Citation Nr: 1329145 Decision Date: 09/11/13 Archive Date: 09/17/13 DOCKET NO. 06-04 618 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for reactive airway disease. 2. Entitlement to service connection for bronchitis. 3. Entitlement to service connection for granulomatous calcifications in the right midlung and right hilar region. 4. Entitlement to service connection for sleep apnea, to include as secondary to service-connected tension headaches. 5. Entitlement to service connection for sinusitis. 6. Entitlement to service connection for chronic upper respiratory infections. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Hudson, Associate Counsel INTRODUCTION The Veteran served in the Army Reserves, with a period of active duty for training from August 1996 to December 1996. She also served on active duty from February 2003 to October 2003 and from June 2007 to July 2008. This matter comes before the Board of Veterans' Appeals (Board) from a June 2004 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) that denied service connection for sleep apnea, urinary urgency and stress incontinence, depressive disorder, and a cervical spine disability manifested by muscle spasms. The Veteran was scheduled for a Board hearing at the Montgomery RO in November 2009. Notice of the hearing was mailed to the Veteran in October 2009. The Veteran did not appear at the scheduled hearing and did not provide a cause for her failure to appear. To date, VA has not received any request from the Veteran to reschedule her November 2009 Board hearing. Therefore, her hearing request is considered withdrawn. See 38 C.F.R. § 20.704(d) (2012). In March 2010, the Board granted service connection for a psychiatric disorder, to include depressive disorder (implemented by a June 2010 rating decision) and remanded the remaining claims. Based on that development, the Appeals Management Center granted service connection for urinary urgency and stress incontinence in June 2011 and for muscle spasms of the cervical spine in September 2011. The Board remanded the case again in September 2012 for further evidentiary development. As a result of this remand and development, the Appeals Management Center granted service connection for asthma and allergic rhinitis in May 2013. The only matters remaining before the Board have been identified on the Title page. A review of the Virtual VA and VBMS paperless claims processing systems reveal additional VA medical treatment records and a July 2013 appellate brief pertinent to the present appeal. The issues of sleep apnea, sinusitis and chronic upper respiratory infections are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's reactive airway disease and bronchitis clearly and unmistakably preexisted active service, but worsened beyond normal progression during or as a result of her active service. 2. The Veteran's granulomatous calcifications in the right midlung and right hilar region clearly and unmistakably preexisted active service and clearly and unmistakably were not permanently worsened beyond normal progression during or as a result of her active service. CONCLUSIONS OF LAW 1. The criteria for service connection for reactive airway disease and bronchitis have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303, 3.304, 3.306, 3.309 (2012). 2. The criteria for service connection for granulomatous calcifications in the right midlung and right hilar region have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303, 3.304, 3.306, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Compliance with Prior Board Remands The Board observes that this case was previously remanded in March 2010 and September 2012. The purpose of the March 2010 remand was to obtain a VA examination to determine if the Veteran's respiratory disorders were linked to her active duty service. The VA examiner was instructed to provide an etiology opinion for all diagnosed respiratory conditions. VA respiratory examinations were conducted in June 2009 and September 2010, with an addendum VA opinion provided in November 2011. However, the examinations did not provide an opinion as to whether the Veteran's respiratory conditions were the result of not having the use of her C-PAP machine in the Southwest Asia Theater in 2003. Thus, in September 2012, the case was remanded by the Board in order to obtain an adequate medical opinion, along with updated VA Medical Center (VAMC) records, service treatment records (STRs) from June 2007 to July 2008, and private medical records from Baptist East Medical Center and Dr. Piedmont. The record documents that upon remand, all of the requested development was accomplished, including a new January 2013 VA examination. The January 2013 VA medical examination is adequate with regards to the claims for reactive airway disease, bronchitis, and granulomatous calcifications in the right midlung and right hilar region. See 38 C.F.R. § 3.159(c)(4). It appears there was substantial compliance with the prior remand orders and the Board may continue with its determination of the claims for service connection for reactive airway disease, bronchitis, and granulomatous calcifications in the right midlung and right hilar region. Stegall, 11 Vet. App. at 271; see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). II. VA's Duties to Notify and Assist The 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). See also Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). Appropriate notice was provided in February 2004, March 2006, and March 2010 letters. As for the duty to assist, the Veteran's VA medical treatment records have been obtained, including some VAMC records placed in the Veteran's Virtual VA paperless claims file. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). While all available STRs were obtained, some STRs appear to be unavailable. The RO has made several attempts to obtain copies of the Veteran's STRs spanning her period of active duty from June 2007 to July 2008. However, in a May 2013 memorandum, the RO noted that several attempts had been made to obtain these missing STRs but that these attempts had been unsuccessful. As such, the Board finds that any further search for these records would be futile. The Board notes that in a case where STRs are unavailable, VA has a heightened obligation to explain its findings and conclusions, and to consider the benefit-of-the-doubt rule. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Veteran has not claimed to be in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c)(2). The Veteran has provided some relevant private medical treatment records, although she did not respond to the RO's September 2012 request for completion of an Authorization and Consent to Release Information form for Baptist East Medical Center and Dr. Piedmont. The Veteran has not identified any additional relevant medical records that have not been obtained and associated with his file. Four VA examinations and one VA addendum opinion have been secured in connection with the current claims for service connection. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300-01 (2008). The Veteran's January 2013 VA medical examination is adequate with regards to the claims for reactive airway disease, bronchitis, and granulomatous calcifications in the right midlung and right hilar region, as it provides explanations for the opinions stated as well as the medical information necessary to reach a decision. VA's duty to assist with respect to obtaining a VA examination has been met. 38 C.F.R. § 3.159(c)(4). VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. III. Service Connection The Veteran contends she has several respiratory conditions that are related to her military service, specifically her exposure to dust and sand and inability to use her C-PAP machine during her time in the Southwest Asia Theater of operations in 2003. See, e.g., Veteran's Application for Compensation and/or Pension, December 2003. Service connection may be granted for disabilities resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. §§ 1110 , 1131. Generally, service connection requires: (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A veteran is considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111. Thus, veterans are presumed to have entered service in sound condition as to their health. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulation provides expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b) , and that "[h]istory of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions." Id. at (b)(1). In order to rebut the presumption of soundness at service entry, there must be clear and unmistakable evidence showing that the disorder preexisted service and clear and unmistakable evidence that the disorder was not aggravated by service. See 38 C.F.R. § 3.304 (b). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 3-2003 (July 16, 2003). VA must also show by clear and unmistakable evidence that the preexisting disorder was not aggravated during service. A preexisting injury or disease will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issues in this case, the nexus between service and subsequent respiratory conditions, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Therefore, medical evidence will be required to establish a medical diagnosis of the Veteran's current respiratory conditions and to address the question of whether her active duty service caused or aggravated her respiratory conditions. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122, 128 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to a veteran). Reactive Airway Disease and Bronchitis The Veteran's STRs show that during active duty for training in September 1996, she was treated for a runny nose, congestion, sore throat and headache and treated for bronchitis versus pharyngitis. There is no other indication that the Veteran was treated for bronchitis during this active duty for training period. The Veteran's May 2001 Report of Medical History, during which time she was not on active duty, states "bronchitis since childhood susceptible to URI." Upon a May 2001 Report of Medical Examination, the examiner found the Veteran's mouth and throat abnormal with some tonsil enlargement. The examiner noted the Veteran's tonsils were consistent with a history of chronic bronchitis. A May 2001 treatment note from the Jacksonville Naval Hospital shows the Veteran seeking treatment for her chest tightness, productive cough, and chills with an audible wheeze. The pertinent medical history listed bronchitis. The diagnosis included reactive airway disease exacerbation. The Veteran entered active service for a second time in February 2003 and was deployed to the Southwest Asia Theater of operations. Upon return from deployment in September 2003, the Veteran complained of chronic upper respiratory problems, including bronchitis and a chronic sore throat. The provisional diagnosis was chronic upper respiratory illness. A September 2003 Preseparation Report of Medical History shows the Veteran had asthma or a breathing problem related to exercise, weather, or pollens, bronchitis, shortness of breath, wheezing or problems with wheezing, been prescribed or used an inhaler, sinusitis, hay fever, and chronic or frequent colds. The Veteran claimed she had developed bronchitis as a result of the desert sand in Kuwait and inability to use her C-PAP machine while in-country. In September 2003, a Certified Family Nurse Practitioner diagnosed the Veteran with chronic upper respiratory illness, including sore throat, allergic rhinitis, sinusitis and bronchitis, worsened by her inability to use her C-PAP while in country, due to a lack of electricity. An October 2003 Post-Deployment Health Assessment found the Veteran's respiratory symptoms had resolved, but diagnosed her with reactive airway disease. A treatment record from the Winn Army Community Hospital from October 2003 diagnosed the Veteran with reactive airway disease with bronchospasm. The record shows the Veteran has continued to have complaints related to bronchitis and reactive airway disease. See Outpatient Clinic Records, September 2007 and April 2008 (assessment of acute bronchitis); see also Postdeployment Health Care Provider Review, June 2008 (bronchitis noted; patient diagnosed with bronchitis in theater). Additionally, the January 2013 VA examiner diagnosed the Veteran with asthma, reactive airway disease, bronchitis and chronic upper respiratory infections. The examiner noted that the Veteran was on Combivent one to two times per day for her reactive airway disease and that she has six to seven bouts of bronchitis per year. The VA examiner opined that the Veteran's bronchitis and reactive airways disease clearly and unmistakably existed prior to service. However, due to the multiple documentations of treatment during service in 2003 for bronchitis and reactive airway disease, the VA examiner found it at least as likely as not that the Veteran's respiratory condition did increase in severity beyond its natural progression during active duty service. The Board finds that the Veteran did clearly and unmistakably suffer from bronchitis and reactive airway disease prior to active duty service in 2003. Specifically, the evidence supports a finding that the Veteran had chronic bronchitis since childhood and was first diagnosed with reactive airway disease in May 2001. With respect to whether there was aggravation of the Veteran's bronchitis and reactive airway disease during service, the Board notes the VA examiner found the Veteran's respiratory conditions increased in severity beyond their natural progression during her 2003 active service period. As the record reveals no medical opinion refuting that set forth above, the Board finds the claims for service connection for reactive airway disease and bronchitis should be granted. Combee, 34 F.3d at 1044. Granulomatous Calcifications in the Right Midlung and Right Hilar Region In May 2001, during which time the Veteran was not on active duty, she sought treatment at the Jacksonville Naval Hospital due to chest tightness, productive cough, and chills with an audible wheeze. A chest x-ray was completed showing a right middle lobe infiltrate. The diagnosis was right middle lobe pneumonia. During active duty in October 2003, a doctor at the Winn Army Community Hospital diagnosed the Veteran with " ? [ left] lung infiltrate of unknown significance." There was no further diagnosis or treatment of lung infiltrates during the Veteran's active duty service. During a September 2010 VA examination, a VA examiner diagnosed the Veteran with nodular density with calcifications in the right midlung and granulomatous calcifications in the right hila. See VA Examination, September 2010; see also March 2010 CT Chest Scan (finding nodular density with calcifications in the right midlung and granulomatous calcifications in the right hila); see also February 2010 Chest X-ray (showing area of density in the right mid lung; the left lung is clear). Additional chest X-rays were taken during the January 2013 VA examination, which showed the Veteran's lungs remained clear with no infiltrate and a stable cluster of nodules in the lateral basal segment of the right lower lobe with right hilar nodes that were stable, completing a benign-appearing Ghon complex. The VA radiologist's impression was prominent Ghon complex with otherwise clear stable chest. Ghon complex is the primary parenchymal lesion of primary pulmonary tuberculosis associated with a corresponding lymph node focus. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 723 (32nd. ed. 2012). The January 2013 VA examiner opined that based on the CT scans and X-rays of record, there was no evidence of an increase in severity of the Veteran's granulomatous calcifications in the right midlung and right hilar region beyond their natural progression during active duty. Overall, the examiner stated that this condition is essentially a benign calcification of the lung. The Board notes that the Veteran has not claimed to have suffered from tuberculosis during active service and there is no evidence in the record to show that the Veteran was diagnosed or treated for tuberculosis while in active service. The Board finds that the Veteran did clearly and unmistakably suffer from granulomatous calcifications in the right midlung and right hilar region prior to active duty service in 2003. Specifically, the evidence supports a finding that the Veteran's May 2001 X-ray, showing a right middle lobe infiltrate, proves that her granulomatous calcifications in the right midlung and right hilar condition preexisted her 2003 active duty service. The Board notes the January 2013 VA examiner opined that there was no evidence of an increase in severity of the Veteran's granulomatous calcifications in the right midlung and right hilar region beyond their natural progression during active duty. Therefore, the record does not support a nexus between service and the Veteran's granulomatous calcifications in the right midlung and right hilar region. Service connection may not be granted as the evidence clearly and unmistakably reflects that the Veteran's preexisting granulomatous calcifications in the right midlung and right hilar did not increase in severity beyond their natural progression in-service. Nor is there any evidence of record to show the Veteran suffered from tuberculosis as a result of service. Consequently, the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55. ORDER Entitlement to service connection for reactive airway disease is granted. Entitlement to service connection for bronchitis is granted. Entitlement to service connection for granulomatous calcifications in the right midlung and right hilar region is denied. REMAND With regard to sleep apnea, the June 2009 VA examiner stated that "[h]eadaches can be associated with sleep apnea." Additionally, a February 2008 private treatment record found the Veteran's headaches, ". . . are constant, lasting entire day, may interfere w/sleep." See ASMC Outpatient, History of Present Illness, February 2008. In August 2009, the Veteran's claim for service connection for tension headaches was granted. However, the September 2010, November 2011, and January 2013 VA examiners did not address the possible relationship between the Veteran's sleep apnea and her service-connected headaches. The Board observes that service connection may be granted for a disability that is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. The record clearly raises a theory of entitlement on a secondary service connection basis. However, no development, to include an examination, has been undertaken with respect to the issue of service connection for sleep apnea on a secondary basis. Therefore, the Board finds that a remand is necessary to afford the Veteran a VA examination to determine if she has sleep apnea that is secondary to her service-connected tension headaches. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Furthermore, given the theory of secondary service connection raised by the evidence, the Veteran should be sent a new letter notifying her of the information and evidence necessary to substantiate a claim of service connection for sleep apnea on a secondary basis to comply with the VA's duties of notification. The Veteran also claims that she is entitled to service connection for sinusitis. The January 2013 VA examiner found no evidence of sinusitis. As a result, the examiner did not provide an opinion as to whether the Veteran's sinusitis was incurred in or aggravated by her active duty service. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110; Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997). The evidence must show that, at some point during the appeal period, the veteran has the disability for which benefits are being claimed. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (in which the Court held that, in the absence of proof of a present disability, there can be no valid claim). It is clear that the Veteran has been diagnosed with sinusitis during the appeal period. See November 2011 VA Addendum Opinion (finding evidence of sinusitis); see also March 2004 VA Examination (diagnosis of chronic ethmoidal and maxillary sinusitis with moderate functional impairment). Despite the fact that the January 2013 VA examiner did not find any evidence of sinusitis at that time, service connection could still potentially be granted as sinusitis was diagnosed at other times during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (stipulates that a service connection claim may be granted if a diagnosis of a chronic disability was made during the pendency of the appeal, even if the most recent medical evidence suggests that the disability resolved). Thus, upon remand, it is necessary for the VA examiner to opine whether the Veteran's previously diagnosed chronic sinusitis was incurred in or aggravated by her active duty service. With regard to the Veteran's service connection claim for upper respiratory infections, the January 2013 VA examination is internally inconsistent. Specifically, the VA examiner diagnosed the Veteran with asthma, reactive airway disease, bronchitis and chronic upper respiratory infections, but subsequently stated there was no evidence of the Veteran having chronic upper respiratory infections. The VA examiner also noted that "upper respiratory infection" is a nebulous umbrella term. It is necessary for the VA examiner to provide a clear and concise definition of the term "upper respiratory infection," provide an opinion as to whether the Veteran has a diagnosis of upper respiratory infection currently or had a diagnosis of upper respiratory infection at any time throughout the claims period, and state whether this condition was incurred in or aggravated by active service. See McClain, 21 Vet. App. at 321; see also McLendon, 20 Vet. App. at 83. The most recent treatment records from the Alabama VAMC are dated in November 2012 and the Pittsburgh VAMC records are dated in March 2013. Accordingly, on remand, records of any ongoing VA treatment for the Veteran's sleep apnea, sinusitis, chronic upper respiratory infections and headaches should be obtained. See 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if pertinent). The Veteran is hereby notified that it is her responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failing to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). Accordingly, the case is REMANDED for the following action: 1. Send a new notice letter to the Veteran, notifying her of the information and evidence necessary to substantiate her claim of service connection for sleep apnea as secondary to her service-connected tension headaches. 2. Obtain the names and addresses of all medical care providers, not previously identified, who have treated the Veteran for sleep apnea, sinusitis, chronic upper respiratory infections and headaches since December 2003. After securing the necessary release(s), obtain these records, including all pertinent treatment records from the Alabama VAMC from November 2012 to present and Pittsburgh VAMC from March 2013 to present. 3. After completion of the foregoing, schedule the Veteran for an appropriate VA examination to determine the nature, extent and etiology of her sleep apnea, sinusitis and chronic upper respiratory infections. The claims file, to include a copy of this Remand, must be made available to the examiner. All indicated tests should be conducted, and the reports of any such studies should be incorporated into the examination report to be associated with the claims file. Based on the examination and review of the record, the examiner is requested to provide the following information: a) It is at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's diagnosed sleep apnea was caused or aggravated (permanently worsened beyond normal progression) by her service-connected tension headaches? If the Veteran is found to have sleep apnea aggravated by her tension headaches, the examiner should quantify the approximate degree of aggravation. In providing this opinion, the examiner should address the significance of the June 2009 VA examiner's finding that "[h]eadaches can be associated with sleep apnea," the February 2008 private treatment record stating the Veteran's headaches, ". . . are constant, lasting entire day, may interfere w/sleep," and the Veteran's grant of service-connection for tension headaches in August 2009. b) Is it clear and unmistakable (obvious or manifest, undebatable) that the Veteran's chronic upper respiratory infection and diagnosed sinusitis existed prior to her entrance into service? c) If so, is it also clear and unmistakable that the Veteran's chronic upper respiratory infection and diagnosed sinusitis did not increase in severity beyond natural progression during active service? d) If the Veteran's chronic upper respiratory infection and/or diagnosed sinusitis is not found to have preexisted service, is it at least as likely as not (i.e. probability of 50 percent or greater) that such disability had its onset in service or is otherwise related to the Veteran's active military service? The examiner should provide a clear and concise definition of the term, "chronic upper respiratory infection" and whether or not it encompasses respiratory conditions for which the Veteran is already service-connected (asthma, allergic rhinitis, bronchitis, and reactive airway disease). In providing these opinions, the examiner should address the significance of the April 1996 Report of Medical History, listing a history of sinusitis, September 2001 Report of Medical History, listing a history of sinusitis, May 2003 and June 2003 chronological records of medical care showing diagnoses of sinusitis, a July 2003 individual sick slip listing upper respiratory problems, a September 2003 diagnosis of chronic upper respiratory illness, including sore throat, allergic rhinitis, sinusitis and bronchitis, worsened by inability to use C-PAP machine while deployed, a September 2003 Report of Medical Examination finding abnormal nose, sinuses, lungs and chest, an October 2003 Post-Deployment Health Assessment, stating that the Veteran's chronic cough, runny nose, fever, weakness, headaches, chest pain or pressure, and difficulty breathing had been resolved, March 2004 VA examiner's finding of chronic sinusitis, May 2009 Montgomery VAMC notation of possible sinusitis, February 2010 Montgomery VAMC impression of acute sinusitis, November 2011 VA examiner's documentation of sinusitis, and the Veteran's contention that her sinusitis and upper respiratory infection were aggravated by her inability to use her C-PAP machine while on active duty in 2003 in the Southwest Asia Theater (Iraq and Kuwait), in addition to her exposure to dust and sand during this deployment. A full rationale must be provided for all stated medical opinions. Note: if the examiner concludes that there is insufficient information to provide an etiology opinion without resorting to mere speculation, the examiner should state whether the inability to provide a definitive opinion was due to a need for further information (please identify) or because the limits of medical knowledge had been exhausted regarding the etiology of the claimed condition. 4. After completion of the above, readjudicate the issues on appeal. If any benefits remain denied, the Veteran and her representative should be provided a supplemental statement of the case and given an appropriate opportunity to respond. The case should then be returned to the Board for further consideration, if otherwise in order. 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). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs