Citation Nr: 1325622 Decision Date: 08/13/13 Archive Date: 08/16/13 DOCKET NO. 94-36 950 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for hiatal hernia, to include as secondary to service-connected non-Hodgkin's lymphoma (NHL). 2. Entitlement to service connection for genitourinary disability (including prostatic hypertrophy), to include as secondary to service-connected NHL. 3. Entitlement to service connection for sleep apnea, to include as secondary to service-connected NHL. 4. Entitlement to service connection for S1 radiculopathy, to include as secondary to service-connected NHL. 5. Entitlement to service connection for polycythemia, to include as secondary to service-connected NHL. 6. Entitlement to service connection for a disability manifested by symptoms of stomach problems, night sweats, and chronic fatigue, to include as secondary to service-connected NHL. 7. Entitlement to service connection for a disability manifested by dizziness, to include as secondary to service-connected NHL. 8. Entitlement to service connection for chest pains and shortness of breath, now claimed as asbestosis. 9. Entitlement to service connection for a disability manifested by vision problems, to include as secondary to service-connected NHL. 10. Entitlement to service connection for a disability manifested by right testicle pain, to include as secondary to service-connected NHL. 11. Entitlement to service connection for a disability manifested by kidney pain, to include as secondary to service-connected NHL 12. Entitlement to an initial evaluation in excess of 10 percent for chemical phlebitis of the right upper extremity. 13. Entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service-connected disability. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from May 1975 to September 1977. He died in July 2010. The appellant is his surviving spouse. These matters come before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In May 2012, the appellant testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These matters were most recently before the Board in January 2013, when they were remanded for development. They have now returned to the Board for further appellate consideration. As is discussed in further detail below, the Board finds that the RO substantially complied with the mandates of the Board's remand and will proceed to adjudicate the appeal. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The issues of entitlement to TDIU, and entitlement to service connection for polycythemia, asbestosis (previously claimed as shortness of breath and chest pain), and entitlement to a disability manifested by dizziness are addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's service-connected NHL was in remission since 1991. 2. The appellant and the Veteran are less than credible with regard to onset of post-service symptoms of stomach problems, night sweats, sleep problems, dizziness, vision problems, right testicle pain, and kidney pain. 3. The most competent credible probative evidence of record is against a finding that the Veteran had a hiatal hernia causally related to, or aggravated by, service, or a service-connected disability. 4. The most competent credible probative evidence of record is against a finding that the Veteran had a genitourinary disability causally related to, or aggravated by, service, or a service-connected disability. 5. The most competent credible probative evidence of record is against a finding that the Veteran had sleep apnea causally related to, or aggravated by, service, or a service-connected. 6. The most competent credible probative evidence of record is against a finding that the Veteran had S1 radiculopathy causally related to, or aggravated by, service, or a service-connected disability. 7. The Veteran's symptoms of left sided loss of feeling are adequately considered under his service-connected peripheral neuropathy of the left upper and lower extremities. 8. The most competent credible probative evidence of record is against a finding that the Veteran had a disability(ies) manifested by stomach problems, night sweats, and chronic fatigue. 9. The most competent credible probative evidence of record is against a finding that the Veteran had a vision disability causally related to, or aggravated by, service, or a service-connected disability. 10. The most competent credible probative evidence of record is against a finding that the Veteran had a right testicle disability causally related to, or aggravated by, service, or a service-connected disability. 11. The most competent credible probative evidence of record is against a finding that the Veteran had a kidney disability causally related to, or aggravated by, service, or a service-connected disability 12. During the rating period on appeal, the Veteran's chemical phlebitis of the right upper extremity was manifested by complaints of swelling and numbness; objectively, the record s against a finding to persistent edema. CONCLUSIONS OF LAW 1. Hiatal hernia was not incurred in, or aggravated by, active service, nor is it caused by, or aggravated by, a service connected disability. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310 (2012). 2. Genitourinary disability (including prostatic hypertrophy) was not incurred in, or aggravated by, active service, nor is it caused by, or aggravated by, a service connected disability 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310 (2012). 3. Sleep apnea, was not incurred in, or aggravated by, active service, nor is it caused by, or aggravated by, a service connected disability. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310 (2012). 4. S1 radiculopathy, was not incurred in, or aggravated by, active service, nor is it caused by, or aggravated by, a service connected disability. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310 (2012). 5. A disability manifested by stomach problems, night sweats, and chronic fatigue, was not incurred in, or aggravated by, active service, nor is it caused by, or aggravated by, a service connected disability. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310 (2012). 6. A vision disability was not incurred in, or aggravated by, active service, nor is it caused by, or aggravated by, a service connected disability. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310 (2012). 7. A right testicle disability was not incurred in, or aggravated by, active service, nor is it caused by, or aggravated by, a service connected disability. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310 (2012). 8. A kidney disability was not incurred in, or aggravated by, active service, nor is it caused by, or aggravated by, a service connected disability. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310 (2012). 9. The criteria for a disability rating in excess of 10 percent for chemical phlebitis of the right upper extremity are not met. 38 U.S.C.A. §§1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.350, 4.118, Diagnostic Code 7704 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the present case, the unfavorable agency of original jurisdiction (AOJ) decisions that are the basis of this appeal were already decided and appealed prior to the enactment of the current section 5103(a) requirements in 2000. Where, as here, the § 5103(a) notice was not mandated at the time of the initial AOJ decision, the AOJ did not err in not providing such notice. Rather, the appellant has the right to a content complying notice and proper subsequent VA process. Pelegrini, 18 Vet. App. at 120. That notice was provided in June 2008 and August 2008. The claims were subsequently readjudicated, most recently in a March 2013 supplemental statement of the case. Mayfield, 444 F.3d at 1333. VA has a duty to assist the appellant in the development of the claims. The claims file includes service treatment records (STRs), VA and private medical records and correspondence, written articles, and the statements of the Veteran and the appellant in support of the claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that adequate VA examinations/opinions are of record for the issues decided herein; they are predicated on consideration of the Veteran's disabilities, his symptoms, and his medical history. Adequate rationale was provided for the opinions offered. In a May 2013 appellant's representative brief, the representative contends that the 2013 VA clinical opinions are not adequate and do not comply with the Board's remand. In its remand, the Board directed that VA opinions be obtained by a physician who had relevant experience in hemic and lymphatic system disorders. The record reflects that Dr. N.B. is an occupational health physician, and also medical board certified in internal medicine with extensive training in hematology and oncology. Thus, the Board finds that there has been substantial compliance with its remand. In addition, the representative contends that phlebitis rating issue was not addressed properly by the physician. The Veteran is deceased; thus, an examination of his right extremity for swelling is not possible. Moreover, the Board finds that record contains sufficient evidence upon which to make a determination. Finally, the representative contends that the RO failed to provide adequate reasons and bases for its determinations. There is no competent evidence that the RO did not consider the entire claims file; thus, there has been no prejudice to the appellant based on an alleged failure of the RO to adequately explain its reasons for denial. The Board will provide adequate reasons and bases in its decision. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease," whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Organic diseases of the nervous system are included in 38 C.F.R. § 3.309(a). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Service Connection on a secondary basis Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). During the course of this appeal, VA amended 38 C.F.R. § 3.310 effective October 10, 2006). See 71 Fed. Reg. 52,744 -47 (Sept. 7, 2006). The amended 38 C.F.R. § 3.310 (b) institutes additional evidentiary requirements and hurdles that must be satisfied before aggravation may be conceded and service connection granted. o whatever extent the revised regulation may be more restrictive than the previous one, the Board will afford the Veteran review under both the old and new versions. See VAOPGCPREC 7-2003 (Nov. 19, 2003). Rating Disabilities in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence pertinent to the claims on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Initially, the Board notes that the issues have been separated below into numerous sections for ease of reading. Although specific evidence has been discussed under each section, the same evidence has also been considered under the other sections where pertinent. For purposes of being concise, it may not have been repeated and summarized under each section even though it has been considered. The Veteran was diagnosed with NHL in 1990 and treated successfully with chemotherapy, which was completed in approximately January 1991. The Veteran is service-connected for NHL. The appellant and the Veteran have not been shown to have the experience, training, or education necessary to make an etiology opinion to the claimed disabilities. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issues in this case in light of the education and training necessary to make a finding with regard to the complexities of NHL, its remission, and chemotherapy. The Board finds that such etiology findings fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board also notes that the claims file includes several written articles. These articles are not specific to the Veteran or his situation. The articles with regard to drugs specifically note that they are not meant to substitute for the expertise and judgment of a physician, pharmacist, or other healthcare professional. The article on "Fatigue" by The National Cancer Institute is a general article which notes that few studies have been done that indicate the impact of fatigue on quality of life, but one study reflects that 31 patients of 90 patients with a diagnosis of Hodgkin's disease or non-Hodgkin's lymphoma reported a lack of energy at a median of 32 months after diagnosis. It further notes that "although many studies document the incident of fatigue in those who are no longer receiving cancer treatment, the specific mechanism of fatigue remains unknown. Because fatigue is a multifaceted problem, determining its etiology is difficult. The Board finds that the articles do not rise to the level of a medical treatise and have little, if any, probative value. Moreover, assuming arguendo, that the articles submitted by the appellant and/or Veteran rise to the level of a medical article or medical treatise, the Court has held that 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 "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999). See also Sacks v. West, 11 Vet. App. 314 (1998). In short, articles and treatises tend to be general in nature and tend not to relate to the specific facts in a given veteran's claim. In the present case, the articles submitted by the appellant fall into this general category. They do not provide in-depth information on factors such as duration of treatment or the age of the individuals at time of treatment. Importantly, the one article notes that the etiology is difficult to determine. In addition, no adequate clinical opinions specific to the Veteran are combined with the articles. Hiatal hernia, to include as secondary to service-connected non-Hodgkin's lymphoma (NHL) The Veteran has averred that his hiatal hernia was due to chemotherapy for his service-connected NHL. (A hiatal hernia occurs when part of one's stomach pushes upward through the diaphragm.) Based on the Veteran's assertion, the Board has considered whether the Veteran is entitled to service connection for a hiatal hernia on a secondary basis. The Board is not bound to discuss a theory of entitlement on a direct-incurrence basis where neither the Veteran nor the record raises the theory of entitlement to service connection on a direct-incurrence basis. Robinson v. Mansfield, 21 Vet. App. 545 (2008). Nonetheless, the evidence of record is against a finding that the Veteran's hiatal hernia was causally related to, or aggravated by, service. (The Board notes that the Veteran's hiatal hernia is being adjudicated as a separate issue from the Veteran's claim for service connection for a disability manifested by stomach problems, which is considered for service connection on a direct incurrence basis as well as on a secondary basis.) A March 1990 clinical record from City of Hope National Medical Center (CHNMC) reflects that the Veteran reported a history of black stools and denied any other gastrointestinal problems. Upon clinical examination, his abdomen was noted to be soft. An April 1990 record reflects that the kidneys enhance and excrete contrast in normal fashion. No hydronephrosis or focal renal lesions were identified. A few small retrocrural nodes were identified and also a few small para-aortic and aortocaval nodes, all of which were less than 1 cm in diameter. There was no definite evidence of adenopathy. The impression was probable thymic residual in the high anterior pre-aortic region, and less than 1 cm lucent focus in the anterior T6 vertebral body which is probably benign although exact etiology is uncertain, and otherwise normal CT scan of the chest, abdomen, and pelvis. The Veteran was diagnosed with NHL in 1990, began treatment in July 1990, and completed treatment in approximately January 1991. A January 1991 record reflects that the Veteran had an increase in gas pain for one year with burning in the chest and throat. He reported no relief from Zantac. A February 1991 clinical record from CHNMC reflects that the Veteran described complaints of belching which had been present for about a year. He reported that he belches multiple times during the day and night. He denied a distinct pain or burning dyspepsia, nor did he have symptoms suggestive of heartburn. The Veteran had no black tarry bowel movements, not lower gastrointestinal symptoms and specifically no change in his bowel habit. The examiner stated as follows: This patient's symptomatology of belching is nonspecific and I do not consider him to have a high grade dyspeptic syndrome that would be suggestive of peptic ulcer disease nor does he have the symptoms of a hiatus hernia. Unfortunately, belching is a nonspecific symptoms and primarily is a functional one based on the swallowing of gas." The February 1991 upper gastrointestinal endoscopy report reflects that there were "no specific UGI endoscopic findings." More than five years after completion of the chemotherapy for NHL, the Veteran had a CT scan. A March 1996 private record reflects that the Veteran had a CT scan of the chest, abdomen, and pelvis. It was noted that a small hiatal hernia was incidentally noted. It was further noted that the small hiatal hernia was newly demonstrated since the previous examination in April 1990. A July 2005 upper endoscopy at C.C. Memorial Hospital reflects that the Veteran had a 1 cm long hiatal hernia. In a statement dated in October 1998, the Veteran stated that he developed a hiatal hernia after chemotherapy treatment in 1990/1991. In a February 1999 statement, the Veteran stated that he had stomach problems in service and that bone scans, MRIs, and CAT scans showed no hiatal hernia. He again stated that he obtained the hiatal hernia after chemotherapy. Merely because the Veteran had a hiatal hernia years after chemotherapy does not mean that the hiatal hernia is due to the chemotherapy. The Veteran contends that the hernia was due to constipation and weight gain from his chemotherapy. The Board notes that the Veteran's weight in service was 210 lbs at the time of his separation in 1977. His weight was noted to be 198 lbs in March 1990, and 202 lbs in June 1995, prior to the diagnosis of a hernia. His weight was 200.5 lbs in 1998. Thus, the competent credible evidence of record does not reflect that the Veteran had a marked weight gain due to chemotherapy. The Veteran was competent to report that he had symptoms which he believed were related to a hiatal hernia (i.e. heartburn, belching, difficulty swallowing, constipation, and fatigue). Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issue in this case in light of the education and training necessary to make a finding with regard to the etiology of hiatal hernias. In addition, while constipation may be a cause of hiatal hernias, there are numerous possible etiologies for constipation, to include diet and diverticulitis, which the Veteran had, and polyps, which the Veteran had. (See July 11, 2005 Comanche County Memorial Hospital record.) The Board finds that hiatal hernia etiology findings fall outside the realm of common knowledge of a lay person. The Veteran has not been shown to have the experience, training, or education necessary to make an etiology as to the cause of his hernia. An October 2001 statement by Dr. J.A. reflects that the Veteran had stomach problems in service, and that his current symptoms were more likely as not the same condition as in service. As the Veteran's hiatal hernia was not found on examination in April 1990 (approximately 13 years after separation from service), and as Dr. J.A. does not make any reference to a hiatal hernia, the Board finds that his opinion is not probative as to a hiatal hernia. His opinion is considered with regard to the claim for a disability manifested by stomach problems, other than a hiatal hernia. A June 2005 VA examination report, with addendum, is of record. The report, by Dr. N.B., reflects the opinion of the examiner that since the Veteran's NHL had been in remission for 10 years, she did not see any relevance of his current hiatal hernia to NHL or therapy for it. A March 2009 VA examiner opined that there is no evidence per view of medical literature that residuals of NHL or its treatment include hiatal hernia. A July 2005 private record reflects that the Veteran reported constipation. A colonoscopy revealed severe tortuosity of the colon, diverticulosis, and rectosigmoid polyps A December 2009 record from Dr. S.C. of Cancer Specialists of Oklahoma reflects that upon physical examination, no hernias were seen. A December 2011 VA examination report is of record. It reflects that there is no evidence in the medical record that the Veteran's hiatal hernia was caused by a service-connected disability. A January 2012 VA addendum to the December 2011 by Dr. N.B. is associated with the claims file. It reflects that Dr. N.B. is Board-certified in internal medicine with extensive training in hematology and oncology. Dr. N.B. opined that the Veteran's hiatal hernia is less likely than not related to his service-connected NHL. Dr. N.B. further stated that the Veteran's hiatal hernia is not a manifestation of either NHL or the chemotherapy for it. The appellant has argued that the Veteran's hiatal hernia may have been related to the NHL or its therapy because treatise evidence published by the National Center Institute states "people who are successfully treated for cancer are at risk for a variety of organ-specific complications that are secondary to their treatment." (See October 2005 correspondence from law office); however, this is a general article which does not discuss hiatal hernias, and is not accompanied by a medical professional's opinion. Thus, the Board finds that it has little, if any, probative value, and far less value than the opinion of Dr. N.B. A March 2013 VA examination report reflects the opinion of the examiner that there is no evidence that the Veteran's hiatal hernia was related to, or caused by, the Veteran's service-connected disabilities, especially to the effects of the chemotherapy for his NHL. In sum, the Veteran completed chemotherapy for his service-connected NHL in approximately January 1991. A February 1991 clinical record from CHNMC reflects that the Veteran did not have symptoms of a hiatal hernia. The earliest clinical evidence of a hiatal hernia is 1996, approximately five years after completion of the Veteran's chemotherapy. The clinical opinion is against a finding that the Veteran's hiatal hernia was related to NHL or chemotherapy. The Board acknowledges that the Veteran was competent to report constipation and weight gain. However, there is no competent credible opinion of record that the Veteran's hernia was due to constipation or weight gain, or that he had constipation or weight gain as a result of chemotherapy or NHL. The Board does not need to obtain a further opinion on such possible etiologies because the Board finds that the competent clinical evidence of record is against a finding of chronic constipation and/or excessive weight gain prior to the diagnosis of a hernia, and there is no clinical indication that constipation and weight gain were the reason for his hernia. In the present claim, there is no clinical opinion, or credible continuity of symptomatology, which supports a causal relationship between a hiatal hernia and service, or between a hiatal hernia and a service-connected disability, to include its treatment. In addition, there is no competent credible evidence of record that a hiatal hernia was aggravated by NHL or its treatment. Thus, service connection for hiatal hernia is not warranted. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Sleep apnea, to include as secondary to service-connected NHL In correspondence dated in October 2001, Dr. J.A. stated that he believed that the Veteran's problems associated with NHL or its treatment included a sleeping disorder. Dr. J.A. did not note that the Veteran had sleep apnea and did not provide an adequate rationale for his opinion. The only description of a sleeping disorder was "problems with sleeping." The Board finds that Dr. J.A.'s opinion, which does not reflect that the Veteran had sleep apnea and does not provide an adequate rationale, is therefore, not probative of the issue. Moreover, the earliest clinical evidence of sleep apnea is not until approximately six years after Dr. J.A.'s opinion, and the Veteran stated that he was diagnosed in 2006. In July 2007 and July 2009 statements, the Veteran stated that he does not get a good night's sleep and that after his chemotherapy his wife had noticed that he stopped breathing while sleeping. He contended that he has sleep apnea as a residual of his chemotherapy for his service-connected NHL. An October 2007 VA clinical record reflects that the Veteran started on a CPAP machine in July 2008 for his obstructive sleep apnea. (As the note was written in 2007, the Veteran could not chronically have been on a CPAP machine since 2008; thus, the Board considers this onset date to be a misprint.) A March 2009 VA examination report reflects that the Veteran reported a diagnosis of sleep apnea sometime in 2006. He reported that he used a CPAP machine. He also reported that his symptoms of pyrosis and regurgitation of acid and stomach contents sometime wake him up at night. A May 2010 VA mental health examination report reflects that the Veteran reported that he sleeps only 1 to 2 hours per night without medication, and 4 to 8 hours with medicine. He reported that is tired all the time and has poor sleep every night, in part because he worries about the welfare of his family, his mortality, and finances, as well as what will happen next in his life. The Veteran was competent to report that he was tired and did not sleep well at night. In addition, his wife is competent to report that she believes that the Veteran stops breathing while he is sleeping. The Board finds that a lay person is not competent to provide a probative opinion as to the specific issue in this case in light of the education and training necessary to make a finding with regard to the etiology of sleep apnea, in the case of a person who was a smoker and obese (as noted in the clinical records). In addition, the Board finds that a lay person is not competent to provide a probative opinion as to residuals or secondary disabilities from NHL and/or chemotherapy treatment. Neither the Veteran nor the appellant has been shown to have the experience, training, or education necessary to make an etiology as to the cause of his sleep apnea. A March 2013 VA clinical opinion reflects that it is less likely as not that the Veteran's sleep apnea is due to the Veteran's service-connected disability. The clinician stated that there is no medical evidence in literature that chemotherapy for NHL leads to sleep apnea. The clinician also noted that there was no evidence of record that that it was aggravated beyond its natural progression by his chemotherapy treatment. In the present claim, there is no competent opinion which supports a causal relationship between sleep apnea and active service. Moreover, there is no competent credible opinion that the Veteran has sleep apnea causally related to, or aggravated by, a service connected disability or its treatment. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). S1 radiculopathy, to include as secondary to service-connected NHL The Veteran contended that he had loss of feeling on his left side that is not a residual of his NHL but which was documented in his Navy records and has been diagnosed as S1 radiculopathy. The Board notes that an April-May 1977 STR reflects that there was slight decrease in the left knee jerk and ankle jerk; however the Board finds that the STRs do not document complaints of, or treatment for, S1 radiculopathy. The Veteran has also questioned whether his loss of feeling could have been caused by lead paint or exposure to asbestos in service. (See May 2009 statement.) He has also stated that his skull lesions in the Navy are responsible for his loss of feeling of the left side. (See October 1998 statement.) The Board notes that the Veteran has also stated that he suffered for a loss of feeling on the left side due to his service-connected NHL and chemotherapy treatment received for that condition. A post service February 1993 VA clinical record reflects that the Veteran had sensory neuropathy of the left side of the body. Correspondence dated in October 2001 from Dr. J.A. stated that he believed that the Veteran's loss of feeling on the left side of his body is related to his biopsy surgery. He did not provide an adequate rationale, or cite to any pertinent diagnostic test results. A June 2005 VA examination report reflects that there is some subjective numbness in the right hand and the left lower leg. The examiner stated that EMGs and all other workup were within normal limits except for the EMG which showed evidence suggestive of S1 radiculopathy. In an addendum, the examiner stated that the Veteran's weakness in his legs and the numbness in his legs had been found to be because of S1 radiculopathy, which is not secondary to his NHL. In correspondence dated in September 2005, the Veteran's attorney stated that the EMG results noted above were "suggestive of S1 radiculopathy, but it is not clear whether or not that finding was medically confirmed. Again, nerve damage could be the result of chemotherapy treatment, with delayed effects possible." In addition, in a July 2007 statement, the Veteran asserted that the diagnosis of S1 radiculopathy of the left leg was a misdiagnosis. An August 2007 neurology note reflects that MRI results showed that there is no evidence of significant spinal canal stenosis, or cord impingement at any level. A December 2011 VA opinion notes that chemotherapy used to treat NHL often causes peripheral neuropathy, which can cause loss of feeling in the feet or hands. A January 2012 VA addendum opinion found it at least as likely as not that the Veteran's complaints of a loss of sensation in the left side are the result of treatment for NHL on the same basis. Based on the December 2011 VA opinion and the January 2012 addendum, the Board, in a January 2013 decision, granted service connection for peripheral neuropathy of the left upper extremity and peripheral neuropathy of the left lower extremity. Thus, the evidence reflects that the Veteran's left sided loss of feeling has been clinically found to be peripheral neuropathy, secondary to his treatment for his service-connected NHL, service connection has been granted for the loss of feeling/numbness. The Board acknowledges that the appellant now contends that those same symptoms are due to S1 radiculopathy, and the Board also acknowledges that the March 2013 VA examiner stated that the Veteran was diagnosed with S1 radiculopathy in June 2005; however, the examiner also opined that there is no evidence in literature that chemotherapy for NHL leads to S1 radiculopathy, nor is there any evidence that it was aggravated beyond its natural progression by the chemotherapy or treatment for NHL. The examiner also stated that it is less likely than not that the Veteran has S1 radiculopathy caused by a service-connected disability. In sum, the Veteran complained of left sided loss of feeling. Although the 2005 EMG suggested that this was due to S1 radiculopathy, the Veteran's attorney and the Veteran asserted that, instead, it may not be due to S1 radiculopathy, but was nerve damage as a result of chemotherapy treatment. Subsequently, the Veteran was granted service connection for his left sided loss of feeling, diagnosed as peripheral neuropathy. The appellant now argues that the Veteran should still be service-connected for loss of feeling of the left side due to S1 radiculopathy. The Board finds that the symptoms have been clinically associated with peripheral neuropathy. For purposes of determining whether the appellant is entitled to separate ratings for different problems or residuals of an injury (such that separate evaluations do not violate the prohibition against pyramiding) the critical element is that none of the symptomatology for any one of the conditions is duplicative of or overlapping with the symptomatology of the other two conditions. Esteban v. Brown, 6 Vet. App. 259 (1994). To the extent that any numbness or loss of feeling that has been complained of, or documented, the Board finds that this is fully contemplated in the Veteran's service connected peripheral neuropathy of the left upper and left lower extremities. Therefore, the Board finds that, as a matter of law, service connection for S1 radiculopathy, as a separate disability may not be granted where the Veteran is already service-connected for a disability producing that same symptomatology. Accordingly, service connection for S1 radiculopathy is not warranted and is precluded as a matter of law. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Assuming arguendo that even if the Veteran also had S1 radiculopathy, the evidence of record does not support a finding that S1 radiculopathy is due to, or aggravated by service, or a service-connected disability. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Genitourinary disability (including prostatic hypertrophy), to include as secondary to service-connected NHL and Disability(ies) manifested by symptoms of stomach problems, night sweats and chronic fatigue, to include as secondary to service-connected NHL and Disabilities of vision problems, right testicle pain, and kidney pain, to include as secondary to service-connected NHL A July 3, 1975 STR reflects that the Veteran reported very frequent bowel movements, and stool color that was tarry black. He also reported pain in the lower left quadrant. The Veteran reported that he had had a previous incident of this 1 1/2 to 2 years early (prior to service), and that a lower GI was negative for ulcers, and the pain had slowly gone away. A July 7, 1975 STR reflects that the Veteran had a two week history of intermittent epigastric crampy pain on four occasion of very short duration (a few minutes). There was no constant pain, no nausea, and no bloating. He had had one dark stool three days earlier (as noted above), but they had been brown since. The clinician felt that the Veteran could be treated symptomatically. An October 1975 STR reflects a complaint of dyspenia and cough. The Veteran noted that he had this problem periodically. The impression was acute asthmatic bronchitis. A December 1975 STR reflects that the Veteran requested a refill of his Pro-Banthine [for his stomach complaints]. February 1976 STRs reflect that the Veteran had continued complaints of stomach pain and need a refill for his Pro-Bathine. It was noted that he had an occasional melena stool. An April 1977 STR reflects that the Veteran reported complaints with regard to the right testicular pain for 30 days. It was noted that he had a history of an infection prior to entry to the navy. An April 11, 1977 STR reflects that the Veteran was returning for his testicular infection. An April 29 - May 11, 1977 STR reflects that the Veteran was admitted for skull surgery. The narrative summary reflects the Veteran's past history and notes that the Veteran had had epididymitis which was treated with antibiotics earlier in the month of April, and he currently did not have any symptoms. Upon clinical examination, he had bilateral diffuse expiratory wheezes with left greater than right and some harsh breath sounds throughout. (It was noted that the Veteran smokes two packs of cigarettes per day.) The STRs are negative for complaints of, or treatment for, chronic fatigue, prostatic hypertrophy, night sweats, abnormal vision problems, and kidney pain. The Veteran separated from service in September 1977. The clinical records of evidence do not reflect that he had a genitourinary disability (including prostatic hypertrophy) upon separation from service, or that he had a disability manifested by complaints of stomach problems, night sweats, and chronic fatigue, or a disability manifested by vision problems, right testicle pain, and kidney pain upon separation from service. The Veteran's September 1977 report of medical examination for separation purposes reflects that his lungs and chest, abdomen and viscera, and G-U system were all normal upon clinical examination. While the Veteran did have right testicular pain in April 1977, he was treated with antibiotics for an infection, and the subsequent STR reflects that he no longer had any symptoms. Moreover, his 1977 report of medical examination for separation purposes does not reflect any abnormality. The Board also acknowledges that the Veteran had numerous complaints with regard to stomach pain in service; however, there is no competent clinical evidence of record that these stomach complaints were manifestations of a disability which he had during the pendency of his claim, and the Board finds that there is no continuity of symptomatology. As noted below, the Veteran stated in 1990, more than 12 years after separation from service, that he had no gastrointestinal problems other than belching. The Board finds that any statement to the contrary (i.e. that he had continued stomach problems since service) is less than credible given, as noted below, that the Veteran was being treated for belching from 1990 to 1992 and denied other problems. Moreover, he noted that he only had the belching since approximately 1989, which is more than a decade after separation from service. A June 1978 neuropsychiatric examination report reflects that the Veteran has reported headaches since October 1975. He also noted that sometimes when he has headaches, he gets light-headed and incoordinated. The Veteran reported that he sleeps adequately but feels tired a lot. (The Veteran is service-connected for lesions with recurrent headaches.) An April 1990 record reflects that the kidneys enhance and excrete contrast in normal fashion. No hydronephrosis or focal renal lesions were identified. A March 1990 private clinical record reflects that the Veteran complained of headaches and black stools, but denied any other gastrointestinal, pulmonary, cardiac, urological, or dermatological problems. He denied any fevers, itching, and his weight has remained stable and increasing. Upon examination, his abdomen was soft, his prostate was normal in size, his stool was hemoccult negative. There were no masses and spincter tone was normal. There was no cyanosis, edema, or clubbing of the extremities. The Board notes that this was approximately 13 years after separation from service. The Veteran was diagnosed with NHL in1990. He underwent treatment his first treatment in July 1990 which resulted in acute renal failure. This was corrected and the Veteran continued treatment, with the final treatment in approximately January 1991. A January 1991 record reflects that the Veteran had an increase in gas pain for one year with burning in the chest and throat. He reported no relief from Zantac. A February 1991 clinical record from CHNMC reflects that the Veteran described complaints of belching which had been present for about a year. The Board notes that this would have been more than 13 years after separation from service, and prior to his chemotherapy for NHL. He reported that he belches multiple times during the day and night. He denied a distinct pain or burning dyspepsia, nor did he have symptoms suggestive of heartburn. The Veteran had no black tarry bowel movements, no lower gastrointestinal symptoms and specifically no change in his bowel habit. The examiner stated as follows: This patient's symptomatology of belching is nonspecific and I do not consider him to have a high grade dyspeptic syndrome that would be suggestive of peptic ulcer disease nor does he have the symptoms of a hiatus hernia. Unfortunately, belching is a nonspecific symptoms and primarily is a functional one based on the swallowing of gas." The February 1991 upper gastrointestinal endoscopy report reflects that there were "no specific UGI endoscopic findings. A March 1981 Medical Evaluation for Physical Evaluation Board report reflects that the Veteran was seen for a long history of headaches. According to the Veteran he had headaches associated with dizziness and lightheadedness. He reported that his unremitting headaches would often wake him up at night. The Veteran testified at the October 1991 hearing that he has problems with his stomach due to stress and ongoing problems of gas and chest pains. (See transcript page 3.) February and August 1992 CHNMC records reflect that the Veteran had undergone chemotherapy and was without evidence of disease recurrence. It was noted that his only complaint was that of intestinal gas for which he underwent an upper GI endoscopy on February 29, 1991 without specific findings. A February 1993 VA examination report reflects that the Veteran complained of intestinal gas, headaches, and chest pain. The Veteran reported that he missed 35 days of work in the past year because of tiredness, fatigue, and headaches. A June 1995 clinical record reflects that the Veteran reported mild night sweats. A September 1995 VA examination report for the Veteran's NHL reflects that he his "weight has remained stable[,] there have been no fever or night sweats." A March 1996 respiratory clinic note reflects that the Veteran reported chronic cough, chronic sinusitis, and chronic night sweats. It was noted that the Veteran was exposed to asbestos as part of his Navy shipyard duty, where he currently worked. He reported that he had "night sweats for years, nothing new." It was noted that the Veteran was a smoker. A May 16, 1996 CHNMC and Beckman Research Institute respiratory disease record reflects that the Veteran reported that he was being treated for some kidney problems; however, the examiner stated, "we have not document that; all his renal laboratories here have been normal." As noted above, an April 1997 VA examination report is of record. It reflects that the Veteran had numerous complaints, including stomach problems, trouble sleeping, vision problems, pain in the right testicle, chronic fatigue, occasional night sweats, and "kidney pain." The examiner also noted that "of [the Veteran's] numerous complaints, I think few of them are directly related to his diagnosis of [NHL] or its treatment; however, many patients complain of chronic fatigue following treatments of their lymphoma that can persist for many years." A March 1998 VA addendum to the April 1997 VA examination report reflects that the Veteran remained in a complete remission eight years after his diagnosis of NHL and was fully employed. The examiner stated that none of the Veteran's complaints could be specifically ascribed to his malignancy or its therapy. He stated that the Veteran's easy fatigability was not of such severity so as to prevent his employment or compromise his usual activities of daily living. Dr. J.A., in an October 2001 letter, opined that based on his review of the Veteran's STRs and then current medical records, the Veteran's stomach problems, chronic fatigue, night sweats, and kidney problems, "are associated with the non-Hodgkin's lymphoma and its treatment." In the February 2009 addendum to the October 2001 letter, Dr. J.A. stated that the "systemic SX [symptoms] related in my note of 10/24/2001 represent fairly standard complications/side effects of lymphoma, attendant chemotherapy." An adequate rationale was not provided because it did not include a discussion of the Veteran's lengthy remission or his polycythemia, sleep apnea, COPD, and smoking. Moreover, it did not provide a diagnosis for his "kidney problems" or "sleep problems." A January 2005 VA clinical record reflects that the Veteran related insomnia and that his wife stated that he has heavy snoring and stops breathing at night. A June 2005 CHNMC record reflects that the Veteran had a history of gallstone diagnosed by ultrasound for the last couple of years. A June 2005 VA examination report reflects that the Veteran reported chronic fatigue, painful joints, problems with sleeping, depression, shortness of breath, chest pain, and occasional nausea. It was noted that his NHL was in complete remission. In a July 2005 addendum the clinician reported that a lot of the conditions that the Veteran described (to include polycythemia, hypertension, depression, fatigue, hiatal hernia, and chest pain) have no direct relevance and cannot be specifically ascribed to his malignancy or therapy. She noted that the Veteran had symptoms of increased frequency of micturation, which was not related to lymphoma or its treatment. In a July 27, 2005 addendum to the report, the examiner stated that she reviewed the Veteran's record and history in detail. She reported that polycythemia has no medical connection or relevance to NHL. The clinician also noted that she did not see any relevance of the Veteran's current fatigue, hiatal hernia, or chest pain to either his NHL or the therapy for it. She also noted that NHL does not affect frequency of micturition. She stated that the Veteran is of an age to have an enlarged prostate and so increased frequency of micturition could be related to that. (In September 2005 correspondence, the Veteran's then-attorney stated that the examiner's "explanation of frequent urination was meaningless. [the Veteran] has difficulty urinating, not frequent urinating."). However, the Board finds that the clinician's statement as to what the Veteran reported is credible as there would be no reason for the clinician to misstate the facts as reported to her. A July 2005 Comanche County Memorial Hospital record reflects that the Veteran had reported reflux disease and occasional dysphasia. The impression after an upper endoscopy was mild gastritis and hiatal hernia. A July 2005 colonoscopy reflects impression of rectosigmoid polyps, severe tortuality of the colon, and diverticulosis. An October 2005 VA clinical record reflects that the Veteran reported a nonpainful lump in the right testicle for one month in duration. A March 2006 VA clinical record reflects that the Veteran reported experiencing difficulty sleeping. He was diagnosed with insomnia. A November 2006 VA clinical record reflects that the Veteran denied abdominal pain, diarrhea, constipation, melena, hematochezia, dysuria, hematuria, and edema. He did endorse night sweats, headaches, visual/hearing changes, shortness of breath, nausea/vomiting, numbness, weakness, eye pain, and occasional heartburn with dysphasia. In a July 2007 statement, the Veteran asserted that he has had stomach problems since 1975. He also stated that his chest pain and chronic fatigue are residuals from his chemotherapy. He reported that he had occasional night sweats and dizziness from 1976 to present, and that it is "not all the time" but is "off [and] on." He also reported that he has "trouble sleeping of and on due to migraine headaches but after chemo, I am doing good to get 3 to 5 hours a night, many nights I do not get any." 2008 VA records reflect that the Veteran denied abdominal pain, nausea, vomiting, diarrhea, testicular pain, dizziness, visual change, and constipation. An October 2008 VA mental health record reflects that the Veteran reported that he has difficulty sleeping, and that his difficulty sleeping began with his treatment for NHL. A March 2009 VA examination report reflects that the Veteran reported a diagnosis of sleep apnea sometime in 2006. He reported he used a CPAP machine. He also reported that his symptoms of pyrosis and regurgitation of acid and stomach contents sometimes wake him up at night. The March 2009 VA examiner stated that sleep apnea and insomnia can lead to chronic fatigue and night sweats. The examiner also stated that it is less likely than not that the Veteran's night sweats and/or chronic fatigue is due to NHL. The clinician examined the Veteran and reviewed the Veteran's VA claims folder, including Dr. J.A.'s October 2001 and February 2009 statements. The examiner, a nurse practitioner, noted that the Veteran has diagnoses of sleep apnea and insomnia and that those conditions can cause chronic fatigue and night sweats. She also noted that the conditions are associated with "active non-Hodgkin's Lymphoma and [are] not seen in people with remission or cured." The Veteran's NHL had been remission for approximately 10 years at the time of the 2001 opinion of Dr. J.A., and more than 18 years at the time of the March 2009 opinion. Finally, the examiner found that the Veteran's genitourinary symptoms are "most likely secondary to [the Veteran's] hydrocele/varicocele as well as enlarged prostate." She stated that there is nothing in the medical literature to suggest that the diagnoses of hydrocele, varicocele or enlarged prostate are residuals of NHL or its treatment. The examiner concluded that it is less likely than not that the night sweats, chronic fatigue or genitourinary disorder are due to non-Hodgkin's lymphoma." The Board acknowledges that the nurse practitioner's opinion did not substantially comply with its remand directive for the RO to obtain a physician's opinion; thus, another opinion by a physician has been obtained. The mere fact that obtaining the opinion from a nurse practitioner's opinion did not comply with the Board's remand, does not mean that it does not have probative value or that it should not be considered. It is still probative of the issues at hand. Stegall, 11 Vet. App. at 268. An October 2009 Baptist Medical Center record of a CT scan for abdominal pain complaints reflects that there as marked intra and extrahepatic biliary duct dilations. There was primary consideration for primary pancreatic malignancy. A December 2009 Cancer Specialist of Oklahoma record reflects that the Veteran presented with symptoms in October 2009 and was noted to have a tumor at the head of the pancreas. A December 2011 VA clinical opinion by Dr. L.B. states there is no evidence in the medical record that the hiatal hernia, genitourinary disorder or a diagnosed disorder manifested by stomach problems, loss of feeling in the left side, night sweats, chronic fatigue and/or a swollen right arm and hand was caused by a service-connected condition. In a January 2012 addendum, Dr. N.B stated that she had reviewed the medical opinion of Dr. J.A., the claims file, and the medical records in detail. The clinician stated as follows: It is this examiner's medical opinion that the claimed condition of hiatal hernia, a genitourinary disorder, or a diagnosed disorder manifested by stomach problems, night sweats, chronic fatigue are less likely than not related to his service-connected [NHL]. Dr. N.B. stated that she is board certified and re-certified in internal Medicine with extensive training in Hematology and Oncology. A March 2013 VA clinical report reflects the opinion of the clinician that the Veteran's stomach problem is secondary to his GERD and cannot be attributed to any other diagnosed disability. The clinician further stated that his symptoms of night sweats and chronic fatigue are related to his sleep apnea, which is also the cause of his insomnia. The 2013 clinician also noted that the Veteran was a long time smoker who has smoked approximately one pack per day since age 15 and that could lead to shortness of breath with cough. His medical records show a diagnosis of COPD by his primary care physician in July 2008 to which his symptoms could be attributed. The 2013 clinician noted that the Veteran's medical record do not show any kidney problems and his BUN/creatine have been normal by laboratory from 1996 until 2008. The 2013 clinician stated that the Veteran's right testicle pain could be related to the Veteran's hydrocele and varicocele which was diagnosed by the ultrasound of the scrotum on October 8, 2005. The 2013 clinician stated that the Veteran's vision problems cannot be attributed to a diagnosed disability. The 2013 clinician opined that there is no evidence that any of the Veteran's diagnoses were related to, or caused by, the Veteran's service-connected disabilities especially to the effects of the chemotherapy for his NHL. In this regard, the Board notes that there is some evidence of a relationship, as evidenced by the opinion of Dr. J.A.; however, the 2013 clinician had previously discussed this opinion in the January 2012 addendum report. Thus, it is apparent, that she found Dr. J.A.'s opinion to be less than probative. In a statement dated in April 2013, the appellant contends that night sweats, chronic fatigue, shortness of breath, dizziness and vision problems are symptoms of polycythemia. The Board has found that the appellant is not competent to make such findings. Moreover, even if she were, her statement would be against a finding that he had a disability related to NHL or its treatment. The Board has considered the entire claims file, to include the numerous medical records, the clinical opinions, the contentions of the Veteran and the appellant, and the written articles of record. The Board finds that the most probative competent evidence is against a finding that the Veteran had a disability, claimed above, causally related to, or aggravated by, active service or a service-connected disability, to include his NHL, which was in remission since 1991, or his treatment for NHL, which was completed in 1991. In addition, the Board find that there is no competent credible evidence of record of continuity of symptoms since service of a chronic disease. See Walker, 708 F.3d at 1331. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Evaluation of Chemical phlebitis of the right upper extremity The Veteran is service connected for chemical phlebitis of the right upper extremity evaluated as 10 percent disabling effective from October 7, 1998, which has been rated under 38 C.F.R. § 4.104, Diagnostic Code (DC) 7121. DC 7121 provides that a 100 percent evaluation is warranted for massive board-like edema with constant pain at rest. A 60 percent evaluation is warranted for persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. A 40 percent evaluation is warranted for persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. A 20 percent evaluation is warranted for persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema. The Board finds, based on the evidence noted below, that a rating in excess of 10 percent is not warranted for any period on appeal because the evidence is against a finding that the Veteran's right upper extremity disability was manifested by persistent edema, incompletely relieved by elevation of extremity. Initially the Board notes that the Veteran and the appellant are competent to report that they believe that the Veteran had swelling of the right upper extremity; however, the Board finds that with regard to a finding of persistent edema, the clinical records are more probative because they are objective and based on numerous physical examinations by medical professionals. A February 1980 clinical record from the University of California Department of neurology reflects that the "concern about a bony skull tumor or an intracerebral process is now resolved and there is no evidence that it is or has, produced any disability or handicap." A March 1990 clinical record from CHNMC reflects that there was no cyanosis, edema, or clubbing of the extremities. A September 1995 VA examination report regarding the Veteran's NHL and remission reflects that no clubbing, cyanosis, or edema was noted. A June 1998 private record from Dr. R.W. reflects that the Veteran reported a new complaint "over the last several months of having right upper extremity numbness from the elbow down to his fingers, primarily in the first through third digits." Upon clinical examination, the examiner noted that "there is some questionable increased edema in the right upper extremity as compared to the left." A June 1998 private letter from Dr. S.S. reflects that the Veteran was seen for complaint of right arm numbness. It was noted that he has "no hard findings on his examination, except for the finding of bilateral up going toes." A July 1998 VA clinical record reflects that the Veteran reported lower hand with swelling and numbness. A January 1999 addendum to the record reflects that with regard to the Veteran's complaints of numbness and swelling of the right hand there was "no objective swelling." Thus, it is clear that the examiner considered the Veteran's complaints of a swelling right hand and examined the hand, yet found no swelling. A January 1999 VA clinical record reflects that the Veteran had "no objective swelling" of the right hand. The Veteran submitted a statement, received on October 7, 1998, in which he noted that his right hand and arm had been swollen due to leakage of chemotherapy. He also reported that it stays numb most of the time. A February 1999 statement from the Veteran states that since his chemotherapy, his right hand has stayed swollen. December 1999 correspondence from Dr. A.N. of the City of Hope National Medical Center (CHNMC) reflects that the Veteran has developed chemical phlebitis. He noted that during the Veteran's first injection of Adriamycin, there was some mold extravsation of Adriamycin which caused local irritation as well as "recurrent pain and swelling of the area." The correspondence does not reflect if this finding of recurrent swelling was based on clinical observations or on the Veteran's reported history. In addition, it describes the swelling as "recurrent" rather than persistent or continuous. A July 2000 clinical record from CHNMC reflects that upon clinical examination there was no peripheral edema of the extremities. The report is negative for any finding of edema of the right hand. A June 2001 clinical record from CHNMC reflects that upon clinical examination there was no peripheral edema of the extremities. The report is negative for any finding of edema of the right hand. A June 2002 clinical record from CHNMC reflects that the Veteran complained of intermittent swelling of the right upper extremity. Upon clinical examination, there was no peripheral edema. The report is negative for any finding of edema of the right hand. Notable, it reflects that the Veteran had reported swelling which was described as "intermittent" rather than persistent or continuous. A July 2003 clinical record from CHNMC reflects that upon clinical examination there was no peripheral edema. The report is negative for any finding of edema of the right hand. A September 2004 VA clinical record reflects that the Veteran had a chief complaint of numbness in the right hand and forearm. He reported that since chemotherapy, he has had numbness in the right forearm below the elbow in a circumferential pattern and also numbness in his thumb and first two fingers. There was no pain, weakness, or atrophy reported. The record is negative for any complaints of or finding of edema. It notes that there was no CCE (clubbing, cyanosis, and edema) of the extremities. A June 2005 VA examination for NHL reflects that the Veteran reported that his hand stays swollen, and that he has numbness and tingling. Upon clinical examination, the extremities showed no signs of edema. A June 2005 CHNMC record reflects that upon physical examination, there was no edema of the extremities. A December 2005 VA clinical record reflects that the Veteran reported experiencing numbness, tingling, and weakness in the right arm. January and February 2006 VA clinical records reflect that the Veteran reported experiencing numbness of the right hand, and tingling of the right hand and forearm. The Veteran was assessed with carpal tunnel syndrome affecting the median nerve on right hand. November 2006 VA clinical records reflect that the Veteran has "smaller hand on left compared to right suggesting a long standing problem of the [left] body with [left] hemiatrophy, probably congenital." The records also reflect that the Veteran reported numbness on his right arm after chemotherapy extravasations in the 1990s. The report reflects that that the Veteran denied edema. August 2007 neurology clinic records reflect that the Veteran reported right upper extremity numbness since chemo extravasation into the right arm. The Veteran reported subjective weakness in the right hand since his last visit. The records also note that upon examination, the Veteran's right hand was cooler and pinker than the left; however, the record is negative for any finding of edema. An August 2008 VA examination report for other disabilities reflects that the Veteran reported that during his treatment in 1991 he experienced chemotherapy extravasation into his right arm and reported that he has had numbness and weakness of the right hand since then. Upon clinical examination, it was noted that the right hand was cooler and more pink in color than the left hand. It was noted that there was also mild edema in the left compared to the right. In an April 2013 statement, the appellant stated that the Veteran had persistent edema, pain, numbness, and color changes of the right hand and that these symptoms never went away. The appellant referenced the above noted VA examination report dated in September 2008 and contended that the description of the hands was reversed and that it was actually his right hand that had edema. The Board finds that the evidence of record does not support such an allegation. Notably, as discussed in further detail below, a March 2009 VA examination report reflects that the Veteran's right hand was noted to be cooler and more pink in color than the left. It was also noted that there was mild edema the left hand compared to the right. Thus, the 2009 record supports the findings of the 2008 examiner. A September 2008 VA record reflects that the Veteran reported that his right forearm and entire left side was numb. Upon examination, there was no edema. A November 2008 VA record reflects that upon examination, there was no edema. A March 2009 VA examination report for the Veteran's NHL reflects that he reported numbness and weakness of the right hand since chemotherapy extravasation. The numbness was located in the index, middle, and thumb of the right hand. Upon clinical review of the extremities, it was negative for edema. The right hand was noted to be cooler and more pink in color than the left. It was also noted that there was mild edema the left hand compared to the right. The record reflects that the Veteran was noted to develop local irritation as well as recurrent pain and swelling after his chemotherapy. The examiner stated that "recurrent swelling, reported by the veteran and documented from the City of Hope Dr. [N.] would be as likely as not related to residuals of treatment of the [NHL] limited to the skin." A July 21, 2009 record by H.H. reflects that the Veteran reported that his right hand "is flaring and itching very badly." It was noted that the Veteran had xerosis of the leg and groin, eczema to the right hand extending to the volar wrist, multiple papules on an erythematous based with some associated excoriations and scale. And some hyperkeratotic scale to the right palmer hand. The assessment was dermatitis. Upon consultation with Dr. C., it was not that Dr. C. had evaluated the situation and concurred that this is eczema. He was prescribed Salex cream to help the hands with the hyperkeratosis papules, and to continue to use Dove and miniaturization. The report is negative for any finding that the Veteran had edema of the right hand. As the Veteran was being clinically examined for his hands, the Board finds that if the right hand was swollen, it would have been reasonable for such to be noted in the clinical records; it is not. An August 2009 record by H.H. reflects that the Veteran's dorsal hands have greatly improved, but he had some purpura noted in the bilateral forearms. In sum, the objective clinical evidence of record is against finding that the Veteran had massive board wide or persistent edema; thus, he is not entitled to a rating in excess of 10 percent. There is also no objective clinical evidence of subcutaneous induration or statis pigmentation, and persistent ulceration. While the Veteran is competent to report persistent edema, the Board finds that the clinical records are more probative. In addition, while the Veteran may have had some swelling, the record is against a finding that any such swelling was persistent. Notable, it was not found on clinical examination in1990, 1995, July 1998, 1999, 2002, 2004, 2005, 2008, or 2009, and was noted to be "questionable" in June 1998. The Board has considered whether there are any other diagnostic codes which would be applicable and would provide the Veteran with a rating in excess of 10 percent, but finds that there is not. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extraschedular Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected phlebitis. The Board acknowledges that the Veteran reported weakness, tingling and numbness; however, as discussed above, his numbness, tingling, and weakness was diagnosed as carpal tunnel syndrome affecting median nerve on right hand. The Veteran is not service connected for carpal tunnel syndrome. Because there is no evidence of symptoms that would present a disability picture more severe than that contemplated by the rating schedule, extraschedular referral is not warranted in this case. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. See Thun, supra. ORDER Entitlement to service connection for hiatal hernia, to include as secondary to service-connected non-Hodgkin's lymphoma (NHL) is denied. Entitlement to service connection for genitourinary disability (including prostatic hypertrophy), to include as secondary to service-connected NHL is denied. Entitlement to service connection for sleep apnea, to include as secondary to service-connected NHL is denied. Entitlement to service connection for S1 radiculopathy, to include as secondary to service-connected NHL is denied. Entitlement to service connection for a disability(ies) manifested by symptoms of stomach problems, night sweats and chronic fatigue, to include as secondary to service-connected NHL is denied. Entitlement to service connection for a disability manifested by vision problems is denied. Entitlement to service connection for a disability manifested by right testicle pain is denied. Entitlement to service connection for a disability manifested by kidney pain is denied. Entitlement to an initial evaluation in excess of 10 percent for chemical phlebitis of the right upper extremity is denied. REMAND Polycythemia, to include as secondary to service-connected NHL. Disability manifested by shortness of breath and/or chest pains Polycythemia is defined as an increase in the total red cell mass of the blood. Secondary polycythemia is defined as any absolute increase in the total red cell mass other than polycythemia vera, occurring as a physiologic response to tissue hypoxia, such as associated with pulmonary disease, alveolar hypoventilation, cardiovascular disease, or prolonged exposure to high altitude, or resulting from defective hemoglobin or drugs, or it may be inappropriate, reflecting excessive erythropoietin production due to renal or extrarenal disorders. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (31st Ed. 2007). There have been a considerable number of opinions as to whether the Veteran's polycythemia is primary or secondary polycythemia. Such a distinction may have a bearing on the final outcome of the claim; thus, the Board will discuss the evidence in detail. A 1977 clinical record from the USAF Medical Center, Keesler Air Force Base reflects that the Veteran was hospitalized from April 1977 to May 11, 1977. The discharge record reflects that the Veteran's "hematocrit on two separate occasions was 50.5 and 51.4. The white counts were normal. Urine for Bence-Jones protein was negative." The record reflects that the Veteran smoked two packs of cigarettes per day. A May 1977 Oklahoma City VAMC nuclear medicine report reflects that the Veteran's plasma volume "is mildly decreased relative to the predicted and this is consistent with a relative polycythemia." Relative polycythemia is a decrease in plasma volume without the change in red blood cell mass of absolute polycythemia, so that the erythrocytes become more concentrated (elevated hematocrit). It occurs in both acute forms (a transient condition due to marked loss of body fluid, lowered fluid intake, or a combination) and chronic forms of stress polycythemia. Stress polycythemia is a chronic type of relative polycythemia occurring without the characteristic symptoms associated with polycythemia vera. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (31st Ed. 2007). A March 1996 respiratory clinic note reflects that the Veteran was a smoker. The report further states: "The patient does have erythrocytosis that we can see. This is probably from carboxyhemoglobin as he is a smoker but we haven't proven this." The Veteran was advised to quit smoking. Erythrocytosis is defined as secondary polycythemia. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (31st Ed. 2007 A May 16, 1996 CHNMC and Beckman Research Institute respiratory disease record reflects that the Veteran reported that he was being treated for some kidney problems; however, the examiner stated, "we have not document that; all his renal laboratories here have been normal." The examiner further stated, in pertinent part, as follows: as far as the polycythemia is concerned, I do not believe that this has anything to do with his smoking. His lung functions have been fine. Oxygenation and saturation have been fine. We do have to be sure that it is not a real polycythemic problem versus that of a kidney problem that is causing erythropoietin and blood production. I will defer this to Dr. [N.] at this time. . . . Again, the patient has been advised to stop smoking to be sure that this is not carbon dioxide that is causing his problem, although his saturation by blood gas has been adequate; this means that it is unlikely that this is the cause of his problem. Correspondence dated in May 1996 from Dr. N., CHNMC, from the hematology clinic reflects, in pertinent part, as follows: Over the last few years there has been persistent high Hemoglobin and progressive increase in his white blood count. His hemoglobin has been ranged between 18 - 18.5 gm.dl. his hematocrit 50-54%. His most recent white count was elevated at 13, 6000 although with normal differential count. his bone marrow examination in 1990 was normal by both morphology and cytogenic studies. He admitted to a history of several packages of smoking and also a history of hypertension on Prinivil. It is possible that this patient has polycythemia either primary polycythemia or secondary polycythemia from a history of smoking volume contraction because of his hypertension and treatment for his hypertension. . . . We have advised him to stop smoking and will follow his hemoglobin/hematocrit closely. Erythropoietin level will be sent. If hemoglobin remains elevated with low erythropoietin level after he stops smoking then this will suggest that he has primary polycythemia. . . . He will come back in about 3 - 6 months after he has stopped smoking and we will plan to investigate his polycythemia if he hemoglobin remains elevated. . . . I believe that he had underlying polycythemia since the time of his diagnosis of his lymphoma in 1990 which has been worse due to his long history of smoking. An April 1997 VA examination report reflects that the Veteran had complaints with regard to migraine headaches, stomach problems which were treated with Zantac and Propulsid, high blood pressure, loss of feeling on the left side of the body, chest pain found be noncardiac in origin, and shortness of breath. It was noted that he smokes approximately one pack per day for the last 20 years, had a chronic nonproductive cough, painful joints, chronic fatigue, occasional night sweats that have occurred over the last three years, kidney pain which he described as lower back pain and not accompanied by any hematuria or pyuria, feeling rundown with no energy, dizziness which has no relation to his headaches, and trouble sleeping. The April 1997 examiner opined that the Veteran seemed to be in a sustained remission of his NHL which was probably cured. The examiner also noted that "of [the Veteran's] numerous complaints, I think few of them are directly related to his diagnosis of [NHL] or its treatment; however, many patients complain of chronic fatigue following treatments of their lymphoma that can persist for many years. I believe he probably has some pulmonary disease on the basis of tobacco use and possibly exposure to asbestos as working as a machinist and on shipyards. His pulmonary function tests display some mild impairment at this time. Polycythemia, not requiring therapy at this time. It bears watching. It is more than likely a secondary polycythemia to his mild pulmonary disease." A March 1998 VA addendum to the April 1997 VA examination report reflects that the Veteran remained in a complete remission eight years after his diagnosis of NHL and was fully employed. The examiner stated that none of the Veteran's complaints could be specifically ascribed to his NHL or its therapy. A 1999 VA clinical record reflects that the Veteran red cell volume and total blood volume were within normal limits. It was noted that the plasma volume was mild decreased relative to the predicted and this was consistent with a relative polycythemia. It was further noted that the Veteran's polycythemia was studied in the past and it is not polycythemia vera, but probably secondary to smoking. He had elevated COHb (carboxyhemoglobin). A July 2000 CHNMC record reflects that since the Veteran was last seen, he says he feels better. It was noted that he smokes less and takes three cigarettes a day. It was further noted that he had no fever or shortness of breath and his breathing is better. It was noted that he was still having intermittent problems with high blood pressure. With regard to polycythemia, it was noted that the Veteran's "erythropoietin level has also been low on two different occasions. The bone marrow examinations did not show any evidence of red cell hyperplasia or hyperplasia of the bone marrow. This could be related to his underlying chronic lung disease as well as carbon monoxide from his smoking and from his occupation." The examiner noted that he was considered that the Veteran may have underlying polycythemia vera. He was advised to stop smoking and it was noted that his blood count would be watched closely. A June 2001 CHNMC record reflects the following statement by the clinician "over the last few years I have noticed that his red cells have been on the high side and I suspect that he has secondary polycythemia from chronic lung disease." The assessment was "high hemoglobin, likely related to secondary polythemia due to hypertension as well as chronic lung problem." A June 2002 CHNMC record from Dr. N. reflects that the Veteran continued to some approximately one pack a day. The Veteran complained of some fatigue, intermittent swelling of the right upper extremity, some headaches and some dizziness. He had multiple symptoms of back pain and abdominal pain. Upon clinical examination, he had no abdominal masses and no peripheral edema. The assessments were NHL in complete remission 11 years after completion of therapy, high hematocrit likely to be secondary polycythemia from chronic smoking, and history of asbestosis. A July 7, 2003 record from Dr. N. of CHNMC reflects that the Veteran was in remission from his NHL. The record reflects that the Veteran had been noted to have polycythemia dating back at least since 1993 when he was noted to have hemoglobin. The clinician stated that "we have done an erythropoietin level on several occasions and he was found to have a very low erythropoietin level. The patient also continues to smoke and he has a history of hypertension." The July 7, 2003 assessment was "polythemia based on the low erythropoietin level. This would be more consistent with primary polycythemia. The patient also was told his oxygen saturation was normal which is against secondary polycythemia from smoking. Although he has also had hypertension and is on medication. The patient is symptomatic from his high hemoglobin and it might be worth it to tray [sic] a phlebotomy to bring the hemoglobin down to 15 or 16 gm level. That might improve his headache and blurred vision." A December 2003 VA clinical record reflects that the Veteran had "documented evidence of [NHL] diagnosed in 1990 status post M-BACOD and CHOP has elevated hgb levels today with complaints of headache and has the documented proof of good room air abgs (arterial blood gas). This is most likely a myelodysplatic syndrome and may be secondary to his previous treatment." A March 2004 VA clinical record reflects that the Veteran reported that he had been diagnosed with primary polycythemia vera and required serial phlebotomies. A September 2004 VA examination report reflects that the Veteran has "diagnoses of primary polycythemia though this has not been confirmed by a nuclear study." A June 2005 CHNMC record reflects that "over the last few years [the Veteran] has developed polythemia. Bone marrow examination was consistent with polycythemia. His workup for secondary polycythemia has been negative." A November 2006 clinical record from CHNMC's hematology clinical reflects that the Veteran has a long history of polycythemia vera which has been treated with phlebotomy. The record also states, in pertinent part, as follows: [the Veteran] had history of high hemoglobin dating back since 1976 when he was in the service. At that time it was found to be secondary to smoking. During the time of diagnosis his non-Hodgkin's lymphoma was also noted. His hemoglobin was high but no further work-up was done. Because of persistent high hemoglobin, work-up for polycythemia vera was made, including bone marrow erythropoietin level. It was felt to be primary-polycythemia. A September 2008 clinical record from VA's hematology-oncology department states that the Veteran's "diagnosis of [polycythemia vera] is questionable given the negative JAK2 and the high Epo (epoetin alfa (erythropoietin; Epogen)) level. As such, we need to look at his previous BM bx (bone marrow biopsy) reports." A November 2008 clinical record from VA's hematology-oncology department states that the Veteran returned for a follow up appointment. The examiner stated, in pertinent part, as follows: I now have his BM bx report from the City of Hope National Medical Center and it says "erythroid hyperplasia" and "normocellular marrow with active hematopoietic." No evidence of malignancy was seen. This was from 10/14/1996. He is JAK2 negative, has a high CO level (8%) and an elevated erythropoietin level of 22.5 as of 10/27/08. The assessment was secondary polycythemia. The examiner noted that the diagnosis of secondary polycythemia is "supported by the negative JAK2 V617F mutation status, the elevated CO level and the elevated Epo level. Also, his BM biopsy simply showed erythroid hyperplasia. Secondary polycythemia is not associated with thrombotic and hyperviscous complications and he does not need any further phlebotomies." The appellant contends that the Veteran was in receipt of worker's compensation for asbestosis; 1996 records reflect that the Veteran was exposed to asbestosis post-service while working in a Navy shipyard. The appellant now also contends that the Veteran had asbestosis due to his active service. A February 2009 primary care note from Dr. J.A. states that the Veteran may have had potential exposure. The clinician stated that the Veteran did not have calcific plaques in the pulmonary pleura but that there are at least three forms of asbestosis that can be diagnosed without findings of pleural plaques. Throughout the years, the Veteran's polycythemia has been noted to be either secondary or primary. The most recent 2013 opinion reflects that the Veteran had secondary polycythemia. The evidence reflects that the Veteran's secondary polycythemia is due to his smoking and the records reflect that he has been diagnosed with COPD; however, clinical records also reflect that his polycythemia may be, in part, due to asbestos exposure. Thus, the Board must first address whether the Veteran has asbestosis due to service, and if so, whether his polycythemia is causally related to, or aggravated by, asbestosis. If not, the Board must address whether the Veteran's polycythemia first manifested in service. See 38 C.F.R. § 3.300. Thus, VA should attempt to obtain the Veteran's service personnel records which may reflect his duties, his workers compensation records, and a VA clinical opinion. Disability manifested by Dizziness The 2013 clinician also stated that the Veteran's reported dizziness could be attributed to the Veteran's hypertension, or to his nonservice-connected polycythemia for which he was getting repeated phlebotomies and was iron deficient because of that. The Board finds that a supplemental opinion as to the Veteran's dizziness should be obtained with a discussion of whether the Veteran had dizziness after he stopped getting phlebotomies. TDIU In a March 2013 VA clinical opinion, the clinician stated that the medical records do not show that the Veteran was rendered unable to follow substantial gainful employment prior to his death because of his service-connected disabilities. The clinician further noted that the medical records show that the Veteran worked as a machinist and stopped working in 2007 after he was diagnosed with deep vein thrombosis and was started on lifelong warfarin because of a history of VTE and multiple inherited hypercoagulable risk factors (elevated homocysteine, weakly positive lupus anticoagulant and heterozygosity for Factor V Leiden.) The Board finds that after the RO has readjudicated the above remanded issues, it should obtain supplemental clinical opinion on the issue of TDIU. The clinician is asked to opine as to whether the Veteran would have been able to maintain substantial gainful employment in a sedentary occupation or manual labor occupation, or both, and provide a rationale for the opinion. Accordingly, the case is REMANDED for the following action: 1. Request the appellant to identify all medical providers (VA and private) from whom the Veteran received treatment for asbestosis, and complete and return a provided VA Form 21-4142, Authorization and Consent to Release Information, for the identified treatment records, for each provider identified. After obtaining completed VA Forms 21-4142, the AOJ should attempt to obtain all identified pertinent medical records. Request the appellant to provide contact information, and authorization, for VA to obtain all workers compensation records for the Veteran with regard to any award of disability benefits, to include all treatment records upon which such determination was based. 2. Obtain a copy of the Veteran's military service personnel records and associate it with the claims file. 3. Thereafter, forward the claims file to a VA physician(s) The clinician is asked to opine as to a.) whether the Veteran had asbestosis, and b.) if so, was it as likely as not (50 percent or greater) that asbestosis was causally related to, or aggravated by, active service, and c.) if so, was it as likely as not that the Veteran's polycythemia was causally related to, or aggravated by, his asbestosis. The clinician should also opine as to d.) whether the polycythemia manifested during service. The clinician should consider the entire claims file, to include the STRs, Dr. J.A.'s February 2009 primary care note, the Veteran's decades long history of smoking, the Veteran's post service employment in a shipyard, and the clinical records which reflect that the Veteran had COPD. The clinician should also provide an opinion as to whether the Veteran's reported dizziness was related to his hypertension and/or his polycythemia, and should discuss whether the Veteran had dizziness continued after he stopped getting phlebotomies. The claimant should also provide an opinion as to whether the Veteran's service connected disabilities alone, and without consideration of his non-service connected disabilities, rendered him unable to maintain substantial gainful employment in a sedentary occupation and/or manual labor occupation, or both, and provide a rationale for the opinion. 4. After undertaking any other development deemed appropriate, the RO should readjudicate the issues on appeal. If any benefit sought on appeal is not granted, the RO should issue a supplemental statement of the case and provide the appellant and representative with an appropriate opportunity to respond. The appellant 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). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs