Citation Nr: 20032278 Decision Date: 05/07/20 Archive Date: 05/07/20 DOCKET NO. 19-38 560 DATE: May 7, 2020 REMANDED Entitlement to service connection for hypothyroidism is remanded. Entitlement to service connection for a pituitary tumor (prolactinoma) is remanded. Entitlement to service connection for a jaw condition is remanded. REASONS FOR REMAND The Veteran had honorable active duty service from August 2000 to December 2000 and from January 2003 to January 2005. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a February 2019 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). While the Board regrets the additional delay, the Veteran’s claims of entitlement to service connection for hypothyroidism, a prolactinoma, and a jaw condition must be remanded. 1. Entitlement to service connection for hypothyroidism 2. Entitlement to service connection for a prolactinoma The Veteran contends that her in-service symptoms of fatigue, exhaustion, headaches, forgetfulness, and eye problems were due to her hypothyroidism and prolactinoma. Thus, she maintains that her disorders began in service. The Veteran also submitted a December 2019 lay statement from her squad leader at Fort Polk. The squad leader wrote that he observed the Veteran experiencing headaches and vision problems that interrupted her work and added that he knew she had to be excused early some workdays due to missed periods for months at a time that caused her more pain than usual. He also stated that he observed a change in her energy levels; that she constantly failed height and weight requirements, although she tried several exercise regiments, she could not manage her weight; her inability to keep focused, which caused him to have to move her around to different sections of finance; and her struggle with forgetting things. The Veteran received VA thyroid examination in May 2019. While clinical findings were recorded, a medical opinion addressing the etiology of the disorder was not provided. As such, the May 2019 VA examination report is inadequate for adjudicative purposes. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Additionally, a VA examination has not been obtained for the Veteran’s prolactinoma. Because the evidence of record suggests that the Veteran’s prolactinoma may have had its onset during service, a VA examination and medical opinion should be obtained. See McClendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 3. Entitlement to service connection for a jaw condition The Veteran attributes her jaw condition, diagnosed as TMJ, to the pain and clicking she experienced after the removal of her four wisdom teeth. In the December 2019 statement, the Veteran’s squad leader stated that after the Veteran’s wisdom teeth were pulled, she began complaining to her leaders, including himself, of jaw pain and dizziness. The service treatment records show that the Veteran underwent extraction of all 4 of her wisdom teeth. VA medical reports show complaints of pain attributable to TMJ and degenerative arthritis of the left TMJ. The Veteran was afforded a VA TMJ examination in May 2019; however, the examiner failed to address whether the Veteran’s jaw disorder, TMJ, is attributable to dental treatment received in service. As such, the May 2019 examination is inadequate. The Veteran must be provided with a VA examination to assess the nature and etiology of her TMJ. Barr, 21 Vet. App. at 311. The matters are REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of any medical provider, VA or private, who has treated her for hypothyroidism, prolactinoma, or TMJ. After securing any necessary releases, request any relevant records identified that are not duplicates of those already contained in the claims file. 2. Request that the Veteran resubmit her December 2018 statement. It appears that a page or pages are missing. 3. After the development directed in paragraph one and two has been completed to the extent possible, schedule the Veteran for a VA examination or VA examinations to determine the nature and etiology of her prolactinoma and hypothyroidism. The examiner should obtain a complete, pertinent history from the Veteran and review the claims file in conjunction with the examination(s), giving attention to the Veteran’s VA treatment records, lay assertions, and the pertinent medical evidence. Based on the examination and review of the record, the examiner is asked to provide an opinion addressing the following: (A) Whether it is at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s prolactinoma had its onset during her active duty service, became manifest to a compensable degree within a year after active duty service, or is in any way related to her active duty service? (B) Whether it is at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s hypothyroidism had its onset during her active duty service, became manifest to a compensable degree within a year after active duty service, or is in any way related to her active duty service? The examiner must provide a complete rationale for any opinion expressed. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 4. Schedule the Veteran for an examination to determine the nature and etiology of her TMJ. The examiner should obtain a complete, pertinent history from the Veteran and review the claims file in conjunction with the examination, giving attention to the Veteran’s VA treatment records, lay assertions, and the pertinent medical evidence. Based on the examination and review of the record, the examiner is asked to provide an opinion whether it is at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s jaw disorder, TMJ, is in any way related to dental treatment received in service, the removal of her four wisdom teeth. The examiner must be advised that the Veteran is competent to report symptoms and treatment and that her reports, including her reports as to the onset and chronic nature of her symptoms, must be considered, along with the other evidence of record, in formulating the requested opinion. The examiner must provide a complete rationale for any opinion expressed. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Temple, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.