Citation Nr: 18145168 Decision Date: 10/26/18 Archive Date: 10/26/18 DOCKET NO. 16-38 961 DATE: October 26, 2018 REMANDED Entitlement to service connection for heat stroke residuals, to include headaches, is remanded. Entitlement to an initial rating greater than 10 percent for lumbar contusion, with degenerative joint disease, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 2009 to June 2015. This case comes before the Board of Veterans’ Appeals (the Board) on appeal from a July 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for heat stroke residuals, to include headaches is remanded. The Veteran contends that he is entitled to service connection for residuals of an in-service heat stroke, in which the Veteran suffered from a temperature of 107 degrees. During the Veteran’s June 2015 separation examination, the Veteran reported that he was hospitalized after experiencing weakness and an altered mental state during a run for BUDs training. The examiner stated that most definitions of heat stroke contain a reference to end organ damage, as evidenced by abnormal liver, renal or muscle labs. The examiner stated that the Veteran’s labs were normal, therefore, he does not have a diagnosis of heat stroke but of exertional hyperthermia. In his July 2015 notice of disagreement, the Veteran reported that he gets extremely dizzy in hot temperatures and has bad headaches. The Veteran was afforded a VA Nervous System and Headache examination in June 2016. The examiner noted that the Veteran suffered from a heatstroke in service and claims that ever since this heatstroke he experiences headaches when exposed to heat that lasts for 2 hours. The Veteran was diagnosed with tension headaches, with nausea and dizziness. The examiner opined that it is less likely than not that the Veteran’s symptoms were caused by his in-service heat stroke. The examiner stated that the literature supports only temporary susceptibility to heatstroke following the initial encounter. He stated that the Veteran does have tension headaches which he believes is an independent condition. The Board finds the July 2015 VA opinion inadequate as the examiner diagnosed the Veteran with tension headaches but failed to provide an etiology opinion regarding the condition. Further, the examiner failed to address the Veteran’s contentions that he has experienced headaches with heat exposure since his in-service heatstroke. Accordingly, an additional examination is in order to clarify whether the Veteran’s in-service heat stroke caused any residual symptoms, to include tension headaches. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). 2. Entitlement to an initial rating greater than 10 percent for lumbar contusion, with degenerative joint disease is remanded. The Board observes that the Veteran was last afforded a VA examination for his service-connected lumbar contusion, with degenerative joint disease in June 2015 and recent evidence indicates that his symptomatology may have worsened. VA treatment records from March 2016 indicate that the Veteran has difficulty standing for more than 1 hour, must shift his weight while sitting and gets a burning sensation in his back after walking 1 block. In his August 2016 Form 9, the Veteran stated that he experiences pain when sitting, lying down or standing and that he sometimes needs assistance getting up. The Veteran also stated that he experiences numbness in his left leg when he does strenuous exercise. In light of this new evidence suggesting a worsening of the Veteran’s lumbar spine condition, the Board finds that a new VA examination is necessary to ascertain the current severity of the Veteran’s lumbar spine condition. The matters are REMANDED for the following action: 1. Obtain an opinion from a qualified clinician, to determine the nature and etiology of any heatstroke residuals, to include headaches. If, and only if, determined necessary by the reviewing clinician, the Veteran should be scheduled for another VA examination. The reviewing clinician should review the Veteran’s claims file and provide an opinion as to whether it is at least as likely as not (50 percent greater probability) that the Veteran’s tension headaches were incurred in or otherwise related to the Veteran’s service, to include his in-service heat stroke. The examiner should discuss the Veteran’s contentions that he experiences headaches when exposed to heat and has experienced them ever since his heatstroke in service. If any other residuals of heat stroke are identified, the reviewing clinician should provide an opinion as to whether it is at least as likely as not (50 percent greater probability) that the Veteran’s heatstroke residuals are the result of his in-service heat stroke. 2. Schedule the Veteran for an examination to determine the current nature and severity of his lumbar contusion. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to degenerative joint disease of the lumbar spine and discuss the effect of the Veteran’s spine disabilities on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). In addition, the examiner should identify, and indicate the severity of, any and all associated neurologic abnormalities, to include radiculopathy of the bilateral lower extremities. (CONTINUED ON NEXT PAGE) 3. After the above development has been completed, readjudicate the claim. If the benefit sought remains denied, provide the Veteran a supplemental statement of the case, and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Brandt