Citation Nr: 21032712 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 16-04 259 DATE: May 27, 2021 REMANDED Service connection for a disorder manifested by swelling is remanded. Service connection for a deterioration of the joints in the feet is remanded. Service connection for hypertension is remanded. Service connection for erectile dysfunction is remanded. Service connection for enlarged prostate is remanded. Service connection for a brittle nail disability is remanded. Service connection for loss of feeling in fingers of the left hand is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1968 to April 1972. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran presented testimony in July 2018 and January 2021 before two of the undersigned Veterans Law Judges (VLJs). A VLJ who conducts a hearing must participate in making the final determination of the claim involved. 38 U.S.C. § 7107 (c); 38 C.F.R. § 20.707. By law, appeals may be assigned only to an individual VLJ or to a panel of not less than three members. 38 U.S.C. § 7102 (a). Accordingly, a third VLJ has been assigned to participate in a panel decision for this case. The Veteran was offered the opportunity to testify before a third VLJ at the January 2021 hearing; however, he waived this right on the record. Arneson v. Shinseki, 24 Vet. App. 379 (2011). The Board remanded the appeal in September 2018 for further development. Service connection for a disorder manifested by swelling is remanded. At the Veteran's January 2021 Board hearing, he contended that one day during service, he suddenly felt itching and swelling in his face, between his legs, under his arms, etc. He stated that he could barely breathe and that he was medevac'd to the 3rd Field Hospital in Saigon. He stated that he was treated for two weeks in Saigon, and then recuperated for three weeks in Cam Ranh Bay. He further testified that following service, he had no major problems until May 1986. At that time, his face, lips, and throat started swelling. He was taken to the ER and given Benadryl and other anti-histamines. Three days later, he had another attack. He testified that he was treated with Benadryl and Prednisone for almost all of 1986. He further testified that his allergist, Dr. T., told him that "we will probably never know the cause of this," but that he had a central nervous system disorder that was caused by a chemical. The Veteran contends that his disability (diagnosed as angioedema and urticaria) is due to Agent Orange exposure sustained while he was in Vietnam. The Veteran's DD Form 214 reflects that he was in Vietnam, and he is therefore presumed to have been exposed to Agent Orange. The claims file contains several nexus opinions. However, they are of little probative value. The first is dated June 2018 and is from Dr. E.G., who stated that the Veteran has had extensive testing and seen numerous specialists, most recently Dr. M.G. Dr. E.G. quoted Dr. M.G. as saying that "I can neither rule in but I can also not rule out agent orange exposure as the cause/trigger for this." Dr. E.G. then opined, without any further explanation, that "Based on this information it is my medical opinion that it is as likely as not that prior agent orange exposure is the cause of this medical condition." This Board finds Dr. E.G.'s opinion to be inadequate insofar as there is no rationale supporting the opinion. Dr. E.G. based his positive nexus opinion simply on the fact that Dr. M.G. could not rule out Agent Orange as a cause/trigger. In short, the basis of Dr. E.G.'s nexus opinion is another physician's completely equivocal/speculative opinion. The second opinion is dated January 2019 and is from Dr. W.D., who stated that "the Veteran developed chronic urticaria per him after exposure to agent Orange in Vietnam." Later in the treatment report, Dr. W.D. stated that the Veteran "again reports that his urticaria and angioedema started when he was in Vietnam and exposed to agent orange." He then stated that it is extremely rare for males to experience chronic urticaria. He opined that "the temporal association with agent orange exposure and time in Vietnam and the fact that males rarely experience chronic urticaria overall point to agent orange or perhaps some other environmental exposure as the etiology of [the Veteran's] Chronic urticaria with angioedema." The Board finds that Dr. W.D.'s opinion is inadequate in that it is not based on an accurate medical history. Dr. W.D. restated the Veteran's position that he developed "chronic urticaria" after exposure to Agent Orange. Moreover, his opinion was in part based on the "temporal association" between the Veteran's exposure to Agent Orange and his development of chronic urticaria. In fact, according to the Veteran's testimony, he had no major problems until 1986 (14 years after active duty service). Consequently, there is no "temporal association" between Agent Orange exposure and development of chronic urticaria which began many years after his exposure to Agent Orange. Neither opinion cited or in any way acknowledged the service treatment records from the 3rd Field Hospital which reflect that in September 1969, the Veteran reported a sore throat and difficulty swallowing, followed by the development of a skin eruption that "spread over his whole body." The skin eruption was thought to be a penicillin allergy. Finally, the Veteran underwent a VA examination in July 2019. The examiner rendered a nexus opinion that weighed against the Veteran's claim. The Veteran, in an October 2019 correspondence, disputed the history that the examiner used to render his opinion. For example, the examination report stated that "the Veteran reports a single episode of angioedema/testicular swelling that took place in 1969." The examiner noted that the records of the episode are not available. The Veteran stated that he reported to the examiner that he had been medevac'd to the 3rd Field Hospital for a swelling reaction over his whole body. As noted above, there is a September 1969 treatment record from the 3rd Field Hospital documenting a skin eruption that spread over the whole body. The examiner failed to acknowledge the treatment report. The examiner also failed to make any attempt to reconcile his findings with that of Dr. W.D. In light of the fact that the examiner rendered his opinion on an incomplete and disputed medical history, the Board finds the opinion to be inadequate. In the absence of an adequate medical opinion, the Board cannot make a fully-informed decision on the issue of whether service connection is warranted for a disorder manifested by swelling (diagnosed as angioedema and urticaria). Consequently, the Board finds that another VA examination is needed to determine the etiology of the Veteran's disability. Service connection for a deterioration of the joints in the feet, hypertension, erectile dysfunction, and enlarged prostate, a brittle nail disability, and loss of feeling in fingers of the left hand is remanded. At his January 2021 Board hearing, the Veteran testified that the remaining disabilities on appeal are secondary to medications taken to control his angioedema (specifically Benadryl and Prednisone). As such, the claims are inextricably intertwined with the issue of whether service connection is warranted for a disorder manifested by swelling (diagnosed as angioedema and urticaria). If, and only if, service connection can be granted for a disorder manifested by swelling (diagnosed as angioedema and urticaria), the Veteran should be scheduled for an examination to determine whether the Veteran's alleged disabilities were caused or aggravated by medications (Benadryl and Prednisone) taken to control his angioedema or urticaria. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his disability manifested by swelling (diagnosed as angioedema and urticaria). The examiner must review the claims file. The examiner is asked to provide a response to the following: Is the Veteran's disability manifested by swelling (and diagnosed as angioedema and urticaria) at least as likely as not related to service, including due to a September 1969 episode of a skin eruption occurring over the entire body? Is the Veteran's disability manifested by swelling (diagnosed as angioedema and urticaria) at least as likely as not related to presumed in-service exposure to herbicide agents? The examiner is advised that a negative opinion cannot be based solely on the fact that the disability is not on the list of diseases that are presumptively associated with exposure to herbicide agents. The examiner should note the Veteran's testimony that his in-service symptoms were severe enough that he was medevac'd to the 3rd Field Hospital (where he spent two weeks) and then he spent an additional three weeks recovering from symptoms. The examiner should note that many of the treatment records are missing, but that the record does contain a September 1969 treatment report from the 3rd Field Hospital which shows that the Veteran reported a sore throat and difficulty swallowing, followed by the development of a skin eruption that "spread over his whole body." The skin eruption was thought to be a penicillin allergy. The examiner should render an opinion that addresses the nexus opinion provided by Dr. W.D. 2. If, and only if, service connection is granted for a disability manifested by swelling (diagnosed as angioedema and urticaria), schedule the Veteran for a VA examination for his deterioration of the joints in the feet, hypertension, erectile dysfunction, and enlarged prostate, a brittle nail disability, and loss of feeling in fingers of the left hand. The examiner must review the claims file. The examiner is asked to provide a response to the following: For each disability, is it at least as likely as not proximately due to medications used to treat the Veteran's disability manifested by swelling (diagnosed as angioedema and urticaria)? (Continued on the next page) For each disability, is it at least as likely as not aggravated, i.e., worsened beyond its natural progression, by medications used to treat the Veteran's disability manifested by swelling (diagnosed as angioedema and urticaria)? D. JOHNSON Veterans Law Judge Board of Veterans' Appeals T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Prem, 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.