Citation Nr: 21075565 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 19-18 369 DATE: December 20, 2021 REMANDED The issue of service connection for residuals of appendicitis is remanded. The issue of service connection for osteoarthritis of the right knee with a total knee replacement is remanded. The issue of service connection for osteoarthrosis carpometacarpal thumb and trigger finger is remanded. The issue of service connection for residuals of an aortic aneurysm repair is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1958 to March 1981. This matter comes before the Board of Veterans' Appeals (Board) from a January 2018 rating decision from a Department of Veterans Affairs (VA) regional office (RO). In August 2021, the Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing. A transcript of the hearing has been associated with the claims file. 1. The issue of service connection for residuals of appendicitis is remanded. 2. The issue of service connection for osteoarthritis of the right knee with a total knee replacement is remanded. 3. The issue of service connection for osteoarthrosis carpometacarpal thumb and trigger finger is remanded. 4. The issue of service connection for residuals of an aortic aneurysm repair is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE ADJUDICATOR. The Veteran stated he received treatment in Mannheim, Ramstein, and Bitburg while serving as a civilian at the Department of Defense (DoD). Because the Veteran was a civilian employee of the DoD, a request to that the DoD is warranted as the records may have been placed in a medical record associated with an overseas civilian DoD employee. At the Veteran's hearing he identified treatment military hospitals at Tinker Air Force Base, Ramstein Air Force Base, and Landstuhl Regional Medical Center. While some records from these facilities are part of the claims folder, they appear incomplete and do not cover the full period the Veteran has identified. VA has not requested records from these facilities. The RO should confirm all available service treatment records have been obtained. The Veteran also indicated he had received treatment from a private provider for a hernia surgery in August 2021. These records have not been associated with the claims file. The record indicates the Veteran received treatment at North Hills Family Medicine in San Antonio, Texas. These records have not been associated with the claims file. VA must provide the Veteran with examinations and/or opinions to determine if his residuals of appendicitis, osteoarthritis of the right knee, osteoarthrosis carpometacarpal thumb and trigger finger, and residuals of an aortic aneurism repair are due to service. In particular: The Veteran has alleged his appendicitis and eventual appendectomy were due to toxins in his body caused by diverticulosis. Treatment records from the time his diverticulosis note positive results for c. diff. toxins. The Veteran has also alleged this disability is due to his exposure to herbicide agents during his service in Vietnam. No opinions or examinations regarding these allegations are in the claims file. The Veteran has alleged his osteoarthritis of the right knee and osteoarthrosis carpometacarpal thumb and trigger finger are due to his diverticulosis. He submitted a journal article discussing instances of arthritis being caused by diverticulosis. The Veteran has also alleged these disabilities are due to herbicide agent exposure. No opinions or examination regarding these allegations are in the claims file. The Veteran has alleged the residuals of an aortic aneurism repair are due to his diverticulosis, herbicide agent exposure, or diabetes mellitus. An examination was performed in December 2017 where the examiner rendered a negative nexus opinion. However, the opinion did not address whether the conditions were related to diverticulosis or diabetes mellitus. Further, the opinion does not provide a supportive rationale specific to the Veteran and instead provides only generalized risk factors for the condition without reference to the Veteran's medical history. THE REMAND DIRECTIVES FOLLOW: 2. Obtain the Veteran's treatment records from hospitals at Tinker Air Force Based, Ramstein Air Force Base, and Landstuhl Regional Medical Center. Document all requests for information as well as all responses in the claims file. All efforts should be undertaken until said records are obtained unless it is reasonably certain that such records do not exist or that further efforts to obtain these identified medical records would be futile. See 38 U.S.C. § 5103A(c)(1)(C). Regardless of the outcome, the RO must make a formal finding as to the efforts undertaken to obtain said medical records, with specificity. 3. Obtain the Veteran's medical records from the DoD pertinent to his civilian service at the agency. Document all requests for information as well as all responses in the claims file. All efforts should be undertaken until said records are obtained unless it is reasonably certain that such records do not exist or that further efforts to obtain these identified medical records would be futile. See 38 U.S.C. § 5103A(c)(1)(C). Regardless of the outcome, the RO must make a formal finding as to the efforts undertaken to obtain said medical records, with specificity. 4. Ask the Veteran to complete a VA Form 21-4142 for the physician and facility that performed the Veteran's hernia surgery in August 2021 as well as for North Hills Family Medicine. Document all requests for information as well as all responses in the claims file Should the AOJ determine that more than one attempt to obtain these relevant records would be futile, the AOJ must make a formal finding delineating the steps that have been taken and explaining, with specificity, why any further attempts to obtain these relevant records would be futile. Should these records not be obtained, the AOJ must (1) inform the Veteran of the records that were not obtained (2) tell the Veteran what steps were taken to obtain them, and (3) tell the Veteran that the claim will be adjudicated without the records. See 38 U.S.C. § 5103A (b)(2)(B) 5. Schedule the Veteran for a VA examination by an appropriately qualified examiner for his residuals of appendicitis. The examiner must review the claims file. All appropriate tests, studies and consultations must be accomplished, and all clinical findings must be reported in detail in the narrative portion of the examination report. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion below. The examiner is asked to provide an opinion on the following: (a.) Whether the Veteran's appendicitis and residuals are related to his active service, to include exposure to herbicide agents. (b.) Whether the Veteran's appendicitis and residuals were proximate to (caused by) his service-connected diverticulosis to include from toxins built up in his system from the condition. (c.) Whether the Veteran's appendicitis and residuals were aggravated (made worse) by his service-connected diverticulosis to include from toxins built up in his system from the condition. The examiner must provide a statement to support the conclusions reached, addressing all relevant lay statements, medical evidence, and medical literature considered in reaching the conclusion. In providing the requested opinions, the examiner must consider the Veteran's lay statements. If examiner does not accept the Veteran's statements, s/he shall state the medical reasoning used to reject the statement and provide an explanation as to whether the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop. The examiner is advised it is not sufficient to state the Veteran's disability is not a presumptive disability related to herbicide agent exposure. The examiner must provide a rationale specific to the Veteran's disability. If it is not possible to provide a specific opinion without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). THE EXAMINER MUST REVIEW THE ENTIRE RECORD IN CONJUNCTION WITH RENDERING THE REQUESTED OPINION, INCLUDING: July 1984 treatment records noting appendicitis and an appendectomy. October 1997 treatment records noting a positive result for c. diff. toxins and possible misdiagnosis of ulcerative colitis. November 1997 treatment records relating to a sigmoid resection due to diverticulosis. An August 2016 correspondence drawing attention to a journal article entitled "Diverticulosis and diverticulitis of the appendix." A July 2017 statement by the Veteran that toxins due to diverticulosis caused his appendicitis. A January 2019 statement by the Veteran that his disabilities are related to sepsis from diverticulosis and herbicide agent exposure. 6. Schedule the Veteran for a VA examination by an appropriately qualified examiner for his osteoarthritis of the right knee and osteoarthrosis carpometacarpal thumb and trigger finger. The examiner must review the claims file. All appropriate tests, studies and consultations must be accomplished, and all clinical findings must be reported in detail in the narrative portion of the examination report. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion below. The examiner is asked to provide an opinion on the following: (a.) Whether the Veteran's osteoarthritis of the right knee is related to his active service, to include exposure to herbicide agents. (b.) Whether the Veteran's osteoarthritis of the right knee is proximate to (caused by) his service-connected diverticulosis to include from toxins built up in his system from the condition. (c.) Whether the Veteran's osteoarthritis of the right knee is aggravated (made worse) by his service-connected diverticulosis to include from toxins built up in his system from the condition. (d.) Whether the Veteran's osteoarthrosis carpometacarpal thumb and trigger finger is related to his active service, to include exposure to herbicide agents. (e.) Whether the Veteran's osteoarthrosis carpometacarpal thumb and trigger finger is proximate to (caused by) his service-connected diverticulosis to include from toxins built up in his system from the condition. (f.) Whether the Veteran's osteoarthrosis carpometacarpal thumb and trigger finger is aggravated (made worse) by his service-connected diverticulosis to include from toxins built up in his system from the condition. The examiner must provide a statement to support the conclusions reached, addressing all relevant lay statements, medical evidence, and medical literature considered in reaching the conclusion. In providing the requested opinions, the examiner must consider the Veteran's lay statements. If examiner does not accept the Veteran's statements, s/he shall state the medical reasoning used to reject the statement and provide an explanation as to whether the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop. The examiner is advised it is not sufficient to state the Veteran's disability is not a presumptive disability related to herbicide agent exposure. The examiner must provide a rationale specific to the Veteran's disability. If it is not possible to provide a specific opinion without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). THE EXAMINER MUST REVIEW THE ENTIRE RECORD IN CONJUNCTION WITH RENDERING THE REQUESTED OPINION, INCLUDING: A March 1977 service treatment record noting joint pain. A January 1981 service treatment record noting swollen or painful joints. October 1997 treatment records noting a positive result for c. diff. toxins and possible misdiagnosis of ulcerative colitis. November 1997 treatment records relating to a sigmoid resection due to diverticulosis. March 2005 emergency department records for a right knee sprain. A December 2009 letter from a treating physician that it was recommended the Veteran' exercise for improvement in symptoms and noting that increased exercise resulted in increased knee pain. An August 2016 correspondence from the Veteran drawing attention to a journal article discussing an association between diverticulitis and arthritis. A December 2016 correspondence containing the abstracts from two journal articles discussing an association between diverticulitis and arthritis. A January 2019 statement by the Veteran that sepsis from diverticulitis and exposure to herbicide agents caused his disabilities. 7. Return the claims file to the December 2017 VA clinician, and request s/he again review the entire claims file and respond to the inquiry below. If the examiner is not available, arrange for another appropriately qualified VA examiner to provide an addendum medical opinion to assist in determining the etiology of the Veteran's residuals of a repair of an aortic aneurysm. All appropriate tests, studies and consultations should be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. The examiner is asked to provide an opinion on the following: (a.) Whether the Veteran's aortic aneurysm and residuals are related to his active service, to include exposure to herbicide agents. (b.) Whether the Veteran's aortic aneurysm and residuals were proximate to (caused by) his service-connected diverticulosis, to include from toxins built up in his system from the condition. (c.) Whether the Veteran's aortic aneurysm and residuals were aggravated (made worse) by his service-connected diverticulosis to include from toxins built up in his system from the condition. (d.) Whether the Veteran's aortic aneurysm and residuals were proximate to (caused by) his service-connected diabetes mellitus. (e.) Whether the Veteran's appendicitis and residuals were aggravated (made worse) by his service-connected diabetes mellitus. The examiner must provide a statement to support the conclusions reached, addressing all relevant lay statements, medical evidence, and medical literature considered in reaching the conclusion. In providing the requested opinions, the examiner must consider the Veteran's lay statements. If examiner does not accept the Veteran's statements, s/he shall state the medical reasoning used to reject the statement and provide an explanation as to whether the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop. The examiner is advised it is not sufficient to state the Veteran's disability is not a presumptive disability related to herbicide agent exposure. The examiner must provide a rationale specific to the Veteran's disability. If it is not possible to provide a specific opinion without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). THE EXAMINER MUST REVIEW THE ENTIRE RECORD IN CONJUNCTION WITH RENDERING THE REQUESTED OPINION, INCLUDING: October 1997 treatment records noting a positive result for c. diff. toxins and possible misdiagnosis of ulcerative colitis. November 1997 treatment records relating to a sigmoid resection due to diverticulosis. August 2017 treatment records relating to treatment for an aortic aneurysm. A January 2019 statement by the Veteran that sepsis from diverticulitis and exposure to herbicide agents caused his disabilities. (CONTINUED ON THE NEXT PAGE) 8. Thereafter, readjudicate the issues on appeal. If the determinations remain unfavorable to the Veteran, he and his representative should be furnished a supplemental statement of the case which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and his representative should be afforded the applicable period in which to respond. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Reed, Counsel The Board's decision is only binding on this case. This action is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.