Citation Nr: 0000718 Decision Date: 01/10/00 Archive Date: 01/19/00 DOCKET NO. 95-42 075 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an increased evaluation for a thyroid disorder. 2. Entitlement to an increased evaluation for a parathyroid disorder. 3. Entitlement to service connection for a left knee disorder. 4. Entitlement to service connection for a left ankle disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Crowley, Associate Counsel INTRODUCTION The veteran served on active duty from May 1974 to March 1976. This appeal initially arose before the Board of Veteran's Appeals (Board) from a rating decision dated June 1995 by the Montgomery, Alabama, Regional Office (RO) of the Department of Veterans Affairs, whereby the veteran's claims identified on the first page of this decision were denied. It was then remanded in October 1997 and again in January 1999, for additional evidentiary and due process development. A hearing was next held at the Montgomery, Alabama, RO in June 1999, by the undersigned Member of the Board. We note that the veteran then submitted an additional piece of evidence concerning her right knee, and that she did not waive the RO's consideration of this material. As the issue of a right knee disorder is not currently before us, and as our review of this document shows that it fails to mention her service-connected disabilities, we find that no further action is warranted on our part concerning this document. However, as she, in essence, submitted an informal claim during her personal hearing in regards to the issue of service connection for a right knee disorder, we note that this claim must be referred to the RO, for the appropriate action. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's claims for increased evaluations of her thyroid and parathyroid disorders has been developed. 2. A hypothyroidism disability is manifested primarily by fatigue, and the requirement for continuous medication. 3. A hypoparathyroidism disability is manifested primarily by the requirement for continuous medication. 4. A left knee disorder is not shown to be related to the veteran's active service. 5. A left ankle disorder, if extant, is not shown to be related to the veteran's active service. CONCLUSIONS OF LAW 1. The criteria for a 10 percent evaluation for a hypothyroidism disability are met. 38 U.S.C. § 1155 (West 1991 & Supp. 1999); 38 C.F.R. Part 4, §§ 4.119, Diagnostic Code 7903 (1998). 2. The criteria for a 10 percent evaluation for a hypoparathyroidism disability are met. 38 U.S.C. § 1155 (West 1991 & Supp. 1999); 38 C.F.R. Part 4, §§ 4.119, Diagnostic Code 7905 (1998). 3. A claim for entitlement to service connection for a left knee disorder is not well grounded. 38 U.S.C. § 5107(a) (West 1991 & Supp. 1999). 4. A claim for entitlement to service connection for a left ankle disorder is not well grounded. 38 U.S.C. § 5107(a) (West 1991 & Supp. 1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Entitlement to increased evaluations for hypothyroid and hypoparathyroid disabilities. Initially, the Board finds that the veteran's claims are well grounded within the meaning of 38 U.S.C. § 5107(a) (West 1991 & Supp. 1999), that is, these claims are plausible. She has not alleged that any records of probative value that may be obtained, and which are not already sought by VA or associated with her claims folder, are available. The Board accordingly finds that the duty to assist her, as mandated by 38 U.S.C. § 5107(a) (West 1991 & Supp. 1999), with regard to her claims for increased evaluations for a hypothyroid and hypoparathyroid disabilities, has been satisfied. The veteran's medical history is quite extensive. Her service medical records show that she was seen in April 1975 with complaints of pain and tenderness in the thyroid gland area of her neck. A narrative summary dated September 1975 shows that she was diagnosed with Hyperthyroidism (Graves Disease). Her administrative separation discharge examination, dated January 1976, shows that her endocrine system was evaluated as normal. Her Report of Medical History of the same date shows that she reported thyroid trouble and a recent loss or gain in weight, which the examiner noted was due to surgically corrected Grave's Disease. An internal medicine record, dated February 1976, reveals diagnoses of: (1) Grave's Disease, (2) radical subtotal thyroidectomy, September 1975, (3) Post operative thyroidectomy, hypoparathyroidism, resolving, (4) Normal intrauterine pregnancy, approximately 4-5 months. A rating decision dated October 1976 established service connection for hypothyroidism with hypoparathyroidism residuals, resulting from a thyroidectomy for hyperthyroidism (Graves Disease). The RO noted in that decision that the veteran was initially treated with medication without an adequate response, resulting in her radical subtotal thyroidectomy. Subsequently, she developed hypothyroidism as well as hypocalcemia due to hypoparathyroidism. The RO also noted that the veteran was treated with thyroid replacement hormone as well as calcium and had a good response. A zero percent (noncompensable) rating was assigned from April 1, 1976. A June 1995 rating decision next increased the veteran's evaluation to 10 percent disabling, noting that the veteran indicated that she was currently medicated for her disabilities. A medical record dated December 1990 reflects that the veteran was assessed with the following conditions, in pertinent part, as entered on a master problem list: (1) status post thyroid and parathyroidectomy, (2) hypothyroidism, post operative. A "continuing medications" record next shows that the veteran is taking Synthroid for her hypothyroidism, and that she was taking Os-Cal and Vitamin D for her status post thyroid and parathyroidectomy thyroid problem. The veteran was afforded a VA rating examination for her hypothyroid disorder in March 1995. That report reveals that she was diagnosed with, in pertinent part, (1) status post total thyroidectomy in 1976 for hyperthyroidism, (2) hypothyroidism and hypoparathyroidism, and (3) diverticulosis. The results of the specific examination show that she reported being fatigued sooner than most other people, but that "she is used to it", and that she was occasionally nervous "but not too bad". The examiner also noted that cardiovascular symptoms were described as sinus tachycardia both prior and after surgery (for hyperthyroidism), but not often. Her gastrointestinal symptoms were "really not present" even though she had loose bowel movements and very occasionally also had blood in the stool for which she was evaluated in the past. The examiner also noted that "Decreased T3 and T4 readings do not exist lately. They were within normal limits." The mental assessment was okay. It was noted that continuous medication was required and will be required for the rest of her life. The examiner also indicated that she did not have mixed edema. Her blood pressure was 110/65 with a pulse rate of about 64-76 and respiration of 16. The results of the laboratory examination conducted in conjunction with that examination shows that her T3 Uptake was reportedly abnormally low, and her "FR T-4" was reportedly abnormally high. The veteran testified before a local hearing officer on May 10, 1996. The hearing transcript reflects that she avers that she was required to take daily medication and have lab work performed every six months. She also contended that she had muscle cramps in her legs, particularly when under stress, and that stress also caused a rapid heartbeat. She also stated that she had fatigue and that she took naps or rested approximately every 30 minutes while doing housework, or took a three hour nap every four hours on the weekends. She averred that she manifested eye problems when her condition was not in adequate control. The results of the veteran's most recent VA rating examination, dated August 1996, show that she was diagnosed with, in relevant part, status post total thyroidectomy with hypothyroidism and hypoparathyroidism (1975), and diverticulosis with spastic colon syndrome. The examiner also indicated that the veteran reported that she was easily fatigued, that she was "to some extent nervous", and had symptoms of irritable bowel or diverticulosis. The examiner also indicated that her T4 and T3 lab results "were not available yet", and that the mental assessment was reportedly normal. The examiner also indicated that continuous medication was required. The listed medications were "Synthroid .1mg", "Vitamin D 50, 000 units and Os- Cal." The examiner also indicated that her disease was stable, and that no myxedema was present. Her blood pressure was reportedly 128/68, with a pulse rate of 72, and respiration of 18. The examiner further noted that she was short of breath on questioning, but had no chest pain, palpitations or night dyspnea. The examiner further stated that she did sometimes have dysphagia "related probably to neck surgery." The veteran also testified before the undersigned Member of the Board in June 1999, sitting in Montgomery, Alabama. She testified at that hearing that her medication requirements had increased to Synthroid, .125 units per day, Os-Cal 500, three times per day, and 50,000 units of Vitamin D. The veteran also reported that her health care practitioners were concerned about her large does of Vitamin D, as it could, she stated in essence, cause organ damage. She also testified that she was no longer employed, that the last time she was employed was "a year and a half ago", and that she felt a mental sluggishness. The severity of an endocrine disability is ascertained, for VA rating purposes, by application of the criteria set forth in VA's Schedule for Rating Disabilities, 38 C.F.R. §4.119 Part 4 (1998) (Schedule). We note in this regard that the veteran is service-connected for residuals of a hyperthyroid disorder, including surgically induced hypothyroidism and hypoparathyroidism. We also note that the regulations concerning the endocrine system were revised in 1996, during the pendency of the veteran's appeal, and that her claims must be addressed under both sets of regulations. Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991) (where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version more favorable to the appellant should be applied unless provided otherwise by statute). Under the criteria in effect prior to June 1996, a hypothyroidism disability was evaluated as zero percent disabling under Diagnostic Code 7903 when it was considered to be in remission. A 10 percent evaluation was assigned for a moderate disability productive of fatigue. A moderately severe disability, with a sluggish mentality and other indications of myxedema, and decreased levels of circulating thyroid hormone (T4 and /or T3 by specific assays) contemplated a 30 percent rating. A severe disability, where the symptoms under "Pronounced" were somewhat less marked, with decreased levels circulating thyroid hormone (T4 and /or T3 by specific assays), contemplated a 60 percent disability; while a pronounced disability, that is one that is productive of a long history of slow pulse, decreased levels of circulating thyroid hormone (T4 and /or T3 by specific assays), a sluggish mentality, sleepiness, and slow return of reflexes was evaluated as 100 percent disabling. A hypoparathyroidism disability, evaluated under criteria enumerated in Diagnostic Code 7905, was rated by analogy with hyperthyroidism for evaluations less than 100 percent. A 100 percent evaluation was assigned when postoperative residuals, that is, those following a thyroidectomy, showed painful muscular spasms (tetany) or marked neuromuscular excitability. A note following the criteria showed that a 10 percent evaluation was also to be assigned when continuous medication was required for control. A hyperthyroidism disability was in turn evaluated under the criteria enumerated in Diagnostic Code 7900. A disorder that was in remission, operated or cured was determined to be zero percent disabling. A 10 percent evaluation was assigned where moderate or postoperative symptoms with tachycardia, which may be intermittent, and tremor were present. A moderately severe disability, that is one with the history shown under severe, but that has reduced symptoms; or one that is postoperative, with tachycardia and increased blood pressure or pulse pressure of moderate degree and tremor, was evaluated as 30 percent disabling. A severe disability, productive of marked emotional instability, fatigability, tachycardia and increased pulse pressure or blood pressure, with increased levels of circulating thyroid hormone (T4 and /or T3 by specific assays), was evaluated as 60 percent disabling. A pronounced disability, with thyroid enlargement, severe tachycardia, increased levels of circulating thyroid hormone (T4 and /or T3 by specific assays), with marked nervousness, cardiovascular, or gastrointestinal symptoms, muscular weakness and loss of weight, or postoperative with poor results with the symptoms persisting was evaluated as 100 percent disabling. Under the regulations currently in effect, a hypothyroidism disability, which is contemplated under Diagnostic Code 7903, is considered to be 10 percent disabling when fatigability is present, or when continuous medication is required for its control. A 30 percent evaluation is contemplated where there is fatigability, constipation and mental sluggishness. A 60 percent evaluation is assigned when there is muscular weakness, mental disturbance, and weight gain, while a 100 percent evaluation contemplates cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. Additionally, the criteria in effect subsequent to 1996 with regard to a hypoparathyroidism disability show that a 10 percent evaluation will be assigned when continuous medication is required for control. A 60 percent evaluation is assigned when there is marked neuromuscular excitability or, paresthesias (of the arms, legs, or circumoral area) plus either cataract or evidence of increased intracranial pressure. A 100 percent evaluation is contemplated where marked neuromuscular excitability (such as convulsions, muscular spasms (tetany) or laryngeal stridor) plus either cataract or evidence of increased intracranial pressure (such as papilledema) is present. After a review of the entire record, we find that two separate 10 percent evaluations are warranted under Diagnostic Codes 7903 and 7905, under the criteria currently in effect. First, we note that the veteran has averred that she suffers primarily from fatigue in connection with her hypothyroidism that she currently manifests as a residual of the surgically treated hyperthyroidism disorder . We also note that continuous medication, in the form of Synthroid, is required for its control. Further, we note that the veteran is also separately medicated for her hypoparathyroidism disability. Specifically, we note that the "continuing medications" record discussed above shows that the veteran is taking Synthroid for her hypothyroidism, and that she was taking Os-Cal and Vitamin D for her status post thyroid and parathyroidectomy thyroid problem. Additionally, the examiner of her 1995 VA rating examination listed Os-Cal and Vitamin D, as well as Synthroid, as her current medications. We do not find, in establishing these percentages, that the anti-pyramiding provisions of 38 C.F.R. § 4.14 are violated. Importantly, we note that the record is replete with references to her fatigability associated with her hypothyroidism. In addition, we note that she is separately medicated for her hypoparathyroidism disability. That is, although Diagnostic Code 7903 reflects that a 10 percent evaluation will be assigned for a disability productive of fatigability or one that requires continuous medication for control, we note that a separate 10 percent evaluation should be assigned for the continuous medication required to control her hypoparathyroidism. However, we also find that evaluations greater than 10 percent are not warranted for either her hypothyroidism or hypoparathyroidism disabilities under the current regulations. First, we note in this regard that the medical evidence does not demonstrate that she has constipation. The report of her 1995 VAME shows that her gastrointestinal symptoms were "really not present" even though she had loose bowel movements and very occasionally also had blood in the stool for which she was evaluated in the past. It also shows that her mental assessment was "Okay". Although she was subsequently diagnosed with irritable bowel syndrome or diverticulosis, there is no evidence to show that this is in any way related to her disorders. Again, her mental assessment was reportedly normal. Thus, as fatigability with constipation and mental sluggishness must be shown for a 30 percent evaluation to be warranted under Diagnostic Code 7903, we find that an evaluation greater than 10 percent is not appropriate. Similarly, the criteria for a 60 or 100 percent evaluation for her hypothyroidism disorder are also not demonstrated by the record. Turning to her hypoparathyroidism disability, we note that an evaluation greater than 10 percent is also not shown. That is, the medical evidence does not demonstrate that she has marked neuromuscular excitability, or; paresthesias (of the arms legs or circumoral area) plus either cataract or evidence of increased intracranial pressure. Although she may aver that she does in fact manifest such signs or symptoms, we note that she has not demonstrated that has any medical training or expertise that would permit her to render a competent medical opinion. See Moray v. Brown, 5 Vet. App. 211 (1993); see also Espiritu v. Derwinski, 2 Vet. App. 492 (1992). We must note that the examiner of her August 1996 VA rating examination made a specific clinical finding that her disorders were stable. Thus, the medical evidence does not demonstrate that an evaluation greater than 10 percent is shown under these criteria. Turning to the regulations effect prior to June 1996, we note that a rating greater than 10 percent is also not warranted for either her hypothyroidism or hypoparathyroidism disabilities. First, we note that a moderately severe hypothyroidism disability is not shown under 7903. That is, the medical evidence does not demonstrate that "other indications of myxedema" are shown so as to warrant a 30 percent evaluation. In fact the examiner of her August 1996 examination specifically found that her disease was stable, and that no myxedema was present. In addition, there is no evidence of a slow pulse or slow return of reflexes, so that a rating greater than 10 percent could be established. Turning the criteria in effect prior to June 1996 relevant to her hypoparathyroidism disorder, we note that evidence is similarly devoid of tremor, or increased blood pressure or pulse, so that evaluations greater than 10 percent would be warranted under those criteria. Thus, we find that a 10 percent evaluation for her hypothyroid disability is warranted under Diagnostic Code 7903, and that a distinct 10 percent evaluation is also appropriate under Diagnostic Code 7905 for her hypoparathyroidism disability. II. Entitlement to service connection for a left knee and a left ankle disability. In making a claim for service connection, the veteran has the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C. § 5107(a) (West 1991 & Supp. 1999). A well grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation." See Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). Establishing a well-grounded claim for service connection for a particular disability requires more than an allegation that the particular disability had its onset in service. It requires evidence relevant to the requirements for service connection and of sufficient weight to make the claim plausible and capable of substantiation. See Tirpak v. Derwinski, 2 Vet.App. 609, 610 (1992); Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). The kind of evidence needed to make a claim well grounded depends upon the types of issues presented by a claim. Grottveit v. Brown, 5 Vet.App. 91, 92-93 (1993). For some factual issues, competent lay evidence may be sufficient. However, where the claim involves issues of medical fact, such as medical causation or medical diagnoses, competent medical evidence is required. Id. at 93. Evidentiary assertions by the veteran must be accepted as true for the purposes of determining whether a claim is well grounded, except where the evidentiary assertion is inherently incredible or is beyond the competence of the person making the assertion. See King v. Brown, 5 Vet.App. 19 (1993). The three elements of a "well grounded" claim for direct service connection are: (1) evidence of a current disability as provided by a medical diagnosis; (2) evidence of incurrence or aggravation of a disease or injury in service as provided by either lay or medical evidence, as the situation dictates; and, (3) a nexus, or link, between the in-service disease or injury and the current disability as provided by competent medical evidence. See Caluza v. Brown, 7 Vet.App. 498 (1995); see also 38 U.S.C.A. § 1110 (West 1991 & Supp. 1998); 38 C.F.R. § 3.303 (1998); Layno v. Brown, 6 Vet.App. 465, 470 (1994); Espiritu v. Derwinski, 2 Vet.App. 492, 494-95 (1992). The veteran's service medical records (SMRs) show that she reportedly had foot difficulty, as reflected on her Report of Medical History, dated January 1974. The examiner noted that she had "minor surgery" on her "foot" after falling, and that she was "recover[ed]" with "NSA [no significant abnormality]". Her SMRs next show that she suffered trauma to her left ankle in May 1974, and was assessed with a "2 [degree] sprain." A subsequent note, also dated May 1974, shows that she had decreased swelling and residual ecchymosis. Her SMRs also show that she was given a physical profile for a left ankle sprain in May 1974. A November 6, 1974, record shows that the veteran presented with a left knee problem. That record shows that she complained of severe pain not associated with any immediate trauma, and that she was to be assessed by orthopedics. A record dated November 7, 1974, shows that she reported falling down a flight of stairs three months prior and had trouble with knee pain since that time. That SMR shows that she had moderate effusion, mild pain, that her range of motion was reportedly zero to 90 degrees with pain. The recommendations were an ace bandage and physical therapy. Radiographic reports, dated November and December 1974 respectively, evaluated the veteran's left knee and ankle. Her November left knee arthrogram shows that "plain films" of the knee were within normal limits. "Both the menisci and the cruciate ligaments are normal. The cartilage of the patello-femoral joint space appears normal thickness on several views." The impression was normal left knee arthrogram. Her December 1974 radiographic record shows that her patellar views revealed "Normal patellofemoral congruence", and that her left ankle was assessed as normal. A February 1975 SMR shows that she complained of her left knee giving out and falling, and that she had been asymptomatic for about two months. That record shows that her knee was evaluated as having no tenderness, effusion, with a full range of motion, a negative McMurray's sign, stable to all stresses, "was able to break, "quad" giving out, but unable to discrete pain", had no patellar bursitis, and had negative straight leg raises. An undated SMR notes that the veteran's knee 'gave out again', and that the pain was localized and intra-patellar. The report of her separation medical examination shows that her feet were clinically evaluated as normal, and that her lower extremities were clinically evaluated as abnormal. The examiner indicated that there was a four inch surgical scar over the anterior left foot. On her Report of Medical History, the veteran noted that she had had both foot trouble and a trick or locked knee. The examiner noted that the "left trick knee and painful joints refers to same, 1974, treated with exercise series and knee brace with good results. NCNS", and that her foot trouble referred to "severe trauma to [the] left ankle, 1974, treated with cast and crutches with good results. NCNS." The medical evidence subsequent to service shows that a radiographic report, dated December 1982, revealed that although post surgical changes of the MTP [metatarsal phalangeal] were present, there were no complications associated with the surgery that were radiographically evident, and showed that there was slight overlying soft tissue swelling along the dorsum of the distal foot. The examiner continued: "Perhaps a bone scan would be helpful to determine if there is some subtle bony process present that is not evident radiographically. The remainder of the examination is unremarkable." A consultation sheet dated September 1994 notes that the veteran complained of knee pain, and found that there was pain on full flexion of her left knee, and on McMurray's examination. The examiner found that there was pain with restricted flexion of extension of knee, no patella-femoral pain, and no ligament instability. The examiner also noted that she was to be treated for the inflammation. A chronologic record of medical care dated September 1, 1994 notes that the veteran reported, via telephone to a help desk medical advice system, that she had knee problems, with pain, swelling, restricted movement, and shooting pain going down her leg. A subsequent record, dated September 7, 1994 shows that she was evaluated and noted to have full range of motion, with knee pain on acute flexion and with hyperextension. There was no swelling or tenderness noted, and no calf tenderness. The assessment was knee pain. A private medical report dated December 1994 shows that the veteran complained of a painful knee. The examiner obtained a history from the veteran, which includes her reporting that she recalled having left knee difficulty in May 1974, and of being on crutches for an additional ankle disorder. The veteran also recalled a "giveway incident" and of having fluid aspirated from her left knee. The examiner's diagnosis was of a possible torn medial meniscus. An operative report is also of record, and shows a preoperative diagnosis as indicated above, and a postoperative diagnosis of chondromalacia, with shaving of the medial femoral condyle, and "plica band". The report of a radiographic examination of the veteran's left knee dated March 1995 is also of record, and shows that there was mild cartilage loss in the medial compartment with hypertrophic changes in the patellofemoral space. The examiner indicated that the findings were consistent with osteoarthritis. The report of a 1996 VA joints examination is also of record. That report shows that the veteran walked without a limp, and that there was an arthroscopic scar on the superior medial aspect of the left knee. There was no swelling, no deformity, no subluxation, lateral instability, non-union, loose motion, malunion, or atrophy noted. The range of motion of the right and the left knee was reported as follows: Right knee flexion 140 degrees, extension 180 degrees; left knee flexion 132 degrees and 180 degrees of extension. The range of motion of the right ankle was 44 degrees of plantar flexion, and 8 degrees of dorsiflexion; the left ankle was reported as having 42 degrees of plantar flexion and 7 degrees of dorsiflexion. The diagnosis was derangement of the left knee and ankle, post traumatic. The radiographic report of the left knee found no evidence of fracture or dislocation, and noted that the left knee appeared normal. Similarly, the left ankle appeared normal with no evidence of fracture or dislocation. An addendum to that examination, dated November 1997, was prepared in an attempt to provide a nexus opinion. The examiner stated that "It is as likely as not or less likely that the left knee and left ankle disabilities are not due to the service. In fact, there is no relationship between the current left knee and left ankle disabilities in the service. She has very little loss of range of motion and negative x- rays. This is in answer to the addendum for the remand." We note that in order for the veteran's claims to be well grounded, all three of the criteria enumerated in Cohen must be satisfied. That is, although she has shown that she did sustain injuries to her left knee and ankle during her active service, the report of her separation medical examination also indicated that these injuries were treated with good results. In addition, although she was treated for chondromalacia, with shaving of the medial femoral condyle, and "plica band" in 1994, the record does not show that these disabilities were in any way related to her service. In addition, the evidence of record subsequent to that operative procedure shows only that osteoarthritis and internal derangement of the left knee is present. That is, it does not show whether these disorders are related either to her active service, her treatment in 1994, or any other factor; therefore, the nexus requirement is not met and the claims are not well grounded. We also note in this regard that the examiner of her VA examination found that it was not as likely or not (or was actually less likely) that her left knee and ankle disabilities were due to her active service. The examiner then continued, "In fact, there is no relationship between the current left knee and left ankle disabilities in the service." We similarly note that there is no evidence that a left ankle disorder, if extant, is related to the veteran's active service. Thus, although the veteran has submitted such a claim, the Board must point out that a nexus must be established by medical evidence, and that the veteran has not established that she has the medical expertise required to make such a finding. Although the veteran's complaints are of record, a nexus between her in-service injuries and any current disorders is not shown by medical evidence. Thus, in the absence of clinical evidence showing a relationship between the veteran's service and any current left knee or ankle disorder, her claims must be denied as not well grounded. We note that the Court has held that when a claimant fails to submit a well-grounded claim under 38 U.S.C. § 5107(a) (West 1991 & Supp. 1999), VA has a duty under 38 U.S.C. § 5103(a) (West 1991 & Supp. 1999) to advise the claimant of the evidence required to complete his application, in circumstances in which the claimant has referenced other known and existing evidence. Robinette v. Brown, 8 Vet. App. 69 (1995); see also Epps v. Brown, 9 Vet. App. 341 (1996). In the case at hand, the Board finds that this duty is not triggered. In this case, we note that the rating decision and statements of the case advised the veteran of the requirements of a well-grounded claim. (CONTINUED ON NEXT PAGE) ORDER Entitlement to a 10 percent evaluation for a hypothyroidism disability is granted, subject to the laws and regulations governing the disbursement of monetary benefits. Entitlement to a 10 percent evaluation for a parathyroid disability is granted, subject to the laws and regulations governing the disbursement of monetary benefits. Entitlement to service connection for a left knee disorder is denied. Entitlement to service connection for a left knee disorder is denied. M. W. GREENSTREET Member, Board of Veterans' Appeals Shortness of breath, a subjective difficulty or distress in breathing, usually associated with disease of the heart or lungs; occurs normally during intense physical exertion or at high altitude. STEDMAN'S MEDICAL DICTIONARY, 26th Ed., Williams &Wilkins, Baltimore. Difficulty in swallowing. Id. Hypothyroidism characterized by a relatively hard edema of subcutaneous tissue, with increased content of proteoglycans in the fluid; characterized by somnolence, slow mentation, dryness and loss of hair, increased fluid in body cavities such as the pericardial sac, subnormal temperature, hoarseness, muscle weakness, and slow return of muscle to neutral position after a tendon jerk; usually caused by removal or loss of function of thyroid tissue. We note in this regard that Stedman's Medical Dictionary defines medication as "1. The act of medicating. 2. A medicinal substance, or medicament." A medicament is in turn defined as "A medicine, medicinal application or remedy". We note that the regulation uses the term "continuous medication", and that the term medication is broader than the term medicine, as it includes a medicament in its definition. Finally, we note, as indicated above, that a medicament is similarly broad, as it includes not only medicine, but also a medicinal application, and a remedy. A remedy is defined as "An agent that cures disease or alleviates its symptoms." We determine that it is sufficiently clear from the record that the veteran will require the remedy of Vitamin D and Os-Cal to alleviate the symptoms of her hypoparathyroid disorder (i.e. the deficiencies in those areas), and thus, find that the assignment of a 10 percent evaluation under Diagnostic Code 7905 is not inappropriate. We note that the examiner appeared to use a double negative when discounting the relationship between the veteran's disorders and service. However, we do not find that this grammatical error is of significance, particularly in light of totality of the examiner's statements negating any connection between service and a left knee or ankle disorder.