Citation Nr: 1310213 Decision Date: 03/26/13 Archive Date: 04/02/13 DOCKET NO. 08-29 546 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas THE ISSUE Entitlement to service connection for a chronic thyroid disability. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Matthew Blackwelder, Counsel INTRODUCTION The Veteran had active military service from May 1968 to May 1972. This appeal comes to the Board of Veterans' Appeals (Board) from a May 2005 rating decision. In August 2011, the Veteran testified at a Travel Board hearing. A transcript of that hearing is of record. In May 2012, the Board reopened the Veteran's claim and remanded it for additional development. The directed development has been completed, and because the Board's order was fully complied with, there is no prejudice for the Board to proceed. See Stegall v. West, 11 Vet. App. 268 (1998). The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also her extensive file on the "Virtual VA" system to insure a total review of the evidence. As was noted in the Board's May 2012 decision which reopened the Veteran's claim, the evidence shows that the Veteran has been diagnosed as having Graves' disease, status post radioactive iodine ablation, now hypothyroidism. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Court held that, in determining the scope of a claim, the Board must consider the claimant's description of the claim; symptoms described; and the information submitted or developed in support of the claim. In light of the Court's decision in Clemons, the Board recharacterized the issue on appeal from service connection for hypothyroidism to service connection for a chronic thyroid disability. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The weight of the evidence is against a finding that the Veteran's thyroid disability either began during or was otherwise caused by her military service. CONCLUSION OF LAW Criteria for service connection for a thyroid disability has not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Service Connection In seeking VA disability compensation, a Veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. "Service connection" basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. In February 1999, the Veteran filed a claim seeking service connection for hypothyroidism. Her claim was denied and she did not appeal. In June 2004, the Veteran filed an application to reopen her previously denied claim. Her application was granted by the Board such that her service connection claim may be considered on the merits. The issue is therefore whether the Veteran's currently diagnosed thyroid disability either began during or was otherwise caused by her honorable military service from 1968-1972. It is noted that the Veteran is currently treated for hypothyroidism and therefore the Board will refer to a thyroid disability and hypothyroidism synonymously in this decision. The Veteran essentially claims that she had weight problems in service which she believes marks the onset of her current thyroid condition. In June 2011, the Veteran wrote that right after getting out of the service, she spent most of her time being sick with her mother having to take care of her. She asserted that they did not know why she was losing so much weight or why she was depressed all the time. She asserted that during that time (as she alleges her VA medical records would show), she started drinking heavily; and her mother had her committed to the Waco VA medical facility. She stated that she had to pretend nothing was wrong to get out. In August 2011, the Veteran asserted that while on active duty she experienced weight gain, dry skin, hair loss, swollen face, hands, legs, ankles and feet, aches and pains, a hoarse voice, irregular periods and fatigue. She believes that all of these symptoms were the result of thyroid problems. She also felt that she was bipolar, which she asserted was associated with thyroid problems. She believes that the first sign of thyroid problems was in June 1969, but it was left untreated until 1992. The Veteran also testified at a hearing before the Board in August 2011, but she mostly read her August statement into the record, then confirmed that she had not begun receiving treatment from VA for her thyroid until approximately 1992. Through the course of her appeal, the Veteran has repeatedly submitted a copy of a service treatment record showing treatment in March and June 1969. In March 1969, the Veteran presented with complaints that she had gained 10 pounds in one month after starting to take birth control pills. In June 1969, the Veteran presented with report of weight problem (although she had lost more than 10 pounds since her March 1969 weight of 152.5) and denied eating heavily. It was noted that her thyroid was "not palp". The Veteran has seized on this statement as evidence that she was diagnosed with a thyroid disorder in service. However, as explained by a VA examiner (discussed below) deeper investigation into the service treatment records shows this not to be the case. Specifically, following the consult in June 1969, the Veteran was scheduled for a PBI test, to test the functioning of her thyroid and to rule out hypothyroidism. The blood test showed a value of 7.5 mcg/100ml, and it was noted that a value between 4-8 was considered normal (or between 4-13.5 if pregnant). As such, the blood test confirmed that the Veteran's thyroid was functioning normally. There is no showing of any additional thyroid testing during the Veteran's remaining three years of service. The Veteran also has cited weight fluctuation in service as evidence of a thyroid problem. However, it is noted that the Veteran weighed 127 pounds at enlistment physical in March 1968 and 128 pounds at her separation physical in May 1972. As noted, the Veteran's weight did increase to 152.5 pounds in March 1969 and it was noted that she had experienced a 10 pound weight gain in the previous month after starting on oral contraceptives. However, her weight notably decreased thereafter to 142 pounds by June 1969 and then to 135 pounds in February 1970, 134 pounds in March 1970, and 131.5 pounds in April 1970. At her separation physical, the Veteran asserted that she had gained 51 pounds from March 1972 to April 1972, but she denied seeking any treatment and the medical officer indicated that there were no complications and no sequelae. However, there is no documentation of this precipitous weight gain (and apparently loss), and it would seem wholly incredible to the Board that the Veteran would have gained 51 pounds in March and April, but then returned to the 128 pounds which she weighed on May 11, 1972. While the Board is often prohibited from finding lay evidence not credible on the sole basis of a lack of contemporaneous records, silence in a record can sometimes be relied upon as contradictory evidence; specifically, the silence in the record can be weighed against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated by the fact finder. See Kahana v. Shinseki, 24 Vet. App. 428, 439 (2011) (Lance, J., concurring) (discussing credibility in relation to medical evidence); Fed. R. Evid. 803 (7) (the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded). For this negative inference to be made, the Board must make two findings: first, that the record being evaluated is complete in relevant part; and, second, that the injury, disease, or related symptoms would ordinarily have been recorded had they occurred. The Board makes both findings in this case, as it is clear from the numerous service treatment records that are of record that the Veteran was willing to seek medical treatment in service, including for weight fluctuation, and numerous service treatment records have been obtained. As such, the Board finds that the lack of any treatment for a 51 pound gain and loss in a 2.5 month period is highly probative evidence that such weight fluctuation did not in fact occur. Thus, the Board notes that the only evidence of weight gain of record during the Veteran's service occurred in the spring of 1969 following her commencing use of oral contraceptives. Moreover, as documented, laboratory testing at that time found that the Veteran's thyroid functioning was within normal limits. On Report of Medical History dated in May 1972, the Veteran did report frequent or severe headache, eye trouble, cramps in her legs, frequent indigestion, stomach, liver, or intestinal trouble, painful urination, recent gain or loss of weight, frequent trouble sleeping, depression or excessive worry, and nervous trouble. However, the clinical evaluation at that time did not find any abnormalities, other than a systolic heart murmur. Following service, there is no medical evidence of any thyroid dysfunction until VA treatment records show that the Veteran was diagnosed with Grave's disease and hypothyroidism in 1992. That is, approximately 20 years after the Veteran had separated from service. In support of her claim, the Veteran submitted an article noting the symptoms of hypothyroidism as chronic fatigue, loss of appetite, inability to tolerate cold, low body temperature, a slow heart rate, easy weight gain, elevated cholesterol, painful premenstrual periods, heavy periods, a milky discharge from breasts, fertility problems, muscle weakness, muscle cramps, dry and scaly skin, a yellow-orange coloration in the skin, yellow bumps on the eyelids, hair loss, recurrent infections, migraines, hoarseness, respiratory infections, constipation, depression, difficulty concentrating, slow speech, goiter, and drooping swollen eyes; with the most common symptoms being fatigue and intolerance to cold. The Court of Appeals for Veterans Claims (Court) has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998) and Wallin v. West, 11 Vet. App. 509 (1998). In the present case, the treatise evidence submitted by the Veteran is not specifically accompanied by the opinion of any medical expert linking her symptoms or hypothyroidism to her service. The Board concludes that this information is insufficient to establish the required medical nexus opinion. Nevertheless, as will be discussed below, a number of medical opinions are of record in this case. In a March 2005 statement, the Veteran asserted that in May 1969 she was gaining and losing weight and experiencing a lot of emotional problems, which continued and worsened due to alcohol abuse and changes in duty assignments. In April 2006, she wrote that at the time she was discharged from service, the medical officer was unaware that she had been diagnosed with "thyroid disease" which is why it was not in her discharge summary. She alleged that she was not treated for the condition because she moved to another base and the condition was never noticed. She asserted that she kept having emotional problems and weight fluctuation, but she missed her scheduled medical appointments. However, as noted above, the evidence of record conclusively shows Veteran was not actually diagnosed with "thyroid disease" in service as blood testing specifically ruled out hypothyroidism. Similarly, in June 2008, the Veteran wrote to her senator, stating that she was medically discharged from the Air Force in May 1972 because of hypothyroidism. To this end, a lay person's account of what a doctor purportedly said is generally thought to be too attenuated and inherently unreliable to constitute "medical" evidence. Robinette v. Brown, 8 Vet. App. 69, 77 (1995) (veteran's statement that his physician told him that he "most probably" had diabetes at time of his discharge from service was not sufficient medical evidence to establish service connection for diabetes). However, in certain instances, a lay person may be competent to report a contemporaneous medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Here, the Veteran's assertion that she was separated as a result of a thyroid condition in service is in direct conflict with her earlier allegation that the doctor at her separation physical did not know about her thyroid condition. Given this discrepancy, even if the Veteran were found to be competent to report such a diagnosis, she has not shown herself to be a credible historian. Moreover, such an allegation is patently refuted by the evidence of record, as the service treatment records affirmatively show that the Veteran did not in fact have a thyroid condition in service. There is similarly no indication beyond the Veteran's assertion that she was discharged from service on account of a thyroid condition, and such a discharge would be difficult to imagine given the lack of any thyroid disability having been of record in the service treatment records. Additionally, her Form DD-214, Record of Discharge, does not indicate she was discharged for medical reasons; rather, she was discharged after exactly four years of active duty based upon an expiration of her term of service. As described, the Veteran clearly believes that her currently diagnosed thyroid disorder is related to her military service. However, while she, as a lay person, is competent to report what comes to her through her senses, she lacks the medical training and expertise to provide a complex medical opinion. See Layno v. Brown, 6 Vet. App. 465 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As such, her opinion is insufficient to provide the requisite nexus between her currently diagnosed hypothyroidism and her military service. A number of medical opinions are of record in this case addressing the etiology of the Veteran's thyroid disorder. In support of the Veteran's claim, her VA primary care provider, Dr. M., has authored a number of statements suggesting that it is at least as likely as not (50 percent or greater) that the Veteran's thyroid disorder was related to her military service. For example, in February 2008, he stated, "[h]er current diagnoses of hypothyroidism is most likely as a result of her thyroid disorder diagnosed while she was in [the] Air Force in 6/18/69[.]" In May 2008, he stated, "... It is my professional opinion this patient's hypothyroidism is more likely than not related to her diagnosis of obesity during service in the Air Force." In September 2008, he wrote a letter stating that he had recently reviewed and examined the Veteran for review of possible service related conditions that have become more severe and limiting over the last ten years. He then listed Grave's disease, and eight other conditions (heart murmur, back condition, stomach condition, schizophrenia, hearing loss, tinnitus, and bilateral foot condition), and opined that after a review of the Veteran's service medical records (which the Veteran brought with her to the evaluation) it was his professional opinion that the above conditions were at least as likely as not caused by service or worsened by service. In February 2009 and April 2009, Dr. M. again wrote that the Veteran's current diagnosis of hypothyroidism is most likely a result of her thyroid disorder diagnosed while she was in the Air Force June 18, 1969. The fundamental problem with Dr. M.'s opinions is that they are universally conclusory in nature. That is he has not explained why or how he reached his ultimate conclusion. To this end, the Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. See Miller v. West, 11 Vet. App. 345, 348 (1998). Likewise, a medical opinion is inadequate when unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Here, Dr. M. indicated that he reviewed the service treatment records that the Veteran brought with her to the appointment. However, Dr. M. in providing his opinion did not explain what records led him to the conclusion that the Veteran's current thyroid problems either began during or were otherwise caused by her military service. It is also unclear, given the fact that Dr. M. has not discussed any record specifically, whether the Veteran brought all of the service treatment records, or only the ones she deemed important. This point is relevant in that the Veteran has repeatedly submitted a service treatment record from June 1969 with the phrase "thyroid not palp", and it would appear that she has equated this statement with being diagnosed with a thyroid disability. Yet, she has not at any time submitted the copy of the subsequent blood test in June 1969 which showed normal thyroid functioning. On another occasion, Dr. M. opined that the Veteran's currently diagnosed thyroid condition was secondary to her diagnosis of obesity in service. However, a review of the service treatment records does not actually show that she was diagnosed as obese; and a medical opinion based on an inaccurate factual premise is not considered to be probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran's in-service weight complaints were discussed above, including the fact that the Veteran's weight gain was attributed to birth control. However, Dr. M. did not discuss this finding. He also did not explain why the Veteran's weight at her separation physical was approximately the same as at entry, if she did in fact have a thyroid disorder; and he did not address the fact that blood tests showed normal thyroid functioning. There is also no indication that Dr. M. had access to the Veteran's claims file, beyond his assertion that he had reviewed the service treatment records. The Board acknowledges that the mere failure to review the claims file does not render a medical opinion inadequate. See Gardin v. Shinseki, 613 F.3d 1374 (Fed. Cir. 2010). However, here, such a failure is relevant in that by the Veteran's own admission at her Board hearing (and supported by the medical evidence of record) she was not diagnosed with any thyroid condition for approximately two decades after she separated from service, which is yet another factor that weighs against her claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that a lengthy period without medical complaints about a condition can be considered as a factor in resolving a claim). Given these inherent problems with Dr. M.'s opinions, the Board finds that they have limited probative value and are therefore afforded little weight. Nevertheless, because of the suggestion that the Veteran's thyroid condition may be service related, VA endeavored to obtain additional medical opinions in this case. In January 2008, the Veteran underwent VA examination. The examiner noted that in 1992, because of loss of weight, cold intolerance, and loss of hair etc., the Veteran was diagnosed with Graves' disease (hyperthyroidism) and that in that year, the Veteran was prepared for radioactive Iodine Thyroid Ablation for few months with Antithyroid medications, then radiated, and followed by Levothyroxin. After physical examination of the Veteran, the examiner diagnosed Graves' disease status post radioactive iodine ablation (now hypothyroidism on hormone replacement). The examiner acknowledged that in June 1969, the Veteran was evaluated for weight gain and that the medical progress note indicated that the thyroid was "not" palpable, but he pointed out that a PBI test was normal (7.5 on thyroid test). The examiner also noted that in 1992, the Veteran was diagnosed with hyperthyroidism (Graves' disease) with loss of weight, double vision, loss of hair, and other symptoms of hyperthyroidism and was treated with radioactive iodine. The examiner allowed that in 1969, the Veteran was gaining weight; but he noted that weight gain was prevalent in more than 50 percent of the population, and that part of the work up when a patient presents with progressive weight gain is evaluation of thyroid function. This explains why the PBI test was conducted in service. The examiner noted that the Veteran's blood PBI was normal in 1969, and that her thyroid gland was "not" palpable. The examiner also noted that Graves' disease comes rather suddenly accompanied by weight loss (not by weight gain), and not preceded by hypothyroidism. The examiner accordingly opined that the Veteran's present thyroid condition was absolutely less likely than not related to her weight gain in service. In June 2012, a second VA examiner reviewed Veteran's the claims file, and noted that the Veteran had brought him a letter as to why she believed her hypothyroidism was service related. The examiner observed that the Veteran had been diagnosed with hypothyroidism since approximately 1993, and been on replacement therapy since that time. The Veteran explained to the examiner that she felt that her main problem in service was weight gain, but the examiner noted that her weight changes were actually minimal during her four years of service. He also felt that the weight changes may have been explained by oral contraceptives she was taking at that time. The examiner noted that one report reflects PBI testing was within normal range during service, which he explained made it less likely that hypothyroidism was causing weight issues. He also stated that the thyroid condition the Veteran asserted during service was not clear. The examiner opined that it was less likely than not that the Veteran's hypothyroidism was related to her military service, explaining that there was no clear cut evidence that the Veteran actually had a thyroid issue prior to 1993. He noted that the Veteran had been diagnosed with Grave's disease in 1992 and explained that it was common for people who have had a history of Grave's disease to subsequently develop hypothyroidism. As described, both VA examiners concluded that it was less likely than not that the Veteran's current thyroid condition either began during or was otherwise caused by her military service. However, the important factor here is that unlike Dr. M.'s opinions, the VA examiners went beyond just the conclusion and explained why they had reached their conclusion. Moreover, the VA examiners' opinions cited specific service treatment records and in-service findings for why the thyroid condition did not actually begin in service, and why it was not related to the reported in-service weight problems. When evaluating the evidence of record, the Board must assess the credibility and probative value of the evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991). While the Board is not free to ignore the opinion of a treating physician, it is free to discount the credibility of that physician's statement. See Guerrieri v. Brown, 4 Vet. App. 467, 471-73 (1993); Sanden v. Derwinski, 2 Vet. App. 97, 101 (1992). The Board notes that there is a difference of opinion among the medical professionals. However, as explained above, the evidence which supports the Veteran's claim is undermined by the lack of any substantive medical rationale, and by reliance on factors which are not supported by either the service treatment records or the post-service medical evidence. Conversely, the VA examiners cited to specific in-service evidence, such as laboratory testing, to reach the conclusion that the Veteran did not actually have a thyroid disorder during service. Given the fact that the VA examiners provided better rationale that was grounded in the evidence of record and facts that were specific to this case, those opinions are found to be the more probative evidence and therefore are afforded the most weight in determining the etiology of the Veteran's hypothyroidism. In August 2011, the Veteran's representative wrote a statement assailing the findings of the VA examiner in January 2008 and arguing that greater weight should be afforded to the opinions of the Veteran's primary care provider, Dr. M. The Board will briefly address the inherent problems with the representative's arguments, but will not belabor the point, as it was thoroughly explained above why little weight is being assigned to Dr. M.'s opinions. The representative first argued that the Veteran's primary care provider, treated her on a routine basis, making him more familiar with her medical history. However, the Court has declined to adapt a "treating physician rule" which would afford greater weight to the opinion of a veteran's treating physician over the opinion of a VA or other physician. Winsett v. West, 11 Vet. App. 420, 424-25 (1998); Guerrieri v. Brown, 4 Vet. App. 467, 471-3 (1993). Rather, what is important is that the opinion that is provided is based on a review of the relevant evidence and is supported by established medical knowledge. It is worth noting that the representative's argument fails more directly in that there is no suggestion that the Veteran has been treated by Dr. M. since she separated from service in 1972, and the medical evidence does not show that any thyroid condition was diagnosed for approximately 20 years after separation. It is not disputed that Dr. M. is highly familiar with the Veteran's current treatment, and the fact that the Veteran currently has thyroid impairment is not in dispute. Rather, the critical issue here is what the etiology of that impairment is. To provide an informed opinion on that question requires a knowledge of what symptoms occurred in service, and what symptoms were experienced in the decades following service. The representative then cited Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) for the proposition that the information gleaned from a review of the claims file is what is critical, not just that the claims file was reviewed. It is true that both VA examiners reviewed the claims file; but it is not their review that is relevant, but rather that they noted in their reviews that laboratory testing in service actually refuted the conclusion that the Veteran had a thyroid disorder in service. Conversely, Dr. M. has given no indication that he had reviewed the claims file and he did not address the lack of any thyroid treatment for approximately two decades after service. This fact, which is readily apparent from a review of the claims file, was entirely ignored in Dr. M.'s opinions; yet, it is found by the Board to be a critical question that would need to be addressed and explained before it could be accepted that the Veteran's current thyroid disorder either began during or was otherwise caused by her military service. Here, Dr. M. appears to have taken the Veteran at her word that she was diagnosed with a thyroid disorder in service. Unfortunately, such an assertion has been found to be wholly inaccurate. The representative then argued that the VA examiner's January 2008 report did not contain a rationale based on contemporaneous scientific medical premises, but it is unclear to what the representative is referring. The 2008 examiner considered the symptoms, such as weight gain, which the Veteran believed marked the onset of her current thyroid disorder, then he explained why they did not in fact show the onset of a thyroid disorder, citing to laboratory testing that was conducted to assess the Veteran's thyroid functioning in service. Finally, the examiner explained the nature of Grave's disease, including the fact that it tended to have a generally sudden onset. As such, the Board believes that this opinion was both thorough and well-supported by medical evidence. Moreover, the Board obtained a second VA examination in 2012 which reached the same conclusion. Finally, the representative noted that in June 1969 while in service, the Veteran sought treatment for throat problems, unexplained weight gain, and thyroid problems. However, this information was readily available to the examiners, and a plain reading of the examination reports makes it clear that the Veteran's in-service symptoms were known to and considered by both VA examiners. As such, the Board finds that the representative's contentions do not undermine the two VA opinions, and the weight of the probative evidence is clearly against the Veteran's claim. Therefore, the Veteran's claim is denied. II. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, a § 5103(a) notice should also advise a claimant of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, required notice was provided by a letter dated in June 2004, which informed the Veteran of all the elements required by the Pelegrini II Court as stated above. An August 2008 letter also informed the Veteran how disability ratings and effective dates were established. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to content. Moreover, the Board finds that any defect concerning the timing of the notice requirement was harmless error. Although the notice provided to the Veteran may not have been given prior to the first adjudication of the claim, the Veteran has been provided with every opportunity to submit evidence and argument in support of her claim and ample time to respond to VA notices. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Additionally, the Veteran's claim was readjudicated following completion of the notice requirements. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). More than a thousand pages of VA treatment records have been obtained and reviewed; service treatment records, private treatment records and Social Security Administration (SSA) records have also been obtained. Additionally, the Veteran testified at a hearing before the Board. The Veteran was also provided with several VA examinations (the reports of which have been associated with the claims file). As discussed in the body of this decision, the Board finds that the examinations were thorough and adequate and provide a sound basis upon which to base a decision with regard to the Veteran's claim. As described, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER Service connection for a thyroid disorder is denied. ____________________________________________ T. D. Jones Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs