Citation Nr: 18154215
Decision Date: 11/29/18	Archive Date: 11/29/18

DOCKET NO. 16-54 260
DATE:	November 29, 2018
ORDER
Service connection for a depressive disorder is granted.
Service connection for coronary artery disease (CAD) is denied.
Service connection for hypertension is denied.
Service connection for erectile dysfunction is denied.
An initial compensable rating for migraine headaches is denied.
REMANDED
The issue of service connection for brain thrombosis, to include as secondary to the service connected disability of migraine headaches, is remanded.
The issue of service connection for left upper extremity paralysis, including as secondary to CAD or brain thrombosis, is remanded.
The issue of service connection for left lower extremity paralysis, including as secondary to CAD or brain thrombosis, is remanded.
FINDINGS OF FACT
1.  Resolving all doubt in the Veteran’s favor, his current depressive disorder is related to active service.
2. The Veteran has not been diagnosed with coronary artery disease since the beginning of the claim and during the pendency of the appeal.
3.  The Veteran did not have elevated blood pressure readings during service or since service separation that resulted in a formal diagnosis of hypertension.
4.  The Veteran has not been diagnosed with erectile dysfunction since the beginning of the claim and during the pendency of the appeal.
5.  For the entire period on appeal, the Veteran’s characteristic headaches are not shown to be prostrating.  
CONCLUSIONS OF LAW
1. The criteria to establish service connection for a depressive disorder are met. 38 U.S.C. §§ 1110; 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017).
2. The criteria to establish service connection for coronary artery disease are not met.  38 U.S.C. §§ 1110; 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017).
3. The criteria to establish service connection for hypertension are not met.  38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017).
4. The criteria for service connection for erectile dysfunction are not met.  38 U.S.C. §§ 1110; 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017).
5.  For the entire period on appeal, the criteria for an initial compensable rating for migraine headaches are not met.  38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.124a, Diagnostic Code 8100 (2017).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from November 1998 to March 2000.
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision dated August 2015 and September 2016 of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky.
Motion to Withdraw from Representative
The Board acknowledges the motion to withdraw submitted by the Veteran’s representative in May 2018, in which he sought to terminate representation of the Veteran, asserting that the Veteran requested that representation be terminated.  See Letter dated May 16, 2018 (“Motion”).  However, as the Board explained in its June 12, 2018 letter responding to the Motion, it does not satisfy the requirements of 38 C.F.R. § 20.608(b) (2017) (Withdrawal of services after certification of an appeal).  As explained in the letter, a motion to withdraw must show good cause for withdrawal, and set forth the requirements under 38 C.F.R. § 20.608(b) for filing a motion to withdraw, including confirmation that the Veteran was provided a copy of the motion, sent by First Class mail, postage prepaid.  Certifications of Appeal (VA Form 8) dated November 14, 2016 and March 29, 2018 establish that the claims were certified to the Board.  See 38 C.F.R. § 19.35 (2017).  Therefore, 38 C.F.R. § 20.608 is for application where the representative files a motion to withdraw.  Because the Board has jurisdiction over this issue, and the representative’s Motion does not satisfy the requirements of 38 C.F.R. § 20.608(b), the representative retains such status until such time that an adequate motion is filed and the Board grants such motion.
Preliminary Matter
The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016).
Service Connection
Pertinent Service Connection Laws and Regulations
Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303(a).  Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service.  38 C.F.R. § 3.303(d).
Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability.  Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009).  The existence of a current disability is the cornerstone of a claim for VA disability compensation.  See Degmetich v. Brown, 104 F. 3d 1328 (1997).
Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability.  38 C.F.R. § 3.310(a) (2017).  Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation.  See 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 8 Vet. App. 374 (1995).
Showing continuity of symptomatology since service under 38 C.F.R. § 3.303(b) is an alternative means of linking a claimed disability to service, but is only available for the “chronic diseases” specifically enumerated in 38 C.F.R. § 3.309(a).  Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  Here, there is a seven-year gap between the service treatment records (STRs) and the earliest post-service treatment records.  Moreover, while the Veteran’s service connection claims include coronary artery disease and hypertension, which are among the enumerated diseases, as discussed below, the evidence does not reflect a diagnosis of coronary artery disease or hypertension.  The Veteran’s psychiatric disorder is not identified as a psychosis, which is also enumerated under 38 C.F.R. § 3.309(a).  As such, establishing service connection for these claims pursuant to 38 C.F.R. § 3.303(b) is not for application.
The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant.  Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011).  This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record.  Id. at 433-34.
A lay person is competent to report on the onset and reoccurrence of current symptomatology.  See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge).  The Board must determine, on a case by case basis, whether a veteran’s particular disability is the type of disability for which lay evidence may be competent.  See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d, 1372, 1376-77 (Fed. Cir. 2007).
Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file.  See Prejean v. West, 13 Vet. App. 444, 448-9 (2000).  Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data.  See Bloom v. West, 12 Vet. App. 185, 187 (1999).  The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record.  Miller v. West, 11 Vet. App. 345, 348 (1998).
A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement.  Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009).  In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence.  Id. at 1287 (quoting 38 U.S.C. § 5107(b)).
Service connection for an unspecified depressive disorder.
The Veteran claims that his depressive disorder is related to service.  See Claim for compensation received March 31, 2015.
The Veteran has a current diagnosis of unspecified depressive disorder.  See VA examination report dated June 15, 2015.  Therefore, the threshold element of service connection is met.
Upon enlistment in the Air Force, the Veteran was negative for psychiatric symptoms and disorders.  However, his STRs reflect subsequent psychiatric symptoms and diagnoses, including personality disorder and adjustment disorder with depressive mood in January 2000, and major depression in March 2000.
Post-service treatment records reflect that the Veteran suffered a cerebrovascular accident (CVA), or stroke, in November 2007, which was attributed to a right carotid artery dissection.  In November 2007, during treatment for the stroke, the Veteran was diagnosed with vascular dementia and depressed mood.  In January 2008, the Veteran was diagnosed with depression and anxiety secondary to stroke.  An April 2008 examination for the development of the Veteran’s Social Security Administration (SSA) disability claim diagnosed personality change due to CVA and unspecified depressive disorder, although the SSA examiner did not attribute the depressive disorder to service.
The Veteran was afforded a VA mental disorders examination in June 2015.  The Veteran said he was hospitalized during service for depression and treated with medication and psychotherapy for homesickness, suicidal ideation, sleep problems, and motivation problems.  The examiner noted symptoms of depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood, and diagnosed unspecified depressive disorder.  The examiner concluded that the Veteran’s symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.  The examiner opined that the Veteran’s unspecified depressive disorder was not caused by his military service.  The examiner explained that the disorder is a current manifestation of a tendency to get depressed when under certain stresses, and during service the stress was homesickness, while the current stresses arise from residuals of his stroke.
It is not clear from the June 2015 VA examination report whether the medical opinion is favorable or unfavorable.  On the one hand, the examiner concludes that the Veteran’s depressive disorder is not caused by service; on the other hand, the examiner concludes that the disorder is a manifestation of the depression the Veteran experienced during service, albeit caused by different stresses.
The Board emphasizes that to resolve the issue of a causal link between the Veteran’s depressive disorder and service, the evidence need only be in equipoise.  It need not be clearly determined whether a disability was caused by service.  38 C.F.R. § 3.303(a).  See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (noting that in a merits adjudication, the evidence need only reach equipoise).
Thus, based on the body of evidence in this case, the Board finds that the June 2015 VA opinion, itself, places in relative equipoise the issue of whether the Veteran’ unspecified depressive disorder is related to service.  Under the benefit of the doubt rule, where there exists “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the appellant shall prevail upon the issue.  Ashley v. Brown, 6 Vet. App. 52, 59 (1993).
Accordingly, the Board finds that, with resolution of any doubt in the Veteran’s favor, service connection for a depressive disorder is warranted.  38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990).

Service connection for hypertension.
The Veteran claims service connection for hypertension.  See Claim for compensation received March 31, 2015.
At the outset, the Board must determine if the Veteran has been diagnosed with hypertension since the date of claim.  See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Circ. 2004).
“Hypertension” refers to persistently high arterial blood pressure.  For VA rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm or greater.  The term “isolated systolic hypertension” means that the systolic blood pressure is predominantly 160 mm or greater with a diastolic blood pressure of less than 90 mm.  See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 (2017).
There is no evidence in the Veteran’s STRs or his post-service treatment records of a diagnosis of hypertension.  The Veteran’s STRs are negative for any complaints, diagnosis, or treatment of hypertension.  Recorded blood pressures during service include 115/76 in September 1999, 135/69 in October 1999, 124/53 in February 2000, and 120/65 in March 2000.  Post-service treatment records note blood pressure readings that include 110/70 in December 2007, 122/74 in April 2008, and 130/90 in August 2015.  While these readings may reflect some elevated blood pressures, there is no evidence of a clinical diagnosis of hypertension in service, during the first post-service year, or at any time during the period on appeal.
In the absence of a diagnosed current disability, it follows that service connection for hypertension cannot be granted as the threshold element of the claim has not been met.  Shedden, supra.
In analyzing this claim, the Board also considered the Veteran’s claim as to a current disability.  While the Veteran may genuinely believe that he has hypertension, the Board finds that the question as to whether the Veteran has hypertension requires substantiation through diagnostic findings, requiring specialized training for a determination, and is not susceptible of lay opinion.  The Veteran’s claim alone cannot be accepted as competent medical evidence in regard to establishing a diagnosis of hypertension.  See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).
There being no competent evidence that the Veteran has been diagnosed with the claimed disability, analysis of the remaining elements of a service connection claim is unnecessary.
Based on this body of evidence, the appeal must be denied.  In reaching this determination, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the appellant’s claim, the doctrine is not for application here.  Gilbert, supra.
Service connection for coronary artery disease.
The Veteran also claims service connection for coronary artery disease.  See Claim for compensation received March 31, 2015.
At the outset, the Board must determine if the Veteran has been diagnosed with coronary artery disease.  Shedden, supra.
Coronary artery disease, or “CAD,” is the narrowing of arteries that supply blood to the heart due to the buildup of cholesterol and other plaque on the inner artery walls, known as atherosclerosis.  See Medline Plus Medical Encyclopedia, https://medlineplus.gov/coronaryarterydisease.html (last visited Nov. 22, 2018).  The Veteran’s STRs and post-service treatment records are negative for any complaints, diagnosis, or treatment of CAD.  As discussed above, the Veteran was diagnosed in 2007 with a right carotid dissection, which is the leaking of blood into the artery wall (dissection), which may cause a clot to form, reducing blood flow and raising the risk of a stroke.  See Medline Plus Medical Encyclopedia, https://medlineplus.gov/ency/imagepages/18124.htm (last visited Nov. 22, 2018).  Indeed, there is no evidence of a clinical diagnosis of CAD in service, during the first post-service year, or at any time during the period on appeal.
In the absence of a diagnosed current disability, it follows that service connection for CAD cannot be granted as the threshold element of the claim has not been met.  Shedden, supra.
In analyzing this claim, the Board also considered the Veteran’s claim as to a current disability.  While the Veteran may genuinely believe that he has CAD, the Board finds that the question as to whether the Veteran has the disease requires substantiation through diagnostic and/or laboratory findings, requiring specialized training for a determination, and is not susceptible of lay opinion.  The Veteran’s claim alone cannot be accepted as competent medical evidence in regard to establishing a diagnosis of CAD.  Barr, supra.
There being no competent evidence that the Veteran has been diagnosed with the claimed disability, analysis of the remaining elements of a service connection claim is unnecessary.
Based on this body of evidence, the appeal must be denied.  In reaching this determination, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the appellant’s claim, the doctrine is not for application here.  Gilbert, supra.
Service connection for erectile dysfunction to include as secondary to any mental condition, migraine headaches and/or secondary to CAD or brain thrombosis.
The Veteran claims service connection for erectile dysfunction.  See Supplemental claim for compensation received June 27, 2016.
At the outset, the Board must determine if the Veteran has been diagnosed with erectile dysfunction.  Shedden, supra.
The Veteran’s STRs and post-service treatment records are negative for any complaints, diagnosis, or treatment of erectile dysfunction.  Notably, during the August 2016 VA central nervous system examination, the Veteran denied having erectile dysfunction.  See VA examination report dated August 17, 2016 at pg. 4.
In the absence of a diagnosed current disability, it follows that service connection for erectile dysfunction cannot be granted as the threshold element of the claim has not been met.  Shedden, supra.
In analyzing this claim, the Board also considered the Veteran’s claim as to a current disability.  The Veteran is competent to describe any discernible symptoms of erectile dysfunction without any specialized knowledge or training.  Barr, supra.  However, the Veteran has not been shown to be competent to render a clinical diagnosis, which is a medical question beyond the scope of lay observation.  Jandreau, supra.
There being no competent evidence that the Veteran has been diagnosed with the claimed disability, analysis of the remaining elements of a service connection claim is unnecessary.
Based on this body of evidence, the appeal must be denied.  In reaching this determination, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the appellant’s claim, the doctrine is not for application here.  Gilbert, supra.
Entitlement to an initial compensable rating for migraine headaches.
Increased Rating
Claim for Higher Disability Ratings – Laws and Regulations 
Disability evaluations are determined by comparing a veteran’s present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity.  38 U.S.C. § 1155; 38 C.F.R. Part 4.  After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran.  38 C.F.R. § 4.3.
A disability rating may require re-evaluation in accordance with changes in a veteran’s condition.  Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment.  See 38 C.F.R. § 4.1.  See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991).
When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found.  Where the veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern.  See Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings.  Hart v. Mansfield, 21 Vet. App. 505 (2007).
As noted above, a veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise.  Layno, supra.
As in a service connection claim, when all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.
Here, in an August 2015 rating decision, the RO granted service connection for migraine headaches, and assigned an initial noncompensable evaluation.  The Veteran seeks a compensable rating.  See Notice of Disagreement dated September 1, 2015.
Under the terms of Diagnostic Code (DC) 8100, a 10 percent rating is warranted for migraine headaches with characteristic prostrating attacks averaging once in two months over the last several months.  A 30 percent rating is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months.  A 50 percent rating, the highest available under DC 8100, is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability.  38 C.F.R. § 4.124a.  The rating criteria under DC 8100 are successive, rendering 38 C.F.R. §§ 4.7 and 4.21 inapplicable here.  Johnson v. Wilkie, No. 16-3808, 2018 U.S. App. Vet. Claims Lexis 1253 (Sept. 19, 2018).
The words "characteristic" and "prostrating" are not defined in the regulation. “Characteristic” is a “trait, quality, or property or a group of them distinguishing an individual, group, or type.” WEBSTER'S THIRD NEW INTERNATIONAL DICTIONARY OF THE ENGLISH LANGUAGE UNABRIDGED 376 (1966) [hereinafter " WEBSTER'S"].  “Prostrating” means "lacking in vitality or will: powerless to rise: laid low.”  Id. at 1822.  
Turning to the record, the Veteran’s treatment records for the period on appeal do not reflect complaints or treatment for headaches.
A VA migraine headache examination report Te dated June 2015 reflects that the Veteran reported that after separation from service he relied on self-medication with Excedrin or ibuprofen, and that he presently takes only ibuprofen with good results.  The Veteran reported that his migraine headaches “improved quite a bit” after a stroke in 2007, and he continues to have headaches and that they occur about once a month, but they are “less severe.”  He described pain from headaches as pulsating or throbbing pain localized behind his right eye, which usually lasts about two hours.  The Veteran stated that his headaches are non-prostrating, and denied non-headache symptoms.  The examiner diagnosed migraines, including migraine variants, characterized as stable.  The examiner concluded that the Veteran’s headaches do not impact his ability to work.  The Board finds the June 2015 VA migraines examination to be competent, credible, and probative.  
An August 2015 SSA examination to review the severity of the residuals of the Veteran’s 2007 stroke does not reflect that the Veteran reported having headaches.
Considering the foregoing, the Board finds that the competent medical evidence weighs against a compensable rating for the entire period on appeal.  Although the Veteran is shown to experience characteristic migraine headaches productive of pulsating or throbbing head pain approximately once a month, they are not shown to be prostrating.  In fact, the Veteran himself indicated, during the 2015 VA examination, that his headaches were non-prostrating, less severe after his 2007 stroke, and generally alleviated within two hours by over-the-counter anti-inflammatory medication.  Additionally, the examiner stated that the headaches were stable and did not impact the Veteran’s ability to work.  As there is no evidence of characteristic prostrating attacks of migraine headaches, a compensable rating is not warranted.  See 38 C.F.R. § 4.124a, DC 8100.  No other diagnostic code is applicable and the Board cannot identify a diagnostic code which would afford a compensable rating for the migraine headaches.
The preponderance of the evidence weighing against the Veteran’s claim of entitlement to an initial compensable rating for migraine headaches, the benefit of the doubt doctrine is not applicable in the instant appeal and the claim must be denied.  38 U.S.C. § 5107; see also Gilbert, 1 Vet. App. 49, 53.
Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record.  See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).

REASONS FOR REMAND
The issue of service connection for brain thrombosis, to include as secondary to service connected disability of migraine headaches, is remanded.
The issue of service connection for left upper extremity paralysis, including as secondary to CAD or brain thrombosis, is remanded.
The issue of service connection for left lower extremity paralysis, including as secondary to CAD or brain thrombosis, is remanded.
The Board finds that further development is necessary prior to adjudicating the Veteran’s claim for service connection for a brain thrombosis.
Here, although VA medical opinions dated August 2016 and December 2017 conclude that the Veteran’s carotid dissection is less likely as not proximately due to the Veteran’s migraine headaches, there is no medical opinion of record addressing whether the Veteran’s thrombosis leading to the dissection was caused or aggravated by the service-connected migraine headaches.  Accordingly, remand is necessary to obtain an addendum opinion to determine the etiology of the Veteran’s brain thrombosis.  McLendon v. Nicholson, 20 Vet. App. 79 (2006).
Given that the Veteran claims service connection for left upper and left lower extremity paralysis, including as proximately due to brain thrombosis, the Board defers its decision for these claims pending remand for a medical opinion to determine the etiology of the Veteran’s brain thrombosis.  See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (finding that two or more issues are inextricably intertwined if one claim could have significant impact on the other).
The matters are REMANDED for the following action:
1.  Ensure that all treatment records are associated with the claims file.
2.  Then, forward the Veteran’s claims file to an examiner with appropriate expertise, with a request for an addendum opinion.  A copy of this remand must be associated with the claims file, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated.  If the designated examiner determines that an additional examination is needed, one should be scheduled.
The examiner should provide an addendum with complete rationale to the following questions:
(a) Whether the Veteran’s November 2007 thrombosis is at least as likely as not related to, or had its onset during, service.
(b) Whether the Veteran’s November 2007 brain thrombosis was, at least as likely as not, proximately due to, or aggravated by, the Veteran’s service-connected migraine headaches.
3.  If, and only if, the examiner concludes that the Veteran’s November 2007 thrombosis is related to service or proximately due to the Veteran’s service-connected migraine headaches, the examiner is requested to also provide opinions to the following questions:
(a) Whether the Veteran’s left upper extremity paralysis is proximately due to the Veteran’s brain thrombosis.
(b) Whether the Veteran’s left lower extremity paralysis is proximately due to the Veteran’s brain thrombosis.
In providing the requested addendum opinions, the examiner should consider the Veteran’s competent lay claims regarding observable adverse symptomatology.
The addendum opinion must include a complete rationale for all opinions expressed.
(Continued on the next page)
 
4. Thereafter, readjudicate the issues on appeal.
 
S. B. MAYS
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Brad Farrell, Associate Counsel 

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