Citation Nr: 1808347 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 09-42 845 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for migraine headaches. 2. Entitlement to service connection for bilateral foot problems, to include flat feet, hallux valgus, and bunions. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected Type II diabetes mellitus or posttraumatic stress disorder (PTSD) with major depressive disorder. 4. Entitlement to service connection for a skin condition. 5. Entitlement to service connection for a gastrointestinal condition, to include as secondary to service-connected PTSD with major depressive disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Stepanick, Counsel INTRODUCTION The Veteran served on active duty from January 1970 to March 1972, with service in the Republic of Vietnam from September 1970 to March 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. In September 2017, the Veteran testified at a Video Conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The issues of entitlement to service connection for bilateral foot problems, hypertension, and a gastrointestinal condition are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. FINDINGS OF FACT 1. During private medical treatment in October 1983, the Veteran reported that he had been experiencing headaches since 1971. He was diagnosed with migraine headaches at that time. 2. During VA treatment in September 2000, the Veteran reported that he had experienced migraine headaches since serving in Vietnam. 3. In August 2008, the Veteran sought VA treatment for what he characterized as a 30-year history of eruptions of blisters on his hands followed by dry and scaly skin. He reported that he experienced the symptoms four to five times per year and that he sometimes had similar eruptions on his feet, but not as frequently. The evaluating clinician diagnosed the Veteran with dyshidrotic eczema and prescribed a cream to treat the symptoms when they appeared. 4. A diagnosis of migraine headaches was confirmed during a VA neurology consultation in September 2008. 5. During his September 2017 Board hearing, the Veteran testified that both the symptoms of his current skin condition-blistering and subsequent peeling of the skin on his hands and feet-and his current migraine headaches began during service and have continued since that time. CONCLUSIONS OF LAW 1. The criteria for service connection for migraine headaches have been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 2. The criteria for service connection for a skin condition, diagnosed as dyshidrotic eczema, have been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Following review of the record, the Board finds that service connection is warranted for both migraine headaches and a skin condition, diagnosed as dyshidrotic eczema, as the relevant evidence, detailed in the foregoing findings of fact, establishes that both conditions arose during service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a), (d). In that regard, the Board finds that a lay person is competent to identify a headache with specific symptoms and to identify symptoms such as blisters and peeling skin. See Layno v. Brown, 6 Vet. App. 465, 470 (1994); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Furthermore, the Veteran's descriptions, detailed above, of his headache and skin symptoms during service and thereafter support the current diagnoses of migraines and dyshidrotic eczema that have been provided by medical professionals. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In other words, the lay evidence of record, coupled with the current diagnoses provided by clinicians, is sufficient to establish that the Veteran initially experienced migraine headaches and dyshidrotic eczema during service and has continued to experience those conditions ever since. As a result, service connection for migraine headaches and for a skin condition, diagnosed as dyshidrotic eczema, is warranted. ORDER Service connection for migraine headaches is granted. Service connection for a skin condition, diagnosed as dyshidrotic eczema, is granted. REMAND Although the Board regrets the delay, further development is necessary prior to adjudication of the remaining issues on appeal. I. VA Examination and Opinions The Veteran has not been afforded an initial VA examination in connection with his claim of entitlement to service connection for bilateral foot problems. VA must provide such an examination when there is competent evidence of a disability (or persistent or recurrent symptoms of a disability) that may be associated with an in-service event, injury, or disease, but insufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Lay testimony as to continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service, and the threshold for finding that the disability (or symptoms of a disability) may be associated with service is low. Id. at 83. Here, as the Veteran's post-service treatment records document foot diagnoses that include bilateral hallux valgus and collapsing arches, and as he has asserted that his current foot symptoms first began during service, the Board finds that the low threshold of the McLendon standard has been met and that the Veteran should be afforded an initial VA examination prior to adjudication of that claim. Turning to the claims of entitlement to service connection for hypertension and a gastrointestinal condition, in August 2013, a VA examiner confirmed current diagnoses of hypertension and gastroesophageal reflux disease (GERD), but opined that those conditions were less likely than not related to service. In support of his negative opinions, he stated only that the Veteran's service treatment records failed to document the existence of hypertension or complaints of or treatment for a gastrointestinal disorder during service. Notably, however, an April 1971 service treatment record documented the Veteran's treatment for some type of stomach upset and his March 1972 separation examination documented an elevated blood pressure reading. Furthermore, the Veteran testified during his September 2017 Board hearing that he initially experienced "heartburn" during periods of stress while he was serving in Vietnam. Thus, opinions that consider that relevant evidence are needed on remand. Furthermore, the Veteran has also suggested that his gastrointestinal condition may have been caused or aggravated by his service-connected PTSD with major depressive disorder and that his hypertension may have been caused or aggravated by PTSD or by his service-connected Type II diabetes mellitus. Accordingly, opinions addressing those theories of entitlement are also needed on remand. II. Treatment Records During his Board hearing, the Veteran reported that he had been receiving treatment for his claimed conditions at Kaiser Permanente for approximately 15 years, but any records associated with that treatment have not been submitted. Thus, those records must be sought on remand, and the Veteran should also be invited to identify any other outstanding private treatment records. The Veteran also receives ongoing treatment for his claimed conditions through VA, but the majority of the VA treatment records that are currently associated with the claims file are dated prior to 2010. Thus, updated VA treatment records must also be obtained on remand. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify and authorize VA to obtain any outstanding private treatment records, to specifically include any records documenting his treatment at Kaiser Permanente. After obtaining any necessary authorization forms from the Veteran, obtain any pertinent records identified and associate them with the claims file. Any negative responses should be in writing and should be associated with the claims file. In addition, obtain any outstanding VA treatment records, to specifically include records dating since 2010, and associate them with the claims file. 2. After the development requested in item 1 has been completed to the extent possible, send the claims file to an internist to obtain an opinion regarding the etiology of the Veteran's hypertension. If he or she determines that a new examination is needed to respond to the questions posed, one should be scheduled. Following review of the claims file, the internist should respond to following: (a) Is it at least as likely as not (50 percent probability or more) that the Veteran's hypertension had its onset in service or is otherwise related to service? Please explain why or why not, specifically discussing the elevated blood pressure reading documented during his March 1972 separation examination. (b) If the Veteran's hypertension is not directly related to service, is it at least as likely as not (50 percent probability or more) that it was either (1) caused by, or (2) aggravated by his service-connected Type II diabetes mellitus and/or his service-connected PTSD with major depressive disorder? Please explain why or why not, specifically addressing whether the Veteran has diabetic nephropathy. If you find that the Veteran's hypertension has been aggravated by his diabetes or PTSD with major depressive disorder, please attempt to quantify the degree of aggravation beyond the baseline level of disability. Please note that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. A complete rationale for the opinions rendered must be provided. If you cannot provide the requested opinions without resorting to speculation, please expressly indicate this and state why it is so. 3. Send the claims file to a gastroenterologist to obtain an opinion regarding the etiology of the Veteran's gastrointestinal condition. If he or she determines that a new examination is needed to respond to the questions posed, one should be scheduled. Following review of the claims file, the gastroenterologist should respond to the following: (a) Is it at least as likely as not (50 percent probability or more) that the Veteran's gastrointestinal condition had its onset in service or is otherwise related to service? Please explain why or why not, specifically discussing his April 1971 treatment for gastrointestinal symptoms and his testimony, during his September 2017 Board hearing, that he overate during service to relieve stress and that he initially experienced heartburn symptoms in connection with experiencing stressful situations in Vietnam. (b) If the Veteran's gastrointestinal condition is not directly related to service, is it at least as likely as not (50 percent probability or more) that it was either (1) caused by, or (2) aggravated by his service-connected PTSD with major depressive disorder, to include as a result of medication prescribed therefore? Please explain why or why not, specifically discussing the Veteran's assertion, during his September 2017 Board hearing, that he experiences heartburn during periods of stress. If you find that the Veteran's gastrointestinal condition has been aggravated by his PTSD with major depressive disorder, please attempt to quantify the degree of aggravation beyond the baseline level of disability. Please note that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. A complete rationale for the opinions rendered must be provided. If you cannot provide the requested opinions without resorting to speculation, please expressly indicate this and state why it is so. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of any left and/or right foot conditions. All indicated tests and studies should be conducted and all clinical findings reported in detail. The entire claims file should be made available to and be reviewed by the examiner in conjunction with this request. Following review of the claims file and examination of the Veteran, the examiner should respond to the following: (a) Please identify all current left and/or right foot conditions. In doing so, please specifically discuss the diagnoses of record, including but not limited to bilateral hallux valgus with cystic arthritic changes at the metatarsophalangeal joints, painful calluses, and collapsing arches. For any diagnoses of record that cannot be validated or confirmed, please explain why such diagnoses cannot be confirmed. In determining the Veteran's foot diagnoses, please consider medical and lay evidence dated both prior to and since the filing of the claim for service connection (March 2007). Please note that although the Veteran may not meet the criteria for a certain diagnosis at the present time, diagnoses made prior to and since the date of claim filing meet the criteria for a "current" diagnosis. (b) For each diagnosed foot condition, is it at least as likely as not (50 percent probability or more) that the condition had its onset in service or is otherwise related to service? Please explain why or why not, specifically discussing the Veteran's assertion, during his September 2017 Board hearing, that the walking and marching he was required to perform during service, particularly while serving in Vietnam, as well as the type of footwear he was required to wear, contributed to his development of flat feet and bunions. Please note that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. A complete rationale for the opinions rendered must be provided. If you cannot provide the requested opinions without resorting to speculation, please expressly indicate this and state why that is so. 5. After completing the requested actions, and any additional action deemed warranted, readjudicate the claims on appeal. If the benefits sought on appeal remain denied, provide a supplemental statement of the case to the Veteran and his representative and afford them an opportunity to respond. Then, return the case to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ S.C. KREMBS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs