Citation Nr: 1311940 Decision Date: 04/10/13 Archive Date: 04/19/13 DOCKET NO. 07-13 759 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a disability of the hands, to include arthritis, and including as secondary to service-connected injuries to the fingers. 2. Entitlement to service connection for a spot on the brain, claimed as a possible residual of a stroke, including as secondary to sarcoidosis. 3. Entitlement to service connection for asthma, including as secondary to sarcoidosis. 4. Entitlement to service connection for a right eye disability, to include residuals of a right eye tumor, including as secondary to sarcoidosis. 5. Entitlement to service connection for the removal of lymph nodes from the neck (cervical lymphadenopathy), including as secondary to sarcoidosis. 6. Entitlement to service connection for skin cancer. 7. Entitlement to service connection for a disability manifested by tooth and gum problems, to include loss of teeth due to trauma and temporomandibular joint dysfunction (TMJ). 8. Entitlement to service connection for dizzy spells with shortness of breath, including as secondary to sarcoidosis. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD W.T. Snyder, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran had active service from August 1974 to August 1979, followed by membership in the California Air National Guard (CAANG) and U.S. Air Force Reserve (USAFR). These matters come before the Board of Veterans' Appeals (Board) from an October 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied the instant claims for entitlement to service connection. In June 2008, the Veteran testified before the undersigned at a hearing at the Board. A transcript of the hearing testimony is in the claims file and has been reviewed. The United States Court of Appeals for Veterans Claims (Court) has held that that provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the June 2008 hearing, the issues on appeal were identified, and the undersigned solicited information as to treatment, and findings related to the claimed disabilities. The Board then remanded the claims to obtain evidence expected to assist the Veteran in substantiating the claims. The Board thereby fulfilled its duty under Bryant. Following a September 2008, Board remand, the Appeals Management Center (AMC), in Washington, DC, granted service connection for a right ankle disability, and ulcerative proctitis, claimed as rectal bleeding and fecal incontinence. In October 2011, the Board remanded the case to the RO, via the AMC for additional development, including completion of development directed in a September 2008 remand. See Stegall v. West, 11 Vet. App. 268 (1998). In a February 2013 rating decision, the AMC granted service connection for loss of teeth numbers 8 and 9 due to trauma and assigned an initial noncompensable rating, effective in November 2004. There is no indication that the Veteran appealed either the initial rating or effective date. This was a full grant of that aspect of the issue on appeal. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues such as the compensation level assigned for the disability and the effective date); see also 38 C.F.R. § 20.200 (2012). The Veteran also has a Virtual VA paperless claims file, which is a highly secured electronic repository that is used to store and review documents involved in the claims process. The Board has reviewed the contents of the paperless file, and there are currently no pertinent records that are not also in the paper claims file. Nonetheless, any further development or adjudication of this matter should take into account this paperless claims file. In the decision below, the Board considers the issue of entitlement to service connection for loss of teeth due to in-service trauma. There is no indication in the claims file that the issue of treatment only has been addressed. Thus, the issue of entitlement to service connection for a dental disability for treatment purposes only has been raised by the record, but this issue does not appear to have been adjudicated. Therefore, the Board does not have jurisdiction over it, and it is referred to the RO for appropriate action. Specifically, the AMC or the RO should refer the claim for dental treatment to the appropriate VA Medical Center (VAMC). The AMC or RO should inform the VAMC the Veteran was discharged from active service before October 31, 1981, and submitted a dental claim to VA within one year of his discharge. The issues of entitlement to service connection for a spot on the brain, claimed as a possible residual of a stroke, including as secondary to sarcoidosis; asthma, including as secondary to sarcoidosis; residuals of a right eye tumor and entitlement to service connection for a disability manifested by tooth and gum problems, to include loss of teeth and TMJ are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC, for further development. FINDINGS OF FACT 1. The AMC completed the additional development directed in the February 2011 remand by obtaining all available service personnel records, VA treatment records, and by arranging VA examinations. 2. A current disability of either hand has not been demonstrated. 3. Current cervical lymphadenopathy or its residuals have not been demonstrated. 4. Skin cancer or its residuals have not been demonstrated. CONCLUSIONS OF LAW 1. The requirements for entitlement to service connection for a disability of the hands are not met. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 1131, 1137, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307(a), 3.309(a) (2012). 2. The requirements for entitlement to service connection for cervical lymphadenopathy are not met. 38 U.S.C.A. §§ 101, 1110, 1131; 38 C.F.R. §§ 3.159, 3.303. 3. The requirements for entitlement to service connection for skin cancer or its residuals are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.159, 3.303, 3.307(a), 3.309(a). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); Pub.L. 112-154, §§ 504(a)(1)-(2), 505(a)-(b) (Aug. 6, 2012) (to be codified at 38 U.S.C.A. §§ 5103(a)-(b), 5103A(b)-(c)); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); C.F.R. § 3.159(b)(1); see also 73 Fed. Reg. 23,353 (Apr. 30, 2008). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The VCAA is not applicable where further assistance would not aid a veteran in substantiating his claim. Wensch v. Principi, 15 Vet App 362 (2001); see 38 U.S.C.A. § 5103A(a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"); see also VAOPGCPREC No. 5-2004; 69 Fed. Reg. 59989 (2004) (holding that the notice and duty to assist provisions of the VCAA do not apply to claims that could not be substantiated through such notice and assistance). The Veteran was provided with VCAA notice in a March 2005 letter. This letter provided notice as to what evidence was required to substantiate his claims and informed him of what evidence VA would obtain, of what evidence he was expected to provide, and of what assistance the VA could provide the Veteran in obtaining evidence from other agencies. This letter provided proper preadjudication notice under Pelegrini. The Veteran has substantiated his status as a veteran. The first and second elements of Dingess notice was provided in the preadjudication March 2005 letter. The remaining elements of Dingess notice were provided in an April 2008 letter and the January 2010 supplemental statement of the case (SSOC). The SSOC could not provide VCAA compliant notice. Mayfield v. Nicholson, 444 F. 3d 1328 (Fed. Cir. 2006). It did, however, provide actual knowledge to the Veteran. The Veteran had a meaningful opportunity to participate in the adjudication of the claims after the notice was provided. In this regard, his representative submitted additional argument in May 2011, the Veteran submitted additional evidence in May 2011 and June 2011, and his representative submitted additional argument in March 2013. A notice error can be cured by actual knowledge of the information on the part of the claimant. Sanders v. Nicholson, 487 F.3d 881, 888-9 (Fed. Cir. 2007), George-Harvey v. Nicholson, 21 Vet. App. 334, 339 (2007). The April 2008 letter and SSOC did provide actual knowledge of the criteria required to establish the degree of disability and the effective date following a grant of service connection, and the Veteran has had the opportunity over the years to submit argument and evidence subsequent to receiving the notice. The Veteran had a meaningful opportunity to participate in the adjudication of his claim and was not prejudiced. In addition, the Veteran has not claimed prejudice from this notice defect. Thus, any VCAA notice error in regard to the Veteran's claim for service connection is deemed harmless and does not preclude appellate consideration of the claimant's claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (holding that a party alleging defective notice has the burden of showing how the defective notice was harmful). The VCAA requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. §5103A; 38 C.F.R. §3.159 (c), (d). This duty to assist contemplates that VA will help a claimant obtain records relevant to a claim, whether or not the records are in Federal custody, and that VA will provide a medical examination and/or opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has met the duty to assist the Veteran in the development of the claims decided herein. The Veteran's service treatment records, VA treatment records and various private treatment records have been obtained. He has been afforded VA examinations and sufficient medical opinions have been obtained. These examinations, along with the Veteran's statements and treatment records, are sufficient for appellate review purposes. See generally Barr v. Nicholson, 21 Vet. App. 303 (2007). Neither the Veteran nor his representative asserts there are additional records or evidence to be obtained. Hence, the Board may address the merits of the appeal without prejudice to the Veteran. The Board's most recent remand to obtain opinions that a VA examiner had not provided after the Board's previous remand, to verify service dates, and afford the Veteran additional examinations. As discussed below, not all service dates have been verified; however, the Board is deciding the issues in this appeal due to the absence of a current disability. Verification of earlier service dates could not substantiate these claims. The AMC contacted the California National Guard, but that organization reported that it had no records and suggested further research at the Records Management Center (RMC). The RMC subsequently reported that it had no records. The AMC then conducted further research at the National Personnel Records Center (NPRC), but no additional records were found. The AMC then directly contacted the Air Force bases where the Veteran reportedly served, but personnel at those bases reported that they had no records. The AMC also contacted the Veteran and asked him whether he had any records or knew where they might be located. He reported that he had no records and did not know where they might be located. These extensive efforts demonstrate that there is no reasonable possibility that there are additional service treatment records and that further efforts would be futile. The AMC provided the Veteran with additional examinations that provided the information sought in the Board's remand. There has been substantial compliance with the Board's remands. Service Connection Criteria Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Under 38 U.S.C.A. § 101(24) , "active military, naval, or air service includes active duty, any period of [ACDUTRA] during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty." Service connection may be granted for disability resulting from disease or injury incurred in or aggravated while performing ACDUTRA or injury incurred or aggravated by inactive duty training (INACDUTRA). 38 U.S.C.A. §§ 101(24), 106, 1110, 1131. Under 38 U.S.C.A. § 101(22) (a) and (c), ACDUTRA means, in pertinent part, full-time duty in the Armed Forces performed by Reserves for training and full-time duty as members of the Army National Guard or Air National Guard of any State. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical 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); see also Shedden, 381 F.3d at 1167; Hickson v. West, 12 Vet. App. 247, 253 (1999); 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 for chronic diseases, such as arthritis or malignant tumors, is through a demonstration of continuity of symptomatology. Walker v. Shinseki, 701 F.3d 708 F.3d 1331 (Fed. Cir. 2013); Barr v. Nicholson, 21 Vet. App. 303 (2007). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a chronic disease was "noted" during service or within the applicable presumptive 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. Walker, supra; see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In relevant part, 38 U.S.C.A. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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 profession." Jandreau, 492 F.3d at 1377; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. §§ 3.303(d), 3.307, 3.309. Certain chronic disabilities such as arthritis and cancer are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. This presumption applies to veterans who have served 90 days or more of active service during a war period or after December 31, 1946. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). Service connection may also be granted for a disorder found to be proximately due to, or the result of, a service-connected disability, 38 C.F.R. § 3.310, including on the basis of aggravation. Allen v. Brown, 7 Vet. App. 439 (1995) (The Board notes the changes to 38 C.F.R. § 3.310 effective in October 10, 2006, but the previous version of 38 C.F.R. § 3.310 is potentially more favorable to the Veteran). Disability of the Hands The Veteran testified at the hearing that his hands stiffened after use at work and he at times experienced pain. He testified further that he was told he had arthritis. Transcript, p. 12. Service treatment records note the Veteran fractured the right index and left little fingers, for which he is service connected. The July 1979 Report Of Medical Examination For Separation reflects the upper extremities were assessed as normal. The September 1981 VA examination report reflects physical examination revealed a mild flexion deficit of the right index finger distal interphalangeal joint. The examiner noted no other pathology of the hands. In July 2005, the Veteran was afforded a VA examination to determine the severity of his service-connected finger fracture residuals. The report reflects the history the Veteran reported related solely to his fingers. He did not report any complaints related to other parts of either hand. Physical examination revealed no deficit of either hand. The X-ray of the left hand was read as having shown intact bony architecture with no fracture lines. The joint spaces appeared unremarkable, and the old fracture of the third finger was noted. The X-ray of the right hand was read was read as normal. The examiner noted that, while the Veteran had occasional pain and soreness, he demonstrated normal finger and hand dexterity bilaterally. The voluminous medical evidence of record notes osteoarthritis of the lower extremities but not of the hands. The February 2011 Board decision allowed a compensable rating for the finger fracture residuals on the basis of painful motion. See 38 C.F.R. § 4.59. The Veteran is competent to report what a physician told him, see 38 C.F.R. § 3.159(a)(2), but the Board still must test whether his recall and report are accurate. In light of the fact the Veteran's outpatient records do not list upper extremity arthritis among his problem areas, and the absence of any X-ray examination report to the effect that either hand manifests arthritis, the Board is convinced that the Veteran's recall is inaccurate or that he was given incorrect information. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012) (providing that arthritis must be demonstrated by X-ray examination) Although disabilities of various fingers have been identified, and service connected, additional disability of the hands has not been identified. Cervical Lymphadenopathy The November 2011 examination report reflects the examiner conducted a review of the claims file. The examiner noted a 1982 biopsy of a left cervical lymph revealed sarcoidosis. The examination report noted the Veteran's medical history was negative for lymph node symptoms. Physical examination revealed no lymph nodes. The examiner noted physical examination revealed no pathology on which to make a diagnosis. Other than the biopsy for the service connected sarcoidosis, the record does not otherwise show any findings indicative of a disability of the lymph nodes. Dizzy Spells and shortness of breath The November 2011 respiratory and cranial nerve examination reports reflect the examiner conducted a review of the claims file. The examiner noted the Veteran's medical history of sarcoidosis and asthma. The examiner noted the Veteran's respiratory disorder did not require the use of corticosteroid medications but did require the use of inhaled medications. Oral bronchodilators, antibiotics, or oxygen therapy were not required. The examiner also noted a March 2010 CT scan of the brain was read as normal. The examiner opined that the objective findings on respiratory and cranial nerve clinical examinations did not reveal any pathology of shortness of breath or dizzy spells on which to base a diagnosis. The record does not otherwise show findings of a disability manifested by dizzy spells or shortness of breath. Skin Cancer The Veteran testified at the hearing that VA had diagnosed him as having cancer, and removed several lymph nodes. Transcript, p. 39. The Veteran did not provide a date when the diagnosis was supposedly made. As noted in the discussion of the Veteran's assertion of arthritis of the hands, the Veteran is competent to report his medical history, to include what a physician told him, see 38 C.F.R. § 3.159(a)(2). Nonetheless, the Board has reviewed all of the medical evidence in the claims file and finds no notation of a diagnosis of skin cancer. An October 1999 VA entry notes lipoma was removed from the flank, and that physical examination revealed the skin was normal. A February 2003 VA entry notes a personal medical history of skin cancer but no other information. The several listings of the Veteran's problem areas and diagnoses do not include skin cancer or any residuals. General Considerations Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. § 1110 (formerly § 310). In the absence of proof of present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997) (Interpreting 38 U.S.C. § 1131 as requiring the existence of a present disability for VA compensation purposes) and Wamhoff v. Brown, 8 Vet. App. 517, 521 (1996). The requirement for a current disability is not satisfied by reports of symptoms without a showing of an underlying disease or disability. See Sanchez- Benitez v. West, 13 Vet. App. 282, 285 (1999) (pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted). In the instant case, no underlying disability of the hands, or a disability causing dizzy spells or shortness of breath has been identified. In addition no current residuals of lymph node removal or skin cancer have been identified. The Board is constrained to find the preponderance of the evidence is against the claims of entitlement to service connection for a disability of the hands, removal of lymph nodes from the neck, dizzy spells and shortness of breath, and skin cancer. 38 C.F.R. § 3.303. In reaching this decision the Board considered the doctrine of reasonable doubt. As the preponderance of the evidence is against the Veteran's claims, however, the doctrine is not for application. Schoolman v. West, 12 Vet. App. 307, 311 (1999). ORDER Entitlement to service connection for a disability of the hands, to include arthritis, including as secondary to service-connected injuries to the fingers, is denied. Entitlement to service connection for the removal of lymph nodes from the neck, including as secondary to sarcoidosis, is denied. Entitlement to service connection for skin cancer is denied. Entitlement to service connection for dizzy spells with shortness of breath, including as secondary to sarcoidosis, is denied. REMAND Although the November 2011 cranial nerve examination report reflects a finding of no active residuals of a stroke; a July 2001 Report Of Medical Examination noted the Veteran's stoke, and that he still complained of vision, slurred speech, memory loss, and that ptosis of the right eye was noted. As earlier discussed, the December 2011 eye examination report reflects that the examiner also noted the presence of ptosis of the right eye. Ptosis is defined as a "drooping of the upper eyelid from paralysis of the third nerve or from sympathetic innervations." See Dorland's Illustrated Medical Dictionary, 31st Edition, (2007) at page 1574. The cranial nerves examiner did not note or comment on the presence of ptosis, or whether it may have been a residual of the Veteran's stroke. The service treatment records note that the Veteran sustained a stroke in June 2001. Service personnel records reflect the Veteran was a member of the CAANG at that time. Although an October 2001 Profile notes "no duty for pay or points," it is not clear whether the Profile refers solely to October 2001, or for the entire Duty Year. The Veteran's ANG/USAFR Points Summary obtained while the case was on remand reflects the Veteran earned 21 active duty points between August 2000 and August 2001. Thus, the case must be remanded to seek the specific month and days, if any, the Veteran performed ACDUTRA or IACDUTRA in 2001, to include June 2001. A disability which is proximately due to or the result of a service-connected injury or disease shall be service connected. 38 C.F.R. § 3.310. Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439 (1995). The November 2011 respiratory examination report reflects the examiner noted sarcoidosis would not cause asthma and, therefore, there was no causal relationship between the Veteran's service-connected sarcoidosis and his asthma. The examiner did not, however, address whether the Veteran's sarcoidosis aggravated his asthma. Id.; see also, e.g., El-Amin v. Shinseki, No. 10-3031, 2013 WL 151154 (U.S. Vet. App. Jan. 15, 2013). As a result, the case must be returned to the examiner so he can address it. The December 2011, eye examination report reflects that the examiner did not find that there had been a tumor of the right eye orbit, but that the Veteran may have been referring to the documented removal of a tumor from the nasal bridge. The examiner added that if this was the case, an ear nose and throat examination was recommended. VA has duty to provide specialized examinations as recommended by VA examiners. Daves v. Nicholson, 21 Vet. App. 46 (2007) Green v. Derwinski, 1 Vet. App. 121, 123-124 (1991). The AMC/RO request for an independent dental review of the Veteran's dental claim reports findings on the January 2012 examination that are not noted in the examination report in the paper claims file or in Virtual VA. For example, the AMC/RO request notes range of motion findings referable to the TMJ, which are not in January 2012 examination report that is in the claims file. There is no copy of the examination report in the Virtual file. Inasmuch as it would be relevant to the Veteran's claim, VA has a duty to include the entire examination report in the record. 38 C.F.R. § 3.159(b). Further, the independent dental examiner relied, at least in part, on the absence of documented dental evidence of TMJ. The examiner must specifically acknowledge and discuss the Veteran's report that symptoms of TMJ first manifested during active service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran's report of in-service injury and relied on the absence of evidence in the Veteran's service medical records to provide a negative opinion). The Board must ensure the dentist assesses the Veteran's lay reports of TMJ in rendering an opinion. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). Expedited handling is requested.) 1. The AMC/RO should obtain service department verification of the dates in June 2001 the Veteran performed ACDUTRA or INACDUTRA for either the Federal ANG or USAFR, if any. Any existing copies of the special order that directed the Veteran to report for ACDUTRA or IACDUTRA would be extremely helpful to further appellate review. 2. The Veteran should also be asked to confirm whether he was on ACDUTRA or INACDUTRA at the time of his stroke in June 2001. 3. If, and only if, additional service department records show the Veteran was on ACDUTRA or INACDUTRA when he sustained the stroke in June 2001; return the claims file to the examiner who conducted the cranial nerves examination. Refer the examiner to the December 2011 eye examination report that referenced ptosis of the right eye. Ask the examiner to opine whether there is at least a 50-percent probability that ptosis of the right eye is a residual of the Veteran's stroke? The examiner is asked to provide a full explanation for any opinion rendered. 3. Ask the examiner who conducted the 2011 respiratory examination to opine whether there is at least a 50-percent probability the Veteran's sarcoidosis aggravated, that is, chronically worsened, the Veteran's asthma? If the examiner advises the requested opinion cannot be provided, the examiner is asked to explain why. For example, what additional evidence is needed in order to provide the opinion. Should the examiner advise the requested opinion cannot be rendered without another examination of the Veteran, the AMC/RO should arrange the examination. The claims file must be provided for review by the examiner as part of the examination. If the examiner is not available, another equally qualified medical professional should provide the necessary opinion. If further examination is recommended, this should be conducted. 4. Return the claims file to the dental examiner who conducted the December 2012 independent review and opinion. Advise the examiner that, in addition to the content of service treatment and dental records, the Veteran's lay reports of in-service symptoms of TMJ, must also be considered when determining whether there is a 50-pecent probability of any causal relationship between any diagnosed TMJ and the Veteran's active service. The dental examiner should provide an explanation for any opinion rendered. If the dental examiner is unavailable, another equally qualified medical professional should review the record and provide the necessary opinions. If further examination is recommended, this should be arranged. 5. The Veteran should be afforded a VA ear, nose and throat examination to determine whether he has any current residual disability (any such disability at any time since 2005) that is a residual of the removal of the mass from the bridge of the Veteran's nose. The examiner should review the claims folder and provide reasons for the opinion. 6. If the decision remains in any way adverse to the Veteran, issue a supplemental statement of the case. The case should thereafter be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The Veteran need take no action unless otherwise notified. VA will notify him if further action is required on his part. He 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). ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs