Citation Nr: 20079692 Decision Date: 12/16/20 Archive Date: 12/16/20 DOCKET NO. 17-39 900A DATE: December 16, 2020 ORDER Entitlement to service connection for thyroid dysfunction is denied. Entitlement to service connection for narcolepsy is granted. REMANDED Entitlement to service connection for hepatitis C is remanded. Entitlement to service connection for enlarged prostate gland is remanded. Entitlement to service connection for disabilities due to high cholesterol is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has a thyroid dysfunction disability that began during active service, or is otherwise related to an in-service injury or disease. 2. The Veteran’s narcolepsy began during active service. CONCLUSIONS OF LAW 1. The criteria for service connection for thyroid dysfunction are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for narcolepsy are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1962 to March 1966. The Veteran testified at a hearing before the undersigned in April 2019. A transcript of the hearing has been associated with the claims file. The case was previously before the Board in May 2019 when it was remanded for additional development. The Board finds there has been substantial compliance with the remand directives for the claims decided herein.  Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for thyroid dysfunction. The Veteran seeks entitlement to service connection for a thyroid dysfunction. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, the Veteran does not have a thyroid dysfunction disability that began during service or is otherwise related to an in-service injury, event, or disease. No thyroid disability was noted on enlistment examination in December 1965 and the Veteran did not report any related problems on the related Report of Medical History. In October 2011 an X-ray report noted small nodules within the isthmus and left lobe of the thyroid. In March 2015 the Veteran had negative endocrine symptoms for goiter, thyroid condition, polydipsia, and polyuria and examination showed the thyroid to be normal. In April 2015 no thyroid disease was noted. A computed tomography (CT) in October 2016 showed no discrete nodule within the thyroid gland. In April 2017 the thyroid was normal in size and demonstrated normal, homogeneous radiopharmaceutical uptake. An ultrasound of the thyroid dated in April 2017 showed that the thyroid was enlarged and multinodular. An August 2017 CT scan showed a thyroid nodule. In April 2018 the Veteran denied thyroid disease. In June 2018 a diagnosis of diabetes mellitus was noted under endocrine. In July 2018 the Veteran was noted to have endocrine symptoms of frequent urination and thirst. In December 2018 the Veteran denied endocrine symptoms. In October 2018 and January 2019 the Veteran was noted to not have any thyroid disease. A thyroid test (TSH) in April 2019 showed a measurement within the stated reference range. In May 2019 the Veteran was noted to have no thyroid disease. On VA examination in January 2020, the Veteran was diagnosed with an incidental thyroid nodule. The examiner noted that thyroid nodules come to clinical attention when noted by the patient; by a clinician during routine physical examination; or during a radiologic procedure, such as carotid ultrasonography as seen in this claimant. The examiner explained that their clinical importance is primarily related to the need to exclude thyroid cancer, which accounts for 4 to 6.5 percent of all thyroid nodules in nonsurgical series. The Veteran’s nodule is thought to be incidental or benign, as his thyroid profile labs otherwise were normal. Incidentalomas are nonpalpable thyroid nodules that are detected during other imaging procedures. The non-functioning nodule, as seen this Veteran, usually is recommended to be monitor every 12 to 24 months. Incidentalomas of thyroid nodule have an idiopathy etiology. Therefore, the examiner found that it is less likely than not proximately due to nor the result of the Veteran’s type II diabetes. In another report, dated in February 2020, based upon the same rationale, the examiner found that it is less likely than not that the incidental thyroid nodule has been aggravated beyond its natural progression by the Veteran’s history of type II diabetes. In another report, the examiner further found that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that reviewing the medical records and examining this claimant, he had a history of incidental thyroid nodule. The examiner stated that an ultrasound in 2017 showed a 1.5 centimeter thyroid nodule. Incidental thyroid nodule is thought to be harmless and of idiopathic etiology. Thus, the examiner concluded that the claimed condition is less likely than not incurred in nor caused by the in-service injury, event nor disease. Entitlement to service connection for thyroid dysfunction is not warranted. Service treatment records do not show any thyroid disability. Post-service treatment records show that the Veteran was found to have thyroid nodule years after separation from service. Laboratory testing indicated a TSH measurement within the stated reference range and other treatment records showed no thyroid disease. Upon VA examination in January 2020 the Veteran was noted to have an incidental thyroid nodule. The examiner reported that the nodule was thought to be harmless and of idiopathic etiology. The examiner found that the Veteran’s thyroid nodule was less likely than not incurred in service, due to type II diabetes, or aggravated beyond natural progression by type II diabetes. As such, the evidence is not at least in equipoise that the Veteran has thyroid dysfunction that is due to service or due to or aggravated by his service-connected diabetes mellitus. Therefore, entitlement to service for thyroid dysfunction is denied. 2. Entitlement to service connection for narcolepsy. The Veteran contends that his narcolepsy was diagnosed in service. The Board concludes that the Veteran has a current narcolepsy disability that began during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Narcolepsy was not noted on enlistment examination and the Veteran did not report any sleep problems or narcolepsy. See Report of Medical Examination and Report of Medical History June 1962. Service treatment records show the Veteran was diagnosed with narcolepsy. See, e.g., February 1966. The service treatment records show reports that the Veteran’s narcolepsy was both EPTS and not EPTS. See December 1965 and February 1966. A Medical Board convened in February 1966 with recommendation that the application for immediate discharge be approved. Service personnel records show that the Veteran submitted a statement requesting discharge from service for physical disability that is considered to have existed prior to enlistment and which appears to not be incident to, or aggravated by military service. Thereafter, the Veteran was relieved from duty and honorably discharged by reason of physical disability. Post-service treatment records show notations of questionable narcolepsy. See, e.g., October 2017 and June 2018. There are also notations that indicate that the Veteran had testing that did not show a level consistent with narcolepsy. See, e.g., February 2017 and April 2018. The Veteran was afforded a VA examination in January 2020. The examiner found that the Veteran was diagnosed with narcolepsy. In the history the examiner noted that the Veteran’s condition started in 1965. The examiner stated that in reviewed of his medical records and examining the Veteran, the Veteran reportedly had a history of narcolepsy. However, it was unconfirmed in regarding to the diagnosis of narcolepsy. The examiner reported that narcolepsy is a complex disorder with multiple etiologies and identified causes of narcolepsy. The examiner concluded stating that due to the complexity of narcolepsy, it is not possible to state the direct correlation of the Veteran's narcolepsy to his service. The claimed narcolepsy is less likely than not incurred in nor caused by the Veteran's military service. In other medical opinions, the examiner found that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service-connected condition. The examiner identified causes of narcolepsy and noted that there is minimal literature connecting the cause of narcolepsy to PTSD. The examiner concluded that the claimed narcolepsy is less likely than not due to or aggravated by the Veteran’s service-connected PTSD. Upon review of the record, the Board finds that entitlement to service connection for narcolepsy is warranted. Service treatment records show that the Veteran was not diagnosed with narcolepsy or any sleep disability upon entrance to service. Therefore, the Veteran is presumed sound. Thereafter, service treatment records identify diagnoses of narcolepsy and notations that it existed prior to service and did not exist prior to service. The Veteran was discharged following a Medical Board that identified narcolepsy and in-service notations are inconsistent as to whether the disability existed prior to service. Post-service treatment records show notations of questionable narcolepsy and indications that testing showed levels not consistent with narcolepsy. However, upon examination in January 2020, the Veteran was found to be diagnosed with narcolepsy and that the condition started in 1965. The examiner further stated that the history of narcolepsy but that it was unconfirmed in regard to the diagnosis and that because it is a complex disorder with multiple etiologies and causes, it was not possible to state the direct correlation of the Veteran’s narcolepsy to service. The Board acknowledges that based upon this rationale the examiner stated that it was less likely than not incurred in or caused by the Veteran’s service or due to or aggravated by PTSD. However, as the evidence shows that the Veteran was sound upon entry to service and was diagnosed with narcolepsy in service, and as the evidence is at least in equipoise that the Veteran currently has a diagnosis of narcolepsy that started in 1965, service connection for narcolepsy is granted. REASONS FOR REMAND 1. Entitlement to service connection for hepatitis C is remanded. The claim is remanded because the most recent medical opinions are inadequate. The January 2020 VA examiner offered a negative nexus opinion. The examiner noted a history of hepatitis C, but the Veteran was asymptomatic with a negative Hepatitis C panel. Laboratory testing showed negative hepatitis C viral titers. The examiner concluded the condition has resolved and did not warrant a current diagnosis of hepatitis C. The medical opinions are not adequate because the significance of the negative hepatitis C viral titers is unclear with regard to whether the Veteran had previously had hepatitis C. Furthermore, although the condition was noted to have been resolved, it remains unclear whether the Veteran has residuals of hepatitis C. Therefore, the claim must be remanded for an adequate medical opinion. 2. Entitlement to service connection for enlarged prostate gland is remanded. The claim is remanded for a medical opinion. Service connection has recently been granted for prostate cancer, to include erectile dysfunction. Previous examinations are inadequate in identifying whether the Veteran has a separate disability related to an enlarged prostate. A January 2020 VA examination report concluded the Veteran had prostate cancer, but no other prostate disorders. That examiner noted an enlarged prostate causing voiding dysfunction. A separate January 2020 examination described the prostate as normal. The opinion on remand should address whether there is a separately diagnosed disability related to an enlarged prostate and if so, whether it is related to service. 3. Entitlement to service connection for disabilities due to high cholesterol is remanded. The claim is remanded again because the January 2020 VA opinion is inadequate. That examiner diagnosed high cholesterol, currently controlled due to anti-lipid medication. The examiner did not address the specific directive to identify any disabilities that could be related to the high cholesterol, including the Veteran’s cerebrovascular accidents, atherosclerotic vascular disease, and peripheral vascular disease, as requested by the prior Board remand. On remand, obtain and associate with the claims file all VA treatment records regarding the Veteran dated since July 2020. See 38 C.F.R. § 3.159. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from July 2020 to the present. 2. After completion of the above, forward copies of all pertinent records to a VA clinician to obtain a medical opinion regarding the nature and etiology of hepatitis or identified residuals. The examiner must opine whether it is at least as likely as not any hepatitis or residuals identified are related to an in-service injury, event, or disease. Given the history of hepatitis C, reported exposure to blood, and diagnosis of yellow jaundice following service in the Republic of Vietnam, a medical opinion is needed to determine the likely etiology. The examiner must specifically discuss the significance of the negative hepatis C viral titers and negative Hepatitis C panel with regard to residuals. In providing the opinion, the examiner should consider the following: (i) the Veteran’s history of hepatitis C; (ii) reported exposure to blood; (iii) reported diagnosis of yellow jaundice following service in the Republic of Vietnam, and; (iv) reported receipt of vaccinations with dirty needles. A complete rationale should be given for all opinions and conclusions expressed. The claims file must be made available to the examiner for review in conjunction with the examination. 3. After associating with the claims file all outstanding VA treatment records, forward copies of all pertinent records to a VA clinician to obtain a medical opinion regarding the nature and etiology of any enlarged prostate gland found to be present. The examiner must answer the following: (a) Identify whether the Veteran has a separate disability (other than prostate cancer) characterized by enlarged prostate gland. (b) for any separately diagnosed prostate gland disability, is it at least as likely as not related to the Veteran’s service? A complete rationale should be given for all opinions and conclusions expressed. The claims file must be made available to the examiner for review in conjunction with the examination. 4. After associating with the claims file all outstanding VA treatment records, forward copies of all pertinent records to a VA clinician to obtain a medical opinion regarding the nature and etiology of any disabilities due to high cholesterol found to be present. The examiner must answer the following: (a) Identify whether the Veteran has any disabilities related to having high cholesterol. The examiner must specifically comment on the Veteran’s cerebrovascular accidents, atherosclerotic vascular disease, and peripheral atherosclerotic vascular disease. (b) For any separately diagnosed prostate gland disability, is it at least as likely as not related to the Veteran’s service? A complete rationale should be given for all opinions and conclusions expressed. The claims file must be made available to the examiner for review in conjunction with the examination. M.E. LARKIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Robert J. Burriesci, 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.