Citation Nr: 1804441 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 14-18 910 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for headaches, to include as secondary to service-connected post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for gastrointestinal disorder, to include as secondary to service-connected post-traumatic stress disorder (PTSD). 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran and A.C. ATTORNEY FOR THE BOARD J. Wozniak, Associate Counsel INTRODUCTION The Veteran served in the U.S. Army from January 1993 to January 1996. This matter came before the Board of Veterans' Appeals (Board) on appeal from a March 2013 decision of the Buffalo, New York, Regional Office (RO). In December 2016, the Board remanded the appeal to the RO for additional development. In May 2016, the Veteran was afforded a travel board hearing before the undersigned Veterans Law Judge. A hearing transcript is in the record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issue of TDIU is addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Headaches originated during active service. 2. The Veteran's currently diagnosed gastrointestinal disorder was not caused or aggravated by his service-connected post-traumatic stress disorder (PTSD). CONCLUSIONS OF LAW 1. The criteria for service connection for headaches, to include as secondary to post-traumatic stress disorder (PTSD) have been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2016). 2. The criteria for service connection for gastrointestinal disorder, to include as secondary to post-traumatic stress disorder (PTSD) have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be granted for current disability arising from disease or injury incurred or aggravated by active service. 38 U.S.C.A. § 1110. Service connection may 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). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310 (a) where it is demonstrated that a service-connected disorder has caused a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection is currently in effect for PTSD. Headaches The Veteran has been diagnosed with headaches. A March 2017 VA examination states the Veteran has a diagnosis of migraines. In a May 1993 service emergency department record the Veteran reported nausea along with dizziness and headaches; the Veteran denied vomiting and diarrhea. The service clinician diagnosed likely dehydration. The Veterans medical records are silent for complaints of headaches until an August 2012 VA treatment record. The Veteran reported a migraine-like headache and was provided with prophylactic medication. The Veteran was seen for headaches again in November 2012. The clinician suggested his headaches could be related to uncontrolled/elevated blood pressure. In a February 2012 lay statement the Veteran noted that in addition to administration of mefloquine, the Veteran identified in-service environmental exposures including pesticides, dust, ingestion of water from third-world countries, and the exposure to particulates from the burning of rubber, vehicles, human remains, and medical waste. An August 2012 VA neurology consultation report reflects that a VA physician opined that the headaches may be related to his hypertension or related to his long-term use of analgesic medications. In the Veteran's May 2016 hearing testimony he indicated that his headache began more than a year after he separated from service. The Veteran also submitted research from Dr. R.N. indicating that the antimalarial drug, mefloquine, could cause adverse psychiatric or neurologic symptoms. The report does not address this Veteran's specific situation and only generally states some lasting side-effects that could result from mefloquine usage. Therefore, the Board affords this medical evidence low probative value. In March 2017, the Veteran was afforded a VA examination. The Veteran reported constant head pain, pulsating or throbbing pain, pain on both sides of the head, and increased pain with physical activity. The examiner opined the Veteran's headaches were not related to his service and cited a lack of treatment or diagnosis for headaches in the Veteran's STRs. The examiner additionally noted no medical evidence showing complaints of headaches within one year of service separation. In October 2017, the Veteran was afforded a VA addendum examination from the same examiner who conducted the March 2017 examination. The examiner cited medical research indicating that headaches are a primary disorder and would generally not be caused by post-traumatic stress. However, in the diagnosis section of the opinion the examiner noted a diagnosis for headaches that are "attributed to post-traumatic stress disorder." The Veteran contends that his headaches began as a result of his service-connected PTSD. The competent evidence as to the etiology of his headaches is in conflict. The Veteran reported having had headaches shortly after he was discharged from active duty. The October 2017 VA examination states that the Veteran's headaches likely began after service separation but also indicated the Veteran's headaches could be attributed to PTSD. Given the existence of evidence both for and against the claim, the Board finds that the evidence is in relative equipoise as to whether the Veteran's headaches arose as a result of his service-connected PTSD. Upon resolution of all reasonable doubt in the Veteran's favor, the Board concludes that service connection is warranted for headaches and the claim is granted. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Gastrointestinal Disorder The Veteran has been diagnosed with gastroesophageal reflux disease and hernia hiatal A March 2017 VA examination states the Veteran has had a diagnosis for these conditions since February 2003. In a May 1993 service emergency department record the Veteran reported nausea along with dizziness and headaches; the Veteran denied vomiting and diarrhea. The service clinician diagnosed likely dehydration. In a November 1994 service treatment record the Veteran's had complaints of abdominal pain, malaise, and fatigue; the service clinician diagnosed dehydration. In a September 2000 private treatment record the Veteran reported episodes of diarrhea. The Veteran was given fluids and released with medication and instructions to be seen if his symptoms persist. The Veteran's medical records are silent for additional relevant treatment until a November 2002 private treatment record. A November 2002 private treatment record reflects that the Veteran reported a five-day history of tarry stools; the private clinician diagnosed a probable gastrointestinal bleed. At the time, the Veteran reported that he "used to have lots of problems with his stomach." In a December 2002 private medical record the Veteran is noted to have a history of indigestion and belching. In a November 2006 private treatment note the Veteran indicated that he vomits twice a week. A November 2006 abdominal sonogram was undertaken due to complaints of severe weight loss and abdominal pain. The clinician noted an unremarkable abdominal sonogram. In a July 2012 lay statement the Veteran reported that he has experienced digestive symptoms since his deployments overseas to Somalia and Haiti. In a July 2012 lay statement the Veteran's friend indicated that the Veteran is unable to go out to eat because he gets sick shortly after eating and has to use the bathroom. In a November 2012 VA treatment record the Veteran reported that his digestive issues started in 2000-2001 and included symptoms of spontaneous vomiting, nausea, and frequent loose stools. In a December 2012 VA treatment report the Veteran attributed his gastrointestinal disorder to mefloquine and/or environmental exposures during service. The VA physician indicated that "it is difficult to make the connection between [the Veteran's] current health issues and [his] mefloquine use." Additionally, the VA clinician noted that the Veteran's gastrointestinal symptoms began in 2003, so "there is unlikely to be a link between deployment-acquired infection ... and [his] current problems." In an SSA examination in October 2013, the Veteran reported a history of gastrointestinal symptoms as early as 2005. In the Veteran's May 2016 hearing testimony he indicated that he started experiencing digestive problems 15 or 16 years preceding the hearing date. The Veteran additional indicated that he was "well out" of service prior to experiencing digestive problems. At his May 2016 hearing the Veteran submitted research from Dr. R.N. indicating that the antimalarial drug, mefloquine, could cause adverse psychiatric or neurologic symptoms. The report does not address this Veteran's specific situation and only generally states some lasting side-effects that could result from mefloquine usage. Therefore, the Board affords this medical evidence low probative value. In March 2017, the Veteran was afforded a VA examination. The Veteran reported recurrent epigastric distress, reflux, regurgitation, and sleep disturbance caused by esophageal reflux. The examiner concluded the Veteran's current gastrointestinal problems were not related to his service because there was no medical records showing diagnosis of a gastrointestinal disorder in service, or in within a year of separation from service. In a July 2017 VA treatment note the Veteran argued his GI symptoms are caused by his treatment with lariam and his deployment to Haiti and Somalia. In October 2017, the Veteran was afforded a VA addendum examination from the same examiner who conducted the March 2017 examination. The examiner noted that the Veteran's stomach conditions are not related to the Veteran's service or his service-connected PTSD. The examiner opined that the Veteran's stomach symptoms were related to his use of nonsteroidal anti-inflammatory drugs (NSAIDs) to treat musculoskeletal discomforts. The examiner also noted that esophagogastroduodenoscopy (EGD) studies from February 2005 and August 2006 indicate normal findings with no residuals of disease. The Board has considered the Veteran's assertions that his gastrointestinal disorder is caused by his military service. The Veteran is not competent, however, to offer an opinion as to the etiology of this type of gastrointestinal disorder due to the medical complexity of the matter involved. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994). A preponderance of the evidence is against a finding that the Veteran's gastrointestinal disorder originated during service. The Veteran's service records indicate dehydration as the cause of the Veteran's stomach discomfort. The Veteran was first diagnosed with a gastrointestinal disorder in November 2002, many years after service separation, when the clinician noted stomach bleeding. No competent medical provider has opined that the Veteran's gastrointestinal disorder began in or as a result of service. Therefore, service connection is not warranted and the claim is denied. ORDER Service connection for headaches, to include as secondary to service-connected post-traumatic stress disorder (PTSD) is granted. Service connection for gastrointestinal disorder, to include as secondary to service-connected post-traumatic stress disorder (PTSD) is denied. REMAND The Veteran's submissions have raised the issue of extraschedular entitlement to a total rating based on individual unemployability. Remand is necessary for referral under established VA protocols. 38 C.F.R. § 4.16 (b). The case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. After completing any necessary development, refer entitlement to an extraschedular rating for a total rating based on individual unemployability. A copy of decision must be included in the VBMS/claims file. 2. Readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response before the case is returned to the Board. 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). (CONTINUED ON NEXT PAGE) 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 2014). ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs