Citation Nr: 0003428 Decision Date: 02/10/00 Archive Date: 02/15/00 DOCKET NO. 95-11 885 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in No. Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for heart disorder, to include tachyarrhythmia and coronary artery disease.. 2. Entitlement to service connection for skin disorder, to include rash on hands, eczema, and contact dermatitis, as due to Agent Orange. 3. Entitlement to service connection for parenchymal nodule on left lung. 4. Entitlement to service connection for chest pain. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. P. Simpson, Associate Counsel INTRODUCTION The appellant served on active duty from February 1970 to November 1971. This case comes before the Board of Veterans' Appeals (the Board) on appeal from September 1993 and October 1993 rating decisions of the , Department of Veterans Affairs (VA) Regional Office (RO). In the September 1993 rating decision, the RO denied service connection for heart condition. In the October 1993 rating decision, the RO denied service connection for skin blisters due to Agent Orange. The Board remanded these claim in December 1997. The requested development has been accomplished, to the extent possible, and the case has been returned to the Board for further appellate review. FINDINGS OF FACT 1. Competent evidence of heart disease in service or manifestations of heart disease within one year following service is not of record. 2. Competent evidence of nexus between the diagnosis of tachyarrhythmia or the assessment of coronary artery disease and service is not of record. 3. Competent evidence of a nexus between the diagnoses of rash on hands, eczema, contact dermatitis and service or exposure to Agent Orange is not of record. 4. Competent evidence of a nexus between the diagnosis of parenchymal nodule on the left lung and service or exposure to Agent Orange is not of record. 5. Chest pain is not a disability for VA purposes. CONCLUSIONS OF LAW 1. The claim for service connection for heart disorder, to include tachyarrhythmia and coronary artery disease, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim for service connection for skin disorder, to include rash on hands, eczema, and contact dermatitis, is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The claim for service connection for parenchymal nodule on the left lung is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. The claim for service connection for chest pain is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant claims that service connection for heart disorder, skin disorder, and parenchymal nodule on the left lung is warranted. He states that he has developed the skin disorder and the parenchymal nodule on the left lung from exposure to Agent Orange. The appellant states that while in Vietnam, he developed a rash and blisters on his hands and that the blisters would burst and itch and then scale off. He also states that he developed a heart disorder in service, which is shown in his service medical records and that he has a current heart disorder as a result. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991). Service connection for arteriosclerosis may be granted if manifest to a compensable degree within one year of separation from service. Service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). In making a claim for service connection, the appellant 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.A. § 5107(a). A well-grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded claim for service connection generally requires medical evidence of a current disability; 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, a nexus, or link, between the inservice disease or injury and the current disability as provided by competent medical evidence. Cohen v. Brown, 10 Vet. App. 128, 137 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995) aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303 (1999); Layno v. Brown, 6 Vet. App. 465 (1994); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Alternatively, the nexus between service and the current disability can be satisfied by evidence of continuity of symptomatology and medical or, in certain circumstances, lay evidence of a nexus between the present disability and the symptomatology. See Savage v. Gober, 10 Vet. App. 488, 495 (1997). Establishing direct service connection for a disability that was not clearly present in service requires the existence of a current disability and a relationship or connection between that disability and a disease contracted or an injury sustained during service. Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). With a "chronic disease," such as arteriosclerosis, service connection may be warranted when the disease is manifested to a compensable degree within one year following service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991); 38 C.F.R. §§ 3.307, 3.309(a) (1999). Moreover, 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 cited above and of sufficient weight to make the claim plausible and capable of substantiation. Tirpak v. Derwinski, 2 Vet. App. 609 (1992); see also Murphy, 1 Vet. App. at 81. The kind of evidence needed to make a claim well grounded depends upon the types of issues presented by the 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. Grottveit, 5 Vet. App. at 93. A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era, and has a certain listed disability, shall be presumed to have been exposed during such service to an herbicide agent (Agent Orange), unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iii) (1999); McCartt v. West, 12 Vet. App. 164, 166 (1999). Specifically, the following diseases shall be service-connected, if the requirements of 38 C.F.R. § 3.307(a) are met, even if there is no record of such disease during service: chloracne or other acneform diseases consistent with chloracne, Hodgkin's disease, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers, and soft-tissue sarcomas. 38 U.S.C.A. § 1116 (West 1991); 38 C.F.R. § 3.309(e) (1999). All of the presumptive cancers, with the exception of respiratory cancers (which have a 30-year presumptive period), may be presumed to have been incurred during active military service as a result of exposure to Agent Orange, if manifest to a degree of 10 percent or more at any time subsequent to exposure to Agent Orange during active service. 38 C.F.R. § 3.307(a)(6)(ii) (1999). The appellant has not claimed that heart disorder, skin disorder, or parenchymal nodule on the left lung arose under combat situation. Thus, entitlement to application of 38 U.S.C.A. § 1154(b) (West 1991) is not warranted. Service medical records reveal that upon entrance, in November 1970, clinical evaluations of the appellant's lungs and chest, heart, vascular system and skin, lymphatics were normal. At that time and in May 1971, the appellant denied ever having or having now shortness of breath, pain or pressure in chest, palpitation or pounding heart, and skin diseases. A chest x-ray taken in May 1971 was negative. In October 1971, clinical evaluations of the appellant's lungs and chest, heart, vascular system and skin, lymphatics were normal. The appellant stated that he was in good health. The appellant underwent a VA examination in January 1986. Examination of the appellant's skin revealed no significant pathology. Examination of the heart revealed no enlargement and regular rhythm. The VA examiner noted that there was a grade I/IV systolic murmur heard at the apex. The lungs were clear to auscultation. A chest x-ray taken at that time was normal. No diagnosis was entered as to the appellant's heart, skin, or lungs. A February 1986 examination revealed that the appellant's skin was clear. A chest x-ray taken at that time revealed that the lungs were clear and the heart size was normal. Examination of the cardiovascular system revealed normal sinus rhythm and no murmurs. An electrocardiogram was done at that time. The VA examiner entered a diagnosis of tachyarrhythmia with intraventricular conduction defect. In a January 1988 fluoroscopic examination of the chest revealed a parenchymal nodule and no definite calcification was noted within it. The diagnosis was left lung nodule. In a May 1991 VA outpatient treatment report, the appellant complained of sharp pain in the sternum and soreness when he touched the left side of his chest. A diagnosis of costochondritis was entered. The appellant underwent a VA examination in June 1991. The appellant reported that in 1970 and 1971, his hands broke out in a rash after cleaning helicopter guns. Cardiovascular examination revealed regular rhythm and rate and a murmur at S3. Examination of the skin and lymphatics revealed no rashes. He was diagnosed with a rash on his hands and left chest wall pain. The appellant underwent a VA examination in February 1992. The appellant reported a history of heart disease since 1970. The appellant reported chest pain that never went away. He described the pain as a knife being twisted in his chest and that it was not relieved by nitroglycerin. He reported shortness of breath with walking and palpitations. The appellant stated that he was able to walk one-quarter mile without stopping and walk up a flight of stairs. He denied intermittent claudication, paroxysmal nocturnal dyspnea, or pedal edema. The VA examiner entered a diagnosis of chest pain, probably non-cardiac. The appellant was hospitalized at a VA facility in April 1992 for a thallium stress test. It was noted that he had been followed for the past six months for atypical chest pain. The appellant reported that he would get sharp substernal chest pain usually on exertion but also occasionally at rest. The VA examiner noted that the appellant reported the chest pain had been occurring since he was in Vietnam but that he did not seek medical attention until 1981. A thallium stress test conducted demonstrated no areas of ischemia, but it did reveal an enlarged right ventricle, which the VA examiner stated was consistent with an electrocardiogram that had been done in the past. A cardiac catheterization was performed in May 1992, which demonstrated normal coronary arteries. The discharge diagnosis was atypical chest pain. In a July 1993 VA outpatient treatment report, the appellant reported continued chest pain. The appellant stated that if he remembered to take his medication, he would do well. The VA examiner entered an assessment of coronary artery disease. The appellant had a hearing before this Board Member in May 1997. The appellant stated that in during service, they called a cardiologist to see him because they were worried about his heart. He stated that he was never told what was wrong with his heart and that he would be check out when he came back to the states upon his discharge, but that he had never been checked out after that. He stated that he had sinus bradycardia at that time. The appellant stated that he did not have the blisters on his hands and feet at that time. He stated that when he first came back from Vietnam that he would get big blisters on his hands and that they would peel two to three times per year. The appellant stated that whenever he would use chemicals that his hands would break out. The appellant underwent a VA examination in January 1998. The VA examiner noted that he had reviewed the appellant's claims file. He stated that the appellant reported that he was not on any medication for his heart problems. The VA examiner stated that review of the electrocardiograms in service showed a sinus mechanism with no significant abnormalities. He stated that an electrocardiogram done in 1986 showed non-specific interventricular conduction delay and had a sinus bradycardia and that he presumed that the examining physician made a diagnosis of tachyarrhythmia. The VA examiner stated that the records showed that in 1992 the appellant was studied thoroughly and that the Thallium stress test and cardiac catheterization were normal. He noted that an electrocardiogram showed enlargement of the right ventricle, but otherwise no abnormalities. The appellant denied palpitations, orthopnea, or paroxysmal nocturnal dyspnea. The VA examiner stated that the appellant did not give a history "suggestive in any way of angina pectoris." Upon physical examination, the VA examiner stated that there was no clinical evidence of heart enlargement, that rhythm was regular, and that the first sound was of normal intensity and that the second sound was normally split. He stated that there was no evidence of a murmur, thrill, or friction rub. His determination was that the appellant did not have heart disease. He stated the following: The service electrocardiograms, in my judgment, do now show any significant abnormality. I am, therefore, unable to diagnose heart disease at that particular time. The electrocardiogram showing a sinus bradycardia with a non-specific interventricular conduction delay is very non-specific. The work-up in 1992 is self-explanatory and with a normal coronary arteriogram and cardiac catheterization, I would conclude that the coronary arteries are normal and that ventricular function is normal. There was no mention of abnormal ventricular function on the echocardiogram that was done. On the basis of this, I am unable to make a diagnosis of heart disease. The appellant underwent a VA examination in May 1999. The appellant reported eczematous vesicles on his hands on the radial side. The VA examiner stated that the appellant's hands did not have vesicles at that time, but that the appellant's description sounded like dyshidrotic eczema; however, he noted that it would be hard to know without seeing it in an active state. The VA examiner added that it could be contact dermatitis, but that it would have to be evaluated at the time the appellant had the rash. Physical examination revealed that the scalp was within normal limits. The neck showed no particular abnormality. The VA examiner stated that the appellant had a small nevus anemicus on one arm that was quite small. Examination of the trunk was within normal limits (he noted bites that the appellant received from a tick). The groin was within normal limits, and the appellant had no lesions of the skin on his lower extremities or his feet. The hands were clear. The impression was history of eruption on the hands that sounded eczematous, probably dyshidrotic eczema or contact dermatitis. I. Heart disorder After having reviewed the evidence of record, the Board finds that the appellant's claim for service connection for heart disorder, to include coronary artery disease, is not well grounded. See Caluza, supra. The Board notes that the appellant underwent a VA examination in January 1998 and that the VA examiner reviewed the service medical records, to include the electrocardiograms that were done in service, and determined that the appellant did not have a heart disorder in service or at the present time. Regardless, in a February 1986 VA examination report, the examiner entered a diagnosis of tachyarrhythmia, intraventricular conduction defect, and in a July 1993 VA outpatient treatment report, the VA examiner entered an assessment of coronary artery disease. When determining whether a claim for service connection is well grounded, the evidence submitted in support of the claim must be accepted as true, and thus the Board will accept the diagnosis of tachyarrhythmia and the assessment of coronary artery disease as current findings of a heart disorder. However, the appellant's claim fails because he has not brought forth incurrence of heart disease in service, manifestations of arteriosclerosis to a compensable degree within one year following service, or a nexus between the diagnosis of tachyarrhythmia or the assessment of coronary artery disease and service. See id. The appellant has not established that he had heart disease in service. Although the appellant is competent to report that he had chest pain in service, he is not competent to state that he had heart disease in service. He has stated and testified that his service medical records establish heart disease in service, however, the Board disagrees. The service medical records are silent for findings or a diagnosis of heart disease. The VA examiner, who conducted the January 1998 examination, stated that he had reviewed the service electrocardiograms and that they did not show any significant abnormality. He stated that he was unable to diagnose heart disease at that particular time. Thus, there is no competent evidence of heart disease in service. Additionally, there are no records or medical opinions which establish that the appellant had manifestations of arteriosclerosis within one year following service. The first diagnosis of a heart disorder was in February 1986, when a diagnosis of tachyarrhythmia was entered in the examination report. This is more than one year following the appellant's discharge from service. This February 1986 examination report and the assessment of coronary artery disease in a July 1993 outpatient treatment report are the only evidence that the appellant has a current heart disorder. Neither of these VA examiners related the diagnosis or the assessment to service. Thus, the appellant has not brought forth competent evidence of manifestations of arteriosclerosis within one year following service or a nexus between the diagnosis of tachyarrhythmia or the assessment of coronary artery disease and service. The claim is not well grounded. See Caluza, supra. Although the appellant has alleged that he developed a heart disorder in service and that he has the same heart disorder now, it has not been shown that he possesses the requisite knowledge of medical principles that would permit him to render an opinion regarding matters involving medical diagnoses or medical etiology. See Espiritu, 4 Vet. App. at 494; see also Edenfield v. Brown, 8 Vet. App. 384, 388 (1995) (en banc) ("[w]here the determinative issue involves either medical etiology or a medical diagnosis, competent medical evidence is ordinarily required to fulfill the well-grounded claim requirement of section 5107(a)"). It must be noted if the Board was denying the claim on the merits, it would determine that the preponderance of the evidence is against a finding of current heart disorder. The VA examiner who conducted the January 1998 examination stated that the 1986 finding of sinus bradycardia with non-specific interventricular conduction delay was very non-specific. Additionally, he stated that the 1992 work-up was self- explanatory and that the appellant had normal coronary arteries and normal ventricular function. He stated that based upon his review of the appellant's records, the appellant's medical history as presented by the appellant, and his examination of the appellant, that he was unable to make a diagnosis of heart disease. The Board finds this VA examiner's medical opinion to be more probative than a cursory assessment of coronary artery disease without any clinical findings to support the assessment and a diagnosis of tachyarrhythmia which was discounted by the VA examiner who conducted the January 1998 examination. In sum, the Board finds that the appellant has not submitted a well-grounded claim for service connection for heart disorder, as all of the Caluza elements have not been met to establish a well-grounded claim. See Caluza, supra. II. Skin disorder After having reviewed the evidence of record, the Board finds that the appellant's claim for entitlement to service connection for skin disorder, to include skin rash on hands, eczema, and contact dermatitis, is not well grounded. See Caluza, supra. Although service medical records are silent for any skin disorder during service, the appellant is competent to report that he had blisters on his hands during service. The appellant was examined in January 1986, February 1986, and June 1991 with normal clinical findings as to his skin. At the time of the May 1997 hearing, the appellant stated that his rash on his hands was not active. At the time of the May 1999 VA examination, the appellant's rash on his hands was not active. The VA examiner stated that based on the appellant's description, he thought the appellant had eczema or contact dermatitis. It must be noted that skin rash, eczema, and contact dermatitis are not among the diseases listed in 38 C.F.R. § 3.309(e). Therefore, that section is not applicable to the appellant's claim, and the appellant's skin rash, possible eczema, or possible contact dermatitis may not be presumed to be due to his exposure to Agent Orange. See McCartt, 12 Vet. App. at 168 (where the veteran has not developed a condition enumerated in 38 U.S.C. § 1116(a) or 38 C.F.R. § 3.309(e), neither the statutory nor the regulatory presumption will satisfy the incurrence element of Caluza). Service connection may also be established on a direct incurrence basis (under the provisions of 38 C.F.R. § 3.303(d)) if the evidence shows that the skin rash, eczema, or contact dermatitis is etiologically related to exposure to Agent Orange in service or is otherwise related to service, even though the disorder is not among those enumerated in 38 C.F.R. § 3.309(e). See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). However, in this case, there is no evidence that any physician or other qualified health care professional has attributed the appellant's diagnoses of skin rash, eczema, or contact dermatitis to Agent Orange or otherwise to service. Additionally, no medical professional has related any of these diagnoses to the symptomatology reported by the appellant. See Savage, supra. Further, there is no competent medical evidence showing that such disease was manifested to a compensable degree within one year of his discharge from service. 38 U.S.C.A. §§ 1101, 1112. Although the appellant has alleged that he developed this skin problem while in service and that it has been reoccurring since service two to three times per month, it has not been shown that he possesses the requisite knowledge of medical principles that would permit him to render an opinion regarding matters involving medical diagnoses or medical etiology. See Espiritu, 4 Vet. App. at 494; see also Edenfield, 8 Vet. App. at 388. It must be noted that the evidence does not establish a chronic skin disorder. When seen in January 1986, February 1986, June 1991, and May 1999, there was no active rash on the appellant's hands. Additionally, the appellant stated at the May 1997 Board hearing that the rash was not active at that time. The Board is aware that the VA examiner entered a diagnosis of rash on hands in the June 1991 examination report, however, the clinical findings revealed no rashes. Regardless, the evidence does not show that the appellant has a chronic skin disorder. In fact, the appellant's own statements establish a lack of continuity of symptomatology. See Savage, supra. The appellant, when fully reporting his skin rash on his hands, stated that the rash occurred two or three times per year. This is not indicative of a chronic skin disorder. In sum, the Board finds that in the absence of medical evidence that the appellant has a skin disorder related to service, including as a result of exposure to Agent Orange during service, the claim must be denied as not well grounded. III. Parenchymal nodule After having reviewed the evidence of record, the Board finds that the appellant's claim for service connection for parenchymal nodule of the left lung is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). He has attempted to relate the parenchymal nodule to exposure to Agent Orange; however, a parenchymal nodule in the lung is not among the diseases listed in 38 C.F.R. § 3.309(e). Therefore, that section is not applicable to the appellant's claim, and the appellant's parenchymal nodule in the left lung may not be presumed to be due to his exposure to Agent Orange. See McCartt, supra. Service connection may also be established on a direct incurrence basis (under the provisions of 38 C.F.R. § 3.303(d)) if the evidence shows that the parenchymal nodule of the left lung is etiologically related to exposure to Agent Orange in service or is otherwise related to service, even though the parenchymal nodule is not among those enumerated in 38 C.F.R. § 3.309(e). See Combee, supra. However, in this case, there is no competent evidence that has attributed the appellant's diagnosis of parenchymal nodule of the left lung. Additionally, there is no competent medical evidence showing that the parenchymal nodule of the left lung was manifested to a compensable degree within one year of his discharge from service. 38 U.S.C.A. §§ 1101, 1112. Although the appellant has alleged that the parenchymal nodule of the left lung is related to service, it has not been shown that he possesses the requisite knowledge of medical principles that would permit him to render an opinion regarding matters involving medical diagnoses or medical etiology. See Espiritu, 4 Vet. App. at 494; see also Edenfield, 8 Vet. App. at 388. Lastly, the record establishes the presence of a nodule, however, there is no competent evidence that the nodule results in disability. Chelte v. Brown, 10 Vet. App. 268 (1997). IV. Chest pain The Board notes that the appellant has asserted that he has left chest pain; however, the Board is unaware as to whether the appellant attributes his left side chest pain with his claim for service connection for heart disorder or with his claim for service connection for parenchymal nodule of the left lung. If he has related it to organic pathology, the Board finds that it has been addressed above. However, if he relates it to non-organic pathology, the Board notes that a diagnosis of chest pain is not a disability due to disease or injury. Service connection is warranted for a "[d]isability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty . . . ." 38 U.S.C.A. §§ 1110, 1131 (West 1991). The findings of chest pain do not establish that there is a disability resulting from an injury or a disease. See id. In the absence of proof of a present disease or injury, there can be no valid claim. V. General duty Although the VA does not have a statutory duty to assist a claimant in developing facts pertinent to the claim when it is determined to be not well grounded, it may be obligated under 38 U.S.C.A. § 5103(a) (West 1991) to advise a claimant of evidence needed to complete his application. This obligation depends on the particular facts of the case and the extent to which the Secretary has advised the claimant of the evidence necessary to be submitted with a VA benefits claim. Robinette, supra. Here, VA fulfilled its obligation under section 5103(a) by issuing a statement of the case in February 1995 and supplemental statement of the case in June 1999. In this respect, the Board is satisfied that the obligation imposed by section 5103(a) has been satisfied at both the RO level and the appellate level. See Franzen v. Brown, 9 Vet. App. 235 (1996) (VA's obligation under sec. 5103(a) to assist claimant in filing his claim pertains to relevant evidence which may exist or could be obtained). ORDER Service connection for (1) heart disorder, to include tachyarrhythmia and coronary artery disease, (2) skin disorder, to include skin rash on hands, eczema, and contact dermatitis, (3) parenchymal nodule on the left lung is denied, and (4) chest pain. H. N. SCHWARTZ Member, Board of Veterans' Appeals