Citation Nr: 21032758 Decision Date: 05/27/21 Archive Date: 05/27/21 DOCKET NO. 18-05 553 DATE: May 27, 2021 REMANDED Entitlement to service connection for pituitary gland disorder, microadenoma is remanded. Entitlement to service connection for thyroid disorder, to include thyroid disorder nodule, is remanded. Entitlement to service connection for a skin disorder is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for residuals of a stroke and intracerebral hemorrhage is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1978 to September 1971. This case comes before the Board of Veteran's Appeals (Board) on appeal from a November 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The claims were previously remanded by the Board in July 2020. REASONS FOR REMAND 1. Entitlement to service connection for thyroid disorder to include thyroid disorder nodule is remanded. This claim was received by VA in June 2015. The Veteran contends that he first experienced problems with his thyroid during service. While he was not sure, at his Board hearing he reported he may have had symptoms of tiredness, slurred speech, issues with understanding others, sudden and severe headaches, dizziness, and balance issues during service, and that they could have been attributed to his thyroid condition. He also testified that his thyroid problems were not present prior to service, but post-service he was told by a private physician to have his thyroid removed after he had surgery for his shoulder. This surgery, according to him, took place within a year after discharge. The Veteran's inservice medical records include complaints of tiredness, headaches, weakness, dizziness, rash, and gastric issues. Specifically, at separation the Veteran reported frequent, severe, headaches, stomach trouble, and recent gain or loss of weight. His recent medical history reports headaches, stomach, liver, and intestinal problems, and recent weight issues. The Board finds a remand is warranted to address whether the Veteran's current thyroid condition is related to his inservice complaints. 2. Entitlement to service connection for pituitary gland disorder, microadenoma is remanded. This claim was received by VA in June 2015. At his Board hearing, the Veteran stated his pituitary gland disorder originated from his Agent Orange exposure. He attributed symptoms of tiredness to his pituitary gland disorder as well. Along with his thyroid condition, he reported symptoms of slurred speech, issues with understanding others, sudden and severe headaches, dizziness, and balance issues while inservice. He testified that he was diagnosed with microadenoma when he was medically evacuated to a Georgetown hospital in 2010 but he started having the associated symptoms in the 1970's. The Veteran's inservice medical records include complaints of headaches, weakness, dizziness, rash, and gastric issues. Specifically, at separation the Veteran reported frequent, severe, headaches; stomach trouble; and recent gain or loss of weight. His recent medical history reports stomach, liver, and intestinal problems, recent weight, and headaches. Accordingly, the Board finds a remand is needed for a VA examination and opinion to determine if the current disorder is linked to the in-service complaints. 3. Entitlement to service connection for a skin disorder is remanded. This claim was received by VA in June 2015. The previous Board remand requested an opinion as to whether the Veteran's chloracne was related to his presumed inservice exposure to herbicides. The November 2020 post remand opinion reports that the Veteran's chloracne does not have a nexus to service. It was reasoned that the medical record was silent for diagnosis of or treatment of chloracne during or after service. Therefore, the Veteran's claim for chloracne was less likely than not caused by exposure to herbicide agents. This opinion is inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). It relies completely on the absence of medical evidence. See Fountain v. McDonald, 27 Vet. App. 258, 272-75 (2015) (indicating that a VA examiner may not generally rely on the absence of evidence as negative evidence). Significantly, the service treatment records document complaints and treatment relating to a rash. Further, the examiner did not address the Veteran's lay reports of symptoms he experienced during service. He testified he was treated for a skin disorder related to the heat. There is some evidence in the service treatment records of pertinent complaints. Accordingly, an addendum opinion is required to address the in-service complaints. 4. Entitlement to service connection for hypertension condition is remanded. This claim was received by VA in June 2015. As it relates to the Veteran's hypertension condition, the Veteran is claiming, in part, that his hypertension is secondary to his service-connected diabetes mellitus. On remand, the examiner should opine as to whether this condition is secondary to his service-connected diabetes condition. 5. Entitlement to service connection for residuals of a stroke and intracerebral hemorrhage is remanded. This claim was received by VA in June 2015. The Veteran is claiming he has residuals of a stroke and an intracerebral hemorrhage, in part, are due to his service-connected diabetes mellitus. He is also claiming that the disorders were linked to hypertension. No opinion has been obtained regarding whether the Veteran experienced residuals of a stroke and/or an intracerebral hemorrhage which are linked to his service-connected diabetes mellitus. As the hypertension claim is being remanded, these issues are also intertwined with that claim. An opinion as to the possible link with hypertension should also be obtained. The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Schedule the Veteran for an examination with a medical professional with appropriate expertise. The examiner should review the Veteran's claims file and comment on the following question: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the thyroid condition is related to service or is caused by or aggravated by military service, to include presumed herbicide exposure? The examiner must specifically consider and discuss the Veteran's pertinent medical history of symptoms associated with his thyroid condition to include the complaints of tiredness, headaches, weakness, dizziness, rash, and gastric issues noted in the service medical records. If a negative opinion is offered based primarily on the length of time between separation and the current diagnosis the examiner should explain the medical significance of this fact, i.e., why this is indicative that any current thyroid condition is not related to service. The fact that his thyroid condition is not listed as a condition for presumptive service connection based on herbicide exposure is not a sufficient rationale. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In any opinion rendered, the examiner is advised that the Veteran is competent to report his symptoms. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. Schedule the Veteran for an examination with a medical professional with appropriate expertise. The examiner should review the Veteran's claims file and comment on the following questions: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the pituitary gland disorder, microadenoma is related to service or is caused by or aggravated by military service, to include presumed herbicide exposure? The examiner must specifically consider and discuss the Veteran's pertinent medical history of symptoms associated with his thyroid condition to include the complaints of tiredness, headaches, weakness, dizziness, rash, and gastric issues noted in the service medical records. If a negative opinion is offered based primarily on the length of time between separation and the current diagnosis the examiner should explain the medical significance of this fact, i.e., why this is indicative that any current pituitary condition is not related to service. The fact that his pituitary condition is not listed as a condition for presumptive service connection based on herbicide exposure is not a sufficient rationale. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In any opinion rendered, the examiner is advised that the Veteran is competent to report his symptoms. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. Arrange for the claims file to be reviewed by a suitably qualified health care professional and request that they respond to the questions below. The need for another examination and/or telephonic or video interview of the Veteran is left to the discretion of the examiner(s) selected to offer the requested opinions. After reviewing the record, the examiner is requested to provide the following opinion: (a.) Is it at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran has a skin disorder, including chloracne, that had its onset during, or is otherwise related to service, to include his presumed Agent Orange exposure? In providing this opinion, the Board directs the examiner's attention to the inservice treatment and complaints for skin issues. This treatment must be addressed in forming the etiology opinion. The examiner must specifically consider and discuss the Veteran's statements regarding his pertinent medical history of skin issues during service. The opinion and rationale should reflect such consideration. If a negative opinion is offered based primarily on the length of time between separation and the current diagnosis the examiner should explain the medical significance of this fact, i.e., why this is indicative that any current skin condition is not related to service. The fact that his skin condition is not listed as a condition for presumptive service connection based on herbicide exposure is not a sufficient rationale. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In any opinion rendered, the examiner is advised that the Veteran is competent to report his symptoms. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 5. Arrange for the claims file to be reviewed by a suitably qualified health care professional and request that they respond to the questions below. The need for another examination and/or telephonic or video interview of the Veteran is left to the discretion of the examiner(s) selected to offer the requested opinions. (a.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that the Veteran's hypertension is proximately due to or the result of his service-connected diabetes? The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. (b.) If the answer to (a) is negative, is it at least as likely as not that the hypertension is aggravated (i.e., permanently or temporarily worsened) by his service-connected diabetes? (c.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. The term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. In any opinion rendered, the examiner is advised that the Veteran is competent to report his symptoms. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 6. Arrange for the claims file to be reviewed by a suitably qualified health care professional and request that they respond to the questions below. The need for another examination and/or telephonic or video interview of the Veteran is left to the discretion of the examiner(s) selected to offer the requested opinions. (a.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that the Veteran's residuals of stroke/ intracerebral hemorrhage are proximately due to or the result of his service-connected diabetes? The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. (b.) If the answer to (a) is negative, is it at least as likely as not that the residuals of stroke/ intracerebral hemorrhage is aggravated (i.e., permanently or temporarily worsened) by his service-connected diabetes? (c.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. The term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. In any opinion rendered, the examiner is advised that the Veteran is competent to report his symptoms. If there is a medical basis to doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Wade 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.