Citation Nr: 21014932 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 16-11 481A DATE: March 16, 2021 ORDER Service connection for hemorrhoids is denied. Service connection for a thyroid disorder is denied. Service connection for a headache disorder is denied. Service connection for a cardiac disorder is denied. FINDINGS OF FACT 1. Hemorrhoids are not shown to be causally or etiologically related to any disease, injury, or event in service. 2. A thyroid disorder is not shown to be causally or etiologically related to any disease, injury, or event in service. 3. A headache disorder is not shown to be causally or etiologically related to any disease, injury, or event in service. 4. A cardiac disorder is not shown to be causally or etiologically related to any disease, injury, or event in service. CONCLUSIONS OF LAW 1. The criteria for service connection for hemorrhoids have not been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 4.30. 2. The criteria for service connection for a thyroid disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 3. The criteria for service connection for a headache disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 4. The criteria for service connection for a cardiac disorder have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 1137, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.29. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Air Force from November 1974 to September 1976. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This case was last before the Board in November 2018, at which time the Board remanded the case in order to obtain the Veteran’s Social Security Administration (SSA) records, as well as his outstanding available VA and private medical records. In August 2019 and October 2019, VA requested that the Veteran provide or identify and authorize the procurement of medical treatment records from his private providers within 30 days. The Veteran did not respond to this request. VA medical treatment records dated up to October 2020, including those from West Los Angeles VA medical center (VAMC), were added to the claims file. In September 2019, medical records from the Long Beach VAMC were also added to the record. Additionally, VA requested the Veteran’s SSA medical records; but in September 2020, the SSA responded that there were no medical records available. Therefore, the Board finds that the remand directives from the November 2018 Board decision were substantially complied with. See Stegall v. West, 11 Vet. App. 268 (1998). The case has been returned to the Board at this time for further appellate review. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for hemorrhoids. The Veteran contends that he is entitled to service connection for internal hemorrhoids. As an initial matter, the Board observes that the Veteran has a diagnosis of internal hemorrhoids, as evidenced by his VA medical treatment records. However, the Veteran’s service treatment records (STRs) are silent for any complaint, diagnosis, or treatment of hemorrhoids. In the Report of Medical Examination from the October 1974 enlistment examination, the examiners marked the Veteran’s anus, rectum, and genitourinary (G-U) system as normal. In the Report of Medical Examination from the September 1976 separation examination, the examiners marked the Veteran’s anus and rectum as normal. The September 1976 examiner noted that the G-U system was abnormal, but the examiner clarified that this referred to a lesion on the frenulum. In the Veteran’s Reports of Medical History from the October 1974 enlistment examination and the September 1976 separation examination, the Veteran reported that he had not experienced any piles or rectal disease or any kidney stone or blood in the urine. There is also no complaint, diagnosis, or treatment of hemorrhoids in the years immediately following the Veteran’s active service. The Board has considered the Veteran’s own statements that his internal hemorrhoids are related to active service. The Veteran, as a layperson, is certainly competent to report matters within his personal knowledge, such as the occurrence of an injury or event, or his own symptoms. However, in the instant case, the Board finds that the question regarding the potential relationship between internal hemorrhoids and any instance of his service to be complex in nature. The Veteran, as a lay person, does not have the requisite training and experience necessary to address such a complex medical matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of internal hemorrhoids involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board finds that the Veteran’s statements as to the etiology of his internal hemorrhoids are not competent evidence and, consequently, are afforded no probative weight. The Board has considered whether a VA examination was required in connection with the Veteran’s claim of service connection for internal hemorrhoids. The Board finds the duty to obtain a medical examination was not triggered in this case as the record from the period on appeal fails to show competent evidence establishing that an event, injury, or disease related to internal hemorrhoids occurred in service. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); McLendon v. Nicholson, 20 Vet. App. 79 (2006). There is no other evidence of record showing a causal relationship between the Veteran’s internal hemorrhoids and his active service. In the January 2014 claim of service connection for internal hemorrhoids, the Veteran noted that he had undergone surgery for the condition. In a November 1998 VA Triage Note and a November 1998 Urgent Care Note, the Veteran states that he had hemorrhoid surgery three years before. A temporary 100 percent evaluation may be assigned when it is established that a service-connected disability required surgery necessitating at least one month of convalescence, surgery with severe postoperative residuals, or treatment with immobilization by cast of one major joint or more. 38 C.F.R. § 4.30. However, as the evidence of record in this case does not warrant a finding of service connection for internal hemorrhoids, consideration cannot be given to evaluation issues such as convalescence following surgery or a period of hospitalization. Based on the foregoing, the Board finds that the Veteran’s internal hemorrhoids were not shown to be causally or etiologically related to any disease, injury, or incident in service. As such, service connection for such disorder is not warranted. In reaching the foregoing conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. Therefore, the Veteran’s claim of entitlement to service connection for internal hemorrhoids must be denied. See 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303; Gilbert, supra. 2. Entitlement to service connection for a thyroid disorder. The Veteran contends that he is entitled to service connection for a thyroid disorder. As an initial matter, the Board observes that the Veteran has a diagnosis of hypothyroidism, as evidenced by his VA medical treatment records. The Veteran’s service treatment records (STRs) are silent for any complaint, diagnosis, or treatment of thyroid problems. In the Reports of Medical Examination from the October 1974 enlistment examination and the September 1976 separation examination, the examiners marked the Veteran’s endocrine system and lymphatics as normal. In the Veteran’s Reports of Medical History from the October 1974 enlistment examination and the September 1976 separation examination, the Veteran reported that he had not experienced any thyroid trouble. There is also no complaint, diagnosis, or treatment of thyroid problems in the years immediately following the Veteran’s active service. A June 1983 VA treatment note shows treatment for hypothyroidism, but there is no indication of any causal relationship to the Veteran’s active service, which ended seven years earlier. The Board has considered the Veteran’s own statements that his hypothyroidism is related to active service. The Veteran, as a layperson, is certainly competent to report matters within his personal knowledge, such as the occurrence of an injury or event, or his own symptoms. However, in the instant case, the Board finds that the question regarding the potential relationship between hypothyroidism and any instance of his service to be complex in nature. The Veteran, as a lay person, does not have the requisite training and experience necessary to address such a complex medical matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of hypothyroidism involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board finds that the Veteran’s statements as to the etiology of his hypothyroidism are not competent evidence and, consequently, are afforded no probative weight. The Board has considered whether a VA examination was required in connection with the Veteran’s claim of service connection for hypothyroidism. The Board finds the duty to obtain a medical examination was not triggered in this case as the record from the period on appeal fails to show competent evidence establishing that an event, injury, or disease related to hypothyroidism occurred in service. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); McLendon v. Nicholson, 20 Vet. App. 79 (2006). There is no other evidence of record showing a causal relationship between the Veteran’s hypothyroidism and his active service. Based on the foregoing, the Board finds that the Veteran’s hypothyroidism was not shown to be causally or etiologically related to any disease, injury, or incident in service. As such, service connection for such disorder is not warranted. In reaching the foregoing conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. Therefore, the Veteran’s claim of entitlement to service connection for hypothyroidism must be denied. See 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303; Gilbert, supra. 3. Entitlement to service connection for a headache disorder. The Veteran contends that he is entitled to service connection for a headache disorder. As an initial matter, the Board observes the Veteran’s VA treatment records reflect complaints of and treatment for headaches during the pendency of the appeal. In an October 2012 VA Emergency Department Note, the Veteran complained of headaches. When asked where his headaches were present, he pointed at his lower left occipital area, saying, “It’s my neck and not head”. A February 2014 Addendum stated that the Veteran complained of occipital or nuchal headaches in distribution of C2. He pointed to his occiput and neck as the site of his headaches. In a February 2014 Neurology Consult, the Veteran complained of bilateral headaches with a steady pressure; he stated that it felt like it started in his neck and radiated to the top of his head. The headaches affected him about four or five days a month and were worse at night. The headaches kept him from falling asleep because of the discomfort, but they were not positional. The Veteran noted that he had no history of headaches before age 50. He endorsed a remote history of a neck injury when a telephone pole fell on him. The examiner gave an assessment of occipital neuralgia versus cervicogenic headache. In a May 2014 H&P Note, the Veteran complained of a morning headache with a sudden onset of neck pain radiating into the head. He stated it was similar to but more severe than the pain he had noted intermittently since 2012, and he attributed it to the sequelae of a workplace injury in which he was struck on the head with neck compression thereafter. He returned a few days later with worsening neck pain and a concurrent sharp pressure sensation throughout his head, with one side worse than the other. The examiner gave an assessment of cervicalgia and headache, and he stated that the presumed etiology was exacerbation of a known occipital nerve irritation. In a May 2014 Pain Consult from the next day, the Veteran presented with severe debilitating neck pain radiating into a severe sharp pressure headache. The examiner noted that the Veteran had a past medical history of neck pain status-post industrial accident, which occurred 15 or 20 years ago when a floodlight fell on his head. In a June 2014 Primary Care Note, the Veteran was noted to have been hospitalized for severe exacerbation of a chronic headache that he has had for over 10 years since a work injury in which a large lamp post was dropped onto his head. The examiner noted that his persistent headache symptoms were consistent with his diagnoses of cervical radiculopathy and cervico-occipital neuralgia. In an August 2014 Physical Medicine Rehab Note, the Veteran reported a five-year history of intermittent neck pain radiating up to cause a pressure headache. Looking at the Veteran’s service treatment records (STRs), an October 1975 treatment note mentions that the Veteran had experienced headaches for one day. However, in the Reports of Medical Examination from the October 1974 enlistment examination and the September 1976 separation examination, the examiners marked the Veteran’s head as normal. In the Veteran’s Reports of Medical History from the October 1974 enlistment examination and the September 1976 separation examination, the Veteran reported that he had not experienced any headaches or head injury. Even if the Veteran experienced headaches during service, there is no indication in the evidence of record that the Veteran incurred any chronic or long-term headache problems during his active service. There is also no complaint, diagnosis, or treatment of headaches in the years immediately following the Veteran’s active service. Also, in a June 1983 VA treatment note, the Veteran denied having any headaches. The Board has considered the Veteran’s own statements that his headache disorder is related to active service. The Veteran, as a layperson, is certainly competent to report matters within his personal knowledge, such as the occurrence of an injury or event, or his own symptoms. However, in the instant case, the Board finds that the question regarding the potential relationship between his current headache disorder and any instance of his service to be complex in nature. The Veteran, as a lay person, does not have the requisite training and experience necessary to address such a complex medical matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of a headache disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board finds that the Veteran’s statements as to the etiology of his headache disorder are not competent evidence and, consequently, are afforded no probative weight. The Board has considered whether a VA examination was required in connection with the Veteran’s claim of service connection for a headache disorder. The Board finds the duty to obtain a medical examination was not triggered in this case as the record from the period on appeal fails to show competent evidence establishing that an event, injury, or disease related to a chronic headache disability that occurred in service. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); McLendon v. Nicholson, 20 Vet. App. 79 (2006). There is no other evidence of record showing a causal relationship between the Veteran’s headache disability and his active service. Based on the foregoing, the Board finds that the Veteran’s headache disorder was not shown to be causally or etiologically related to any disease, injury, or incident in service. As such, service connection for such disorder is not warranted. In reaching the foregoing conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. Therefore, the Veteran’s claim of entitlement to service connection for a headache disability must be denied. See 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303; Gilbert, supra. 4. Entitlement to service connection for a cardiac disorder. The Veteran contends that he is entitled to service connection for a cardiac disorder (claimed as cardiomegaly or enlarged heart). In a March 2018 Addendum, the examiner noted that the Veteran had angina with a sensation of pressure in the mid chest when sleeping right after eating. He sometimes experienced it during the daytime as well. The Veteran stated that this started three years ago. He reported intermittent chest pain that felt like a weight on the chest, but he denied any exertional chest pain or chest pressure In a March 2018 Cardiology Consult and Addendum with the results of a myocardial perfusion with pharmacologic stress test, the examiner noted that the Veteran’s heart was mildly enlarged in size with no coronary artery calcifications. The examiner stated that the myocardial perfusion images demonstrated no evidence for ischemia and no significant perfusion defects. There was mild post-stress left ventricular dilatation, which the examiner said may indicate three vessel coronary artery disease. In an August 2018 Primary Care Resident Note, the examiner noted that the Veteran had chest pain with unclear etiology, but it was unlikely to be coronary ischemia given the timing and duration and history of MPI without perfusion defects. Looking at the Veteran’s service treatment records (STRs), in a June 1976 treatment note, the Veteran noted that he had a heart murmur at age 17, but the examiner found that the Veteran’s chest was now clear. In a June 1975 treatment note from an acute care clinic, the Veteran noted that, at one time, he was told he had a heart murmur; but the examiner gave an assessment of a normal examination. In notes of dental patient history from May 1975 and June 1976, the Veteran again noted that he had a heart murmur in his childhood. However, in the Report of Medical Examination from the October 1974 enlistment examination, the examiner marked the Veteran’s heart and vascular system as normal. In the Veteran’s Report of Medical History from the October 1974 enlistment examination, the Veteran reported that he had not experienced any heart trouble or palpitation or pounding heart. No cardiac problems, defects, infirmities, or disorders were noted at the Veteran’s enlistment examination. VA law stipulates that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). When a pre-existing disability is noted upon entry into service, the veteran cannot bring a claim for service connection for that disability, only a claim for service-connected aggravation of that disability. In this circumstance, 38 U.S.C. § 1153 applies and the burden falls on him, not VA, to establish an increase in severity of the disability in service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). In this case, although the Veteran reported having a heart murmur in childhood prior to active service, no heart or cardiac conditions were noted upon entry into active service. Thus, the Veteran cannot bring a claim of service connection based on aggravation of a pre-existing cardiac disability. In an October 1975 treatment note, the Veteran complained of nausea, vomiting, and abdominal cramps; and he stated that his heart did not feel like it always does. However, no heart conditions were diagnosed. The examiner’s physical examination was negative except for diffuse abdominal discomfort and increased bowel activity, and the Veteran was diagnosed with gastroenteritis. In the Report of Medical Examination from the September 1976 separation examination, the examiner marked the Veteran’s heart and vascular system as normal. In the Veteran’s Report of Medical History from the September 1976 separation examination, the Veteran reported that he had not experienced any heart trouble or palpitation or pounding heart. Thus, even if the Veteran experienced a heart issue during service, there is no indication in the evidence of record that the Veteran incurred any chronic or long-term cardiac problems during his active service. There is no complaint, diagnosis, or treatment of cardiac issues in the years immediately following the Veteran’s active service. The Board has considered the Veteran’s own statements that he has a cardiac disorder related to active service. The Veteran, as a layperson, is certainly competent to report matters within his personal knowledge, such as the occurrence of an injury or event, or his own symptoms. However, in the instant case, the Board finds that the question regarding the potential relationship between his currently claimed cardiac disorder and any instance of his service to be complex in nature. The Veteran, as a lay person, does not have the requisite training and experience necessary to address such a complex medical matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of a cardiac disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board finds that the Veteran’s statements as to the etiology of his claimed cardiac disorder are not competent evidence and, consequently, are afforded no probative weight. The Board has considered whether a VA examination was required in connection with the Veteran’s claim of service connection for a cardiac disorder. The Board finds the duty to obtain a medical examination was not triggered in this case as the record from the period on appeal fails to show competent evidence establishing that an event, injury, or disease related to a chronic cardiac disability that occurred in service. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010); McLendon v. Nicholson, 20 Vet. App. 79 (2006). There is no other evidence of record showing a causal relationship between a cardiac disorder and his active service. In the January 2014 claim of service connection for a cardiac disorder (claimed as cardiomegaly or enlarged heart), the Veteran noted that he had been hospitalized for the condition for 30 days. A total disability rating will be assigned without regard to other provisions of the rating schedule when the evidence establishes that a service-connected disability has required hospitalization in a Department of Veterans Affairs Medical Center or an approved hospital for a period of more than 21 days. 38 C.F.R. § 4.29. However, as the evidence of record does not warrant a finding of service connection for a cardiac disorder, consideration cannot be given to evaluation issues such as convalescence following surgery or a period of hospitalization. Based on the foregoing, the Board finds that the Veteran’s claimed cardiac disorder was not shown to be causally or etiologically related to any disease, injury, or event in service. As such, service connection for such disorder is not warranted. (Continued on the next page)   In reaching the foregoing conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. Therefore, the Veteran’s claim of entitlement to service connection for a cardiac disability must be denied. See 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303; Gilbert, supra. M. M. Celli Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dawn A. Leung, 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.