Citation Nr: 1339985 Decision Date: 12/04/13 Archive Date: 12/18/13 DOCKET NO. 12-31 293 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Sioux Falls, South Dakota THE ISSUE Entitlement to service connection for Crohn's disease. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD D. Chad Johnson, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1966 to October 1968. This matter comes to the Board of Veterans' Appeals (the Board) on appeal from an August 2012 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Sioux Falls, South Dakota. A review of the Virtual VA or VBMS paperless claims processing system does not reveal any additional documents pertinent to the present appeal that are not already of record. FINDING OF FACT The Veteran's Crohn's disease was not shown in service, was first diagnosed in 1984, and is not etiologically related to active service. CONCLUSION OF LAW The criteria for service connection of Crohn's disease have not been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Due Process VA has duties to notify and assist claimants in substantiating a claim for VA benefits. See, e.g. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. § 3.159 (2013). VA provided the requisite notice by a letter sent to the Veteran in May 2012, prior to the adjudication of the claim. 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). The RO has obtained the Veteran's service treatment records, VA treatment records, and private treatment records and associated such records with the claims file. In June 2012, VA provided an examination and obtained an expert medical opinion. The examiner noted review of the Veteran's claims file and VA treatment records. The examiner described the disability in sufficient detail and provided sufficient rationale to support the conclusions reached in the opinion. For these reasons, the Board finds that the examination and opinion are adequate. The Veteran indicated in May 2012 that he had no additional evidence or information to provide to VA in support of his claim. Neither the Veteran, nor his representative, has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duties. II. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2013). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board finds that the Veteran has a current diagnosis of Crohn's disease which meets the first requirement to establish service connection, the existence of a present disability. VA treatment records and private medical records clearly indicate that the Veteran was diagnosed with Crohn's disease in August 1984 and he has continued to receive follow up treatment for the diagnosed condition. The second requirement for service connection requires proof of an in-service incurrence or aggravation of a disease or injury. Service treatment records do not document any diagnosis or treatment of Crohn's disease specifically. A September 1966 pre-induction examination contains normal clinical findings. The Veteran indicated frequent indigestion on a contemporaneous report of medical history, and a subsequent note by the examining physician records: "gas in stomach". An October 1968 examination at the time of separation also contains normal clinical findings. The Veteran again noted frequent indigestion on the contemporaneous report of medical history but reported he was in "very good" health; a physician's subsequent note states: "No sequela to above medical history". Finally, the Veteran's chronological medical record from service contains a February 1968 entry wherein the Veteran reported diarrhea and stomach cramps lasting four days which did not include vomiting or other symptoms. The service treatment records do not contain any other entries which appear to be reasonably related to Crohn's disease or another gastrointestinal condition. The Board now turns to the question of whether the record establishes a causal relationship, or nexus, between the Veteran's reported diarrhea and stomach cramps in February 1968 and the Veteran's diagnosed Crohn's disease. The Board finds the evidence is against such a finding. On his April 2012 claim form, the Veteran contends that the stress of his experience in Vietnam contributed to his Crohn's disease and that his trouble with diarrhea began in service and continued after discharge. The Board acknowledges the Veteran's lay opinion attributing his Crohn's disease to diarrhea occurring in service but finds that such a statement is not competent evidence. It is error for the Board to categorically reject lay statements of diagnoses or nexus as incompetent evidence. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Rather, the Board must consider on a case by case basis whether a particular disability is the type of disability for which lay evidence is competent. Jandreau v. Nicholson, 492 F. 3d 1372, 1377 n.4 (Fed. Cir. 2007) (providing that lay evidence is competent to identify a simple condition, such as a broken leg, but not something complex such as a form of cancer). Certain conditions that are subject to identification by personal observation, such as varicose veins, can be diagnosed by a layperson. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Whether the Veteran's diarrhea and stomach cramps occurring during active service are symptoms or manifestations of his later diagnosed Crohn's disease is not a simple determination that can be made by lay observation. Rather, it is a complex question, more in line with a question of what type of cancer someone has, as opposed to a simpler, more obvious question, like whether a leg is broken. Identifying a relationship between symptoms and a medical diagnosis of Crohn's disease is not like identifying a visible and readily apparent condition like varicose veins. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. As such, the Board finds the Veteran's contention that his symptom of diarrhea occurring during active service is the underlying cause or the initial expression of Crohn's disease is not competent evidence. Further, while the Veteran is competent to describe symptoms experiences, the Veteran's inconsistent history regarding the onset of his Crohn's disease brings his credibility into question. The Veteran claims that his symptoms, specifically diarrhea, began during service and continued until he was later diagnosed with Crohn's disease. During the June 2012 VA examination, the Veteran reported that chronic diarrhea began during service about three months prior to discharge and persisted until his subsequent diagnosis of Crohn's disease. These statements are inconsistent with the Veteran's service treatment records reviewed above, which appear complete and detailed and reflect that the Veteran freely reported other conditions unrelated to Crohn's disease or symptoms thereof. The record also contains a September 1984 Agent Orange Registry Code Sheet which was completed by an examining physician based upon information provided by the Veteran. This document indicates that the Veteran had a three year history of Crohn's disease, which was in remission at the time. This is also inconsistent with the Veteran's claim of onset during or immediately following service. The Veteran's statements of medical history regarding the onset of his condition are therefore afforded little probative value. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006) (explaining that facts affecting credibility include timing of the reports of the disability, conflicting statements, and lack of contemporaneous medical records); see also Caluza v. Brown, 7 Vet. App. 498-511 (1995) (stating that "[t]he credibility of a witness can be impeached by a showing of interest, bias, [and] inconsistent statements . . . "). The Board also acknowledges the April 2012 statements of Dr. S.G. and S.H., a Nurse Practitioner of gastroenterology. Dr. S.H., who in August 1984 initially diagnosed and subsequently treated the Veteran's Crohn's disease, opined that "what [the Veteran] went through in the service is a contributing factor to his Crohn's disease" based upon the Veteran's reported service history and onset of problems when he got out of the service. Nurse Practitioner S.H. reported that the Veteran started noticing symptoms while in service and his belief that the stress of his military service contributed to his initial onset of therapy; she agreed that "patients tend to have flares during stressful times in their lives." The Board finds that the medical opinions of Dr. S.G. and Nurse practitioner S.H. are competent evidence, but the Board affords them less weight than the VA examiner's opinion reviewed below. Dr. S.G.'s opinion is based upon history related by the Veteran, which as noted above has been found by the Board not to be credible; it additionally lacks a rationale. The opinion of Nurse Practitioner S.H. is also based upon the Veteran's reported history and merely states a general principle regarding patients with Crohn's disease; it is not evidence that the Veteran's active service is related to his Crohn's disease. The most probative competent evidence regarding the nexus requirement in this case is the June 2012 VA examination and the resulting medical opinion which concluded the Veteran's Crohn's disease "was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness." The examiner provided the following rationale: "[T]he etiology for Crohn's disease is unknown. This veteran had one episode of abdominal cramping in 1968 and this resolved with treatment." He noted that there was no other treatment for abdominal complaints or diarrhea within the service treatment records. Finally, the examiner noted the delayed diagnosis of the Veteran's Crohn's disease, which "was made in 1984, 16 years after discharge." The Board finds the examiner's opinion to be supported by adequate reasoning and highly probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The evidence is, therefore, against a finding of a nexus between the Veteran's active service and his Crohn's disease. Based upon the evidence within the record and for the reasons explained above, the Board concludes that the preponderance of evidence is against a finding of service connection for Crohn's disease. The appeal, therefore, must be denied. There is no reasonable doubt to be resolved in this case. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for Crohn's disease is denied. ____________________________________________ M. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs