veteran contends that his being prescribed an improper dosage of a particular medication to treat a thyroid condition caused him to develop depression. He claims this occurred because medical personnel at the Logan VA outpatient clinic prescribed an amount in excess of what was medically required. VA medical records on file show that the Veteran was prescribed a thyroid supplement on December 22, 2004. This medication, Levothyroxine, in the form of a tablet, was prescribed at a dosage of .2 milligrams. A VA primary care physician note, also dated December 22, 2004, shows a past medical history hypothyroidism. In a March 2005 private treatment report, the Veteran reported that he had been depressed for 4 to 6 months, and it was gradually worse in the last 3 to 4 weeks. He related that he had been retired while his wife went to work and that he was worried. The impression was depression and depression counseling was recommended. A May 25, 2005, progress note from the Logan CBOC shows that the Veteran was called and advised to discontinue his current synthroid medications and to wait until the bottle containing a dosage of .025 milligrams arrived. A September 2005 private treatment report noted the Veteran's complaint of depression regarding retirement. The impression was depression. In a January 2006 private treatment report, the Veteran reported that his depression was gone now and not as bad. It was noted that he was no longer taking Klonopin and Celexa. In a July 2008 letter, a private registered pharmacist discussed possible adverse reactions due to the taking of an excessive dosage of thyroid hormone replacement medication. While many of the signs and symptoms were noted to be subtle and insidious, the pharmacist also listed many symptoms associated with thyroid hormone excess, to include nervousness, anxiety and depression. At his June 2010 hearing, the Veteran testified that his private "regular doctor" (see page 11 of transcript) had treated him for his depression, which he claimed occurred due to his being overprescribed medication from VA. Pursuant to the September 2010 remand, the Veteran underwent additional VA examinations in October 2010. Concerning depression, the VA examiner, S.S., reviewed the Veteran's claims file and noted that the Veteran had been seeing his primary physician, Dr. T., after his retirement in May 2004 regarding depression and anxiety issues. Dr. S.S. observed that the records from Dr. T. indicated the Veteran's depression and anxiety secondary to retirement and "nothing to do," and prescription of anti-depressant and an anti-anxiety medication. The Veteran reported that "during the time of overdose of medication, I had a bad time." He described that he was doing fairly well, except for occasional crying without any reason, but reported that "just when I was taking those pills, I had suicidal thoughts." He denied any current suicidal thoughts. The examiner stated that prior to the improper prescription of thyroid medication, the Veteran had history of depression for which he was seen after retirement by his primary physician. Dr. S. explained that Levothyroxine is prescribed for hypothyroidism and the maximum dose of hypothyroidism is 0.3 mg; 0.2 mg is still in the therapeutic range. Dr. S. further stated that there is no scientific evidence that hyperthyroidism, either by itself or due to overdose of thyroid hormone, relates to depression; however, hypothyroidism, on the other hand, may cause depression. The examiner stated that the Veteran's depression is not caused or aggravated by carelessness, negligence, lack of proper skill, or error in judgment or similar instance of fault on the part of the VA CBOC in Logan, West Virginia in its prescribing Levothyroxine at a dose of 0.2 mg on December 22, 2004 and not adjusting the level to 0.025 mg until May 25, 2005. Dr. S. thus concluded that the Veteran did not suffer disability relating to depression attributable to the VA's failure to properly prescribe the Levothyroxine from December 22, 2004 to May 25, 2005. He added that although the VA physician exercising their ordinary reasonable depress of skill and care should have prescribed the correct dose, the Veteran did not suffer disability relating to Levothyroxine at the time he was prescribed an improper dosage, because increasing Levothyroxine dose does not cause depression. Additionally, the examiner stated that "[i]n case of overdose, it can cause associated temporary anxiety as long as the increased dose is in the system, but [L]evothyroxine at 0.2 mg is still a therapeutic dose as 0.3 mg is the highest dose which can be given in hypothyroidism." The Board will begin with an analysis as to whether the Veteran has an additional disability of depression as a result of VA care. The Board concludes that the probative and persuasive evidence of record reflects that he does not. In this regard, the Board does not dispute that around the time of the improper prescription of the Veteran's thyroid medication, his depression worsened. As noted above, the Veteran reported in March 2005 that he had been depressed for 4 to 6 months and it was gradually worse. He also reported on the October 2010 VA examination that he had a bad time during the time of improper medication, including having suicidal thoughts. However, it is not an issue of whether something occurred during the time of VA treatment. Rather, the issue is whether the Veteran has an additional disability of depression as the result of VA's failure to properly prescribe thyroid medication. Concerning this, the Board affords Dr. S.'s conclusion that the Veteran did not suffer disability relating to depression attributable to the VA's failure to properly prescribe the Levothyroxine to be highly probative. Following review of all pertinent evidence, Dr. S. concluded that the Veteran's depression claimed to be secondary to higher dose of Levothyroxine did not relate to the medication, but it related to the Veteran's retirement as reflected in the records of treatment for depression at the particular time concerned. In the course of the examination, the examiner referenced the higher dosage of 0.2 mg of Levothyroxine and the Veteran's statements regarding his symptoms during the period for which the medication was improperly prescribed. The examiner noted the Veteran's prior history of depression for which he was seen after retirement by his primary physician. The examiner further stated that hyperthyroidism, either by itself or due to overdose of thyroid hormone, does not affect depression, although hypothyroidism, for which the Veteran is being treated, may cause depression. This negates any notion that the improper dosage of thyroid hormone in excess of what was medically required aggravated the Veteran's pre-existing depression. Additionally, the examiner stated that in case of overdose, it can cause associated temporary anxiety as long as the increased dose is in the system. However, the examiner implicates that because Levothyroxine at 0.2 mg is still a therapeutic dose (0.3 mg being the highest dose which can be given in hypothyroidism), there was no overdose. Further, in case of any possible temporary anxiety due to the increased dose of thyroid medication, the examiner notes that it occurs only as long as the increased dose is in the system. Therefore, no permanent disability relating to anxiety as a result of the VA's improperly increased dosage of Levothyroxine is shown in this case. As discussed above, the examiner referenced the Veteran's statements regarding his symptoms during the period for which the medication was improperly prescribed. Moreover, the opinion is based on the examiner's expertise as a physician specializing in psychiatry and neurology. The Board affords this opinion great weight and persuasive value. On the other hand, the Board does not find the July 2008 private registered pharmacist's statement to be persuasive. The pharmacist listed numerous symptoms associated with thyroid hormone excess, to include nervousness, anxiety and depression. However, the pharmacist failed to discuss the amount of the specific thyroid mediation that may constitute "thyroid hormone excess" in the Veteran's case. Thus, although the Veteran's depression or anxiety might have increased during the time of improper dosage of thyroid medication, it cannot be concluded that the improper dosage of thyroid medication in this case was a casual factor. 38 C.F.R. § 3.361(c)(1). Although the pharmacist's opinion appears on its face to be favorable to the Veteran, it cannot be assigned as much weight as Dr. S.'s more thorough opinion. Because Dr. S.'s opinion is more detailed, complete and fully addresses the question at issue, the Board affords it more weight than the July 2008 private pharmacist's statement. Accordingly, the probative and persuasive medical evidence does not establish the presence of an additional disability as the result of VA care, the claim cannot be granted. Thus, it is not necessary to discuss whether 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 whether there was an event that was not reasonably foreseeable. Therefore, the claim cannot be granted under the provisions of 38 U.S.C.A. § 1151. ORDER Entitlement to compensation under 38 U.S.C.A. § 1151 for additional disability of depression claimed to be the result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia is denied. REMAND The Veteran contends that he developed hypertension, vision problems, and tinnitus as a result of being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia. Previously, in its September 2010 remand, the Board determined that the two VA opinions, dated in June 2007, did not fully address the issues pertaining to a 38 U.S.C.A. § 1151 claims and requested further evidentiary development. Pursuant to the September 2010 remand, the Veteran underwent additional VA examinations in October and November 2010. However, the Board finds that these VA examinations not adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that if VA provides a Veteran with an examination in a service connection claim, the examination must be adequate). Concerning tinnitus, the October 2010 VA audiology examination report noted the Veteran's report of increased severity of tinnitus after being prescribed Levothyroxine in the amount in excess of what was medically required. The examiner stated "[t]innitus is a documented side effect of metabolic abnormalities, and the possible side effects of an overdose of Levothyroxine can possibly effect (sic) tinnitus." However, the Board accords little probative value to this opinion as it is based on speculation or remote possibility. 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. 30, 33 (1993); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992). Statements like this from VA examiners that are, for all intents and purposes, inconclusive as to the origin of a disorder generally cannot be employed as suggestive of a linkage between the disorder and the specific VA treatment in question. Warren v. Brown, 6 Vet. App. 4, 6 (1993); Sklar v. Brown, 5 Vet. App. 104, 145-6 (1993). Ultimately, noncommittal opinions like this amount to "nonevidence," neither for nor against the claim, because they are based on speculation or remote possibility. See generally Bloom v. West, 12 Vet. App. 185 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty); see also 38 C.F.R. § 3.102 (when considering application of the benefit-of-the-doubt doctrine, reasonable doubt is one within the range of probability, as distinguished from pure speculation or remote possibility). The Board also notes that there is conflicting medical evidence with regard to the effect of excessive thyroid hormone medication on hypertension. Concerning hypertension, an October 2010 VA examiner, Dr. F.U., noted that "[a]s per literature, [L]evothyroxine does not cause or aggravated (sic) hypertension. Therefore, it is not carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA CBOC in Logan, WV in his prescribing [L]evothyroxine." However, in November 2010, the Veteran was also examined by VA optometrist, D.H., who reviewed the Veteran's claims file and performed a physical examination. This examiner stated that "[o]f the numerous bodily functions that may be affected by excessive thyroid dosing, blood pressure is the one that is likely to have ocular effects. It is known that excessive amounts of the hormone can elevate blood pressure and pulse. Excess doses have resulted in hypertension, palpitations, stroke, heart attack, and death." The examiner then noted that the examination revealed a moderate amount of venous tortuity and reduction in caliber of the arteries that was an effect caused by prolonged hypertension, as well as general narrowing of the arterioles. The examiner stated "[w]hat can also be said is that prolonged excessive dosing of thyroid medication can lead to hypertension (as well as more serious effects). What cannot be stated is whether there is a link between [the Veteran's] thyroid overdosing and the development of vascular changes." The examiner further stated that numerous sources were consulted while preparing the opinion, as well as a number of years in clinical experience. In short, the Board finds the medical evidence ambiguous as to whether the Veteran currently has any additional disability relating to hypertension and hypertensive retinopathy as a result of being prescribed an improper dosage of his thyroid medication. Therefore, the Board finds that a clarifying medical opinion is necessary to adequately decide the merits of the claims here. See Littke v. Derwinski, 1 Vet. App. 90, 93 (1990) (noting that remand may be required if record before the Board contains insufficient medical information for evaluation purposes); Colvin v. Derwinski, 1 Vet. App. 171 (1991); see also Hatlestad v. Derwinski, 3 Vet. App. 213 (1992). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be asked to identify or submit any new evidence not already of record that addresses his claimed conditions. 2. The claims files should be forwarded to an appropriate VA physician(s) to provide an opinion as to whether there are additional disabilities (hypertension, vision problems, or tinnitus) as result of the Veteran being prescribed an improper dosage of thyroid medication at the VA CBOC in Logan, West Virginia. The claims file and all records on Virtual VA, as well as this REMAND, must be made available to the examiner in conjunction with the examination, and the examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records, if any, that are reviewed. The examination report must include responses to the each of the following items: Based on the review of the entire claims folder, the examiner must express opinions, including the degree of probability expressed in terms of "is it at least as likely as not," regarding the following questions: (a) Does the Veteran have additional disability (to include hypertension, vision problems, and tinnitus) that was caused or aggravated by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA CBOC in Logan, West Virginia in its prescribing Levothyroxine, at a dosage of 0.2 milligrams, on December 22, 2004, and not adjusting the level to .025 milligrams until May 25, 2005? If so, (b) was the additional disability proximately caused by: (1) carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of the VA in its prescribing the above-mentioned medication; and if so, did VA fail to exercise the degree of care that would be expected of a reasonable health care provider, or (2) from an event not reasonably foreseeable? Additionally: (c) did the Veteran suffer a disability - to include hypertension, vision problems, tinnitus, and depression-attributable to VA's failure to properly prescribe the Levothyroxine from December 22, 2004, to May 25, 2005? (1) should a physician exercising the degree of skill and care ordinarily required of the medical profession reasonably have prescribed the correct dosage? (2) did the Veteran suffer disability which probably would have been avoided if the correct dosage of Levothyroxine had been prescribed? (d) In rendering the opinion, the examiner is asked to consider and attempt to reconcile any conflicting medical opinions of record, specifically the October 2010 VA hypertension examination and the November 2010 VA eye examination reports. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Since it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1 (2011), copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review 3. When the development requested has been completed, the case should be reviewed by the RO on the basis of additional evidence. If any benefit sought is not granted, the Veteran and her representative should be furnished a Supplemental Statement of the Case (SSOC) and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs