Citation Nr: 18158015 Decision Date: 12/14/18 Archive Date: 12/13/18 DOCKET NO. 15-09 361 DATE: December 14, 2018 ORDER Service connection for residuals of enterococcus, to include chronic diarrhea, is granted. REMANDED Service connection for hearing loss is remanded. Service connection for a low back condition is remanded. Service connection for a skin condition is remanded. Service connection for a respiratory condition is remanded. FINDING OF FACT The Veteran has residuals of enterococcus, to include chronic diarrhea, that began during active service. CONCLUSION OF LAW The criteria for service connection for residuals of enterococcus, to include chronic diarrhea, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1965 to November 1968. This case is on appeal from a January 2014 rating decision. In March 2018, the Veteran testified at a Board hearing. He submitted additional evidence and waived initial RO consideration. See 38 C.F.R. § 20.1304(c). Service connection for residuals of enterococcus. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. A Veteran seeking compensation under these provisions must establish three elements: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). When there is approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis The Veteran seeks service connection for chronic enteritis as result of his military service. He makes reference to his inpatient treatment received for enteritis and chronic diarrhea while hospitalized for three months during his service in Vietnam. A review of the Veteran’s service treatment records (STRs) reveals that, in November 1966, he went to his aid station complaining of severe sharp pain between the rectum and the scrotum and dark urine for approximately three months. The Veteran was later hospitalized for chronic hematuria with persistent enterococcus infection. STRs reflect weight loss related to continuous watery stools. The Veteran contends that should he have been cured of his infection, he would not have been released from the hospital under prescription for antibiotics. After service, VA treatment records show that in August 2012, the Veteran underwent a colonoscopy for complaints of blood in his stools. He was later diagnosed with gross hematuria. VA treatment records are silent as to complaints for blood in urine or stools prior to this episode. The Veteran was afforded a VA examination in June 2013. At that time, the examiner confirmed the continuity of symptoms mentioned above and his history of GI Bleeding at least once a year since service in Vietnam. Also, the examiner noted that there were complaints of loose watery stools and diarrhea “for which a continuity of treatment is necessary for control of the Veteran’s intestinal conditions.” The examiner’s remarks and medical opinion stated that the Veteran’s current symptoms of diarrhea and loose stools are at least as likely as not as a result of service in Vietnam. The examiner’s rationale highlighted that the Veteran began to have loose stools and weight loss in Vietnam. She further stated that “although he did not have diagnosis of diarrhea in STRs, he did have enterococcus which can infect both, urinary tract and GI tract. He has had several episodes of lower GI bleed since service. Parasitic infections can cause permanent damage to [gastrointestinal] and urinary tract, which can result in intermittent and chronic symptoms such as diarrhea and bleeding.” Evidence of record reflects that an addendum to the June 2013 opinion was obtained. The VA examiner stated that “[t]he Veteran’s enterococcus in service is less than likely than not the cause of the Veteran’s current gastrointestinal symptoms.” The examiner’s rationale relied on that after reviewing the Veteran’s medical records, it was revealed that the Veteran had no complaints on separation and that prior to August 2012, the Veteran states he had normal BM daily. Based on that information, the examiner opined that it was less than likely that his diverticulitis and polys are related to his enterococcus in service. The Board acknowledges and weighs both medical opinions from the same VA examiner. Although the June 2013 addendum provided by the VA examiner shows a negative nexus, contrary to the original opinion, the Board finds the first opinion more persuasive as it had comprehensive explanation of the Veteran’s condition and medical literature was cited in support of it. The first opinion contains not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Veteran’s lay statements reflect that he was evacuated from the field in Vietnam and sent to a hospital in Japan, where he was admitted for three months for treatment. He adds that after released from the hospital in February 1967, he never felt cured from the infection. As he highlights, he was sent back to duty with a one-month prescription supply, including antibiotics. Such statements are supported by the entries in his STRs. The Veteran also states that up until today het gets blood in his urine and, had the doctors at that time provided continuous treatment for the infection, he would not be suffering from his enterococcus disorder today. The Board finds the Veteran’s them credible given the history of the case and other evidence of record. In light of the findings and the evidence discussed above, the Board finds that the Veteran’s residuals of enterococcus, to include chronic diarrhea, began in service. This is particularly so when reasonable doubt is resolved in the Veteran’s favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection for residuals of enterococcus, to include chronic diarrhea, is warranted.   REASONS FOR REMAND 1. Service connection for hearing loss. The Veteran seeks entitlement to service connection for hearing loss as a result of his work as a Hawk Missiles and Launcher Repairer (MOS 22K), while attached to an artillery battalion during service in the Republic of Vietnam. STRs show that the Veteran had an entrance audiological evaluation in August 1965, at which time auditory thresholds were normal. The separation audiological evaluation performed in September 1968, reported threshold shifts in relevant categories. VA examination dated June 2013 reflects hearing impairment for VA purposes under 38 C.F.R. § 3.385. The VA examiner diagnosed the veteran with bilateral sensorineural hearing loss. He further opined that the Veteran may have had a moderate probability of noise exposure but concluded that after comparing the enlistment and separation hearing tests performed, there were stable auditory thresholds between both exams for which the Veteran’s reported hearing loss was less likely as not caused by or a result of his military noise exposure. The examiner’s rationale relied on the fact that hearing remained stable in both ears after comparing the enlistment and separation hearing examinations. He further pointed out that having the Veteran served as a police officer for ten years, which entails yearly weapons qualification while using hearing protection, and having the Veteran worked in construction sites for over twenty-five years while reportedly using hearing protection as well, could be considered intercurrent events that cannot be ruled out as the probable cause for the Veteran’s hearing loss. He further pointed out that the Veteran’s induction hearing test was considered as converted from ASA to ANSI units since there was no documentation as to which measurement unit was used in his hearing tests. A review of the Veteran’s private medical records reveals that there have been complaints related to the ears as early as 1975. In his lay statements, the Veteran asserts that his hearing loss was caused by his service in the Army, small arms fire, heavy weapons noise and artillery work combined with ear infections and scarring while stationed in Vietnam. During a Board hearing, the Veteran testified that such exposure to noise was much worse than the post-service noise exposure as a police officer, which only consisted of firing twelve rounds a year for weapons qualifications. The Board finds that another VA audiological examination is warranted to further address these specific aspects of the case. 2. Service connection for a low back condition. The Veteran seeks entitlement to service connection for his low back condition as a result of his military service. He asserts the onset of symptoms began when on guard duty, he felt a burning sensation inside his back and then realized he was being hit directly in his lower back by a beam from a high-powered hawk missiles radar. A review of his STRs shows that, in October 1967, the Veteran reported to the unit’s aid station in Vietnam complaining of constant pain in the lower part of his back for one week. He asserts he has suffered of back problems thereafter. After service, private medical records account for historical complaints of low back pain and reflect that the Veteran has sought treatment for it since at least 1983. There may be an intercurrent cause as there is evidence of a 2006 injury suffered while playing catch with his daughter, along with the MRI results dated July 2006, which revealed that the Veteran suffered from a left lateral disc protrusion T12-L1; far left lateral disc protrusion L1-L2; facet disease at all levels; triangulation of the canal at L2-L3, L3-L4; and L4-L5 secondary to a combination of disc bulging and facet disease. The Veteran was afforded a VA examination in October 2013. The VA examiner confirmed that the Veteran has a current thoracolumbar spine condition, with flare-ups up to five times per week. The examiner’s remarks and opinion stated that “the Veteran had pain while he was in the military. He did have surgery in 2006 for his back. He had continued to seek treatment and management for his back condition, he is still treating and his physical exam and MRI are both abnormal for which the Veteran’s lumbar djd is at least as likely as not related to his military service.” The Board notes that an addendum to the opinion was obtained days later. The examiner noted that “no evidence was submitted showing the degenerative effects of radar laser. There are no reports of continued back treatment. In June 2006, the Veteran suffered an injury to his back while playing baseball with radiating pain from his LS spine, requiring surgery for this. In the discharge summary from the hospital, the Veteran’s provider [reported] his back problems began in June of that year when he suffered the baseball injury. It is less likely than not the Veteran’s back condition is due to his exposure to the radar laser and more likely due to the back injury reported in 2006.” The Board finds a remand is warranted to obtain another VA examination and opinion to further address these aspects. 3. Service connection for a skin condition. The Veteran contends that he is entitled to service connection for a skin condition because it was caused by his herbicide exposure while serving in the Republic of Vietnam, to specifically include the condition of chloracne A review of the Veteran’s STRs shows that, in February 1967, while hospitalized for a gastrointestinal bacterial infection, a consult for a dermatologist was recorded without any further details as to the reasons for the request. Later, in October 1967, the Veteran received treatment for a rash in the groin area. He was prescribed an ointment. Thereafter, STRs are silent for any other episodes or complaints for skin conditions. In addition, the Veteran’s separation physical examination found no evidence of a skin condition. However, the Veteran stated during his March 2018 Board hearing that “rashes in Vietnam was a normal occurrence. Many times, since [his] tour in Vietnam, [he has] broken out, as it still does today, with blackheads, cysts, and skin eruptions.” The Veteran’s private medical records account for multiple skin complaints. Emergency care records show that in September 1992, the Veteran visited the ER for a rash over the arms which reflects a diagnosis of multiple insect bites. Private records also reflect that in April 1995, the Veteran complained of face, nose and cheeks break outs and a diagnosis of moderate rosacea. Another diagnosis for rosacea was provided in a visit dated May 1996. In May 2008, the Veteran complained of a rash on the face and neck area with a diagnosis of dermatitis. Lastly, a complaint of face rash is registered for June 2008 with another diagnosis of dermatitis and a possible bacterial infection. VA treatment records account for multiple complaints for skin conditions for which the Veteran has been receiving treatment. In March 2012, the Veteran had a general surgery consult at for a 3-4 cm intradermal mass with central comedome and superficial erythema overlying the central focus on his back. VA treatment records reflect a June 2015 dermatology consult for an evaluation of a rash present on the Veteran’s face. The examiner notated that the Veteran reported “he has had this type of rash that comes and goes ever since he served in Vietnam.” In March 2017, VA treatment records account for a follow up yearly skin examination. The examiner’s notes include a comment that the Veteran has a history of cystic lesions since his time in Vietnam. The Veteran was afforded a VA examination in October 2013. The examiner diagnosed the Veteran with acne. The examiner further stated that his skin condition is less than likely related to his groin rash in service since “the Veteran does not have a groin rash presently nor a current diagnosis of chloracne in his records.” The Board finds that another VA skin examination with a medical opinion is warranted to address these aspects of the case. 4. Service connection for a respiratory condition. The Veteran seeks entitlement to service connection for a respiratory condition as incurred during active military service. He asserts that his respiratory problems began in basic training and have continued thereafter. The Veteran also states that while serving in Vietnam, he was constantly exposed to smoke from the burning of foliage, human waste and disposable items such as tires and wood. The evidence of record reflects that treatment was received during service for respiratory problems and infections. A review of the Veteran’s private medical records reveals that there have been several complaints of and treatment for respiratory problems. In this case, the in-service injury or event, and current diagnosis are established. However, the Veteran has not been afforded a VA examination to determine whether is a nexus between the two. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). In light of the remand, updated VA treatment records should be obtained. The matters are REMANDED for the following actions: 1. Obtain updated VA treatment records dated since December 2017. 2. Schedule the Veteran a VA audiological examination. The examiner should provide an opinion as to whether the Veteran’s hearing loss, at least as likely as not (50 percent or greater possibility), had its onset during, or is otherwise related to, his military service. Consideration should be given to the Veteran’s contentions that: (1) the in-service noise exposure had a much worse impact on his hearing than his noise exposure as a police officer; and (2) the post-service ear/hearing complaints beginning in 1975. A complete rationale or explanation should be provided for any opinion reached. 3. Schedule the Veteran for a VA examination by an appropriate medical professional with respect to the Veteran’s low back condition claim. The examiner should first identify the Veteran’s current low back condition(s). The examiner should then provide an opinion as to whether it is at least as likely as not (50 percent or greater possibility) that any identified low back condition had its onset during, or is otherwise related to, the Veteran’s service. Consideration should be given to (1) the in-service treatment received; (2) post-service low back complaints beginning at least in 1983; and (3) the 2006 reported injury and treatment to his low back. A complete rationale or explanation should be provided for any opinion reached. 4. Schedule the Veteran for a VA examination by an appropriate medical professional with respect to the Veteran’s skin condition claim. The examiner should first identify the Veteran’s current skin condition(s), including whether the Veteran has, or has ever had, a diagnosis of chloracne. If chloracne is not diagnosed, it should be explained why this is so. The examiner should then provide an opinion as to whether it is at least as likely as not (50 percent or greater possibility) that any identified skin condition had its onset during, or is otherwise related to, the Veteran’s service. Consideration should be given to the (1) in-service skin complaints and (2) the presumed exposure to herbicide agents, such as Agent Orange. A complete rationale or explanation should be provided for any opinion reached. 5. Schedule the Veteran for a VA examination by an appropriate medical professional with respect to his respiratory condition claim. The examiner should first identify the Veteran’s current respiratory condition(s). The examiner should then provide an opinion as to whether it is at least as likely as not (50 percent or greater possibility) that any identified respiratory condition had its onset during, or is otherwise related to, the Veteran’s service. Consideration should be given to (1) the Veteran’s contention that his current respiratory condition(s) began right after basic training; and (2) the STRs noting treatment provided for respiratory infections. (Continued on the next page)   A complete rationale or explanation should be provided for any opinion reached. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD William Pagan, Associate Counsel