Citation Nr: 1312552 Decision Date: 04/16/13 Archive Date: 05/02/13 DOCKET NO. 11-09 357 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas THE ISSUE Entitlement to service connection for Parkinson's disease with essential tremors and memory loss, to include as due to lead exposure. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD M. Postek, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1953 to May 1956 and August 1957 to February 1958. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision by the RO. In March 2013, the Veteran testified at a hearing held at the RO before the undersigned Veterans Law Judge. A transcript of the proceeding is of record. During the hearing, the Veteran submitted additional evidence, along with a written waiver of initial RO consideration. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The appeal is being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. REMAND The Board finds that further development is necessary prior to final adjudication of the Veteran's claim. A remand is required to attempt to obtain additional records, and to obtain an addendum medical opinion, as discussed in greater detail below. The Veteran's primary contention is that his current Parkinson's disease with related impairment is due to his exposure to lead during service. Specifically, he contends that he experienced direct contact to lead through paint fumes, chips, and dust performing his duties as a deck hand and a boatswain's mate during his two periods of service. In regard to the records, it appears that additional evidence that could be supportive of the Veteran's claim might be available. Specifically, in an April 2009 written submission, the Veteran indicated that the VA had sent him to receive treatment from a private dentist in 1958, following his second period of service. He requested that an attempt be made to obtain these records, as VA paid for this treatment. A hand-written notation on the bottom of the submission noted "Knoxville VA records already in file - Rec'd 7-25-56." In an April 2011 written submission, the Veteran again mentioned the private dental treatment, indicating that the dentist told him that the black rings around his teeth were a sign of lead poisoning. He stated that he was subsequently taken to Baptist Hospital in Knoxville, where was diagnosed with severe lead poisoning. The Veteran has repeatedly indicated that his attempts to obtain the treatment records from Baptist Hospital have been unsuccessful, as they are no longer available. During the March 2013 hearing, the Veteran and his wife testified that, prior to seeking his current treatment with VA, the Veteran was seen by a private specialist in the 1990s (Dr. C.S., initials used to protect privacy) for treatment of his Parkinson's disease following the first diagnosis by a doctor around that time. The Veteran indicated that Dr. C.S. told him that his Parkinson's disease and essential tremors could be related, and that there was an 80 percent possibility that his current essential tremors and Parkinson's disease were related to previous nerve or brain damage. See Bd. Hearing Tr. at 8, 18-22. In light of these considerations, the Board finds that any relevant written opinion or other notations provided in available treatment records could be supportive of the Veteran's claim. Moreover, the record suggests that there is a potentially outstanding VA treatment record pertinent to the claim. Accordingly, further development to obtain these records is in order. 38 U.S.C.A. § 5103A (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). In regard to the medical opinion of record, the Veteran was afforded a VA examination in April 2009 when the examiner was asked to opine as to whether it was at least as likely as not that the Veteran's Parkinson's disease was the result of his acknowledged in-service lead paint exposure, and if so, to provide an opinion as to the etiology of the Veteran's current essential tremors and memory loss, to include if they are considered complications of the Parkinson's disease. During the examination, the Veteran reported developing tremors in his hands while in service, but he was unsure if this was entered into his medical records even though his tremors gradually worsened following service. His wife recalled him having tremors when she met him in the early 1970s. He also stated that he worked with lead-based paints and developed poisoning requiring chelation treatment. He reported suffering mental symptoms and confusion related to his poisoning. He was later diagnosed with Parkinson's disease many years following service. Following examination, the examiner was noted that he was unable to find a linkage from the current parkinsonism to service without resorting to speculation, in the absence of records of diagnosis or treatment for lead encephalopathy or another major acute lead-related toxic complication. In so finding, the examiner noted that acute lead poisoning with encephalopathy could plausibly injure the brain sufficiently as to increase the risk for later development of parkinsonism. The examiner further noted that, unfortunately, lead encephalopathy was not established in the available medical records, an alterative cause for mental symptoms was noted in the service psychiatric evaluation (situational maladjustment due to recent death of wife) and adjunctive evidence such as diagnosed lead neuropathy was absent from available records. The Board notes that once VA undertakes the effort to provide an examination when developing a service connection claim, the examination and corresponding report must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In this case, the Board finds that the April 2009 opinion is inadequate. Specifically, an addendum opinion is needed for the examiner to provide additional opinions in this case based on given factual premises, as outlined in the remand instructions below. These additional opinions are needed to have sufficient medical evidence to decide the Veteran's claim. 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) (2012). Expedited handling is requested.) 1. The RO should take appropriate steps to contact the Veteran in order to have him provide the names and addresses of any and all health care providers who have provided treatment for his Parkinson's disease. After acquiring this information and obtaining any necessary authorization, the RO should obtain copies of any outstanding records and associate them with the claims file. A specific request should be made for treatment records from Dr. C.S., the doctor who the Veteran identified during the March 2013 hearing. The RO should also attempt to obtain the Knoxville VA dental treatment records from 1958 identified by the Veteran in his April 2009 and April 2011 written submissions. All efforts to obtain these records should be documented in the claims file, including whether additional efforts would be futile. 2. After obtaining any identified and outstanding records, the RO should forward the claims file to the VA physician who provided the April 2009 VA opinion or a suitable substitute for a complete review and preparation of an addendum opinion that addresses the following: a. Only for the purposes of providing the requested opinion in this case, the examiner is asked to presume that the Veteran first suffered from tremors that began during service which became gradually more severe after service. In light of this consideration, the examiner is asked to state whether it is at least as likely as not (50 percent probability or more) that the Veteran's tremors or any other relevant symptomatology noted in the record during or within one year following his periods of service (January 1953-May 1956; August 1957-February 1958) constitute early manifestations of his current Parkinson's disease or related impairment. b. Only for the purposes of providing the requested opinion in this case, the examiner is asked to presume that the Veteran suffered from complications related to lead poisoning shortly after service due to his in-service exposure to lead paint. In light of this consideration, the examiner is asked to state whether it is at least as likely as not (50 percent probability or more) that the Veteran's Parkinson's disease manifested during or is otherwise etiologically related to active duty service, to include as a result of such exposure to lead paint. The supporting rationale for all opinions expressed must be provided. If the required opinion cannot be provided, the examiner should explain why the opinion cannot be provided. If the April 2009 VA physician is not available, the claims file should be provided to and reviewed by another physician with sufficient expertise to provide the required opinion. An additional examination of the Veteran should be performed if deemed necessary by the person providing the opinion. 3. After completing all indicated development, the RO should readjudicate the claim remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished with a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the 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. 2012). _________________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).