Citation Nr: 18145508 Decision Date: 10/29/18 Archive Date: 10/29/18 DOCKET NO. 16-25 926 DATE: October 29, 2018 ORDER Service connection for hypertension is granted. Service connection for kidney cancer is granted. Service connection for a lymph node disability is denied. An initial compensable rating for bilateral hearing loss prior to January 9, 2016, and 40 percent thereafter is denied. An increased initial rating for tinnitus, currently rated as 10 percent disabling, is denied. REMANDED Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to service connection for a heart murmur is remanded. Entitlement to service connection for a heart disability other than a heart murmur is remanded. Entitlement to service connection for a liver disability is remanded. Entitlement to service connection for a thyroid disability is remanded. Entitlement to a total rating based on individual unemployability is remanded. FINDINGS OF FACT 1. The Veteran was exposed to Agent Orange and herbicides during his service in the Republic of Vietnam at Danang base as a Navy Dog handler. 2. The competent and probative evidence establishes that the Veteran’s hypertension is due to his exposure to Agent Orange and herbicides from his service in Vietnam. 3. The competent and probative evidence establishes that the Veteran’s kidney cancer is due to his exposure to Agent Orange and herbicides from his service in Vietnam. 4. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of a lymph node disability. 5. Prior to January 9, 2016, the Veteran has had Level II hearing loss in the right ear and Level IV hearing loss in his left ear, with no exceptional patterns of hearing loss in either ear. 6. From January 9, 2016, onward, the Veteran has had Level VII hearing loss in both ears, with an exceptional pattern of hearing loss in both ears. 7. The Veteran is at the maximum schedular rating for tinnitus. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309, 3.310. 2. The criteria for service connection for kidney disease are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309, 3.310. 3. The criteria for service connection for a lymph node disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310. 4. Prior to January 9, 2016, the criteria for entitlement to a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.10, 4.85, Diagnostic Code (DC) 6100. 5. From January 9, 2016 onwards, the criteria for entitlement to a rating in excess of 40 percent for bilateral hearing loss have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.10, 4.85, Diagnostic Code (DC) 6100. 6. There is no legal basis for the assignment of an increased schedular disability rating for the Veteran’s tinnitus disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.87, DC 6260; Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Navy from July 1966 to September 1969, and the United States Army from September 1976 to September 1980. This matter is before the Board of Veterans’ Appeals (Board) on appeal from February 2014, May 2015, and January 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be 1) 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) causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Regulations provide that service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439, 449 (1995); 38 C.F.R. § 3.310(b). In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 57–58 (1990). Service incurrence for certain diseases, will be presumed on the basis of an association with certain herbicide agents (e.g., Agent Orange). 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Such a presumption, however, requires evidence of actual or presumed exposure to herbicides. Id. “Service in Vietnam” means actual service in the country of Vietnam from January 9, 1962 to May 7, 1975, and includes service in the waters offshore, or service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307 (a)(6)(iii); See generally Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008) (finding that VA’s requirement that a veteran must have stepped foot on the landmass of Vietnam or the inland waters of Vietnam for agent orange/herbicide exposure presumption is a valid interpretation of the statute). VA guidance indicates that in order for the presumption of exposure to Agent Orange to be extended to a Blue Water Navy Veteran, development must provide evidence that his ship operated temporarily on the inland waterways of Vietnam or that the veteran’s ship docked to the shore or a pier. In claims based on docking, a lay statement that the Veteran personally went ashore must be provided. Although evidence that a veteran’s ship docked, along with a statement of going ashore, is sufficient for the presumption of herbicide exposure, service aboard a ship that anchored temporarily in an open deep-water harbor or port has generally not been considered sufficient. The United States Court of Appeals for Veterans Claims (Court) determined that VA’s interpretation of 38 C.F.R. § 3.307 (a)(6)(iii), designating Da Nang Harbor as an offshore, rather than an inland waterway was inconsistent with the purpose of the regulation and did not reflect the VA’s fair and considered judgment. Gray v. McDonald, 27 Vet. App. 313 (2015). In particular, the Court could not discern any reason as to why, in VA’s determination, certain bodies of water such as Quy Nhon Bay and Ganh Rai Bay, were brown water, but Vung Tau Harbor, Da Nang Harbor, and Cam Ranh Bay, were blue water. Subsequent to the Court’s decision in Gray v. McDonald, VA updated its guidance/policy to state that service aboard a ship that anchored in a deep-water costal harbor, such as Da Nang, Vung Tau, Qui Nhon, Ganh Rai Bay, or Cam Ranh Bay, along the Republic of Vietnam coast, does not constitute inland waterway service or qualify as docking to the shore and is not sufficient to establish presumptive exposure to herbicides, unless the evidence of record confirms the Veteran went ashore during anchorage. In light of the foregoing, service connection may be presumed for residuals of Agent Orange exposure by showing two elements. First, the Veteran must show that he served in the Republic of Vietnam during the Vietnam era. 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6). Second, the Veteran must be diagnosed with one of the specific diseases listed in 38 C.F.R. § 3.309(e). Agent Orange Exposure The Veteran asserts that he was exposed to Agent Orange and herbicides while he served in the U.S. Navy. His service treatment records show that he was awarded the Navy Unit Commendation Ribbon for service at Naval Support Activity, DANANG, Republic of Vietnam from August 16, 1966 to December 15, 1967. He was also a Navy Dog Handler while in Vietnam. As such, the Veteran is presumed to have been exposed to herbicides consistent with such service. 38 U.S.C. § 1154(a). 1. Entitlement to service connection for hypertension. The Veteran has a current diagnosis of hypertension. The Board concludes that the Veteran has a current diagnosis of hypertension that is related to Agent Orange and herbicide exposure during service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). VA treatment records show the Veteran has a current diagnosis of hypertension, and the March 2017 private physician opined that the Veteran’s hypertension was at least as likely as not caused by his presumed exposure to Agent Orange and herbicides. The rationale was that a November 2016 study documented occupational exposure to Agent Orange and service in Vietnam are associated with the development of hypertension. The medical doctor also discussed the relationship between Korean War Veterans and Vietnam War Veterans in the incidence of hypertension compared to when Agent Orange was sprayed and when it was not. The Board finds this opinion to be highly probative as the physician thoroughly reviewed the Veteran’s clinical history, military history, and detailed the affect that chemicals in Agent Orange and other herbicides have with the Veteran’s hypertension. The Board also notes that there is no negative medical opinion addressing whether the Veteran’s hypertension is related to his exposure to Agent Orange and herbicides. As such, the competent and probative evidence warrants finding that the Veteran’s hypertension is related to his exposure to Agent Orange and herbicides while in service. Therefore, service connection for hypertension is warranted. 2. Entitlement to service connection for kidney cancer. The Veteran has a current diagnosis of kidney cancer – renal cell carcinoma. The Board concludes that the Veteran has a current diagnosis of renal cell carcinoma that is related to Agent Orange and herbicide exposure during service. VA treatment records show the Veteran has a current diagnosis of renal cell carcinoma, and the March 2017 private physician opined that the Veteran’s renal cell carcinoma was at least as likely as not caused by the his presumed exposure to Agent Orange and herbicides. The rationale was as the Veteran was exposed to Agent Oranges and herbicides, he was exposed to dioxins and dioxin-like compounds which comprise, in part, Agent Orange. The medical doctor explained that they are cancer promoters. The report also addressed the rarity of renal cell carcinoma compared with other cancers. Moreover, the private opinion discussed relevant studies that explain the relationship between Agent Orange, herbicides, and the development of renal cancers. The Board finds this opinion to be highly probative as the physician thoroughly reviewed the Veteran’s clinical history, military history, and detailed the affect that chemicals in Agent Orange and other herbicides have with the Veteran’s renal cell carcinoma. Additionally, he cited relevant studies and discussed the relationship between the chemicals in herbicides and Agent Orange and the development of renal cancer. The Board also notes that there is no negative medical opinion addressing whether the Veteran’s renal cell carcinoma is related to his exposure to Agent Orange and herbicides. As such, the competent and probative evidence warrants finding the Veteran’s renal cell carcinoma is related to his exposure to Agent Orange and herbicides while in service. Therefore, service connection for renal cell carcinoma is warranted. 3. Entitlement to service connection for a lymph node disability. The Veteran asserts service connection for a lymph node disability. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of lymph node cancer or any other lymph node disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran’s medical records show normal lymph nodes. Additionally, his records are absent for any lymph node disability. While Veteran believes he has a lymph node disability, to include cancer, he is not competent to provide a diagnosis in this case. The issue is medically complex as it involves the workings of the lymphatic system. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). As such, the Veteran is not competent to report on such matter and his statements in this regard lack weight. Consequently, the Board gives more probative weight to the competent medical evidence. For the above reasons, reasonable doubt does not arise, and the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentages are based on the average impairment of earning capacity as a result of service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 509–10 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). 4. Entitlement to an initial compensable rating for bilateral hearing loss prior to January 9, 2016, and 40 percent thereafter. Disability ratings for hearing loss are assigned based on the results of controlled speech discrimination tests combined with the results of pure tone audiometry tests. See 38 C.F.R. §§ 4.85–4.87. An examination for VA rating purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test, specifically, the Maryland CNC test, and a pure tone audiometry test. 38 C.F.R. §4.85(a). Further, disability ratings for hearing impairment are assigned through a structured formula, i.e., a mechanical application of the rating schedule to numeric designations that are assigned after audiometric evaluations have been rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The rating criteria for hearing loss provide tables for combining the level of loss in the ears. Table VI is used to determine a Roman numeral designation for each ear based on a combination of the speech discrimination percentage and the average pure tone threshold, or the sum of thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. Table VIA designates a Roman numeral based on the average pure tone thresholds only. Table VI is typically used, but Table VIA may be used for exceptional patterns of hearing loss. After a Roman numeral designation has been assigned for each ear, Table VII is used to determine the compensation rate by combining such designations for impairment in both ears. 38 C.F.R. §§ 4.85, 4.86. When the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). When the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher. 38 C.F.R. § 4.86(b). The Board first notes that the Veteran did not have an exceptional pattern of hearing impairment prior to January 2016, which after that time he had such an exceptional pattern. See 38 C.F.R. § 4.86. All applicable tests include valid pure tone and speech discrimination scores. As such, Table VI applies prior to January 2016, and the more favorable Table applies after January 2016. See 38 C.F.R. §§ 4.85, 4.86. The Veteran underwent a VA examination in October 2013, and his results were as follows: Right Ear A B C D E F G 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz 8000 Hz 25 35 40 55 80 100 95+ Left Ear A B C D E F G 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz 8000 Hz 25 35 40 60 90 100 95 The pure tone average in the right ear was 53 decibels and 56 decibels in the left ear. Speech recognition scores were 88 percent in the right ear and 80 percent in the left ear. Such findings translate to Level II in the right ear and Level IV in the left ear. 38 C.F.R. § 4.85, Table VI. Applying Table VII, DC 6100, this equates to a noncompensable or 0 (zero) percent disability rating. In January 2016, the Veteran underwent another VA examination, and his results were as follows: Right Ear A B C D E F G 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz 8000 Hz 75 75 75 80 100 105 105 Left Ear A B C D E F G 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz 8000 Hz 70 70 70 80 100 105 105 The pure tone average in the right ear was 83 decibels and 80 decibels in the left ear. Speech recognition scores were 96 percent in both ears. Such findings translate to Level III in the right ear and Level II in the left ear under Table VI. 38 C.F.R. § 4.85, Table VI. Applying Table VII, DC 6100, this equates to a 0 (zero) percent disability rating Here, however, the Board notes that the Veteran has an exceptional pattern of hearing impairment in the left and right ears per 38 C.F.R. § 4.86(a). In this situation, Table VIa is for application. Based only on puretone thresholds, the Veteran’s ears are rated as Level VII each. Applying Table VIa, DC 6100, this equates to a 40 percent disability rating. The Board notes that at the 2013 VA examination the Veteran reported a frequent need for other to repeat themselves, difficulty in crowds, and missed phone calls. At the 2016 VA examination, the Veteran reported difficulty hearing people in noise places, asking people to repeat themselves, and missing calls. The Board notes that VA’s rating of hearing impairment is based on specific measurements that must be gathered by a state-licensed audiologist using specific tests, as discussed above. As such, the medical evidence and test results are probative because they directly address the rating criteria for the Veteran’s hearing loss. The Board notes that VA’s Schedule for Rating Disabilities has been found to contemplate the problems reported by the Veteran in terms of his difficulty hearing others. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that “the rating criteria for hearing loss contemplate the functional effects of difficulty hearing and understanding speech”). Accordingly, this claim must be denied. The Board has considered the applicability of the benefit of the doubt doctrine, but the preponderance of the evidence is against a compensable rating prior to January 9, 2016, and a rating in excess of 40 percent disabling thereafter. Under these circumstances, the doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 5. Entitlement to an initial rating in excess of 10 percent for tinnitus. The Veteran seeks a higher initial rating for his tinnitus, currently rated at 10 percent disabling. DC 6260 provides that recurrent tinnitus will be assigned a 10 percent rating. 38 C.F.R. § 4.87. Only a single evaluation will be assigned for recurrent tinnitus, whether it is perceived in one ear, both ears, or the head. Id. at Note (2). As the Veteran is already in receipt of the maximum rating available under DC 6260, a higher rating must be denied as a matter of law. See Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006) (concluding that the CAVC erred in not deferring to the VA’s interpretation of its own regulations, 38 C.F.R. § 4.25(b) and DC 6260, which limits a veteran to a single disability rating for tinnitus, regardless of whether the tinnitus is unilateral or bilateral). REASONS FOR REMAND 1. Entitlement to service connection for obstructive sleep apnea is remanded. The Veteran has a current diagnosis of obstructive sleep apnea. However, the Board notes that the Veteran’s service treatment records are absent for any sleep related complaints or diagnosis. Moreover, he has not been scheduled for a VA examination to determine the nature and etiology of his OSA. The Board finds that a VA examination is warranted as such would be useful for a full and fair adjudication of this issue. Indeed, VA has not obtained a medical opinion as to whether the Veteran’s OSA disability was incurred in or is otherwise related to service, and the Board finds such would be useful to adjudicate this issue. 2. Entitlement to service connection for a heart murmur is remanded. The Veteran has a current diagnosis of a heart murmur. However, the Board notes that the Veteran’s service treatment records are absent for any heart murmur diagnosis. Moreover, he has not been scheduled for a VA examination to determine the nature and etiology of his heart murmur. The Board finds that a VA examination is warranted as such would be useful for a full and fair adjudication of this issue. Indeed, VA has not obtained a medical opinion as to whether the heart murmur was incurred in or is otherwise related to service, and the Board finds such would be useful to adjudicate this issue. 3. Entitlement to service connection for a heart disability other than a heart murmur is remanded. The Veteran has a current diagnosis of mitral insufficiency. However, the Board notes that the Veteran’s service treatment records are absent for any mitral insufficiency diagnosis. Moreover, he has not been scheduled for a VA examination to determine the nature and etiology of his mitral insufficiency. The Board finds that a VA examination is warranted as such would be useful for a full and fair adjudication of this issue. Indeed, VA has not obtained a medical opinion as to whether the Veteran’s mitral insufficiency was incurred in or is otherwise related to service, and the Board finds such would be useful to adjudicate this issue. 4. Entitlement to service connection for a liver disability is remanded. The Veteran has documented liver problems, to include cysts as well as liver hypodensity. However, the Board notes that the Veteran’s service treatment records are absent for any liver condition or diagnosis. Moreover, he has not been scheduled for a VA examination to determine the nature and etiology of any liver disability. The Board finds that a VA examination is warranted as such would be useful for a full and fair adjudication of this issue. Indeed, VA has not obtained a medical opinion as to whether the Veteran has a liver disability, and if so, whether it was incurred in or is otherwise related to service, and the Board finds such would be useful to adjudicate this issue. 5. Entitlement to service connection for a thyroid disability is remanded. The Veteran has a current diagnosis of hypothyroidism, as well as a colloid nodule with cystic degeneration. However, the Board notes that the Veteran’s service treatment records are absent for any thyroid condition or diagnosis. Additionally, the Board acknowledges that the Veteran’s medical records indicate that his hypothyroidism is related to medication he takes for his renal cell carcinoma. However, he has not been scheduled for a VA examination to determine the nature and etiology of his thyroid disability. The Board finds that a VA examination is warranted as such would be useful for a full and fair adjudication of this issue. Indeed, VA has not obtained a medical opinion as to whether the Veteran’s thyroid disability was incurred in or is otherwise related to service, and the Board finds such would be useful to adjudicate this issue. 6. Entitlement to a total rating based on individual unemployability is remanded. The Board cannot decision on the issue of a TDIU because it is inextricably intertwined with the above granted service-connection issues. See Harris v. Derwinksi, 1 Vet. App. 180 (1991) (noting that two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). As such, this issue is deferred pending the receipt of additional evidence, as directed below. The matters are REMANDED for the following actions: 1. Obtain any outstanding VA treatment records. All requests and responses for the records must be documented. If any identified records cannot be obtained, notify the Veteran of the missing records, the efforts taken, and any further efforts that will be made by VA to obtain such evidence, and allow him an opportunity to provide the missing records. 2. After associating any treatment records with the claims file, then schedule the Veteran for appropriate VA examination(s) to determine the etiology of the Veteran’s above listed diseases and disabilities. The claims file should be made available to the examiner(s) and reviewed in conjunction with the examination. After reviewing the record and examining the Veteran, the examiner for the sleep disorder is to respond to the following: (a.) Is it at least as likely as not (50 percent or greater) that the Veteran’s sleep disability was caused by a disease or injury in service? (b.) If no, is it at least as likely as not (50 percent or greater) that the Veteran’s sleep disability was either 1) proximately due to or 2) aggravated by any service-connected disability? Then, please address regarding the Veteran’s heart disorder(s), address whether: (c.) Is it at least as likely as not (50 percent or greater) that the Veteran’s heart murmur and any other related heart disabilities were caused by a disease or injury in service? (d.) If no, is it at least as likely as not (50 percent or greater) that the Veteran’s heart murmur and any other related heart disabilities were either 1) proximately due to or 2) aggravated by any service-connected disability? Next, regarding the Veteran’s liver disorder(s), address whether: (e.) Is it at least as likely as not (50 percent or greater) that the Veteran’s liver disability was caused by a disease or injury in service? (f.) If no, is it at least as likely as not (50 percent or greater) that the Veteran’s liver disability was either 1) proximately due to or 2) aggravated by any service-connected disability? Finally, regarding the Veteran’s thyroid disorder(s), address whether: (g.) Is it at least as likely as not (50 percent or greater) that the Veteran’s thyroid disability was caused by a disease or injury in service? (h.) If no, is it at least as likely as not (50 percent or greater) that the Veteran’s thyroid disability was either 1) proximately due to or 2) aggravated by any service-connected disability? ** Please note and account for the Veteran’s medical records indicating a relationship between the Veteran’s medication and his hypothyroidism.** The term “aggravated” refers to a worsening of the underlying condition beyond the natural progression of the disease, as opposed to temporary or intermittent flare-ups or symptoms that resolve with return to the baseline level of disability. If aggravation is found, please state, to the extent possible, the baseline level of disability prior to aggravation. 3. A comprehensive rationale for all opinions must be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be provided without resorting to speculation, the examiner must explain why this is so and 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), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. Morales, Associate Counsel