Citation Nr: 1815456 Decision Date: 03/16/18 Archive Date: 03/23/18 DOCKET NO. 14-20 319A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for right shoulder impingement. 2. Entitlement to service connection for a right hand disability manifested by pain post right hand trauma. 3. Entitlement to service connection for a skin disability, to include idiopathic urticaria and methicillin resistant staphylococcus aureus (MRSA). 4. Entitlement to service connection for insomnia with memory loss as secondary to service-connected traumatic brain injury and tension and migraine headaches associated with traumatic brain injury. 5. Entitlement to service connection for angioedema. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD N. Laroche, Associate Counsel INTRODUCTION The Veteran served on active duty with the United States Army from January 1986 to January 2011, including combat service in Iraq as discussed below. This appeal comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico which, inter alia, denied service connection for status post, right shoulder trauma; status post, right hand trauma; hereditary angioedema; status post, MRSA; and insomnia with memory loss. The Veteran timely filed a notice of disagreement (NOD) and substantive appeal, via a VA Form 9. In a June 2017 statement, the Veteran withdrew his 12 claims previously on appeal for increased ratings for various service-connected disabilities. Consequently, these issues are not before the Board. 38 C.F.R. § 20.204 (2017). Additionally, he withdrew his request for a videoconference hearing before the Board. See 38 C.F.R. § 20.704(e) (2017). The Board's decision address the claims for service connection for a right shoulder disability, right hand disability, skin disability, and insomnia with memory loss are set forth below. The claim for entitlement to service connection for angioedema is addressed in the remand following the order; the claim is being remanded to the agency of original jurisdiction (AOJ). FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's right shoulder impingement is related to his active military service. 2. The evidence is at least evenly balanced as to whether the Veteran's right hand disability is related to his active military service. 3. The evidence is at least evenly balanced as to whether the Veteran's idiopathic urticaria and MRSA are related to his active military service. 4. The evidence is at least evenly balanced as to whether the Veteran's insomnia with memory loss was caused by the Veteran's service-connected traumatic brain injury. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for right shoulder impingement are met. 38 U.S.C. §§ 1110, 1111, 1113, 1131, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 2. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for right hand disability are met. 38 U.S.C. §§ 1110, 1111, 1113, 1131, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 3. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for idiopathic urticaria and MRSA are met. 38 U.S.C. §§ 1110, 1111, 1113, 1131, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 4. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for insomnia with memory loss have been met on a secondary basis. 38 U.S.C. §§ 1110, 1111, 1113, 1131, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Board notes that VA has certain duties to notify and assist the Veteran. See 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). Given the favorable actions taken below concerning the claims for entitlement to service connection herein decided, the Board will not discuss further whether those duties have been accomplished. II. Legal Principles and Analysis Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection also may be granted for a disability shown after service, when all of the evidence, including that pertinent to service, shows that it was traceable to a disease or injury incurred or aggravated in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the current disability and an in-service precipitating disease, injury or event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006). Service connection may be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). In addition, a claimant is entitled to service connection on a secondary basis when it is shown that a service-connected disability has chronically aggravated a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995), codified in 38 C.F.R. § 3.310 (b). The Veteran's DD Form 214, as amended by a DD Form 215, reflects that he received the Combat Action Badge. This is one of the decorations that are considered evidence of combat participation. VA Adjudication Procedures Manual, IV.ii.1.D.1.e (updated March 31, 2017). The fact that the Veteran engaged in combat is significant because it allows a combat veteran to use "satisfactory lay or other evidence" to establish that he was injured or incurred a disability while on active duty, even in cases where "there is no official record" that such injury or disability occurred. Reeves v. Shinseki, 682 F.3d 988, 998 (Fed. Cir. 2012) (quoting 38 U.S.C. § 1154(b)). A. Right Shoulder Impingement The Veteran contends that his current right shoulder impingement is related to an in-service injury and he has experienced continuous right shoulder pain since service. Service treatment records (STRs) reflect that the Veteran was seen in July 2007 for "annoying pain" in his right shoulder and tightness. The Veteran was noted to have difficulty holding his arm over his head. He reported that he injured his right shoulder lifting (bench press) in the 1990s. The examiner noted that the Veteran had right shoulder discomfort secondary to right posterior capsule. September 2010 radiology testing revealed no fracture or other significant bone, joint, or soft tissue abnormality. During a September 2010 Compensation & Pension (C&P) examination, the Veteran reported that he sustained injury to his right shoulder during physical activity training for the Special Forces. He reported that his symptoms included weakness, stiffness, and pain which were elicited by physical activity. On examination, the physician noted that there was no detectable alteration in form or function of the right shoulder. There was no sign of edema, effusion, weakness, tenderness, redness, heat, or abnormal movement. Additionally, there was no instability, deformity, guarding of movements, malalignment, or drainage. The examiner noted that there was normal strength. The examiner reported that the Veteran's status post trauma to the right shoulder was resolved without complication or disfigurement, and noted that the X-ray was negative. In an August 2011 statement, the Veteran reported that his right shoulder injury happened in 1991 while he was training for Special Forces assessment and selection, which he reportedly had to postpone due to his injury. He reported that the right shoulder always bothered him, but not enough to complain about until 2007. VA treatment records from March 2013 reflect an assessment of right shoulder impingement controlled by medication. For the following reasons, service connection for right shoulder impingement is warranted. As noted, the Veteran has a current diagnosis of right shoulder impingement as reflected by the most recent assessment of his right shoulder in March 2013. Therefore, although the September 2010 physician found that the Veteran's right shoulder disability resolved, the most recent assessment reflects a current disability and the Veteran meets the current disability requirement. Thus, the dispositive issue in regard to this claim is whether the Veteran's diagnosed right shoulder impingement is related to service. The September 2010 C&P examiner did not provide an opinion as to whether there exists a relationship between the Veteran's current disability and his in-service injury. However, there is lay evidence suggesting a nexus between the current right shoulder disability and service; specifically, lay testimony of some continuity of right shoulder impingement symptomatology. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("If the Board concludes that the lay evidence presented by a veteran is credible and ultimately competent, the lack of contemporaneous medical evidence should not be an absolute bar to the veteran's ability to prove his claim of entitlement to disability benefits based on that competent lay evidence"). Although the Veteran's 1991 injury is not recorded in his STRs, the section 1154(b) combat rules allow the Veteran to show that he incurred the disability itself while in service. Reeves, 682 F.3d at 999. Here, the Veteran eventually reported symptoms following the right shoulder injury in 2007 and was diagnosed with the same disability in service and in March 2013-two years after separation. Furthermore, the Veteran's statements regarding his right shoulder symptoms and its onset have remained consistent throughout the pendency his appeal. Finally, his lay statements, as a combat Veteran, indicating a relationship between his current right shoulder impingement and the right shoulder injury suffered in service via continuity of symptoms, is entitled to probative value. The evidence is therefore at least evenly balanced as to whether the Veteran's right shoulder impingement is related to his active military service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for right shoulder impingement is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Buchanan, 451 F.3d at 1335 ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). B. Right Hand Disability The Veteran contends that his current right hand disability manifested by pain is a result of an in-service injury. February 2001 medical treatment records from Lahey Clinic Emergency Department reflect that the Veteran was seen for a fourth metacarpal bone fracture in his right hand as a result of a fall. September 2010 radiology testing revealed radiopaque foreign body in his right hand. There was no acute fracture or dislocation. During the September 2010 C&P examination, the Veteran reported that 10 years ago, his right hand was injured when he sustained a broken bone during an explosive door charge. He reported that the area healed after application of a cast and conservative management without the appearance of any complication or disfigurement. On examination, the examiner noted that there was no detectable alteration in the form or function of the right hand or fingers. No ankylosis was identified and the Veteran was able to tie shoelaces, fasten buttons, and pick up a piece of paper and tear it. There was no instability, deformity, guarding of movements, malalignment, or drainage and his hand strength was noted as normal. The examiner found that the Veteran had no current pathology identified on physical examination; however, noted the radiopaque foreign body found on X-ray. In an August 2011 statement, the Veteran reported that his right hand injury happened during training in February 2001 from an explosive door charge that split his hand open during close quarters combat. He reported that his team medic "fixed [him] up" with Steri-strips. He reported that they still had multiple days left of training and he continued to train while the medic changed his dressing. He stated that unbeknownst to him, metal silver lodged into his hand from the explosive door charge. Additionally, during this training, he slipped and fell on ice and broke a finger. He reported that he was sent to the local hospital as a result. Post service VA treatment record from March 2013 reflects that the Veteran reported pain in his right hand which has persisted years after multiple injuries to his hand as a part of combat training. The examiner noted that it was difficult to say why the pain was there and if it was related to the old fracture of the shrapnel. He reported that the pain may possibly be related to scar tissue as a result of the injuries in the hand. Radiology testing from June 2016 document linear metallic foreign body projects over the dorsum of the hand posterior to the third metacarpal. For the following reasons, service connection for a right hand disability is warranted. While there is no specific diagnosis with regard to the right hand, there is evidence of a broken bone during an explosive door charge during service, pain since that time, and a foreign body in the Veteran's right hand. The question of whether symptoms such as pain could constitute "disability" for purposes of the VA compensation laws and regulations in the absence of a specific diagnosis is one that the courts have not definitively answered. See Joyner v. McDonald, 766 F.3d 1393, 1396, n. 1 (Fed. Cir. 2014) (specifically declining to reach the question of whether pain alone can constitute a disability under 38 U.S.C. §§ 1110 and 1131); Sanchez-Benitez v. Principi, 259 F.3d 1356, 1362 (Fed. Cir. 2001) ("Mr. Sanchez-Benitez presents an interesting, indeed perplexing, question, but not one that we need or can decide in this appeal"). In Sanchez-Benitez, the Federal Circuit held that, in order for a veteran to qualify for entitlement to compensation under the pertinent statutes and regulations pertaining to direct service connection, a veteran must prove existence of disability that has resulted from a disease or injury that occurred in service. Id. at 1361-1362. Thus, for example, a claim based on "pain alone" fails "when there is no sufficient factual showing that the pain derives from an in-service disease or injury." Id. In contrast to Sanchez-Benitez, the evidence in this case reflects right hand pain that is associated with an in-service injury corroborated not only by the Veteran's statements but by X-ray evidence. The Veteran has a documented in-service right hand injury including a fourth metacarpal bone fracture. Additionally, although the hand injury resulting from the explosive door charge is not documented, as noted, the section 1154(b) combat rules allow the Veteran to show that he incurred the disability itself while in service. Reeves, 682 F.3d at 999. The Veteran's report of the explosion clearly correlates with radiology imaging that document foreign body in his right hand. The Board also points out that the Court has recognized any physical defect as within the purview of a current disability for VA compensation purposes. Allen v. Brown, 7 Vet. App. 439, 444-45 (1995) (applying definition of disability in section 1701(1) to statutes describing "eligibility for disability compensation for service connected disabilities"). In light of the above, the Board does not consider the September 2010 C&P examination report persuasive to show that the Veteran's reports of right hand pain do not constitute a current disability. In this regard, the Board notes that there is a case pending before the United State Court of Appeals for the Federal Circuit addressing this precise issue. See Saunders v. Shulkin, No. 17-1466 (Notice of Docketing filed Jan. 1, 2017). In the absence of definitive guidance on this issue, the Board will not deny the claim based on lack of current disability due to the lack of a specific diagnosis. The evidence is therefore at least evenly balanced as to whether the Veteran's right hand disability is related to his active military service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for a right hand disability is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Buchanan, 451 F.3d at 1335 ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). C. Skin Disability The Veteran contends that his MRSA is related to his active military service. STRs reflect treatment for MRSA in August 2009. The Veteran had an open lesion on his left calf that was treated. During the C&P examination, the Veteran reported that he had attack of MRSA in the back of his left leg in 2009, and that this was associated with exudation, itching, ulcer, and swelling. He reported that he has taken treatment over the past 12 months twice a day of clindamycin but "multiple antibiotics did not work." He reported that he contracted MRSA in combat deployment in Iraq and he needed to be medically evacuated. On examination, the examiner noted that the Veteran's skin was healthy in appearance, texture, and pigmentation. No disfigurement from scars was apparent. The examiner reported that the Veteran developed MRSA at the back of his left leg which was resolved by antibiotic treatment. He reported that current evaluation revealed restoration of normal form and function of the left leg without evidence of any side effects from the treatment or complications from the condition. He was diagnosed with status post MRSA infection of skin of the left leg, condition resolved; no residual pathology was identified. In an August 2011 statement, the Veteran reported that his MRSA began while he was deployed to Iraq at an outstation and none of the antibiotics administered to him worked. He reported that he was evacuated back to Balad Combat Support Hospital where doctors informed him it was the worst they had seen. During a December 2014 VA examination, the Veteran was diagnosed with idiopathic urticaria. He reported that beginning in 2008, after he left Southwest Asia, he has had swelling, redness, itching, and pain migrating from his arms to his trunk, scrotum, and face. He reported that the problem persisted. At the time of the examination, the Veteran was treated with systemic corticosteroid medication for his skin. Post-service VA treatment records reflect that in May 2016 the Veteran was treated for an abscess in the back of his right knee that was noted as staphylococcus. For the following reasons, service connection for idiopathic urticarial and MRSA is warranted. The Veteran has a current skin disability to include MRSA, as evidenced by his May 2016 treatment for an abscess noted as staphylococcus, and idiopathic urticarial as diagnosed during the December 2014 VA examination. Thus, the dispositive issue in regard to this claim is whether the Veteran's diagnosed disabilities are related to service. The December 2014 VA examiner did not provide an opinion as to whether there exists a relationship between the Veteran's current disability and his active military service. However, there is sufficient lay evidence suggesting a nexus between the Veteran's idiopathic urticarial and MRSA; specifically, lay testimony of some continuity of the skin disabilities symptomatology. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("If the Board concludes that the lay evidence presented by a veteran is credible and ultimately competent, the lack of contemporaneous medical evidence should not be an absolute bar to the veteran's ability to prove his claim of entitlement to disability benefits based on that competent lay evidence"). Moreover, STRs document the Veteran's complaints of a skin problem in service. The Veteran's skin problems continued after service. The December 2014 VA examination notes that the Veteran has had idiopathic urticarial in service and, at the time of the examination, was taking medication to help control it. Additionally, in May 2016, the Veteran was treated for a staphylococcus abscess. Treatment for the Veteran's skin disabilities have been during service and continued soon after separation. Furthermore, his lay statements, as a combat Veteran, indicating a relationship between his current idiopathic urticarial and MRSA suffered in service via continuity of symptoms, is entitled probative value. The evidence is therefore at least evenly balanced as to whether the Veteran's idiopathic urticaria and MRSA is related to his active military service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for a skin disability is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Buchanan, 451 F.3d at 1335 ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). C. Insomnia with Memory Loss The Veteran contends that his insomnia with memory loss is a result of his active military service. In a July 2010 letter from a physician's assistant at the Department of the Army, the physician assistant reported that the Veteran's insomnia was directly related to his cluster headaches which usually appear in the middle of the night. Additionally, he reported that the Veteran has had a notable amount of short term memory loss and was diagnosed with memory lapses or loss on July 8, 2010. He reported that the Veteran had difficulty remember facts in which he was a subject matter expert and has never experienced this problem before. In a November 2010 C&P examination report, the examiner noted that there were no complaints of impairment to memory, attention, concentration, or executive functions. The Veteran was able to register six of a list of six words in two presentation trials, and after a delay of over ten minutes was able to recall all of them. The Veteran was able to recite his phone number backward and to perform serial subtractions by the sevens. The Veteran reported that his symptoms of memory loss began around 2006 with no apparent cause. He reported that he first noticed instances of completely losing his train of thought when he was presenting reports to superiors on topics he had prepared to present. He described his current symptoms as "a lot of stuff going through his head at night," and losing his train of thought even in casual conversation once every few weeks. He reported that he could feel himself starting to forget more often than that, but would catch himself and prevent an interruption. In regard to his insomnia, he reported that he was thinking ahead to the next day while he was trying to sleep. He reported that he had trouble sleeping for years and reported delayed sleep onset and waking to the slightest noise. Additionally, he reported that if the noise seemed unfamiliar, he became alert and got up to check it out, but this occurred only once in the past two months. He reported an average of six to seven hours of sleep, though he would like to get a little more. The examiner found that there was no diagnosis of memory loss. The examiner noted that the Veteran's reported symptoms were deemed so mild, or infrequent, or both, that no Axis I diagnosis was warranted. He reported that the Veteran did not exhibit cognitive or behavioral characteristics that would prevent adequate management funds. In an August 2011 statement, the Veteran noted that he was taking Ambien due to his insomnia. He reported that a couple of years ago, he started to have complete memory loss. During a November 2015 C&P examination, the Veteran complained of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing. The Veteran described his impairment of memory as he would be in the middle of teaching and would forget what he was saying and talking about. He reported that this happened "pretty frequently" in conversation and less often while teaching. He reported that this can happen 20 to 30 times a year while teaching. The examiner assigned a level of severity of "0" for the Veteran's memory, attention, concentration, executive functions facet, indicating that he found evidence such as no complaints of impairment of memory, attention, concentration, or executive functions. VA treatment records reflect that the Veteran had unspecified insomnia and was positive for traumatic brain injury memory loss due to combat. Upon review of the evidence of record, the Board finds that the Veteran's service-connected traumatic brain injury and tension and migraine headaches associated with the traumatic brain injury caused the Veteran's insomnia with memory loss. The Veteran has a current diagnosis of insomnia and memory loss as indicated by the July 2010 letter from a physician's assistant. The dispositive issue in regard to this claim is whether these disorder were caused by his service-connected traumatic brain injury and his tension and migraine headaches. The July 2010 physician assistant reported that the Veteran's insomnia was directly related to his cluster headaches which usually appear in the middle of the night. Although the rationale was not extensive, reading his opinion as a whole and in context of the evidence of record, to include his familiarity with the Veteran's medical history, as well as the consistency of the Veteran's statements, entitles his positive nexus opinion to at least some probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). Moreover, while the medical opinion relied, in part, on the service history provided by the Veteran, such reliance only warrants the discounting of a medical opinion in certain circumstances, such as when the opinions are contradicted by other evidence in the record or when the Board rejects the statements of the veteran. See Coburn v. Nicholson, 19 Vet. App. 427, 432-433 (2006); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2006). Here, the Board has found the Veteran's statements to be credible. Additionally, a VA treating physician reported that the Veteran was positive for traumatic brain injury memory loss due to combat. Although the rationale was not extensive, reading his opinion as a whole and in context of the evidence of record, to include his familiarity with the Veteran's medical history, as well as the consistency of the Veteran's statements, entitles his positive nexus opinion to at least some probative weight. Moreover, while the medical opinion relied, in part, on the service history provided by the Veteran, such reliance only warrants the discounting of a medical opinion in certain circumstances, such as when the opinions are contradicted by other evidence in the record or when the Board rejects the statements of the veteran. Given the adequate positive medical nexus opinions and competent, credible lay evidence of current insomnia and memory loss that resulted from service-connected traumatic brain injury and tension migraine headaches, the evidence is at least evenly balanced as to whether the Veteran's service-connected traumatic brain injury and tension migraine headaches caused his insomnia with memory loss. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for insomnia with memory loss as secondary to service-connected traumatic brain injury and tension migraine headaches is granted. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for right shoulder impingement is granted. Entitlement to service connection for a right hand disability is granted. Entitlement to service connection for idiopathic urticarial and MRSA is granted. Entitlement to service connection for insomnia with memory loss as secondary to service connected traumatic brain injury and tension migraine headaches is granted. REMAND The Board finds that additional development is needed to decide the claim for service connection for angioedema. The Veteran has a diagnosis of hereditary angioedema and specifically contends that his angioedema is not hereditary and is a result of his active military service. He reported that his symptoms began while he was deployed and has progressively worsened. He was diagnosed with hereditary angioedema in service. Significantly, hereditary angioedema was not noted on entrance examination in October 1985. The Board observes that congenital and developmental defects are not "diseases or injuries" in the meaning of applicable legislation for disability compensation purposes. 38 C.F.R. § 3.303 (c), 4.9. VA's General Counsel has held, however, that service connection may be granted for diseases (but not defects) of congenital, developmental or familial origin if the evidence as a whole shows that the manifestations of the disease in service constituted "aggravation" of the disease within the meaning of applicable VA regulations. VAOPGCPREC 82-90 (July 18, 1990); 38 C.F.R. §§ 3.303 (c), 3.306. According to the VA General Counsel's opinion, however, although service connection cannot be granted for a congenital or developmental defect, such a defect can be subject to superimposed disease or injury, and if that superimposed disease or injury occurs during military service, service connection may be warranted for the resultant disability. VAOPGCPREC 82-90. Additionally, every Veteran is presumed to have been in sound condition at entry into service except as to defects, infirmities, or disorders noted at the time of such entry, or where clear and unmistakable evidence demonstrates that the injury or disease existed before entry and was not aggravated by such service. 38 U.S.C. § 1111. The presumption of soundness applies to congenital diseases, but not congenital defects. See Quirin v. Shinseki, 22 Vet. App. 390 (2009). It is unclear from the evidence of record whether the Veteran's hereditary angioedema is a congenital disease or defect. As noted, it was not noted at entry. Due to the nature of this condition, an evaluation of whether the pathology is inherited and worsens is better explained by a medical professional as it is a complex assessment. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). As such, a medical opinion as to the nature and etiology of the Veteran's hereditary angioedema is required. Accordingly, the claim remaining on appeal is REMANDED for the following action: 1. Request an opinion from an appropriate physician as to the nature and etiology of the Veteran's angioedema. Furnish the Veteran's claims file, including a copy of this REMAND, to the physician. After reviewing the claims file, the physician should address the following: a. Is the Veteran's angioedema a congenital defect or a congenital disease? (For VA purposes, a defect differs from a disease in that the former is "more or less stationary in nature" while the latter is "capable of improving or deteriorating.") b. If the Veteran has a congenital defect, was this defect subject to a superimposed disease or injury during service? If the answer is "Yes," please describe the resultant disability. c. If the Veteran has a congenital disease, did this disease, which was not noted upon entrance into service, clearly and unmistakably (obviously or manifestly) exist prior to the Veteran's entry into active duty service? d. If the disorder clearly and unmistakably existed prior to service, was it clearly and unmistakably (obviously or manifestly) not aggravated by military service? A complete rationale for all opinions should be provided. 2. After completing the requested action, and any additional notification and/or development deemed warranted, adjudicate the claim for entitlement to service connection for angioedema. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matter 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.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs