Citation Nr: 1727167 Decision Date: 07/13/17 Archive Date: 07/25/17 DOCKET NO. 12-08 801 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for residuals of a back injury. 2. Entitlement to service connection for a respiratory disability, claimed as asthma, to include as due to exposure to mustard gas, or in the alterative, as due to exposure to sand and dust. 3. Entitlement to service connection for a cardiovascular disability, to include hypertension with chest pain. WITNESSES AT HEARING ON APPEAL The Veteran and his mother ATTORNEY FOR THE BOARD M. Espinoza, Associate Counsel INTRODUCTION The Veteran had active service from June 1985 to June 1988. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Decatur, Georgia. These matters were previously before the Board in July 2013 and December 2014, when they were remanded for further development. They now return to the Board for further appellate consideration. In August 2015, the Veteran' then representative, Kenneth L. LaVan, Attorney, withdrew his representation of the Veteran. The Veteran was sent a letter in February 2017 that notified him of his right to appoint another representative. To date, the Veteran has not appointed another representative. As such, the Board will recognize the Veteran as pro se. In May 2014, the Veteran and his mother testified at a hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The Board has recharacterized the Veteran's service connection claim for asthma more broadly to include any respiratory disability. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009) (holding that a claimant may adequately identify the disability for which compensation benefits are sought by referring to a body part or system that is disabled, or by describing the symptoms of that disability). The issue of entitlement to service connection for a respiratory disability, claimed as asthma, to include as due to exposure to mustard gas, or in the alterative, as due to exposure to sand and dust, is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The most probative evidence of record does not establish that the Veteran has a current cardiovascular disability, to include hypertension, that manifested in service, or within one year of separation from service, nor was it shown to be the result of any injury, disease, or event during active service. 2. The most probative evidence of record does not establish that the Veteran has residuals of a back injury, currently diagnosed as lumbar spondylosis, that manifested in service, nor is it shown to be the result of any injury, disease, or event during active service, to include as a result of an in-service motor vehicle accident. CONCLUSIONS OF LAW 1. The criteria for service connection for a cardiovascular disability, to include hypertension, are not met. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1154, 5107 (West 2015); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2016). 2. The criteria for service connection for residuals of a back injury, currently diagnosed as lumbar spondylosis, are not met. 38 U.S.C.A. §§ 1131, 1154, 5107 (West 2015); 38 C.F.R. §§ 3.102, 3.303 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions, including pursuant to 38 C.F.R. § 3.103 (c)(2) (2016) and Bryant v. Shinseki, 23 Vet App 488 (2010). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2015); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Additionally, there has been substantial compliance the Board's July 2013 and December 2014 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Additionally, the Board acknowledges a remand directive below is specific for an attempt to obtain additional service treatment records from George Air Force Base for the Veteran's respiratory claim; however, as the Veteran reported such was in relation to the removal of his tonsils, there is no indication that any such records are relevant to the claims for a cardiovascular disability or a back disability decided herein, or that such would impact the outcome of these particular issues. Generally, service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1131 (West 2015); 38 C.F.R. § 3.303 (2016). To establish service connection on a direct incurrence basis, the Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; 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, 1167 (Fed. Cir. 2004). Certain chronic diseases, including hypertension, arteriosclerosis, cardiovascular-renal disease and arthritis, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2015); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2016). Additionally, service connection on the basis of continuity of symptomatology can be established for the chronic diseases specified at 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). I. Cardiovascular Disability, to include Hypertension The Veteran contends that service connection is warranted for a cardiovascular disability, to include hypertension. Specifically, the Veteran has asserted, including in May 2014 testimony, that during service, when he ran his chest beat so hard that he had to stop for a while just to try to catch his breath. He further testified that when he reported to an aid station for shortness of breath and because his chest hurt, he was told his blood pressure was elevated. He also testified he believed his cardiac disability was linked to stress during service as he was stationed in the Mohave desert with asthma, due to cliques that existed within his unit and the pressure of his job. In May 2014 testimony, the Veteran also reported that he had a heart attack in 1989 or 1990 and collapsed in his garage. In his October 2009 notice of disagreement, the Veteran stated that during service, while home on days off, he experienced chest pains but did not know what was going on with his body. He also reported, in his October 2009 notice of disagreement that his first post-service employer told him he had hypertension and in May 2014 testimony, he reported the same employer told him that he had elevated blood pressure. Turning to the first element of service connection, the existence of a present disability, the Board finds that the evidence of record confirms the Veteran has a diagnosed cardiovascular disability. September 2008 VA treatment records, noted in part, cardiomyopathy with questionable angina, hypertension, and an impression of mild reversal in the septal to lateral wall count ratio, and noted such could occur due to lateral wall ischemia but may also occur due to soft tissue attenuation. A May 2011 private medical record noted an impression of borderline cardiomegaly without evidence of acute process of the chest. A May 2011 VA treatment record also noted the Veteran had a history of atypical chest pain and noted such was felt to be musculoskeletal. In April 2016, a VA examiner noted diagnoses of cardiomyopathy and hypertensive heart disease, and found each were diagnosed in 2008. The April 2016 VA examiner stated, in part, that her findings upon examination were consistent with hypotensive cardiomyopathy with no signs of decompensation. In a separate disability benefit questionnaire specific to hypertension, the same April 2016 VA examiner also endorsed a diagnosis of hypertension. As the Veteran is acknowledged to have a cardiovascular disability, best characterized as hypotensive cardiomyopathy, as well as hypertension, the issue before the Board becomes whether his cardiovascular disabilities are as a result of his active service. The second element of a claim for service connection is medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease. As noted above, Veteran asserts that his current cardiovascular disability, to include hypertension, onset during service. Specifically, in May 2014 testimony, the Veteran reported shortness of breath and chest pain upon exertion during service and that he was told his blood pressure was elevated during service. The Veteran's service treatment records have not been obtained in the entirety, however, the existing records are negative for complaints or clinical findings related to high blood pressure or hypertension. In this regard, in an April 1988 heath questionnaire for dental treatment, the Veteran did not check the corresponding box indicating heart trouble/chest pain, heart murmur or high blood pressure. Additionally, a June 1998 service record reflected the Veteran declined a separation examination which is also suggestive of the proposition that he was not suffering from any disabilities, including a cardiovascular disability. Nonetheless, the Veteran is competent to attest to the factual matters of which he has first-hand knowledge, such as chest pain and shortness of breath. See Layno v. Brown, 6 Vet. App. 465 (1994). Thus, the Board finds Veteran's lay assertions of in-service events to be credible and the element of in-service disease or injury is met. However, the Board finds, for the reasons noted below, that the third requirement for service connection, competent evidence of a nexus between a current cardiovascular disability, to include hypertension, and an in-service disease or injury, has not been met. There is no competent, credible clinical evidence of record that any current cardiovascular disability, to include hypertension, is causally related to active service. There is no record of a diagnosis of hypertensive vascular disease or heart disease within the first year following the Veteran's separation from active service in June 1988. In a September 2012 record from the Social Security Administration, the Veteran reported his hypertension onset in 1988. However, there is no record of any blood pressure readings presented during the one year period post-service, which are indicative of essential hypertension. Indeed, the April 2016 VA examiner found, in part, that the first indication of a diagnosis of hypertension was from private medical records in October 2005 and that a diagnosis was established at that time but there was no mention of the onset. The April 2016 VA examiner stated that none of Veteran's medical records indicated the timing of his diagnosis and as such, onset prior to 2005 could not be established. However, the April 2016 VA examiner found there was no indication that the Veteran was diagnosed with hypertension in service or soon after discharge. Thus, the preponderance of the evidence is therefore also against a claim for service connection for hypertension on a presumptive basis as a chronic disease or on the basis of continuity of symptomatology. 38 C.F.R. § 3.309. The April 2016 VA examiner also noted the Veteran reported that he had been told in about 2003, or so, that he had had a heart attack. He indicated that he had not known it, and that he saw cardiology and had an angioplasty performed following that, but did not recall the results. However, the April 2016 VA examiner noted that the Veteran was a poor historian and many of the details in his history were recalled incorrectly and that it appeared the Veteran complained of a history of heart disease on his first presentation to the Tampa VA in 2008. The April 2016 VA examiner noted that an echocardiogram and electrocardiogram (EKG) were performed on the Veteran's presentation to the Tampa VA in 2008 and returned abnormal so the Veteran was referred to cardiology and also had a stress test due to the abnormal findings. The April 2016 VA examiner noted the stress test showed possible lateral wall ischemia so the Veteran was referred for cardiac catheterization, which returned showing normal coronary arteries but there also was decreased ejection fraction. Thus, the April 2016 examiner reported the Veteran was started on hydrochlorothiazide (HCTZ) initially and then changed to furosemide in 2011 and that he has been continued on furosemide and uses compression hose for his lower extremity swelling. Contrary to the Veteran's report during the April 2016 examination that he suffered a heart attack in 2003, the Veteran, in May 2014 testimony, reported that he had a heart attack shortly after separation from service in 1989 or 1990. He also testified that he told by his first employer that he had high blood pressure. However, pursuant to the December 2014 Board remand, in January 2016, the Veteran was provided with the opportunity via an authorization form to provide any additional relevant records, but he did not respond to this request with respect to records of a heart attack in 1989 or 1990, nor for any post-service employment records. In this regard, the absence of any corroborating medical evidence supporting assertions, in and of itself, does not render lay statements incredible, but such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of appellant's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent to establish a diagnosis when . . . a layperson is competent to identify the medical condition.) Thus, as described above, there is no medical evidence of record that objectively demonstrates that the Veteran had treatment related to a heart disability or hypertension until many years after his separation from active service. This long gap between his discharge from service and the earliest clinical evidence of a cardiovascular disability or hypertension is considered to be evidence that weighs against his claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Pursuant to the December 2014 Board remand, an April 2016 VA examiner opined the Veteran's claimed hypertension was less likely than not incurred in or caused by his claimed in-service chest pain. The April 2016 VA examiner stated the Veteran's medical records were reviewed extensively, including the electronic claims file records, as well as both private and VA treatment records and noted there were no service treatment records showing the Veteran was treated for hypertension while in service. The August 2016 VA examiner further noted that the blood pressure on the Veteran's entrance physical was normal and there were no records documenting elevated blood pressure readings while in service and there were also no records documenting the Veteran's claim of chest pain while in service. As described above, the April 2016 VA examiner noted the first indication of a diagnosis of hypertension was in October 2005. The April 2016 VA examiner opined that, based on the available medical evidence, in order to relate Veteran's diagnosis to service, speculation would be required as the earliest evidence established the diagnosis in 2005 and such was not consistent with a service-connected condition. Moreover, the April 2016 VA examiner opined that the Veteran's contention that "stress" related to his service in the Mojave desert and job pressures caused his hypertension was unsubstantiated and stress alone was not a cause for hypertension, thus such was a medically unfounded claim. Based on the evidence of record as presented above, the Board finds that the preponderance of the evidence is against the Veteran's claim that his current cardiovascular disability, to include hypertension, was incurred as a result of an event, injury, or disease during active service or onset during his active service. In essence, there is no persuasive medical evidence of record that provides a nexus between current cardiovascular disability, to include hypertension, and his active service. The Veteran has not provided any competent medical evidence to demonstrate any current cardiovascular disability, to include hypertension, was caused by, or was a result of, his active service. Indeed, the opinion of the April 2016 examiner provided in the heart conditions and hypertension disability benefit questionnaires was predicated on a full overview of the entire relevant record and was presented by an examiner who was specifically tasked to present a nexus opinion after review of the evidence. The April 2016 VA examiner explained the reasons for her conclusions based on review of the record, to include the Veteran's report of chest pain during service. Thus, the April 2016 VA examiner's opinion is entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. 295 (2008). In reviewing the Veteran's claim for service connection for a current cardiovascular disability, to include hypertension, the Board has reviewed the statements of the Veteran. Lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. Layno, 6 Vet. App. at 469. The Veteran is certainly competent to describe the extent of his current symptomatology and the continuity of perceivable symptomatology from service onwards, such as chest pain and shortness of breath upon exertion during service, as described in May 2014 testimony. The Board notes, however, that there is no evidence that the Veteran possesses the requisite medical training or expertise necessary to render him competent to offer evidence on the causal question of whether any current cardiovascular disability, to include hypertension, can be attributed to active service. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau, 492 F.3d 1372. Although lay persons may be competent to provide opinions as to some medical issues, as the specific questions in this case pertain to the actual diagnoses, etiologies, time of onset, and degree of severity at time of onset of current cardiovascular disability, to include hypertension, such falls outside the realm of common knowledge of a lay person, he lacks the competence to provide a probative medical opinion linking his current cardiovascular disability to his military service. Jandreau, 492 F.3d 1372 Moreover, as described above, although the Veteran testified he was told he had elevated blood pressure during service, and shortly after service by his employer, to the extent the Veteran proffers this information as a positive nexus between his hypertension and service, the Board finds that a layperson's account of what personnel at an aid station during service and/or a provider associated with his post-service employer purportedly said, filtered as it was through a layman's sensibilities, is simply too attenuated and inherently unreliable to hold any probative value. Robinette v. Brown, 8 Vet. App. 69 (1995). Furthermore, episodic readings of elevated blood pressure are not synonymous with hypertension In sum, the Board finds that the ultimate medical conclusion presented in the record is that there is no etiological link relating any current cardiovascular disability, to include hypertension, to his active service, including exposure to tactical herbicides. The clinical records do not indicate that the Veteran's service was a possible cause of any current cardiovascular disability, to include hypertension, except as such documented the Veteran's own assertions. The April 2016 heart conditions and hypertension disability benefits questionnaires opinions found that the Veteran's current cardiovascular disability, to include hypertension, was less likely than not incurred in or caused by a claimed in-service injury, event, or illness. Thus, based on the reasons and bases discussed, the Board has considered the benefit of the doubt doctrine, but does not find that the evidence is of such approximate balance as to warrant its application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Accordingly, entitlement to service connection for a current cardiovascular disability, to include hypertension, is denied. II. Residuals of a Back Injury The Veteran contends that service connection is warranted for residuals of a back injury. Specifically, the Veteran has asserted, including in May 2014 testimony, that during service, in1987, he was involved in a motor vehicle accident where the car flipped and rolled injuring his back. Turning to the first element of service connection, the existence of a present disability, the Board finds that the evidence of record confirms the Veteran has a diagnosed back disability. The April 2016 back conditions examiner endorsed a diagnosis of lumbar spondylosis. As the Veteran is acknowledged to have a back disability diagnosed as lumbar spondylosis, the issue before the Board becomes whether his lumbar spondylosis is as a result of his active service. With respect to the second element of a claim for service connection, medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, in May 2014 testimony the Veteran reported he had been involved in a motor vehicle accident during service. The Veteran's service treatment records have not been obtained in the entirety, however, the existing records are negative for complaints or clinical findings related to back complaints or a motor vehicle accident. Additionally, a June 1998 service record reflected the Veteran declined a separation examination which is also suggestive of the lack of any disabilities, including a back disability incurred as a result of a motor vehicle accident. Nonetheless, the Veteran is competent to attest to the factual matters of which he has first-hand knowledge, a motor vehicle accident and back problems. See Layno, 6 Vet. App. at 469. Thus, the Board finds Veteran's lay assertions of in-service events to be credible and the element of in-service disease or injury is met. However, the Board finds, for the reasons noted below, that the third requirement for service connection, competent evidence of a nexus between a current back disability and an in-service disease or injury, has not been met. There is no competent, credible clinical evidence of record that the Veteran's current back disability is causally related to active service. There are no records of complaints of back pain until many years after separation from service. Indeed, October 2005 private medical records are absent for a complaint of back pain. Although the Veteran, including in November 2008 and July 2014 VA treatment records noted back pain since 1987, November 2008 VA imaging noted an impression of a normal study with respect to lumbar imaging. Additionally, a December 2011 private medical record documented the Veteran sought treatment for acute low back pain due to a motor vehicle collision that had occurred two days prior and was discharged home with instructions on back pain. Subsequently, September 2012 private imaging of the lumbar spine revealed a normal x-ray. The Board finds that the medical records in November 2008 and September 2012, which did not reveal a back disability, are more credible than statements made by the Veteran several decades later for compensation purposes. See Curry v. Brown, 7 Vet 59 (1994). Additionally, the lapse of time between service separation and the earliest documentation of current back disability is a factor for consideration in deciding a service connection claim. See Maxson, 230 F.3d at 1333. As described above, the medical evidence does not reflect the Veteran complained of back problems until many years after service. Indeed, the April 2016 VA examiner found that, after review of the record, that the Veteran's claimed lumbar spondylosis was less likely than not incurred in or caused by his claimed in-service motor vehicle accident with back injury. While the April 2016 VA examiner noted the Veteran claimed a motor vehicle accident while in service, the April 2016 examiner further noted that, while there were a limited number of medical records from the Veteran's period of active duty, there were no records which document a history of a motor vehicle accident while Veteran was in service nor were there any medical records showing injuries suggestive of a motor vehicle accident in service or treatment for injuries related to such. The April 2016 examiner noted the Veteran declined a separation physical in June 1988 which was suggestive of no significant medical conditions present at discharge. The April 2016 VA examiner found that the first documentation of medical care following discharge from service was in October 2005 from a private hospital and at that time the only listed medical issue was hypertension. The April 2016 examiner found there was no mention of back pain as a chronic medical condition related to Veteran's back until November 2008 and plain films associated with that complaint were normal with no spondylosis, no suggestion of disc abnormalities, and no bony fractures. The April 2016 VA examiner further stated that medical notes did not mention back pain regularly in the Veteran's medical records after that date but he was seen in December 2012 related to a motor vehicle accident and plain films of the back related to that visit were negative for disease. Although the April 2016 VA examiner noted the Veteran was seen in December 2012 related to a motor vehicle accident, such appears to have been a typographical error as the cited records are actually dated in December 2011. Ultimately, the April 2016 VA examiner found the Veteran's current back pain diagnosis in his medical record was chronic back pain first entered into his record in November 2008. Thus, the April 2016 VA examiner opined, that based on available medical records, Veteran had no findings related to chronic lumbar disease prior to spondylosis findings first seen with the current visit in April 2016 and there were no findings prior to that to relate to a back injury in service, whether in a motor vehicle accident or otherwise. The April 2016 VA examiner found the Veteran had offered no medical records to substantiate his claims and all of the available medical evidence was more consistent with back pain presently related to age and mild degenerative changes and there was no evidence of other significant back disease which could be related to a motor vehicle accident in service. The April 2016 VA examiner found this was a medically unsubstantiated claim with the preponderance of evidence being more consistent with disease which had recently developed and was unrelated to service. Based on the evidence of record as presented above, the Board finds that the preponderance of the evidence is against the Veteran's claim that his current back disability, diagnosed as lumbar spondylosis, was incurred as a result of an event, injury, or disease during active service or onset during his active service. In essence, there is no persuasive medical evidence of record that provides a nexus between the Veteran's current lumbar spondylosis and his active service. The Veteran has not provided any competent medical evidence to demonstrate his current back disability, currently diagnosed as lumbar spondylosis, was caused by, or was a result of, his active service. Indeed, the opinion of the April 2016 examiner provided in the back conditions disability benefit questionnaires was predicated on a full overview of the entire relevant record and was presented by an examiner who was specifically tasked to present a nexus opinion after review of the evidence. The April 2016 VA examiner explained the reasons for her conclusions based on review of the record, to include the Veteran's report of a motor vehicle accident during service, but instead found his lumbar spondylosis was more consistent with disease which had recently developed, to include as due to age. Thus, the April 2016 VA examiner's opinion is entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. In reviewing the Veteran's claim for residuals of a back injury, the Board has reviewed the statements of the Veteran and finds the Veteran is certainly competent to describe the extent of his current symptomatology and the continuity of perceivable symptomatology from service onwards, such as back pain and related problems. Layno, 6 Vet. App. at 469. However, there is no evidence that the Veteran possesses the requisite medical training or expertise necessary to render him competent to offer evidence on the causal question of whether his lumbar spondylosis can be attributed to active service. See Jandreau, 492 F.3d 1372. To the extent that the Veteran attempts to relate his lumbar spondylosis to his period of active service based on his own personal knowledge of medicine and his familiarity with his individual medical history, as noted above, the Veteran is not shown in the record to be a trained medical clinician. Although lay persons may be competent to provide opinions as to some medical issues, as the specific questions in this case pertain to the actual diagnoses, etiologies, time of onset, and degree of severity at time of onset of his current back disability, such falls outside the realm of common knowledge of a lay person. The Veteran lacks the competence to provide a probative medical opinion linking his current cardiovascular disability to his military service. Jandreau, 492 F.3d 1372. In sum, the Board finds that the ultimate medical conclusion presented in the record is that there is no etiological link relating the Veteran's currently diagnosed lumbar spondylosis to his active service, including as due to an in-service motor vehicle accident. The clinical records do not indicate that the Veteran's service was a possible cause of any current back disability, except as such documented the Veteran's own assertions. The April 2016 back conditions disability benefits questionnaire opinion found that the Veteran's lumbar spondylosis was less likely than not incurred in or caused by a claimed in-service injury, event, or illness. Thus, based on the reasons and bases discussed, the Board has considered the benefit of the doubt doctrine, but does not find that the evidence is of such approximate balance as to warrant its application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49, 54-56 (1990). Accordingly, entitlement to service connection for residuals of a back injury, currently diagnosed as lumbar spondylosis, is denied. ORDER Entitlement to service connection for a cardiovascular disability, to include hypertension, is denied. Entitlement to service connection for residuals of a back injury, currently diagnosed as lumbar spondylosis, is denied. REMAND Although the Board regrets the additional delay with regard to the issue of entitlement to service connection for a respiratory disability, another remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. As noted above, the Veteran's service treatment records have not been located in their entirety, even after attempts by the AOJ to do so through official sources. In an April 2016 statement, as part of his claim for service connection for respiratory disability, the Veteran reported his tonsils were removed a month prior to service at George Air Force Base. The record does not reflect such records have been obtained or attempted to be obtained. Thus, a request for clinical and hospitalization records from George Air Force Base dated in1988, should be made on remand. Additionally, pursuant to the December 2014 Board remand, an April 2016 respiratory conditions disability benefit questionnaire was obtained. The April 2016 examiner noted, in part, that pulmonary input for clarification of Veteran's diagnosis would be useful; however, based on available medical records, the earliest date of this diagnosis [of asthma] was October 2005. However, the April 2016 VA examiner opined that Veteran's claimed asthma, which clearly and unmistakably existed prior to service, was clearly and unmistakable not aggravated beyond its natural progression by an in-service injury, event, or illness. As part of the proffered rationale, the April 2016 VA examiner also noted, in part, that review of the medical record showed no mention of asthma on Veteran's service entrance exam in 1984 and there were no medical records which showed the Veteran required a waiver for entrance into service due to his asthma. The April 2016 VA examiner stated that while medical records only supported a diagnosis of asthma beginning in 2008, the Veteran stated in supporting documents that he had asthma on entrance and based on current regulations, this statement by the Veteran is used to establish a history of asthma prior to service. However, the United States Court of Appeals for Veterans Claims (Court) has held on multiple occasions that lay statements by a Veteran concerning a preexisting condition, alone, are insufficient to rebut the presumption of soundness. See Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238 (1994). Thus, the April 2016 VA examiner did not appear to consider the standard that the evidence must show it is clear and unmistakable (obvious, manifest, or undebatable) that the Veteran's asthma existed prior to active service in order to rebut the presumption of soundness. Additionally, VA treatment records, including in March 2015, indicated a diagnosis of allergic rhinitis, and an October 2012 record, from the Social Security Administration, provided an indication of a diagnosis of chronic obstructive pulmonary disease (COPD), neither which were addressed by the April 2016 VA examiner. However, as noted above, the April 2016 VA examiner did indicate pulmonary input for clarification of Veteran's diagnosis would be useful. Accordingly, on remand, another VA opinion must be obtained to address these deficiencies. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Accordingly, the case is REMANDED for the following actions: 1. Request and attempt to obtain any of the Veteran's clinical and hospitalization records, from George Air Force Base in 1988. All attempts to obtain these records must be documented in the claims file. The Veteran must be notified of any inability to obtain the requested documents. 2. Forward the claims file to an examiner other than the April 2016 VA examiner. The entire claims file should be made available for review, to include a complete copy of this remand. Upon review of the record, the examiner must determine with respect to the Veteran's asthma: (a.) Is it clear and unmistakable (obvious, manifest, or undebatable) that such existed prior to active military service? If it is found that asthma preexisted service, the examiner should identify the evidence upon which this opinion is based. The examiner should then provide an opinion as to whether the asthma was clearly and unmistakably (obvious, manifest, or undebatable) not aggravated by service. In other words, if there was an increase, was it clearly and unmistakably due to the natural progression of the disease. The examiner should identify the evidence upon which this opinion is based. (b.) In the event that it is not clear and unmistakable (obvious, manifest, or undebatable) that the Veteran's asthma preexisted service or, if preexisting, was not aggravated by service, is it is at least as likely as not (50 percent probability or more) that the Veteran's asthma and/or any other diagnosed respiratory disability (to include allergic rhinitis and COPD) was incurred in or was caused by, or is otherwise related to, the Veteran's active service? The examiner should give consideration to the Veteran's theory a respiratory disability was due to or aggravated by exposure to mustard gas, or in the alterative, as due exposure to sand and dust. In the event that the examiner feels that another VA examination is necessary, such should be scheduled, and the Veteran should be notified of the time and place of the examination. A complete rationale for all opinions expressed must be provided. 3. Finally, readjudicate the issue on appeal. If the benefit sought is not granted, furnish the Veteran with a supplemental statement of the case and afford him an opportunity to respond before the record is returned to the Board for further review. 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 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 2015). ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs