Citation Nr: 1342166 Decision Date: 12/19/13 Archive Date: 12/31/13 DOCKET NO. 08-37 168 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to Department of Veterans Affairs (VA) compensation under 38 U.S.C.A. § 1151 for memory loss and a speech impairment due to VA prescribed medication. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL The Veteran and his friend ATTORNEY FOR THE BOARD M. J. In, Counsel INTRODUCTION The Veteran served on active duty from July 1982 to June 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified at an RO hearing in June 2008 and a Travel Board hearing before the Board sitting at the RO in July 2010. Transcripts of the hearings are of record. This case was previously before the Board in July 2011, July 2012 and April 2013 and was remanded for additional development. For the reasons discussed below, the Board finds that there has been substantial compliance with its prior remands. See Stegall v. West, 11 Vet. App. 268 (1998). FINDING OF FACT The evidence of record does not show that the Veteran has an additional disability manifested by memory loss and speech impairment that was the result of VA care. CONCLUSION OF LAW The criteria for compensation under 38 U.S.C.A. § 1151 for memory loss and a speech impairment have not been met. 38 U.S.C.A. §§ 1151, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.358, 3.361, 17.32 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION As provided for by the Veterans Claims Assistance Act of 2000 (VCAA) VA has 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, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice 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. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In correspondence dated in September 2007, VA informed the Veteran of what evidence was required to substantiate his claim for compensation under38 U.S.C.A. § 1151, and his and VA's respective duties for obtaining evidence. It also notified him that a disability rating and effective date would be assigned, in the event of award of the benefit sought, as required by the Court in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Because VCAA notice in this case was completed prior to the initial AOJ adjudication denying the claim, the timing of the notice complies with the express requirements of the law as found by the Court in Pelegrini. The content of the notice fully complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), and Dingess/Hartman. Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, including the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d 892, 896 (Fed. Cir. 2007). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). The Board also concludes that VA's duty to assist has been satisfied. The Veteran's VA medical treatment records, as well as his SSA records, have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The record does not reflect that there has been relevant private treatment. 38 C.F.R. § 3.159 (c)(2). The record also indicates that multiple VA medical opinions were obtained in order to evaluate the nature and etiology of the claimed disability at issue. Most recently, pursuant to the Board's April 2013 remand, a VA medical opinion was obtained in September 2013. The opinion considered all of the pertinent evidence of record, to include the Veteran's medical records and statements, and provides a complete rationale for the opinion stated. There is adequate medical evidence of record to make a determination with regard to the issue on appeal. 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). On that basis, the Board finds the RO substantially complied with all prior remand directives. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders, 129 S. Ct. 1696 (2009). 38 C.F.R. § 3.103(c)(2) (2013) requires that the Decision Review Officer (DRO) who conducts 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. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) recently held that the requirements under 38 C.F.R. § 3.103(c)(2) also applies to the Veterans Law Judge (VLJ) who conducts a hearing. Here, during both the June 2008 RO and the July 2010 Travel Board hearings, the DRO/VLJ fully explained the issue. The Veteran was assisted at the hearing by an accredited representative from the Florida Department of Veterans Affairs (FDVA). The representative and the DRO/VLJ asked questions to ascertain the circumstances involving the VA prescribed medication in question and the Veteran's symptoms of memory loss and speech impairment, as well as any casual connection between VA's prescribed medication and his claimed additional disability. The DRO/VLJ also asked questions to solicit information regarding any potentially outstanding records. During the hearings, the Veteran indicated that his current VA treatment records, as well as his SSA records, were outstanding. On remand, these records were associated with the claims file and a VA examination was conducted; otherwise, no pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or the representative that has yet to be obtained. The hearings focused on the evidence necessary to substantiate the Veteran's claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for compensation under 38 U.S.C.A. § 1151. Neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearings. Therefore, the Board finds that the DRO/VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), consistent with Bryant. The Veteran contends that benefits are warranted under the provisions of 38 U.S.C.A. § 1151 for additional disability involving memory loss and a speech impairment resulting from VA prescribed medication. Specifically, he claims that VA had prescribed Gabapentin in error, or that VA had furnished Dubutamine, a medication other than as prescribed, which resulted initially in paralysis and later in memory loss and a speech impairment. At his June 2008 RO hearing, the Veteran testified that since his allergic reaction to drug in April 2003, he experienced memory problems. He believed that he took Gabapentin and Dobutamine, which was incorrectly listed as Lansoprazole in his medical records. He reported that he started college in July 2003 and graduated in October 2006. During the July 2010 Board hearing, he testified that he recognized his memory problem approximately 4 months after the allegedly improper prescription of mediation in April 2003. Under 38 U.S.C.A. § 1151, if VA hospitalization or medical or surgical treatment results in additional disability or death that is not the result of the claimant's own willful misconduct or failure to follow instructions, compensation may be awarded in the same manner as if the additional disability or death were service connected. See 38 C.F.R. §§ 3.361. Then, in order to constitute a qualifying additional disability, the proximate cause of the additional disability must have been (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the facility furnishing the care, treatment, or examination, or (2) an event not reasonably foreseeable. 38 C.F.R. § 3.361(a). 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 that disability; and (1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (2) VA furnished the hospital care or medical or surgical treatment without the veteran's informed consent. In evaluating the Veteran's claim, the Board first must consider whether the evidentiary record shows that he has additional disability that was caused by negligent VA medical treatment. See 38 U.S.C.A. § 1151(a)(1). A VA internal medicine clinic (IMC) note dated April 3, 2003 reflects that the Veteran complained of pain in the mid chest and shortness of breath with pain in the left arm. It was noted that atypical chest pain was likely not cardiac in origin and his left arm pain was likely neuropathic. The Veteran was provided a trial Gabapentin (Neurontin). Later that night, the Veteran presented with complaints of slurred speech, headache and inability for legs to support him. The Veteran related that two hours after he took the medication the symptoms came on. He was brought to emergency room and received Benadryl, after which his headache and slurred speech resolved, but his legs did not improve as quickly. The impression was medication reaction, resolving status post Benadryl with good effect (possibly dystonic reaction with Neurontin). In a neurology consultation note, the Veteran stated that he took a dose of Gabapentin and Prevacid at noon and developed pressure-like pain in the head and fatigue after two hours. Later, he noticed that his speech was slowed and while walking his bilateral lower extremities gave away, which progressed with severe difficulty in speaking-stammering, but it resolved on its own. Weakness in the legs also resolved after a while, and Benadryl helped with his speech. The Veteran reported repeated episodes of these attacks with complete resolution in minutes to hours. The impression was intermittent "stammering" and bilateral lower extremity weakness, which did not appear to be of neurological origin. A physician's medical attending note states that the Veteran's condition was puzzling as the consulting neurologist felt that there was no neurological problem present. The Veteran had a stammer and some slight slurring of speech while being interviewed. The Veteran was discharged on April 4, 2003. It was noted that his stammering speech continued and was periodic; no etiology was found. Internet article submitted by the Veteran indicates that Gabapentin (Neurontin) is effective in helping to control partial seizures in adults with epilepsy and also used to help relieve certain types of nerve pain and may be prescribed for other nervous system disorder. Among common side effects (that usually do not require medical attention) listed are difficulty walking or controlling muscle movements and, slurred speech. A February 2004 VA neurology outpatient note reflects that the Veteran was seen in a consult in March 2003 for sudden onset "stuttering speech" and paralysis. As per the Veteran, he had this event following a dose of Gabapentin. It was noted that he improved his weakness with persistence of his stuttering to some degree. Although occasional mild stuttering was noted during interview, there was no other obvious neurological deficit. The assessment was stuttering of unknown etiology. An April 2004 VA speech pathology consultation report reflects that the Veteran was referred for evaluation of stuttering. He related that he developed slurred speech in March of 2003 immediately following the ingestion of a medication. His speech subsequently "cleared," but he was left with intermittent stuttering. It was noted that a CT scan of the brain on April 4, 2003 showed a subcentimeter rounded focus of decreased attenuation adjacent to the left lateral ventricle and that other prior medical history was significant for hyperlipidemia, obesity, and sinusitis. The impression was atypical presentation of speech dysfluencies, which was inconsistent performance within and across speech tasks. No speech diagnosis was offered and speech treatment was not recommended. VA IMC progress notes dated from March 2004 to June 2005 reflect that the Veteran with history of GERD, obesity, and hyperlipidemia who was briefly admitted in April of 2003 for slurred speech. MRI and CT showed no acute changes that could explain symptoms and neurology did not feel a neurological process was occurring; symptoms resolved and the Veteran was discharged. In a September 2007 VA IMC progress note, the Veteran complained of memory loss. He stated that since he had an allergic reaction to a medication two years previously, he had been having trouble with his memory, not only with new memories but also remote. The assessment was memory loss of unclear etiology. VA treatment records dated in September 2007 show that the Veteran was hospitalized for transient ischemic attack (TIA) with cerebrovascular disease. An October 2007 VA psychology consultation report stated that the Veteran was referred for assessment of cognitive status. It was noted that there were concerns about possible TIAs or other neurological phenomenon. The Veteran reported that he initially developed memory problems after an allergic reaction to Gabapentin in 2003; however, despite memory problems, he was able to complete a college level program in 2006. Following a comprehensive neuropsychological evaluation, the diagnosis was mild cognitive decline. In an October 2007 VA neurology consultation report, the Veteran was seen for abnormal memory problems that he had "after he is being placed on Neurontin [given for pain in left breast] for which he had allergic reaction." It was noted that he was seen in neurology a few times and was ordered appropriate workup, which revealed normal examination. It was further noted that the Veteran seemed to be very nervous and his anxiety might exacerbate his problems. The Veteran was provided a VA examination in November 2007. The VA examiner noted that the claims file was reviewed. It was noted the Veteran was seen multiple times for complaints of memory loss and he had a very mild cognitive deficit with testing. The Veteran claimed that it was caused by Gabapentin that was prescribed for him. The examiner opined that Gabapentin would be a very unlikely [cause] of any memory loss or speech impairment that the Veteran had. In reaching this conclusion, the examiner stated that any possible side effects of that medication would have certainly worn off three or four years later, and there was no evidence that a sustained effect on memory or speech is associated with that medication. In an April 2008 VA neurology outpatient report, the Veteran was seen for follow up on possible TIA. He did not sleep well at night. The impression was memory complaints of unclear etiology, which was possibly related to poor sleep hygiene and anxiety. In an April 2008 VA psychology consultation report, the Veteran was re-referred for assessment of cognitive status by neurology. The Veteran reported that the memory problems were increasing. The Veteran reported that he worked intermittently as a security guard but could not sustain employment because of physical problems. He again gave the history of an allergic reaction to Gabapentin with transient leg paralysis in 2003, and reported that slurred speech after that incident improved over time. Clinical test results were relatively unchanged from 2007 and did not indicate any progression of deficits and cognitive difficulties appeared to be stable. The diagnosis was mild cognitive decline, with stable deficits. The Veteran filed a disability benefits claim with the SSA in April 2008. SSA records dated July 2008 reflect diagnoses of mild cognitive disorder, not otherwise specified, and adjustment disorder. It was noted that the Veteran alleged depression and memory problems post cerebrovascular accident (CVA) in 2007. The consultant noted that attention and concentration were mildly impaired and short term memory was intact. A January 2009 disability evaluation report reflects the Veteran's history of memory loss. He stated that initially he forgot everything in his life before 1981 and also lost memory for very recent events. It was noted that the Veteran alleged depression secondary to physical medical condition. As regards cognitive ability, it was noted that although the record contained a diagnosis of mild cognitive decline, allegations of memory/cognitive/intellectual dysfunction were not supported by the objective evidence. In a June 2010 SSA decision, the Veteran was found disabled. Significantly, it was noted that in September 2007, the Veteran experienced a syncopal episode and onset of slurred speech, with chronic memory loss, and was later diagnosed with carotid artery stenosis. In the disability report, the Veteran reported that he was unable to work because of not being able to walk or lift and his memory loss prevented him from remembering what he needed to do; the approximate beginning date was reported as December 2008. In the work history report, completed in May 2008, the Veteran stated that his TIAs had taken a great deal of his memory away and it had gotten worse over time, but his doctors could not find any reason for his memory loss and all tests returned normal. A May 2008 statement from D.H. indicated that after the Veteran's visit to Tampa VAMC in 2003, the Veteran requested a medical alert bracelet to wear, listing his medications. In March 2009, the Veteran presented to emergency room with a chief complaints of slurred speech. He reported that he was having a reaction to Amitriptyline. He had a documented history of nonepileptic pseudo-seizure, atypical speech dysfluency (stuttering, episodic loss of voice, dysphonia), and episodes of sudden onset of transient paralysis and weakness that were not consistent with expected neurologic patterns. A March 2009 VA psychology consultation report reflects that the Veteran was referred by neurology for neuropsychological re-evaluation. Following an extensive clinical testing, conclusion was that the Veteran was currently endorsing a moderate to severe amount of depressive symptoms and was not currently followed by mental health. The neuropsychologist noted that overall, the Veteran's current functional problems and somatic complaints were likely the result of underlying problems coping with environmental stressors and unresolved depressive symptomatology. It was further noted that typically, significant emotional disturbance can reduce the amount of cognitive resources available to an individual, thus impacting one's ability to mentally manipulate and remember novel information, which can be experienced as a problem with "memory" and can certainly impact one's ability to function at expected levels. The diagnostic impression was conversion disorder (motor, cognitive and sensory symptoms). In April 2010, the Veteran was admitted with a chief complaint of speech difficulties. In the history & physical report, the Veteran complained of transient left upper extremity numbness. He denied slurred speech, which was inconsistent with the history he reported in the emergency room. He stated that he had been having memory problems. He further stated that he all his problems, including memory deficit, paralysis from waist down, and TIAs, started in 2003 when he was given Gabapentin "for chest pain." The assessment was transient left upper extremity numbness/weakness; strongly suspected malingering; history of pseudo-seizures and multiple neurological complaints with negative workups; and possible depression. The discharge diagnosis was conversion disorder. An August 2010 VA psychiatry consultation report noted that neurology, psychology and psychiatry had seen the Veteran and, after evaluations and neuropsychological testing, concluded likely conversion/somatoform disorder. It was further noted that the Veteran had minimal insight and attributed most of his ailments to side effects from previous medicines. An October 2010 VA psychology progress note stated that the Veteran reported no significant mental status changes since last session. The diagnosis was adjustment disorder, with mixed emotional features, per history. The Veteran was provided a VA examination in September 2011 but the Board found it inadequate because the September 2011 VA examination report contained inconsistent information. Specifically, it stated that the Veteran did not have any additional evidence of cognitive impairment such as memory loss and/or a speech defect, but subsequently acknowledged that the Veteran had a dystonic reaction to VA prescribed Gabapentin, and that it was unforeseen, and then opined that the Veteran's additional disability was caused by or a result of an event not reasonably foreseeable. An August 2012 VA neurology consultation report from a VA neurologist, Dr. Shafe Huda, stated that few years previously, the Veteran, with left sided chest pain, went to Tampa VA Hospital and was given Gabapentin, which resulted in side effects of becoming paralytic in the lower extremity and speech problem. The Veteran stated that the symptoms improved except it affected his memory, poor concentration, emotional instability, low tolerance and weak comprehension, and loss of train of thoughts while communicating. In a December 2012 addendum, Dr. Huda stated that the Veteran's claims file was reviewed and provided an opinion that "[t]he [V]eteran's memory loss and cognitive impairment are less likely as not (less than 50/50 probability) caused by the medications and or treatment provided by the VA. Gabapentin is not likely the cause of [c]ognitive decline, [s]peech or behavior problem." A December 2012 VA psychology consultation report stated that the Veteran was referred by neurology, for follow-up neuropsychological evaluation. It was noted that he had a longstanding history of cognitive complaints and has participated in 3 previous neuropsychological evaluations. The Veteran reported that difficulties began in 2003 following a reported reaction to Gabapentin. By the Veteran's report, he experienced transient bilateral lower extremity weakness; he was reportedly hospitalized and treated with Benadryl and symptoms subsided, but he began to notice changes in his memory, concentration, and speech fluency. He reported that cognitive difficulties had progressed since that time. Despite difficulties, he was able to complete a Bachelor's degree in 2006. He reported that he currently forgets conversations, the reason he walked into a room, and items at the supermarket. He reported that while these difficulties are frustrating and represent a change, they do not significantly interfere with daily functioning. He was reportedly independent in all activities of daily living. The neuropsychologist noted that the pattern of neuropsychological testing revealed reduced processing speed and attention/concentration in the context of intact cognitive functioning across other cognitive domains, with valid effort. However, while attention difficulties limited initial acquisition of information and he demonstrated mild retrieval difficulties, he displayed intact memory consolidation. Other assessed domains revealed intact language, visual cognitive, and executive functioning abilities. It was further noted that in 3 prior neuropsychological screening evaluations conducted in 2007, 2008, and 2009, the results similarly demonstrating reduced attention and processing speed in the context of preserved abilities in other domains; and comparing to these results, current testing did not reveal decline in performance. The Veteran's presentation and overall test performance did not meet criteria for a diagnosis of dementia or other cognitive diagnosis at this time. Further, his complaints were consistent with observed suboptimal consistency of attention and concentration and within expectation in light of severe chronic pain and sleep difficulties. Therefore, it was recommended that optimized management of chronic pain should remain the focus of his care. The diagnostic impression was pain disorder associated with both psychological factors and a general medical condition. In a September 2013 neurology progress note, Dr. Huda stated that the Veteran's claims file was reviewed and opined that "it is less likely as not (less than 50 percent probability) that the memory loss and cognitive impairment was (1) due to carelessness, accident, negligence, lack of proper skill, error in judgment, or similar instances of fault by the Tampa VA, nor was there in (sic) any indication that his change in cognition [is] reasonably foreseeable or caused by his receiving VA medical treatment/medication." In support of this opinion, Dr. Huda noted that although the Veteran experienced a dystonic reaction to Gabapentin which unfortunately was not uncommon, per mainstream neurological medical literature, there was no documentation of any long-term cognitive problems associated with that transient reaction. In this regard, it was noted that the Veteran's subjective complaints relating to Gabapentin having caused decreased cognition was not supported by his previous psychology evaluations nor was it supported by review of side effects reported in mainstream medical neurology literature. Dr. Huda added that the Veteran's reported cognitive symptoms were mainly subjective, unpredictable, and not established by neuropsychological testing. Dr. Huda concluded that the Veteran's cognitive decline was more likely as not associated with/caused by his multiple medical problems to include lacunar stroke, hypothyroidism and his multiple co morbid conditions. 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 memory loss and a speech impairment claimed to be the result of being erroneously prescribed at the VAMC in Tampa, Florida. The Board will begin with an analysis as to whether the Veteran has an additional disability of memory loss and a speech impairment 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 following the allegedly improper prescription of medication in April 2003, the Veteran experienced a dystonic reaction to the medication. As noted above, on the day the Veteran was seen for his complaint of chest pain and was given a trial dose of Gabapentin, he was subsequently admitted with slurred speech, headache and lower extremity weakness. However, it is not an issue of whether something occurred due to VA treatment. Rather, the issue is whether the Veteran has an additional disability of memory loss and a speech impairment as the result of VA's failure to properly prescribe medication. Concerning this, the Board affords Dr. Huda's conclusion that the Veteran did not have any long-term problems associated with the transient reaction to the medication attributable to the VA's failure to properly prescribe medication to be highly probative. In the September 2013 opinion, Dr. Huda referenced the Veteran's complaints relating to Gabapentin having caused decreased cognition. However, it was noted that such complaints were not supported by his previous psychological evaluations and was mainly subjective, and further that the mainstream medical neurology literature did not indicate that such complaints are caused by Gabapentin. The medical evidence of record reflects that the Veteran was clinically found to have mild cognitive decline. Regardless of whether this is manifested by the Veteran's claimed disability of memory loss and a speech impairment, Dr. Huda concluded that following review of all pertinent evidence, the Veteran's cognitive decline was more likely as not associated with or caused by his multiple medication problems, including lacunar stroke and hyperthyroidism, and did not relate to the medication. Dr. Huda's opinion is not only consistent with but is further supported by the other medical opinions of record. Although the Veteran has consistently reported to his physicians that he had memory problems following the allergic reaction to a medication in 2003, no physician ever related his reported memory loss/speech impairment to this incident; rather, they noted that the speech problem and memory loss were of unknown or unclear etiology. Significantly, the VA neuropsychologist in March 2009 concluded that the Veteran's problems relating to the currently diagnosed mild cognitive decline were likely the results of underlying problems coping with environmental stressors and unresolved depressive symptomatology. To that effect, it was noted that significant emotional disturbance can reduce the amount of cognitive resources available to an individual, thus impacting one's ability to mentally manipulate and remember novel information, which can be experienced as a problem with "memory." Further, the December 2012 neuropsychologist noted that the Veteran's complaints were consistent with observed suboptimal consistency of attention and concentration and within expectation in light of severe chronic pain and sleep difficulties. Additionally, the November 2007 examiner stated that any possible side effects of medication would have certainly worn off three or four years later. Therefore, no permanent disability relating to allergic reaction as a result of the VA's prescribed medication is shown in this case. As discussed above, the examiner referenced the Veteran's statements regarding his symptoms following the VA prescription of medication in April 2003. Moreover, the opinion is based on the examiner's expertise as a physician specializing in neurology. Thus, the Board affords this opinion great weight and persuasive value. The Board considered the Veteran's statements made in support of his claim. In certain instances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, the Veteran is not competent to state that any memory loss or speech or cognitive symptoms or problems are etiologically related to VA carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in the prescription of medication in April 2003. It is not shown that the Veteran is otherwise qualified through specialized education, training or experience to offer a medical etiological opinion. The Board also finds his statements are less than credible in this regard because they are inconsistent with his other statements of record. To that effect, he reported on his SSA records that his TIAs caused a great deal of memory loss and that his problems involving memory loss began in December 2008. Thus, the Veteran's assertions are outweighed by the September 2013 opinion by Dr. Huda. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that the Board is prohibited from substituting its own medical judgment in place of the opinions of competent medical professionals). There is no other medical evidence of record showing that the Veteran has additional disability of memory loss and/or a speech impairment that was caused by VA prescribed medication in April 2003, and the Board may not accept unsupported lay speculation with regard to medical issues. The Veteran has claimed that in addition to Gabapentin, he was prescribed Dubutamine in error, and VA failed to properly document the erroneous prescription. The Board acknowledges that despite the lack of documentation in the record it is possible that he might have been prescribed Dubutamine in error. Nevertheless, regardless of whether he experienced a dystonic reaction as a result of the VA's prescription of Gabapentin or erroneous prescription of Dubutamine, it cannot be concluded that prescription of any medication in this case was a casual factor. 38 C.F.R. § 3.361(c)(1). Additionally, the internet article regarding Gabapentin submitted by the Veteran does not provide statements for the facts of the Veteran's specific case or show in any degree of specificity a relationship between the Veteran's claimed disability of memory loss and a speech impairment and VA fault in prescribing Gabapentin in April 2003. See Sacks v. West, 11 Vet. App. 314, 316-17 (1998); Wallin v. West, 11 Vet. App. 509, 514 (1998) (noting that the medical treatise, [textbook, or article] must provide more than speculative, generic statements not relevant to the veteran's claim but must discuss generic relationships with a degree of certainty for the facts of a specific case). Accordingly, the probative and persuasive medical evidence does not establish the presence of an additional disability as the result of VA care. 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 memory loss and a speech impairment due to VA prescribed medication is denied. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs