Citation Nr: 18155352 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 15-15 646 DATE: December 4, 2018 REMANDED Entitlement to service connection for Parkinson’s Disease is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1961 to June 1986. The Veteran served in the Republic of Vietnam from July 1965 to August 1966. Entitlement to service connection for Parkinson’s Disease is remanded. The Board finds that additional development is needed prior to final adjudication of the issue on appeal. Specifically, the Board finds that a clarification of the Veteran’s diagnosis is required. The Veteran was afforded a VA examination in October 2012. The examiner found that the Veteran does not have a diagnosis of Parkinson’s Disease, based on his history, exam, or review of the medical records. The examiner acknowledged that the Veteran does have some features similar to Parkinson’s Disease. He also acknowledged that the Veteran stated that his primary care physician diagnosed him with the disease. However, the examiner provided no further development or discussion of these contentions. The record contains a DBQ from October 2011, completed by Dr. S.J., which indicates that the Veteran now has, or has had in the past, a diagnosis of Parkinson’s Disease. The examiner notes that the Veteran suffers from ataxia, primarily cerebellar degeneration and notes the following symptoms: stooped posture; balance impairment; slowed motion; loss of automatic movements; speech changes; mild and moderate tremors; muscle rigidity and stiffness; depression; cognitive impairment or dementia; sleep disturbance, difficulty chewing/swallowing; sexual dysfunction; gait instability; fall risk; slurred speech, and difficulty with communication. The October 2011 physician noted the year of the Veteran’s Parkinson’s diagnosis as 2002. In July 2011, the Veteran submitted a statement indicating that on August 16, 2002, his doctor noted that he was suffering from “unusual Parkinson syndrome.” The Board has reviewed this record, and it appears to state that the Veteran’s “uncle had unusual Parkinson syndrome” (emphasis added), although the Board allows that the handwritten note is difficult to decipher. However, it is clear that the Veteran’s assessment from this date of treatment is “CVA ataxia,” not Parkinson’s Disease. Indeed, the Veteran’s treatment records are silent as to treatment of Parkinson’s Disease. Rather, he is consistently noted to suffer from cerebellar ataxia. Both the Veteran and his wife have noted his diagnosis. See Veteran’s statement, October 2009; see also Spouse’s statement, June 2016. The Veteran was provided a VA examination for cerebellar ataxia in January 2013. The examiner noted a diagnosis of cerebellar ataxia associated with cerebellar stroke. The Veteran reported that this diagnosis was from 2002. The examiner noted the following symptoms: speech not intelligible/ individual is aphonic; mild swallowing difficulties; abnormal speech with significant slurring and some words unintelligible; abnormal gait with the Veteran being wheelchair bound; depression, cognitive impairment or dementia, or any other mental health conditions attributable to the disability and its treatment. The examiner did not indicate that the Veteran suffers the following symptoms: sleep disturbances or erectile dysfunction. Given that the weight of the medical evidence does not support a finding, at present, that the Veteran suffers from Parkinson’s Disease, the Board is not prepared to grant at this time. However, the Board acknowledges that there are conflicting diagnoses in the record for disabilities, which appear to encompass similar symptoms. The Veteran’s representative argues that this matter should be remanded to address the conflicting diagnoses. The Board agrees. Accordingly, the Board will remand for further clarification of the Veteran’s diagnosed disability. In addition, there may be outstanding treatment records that have not yet been associated with the claim file. In his May 2015 VA Form 9, the Veteran states that he has an upcoming VA appointment with neurology in June 2015. The Board does not see this treatment record in the claim file. Further, the Veteran’s representative indicates that there may be additional medical support for the October 2011 diagnosis by Dr. S.J. Accordingly, the Board will remand to obtain any outstanding treatment records. Finally, in addition to seeking service connection via the presumption due to herbicide exposure, the Veteran also appears to be claiming a connection due to a head injury. See Veteran’s statement, July 2011. Accordingly, upon remand, the Board asks that this claim be addressed by an examiner. The matter is REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding treatment records, to include any VA and/or private treatment records, pertaining to the issue on appeal. In particular, the Board points to possibly outstanding VA neurology treatment records from June 2015, as well as outstanding treatment records from Dr. S.J. All efforts to obtain these records should be documented in the claim file. If any records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, obtain an opinion and, if necessary, schedule an examination to clarify the diagnosis of the Veteran’s claimed disability. For each disability diagnosed, the examiner is asked to address whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it was caused by the Veteran’s active duty service or, if preexisting service, was aggravated therein. The examiner is asked to specifically address: (a) The October 2012 VA examination, which found that the Veteran does not have a diagnosis of Parkinson’s Disease, based on his history, exam, or review of the medical records. (b) The October 2011 DBQ, completed by Dr. S.J., which indicates that the Veteran now has, or has had in the past, a diagnosis of Parkinson’s Disease. (c) The August 16, 2002 treatment record, which appears to state that the Veteran’s “uncle had unusual Parkinson syndrome” (emphasis added), and assesses the Veteran with “CVA ataxia.” (d) The January 2013 VA examination for cerebellar ataxia, which notes similar symptoms as those noted in the October 2011 DBQ. In addition, the Board asks that the Veteran’s claim of a nexus due to an in-service head injury be addressed. For all examinations, all necessary development should be taken. The VA examiner should be given access to the claim file. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided. 3. If upon completion of the above action the issue is denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Foster, Associate Counsel