Citation Nr: 1121902 Decision Date: 06/07/11 Archive Date: 06/20/11 DOCKET NO. 07-31 611 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to an increased evaluation for headache, currently evaluated as 10 percent disabling. 2. Entitlement to service connection for Prinzmetal angina. 3. Entitlement to service connection for tremor. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C.A. Skow, Counsel INTRODUCTION The appellant had active service from January 1966 to January 1969, and from August 1970 to March 1987. This matter comes before the Board of Veterans' Appeals (BVA or Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. After reviewing the contentions and evidence of record, the Board finds that the issues on appeal are more accurately stated as listed on the title page of this decision. The issues of service connection for coronary artery disease and hypertension have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Likewise, the appellant has raised the issue of error in the rating decision assigning the initial disability evaluation for headaches. This has not yet been considered by the AOJ. Therefore, the Board does not have jurisdiction over the above matters, and they are referred to the AOJ for appropriate action. The issues of entitlement to an increase rating for headache and service connection for tremor are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The appellant had chest pain in service and since discharge, which has been diagnosed as Prinzmetal angina. CONCLUSION OF LAW Prinzmetal angina was incurred in service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.303, 3.307, 3.309 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION I. VCAA The Veterans Claims Assistance Act of 2000 (VCAA), (codified at 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126), imposes obligations on VA in terms of its duty to notify and assist claimants. Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VA must inform the claimant of any information and evidence not of record that (1) is necessary to substantiate the claim as to all five elements of the service connection claim (including degree of disability and effective date of disability (See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006)); (2) VA will seek to provide; and (3) the claimant is expected to provide. 38 U.S.C.A. § 5103(a); Quartuccio, supra. at 187; 38 C.F.R. § 3.159(b). Notice should be provided at the time that VA receives a completed or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) at 119 (2004). This timing requirement applies equally to the initial- disability-rating and effective-date elements of a service connection claim. Dingess/Hartman, supra. VA has satisfied its duty to notify. VA sent to the appellant a letter dated March 2006 that essentially complied with statutory notice requirements as outlined above. At that time, VA notified the appellant of the type of evidence needed to substantiate his claim, the evidence obtained, the evidence VA was responsible for obtaining, and the evidence necessary to establish entitlement to the benefits sought including the types of evidence that would assist in this matter. VA further notified the appellant of the disability rating and effective date elements of his claim. This action was prior to the determination appeal by the appellant. The appellant has not been deprived of information needed to substantiate his claim. Moreover, the very purpose of the VCAA notice has been satisfied. VA has also satisfied its duty to assist. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Pertinent records were obtained or requested. VA afforded the appellant an opportunity to appear for a hearing. The appellant declined a personal hearing. Consistent with VA's duty to assist, a VA examination and opinion was obtained in this matter. The report of examination is associated with the claims folder. The report of examination dated August 1998 in conjunction with the addendum dated September 1998 reflects that VA medical examiner (1) reviewed the claims file, (2) noted pertinent medical history and current symptoms, (3) examined the appellant, and (4) reached a conclusion and (5) provided reasoning for the conclusion. Such an examination, based upon the appellant's medical history and examinations, and describing the disability in sufficient detail so that the Board's evaluation will be a fully informed one, is adequate. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see Green v. Derwinski, 1 Vet. App. 121 (1991) (medical opinion is adequate if it "takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one"). Therefore, the Board finds that the report of examination along with the addendum is adequate and there is no basis for return of the examination or re-examination. The Board finds that there is no indication that there is any additional relevant evidence to be obtained either by the VA or by the appellant, and there is no other specific evidence to advise him to obtain. See Quartuccio v. Principi, 16 Vet. App. 183 (2002) (holding that both the statute, 38 U.S.C. § 5103(a), and the regulation, 38 C.F.R. § 3.159, clearly require the Secretary to notify a claimant which evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by the Secretary). Accordingly, appellate review may proceed without prejudice to the claimant. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Claims for Service Connection Initially, the Board notes the appellant does not assert that his claimed problems are a result of combat. Therefore, the provisions of 38 U.S.C.A. § 1154(b) are not for application in this matter. Compensation may be awarded for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131. Service connection basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in- service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997); 38 C.F.R. § 3.303(b). The Board is required to analyze the credibility and probative value of the evidence, account for any evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Daye v. Nicholson, 20 Vet. App. 512, 516 (2006). It is noted that competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). Prinzmetal Angina The appellant seeks service connection for chest pain diagnosed as Prinzmetal angina, which he avers he has had since service. Numerous medical records have been submitted in support of his claim and documenting chest pain both in service and since service discharge. The Board notes that it has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will provide a summary of the relevant evidence where appropriate. The Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. 1. Factual Background Service treatment records reflect that the appellant was seen for atypical angina. Clinical record dated June 1974 reflects a diagnosis for nonspecific EKG changes. It was noted that, because of the appellant's atypical anginal history and his nonspecific EKG changes, a cardiologist was consulted. On EKG dated September 1975 the clinical impression was left sided chest pain. Reports of examinations dated September 1976 and April 1980 reflect normal clinical evaluation of the heart and vascular system. A report of medical history dated October 1981 reflects a history of pain or pressure the chest. The appellant was seen for chest pain in April 1982, without diagnosis or treatment. X-ray was normal. EKG was normal. Examination dated July 1982 reflects normal clinical evaluation of the heart and vascular system. An emergency room note dated April 1983 reflects an assessment for recurrent chest pain. It was noted that EKG was unchanged since 1975. Service retirement examination dated February 1987 reflects normal clinical evaluation of the heart, and vascular system. The medical history reflects pain or pressure in chest. The appellant indicated that he did not know if he had heart trouble. The examiner elaborated that the appellant had been to treatment room several times for chest pain, thought to be noncardiac in nature. Report of VA examination dated February 1988 reflects, by history, episodes of sharp chest pain lasting 5 -10 seconds, about once or twice a year for the past 17 years. The appellant denied associated symptoms, radiation to the extremities, and any known cardiac problems. He reported normal EKG's obtained during these episodes. Physical examination revealed a moderately obese male. Heart rate was 64 and regular. EKG was normal except for IVCD. Chest x-ray was normal except for nodular density lateral to the left hilum. The impression was that "The etiology of the chest pain is unclear, but is unlikely to be associated with significant cardiac disease." A private treatment note (T. Bartley MD) dated December 1989 reflects complaints of sudden onset of chest pain. Examination and EKG testing showed no evidence of acute ischemia. The assessment was that abdominal and chest pain was most likely secondary to GERD (gastroesophageal reflux disease). The examiner stated "Doubt this is of cardiac origin." Private treatment notes dated September 1993 reflect complaints of headache and chest pain. There was no shortness of breath, diaphoresis or nausea. Self-taken blood pressure was 160/110. EKG showed sinus rhythm with normal axis and intervals, no acute changes of ischemia and no changes from previous tracing of 1989. Chest x-ray was normal without cardiomegaly, pulmonary infiltrates or pleural effusions. The assessment was hypertension, headache most likely secondary to hypertension, and chest pain "probably related to the HTN [hypertension] but doubt it was angina." A letter dated September 1994 from J. Sanders., MD, to L. Long, MD, reflects that Dr. Sanders had seen the appellant for 5 minute episode of chest pain. The appellant had denied any history of exertional chest pain. It was noted that he had risk factors of his sex, age, and father who had a myocardial infarction at age 70. Adult onset diabetes and hypertension were also noted. An exercise tolerance test was recommended. The physician referred the appellant to Dr. Long for a stress tolerance test. Dr. Long responded in a letter dated September 1994. The assessment was that the appellant reached near 100 percent of his maximum predicted heart rate, he had no chest pain, or excessive shortness of breath, or other cardiovascular signs or symptoms. EGK monitored throughout the treadmill demonstrated no significant STT changes. Post exercise there was a slight amount of ST segment depression in one lead only, deemed "probably insignificant." An emergency room note dated December 1994 reflects that the appellant presented with complaint of chest pain. By history, over the last 3 years, the appellant reported having had at least 10 similar episodes of chest pain. The diagnosis was acute chest pains, etiology undetermined. Private treatment notes dated December 1994 of A. Dickson, MD, reflects consideration of laparoscopy. It was noted that the appellant had a 20-25 year history of chest pain initially considered a heart problem but that had been excluded by multiple EKGs, whereas recent testing showed gastroesophageal reflux disease (GERD) and gallstones. A letter dated December 1994 from Dr. Bartley to Dr. Dickson reflects that the appellant was evaluated for chest pain after a recent emergency room visit, and that this did not seem to be cardiac in nature. It was noted that he had no other symptoms associated with chest pain and no EKG changes. The physician opined that chest pain was "most likely on the basis of GERD or esophageal spasm and possibly cholelithiasis." A work up showed some reflux plus gallstones on ultrasound. Evaluation for laparoscopic cholecystectomy was requested. A private hospital report dated December 1994 reflects that the appellant was admitted for an elective laparoscopic procedure. By history, he had substernal pain episodically for 20-25 years, lasting only a few minutes, and occurring more frequently of late. It was noted that multiple EKGs had been normal. Nitroglycerin has provided only minimal relief. He reported that he had gone to the ER two weeks prior. Private hospital records dated September 1995 reflect that the appellant was admitted after onset of chest pain for cardiac evaluation to rule out myocardial infarction. It was noted that a treadmill test one year prior was negative. An assessment reflects that "At present etiology of this chest pain is unclear. The patient's EKG is abnormal, but it is not changed over the long haul." Due to abnormal EKG, graded exercise stress testing was initiated; the appellant reached a maximal heart rate and the impression was for "subtle zone of reversible ischemia in the inferior wall." Chest x-ray showed no evidence of acute abnormality. The plan was for the appellant to follow up with his private physician. The discharge diagnoses included chest pain, likely atypical. A letter dated September 1995 from Dr. Long to D. Langrock, MD, reflects his opinion that "recent chest pain was probably non-cardiac in nature." Private treatment notes dated October 1995 reflect follow up for atypical chest pain. The assessment was "Persistent atypical chest pain with cardialite [sic] treadmill read by Dr. Long as negative although there was a subtle area of perfusion defect in the inferior wall." A subsequent October 1995 note reflects an assessment of "Persistent chest pain, still quite worrisome for coronary ischemia in spite of recent reassuring Cardiolite treadmill." A subsequent October 1995 note reflects an assessment for "Resistant occasional chest pain at rest despite a negative Cardiolite treadmill by Dr. Long. Symptoms seem to be lessening with the combination of Prilosec for GERD and increased Tenormin." Private treatment notes dated June and September 1997 reflect complaints of occasional chest pain, including shortness of breath with exertion. Objectively, the appellant was very overweight. The assessment in June 1997 included exertional dyspnea and chest pain, "may very well be cardiac." In September 1997, the assessment was "Chest pain, which I feel in this pt (patient) may very well represent angina, although prev[ious] stress has been neg[ative] as the ST segments are normal and the QRS net deflection is neg[ative] in each lead." The appellant was referred to N. Every, MD, for evaluation. In a letter dated November 1997, Dr. Langrock requested that Dr. Every evaluate the appellant for chest pain. He stated that "I think by history and presentation, is quite likely ischemic." He noted that the appellant had symptoms since 1975 and that the military had dismissed as nonischemic. Dr. Langrock stated that "I am highly suspicious that it is now and probably has always been ischemic. If you believe this is the case, he may be eligible for a service related disability." A letter dated November 1997 from Dr. Every to Dr. Langrock reflects an assessment for coronary artery disease. He stated that the appellant's recollection of treadmill testing sounded like ischemia. It was noted that he was not limited by chest pain, but the examiner had concerns about "occasional rest symptoms." Angioplasty and cardiac catheterization was planned. A letter to VA dated January 1998 from Dr. Langrock reflects that the appellant was a patient of his with diabetes of poor control, obesity with unsuccessful attempts at weight loss, and chest pain of unknown etiology. It was noted that he also had hypertension, hypercholesterolemia, and that this was consistent with Syndrome X. He asked that VA consider the appellant for medical disability. A letter to VA dated March 1998 from Dr. Langrock reflects that the appellant was evaluated and treated for coronary artery disease in the past year. He further stated that: He has previously, on many occasions, complained of chest pain when he was on active duty military, and the workup in the military indicated that he was not suffering from ischemic heart disease. In light of the findings of the past year, I think that this determination was made in error, and that Mr. [redacted] had on a more probable than not basis, significant coronary artery disease while he was engaged in US military service. In March 1998, the appellant provided VA with a copy of textual information on Prinzmetal angina, which was a condition with a principle finding of angina at rest, with episodes often occurring in the early morning hours, and may include vasomotor-related symptoms such as migraine headache. The appellant did not provide any citation or source information regarding this extract. Report of VA examination dated August 1998 reflects that, by history, chest pain numerous times throughout military service without any specific diagnosis. The examiner noted that a November 1997 evaluation by a cardiologist showed normal coronary arteries on angiogram. An echocardiogram at that time showed an ejection fraction within normal limits, range of 55 to 65 percent. The appellant was given a diagnosis of Prinzmetal angina and started on Cardizem CD. The examiner stated that, since November 1997, the appellant has done well, but has occasional chest pain at rest, which he treats with sublingual nitroglycerin. He uses one tablet about once every 2 to 3 months. There is no history of congestive heart failure or myocardial infarction. Hypertension was diagnosed within the last 5 years for which he takes mediation. It was noted that the appellant's last EKG in November 1997 was within normal limits. Physical examination was conducted. The impression was "history of recent diagnosis of Prinzmetal or variant angina, which is caused by coronary vasospasm." The examiner stated that the appellant did not have coronary artery disease and he did not have cardiac complications. He reported that the appellant had no chest pain on exertion but had occasional chest pain at rest, which would be classified as "New York Heart Association Functional Classification I, able to exercise up to 7-10 minutes without development of chest pain." The report of examination expressly states that the examiner reviewed the claims file and medical record available at the time of examination. In an addendum to the August 1998 VA examination, dated September 1998, the examiner opined as follows: Without a diagnosis of Prinzmetal's angina and/or coronary vasospasm during military service, it is undetermined whether or not the chest pain the patient had in the 1970s is the same pain that he has today and is caused by the same mechanism. After consulting with Dr. [redacted], M.D., in the department of cardiology at the Seattle VA Medical Center, and discussion about the natural history of Prinzmetal's angina, he said that his recommendation was the same. Private treatment notes dated from October 1998 reflect diagnoses for coronary artery disease and Prinzmetal's angina. A December 2000 assessment included hypertension, hyperlipidemia, diabetes, and shortness of breath. A VA cardiology outpatient visit note dated May 1999 reflects a "problem list" that included atypical chest pain and treatment with Cardizem for possible Prinzmetal angina. A cardiology note dated September 2001 reflects the same. The assessment was atypical chest pain, doing well on Cardizem for possible Prinzmetal angina, with rare chest pain while taking medication. Cardiology notes dated September 2002 and September 2003 reflect similarly. A private medical evaluation dated April 2001 reflects that the appellant was referred for cardiology evaluation, currently with a diagnosis for syndrome X. A very long history of nonexertional and somewhat atypical chest pain was noted. After a severe episode of chest pain about 4 years ago, a perfusion scan suggested ischemia. There was no prior abnormal EKG with exercise or pain, and a coronary angiography was "completely clean." The examiner stated that "the possibility of coronary spasm or syndrome X was entertained, but it seems clear that this was a presumptive diagnosis, since no ischemia was apparently ever proven." The examiner indicated that the appellant was placed on medication. Coronary risk factors were noted, to include hypertension, diabetes mellitus, and possibly slightly elevated lipids. Past medical history included morbid obesity, hypertension, type II diabetes mellitus, and history of cholecystectomy. Examination was performed. Chest x-ray and EKG of 2000 was reviewed. The impression included no documented evidence of structural heart disease; and chest pain syndrome, possibly syndrome X. The cardiologist commented that that he believed that he diagnosis for syndrome X was a presumptive one and not proven, noting that this was a diagnosis given to patients with typical angina but no evidence of epicardial coronary stenosis. Syndrome X was felt to represent decreased coronary reserves, perhaps due to problems with resistance vessels in the myocardium. The appellant was assessed as low risk for gastric bypass surgery. Private treatment records dated 2004 and 2006 from L. Tan, MD, reflect history of Prinzmetal angina, diagnosed after negative cardiac angiogram. It was noted that prior stress test showed reversible ischemia. By history, the appellant had three episodes of chest pain a year. A letter dated October 2006 from Dr. Tan to VA reflects that the appellant had a history of chest pain dating from 1974, ongoing complaints throughout service, and symptoms following service. The physician noted that the appellant had EKG changes in 1974 during a hospitalization for tonsillectomy, which was cancelled due to those results. The physician indicated that he appellant had an ongoing issue which was not diagnosed or treated until after discharge from service, and that he continued to experience symptoms and receives treatment. He indicated that the appellant under medical care for Prinzmetal's angina as related to and consistent with Syndrome X. In a letter dated October 2007, Dr. Tan reported that the appellant had a history of chest pain dating to service currently diagnosed at Prinzmetal angina. He noted that normal diagnostic testing does not rule out Prinzmetal angina. The physician stated that the prior medical conclusions that chest pain was noncardiac were erroneous, and that the appellant's symptoms are now correctly diagnosed as Prinzmetal angina. 2. Analysis Having carefully reviewed the evidence of record, the Board finds that the weight of the evidence supports entitlement to service connection for Prinzmetal angina. The record clearly establishes that the appellant had episodes of chest pain in service. It further establishes that he has had continued complaints of chest pain following service. Although the complaint of chest pain was initially of undetermined etiology, that same chest pain has been in recent years diagnosed and treated as Prinzmetal angina. Ultimately, the evidence shows that a condition noted in service has continued since service and is now diagnosed as the disability Prinzmetal angina. Furthermore, Dr. Tan has specifically related the appellant's currently diagnosed Prinzmetal angina to the symptoms of chest pain noted in service. While cardiac work-ups in service were negative for cardiac abnormality, and there is some post service medical evidence suggesting that the appellant's chest pain was noncardiac in origin based on essentially negative EKGs, chest x-ray, and stress test findings, the more recent medical evidence reflects that the appellant's chest pain symptoms were attributable to Prinzmetal angina and that the prior normal diagnostic testing would not rule out the presence of Prinzmetal angina. Additionally, the Board finds that the appellant is competent and credible to report having had chest pain in service and since service. He is further competent to report that his symptoms have not changed or are the same as he had in service. Layno v. Brown, 6 Vet.App. 465, 469 (1994); Falzone v. Brown, 8 Vet.App. 398, 405 (1995). See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The appellant's statements of symptoms in service and since service are corroborated by the documented medical complaints and history given during treatment, as well as, during evaluation of chest pain. As such, his statements in this regard have significant probative value. The Board further finds that the favorable medical opinion of Dr. Tan is highly probative. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993)(An evaluation of the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached; the credibility and weight to be attached to such opinions are within the province of the Board as adjudicators). Dr. Tan reported in 2006 that the appellant's in-service chest pain symptoms were the same as his current chest pain symptoms, diagnosed as Prinzmetal angina. He reported again in 2007 that the appellant's history of chest pain dating to service was currently diagnosed as Prinzmetal angina. Dr. Tan's opinion is highly probative because it appears to have been based on an accurate medical history and the physician's current treatment of the appellant. See Coburn v. Nicholson, 19 Vet. App. 427, 432-433 (2006); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2006) (reliance on the service history provided by the veteran only warrants the discounting of a medical opinion in certain circumstances, such as when the opinions are contradicted by other evidence in the record or when the Board rejects the statements of the veteran). See also Nieves-Rodriguez, 22 Vet. App. at 304 (a private medical opinion may not be discounted solely because the opining physician did not review the claims file and the Board may not prefer a VA medical opinion over a private medical opinion solely because the VA examiner reviewed the claims file). Furthermore, Dr. Tan is a trained physician treating the appellant for Prinzmetal angina, so he is therefore knowledgeable on medical matters generally, as well as, on the appellant's medical history, symptoms, and objective findings specifically. It is noted that VA attempted to obtain a medical opinion on the question of whether chest pain diagnosed as Prinzmetal angina is related to service, including chest pain noted in service. However, in an August 1998 VA medical opinion, the examiner stated that she could not answer that question without there having been a diagnosis for Prinzmetal angina or coronary vasospasms in service. The examiner concluded stated that it is undetermined whether the chest pain in service is the same chest pain had presently, and caused by the same mechanism. The Board finds that, because the examiner did not respond to the question posed for adjudication purposes, the evidence is best characterized as "non- evidence." See Tirpak v. Derwinski, 2 Vet. App. 609 (1992); Sklar v. Brown, 5 Vet. App. 140 (1993); Perman v. Brown, 5 Vet. App. 237, 241 (1993). See also Jones v. Shinseki, 23 Vet. App. 382, 390 (2010) (An examiner's conclusion that a diagnosis or etiology is not possible without resort to speculation is a medical conclusion just as much as a firm diagnosis or a conclusive opinion; however, the examiner must explain the basis for such an opinion, or the basis must otherwise be apparent in the Board's review of the evidence). Therefore, the Board finds that the August 1998 VA medical opinion weighs neither for nor against the claim. This evidence has no probative value. The Board has further considered the evidence of record suggesting that the appellant's chest pain was attributable to GERD and/or gallstones. However, in view of the subsequently dated treatment and evaluation records for chest pain showing that it did not resolve with treatment for GERD and/or gallstones, coupled with the favorable medical opinion to the effect that the appellant's chest pain is properly diagnosed as Prinzmetal angina, the Board finds that this medical evidence has less probative as compared to that favorable to the claim. Weighing the evidence of record, the Board finds that the preponderance of the evidence supports entitlement to service connection for Prinzmetal angina. Regulation requires continuity of symptomatology, not continuity of treatment. Wilson v. Derwinski, 2 Vet. App. 16 (1991). In this case, the Board finds that the lay evidence is competent, credible, and persuasive. Likewise, the Board finds that the medical evidence favorable to the claim is persuasive. Therefore, based upon the lay and medical evidence, the Board finds that the appellant's assertions of in-service onset and continuity of symptoms are sufficient to establish service connection for Prinzmetal angina. Accordingly, the claim is granted. ORDER Service connection for Prinzmetal angina is granted. REMAND VA's duty to assist includes obtaining pertinent medical records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. It further includes providing an adequate examination when such an examination is indicated. Id.; Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) Headache In a July 1988 rating decision, the RO awarded service connection for headache at the 10 percent disability level, effective from April 1, 1987, under Diagnostic Code 8100. Under Diagnostic Code 8100, a 10 percent rating is warranted for characteristic prostrating attacks averaging one in 2 months over the last several months; a 30 percent rating is warranted for characteristic prostrating attacks occurring on an average once a month over last several months and with less frequent attacks; and a 50 percent rating is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. A VA treatment note dated September 2003 reflects that migraine headaches had improved since the appellant had started Cardizem for Prinzmetal angina. In May 2006, the appellant requested an increased rating for headache. He did not describe the severity, frequency, or duration of his headache symptoms. On VA examination in June 2006, the appellant reported that he had headaches 4 times a week, on average, associated with symptoms of nausea, vomiting, odor sensitivity, and chest pain. The symptoms described "occur intermittently as often as once a day with each occurrence lasting for 8 hours." He treated with Metoprolol. The appellant stated that, when an attack occurs, he stays in bed and is unable to do anything. Neurological examination was within normal limits. The diagnosis was headaches, no change subjectively or objectively. In October 2007, Dr. Tan reported that the appellant had headaches several times a week to several times a month, and that he had referred him to Dr. Rubenstein, a neurologist. An attached letter from Dr. Rubenstein reflects that he evaluated the appellant in December 2004 and that the appellant had migraine headaches with aura. His headaches were described as much less severe since being placed on Diltiazem for Prinzmetal angina 5 years earlier. The physician reported that the appellant had headaches occurring frequently, twice or more weekly, and with intensity rated as 5 out of 10. In a statement dated October 2007, the appellant cites treatment notes dated 1982 and 1985 in support of his request for an increase rating. He further notes that his military records show migraines occurring 2-3 times a month, and that his civilian records document headaches several times a week. He reports that he should have been awarded a 50 percent rating for migraines during the initial assignment of a disability rating. On review of the evidence, the Board finds that further evidentiary development is required. First, VA should attempt to obtain the private treatment records or evaluation report of Dr. R. Rubenstein pertaining to headache. Second, VA should attempt to obtain all private treatment records of Dr. Tan dated since December 2006. Third, the appellant should be scheduled for a VA examination to ascertain severity of his headache disorder. Tremor The appellant seeks service connection for a neurological disorder that he reports is diagnosed as tremor. A review of the record shows that service retirement examination dated February 1987 reflects normal clinical evaluation of the neurological system. Report of VA examination dated June 2006 reflects that hand tremor was absent on examination. Neurological examination of the upper extremities revealed normal motor and sensory function. Coordination was within normal limits. Biceps and triceps jerks were 2+, bilaterally. The diagnosis did not include tremor. A letter from Dr. Rubenstein reflects that the appellant had normal neurological examination during a December 2004 evaluation except for essential tremor, left greater than right. The record suggests that there are outstanding medical records pertaining to tremor of Dr. Rubenstein. VA's duty to assist requires that VA attempt to obtain these records. Therefore, a decision cannot be rendered at this time. Accordingly, the case is REMANDED for the following action: 1. VA should request all private treatment records of Dr. R. Rubenstein pertaining to headache and tremor. 2. VA should request all private treatment records of Dr. L. Tan dated since December 2006. 3. The appellant should be scheduled for a VA examination to ascertain the severity of his current headache disorder. The report of examination should address the frequency, duration, and severity of the appellant's headaches. The claims folder should be available for review. Any opinion expressed must be accompanied by a complete rationale. 4. After the development requested above has been completed to the extent possible, the RO should again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the appellant and representative, if any, should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs