Citation Nr: 0005620 Decision Date: 03/01/00 Archive Date: 03/14/00 DOCKET NO. 96-04 057 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Washington, DC THE ISSUE Entitlement to service connection for the excision of an enlarged lymph node secondary to service-connected thyrotoxicosis with Grave's Disease. ATTORNEY FOR THE BOARD Jonathan B. Kramer, Associate Counsel INTRODUCTION The veteran served on active duty from July 1986 to July 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 1994 rating decision rendered by the Department of Veterans Affairs (VA) Regional Office (RO) in Washington, DC, which denied the benefit sought on appeal. This matter was previously before the Board in March 1997, at which time the case was remanded to the RO for additional development. The additional development having been completed, the matter is again before the Board for appellate review. The Board also notes that since the case was returned to the Board, additional evidence has been submitted, along with a signed waiver of RO consideration of this evidence, dated in February 2000. FINDING OF FACT There is no medical evidence that the veteran's excision of an enlarged lymph node is productive of a current disability. CONCLUSION OF LAW The veteran's claim of entitlement to service connection for the excision of an enlarged lymph node secondary to service connected thyrotoxicosis with Grave's Disease is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION The law provides that a veteran is entitled to service connection for a disability resulting from a disease or injury incurred or aggravated while in service. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Additionally, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disability, including on the basis of aggravation. 38 C.F.R. § 3.310 (1999); Allen v. Brown, 7 Vet. App. 439 (1995). Initially, however, the threshold question that must be addressed in this case is whether the veteran has presented a well-grounded claim for service connection. A well-grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. In this regard, 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.A. § 5107(a); Grivois v. Brown, 6 Vet. App. 136, 140 (1994); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). If the evidence presented by the veteran fails to meet this threshold level of sufficiency, no further legal analysis need be made as to the merits of the claim. See Boeck v. Brown, 6 Vet. App. 14, 17 (1993). To establish that a claim for service connection is well grounded, a veteran must present a medical diagnosis of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Epps v. Gober, 126 F.3d 1464, 1467-68 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Alternatively, the United States Court of Appeals for Veterans Claims (Court) has indicated that a claim may be well grounded based on application of the rule for chronicity and continuity of symptomatology, set forth in 38 C.F.R. § 3.303(b). See Savage v. Gober, 10 Vet. App. 488 (1997). The Court held that the chronicity provision applies where there is evidence, regardless of its date, which shows that a veteran had a chronic condition either in service or during an applicable presumption period and that the veteran still has such condition. That evidence must be medical, unless it relates to a condition that the Court has indicated may be attested to by lay observation. If the chronicity provision does not apply, a claim may still be well grounded "if the condition is observed during service or any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology." Savage, 10 Vet. App. at 498. In her variously dated written statements, the veteran contends that the enlargement of a lymph node in her neck, and its resultant excision in May 1993, was secondary to her service-connected thyrotoxicosis with Grave's Disease. Pursuant to an April 1991 rating decision, the veteran was initially granted service connection for thyrotoxicosis and assigned a 10 percent disability rating, effective July 1990. A January 1995 Board decision determined that an increased disability rating to 30 percent was warranted for the veteran's service-connected thyrotoxicosis. A February 1995 RO rating decision assigned a 30 percent disability rating for service-connected thyrotoxicosis, effective July 1990. A May 1993 operation report from a private physician, Frederick H. Hartwig, M.D., explained that a firm lymph node was excised. The lymph node was noted to be benign. A contemporaneous private pathology report, prepared by L. A. Callaway, M.D., revealed "[n]o foci of abnormal cells are seen in the lymph node." Private treatment records, dated in June 1993, noted that the veteran was not feeling well and was running a low-grade fever. Examination revealed nodules in both neck areas. A follow-up examination in July 1993 noted there was some irritation in the area of the operation site, which was treated by removing an old stitch from the area. In response to the Board's March 1997 Remand for additional development, the veteran underwent a July 1998 VA examination to address the issue of whether the veteran's lymph node enlargement and excision was secondary to the veteran's service-connected thyrotoxicosis with Grave's Disease. The examination report noted that the veteran's medical records were reviewed. The diagnosis was possible postpartum hypothyroidism. The examiner commented that there was "[n]o relationship of Grave's [D]isease to normal lymph node[,] which was removed in 1993." A November 1998 VA examination report noted the veteran's complaints of not feeling well, but she made no specific complaints of enlarged or troublesome lymph nodes. The diagnosis included a "[p]ast history of hyperthyroidism, symptoms as noted, treated, apparently controlled." An undated letter from a private physician, Richard Hellman, M.D., received by VA in February 2000, states that the veteran has had a "long history of Grave's Disease. In my opinion, her May 1993 lymph node disorder and surgery was probably due to the underlying thyroid/endocrine Grave's Disease. The lymph node disorder and subsequent surgery was therefore secondary to the Grave's Disease." The veteran has presented a copy of a page from the textbook Harrison's Principles of Internal Medicine 355 (J. D. Wilson, et al., eds., 12th ed. 1991). That evidence consists of a table of diseases associated with lymph node enlargement, including "[e]ndocrine diseases: hyperthyroidism." What we have in this case is evidence from one physician that the instance of lymph node enlargement and resultant lymph nodes excision in May 1993 may have been secondary to the veteran's service-connected thyrotoxicosis with Grave's Disease and evidence from another physician stating no relationship existed between the two. More importantly, however, it has not been articulated by Dr. Hellman or any other physician, how the enlargement and removal of the lymph node has caused her any current impairment Clearly, the VA physician did not diagnose a current disability. The excised lymph node had been found to be benign. Moreover, the enlarged lymph node appeared to be an isolated incident and not part of any generalized disease process; there is no evidence of any other enlarged lymph nodes having been found or excised before or since. Thus, assuming that the veteran's service-connected thyrotoxicosis with Grave's Disease caused the enlarged lymph node and resulting excision, the medical evidence does not show how this results in current disability. As such, the veteran's claim is not well grounded. The only evidence of record supporting the veteran's contentions that she suffers from a current disability are her own statements. As a matter of law, however, the veteran, as a layperson, is not competent to render a medical diagnosis of a current disability. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). In other words, the veteran needs to show she is medically diagnosed with a disability due to her lymph node enlargement and removal. By this decision, the Board is informing the veteran that a medical diagnosis of a current disability and medical evidence of causation is required to render her claim well grounded. See 38 U.S.C.A. § 5103(a); Robinette v. Brown, 8 Vet. App. 69 (1995). ORDER Evidence of a well-grounded claim not having been submitted, entitlement to service connection for the excision of an enlarged lymph node secondary to service-connected thyrotoxicosis with Grave's Disease, is denied. BRUCE KANNEE Member, Board of Veterans' Appeals