Citation Nr: 18141556 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 16-12 249 DATE: October 10, 2018 REMANDED Entitlement to service connection for a gout disability is remanded for additional development. REASONS FOR REMAND The Veteran had active military service with the U.S. Army from November1983 to November 2005. During this time, he was awarded the Bronze Star, the Korea Defense Service Medal, the Southwest Asia Service Medal, the Kuwait Liberation Medal, the Iraq Campaign Medal, the National Defense Service Medal, and the Global War on Terrorism Medal, among other medals. This matter comes to the Board of Veteran’s Appeals (Board) on appeal from May 2014 rating decision from the Department of Veterans Affairs (VA) regional office (RO) in Waco, Texas. In April 2018, the Veteran presented testimony before the undersigned Veterans Law Judge at a Travel Board hearing. A transcript of that hearing has been reviewed and associated with the claims file. Entitlement to service connection for a gout disability is remanded. While the Board sincerely regrets the delay, a remand is required before the Board may make a determination on the merits of the remaining outstanding claims on appeal. The Veteran has asserted that he is entitled to service connection for gout. A review of the relevant evidence reflects that the Veteran was first diagnosed with gout in 2009, was subsequently prescribed allopurinol, and is currently taking medication for gout. See, e.g., April 2009 Family Medicine Clinic Encounter Note (diagnosing the Veteran with gout with elevated uric acid levels); March 2010 Family Medicine Clinic Encounter Note (prescribing the Veteran allopurinol to treat gout); August 2018 Olin Teague Center Neurology Note (reflecting that the Veteran is currently taking allopurinol for gout). At his April 2018 Board hearing, the Veteran presented testimony regarding the initial manifestations of his gout condition. See April 2018 Board Hearing Transcript. He reported that he when he first had pain in his big toe while on active service in the late 1990’s, he thought he had broken it. Id. He further indicated that he had conversations with his doctors while on active service about the possibility that he may have gout, and that his blood test results while he was in Kuwait reflected that he had elevated uric acid levels. Id. The Veteran’s enlistment examination is silent for any references to or manifestations of gout, and the Veteran’s service treatment records reflect multiple references to elevated uric acid levels. See, e.g.¸ June 1997 Al Jahra Hospital Blood Chemistry Record (recording the Veteran’s uric acid level at 555 umol/L, noting the reference range is 150 to 400, and classifying the Veteran’s uric acid level as high); June 1997 Camp Doha Clinic Health Record (observing that the Veteran’s uric acid level was 9.32 with a notation of an upwards pointing arrow); July 1997 Al Jahra Hospital Blood Chemistry Record (recording the Veteran’s uric acid level at 438 umol/L, noting the reference range is 150 to 400, and again classifying the Veteran’s uric acid level as high); January 1999 Portsmouth NMC General Chemistry Record (yielding a uric acid test result for the Veteran of 7.0 mg/dL and noting that the normal range was 3.7 to 8.0 mg/dL). However, the Veteran has not been provided an examination to determine the nature and etiology of his current gout disability, nor do multiple previous VA examinations for the Veteran’s feet, knees, or joints make any references to his gout. Given the evidence of record, and in light of VA’s duty to assist, the Board finds the evidence of record meets the low threshold of an “indication” that the claimed disability has a causal connection or association with service. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (reflecting that VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim). Accordingly, on remand, the Veteran should be afforded an appropriate VA examination for an opinion as to whether his current gout disability is etiologically-related to his active military service. The matter is REMANDED for the following action: 1. Obtain any additional outstanding VA treatment records for the Veteran and associate them with the claims file. All attempts to secure any identified records and any response received must be documented in the case file. 2. After any available records are associated with the claims file, schedule the Veteran for additional VA examinations in the appropriate specialty to determine the nature and etiology of the Veteran’s current gout disability. The electronic claims file, including a copy of this remand, must be made available for the examiner to review. The examination report must include a notation that this record review took place. The Veteran must be interviewed. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. The examiner must provide a clear explanation for the opinion, to include any comment on any credibility issues raised by the record from a medical perspective. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results as to the claimed condition of gout, the examiner is requested to provide an opinion as to the following question: Is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s current gout disability began during, or is otherwise related to the Veteran’s active duty service? The examiner must provide a complete rationale for all opinions expressed. As part of the rationale, the examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the issue on appeal should be readjudicated. If the benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case and allowed an appropriate period of time for response. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Raj, Associate Counsel