Citation Nr: 18159353 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 17-04 963 DATE: December 18, 2018 REMANDED Entitlement to a thyroid disorder, to include hypothyroidism and a thyroidectomy, with residuals of memory loss, fatigue, foggy headedness, inability to sleep and weight gain, is remanded. Entitlement to service connection for a headache disorder is remanded. REASONS FOR REMAND The Veteran had active service from September 1991 to October 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision of the Department of Veterans Affairs (VA). The rating decision characterized the Veteran's claims as six issues. He appealed the denials of all six issues. VA issued a Statement of the Case in December 2016 with six issues. The Veteran perfected an appeal, via a January 2017 VA Form 9, of three of the six issues. Upon reviewing the nature of the Veteran's claims, the undersigned has recharacterized the issues on appeal to the two named above for clarity and efficiency. Remand is warranted for several reasons. First, the September 2014 VA examination for both issues was flawed. For the headaches, the examiner did not fully explain how the Veteran's in-service headaches differ from those he currently has. For the thyroid, the examiner stated "there was not noted any TSH [thyroid stimulating hormone] levels between 2001 and 2012." This is false. A May 2012 treatment record from Dr. D.G. shows TSH levels recorded annually from 2006 to 2012. Remand for new examinations is warranted. Second, the Veteran noted in a March 2014 statement that he "transferred to the United Sates in 1997, and this is when [he] noticed [his] thyroid blood tests start to get abnormal." He further stated that he "was honorably discharged from the navy in 2001, but continued getting [his] blood work done." The undersigned has reviewed the Veteran's service treatment records but has not found any mention of elevated TSH levels in service. The undersigned notes that the Veteran restricted the date range of Dr. D.G.'s records to those beginning in January 2011. Therefore, the undersigned is unclear where the TSH levels cited in the previous paragraph came from if Dr. D.G. started treating the Veteran five years after the first-recorded TSH level. Remand is warranted to allow the Veteran to clarify if additional treatment records exist. Third, the Veteran noted in his March 2014 statement that Dr. D.G. told him that "he was surprised, due to my age, that [his] thyroid is in as bad shape as it is. He said he normally sees these symptoms in much older patients." Dorland's Medical Dictionary defines Hashimoto's Disease, which the Veteran had, as a "progressive type of autoimmune thyroiditis … [that] usually affects women." Dorland's, in turn, notes that "autoimmune thyroiditis" may "occur in any age or sex but particularly affect[s] middle-aged to elderly women." The undersigned notes that the Veteran was 28 when he separated from service, and he was 33 at the first evidence, as of now, of elevated TSH levels. Given this and the nature of Hashimoto’s Disease, this merits additional inquiry during the new VA thyroid examination. The matters are REMANDED for the following action: 1. Ask the Veteran to submit all thyroid-related bloodwork and treatment records not already of record, to include any during military service, that shows elevated thyroid levels. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed thyroid disorder. The following considerations govern: The claims folder, and a copy of this Remand, will be made available to the examiner who must acknowledge such receipt and review in any report generated because of this Remand. The examiner must state the medical and factual basis or bases for any opinions rendered based on his clinical experience, medical expertise, and established medical principles, and with identification of the evidence. If the examiner finds he cannot provide a requested finding without resort to pure speculation, he must explain why. He must indicate whether his inability to provide such an opinion is a result of such factors as: (i) an intractable lack of sufficient information, (ii) a lack of sufficient specialization or expertise on his part, or (iii) a lack of sufficient knowledge or information in the medical community at large under the current state of the art of medical care and research. The examiner must answer the following question: Was the Veteran's thyroid disorder incurred in or is it etiologically related to his period of service? Why or why not? In answering, specifically address: - The relationship, if any, of environmental factors to the Veteran's development of his thyroid disorder. The Veteran cited sand storms and the inhalation of fumes and exhaust from non-pollution controlled vehicles while on guard duty as such environmental factors in his March 2014 statement. - The likelihood that the thyroid disorder began in service, even if not diagnosed, given the Veteran's gender, age, nature of autoimmune thyroiditis, and the predominant impact of autoimmune thyroiditis on older women as noted in Dorland's Medical Dictionary. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed headache disorder. The following considerations govern: The claims folder, and a copy of this Remand, will be made available to the examiner who must acknowledge such receipt and review in any report generated because of this Remand. The examiner must state the medical and factual basis or bases for any opinions rendered based on his clinical experience, medical expertise, and established medical principles, and with identification of the evidence. If the examiner finds he cannot provide a requested finding without resort to pure speculation, he must explain why. He must indicate whether his inability to provide such an opinion is a result of such factors as: (i) an intractable lack of sufficient information, (ii) a lack of sufficient specialization or expertise on his part, or (iii) a lack of sufficient knowledge or information in the medical community at large under the current state of the art of medical care and research. The examiner must answer the following question: Was the Veteran’s headache disorder incurred in or is it etiologically related to his period of service? Why or why not? In answering this question, expressly address the relationship, if any, between the headaches the Veteran experienced in service and his headaches now. If you believe they are related to fatigue caused by the Veteran's thyroid disorder and not to the in-service headaches, as found by the September 2014 examiner, explain how you concluded this. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Sopko, Counsel