Citation Nr: 21001031 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 12-01 880 DATE: January 6, 2021 ORDER Entitlement to service connection for a low back disability is denied. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD) with major depressive disorder (MDD) is denied. Entitlement to service connection for a heart disability, to include as secondary to hypertension, a stroke, and/or service-connected PTSD with MDD is denied. Entitlement to service connection for a stroke, to include as secondary to hypertension and/or a heart disability is denied. Entitlement to service connection for a left upper extremity disorder, to include as secondary to a stroke is denied. Entitlement to service connection for a bilateral hand disability, to include as secondary to a stroke is denied. REMANDED Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a left lower extremity disorder is remanded. Entitlement to service connection for a seizure disorder, to include as secondary to a stroke, a heart disability, and/or service-connected PTSD is remanded. Entitlement to service connection for a bowel disorder, to include as secondary to a seizure disorder remanded. Entitlement to service connection for a bilateral eye disorder (claimed as vision loss), to include as secondary to a stroke is remanded. Entitlement to a total disability rating for individual unemployability (TDIU) for the period prior to May 10, 2016 is remanded. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance for the period prior to May 10, 2016 is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s low back disability, began during active service, or is otherwise related to an in-service injury or disease. 2. The Veteran’s hypertension was not shown as chronic in service and did not manifest to a compensable degree within one year following his separation in September 1977; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 3. The Veteran’s current hypertension and heart disability are not proximately due to or aggravated beyond its natural progression due to his service-connected PTSD with MDD. 4. The preponderance of the evidence is against finding that the Veteran’s heart disability began during active service, or is otherwise related to an in-service injury or disease. 5. The Veteran’s stroke, a left upper extremity disorder, and a bilateral hand disability are not secondary to his service-connected disabilities. 6. The preponderance of the evidence is against finding that the Veteran’s bilateral hand disability began during active service, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disability have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 2. The criteria for service connection for hypertension, to include as secondary to service-connected PTSD with MDD have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 3. The criteria for service connection for a heart disability, to include as secondary to hypertension, a stroke, and/or service-connected PTSD with MDD have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 4. The criteria for service connection for a stroke, to include as secondary to hypertension and/or a heart disability have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 5. The criteria for service connection for a left upper extremity disorder, to include as secondary to a stroke have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 6. The criteria for service connection for a bilateral hand disability, to include as secondary to a stroke have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1977 to September 1977. This case is before the Board of Veterans’ Appeals (Board) on appeal from March 2010 and September 2011 rating decisions by a Department of Veterans Affairs (VA) Regional Office. In April 2015, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the electronic claims file. In June 2015 and August 2017, the Board remanded the matters for further development. Now the matters are returned to the Board. Service Connection A veteran is entitled to VA disability compensation if there is disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. § 1131 (2012). To establish an entitlement to service connection for a disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2019); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2019). This includes disability made chronically worse by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims stated that “a veteran need only demonstrate that there is an ‘approximate balance of positive and negative evidence’ in order to prevail.” When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (2012). For VA to deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App., at 54. The Veteran contends that his current low back, neck, left knee, and seizure disorder conditions are due to his in-service injury. He testified that he had hit his head and knee on a tree stump while diving down to throw a grenade during his basic training. See April 2015 Hearing Transcript, at 11. He provided that he was not allowed to go into the hospital since he was at the bivouac site and only had access to medics out in the field. See id., at 6. Also, the Veteran contends that his current hypertension had its onset in service, and his heart disability is secondary to his hypertension. See April 2015 Hearing Transcript, at 27. 1. Low back disability The record shows the Veteran’s chronic low back pain and lumbar spine surgery in August 2009. See e.g., June 2011 General Medical Compensation and Pension Examination. Thus, the Board finds that the first Shedden element for service connection is met. As to the in-service injury of the Veteran’s low back, the Board notes that his service treatment record (STR) does not reflect any injuries or complaints related to low back. However, the Board finds the Veteran’s testimony regarding the claimed in-service injury competent and credible. Therefore, the Board resolves reasonable doubt in the Veteran’s favor and finds that the second Shedden element for service connection is also met. The Veteran’s private chiropractor P. Y. provided an opinion in March 2014 that the Veteran’s well-advanced post traumatic residual degenerative joint disease and osteoarthritis of the lumbar spine is more likely than not directly and causally related to his in-service injury. However, Dr. P.Y. did not provide any rationale for his opinion. Thus, although the Board finds Dr. P.Y. competent and credible to provide a medical opinion, less probative weight is assigned to his March 2014 opinion. In December 2015, the Veteran underwent a VA examination for back (thoracolumbar) conditions. The examiner noted the Veteran’s diagnoses of degenerative arthritis of the spine and intervertebral disc disease, but opined that the conditions were less likely than not incurred in or caused by the claimed in-service injury, event or illness. However, the examiner only provided that there was insufficient evidence to support the Veteran’s claim that his conditions were caused by his in-service injury during boot camp training. Therefore, additional medical opinion to determine the etiology of the Veteran’s low back disability was obtained in March 2018. In March 2018, a VA examiner opined that the Veteran’s low back disability was less likely than not proximately due to or the result of his military service. The examiner noted that the Veteran’s separation examination on September 14, 1977 shows that he has been in good health without any back problem. The examiner provided that the Veteran’s contended in-service injury does not fit the current low back disability, and his low back pain after service was not documented in the clinical evaluation in Houston VA medical facility where he obtained a back surgery. Notably, the examiner indicated that the Veteran had a well-documented fall in August 2006 which resulted in low back injury and left leg radiculopathy. The Board finds the March 2018 VA medical opinion to be competent and credible evidence and assigns high probative weight, because the examiner rendered the opinion after reviewing the Veteran’s records and contentions. Moreover, another VA examiner in August 2019 opined that the Veteran’s diagnosed back conditions were less likely than not incurred in or related to military service. The examiner noted that there is no mention of a back injury or back pain in the Veteran’s STR, and the Veteran denied of any spine issues at the separation examination. The Board acknowledges the Veteran’s contention that he did not have any low back issues before his military service and that his back condition from the in-service injury has worsened over the years. See April 2015 Hearing Transcript, at 9. Also, the Veteran testified that he did not have any other injuries to his back after separation. See id. However, as the March 2018 VA examiner have noted in his opinion, the evidence of record shows the Veteran’s previous low back injury since his separation. See August 2006 Radiology Report (clinical diagnosis of back pain secondary to a fall from ladder was noted); see also February 2005 Inpatient Progress note (no residual effects from a fall on February 21, 2005 observed; no complaints of pain noted, but was very unsteady on feet and needed assistance in ambulation and transferring). Based on above, the Board finds that the preponderance of the evidence is against finding that the Veteran’s low back disability began during active service, or is otherwise related to an in-service injury or disease. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply here. Consequently, the Board finds that the Veteran’s entitlement to service connection for a low back disability is not warranted. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 2. Hypertension Hypertension is categorized as a chronic disease under 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a), and it will be service-connected if it manifested to a compensable degree within one year period following separation from service. As the record shows the Veteran’s current diagnosis of hypertension, the issue in this case is whether his hypertension manifested to a compensable degree (10 percent) within one year period following his separation in September 1977. In this regard, the Veteran contends that he was prescribed a high blood pressure medication about two to three months after his separation by his now-deceased family physician. See April 2015 Hearing Transcript, at 26. The record also contains lay statements from M.W., H.D., and B.D., in which they stated that the Veteran was on hypertension medication since 1978. See May 2010 Lay Statements from M.W., H.D., and B.D. The Board notes that there are three ways to obtain a 10 percent rating for hypertension under 38 C.F.R. § 4.104, Diagnostic Code 7101: (1) diastolic pressure predominantly 100 or more; (2) systolic pressure predominantly 160 or more; or (3) minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2019) (emphasis added). Also, for VA purposes, hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101, at note 1 (2019). The Veteran’s STR does not show any complaints related to high blood pressure. The only blood pressure reading available in the STR is from the Veteran’s entrance and separation examinations, which were reported as 138/82 and 122/76, respectively. See Report of Medical Examinations dated January 6, 1977 and September 14, 1977. The Veteran also denied having been treated for high blood pressure. See July 17, 1977 Dental Patient History. During the April 2015 hearing, the Veteran testified that a military doctor once told him that his blood pressure was getting a little high, but there was no need to worry at that moment since the he was under a lot of stress. See April 2015 Hearing Transcript, at 31. The Veteran also stated that he was taking the blood pressure medication on and off, because he could not afford it. See id., at 28-29. The Board notes that the first notation of the Veteran’s hypertension diagnosis of record which was not based on his own report was from 2002. The Board acknowledges the Veteran’s and others’ lay statements regarding having been prescribed a high blood pressure medication in late 1977 or early 1978. However, the evidence of record does not show that the Veteran had a history of diastolic pressure predominantly 100 or more when he was first prescribed hypertension medication. Also, it is unclear to the Board as to when the Veteran’s hypertension condition became severe enough to require continuous medication for control considering the Veteran’s testimony of being “on and off” of the medication due to financial reasons. Based on above, the Board finds that the Veteran’s hypertension was not shown as chronic in service and did not manifest to a compensable degree within one year following his separation in September 1977; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. Further, the Board notes that medical opinions on whether the Veteran’s current hypertension is secondary to his service-connected PTSD with MDD were obtained in March 2018 and August 2019. The March 2018 VA examiner opined that the Veteran’s current hypertension was less likely than not proximately due to his service-connected PTSD. The examiner provided that the Veteran’s current diagnosis is essential hypertension, which is idiopathic 90 percent of the time. The examiner noted that there are identifiable specific structural, biochemical, or genetic defects that cause secondary hypertension, but PTSD is not accepted as a cause of secondary hypertension. Also, the examiner opined that the Veteran’s current hypertension was less likely than not aggravated by chronic pain related to his musculoskeletal conditions. The examiner reasoned that there is no evidence in the medical literature to show the Veteran’s hypertension may be exacerbated by chronic pain due to his musculoskeletal conditions, and a study has shown that blood pressure in the early hours of the morning tends to be higher which may contribute to myocardial infarction and stroke. The August 2019 VA examiner also provided that the Veteran has a current diagnosis of essential hypertension, which has no clear etiology at this time. The examiner opined that the Veteran’s hypertension is not at least as likely as not aggravated beyond its natural progression by his service-connected PTSD with MDD. The examiner provided that the Veteran’s hypertension appeared after service, and its intensity is not related to factors like PTSD and depression. The examiner reasoned that the changes in blood pressure settings are not recognized as being dependent of PTSD or depression in the medical literature. The Board finds the March 2018 and August 2019 VA medical opinions to be competent and credible evidence with high probative weight, since both examiners reviewed the Veteran’s records in conjunction with an in-person examination of the Veteran before rendering their opinions. Based on above, the Board finds that the Veteran’s current hypertension is not proximately due to or aggravated beyond its natural progression by his service-connected PTSD with MDD. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply here. Consequently, the Board finds that the Veteran’s entitlement to service connection for hypertension, to include as secondary to service-connected PTSD with MDD is not warranted. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 3. Heart disability The Veteran contends that his current heart disability is secondary to his hypertension and/or a stroke. However, as discussed in this decision, the Veteran is not entitled to service connections for hypertension or stroke. As such, the Veteran’s service connection claim for a heart disability as secondary to hypertension and/or stroke must be denied. Also, the Board notes that the March 2018 and August 2019 VA examiners opined that the Veteran’s current heart disability was less likely than not proximately due to or aggravated beyond its natural progression by his service-connected PTSD with MDD. The March 2018 examiner provided that there is no evidence in the medical literature to support that the Veteran’s heart disability symptoms are due to PTSD with MDD. The August 2019 examiner also provided that PTSD with depression cannot cause coronary artery disease, which is a cause for myocardial infarction, and it cannot aggravate it beyond the natural progression of the disease. Based on above, the Board finds that the evidence of record does not show that the Veteran’s heart disability is secondary to his service-connected PTSD with MDD. Thus, the Veteran’s entitlement to service connection for a heart disability as secondary to his service-connected PTSD with MDD is not warranted. Now the Board will examine whether the Veteran is entitled to direct service connection for a heart disability. First, the record shows that the Veteran has current heart disability. See e.g., August 2019 Heart Conditions Disability Benefits Questionnaire (DBQ) (the Veteran’s diagnoses of myocardial infarction and coronary artery disease in 2002, cardiac pacemaker implant in 2004, and congestive heart failure in 2019 were noted). Thus, the Board finds that the first Shedden element for service connection is met. As to the in-service incurrence of a heart disability, the Board notes that the Veteran’s STR does not show any complaints, diagnosis, or treatment related to a heart disability. However, the Veteran’s report of having chest pains in service was noted by Dr. P.Y. in his March 2014 opinion. See March 2014 Report of Consultation and Examination. Thus, the Board resolves reasonable doubt in the Veteran’s favor and finds that the second Shedden element for service connection is also met. However, the Board notes that the March 2018 and August 2019 VA examiners opined that the Veteran’s current heart disability was less likely than not incurred in service. The March 2018 examiner noted that no risk factors for ischemic heart disease or chest symptoms were shown during the Veteran’s separation examination conducted on September 14, 1977, and he had a normal blood pressure reading of 122/76 during the examination. The August 2019 examiner discussed the Veteran’s report of having his first heart attack in 1978, and provided that myocardial infarction is caused by coronary artery disease. The examiner stated that coronary artery disease is caused by diabetes, hypertension, hyperlipidemia, and chronic inflammatory conditions, but not by any kind of occupation, including the military service. The Board finds the opinions from March 2018 and August 2019 examiners to be competent and credible evidence and assigns them high probative weight as the examiners reviewed the Veteran’s records prior to rendering the opinions and provided supporting rationale. The Board acknowledges that Dr. P.Y. opined in March 2014 that the Veteran’s current ischemic heart disease is more likely than not directly and causally related to his military service. Dr. P.Y. based his opinion solely on the Veteran’s report of having “many episodes of chest pain” during active duty service for which he sought medical treatment. Although the Board finds Dr. P.Y. competent and credible to provide an opinion, the Board cannot assign more probative weight to his opinion because the Veteran’s STR does not show any documentation of complaints or visits related to the many episodes of chest pain and Dr. P.Y. has failed to provide any further rationale to support his opinion. Based on above, the Board finds that the preponderance of the evidence is against the claim. Consequently, the Board finds that the Veteran’s entitlement to service connection for a heart disability, to include as secondary to hypertension, a stroke, and/or service-connected PTSD with MDD is not warranted. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 4. Stroke The Veteran contends that the stroke he had in 2003 was a result of hypertension and/or a heart disability. See April 2015 Hearing Transcript, at 27-28. However, as discussed above, the Veteran is not service-connected for hypertension or a heart disability. Thus, the Board finds that the Veteran’s stroke is not secondary to his service-connected disability. Also, the Board does not need to address the Veteran’s entitlement to direct service connection for a stroke, because the Veteran testified that he did not have an in-service incurrence of a stroke and his contention was limited to secondary service connection claim for the condition. See April 2015 Hearing Transcript, at 25-26 (the Veteran denied of having a stroke in service). Consequently, the Board finds that the Veteran’s entitlement to a stroke, to include as secondary to hypertension and/or a heart disability is not warranted. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 5. Left upper extremity The Veteran contends that his current left arm weakness is due to his stroke, and his left arm symptoms came after the stroke. See April 2015 Hearing Transcript, at 30. The Board notes that the Veteran did not have any other contentions regarding his current left arm disorder. As discussed above, the Veteran is not entitled to service connection for a stroke. Thus, the Board finds that the Veteran’s entitlement to service connection for a left upper extremity disorder, to include as secondary to a stroke is not warranted. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). 6. Bilateral hand disability The Veteran also contends that his current bilateral hand disability is secondary to his stroke. However, his secondary service connection claim for bilateral hand disability must be denied as well, since he is not entitled to service connection for a stroke. Now the Board will examine whether Veteran is entitled to direct service connection for a bilateral hand disability. First, the record shows the Veteran’s current bilateral hand disability. See e.g., December 2015 Hand and Finger Conditions DBQ (the Veteran’s diagnosis of degenerative arthritis of both hands was noted). Thus, the Board finds that the first Shedden element for service connection is met. The Veteran’s STR shows that the Veteran dropped a wrench on his hand and was treated for the injury. See STR dated September 13, 1977. Therefore, the Board finds that the second Shedden element for service connection is also met. However, the August 2019 VA examiner opined that the Veteran’s bilateral hand disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran had a wrench falling on his hand in 1977, but his STR shows that the X-ray taken at the time showed no bone injury. The examiner also provided that the Veteran’s separation examination was negative for any hand complaints or findings. Moreover, the examiner pointed out that the Veteran currently has equal complaints about both hands, although his left hand has not been involved in any previous injury. The Board finds the August 2019 examiner competent and credible and assigns the examiner’s opinion high probative weight as it was given after the examiner’s review of the Veteran’s records in conjunction with an in-person examination of the Veteran’s hands. The Board finds that the preponderance of the evidence is against this claim; thus, the benefit-of-the-doubt doctrine does not apply here. Consequently, the Board finds that the Veteran’s entitlement to service connection for a bilateral hand disability, to include as secondary to a stroke is not warranted. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). REASONS FOR REMAND 1. Neck disability In August 2017, the Board remanded the issue of the Veteran’s service connection for a neck disability to obtain an addendum opinion addressing the Veteran’s contention of his in-service injury and experiencing continuous neck pain since the injury. In particular, the Board directed the examiner to specifically address the notations in the Veteran’s service treatment record regarding a cyst, boil, and/or carbuncle on neck as it relates to his current neck disability. See August 2017 Board Remand Order, at 16. However, the Board notes that the addendum opinions obtained in March 2018 and August 2019 did not include any discussion on the Veteran’s contentions or the STR documented his visit regarding the cyst on his neck. The August 2019 examiner provided that she was unable to locate the STR mentioned in the August 2017 Board remand order. However, the Board notes that the STR at issue has been associated with the Veteran’s electronic claims file at the time of the examiner’s review. See “STR - Medical” received on February 6, 2015. As such, the Board finds that there has not been a substantial compliance with the August 2017 Remand directives in regard to obtaining an addendum opinion to determine the etiology of the Veteran’s neck disability. See Stegall v. West, 11 Vet. App. 268 (1998). 2. Left knee disability The Board notes that medical opinions regarding the Veteran’s service connection claim for a left knee disability were obtained in March 2018 and August 2019. However, the Board finds that both opinions are inadequate, and an addendum opinion should be obtained prior to final adjudication of the matter. First, the March 2018 opinion was given without any supporting rationale. As to the August 2019 opinion, the Board notes that the examiner based his opinion solely on the fact the Veteran’s claimed in-service left knee injury was not documented in his STR. However, the Board finds that the Veteran’s competent and credible account of the left knee injury in-service should be fully considered in formulating the etiology opinion regardless of its notation in the STR. In that regard, during the April 2015 hearing, the Veteran competently testified that he dove down on a tree stump during a grenade field training and injured his left knee. See April 2015 Hearing Transcript, at 11. The Veteran provided that he had to lie down and rest for the remainder of that day and the following day, and was given icepacks, bandages, and a set of crutches which he had used for several months. Id. He also stated that his left leg was primarily injured as he landed on his knee during the incident, and it was hurting throughout his remaining service period of approximately 7 months. Id. In light of the above, the Board finds that obtaining an addendum opinion is necessary in order to make a fully informed decision of the matter. 3. Left lower extremity disorder The Veteran competently testified that his left leg as a whole was injured during the field grenade training incident, although his left knee was more severely impacted. See April 2015 Hearing Transcript, at 11-12. He also provided that his left leg symptoms were present before having a stroke. See id., at 29-30. As such, the Board finds that the issues of service connection claim for a left lower extremity disorder and a left knee disability are inextricably intertwined as a decision on the remanded issue of service connection claim for a left knee disability could significantly impact a decision on the issue of service connection claim for a left lower extremity disorder. Therefore, a remand of the issue of service connection for a left lower extremity is also required. 4. Seizure disorder The Veteran contends that he first had his seizure episode after the in-service injury of hitting his head on a tree stump during a field grenade training. Since the August 2017 Board remand, the Veteran underwent a VA examination for seizure disorders in August 2019. The August 2019 examiner opined that the Veteran’s seizure condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner provided that the Veteran’s separation examination does not show any seizure condition, and the stroke he had later is the probable origin of the seizures. However, the Board find the examiner’s opinion to be incomplete, because the examiner failed to address the Veteran’s report of having his first seizure in service when rendering the etiology opinion. See August 2019 Seizure Disorders DBQ, at 2 (the Veteran’s report of having a seizure in service “after the head trauma at Ft. Gordon” was noted). The Board also notes that the Veteran competently testified during the April 2015 hearing that he started to have seizures after hitting his head during the in-service incident at Ft. Gordon. See April 2015 Hearing Transcript, at 6, 33. He provided that he had two seizures in service, but was not taken to a hospital because those lasted about one or two minutes. See id., at 33-34. He stated that he had lost consciousness during those seizures and urinated on himself. See id. In light of the Veteran’s consistent report of the onset of his first seizure in service, the Board finds that an addendum opinion addressing such report should be obtained in order to make a fully informed decision. 5. Bowel disorder The Veteran is seeking service connection for a bowel disorder, to include as secondary to a seizure disorder. Because a decision on the remanded issue of service connection for a seizure disorder could significantly impact a decision on the issue of service connection for a bowel disorder, the issues are inextricably intertwined. Thus, a remand of the service connection claim for a bowel disorder is required. 6. Bilateral eye disorder The Veteran initially claimed service connection for vision loss, to include as secondary to a stroke. However, the latest VA eye examination report from August 2019 indicates that he currently has an additional diagnosis of dry eye syndrome. In light of the new diagnosis found during the August 2019 and other bilateral eye disorder diagnoses noted in previous VA examination, the Board recharacterized the issue of this case as the Veteran’s service connection claim for a bilateral eye disorder, to include as secondary to a stroke. With that, the Board finds that more development is necessary since an etiology opinion for the Veteran’s dry eye syndrome has not been obtained. The August 2019 examiner’s opinions only addressed the Veteran’s secondary service connection claim. Thus, the Board find that a remand is required to obtain an addendum opinion from the August 2019 examiner to determine the nature and etiology of the Veteran’s dry eye syndrome prior to final adjudication of the matter. 7. TDIU and SMC based on the need for aid and attendance for the period prior to May 10, 2016 Finally, because decisions on the above remanded issues of service connection claims could significantly impact decisions on the issues of the Veteran’s entitlement to TDIU and SMC for the period prior to May 10, 2016, the issues are inextricably intertwined. Thus, the claims for TDIU and SMC based on the need for aid and attendance for the period prior to May 10, 2016 must be remanded as well. Accordingly, the matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) must obtain an addendum opinion from the August 2019 VA examiner regarding the Veteran’s service connection claim for a neck disability. If the August 2019 VA examiner is not available, the requested opinion with rationale should be rendered by another appropriate medical professional. If the examiner determines that a new examination is necessary, the AOJ should schedule one for the Veteran. The examiner should review the Veteran’s claims file and a copy of this REMAND order before rendering the requested addendum opinion. (a.) The examiner must opine whether the Veteran’s current neck disability disorder is at least as likely as not (50 percent or greater probability) incurred in or otherwise related to his active duty service. (b.) The examiner specifically is asked to address the contention of in-service injury of his neck and experiencing neck pain since the in-service injury. See April 2015 Hearing Transcript, at 42-44. The examiner is advised that the Veteran is competent to report his symptoms and history. Such reports, including those of continuity of symptomatology, must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, the examiner must provide an explanation for such rejection. (c.) The examiner is also asked to address the notations in the Veteran’s STR regarding cyst, boil, and/or carbuncle on his neck as it relates to the etiology of his current neck disability. See March 30, 1977, April 1, 1977, and April 4, 1977 STR, received on February 6, 2015. (d.) The examiner must provide a complete written rationale for any opinion offered. 2. The AOJ must obtain an addendum opinion from the August 2019 VA examiner regarding the Veteran’s service connection claim for a left knee disability. If the August 2019 VA examiner is not available, the requested opinion with rationale should be rendered by another appropriate medical professional. If the examiner determines that a new examination is necessary, the AOJ should schedule one for the Veteran. The examiner should review the Veteran’s claims file and a copy of this REMAND order before rendering the requested addendum opinion. (a.) The examiner must opine whether the Veteran’s current left knee disability is at least as likely as not (50 percent or greater probability) incurred in or otherwise related to his active duty service. (b.) The examiner specifically is asked to address the contention of in-service injury of his left knee and experiencing left knee issues since the in-service injury. See April 2015 Hearing Transcript, at 11-12 (the Veteran landed on his left knee while diving down on a tree stump during a grenade field training; had to lie down and rest for the remainder of that day and the following day, and was given icepacks, bandages, and a set of crutches which he had used for several months; the Veteran’s left leg was primarily injured during the incident which was hurting throughout his remaining service period of approximately 7 months). The examiner is advised that the Veteran is competent to report his symptoms and history. Such reports, including those of continuity of symptomatology, must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, the examiner must provide an explanation for such rejection. (c.) The examiner must provide a complete written rationale for any opinion offered. 3. The AOJ must obtain an addendum opinion from the August 2019 VA examiner regarding the Veteran’s service connection claim for a seizure disorder. If the August 2019 VA examiner is not available, the requested opinion with rationale should be rendered by another appropriate medical professional. If the examiner determines that a new examination is necessary, the AOJ should schedule one for the Veteran. The examiner should review the Veteran’s claims file and a copy of this REMAND order before rendering the requested addendum opinion. (a.) The examiner must opine whether the Veteran’s current seizure disorder is at least as likely as not (50 percent or greater probability) had its onset in service or otherwise related to his active duty service. (b.) The examiner is also specifically asked to consider the Veteran’s April 2015 testimony regarding his first episode of seizure experienced after the in-service injury of hitting his head on a tree stump during a field grenade training. See Apri 2015 Hearing Transcript, at 33-34 (the Veteran had two episodes of seizures after the incident, but was not taken to a hospital since those lasted about one or two minutes; and he lost consciousness during those seizures and urinated on himself). (c.) If the examiner is making a distinction between the Veteran’s first seizure experienced in service and his current seizure disorder, the examiner must provide a complete explanation. (d.) The examiner must provide a complete written rationale for any opinion offered. 4. The AOJ must obtain an addendum opinion from the August 2019 VA examiner regarding the Veteran’s service connection claim for a bilateral eye disorder. If the August 2019 VA examiner is not available, the requested opinion with rationale should be rendered by another appropriate medical professional. If the examiner determines that a new examination is necessary, the AOJ should schedule one for the Veteran. The examiner should review the Veteran’s claims file and a copy of this REMAND order before rendering the requested addendum opinion. (a.) The examiner must opine whether the Veteran’s current dry eye syndrome is at least as likely as not (50 percent or greater probability) incurred in or otherwise related to his service. (b.) If any new diagnosis were found, the examiner is asked to opine on whether each additional diagnosis is at least as likely as not (50 percent or greater probability) incurred in or otherwise related to his service. (c.) The examiner is advised that the Veteran is competent to report his symptoms and history. Such reports, including those of continuity of symptomatology, must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, the examiner must provide an explanation for such rejection. (d.) The examiner must provide a complete written rationale for any opinion offered. 5. After completing the above actions and any other necessary development, the issues on appeal, including the inextricably intertwined issues of service connection claims for left lower extremity disorder and bowel disorder, and claims of TDIU and SMC based on the need for aid and attendance for the period prior to May 10, 2016, must be readjudicated. If the claims remain denied, a Supplemental Statement of the Case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. E. Kim, 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.