Citation Nr: 1310946 Decision Date: 04/02/13 Archive Date: 04/11/13 DOCKET NO. 09-50 883 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for a respiratory disorder, to include as secondary to the service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for residuals of a stroke, to include as secondary to the service-connected PTSD. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 U.S.C.A. § 7107(a)(2) (West 2002) and 38 C.F.R. § 20.900(c) (2012). The Veteran served on active duty from January 1951 to October 1952. His awards and decorations include the Combat Infantryman Badge (CIB) for combat action during the Korean Conflict. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a March 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia that in relevant part denied the Veteran's request to reopen previously-denied claims of service connection for a left lung condition and for pneumonia. The rating decision also denied a new claim of service connection for stroke. In November 2010, the Board issued a decision that new and material evidence had been received to reopen the previously-denied claims of service connection for a left lung condition and for pneumonia; that action remanded the case to the Originating Agency for adjudication of the merits. The same action remanded the issue of service connection for stroke. The Board has remanded these issues to the Originating Agency on several occasions, most recently in December 2012. The development requested by the Board has been completed, and the file has been returned to the Board for further appellate review. FINDINGS OF FACT 1. The Veteran does not have a respiratory disorder that is etiologically related to service or that is caused or permanently worsened by his service-connected disabilities, to include PTSD. 2. The Veteran's first stroke was in 2008, 56 years after discharge from service; there is no indication that an underlying cardiovascular-renal disease was manifested during service or to a compensable degree within the first year after discharge from service. 3. The Veteran does not have residuals of a stroke that are etiologically related to service or that are caused or permanently worsened by his service-connected disabilities, to include PTSD. CONCLUSIONS OF LAW 1. A respiratory disorder was not incurred in or aggravated by service or proximately due to or aggravated by a service-connected disability. U.S.C.A. §§ 1101, 1110, 1112 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. Residuals of a stroke were not incurred in or aggravated by service or proximately due to or aggravated by a service-connected disability, nor may incurrence during service of a cardiovascular-renal disease be presumed. U.S.C.A. §§ 1101, 1110, 1112 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Before addressing the merits of the Veteran's claims on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The VA is required to assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The VA is required to notify a claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, the VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, the VA will attempt to obtain on behalf of the claimant. In addition, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant be provided "at the time" of, or "immediately after," the VA's receipt of a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). Complete notification in this case was not provided to the Veteran prior to the rating decision on appeal, in that he was not notified of the elements to show entitlement to service connection on a secondary basis (in that regard, he raised the claim for secondary service connection after the rating decision, during the course of the appeal). However, complete notice was provided to the Veteran by a letter in November 2010, and the Veteran had ample opportunity before the Originating Agency readjudicated the appeal in April 2011. In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing an error is harmful or prejudicial normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. In February 1993 the National Personnel Records Center (NPRC) notified VA that the Veteran's service treatment records (STRs) could not be located and were presumed to have been destroyed by a fire at that facility. The RO sent an inquiry for records to the U.S. Army Reserve Personnel Center, which advised VA in May 1993 that the request had been forwarded to the National Archives and Records Administration (NARA), but no records relating to the Veteran have been uncovered by that agency. In April 1994 it was determined that the U.S. Army Surgeon General's Office did not have any treatment records. The Veteran has been notified of the loss of his records and has stated on numerous occasions that he does not have any additional records in his personal possession. The Veteran's Social Security Administration (SSA) disability records have been obtained, as have treatment records from those VA and private medical providers the Veteran identified as having potentially relevant records. The Veteran was notified of his entitlement to a hearing before the Board but has not requested a hearing. The Board remanded the claim to the Originating Agency in November 2010 for the purpose of affording the Veteran a VA examination, which was performed in January 2011. In September 2011 the Board returned the case to the RO for an addendum opinion by the examiner, which was provided in December 2011. In December 2012 the Board remanded the case yet again for medical examination to consider arguments that had been newly submitted by the Veteran's representative; the opinion was provided in January 2013. The Board has reviewed these examination reports/opinions and finds that they substantially comply with the requirements articulated in the Board's remands. See D'Aries v. Peake, 22 Vet. App. 97 (2008), citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that in the context of medical examinations/opinions only substantial compliance, not strict compliance, with the terms of the Board's opinion request is necessary). Neither the Veteran nor his representative has made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and neither has argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced the appellant in the adjudication of his appeal. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield, 499 F.3d 1317. Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Legal Principles Service connection Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be presumptively granted for cardiovascular-renal disease that becomes manifest within one year of discharge from service, even if not shown during service. 38 C.F.R. §§ 3.307, 3.309(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). The second and third elements may be established by showing continuity of symptomology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (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." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). Service connection may also be granted for disability that is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability is also compensable under 38 C.F.R. § 3.310, which provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service- connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity due to the natural progress of the disease from the current level. To prevail on the issue of secondary service causation, the record must generally show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Evidentiary considerations In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d 1313, 1316; Jandreau, 492 F.3d 1372, 1376-77. When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. 498, 511. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Where service medical records were destroyed, the veteran is competent to report about factual matters about which he had firsthand knowledge, including experiencing pain during service, reporting to sick call, and undergoing treatment. Washington v. Nicholson, 19 Vet. App. 362 (2005). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Case law does not establish a higher benefit-of-the-doubt standard in situations where service records were destroyed, but rather heightens the duty of the Board to consider the benefit-of-the-doubt rule, to assist the claimant in developing his claim, and to explain its decision. Ussery v. Brown, 8 Vet. App. 64 (1995). Evidence and Analysis Service connection for a respiratory disorder Service treatment records (STRs) are not available and are presumed to have been destroyed in a fire at the National Personnel Records Center (NPRC) in 1973. In September-October 1972 the Veteran was treated at a VA hospital for complaint of a three-day history of left lower chest pain, associated with a low-grade fever and unproductive cough. At the time of examination the Veteran began to exhibit hemoptysis and considerable dyspnea. The Veteran reported having been treated for pneumonia in 1966. Physical examination showed fine rales in the left base posteriorly and a very notable splinting in the left. Chest X-ray revealed a blunted right hemidiaphragm, prominent vascular markings bilaterally and a high left hemigiaphragm with a questionable lingular segment infiltrate. The diagnosis was idiopathic multiple emboli with infarction. No source was shown for the pulmonary emboli because a venogram performed during inpatient treatment was entirely normal. The file contains a Social Security Administration (SSA) disability report executed by the Veteran in April 1993 in which he reported shortness of breath; he reported having been treated for a collapsed lung/blood clot in 1972, with no subsequent problem or treatment. Thereafter, an SSA Report of Contact in May 1993 titled "clarification" states the Veteran had gone to SSA in 1972 because he thought he had pneumonia but he was informed at the time that he had a blood clot and collapsed lung. The Veteran continued to suffer from shortness of breath but had not had X-rays or pulmonary function tests since 1972, The Veteran had a disability examination in May 1986 in conjunction with a claim for Social Security Administration (SSA) disability benefits. The Veteran's primary complaint was back pain. In regard to respiratory complaints, the Veteran reported having had a blood clot in the lungs in 1973 with dyspnea and shortness of breath thereafter. The Veteran denied chronic cough but endorsed intermittent chest pain. The Veteran endorsed having had pneumonia in the past; chest X-ray showed old pleural thickening. The examiner performed a thorough physical examination and noted observations in detail; no current disorder of the lungs was recorded. A VA chest X-ray in June 1987 showed elevation of the left hemidaphragm with adhesions peripherally, and pleural adhesions in the left chest wall with pleural thickening. The examiner stated an opinion that such findings were the result of an old trauma to the left chest and possibly to a previous rupture of the left hemidiaphragm. A VA triage record dated in December 1992 shows the Veteran was seen for complaints including trouble breathing, chest pain and a feeling of heavy legs, reportedly for a period of several months. He reported previous history of blood clot in the lungs in 1972 or 1973 and pneumonia. In January 1993 the Veteran filed a claim for service connection for a lung condition. In conjunction with the claim, he stated his lung had been injured in a jeep accident in Korea during which his ribs were fractured and his lung punctured. (The Board notes parenthetically that VA has conceded that the Veteran had a jeep accident in Korea as he asserts despite the absence of objective evidence; see Remand in September 2011, page 5-6). Therefore, the question of whether the accident did or did not occur is moot and will not be addressed below, although the severity of such an accident is relevant.) The Veteran submitted a letter in February 1993 asserting he had problems with his lungs ever since he came out of service. The Veteran had a VA examination in March 1993 during which he complained of chest pains and productive cough; he also reported dyspnea when walking 400-500 yards. Clinical examination showed the chest to be symmetrical and non-tender, with no restriction of expansion. The lungs were clear to pulsation, but diminished sounds were noted over the left lung fields more than right. No rales or wheezes were heard. Chest X-ray showed parynchymal and pleural scarring in the left lung base but was essentially normal in regard to a current disorder, and X-ray of the ribs was normal. The examiner did not diagnose a current lung disorder. During an RO hearing in February 1994 the Veteran reiterated he had been in a jeep accident in Koreas that had "mashed all the air out of him." The Veteran stated he believed his lung had collapsed and never subsequently straightened out. He reported having been treated in the late 1950s or early 1960s for pneumonia and pleurisy, and that he was subsequently treated for pneumonia. He was informed on one occasion that his left lung was essentially lying at an angle. An April 1996 "buddy statement" from RW states he remembered that a jeep rolled over the Veteran during service; RW had helped to lift the jeep off the Veteran at the time. RW knew the Veteran was injured, but he did not know the extent of those injuries because the patrol had to continue. The file contains a letter from the Veteran's sister dated in May 1994 stating the Veteran had told her of the jeep accident in Korea that had broken his ribs and forced the breath from his body. She stated her belief that the Veteran had been injured more than anyone recognized at the time, and stated the Veteran had lots of trouble with his lungs over the years. The file contains a December 1997 psychiatric evaluation by Dr. F. Joseph Whelan, in which the Veteran reported a jeep accident in service in which his ribs on the right side were fractured and his left lung was collapsed. Dr. Whelan diagnosed PTSD (for which the Veteran was later granted service connection) and stated an opinion that it was very probable that much of the Veteran's difficulties with his lungs (and heart and legs) were causally related to injuries sustained during active duty, and that to a reasonable degree of medical certainty that the Veteran's present debilitating and disabling conditions were in large part related to injuries sustained during service. In April 1999 the Veteran submitted copies of various articles describing the effects of blunt force trauma to the heart and chest, posttraumatic pulmonary insufficiency and pneumonia. The Veteran testified before the Board in August 1999 by videoconference in support of his request to reopen previously-denied claims for numerous disabilities including a lung injury and pneumonia. During that hearing he related having suffered broken ribs in a jeep accident in service. He was taped up and returned to duty. After several months the Veteran sought hospital treatment and was hospitalized for approximately 33 days; the only diagnoses he could remember were hepatitis and intestinal worms. After service, the Veteran had a blood clot in the lung in 1972. In conjunction with the hearing cited above the Veteran presented a document he had written in which he described having been pinned beneath a jeep with resultant inability to get a deep breath and loss of control of the bowels; following the injury he was forced to remain in combat with his unit but he became progressively sicker until he had to be hospitalized. He also reported therein a post-service medical history significant for problems including acute pulmonary emboli that developed approximately 20 years after discharge from service; chest X-ray at the time showed a consolidated lower left lobe. The document bears the signatures of seven physicians or other medical providers, indicating their endorsement that an untreated injury as described in the Veteran's scenario could have created chronic medical problems including pulmonary emboli. The Veteran had a VA-contracted psychiatric examination in August 1999 in which he reported shortness of breath that he attributed to being in a jeep accident in which his left lung "half collapsed" and never subsequently reinflated. The examiner diagnosed moderate PTSD related to combat experiences in Korea. The report is silent in regard to any association between the diagnosed PTSD and the ongoing lung condition. The Veteran presented to the VA primary care clinic (PCC) in October 1999 complaining of shortness of breath. The Veteran was noted to have chronic obstructive pulmonary disease (COPD). The Veteran had a VA psychiatric examination in April 2000 in which he stated that in addition to combat-related stressors he had a jeep accident in which a jeep turned over on him, resulting in broken ribs and collapsed lungs. The examiner diagnosed PTSD as due both to combat trauma and the jeep accident. The report does not list shortness of breath or any other respiratory disorder as a significant current medical problem, and the report is silent in regard to any exacerbation of PTSD from a current lung condition. The file contains a November 2000 Supplemental Psychiatric Report by Dr. Whelan stating a diagnosis in Axis I (current clinical disorders) of PTSD causally related to being in service during the Korean Conflict. In Axis III (general medical conditions) Dr. Whelan noted "trouble with the heart, lungs and orthopedic problems which are also causally related to basic training in the Army, as well as the Korean Conflict." (Axis III is for reporting current general medical conditions that are potentially relevant to the understanding or management of an individual's mental disorder; when a mental disorder is judged to be a direct psychological consequence of the general medical condition, a Mental Disorder Due to a General Medical Condition should be diagnosed on Axis I and the general medical condition should be recorded on both Axis I and Axis III. See Quick Reference to the Diagnostic Criteria from DSM-IV, Washington, D.C., American Psychiatric Association, 1994, pg. 39-40.) The Veteran had a VA psychiatric examination in January 2001 in which the Axis I diagnosis was PTSD and the Axis III diagnosis was COPD, as well as arteriosclerotic heart disease, diabetes mellitus, chronic arthritis and chronic pain in the lower extremities. The examination report is silent in regard to any relationship between PTSD symptoms and respiratory problems. A VA chest X-ray in February 2001 showed an impression of no acute process, pulmonary emphysema, minimal pleural thickening of the left hemothorax and no significant change to the chest since December 1992 or August 1998. A VA outpatient treatment note in April 2001 noted an impression of COPD, stable. The Veteran presented to the VA emergency room in December 2006 complaining of productive cough for the last 4 days, with low-grade fever and continued chronic shortness of breath. Chest X-ray showed COPD and eventration of the left hemidiaphragm. The clinical assessment was upper respiratory infection (URI), hyperglycemia and mild hyponatremia. The Veteran had a VA chest X-ray in November 2008, performed in conjunction with emergency treatment for a cerebrovascular accident (CVA). The interpreter's impression was chronic elevation of the left hemidiaphragm unchanged from prior studies; there was no cardiomegaly or congestive heart failure (CHF) or infiltrate or effusion. The file contains a letter from the Veteran's daughter, who identifies herself as a Registered Nurse (RN), dated in December 2008. The Veteran's daughter asserts the Veteran having lost half of his left lung in the jeep accident in Korea and that the body is able to compensate for injuries while the injured person is young, but as the person ages the body becomes weaker and unable to compensate. The fact the Veteran was currently using oxygen 24 hours per day indicates that his respiratory symptoms had won out over his formerly strong body and showed his lung disorder was due to the jeep injury. The Veteran had a VA examination in January 2011, performed by a physician who reviewed the claims file. The Veteran was accompanied by his daughter, who helped answer questions regarding the Veteran's medical history. The Veteran recounted his jeep accident in Korea, with reported broken ribs and left lung blood clot. The Veteran reported his current respiratory symptoms; he denied history of bronchial asthma, COPD or lung malignancy. The examiner performed a clinical examination of the Veteran and diagnosed COPD. The examiner stated an opinion that the Veteran's COPD was not related to service. The examiner stated in support of his opinion that there was no indication of pneumonia on current chest X-ray, and COPD with left lung scarring was more likely due to past history of smoking. The Veteran submitted a letter in February 2011 attacking the VA examination cited above. The Veteran asserted he had never been diagnosed with COPD and that such diagnosis is not appropriate in his case. In December 2011 the file was returned to the VA physician who had performed the January 2011 examiner, with a request to provide a more extensive opinion in regard to the etiology of the Veteran's respiratory disorder; he was specifically instructed that VA had conceded the Veteran's in-service jeep accident. The examiner continued his previous opinion that the Veteran's current COPD was not related to service. The examiner stated the Veteran had an accident in 1951 that resulted in broken ribs with lung injury, but per medical literature a simple jeep accident in 1951 (healed) does not cause COPD or obstructive airway disease. The Veteran had a history of smoking, although he quit smoking in 1974. The examiner stated he believed the Veteran's diagnosis of COPD had a contributing factor from smoking. Chest X-ray in January 2011 showed left costophrenic angle pleural thickening, lateral chest wall pleural thickening, chronic changes and normal-sized heart; the X-ray does not show a rib fracture or rib injury. Thus, the Veteran's pleural thickening was related to COPD but not caused by or related to the jeep accident. In November 2012 the Veteran's representative submitted a Post-Remand Brief asserting that the Veteran had smoked in an effort to self-medical from symptoms of PTSD; thus, PTSD caused smoking, and since smoking caused COPD, a causal relationship was established between PTSD and COPD. In December 2012 the Board remanded the case to the Originating Agency for the specific purpose of obtaining a medical opinion as to whether the Veteran's respiratory disorder (to include left lung scarring and COPD) was caused or aggravated by the service-connected PTSD. In response to the Board's remand the Veteran was re-examined in January 2013 by the same VA physician who had performed the examination in January 2011 and who had provided the addendum opinion in December 2011. The Veteran reported history of being treated for a blood clot on the lungs and having been diagnosed with COPD in 2002. The examiner performed a clinical examination and noted observations in detail; current chest X-ray showed chronic changes with lateral chest wall pleural thickening including left costophrenic angle pleural thickening. The examiner diagnosed COPD. In regard to etiology, the examiner stated the blood clot on the Veteran's lung appears to have been treated properly and was acute, with no evidence of subsequent clot on repeated X-rays. Multiple chest X-rays also showed no indication of rib fractures. There was no evidence of continuation of symptoms after service. The examiner stated there is no medical evidence that PTSD causes or worsens COPD with lung scarring. While PTSD may temporarily worsen symptoms there are no documented studies showing PTSD causes permanent problems that lead to a diagnosis of COPD with lung scarring or that PTSD worsens such disability; there are some speculative reports but these are only speculation without firm documented evidence as to cause-and-effect. On review, the evidence of record demonstrates the Veteran has been diagnosed with COPD. Thus, the first element of service connection - medical evidence of a claimed disability - is met. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000. This is the essence of the third part of the service-connection analysis. Because the Veteran's service records were destroyed while in government custody his account of symptoms in service is considered credible, and his account of a jeep accident in service has also been deemed credible. Washington, 19 Vet. App. 362. However, in such a situation case law does not lower the legal standard for proving a case of service connection, but rather increases the Board's obligation to evaluate and discuss in its decision all the evidence that may be favorable to the veteran. Russo v. Brown, 9 Vet. App. 46 (1996). The Veteran asserts he had a punctured lung during service and that he has had continuous respiratory since service, but he does not have a diagnosed respiratory disorder that is included in 38 C.F.R. § 3.309(a). Accordingly, service connection for a chronic disorder is not for application based on the Veteran's report. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where an opinion is used to link the current disability to a cause during service, a competent opinion of a medical professional is required. Caluza, 7 Vet. App. 498. In this case, there is conflicting medical opinion regarding whether the Veteran has a respiratory disorder due to service. Supporting the Veteran's claim is the evaluation by Dr. Whalen in December 1997 asserting it is "very probable" that much of the Veteran's difficulties with his lungs (and heart and legs) were causally related to injuries sustained during active duty and that to a reasonable degree of medical certainty that the Veteran's present debilitating and disabling conditions were in large part related to injuries sustained during service. Similarly, Dr. Whelan stated in November 2000 that trouble with the heart, lungs and orthopedic problems are causally related to basic training in the Army, as well as the Korean Conflict. Also supporting the Veteran's claim is the August 1999 document signed by seven physicians or other medical providers, indicating their endorsement that an untreated injury as described in the Veteran's scenario could have created chronic medical problems including pulmonary emboli. Finally, the December 2008 letter from the Veteran's daughter, who is a nurse, asserts the Veteran lost half of his left lung in the jeep accident in Korea and that the current severity of the Veteran's respiratory disorder shows his lung disorder is due to such injury in service. Medical opinion against the claim is provided by the VA examination report in January 2011, the addendum opinion in December 2011 and the new examination report in January 2013, all of which were provided by the same VA physician. These reports consistently show an opinion that the Veteran's diagnosed COPD was not related to service, to include the jeep injury, but more likely related to history of smoking. It is the Board's duty to assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. Owens v. Brown, 7 Vet. App. 429, 433 (1995). As true with any piece of evidence, the credibility and weight to be assigned to these opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Applying the standards of Nieves-Rodriguez to the medical opinions of record, the Board finds the opinions of the VA examiner are more probative than the conflicting opinions cited above. The first inquiry of Nieves-Rodriguez is whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; review of the claims file, in and of itself, does not make a medical opinion more or less probative. The VA examiner had access to the Veteran's compete VA and private treatment records, as well as the Veteran's subjective history as articulated in treatment records and correspondence to VA; the VA examiner is accordingly shown to have been fully informed of the pertinent factual premises. In contrast, Dr. Whalen in not shown to have had access to any records other than his own treatment notes, and the providers who signed the Veteran's letter in August 1999 apparently had no factual premises other than the Veteran's scenario that was presented to them as a hypothetical. Finally, the Veteran's daughter apparently stated as a factual premises that the Veteran had "lost half his left lung" in Korea, but this is not shown by any evidence of record and is thus an insufficient factual predicate. Thus, of the medical opinions of record, the aggregate opinions of the VA examiner more fully satisfy the first element of Nieves-Rodriguez. The second inquiry of Nieves-Rodriguez involves consideration of whether the medical expert provided a fully-articulated opinion versus speculation. The VA examiner stated it is less likely than not that COPD is related to service to include jeep accident, and Dr. Whalen stated that to a reasonable degree of medical certainty that the Veteran's present debilitating and disabling conditions were in large part related to injuries sustained during service. Thus, while these opinions are conflicting, both are fully-articulated. In contrast, the August 1999 letter by seven medical providers states that an untreated injury as described in the Veteran's scenario "could have" created chronic medical problems including pulmonary emboli, which is a speculative opinion and does not relate to a current diagnosis. Similarly, the Veteran's daughter asserted the severity of the Veteran's current respiratory disorder demonstrated a relationship to a severe chest injury in service, but this is speculation rather than a fully-articulated opinion. The third, and most important, inquiry in Nieves-Rodriguez involves consideration of whether the opinion is supported by a reasoned analysis. The VA examiner provided extensive clinical rationale for his opinions to include citations of documented and subjective medical history and observations of clinical examination. In contrast, Dr. Whalen provided no clinical rationale whatsoever in support of his opinion, nor did the seven medical providers in August 1999. The Veteran's daughter provided as rationale that the Veteran had been able to compensate for his severe in-service injury until his later year, but her rationale is based on a factual predicate that was not demonstrated (loss of half the left lung during service). In sum, the Board has found the opinions articulated in aggregate by the VA examiner are the most probative opinions of record and show the Veteran does not have a respiratory disorder that is directly related to active service. Turning to the question of secondary service connection, the VA examiner stated the Veteran's service connected PTSD did not cause and does not aggravate the Veteran's current COPD. This is consistent with the voluminous treatment records in the claims file addressing PTSD symptoms and respiratory symptoms, none of which show a relationship or association between the two disorders. Further, this opinion regarding possible secondary service connection is not contradicted by any other medical opinion of record. The Veteran is also service-connected for loss of use of the bilateral feet, degenerative joint disease (DJD) of both knees and DJD of the lumbosacral spine. The Veteran has not asserted, and the evidence of record does not suggest, that his claimed respiratory disorder is etiologically related in any way to these other service-connected disorders. The Board acknowledges at this point that the Veteran has submitted copies of various articles describing the effects of blunt force trauma to the heart and chest, posttraumatic pulmonary insufficiency and pneumonia, and that the Veteran's representative has cited medical articles relating psychiatric disorders such as PTSD to increased respiratory symptoms. "Competent medical evidence" may mean statements conveying sound medical principles found in medical treatises, and can include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). However, treatise evidence alone is usually "too general and inconclusive" to establish a medical nexus; see Sacks v. West, 11 Vet. App. 314, 317 (1998). A medical article or treatise can provide important support when combined with an opinion of a medical professional if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least a plausible causality based upon subjective facts rather than unsubstantiated lay opinion; see Mattern v. West, 12 Vet. App. 222, 228 (1999). In this case the articles provided by the Veteran or cited by his representative are not accompanied by any medical evidence showing the general opinions cited therein are specifically applicable in the Veteran's case. Finally, VA must consider all favorable lay evidence of record. 38 U.S.C.A. § 5107(b); Caluza, 7 Vet. App. 498. Accordingly, in addition to the medical evidence of record the Board has carefully considered the lay evidence offered by the Veteran in the form of his correspondence to VA and his statements to various medical providers and examiners. The Board must consider the purpose for which lay evidence is offered. Washington, 19 Vet. App. 362. The Veteran's lay evidence is offered to show a relationship between his chronic respiratory disorder, diagnosed as COPD, with an injury in service; alternatively, his lay evidence is offered to show that his chronic respiratory disorder is caused or aggravated by the service-connected PTSD. However, a respiratory disorder such as COPD, which has multiple possible contributing causes, is not a disability for which lay opinion is competent. Kahana, 24 Vet. App. 428; Jandreau, 492 F.3d 1372. In sum, the Board has found the most probative medical opinion of record shows the Veteran's current respiratory disorder, diagnosed as COPD, is not likely related to service or to the service-connected PTSD. Accordingly, the preponderance of the evidence is against the claim and the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54; Ussery, 8 Vet. App. 64. Service connection for residuals of a stroke As noted above, STRs are not available and were presumably destroyed by a fire at the NPRC in 1973. Stroke, or cardiovascular accident (CVA), is a cardiovascular-renal disease. Service connection may be granted presumptively if such disease is manifested to a compensable degree within the first year after discharge from service. The Veteran in this case has not asserted, and the evidence of record does not suggest, that he had a stroke prior to 2008, or that an underlying cardiovascular-renal disease was manifested during service or to a compensable degree within the presumptive period. In that regard the Veteran is shown to have post-service cardiovascular diseases including coronary artery disease, ischemic heart disease and hypertension, but these are not service-connected disabilities and no relationship has been demonstrated between these disorders and service. Accordingly, service connection for strokes on a presumptive basis is not for consideration. In September-October 1972 the Veteran was treated at a VA hospital for complaint of a three-day history of left lower chest pain; during treatment he was diagnosed with idiopathic multiple pulmonary emboli with infarction and with thrombophlebitis of both lower extremities. However, a venogram performed during inpatient treatment was entirely normal. The Veteran was examined by Dr. Donald N. Berning in March 1983 in conjunction with a claim for worker compensation benefits for a back disorder. During interview the Veteran reported having had blood clots in 1972 and that he still had a great fear of that particular situation. Examination showed the peripheral pulses to be good, and no cardiopulmonary abnormality was noted on examination. In a follow-up note dated in June 1983 Dr. Berning stated the Veteran's blood clot in 1972 had apparently come "out of the clear blue sky." Dr. Berning alluded to no subsequent or current instances of blood clots. A treatment note by Dr. David Mattingly, dated in May 1983, states the Veteran presented complaining of pain in the low back, right leg and left foot. Peripheral vascular examination was within normal limits. Dr. Mattingly's impression was chronic mechanical low back pain, left plantar fasciitis and no evidence of claudication, with good peripheral vascular status. The Veteran had a disability examination in May 1986 in conjunction with a claim for SSA disability benefits. The Veteran reported having had a blood clot in the lungs in 1973, but he denied current cardiopulmonary treatment or medication. On examination the peripheral pulses were palpable bilaterally, with no evidence of peripheral vascular insufficiency, varicose veins or stasis ulcers. In relevant part, the examiner's diagnosis was dyspnea probably secondary to exogenous obesity. The Veteran was examined by Dr. Ron Koppenhoefer in September 1987 in conjunction with a claim for worker compensation for a back injury. The Veteran reported during interview that he had worn support stockings for the past 3 years due to leg edema, and that without such stockings his legs would swell tremendously. Dr. Koppenhoefer noted the Veteran had gained 40 pounds over the last 7 years (his current weight was 240 pounds) and that he had a 20-pack-year history of smoking. Examination of the lower extremities showed marked edema bilaterally. A VA triage record dated in December 1992 shows the Veteran was seen for complaints a feeling of heavy legs, reportedly for a period of several months. A VA interim progress note dated in July 1995 states that in February of that year the Veteran had been diagnosed with ischemic heart disease, coronary artery disease (CAD), angina pectoris, exogenous obesity, hypoalphalipoproteinemia, hypertension and hyperlipidemia. The Veteran was placed on a number of medications. The Veteran presented to the VA PCC in August 1998 complaining of pain in the legs and knees. Examination showed non-pitting edema of both legs with signs suggestive of venous insufficiency. The Veteran testified before the Board in August 1999 by videoconference in support of his request to reopen previously-denied claims for numerous disabilities. He reported having a blood clot in the lung in 1972, and that during the period 1973-74 he was on blood thinners "and stuff." The Veteran presented to the VA PCC in October 1999 complaining of leg pain. The clinician noted the Veteran had heart catheterization in 1993 that revealed two blocked coronary arteries. Examination showed no current peripheral edema or venous insufficiency. However, the clinician noted that ultrasound of the carotid arteries had shown 66 percent and 44 percent blockage of the right and left internal carotid arteries, respectively. The Veteran had a VA Doppler ultrasound in June 2001 that showed 56 percent stenosis in the right carotid and 43 percent stenosis in the left carotid, both of which were characterized as moderate-diameter stenosis. The Veteran presented to the VA emergency room in November 2008 because of weakness in the left arm and left leg. Computed tomography (CT) scan of the head showed moderate diffuse enlargement of the cerebrospinal fluid (CSF) spaces consistent with age-related atrophy with additional indication of possible early edema and possible early ischemic infarct. The clinical impression was cerebrovascular accident (CVA) due to left cerebellar ischemic infarct and ischemic infarct high convexity mid-left parietal lobe; and, hypertension. During inpatient treatment the Veteran had an echo-carotid study that showed 60-70 percent stenosis of the proximal right internal carotid artery and 40-50 percent stenosis of the proximal left internal carotid artery. Clinical history noted risk factors for CVA including hypertension, diabetes and CAD. The Veteran stated he had a crush injury to the chest in service and that he had "read in a doctor's manual" that he could have a resultant clot lying between the heart and the lung. The file contains a letter from the Veteran's daughter, who identifies herself as an RN, dated in December 2008. The Veteran's daughter asserts that stroke can be due to lack of oxygen to the brain (also called anoxic head injury) which could be related to the Veteran having lost half of his left lung in the jeep accident in Korea. The Veteran presented to the VA emergency room in December 2008 because he had become dizzy at home and suffered a fall. The clinical assessment was dizziness due to old cerebellar infarction; doubt new CVA. An updated treatment note shows formal diagnosis of generalized weakness, old CVA and type II diabetes. The Veteran had a VA examination in January 2011, performed by a physician who reviewed the claims file. The Veteran was accompanied by his daughter, who helped answer questions regarding the Veteran's medical history. The Veteran endorsed having had strokes in November and December 2008; although he had been getting better day-by-day since then he continued to have weakness on the left side. The examiner performed a clinical examination of the Veteran and diagnosed stroke with complete recovery. The examiner stated an opinion that the Veteran's stroke had not been caused by or worsened by his left lung injury or pneumonia. The examiner stated in support of his opinion that it is more likely the Veteran's stroke was multifactoral, including his history of diabetes, hypertension and hyperlipidemia. The Veteran had a history of pulmonary embolism documented in 1972, but that resolved; he had a subsequent stroke in 2008. Per medical literature, remote pulmonary embolism does not cause or worsen stroke or transient ischemic attack (TIA). The Veteran submitted a letter in February 2011 attacking the VA examination cited above. The Veteran asserted the examiner's opinion regarding likely causes of stroke was speculative and the examiner had not considered the significance of the Veteran's umbilical hernia or his treatment for blood clot (pulmonary embolism); the examiner also did not discuss the Veteran's reported blood clot in the shoulder. The Veteran received inpatient treatment at VA in April 2011 for complaint of right-side weakness and numbness. During inpatient treatment the right-side weakness essentially resolved versus baseline. The discharge diagnosis was acute CVA with right side weakness, arteriosclerotic cardiovascular disease (ASCVD), COPD and hilar adenopathy. The Veteran submitted a letter in May 2011 stating he had recently had another stroke, this one resulting in decreased function of his right side. A VA primary care clinic (PCC) treatment note dated in May 2011 states the Veteran presented with complaint of right hand weakness status post CVA. In December 2011 the file was returned to the VA physician who had performed the January 2011 examiner, with a request to provide a more extensive opinion in regard to the etiology of the November 2008 stroke (and other recent stroke with residuals). The examiner stated an opinion that the Veteran's stroke was not caused or aggravated by the Veteran's COPD; it was more likely that the Veteran's stroke was related to longstanding hypertension, hyperlipidemia and diabetes mellitus. A remote jeep accident is not a risk factor for stroke. In November 2012 the Veteran's representative submitted a Post-Remand Brief asserting that psychosocial factors (such as PTSD symptoms) can be associated with cardiovascular disease; thus, PTSD may be related to the Veteran's history of stroke. The representative also cited several medical studies suggesting a relationship between PTSD and cardiovascular disease In December 2012 the Board remanded the case to the Originating Agency for the specific purpose of obtaining a medical opinion as to whether the Veteran's stroke was caused or aggravated by the service-connected PTSD. In response to the Board's remand the Veteran was re-examined in January 2013 by the same VA physician who had performed the examination in January 2011 and who had provided the addendum opinion in December 2011. The Veteran reported a history of mini-stroke or TIAs in 2008 and 2009; the Veteran reported residual left arm weakness and difficulty speaking but stated these residuals had improved significantly. During examination the Veteran's speech was normal; his gait was abnormal due to bilateral knee osteoarthritis that rendered him unable to walk. No muscle weakness was observed in the upper or lower extremities. The examiner noted diagnosis of a central nervous system (CNS) condition of vascular disease (thrombosis, TIA or cerebral infarction). The examiner stated the Veteran had recovered from his two mini-strokes in 2008 and 2009, with no residuals on examination. The examiner stated again that the Veteran's risk factors for stroke were multifactoral and included hypertension, diabetes and hyperlipidemia. The examiner stated there is no medical evidence that PTSD causes or worsens strokes/TIAs. While PTSD may temporarily worsen symptoms there are no documented studies showing PTSD causes permanent problems that lead to a diagnosis of strokes/TIAs or that PTSD worsens such disability; there are some speculative reports but these are only speculation without firm documented evidence as to cause-and-effect. The Veteran's representative submitted a Post-Remand Brief in March 2013 asserting citing that medical studies showed a relationship between PTSD and CVD. The Veteran is shown on review to have had CVAs/TIAs on several occasions beginning in 2008. The Veteran's daughter, an RN, asserted in her letter dated in December 2008 that stroke "can be" due to lack of oxygen to the brain which "could be" related to the Veteran having lost half of his left lung in the jeep accident in Korea, but medical opinions expressed in speculative language such as "can be" and "could be" do not provide the degree of certainty required for medical nexus evidence. Bostain v. West, 11 Vet. App. 124, 127-28 (1998); Obert v. Brown, 5 Vet. App. 30, 33 (1993). The VA examiner provided an opinion stating the Veteran's CVAs/TIAs since 2008 were not related to service and that in any case the Veteran does not have residuals of such events. The VA examiner's opinion is probative under the three elements cited by Nieves-Rodriguez and is not contradicted by any other probative medical opinion of record. The Board acknowledges that the August 1999 letter, signed by multiple medical providers, asserts that a jeep accident as described by the Veteran "could have" created chronic medical problems including pulmonary emboli. As explained above, "could have" is a speculative opinion that does not rise to the degree of certainty required for medical nexus evidence. Bostain and Stegman, id. Further, even if arguendo the pulmonary embolism in 1972 was related to the jeep accident in service, the VA examiner has provided competent and uncontroverted medical opinion stating the embolism resolved without residuals and did not cause the Veteran to have subsequent strokes or predispose him to strokes. The Veteran has submitted medical articles suggesting a relationship between a chest injury and subsequent cardiovascular problems, and the Veteran's representative has submitted the titles of medical articles similarly suggesting such a relationship. However, treatise evidence alone is usually "too general and inconclusive" to establish a medical nexus. Sacks v. West, 11 Vet. App. 314, 317 (1998). The Veteran has not provided any medical opinion showing that the general findings of his cited treatises apply in his specific situation; accordingly, those treatises are probative, but are not dispositive in the face of contrary competent medical opinion. Mattern, 12 Vet. App. at 228. Turning to the lay evidence of record, the Veteran has asserted his personal belief that his strokes since 2008 are related to the jeep accident, and he stated that he "read in a doctor's manual" that he could have a clot lying between the heart and the lung that caused such strokes. The VA examiner has stated the etiology of the Veteran's strokes is multifactoral, which demonstrates that such etiology is not within the competence of lay opinion. Kahana, 24 Vet. App. 428; Jandreau, 492 F.3d 1372. The Board having found direct service connection for stroke is not warranted, the Board also finds the criteria for secondary service connection are not met. The competent and uncontroverted medical opinion of the VA examiner shows that the Veteran's service-connected PTSD did not proximately cause the Veteran's strokes or aggravate such strokes. The Veteran's VA claims file contains voluminous treatment records documenting his PTSD treatment and his treatment for strokes since 2008, but there is no indication therein of any relationship between PTSD symptoms and strokes. The Veteran does not assert, and the evidence of record does not suggest, that his other service-connected disabilities (DJD of the bilateral knees, DJD of the spine and loss of use of the feet) are etiologically related to strokes. In sum, the Board has found the most probative medical opinion of record shows the Veteran does not have residuals of strokes that are likely related to service or to the service-connected PTSD. Accordingly, the preponderance of the evidence is against the claim and the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54; Ussery, 8 Vet. App. 64. ORDER Service connection for a respiratory disorder is denied. Service connection for residuals of a stroke is denied. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs