Citation Nr: 1326514 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 08-25 404 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to service connection for upper respiratory infection-pulmonary complaints, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 2. Entitlement to service connection for rhinitis and sinusitis (claimed as upper respiratory infection). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD P. Childers, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran served on active duty from June 1955 to June 1958, and from January to June 1991, including service in the Southwest Asia Theater of Operations. This case comes to the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2013, the Veteran asked for a videoconference Board hearing, which he has withdrawn that request. In May 2013, the Veteran submitted additional evidence directly to the Board and his representative indicated that he wished to waive initial RO consideration of the evidence; thus, it will be considered by the Board in the adjudication of this appeal. In May 2013, the Board requested the opinion of a medical specialist from the Veterans Health Administration (VHA). After receiving the requested opinion, in June 2013 the Board informed the Veteran and his representative that it had requested a specialist's opinion in conjunction with the adjudication of his appeal, provided him a copy of that opinion and indicated that he was entitled to submit additional evidence or argument provided within 60 days of the date of that letter. In a signed statement, dated later that same month, the Veteran stated that he had no further evidence or argument to present, and in July 2013, his representative offered additional argument in support of the appeal. As such, the Board will proceed with the consideration of his case. The issue of service connection for rhinitis and sinusitis (claimed as upper respiratory infection) is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDING OF FACT The Veteran's upper respiratory-pulmonary complaints of chronic cough and intermittent wheezing are already rated as symptoms of his service-connected intermittent bronchospastic disease disability. CONCLUSION OF LAW As the Veteran's upper respiratory-pulmonary complaints of chronic cough and intermittent wheezing are already contemplated by, and rated under, the diagnostic criteria used to evaluate his service-connected intermittent bronchospastic disease, the appeal for service connection for these pulmonary complaints is dismissed. 38 U.S.C.A. § 7105 (West 2002). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist VA has a duty to notify the claimant of the information and evidence necessary to substantiate the claims submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The notice requirements were accomplished in a letter dated in June 2009. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006). The Veteran was apprised of the information and evidence needed to substantiate his claim for service connection, including the information and evidence to be submitted by him and the information and evidence to be obtained by VA. He was also apprised of how disability evaluations and effective dates are assigned, and of the type of evidence that impacts those determinations. As for VA's duty to assist, VA has associated with the claims file the service treatment records and reports of his post-service care. The Veteran has also been afforded numerous VA examinations, and offered the opportunity to testify at a hearing before the Board; which he initially accepted, but later declined. As the Veteran has not identified any additional evidence pertinent to the claims, and as there are no additional records to obtain, the Board concludes that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159, and that the Veteran will not be prejudiced by the Board's adjudication of his claims. II. Merits Service records confirm that the Veteran served in the Persian Gulf in support of Operation Desert Shield/Desert Storm from February through April of 1991. A service treatment record dated in April 1991 (while the Veteran was in the Persian Gulf) notes the Veteran's report of a repeated cough that was treated by medics; and a service treatment records dated in May 1991 documents complaints of, and show treatment for, chronic cough and problem with ears. Diagnosis in May 1991 was upper respiratory infection/bronchitis. In June 1991 the Veteran separated from active duty service. VA medical records dating from 1992 relate complaints of persistent cough since the Veteran's return from the Persian Gulf in 1991. Diagnosis on VA examination in September 1992 was mild restrictive ventilator defect. Diagnosis on VA examination in May 1996 was "persistent cough after returning from Persian Gulf." The examiner added that the Veteran most likely had intermittent bronchospastic disease. In a decision dated in June 1997, the Board granted service connection for pulmonary disorder; and in a rating decision dated in October 1997 the RO effectuated the Board's decision as a grant of intermittent bronchospastic disease and rated the Veteran's "persistent cough, most likely intermittent bronchospastic disease" under the bronchial asthma provisions of Diagnostic Code 6699-6602. The Veteran is also service-connected for epistaxis. A general physical examination by VA in May 2003 found the throat and lungs to be clear. X-rays of the chest in May 2003 were negative. Pulmonary function testing in June 2003 showed mild obstruction. Diagnosis was chronic obstructive pulmonary disease. A CT scan of the chest in December 2003 was negative. Diagnosis on follow-up consult was "asthma that began in the Gulf 1991 with intermittent exacerbations since." In March 2007 the Veteran reported for evaluation of a productive cough with greenish mucoid phlegm of some six weeks duration. Physical examination found the chest to be clear, with no rales, rhonchi, or expiratory wheezes. Diagnosis was pharyngitis; history of asthma; and history of shortness of breath. Chest x-rays done by VA in May 2007 revealed both lungs well expanded and free of infiltrates, but CT scan found bilateral parenchymal nodules. Follow-up consult by the Chief of Pulmonary Medical Service in June 2007 included a physical examination, which found no nodes, clubbing, edema, or jugular venous distention, and the lungs were clear. Diagnosis was chronic bronchitis, extrinsic asthma; and lung nodules. Treatment included inhaled steroids. On VA examination in July 2007, the Veteran complained of a persistent cough that he said began during his active duty in the Persian Gulf in 1991. He reported that he was exposed to a lot of gas, sand storms, fumes, dust, smoke from burning structures and gas fires, sarin gas, and gas from burning scud missiles during that service. He added that he was given bronchodilators to use because he heard himself wheezing, and said that he continued to be bothered by a constant cough. Physical examination found no oropharyngeal lesion, jugular venous distention, or lymphadenopathy, and the lungs were clear, but the examiner noted that the Veteran coughed constantly during that visit. X-rays of the chest showed the heart and lungs within normal limits. Diagnosis was history of exposure to dust, fumes, sand, sarine gas causing recurrent bronchitis. The examiner, who happened to be the Chief of Pulmonary Medical Service, added that the Veteran's symptoms were typical of chronic bronchitis. The examiner also stated that the Veteran had chronic sinusitis, which he said could also cause chronic cough. A VA medical record dated in September 2007 describes an office visit for evaluation of dry cough. The chest and throat were clear. Diagnosis was history of bilateral parenchymal nodules, and history of chronic bronchitis. The provider stated that the Veteran's dry cough could be secondary to ACE inhibitor. A CT scan of the chest in October 2007 revealed small nodular densities in both lungs, moreso in the right. In January 2008 the Veteran underwent a routine physical examination, which found clear lungs and throat. A CT scan of the chest/thorax in February 2008 showed several small stable pulmonary nodules. A VA medical record dated in March, 2008, documents an office visit for upper respiratory infection. During the consult the Veteran reported that he had been having nonproductive cough, associated with hoarseness, sore throat and low grade temperature for the past three days. Physical examination found erythema over the pharyngeal wall, but the chest was clear, with no rales, rhonchi, or expiratory wheezes. Diagnosis was upper respiratory infection. A CT scan done by VA in September 2008 found several small stable lung nodules. On VA examination in November 2008, the Veteran complained of a frequent productive cough with white mucous, occasionally productive of lightheadedness, dizziness, knife-like chest wall pain on deep inspiration, and near syncope. X-rays of the chest were negative, but pulmonary function testing in November 2008 found abnormal pulmonary function. In February 2009 the Veteran filed his claim for service connection for upper respiratory infection. In correspondence dated in May 2009 he referred specifically to chronic bronchitis, nodules/granulomas on both lungs, and sinusitis. A VA primary care medical record dated in August 2009 reflects that the Veteran had a history of chronic obstructive pulmonary disease/asthma and was using inhalers; and that he had a history of pulmonary nodules, confirmed by CT scan. During an October 2009 VA pulmonary consult the Veteran denied dyspnea, but complained of a persistent cough. The pulmonologist noted that the Veteran had a history of chronic cough, bronchitis, and cough precipitated by many substances like cold air, perfumes, and swimming pools. The pulmonologist also noted that the Veteran had never smoked, and that the Veteran's symptoms had commenced during his tour in the Persian Gulf. Physical examination found normal chest sounds and no wheezes or rales, but forced expiration was not that long, and the pulmonologist noted that the Veteran coughed more than usual. Chest x-rays and CT scan were "ok." According to the pulmonologist, the Veteran has had persistent airways irritability and bronchitic episodes since his 100 day tour of duty in the Persian Gulf in 1991. He added that the Veteran clearly has a history consistent with bronchitic episodes, and likely asthma, though the usual treatment for asthma did not eliminate the Veteran's symptoms. On VA Gulf War examination in October 2009, the Veteran complained of intermittent shortness of breath. He reported that he had served in Kuwait, Iraq, and Saudi Arabia while in the Persian Gulf, and was exposed to smoke from oil fires, fumes from tent heaters, diesel and petrochemical fumes, burning trash and feces, solvents and paints, and second-hand cigarette smoke. He also reported that he was exposed to depleted uranium, microwave towers, personal pesticides, nerve gas, and mustard gas, and that he participated in post scud missile attack cleanup. He added that he is a non-smoker, and described his health as very poor after his Persian Gulf service. The examiner noted that the Veteran had a history of chronic obstructive pulmonary disease and a history of pulmonary nodules, which were stable on CT scan. He also noted that the Veteran had a history of recurrent sinus infections, allergies, and intermittent shortness of breath, for which he used inhalers. Physical examination revealed moist oral mucosa. Pulmonary function testing found normal pulmonary function with significant response to bronchodilators, and chest x-rays showed no active lung disease. Sinus films showed frontal sinusitis. Diagnoses included chronic obstructive pulmonary disease/asthma-controlled with inhalers, and pulmonary nodules-stable on CT scan. VA medical records dated in January, 2010, describe the Veteran as having a history of chronic obstructive pulmonary disease/asthma, and a history of pulmonary nodules, per CT scans. Examination of the chest revealed fair bilateral air entry, but no rales, rhonchi, or expiratory wheezing. The provider noted that the Veteran had a history of occasional productive cough with mucus and wheezing, which was symptomatic during the examination. On VA physical examination in April 2010 the provider noted that the Veteran had a history of recurrent dry cough. Physical examination found the chest to be clear. Diagnoses included chronic obstructive pulmonary disease/asthma; history of stable pulmonary nodules; and history of sinusitis. During that visit the Veteran reported that he had not been using the inhalers albuterol/Atrovent, as ordered, since August of 2009, and stated that he had remained asymptomatic. On VA physical examination by a new primary care physician in April 2011, the provider noted that the Veteran had a history of chronic cough of unknown etiology; that the Veteran had a history of lung nodules; and that the Veteran had been diagnosed with chronic obstructive pulmonary disease and asthma. Physical examination found the lungs to be clear but there was a "wheezy-type of cough very, very frequently." There were no decreased breath sounds at the base, and no wheezes or rhonchi. On VA respiratory examination in February 2013 the Veteran reported that he had developed a cough approximately 4 days after his arrival in the Persian Gulf in January 1991, which he said was, for the most part, nonproductive, or productive of a scant amount of clear sputum. He also recalled having had the sensation of low grade fever and chills, and said that he was told by field medics that he had "desert cough." He stated that he was treated with cough suppressants, but continued to cough, and at times would develop sharp chest pain and lightheadedness when coughing. He further stated that he was treated with antibiotics for 90 days, and that on his return to his stateside post he was told that he had chronic bronchitis and given more antibiotics and a cough preparation prior to separation. He also complained of chest pain since 1991, and said that he coughed day and night; though the examiner noted that he did not cough during the examination. He further reported that he was exposed to dust storms, during which he did not wear a mask; and added that he had had a cough for the past 22 years; since his return from the Persian Gulf. The examiner, a VA pulmonologist, noted that the Veteran was a nonsmoker, and was using a nasal spray, inhaled bronchodilators, and antibiotics. Physical examination, which was of the chest only, found normal chest expansion and no respiratory abnormalities or chest wall scarring or deformity. X-rays were negative. Diagnosis was asthma, chronic bronchitis, and desert cough. In an opinion dated May 28, 2013, a VHA pulmonary expert stated that the Veteran does not suffer from a chronic upper respiratory infection disorder; rather, it is more likely than not that the Veteran's pulmonary complaints, namely, chronic cough and intermittent wheezing, were a manifestation of his service-connected asthma/intermittent bronchospastic disease, which is related to the Veteran's 1991 environmental hazards exposure. The pulmonary expert explained that a cough related to environmental hazards exposure, as experienced by the Veteran, can persist for years and may not respond well to treatment with bronchodilators and inhaled steroids. The pulmonary expert added that some of these patients can have a cough despite normal lung function tests and negative methacholine tests. Laws & Regulations Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 C.F.R. § 3.303(a). Disorders diagnosed after service may still be service connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability, which includes the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995). To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516- 17 (1995). Because the Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, service connection may also be established under 38 U.S.C.A. § 1117 (West 2002 & Supp. 2012) and 38 C.F.R. § 3.317 (2012). Under those provisions, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of Operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of Operations or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. at 8-9. Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Presumptive service connection is warranted for certain infectious diseases: (i) Brucellosis; ii) Campylobacter jejuni; (iii) Coxiella burnetii (Q fever); (iv) Malaria; (v) Mycobacterium tuberculosis; (vi) Nontyphoid Salmonella; (vii) Shigella; (viii) Visceral leishmaniasis; and (ix) West Nile virus. 38 C.F.R. § 3.317(c)(1-2). The diseases listed in paragraph 38 C.F.R. § 3.317(c)(2) will be considered to have been incurred in or aggravated by service under the circumstances outlined in paragraphs (c)(3)(i) and (ii) of this section even though there is no evidence of such disease during the period of service. With three exceptions, the diseases listed in 38 C.F.R. § 3.317(c)(2) must have become manifest to a degree of 10 percent or more within 1 year from the date of separation from a qualifying period of service as specified in paragraph (c)(3)(ii) of this section. Malaria must have become manifest to a degree of 10 percent or more within 1 year from the date of separation from a qualifying period of service or at a time when standard or accepted treatises indicate that the incubation period commenced during a qualifying period of service. There is no time limit for visceral leishmaniasis or tuberculosis to have become manifest to a degree of 10 percent or more. Further, if a Veteran who has or had an infectious disease identified in column A of 38 C.F.R. § 3.317(d)(2) also has a condition identified in column B of that section as potentially related to that infectious disease, VA must determine, based on the evidence in each case, whether the column B condition was caused by the infectious disease for purposes of paying disability compensation. This does not preclude a finding that other manifestations of disability or secondary conditions were caused by an infectious disease. If a Veteran presumed service connected for one of the diseases listed in paragraph (c)(2) of this section is diagnosed with one of the diseases listed in column "B" in the table within the time period specified for the disease in the same table, if a time period is specified or, otherwise, at any time, VA will request a medical opinion as to whether it is at least as likely as not that the condition was caused by the Veteran having had the associated disease in column "A" in that same table. "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). In deciding a claim for service connection on the merits, the Board must assess the credibility and weight of all evidence, including the Veteran's statements and the medical evidence to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. See Owens v. Brown, 7 Vet. App. 429 (1995) (it is the Board's fundamental responsibility to evaluate the probative value of all medical and lay evidence); see also Evans v. West, 12 Vet. App. 22, 30 (1998) (providing that it is the responsibility of the Board to weigh the evidence and determine where to give credit and where to withhold the same). Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. See Cartwright v. Derwinski, 2 Vet. App. 24, 26 (1991); Hatlestad v. Derwinski, 1 Vet. App. 164, 169-70 (1991); Gilbert v. Derwinski, 1 Vet. App. 49, 59 (1990). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). Analysis The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on the evidence needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Preliminarily, the Board notes that the provisions of 38 C.F.R. § 3.317 do not apply in this case since the Veteran's pulmonary complaints, anecdotally referred to as desert cough, are of medically determinable/known etiology. The evidence confirms that the Veteran has had chronic cough and recurrent wheezing since service, but according to all of the pulmonologists, including the May 2013 VHA expert, the Veteran's chronic cough and intermittent wheezing are symptoms of his service-connected pulmonary disorder, diagnosed variously as asthma, bronchitis, chronic obstructive pulmonary disease, and intermittent bronchospastic disease; and in an August 2007 rating decision these respiratory complaints were acknowledged to be symptoms of the Veteran's service-connected intermittent bronchospastic disease. There is no medical evidence to the contrary. See Colvin v. Derwinski, 1 Vet. App. 171 (1991) (holding that the Board must consider only independent medical evidence to support its findings rather than provide its own medical judgment). Therefore, inasmuch as the RO acknowledged that the Veteran's service-connected pulmonary disability (identified as intermittent bronchospastic disease cold injury) includes objective findings and subjective symptoms of chronic cough, intermittent wheezing, and lung nodules and has evaluated the disability under the asthma provisions of Diagnostic Code 6699-6602, service connection for these pulmonary complaints has, in effect, been granted. See Baughman v. Derwinski, 1 Vet. App. 563, 566 (1991) (holding that when the RO listed a condition as service-connected on a rating sheet, it effectively granted service connection). Thus, the Veteran's claim of entitlement to service connection for upper respiratory infection-pulmonary complaints is moot as the benefit sought on appeal (namely, service connection) is already in effect. Accordingly, the appeal on this issue is dismissed. ORDER The appeal for service connection for upper respiratory infection-pulmonary complaints, including chronic cough, intermittent wheezing, and lung nodules, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is dismissed as moot. REMAND In the July 2009 rating decision on appeal the RO denied the Veteran's claim for service connection for upper respiratory infection via Diagnostic Codes 6522 (allergic or vasomotor rhinitis), and 6511 (chronic ethmoid sinusitis), on the grounds that while the Veteran had submitted medical evidence of chronic rhinosinusitis, there was no evidence relating this condition to service. However, the Veteran has repeatedly reported that he was exposed to airborne hazards, including sand storms, smoke from oil fires, fumes from tent heaters, diesel and petrochemical fumes, burning trash and feces, solvents and paints, second-hand cigarette smoke, depleted uranium, microwave towers, personal pesticides, nerve gas, mustard gas, and scud missile debris, during his service in the Persian Gulf warzone, and he maintains that his sinus complaints are related to those events. Based on this evidence the Veteran was entitled to a VA examination and in September 2009 he was accorded a VA examination, which returned a diagnosis of frontal sinusitis. Unfortunately, an opinion as to a nexus to service was not proffered and a February 2013 VA examination report likewise does not address this issue. VA medical records also show diagnoses of, and show treatment for, sinusitis and rhinitis, and note the Veteran's exposure to environmental hazards in the Persian Gulf, but there is no opinion regarding a nexus to service in these records either. Remand for a new VA examination with opinion is therefore warranted. See Colvin v. Derwinski, 1 Vet. App. 171 (1991) (holding that the Board must consider only independent medical evidence to support its findings rather than provide its own medical judgment); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination when developing a service-connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). On remand VA treatment records dating from January 2013 should be associated with the claims file. Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Send VCAA notice to the Veteran on the issue of service connection for rhinitis and sinusitis, claimed as upper respiratory infection, including as secondary to a service-connected disability. 2. Associate all of the Veteran's VA medical records dating from January 2013 with the claims file. Any additional pertinent records identified by the Veteran during the course of the remand should also be obtained, following receipt of any necessary authorizations from the Veteran. 3. Then schedule the Veteran for an appropriate VA examination regarding the issue of service connection for rhinitis and sinusitis. The claims file must be made available to and reviewed by the examiner. All indicated tests should be done and all findings should be reported in detail. In offering any requested opinion, the examiner must specifically acknowledge and comment upon the Veteran's competent report of his in-service and post-service experiences and symptoms. The examiner is then requested to state whether it is at least as likely as not that that the Veteran's rhinitis and sinusitis a) had its onset during service, or is related to some incident of service, including the Veteran's exposure to sand storms, smoke from oil fires, fumes from tent heaters, diesel and petrochemical fumes, burning trash and feces, solvents and paints, second-hand cigarette smoke, depleted uranium, microwave towers, personal pesticides, nerve gas, mustard gas, and/or scud missile debris, during his service in the Persian Gulf; b) is proximately due to or the result of a service-connected disease or injury, to include service-connected intermittent bronchospastic disease; PTSD; fibromyalgia; irritable bowel syndrome, left hand dermatitis, epistaxis as a residual of a varicosity of the right septum; otitis media; and right cheek scar; or c) is aggravated by a service-connected disability. The term aggravation means that there has been an increase in severity of the Veteran's rhinitis and/or sinusitis by a service-connected disability beyond its natural progression. If the examiner concludes that the Veteran's sinusitis and/or rhinitis is aggravated by a service-connected disability, the examiner should attempt to provide the baseline degree of severity prior to the aggravation. If the VA examiner determines that he or she is unable to provide the requested medical opinion(s) without resorting to speculation, this should be indicated in the report, along with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Thereafter, readjudicate the Veteran's claim. If the benefit sought on appeal remains denied, issue the Veteran and his representative a supplemental statement of the case and provide the Veteran an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matter 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). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs