Citation Nr: 18154414 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 16-23 542 DATE: November 29, 2018 ORDER Entitlement to service connection for a low back disorder is denied. Entitlement to service connection for a left hip disorder is denied. Entitlement to service connection for left lower extremity radiculopathy is denied. Entitlement to service connection for right lower extremity radiculopathy is denied. REMANDED Entitlement to service connection for a chronic respiratory disorder (claimed as diminished breathing and tiredness and asbestosis) is remanded. Entitlement to a disability rating in excess of 20 percent for a cervical spine disorder. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The most probative evidence of record shows that a low back disorder was not manifested during service or within one year after service, and such disorder is not otherwise shown to be a result of active military service. 2. The most probative evidence of record shows that a left hip disorder was not manifested during service or within one year after service, and such disorder is not otherwise shown to be a result of active military service. 3. The most probative evidence of record shows that right lower extremity radiculopathy was not manifested during service or within one year after service, and such disorder is not otherwise shown to be a result of active military service or his service-connected cervical spine disorder. 4. The most probative evidence of record shows that left lower extremity radiculopathy was not manifested during service or within one year after service, and such disorder is not otherwise shown to be a result of active military service or his service-connected cervical spine disorder. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for a low back disorder are not met. 38 U.S.C. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2017). 2. The criteria for establishing service connection for a left hip disorder are not met. 38 U.S.C. §§ 1101, 1112, 1113, 1110, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 3. The criteria for service connection for right lower extremity radiculopathy as secondary to service-connected cervical spine disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2017). 4. The criteria for service connection for left lower extremity radiculopathy as secondary to service-connected cervical spine disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from July 1970 to July 1990. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012). Generally, the evidence 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, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Service connection may also be established on a secondary basis for a disability which is proximately caused by or aggravated by a condition for which service connection has already been established. 38 C.F.R. § 3.310. 1. Entitlement to service connection for a low back disorder The Veteran contends that service connection is warranted for a low back disorder. The Veteran’s service treatment records reveal that in April 1977, the Veteran complained of back pain lasting three weeks after a softball related fall. The Veteran was diagnosed with muscle strain. In another service treatment record with an illegible date, the Veteran noted low back pain, at which time he was diagnosed with a strain. In May 1981, the Veteran noted low back pain, lasting four days. He was diagnosed with right para lumbar strain and assigned to light duty. In September 1989, the Veteran was provided a consult to physical therapy for low back pain. In a June 1990 Report of Medical History, the Veteran reported that he currently had or had recurrent back pain in the past. The Veteran’s spine was deemed abnormal on the June 1990 Report of Medical Examination; the abnormality was listed as relating to the cervical spine, however. In July 2002, the Veteran sustained a low back injury while moving boxes. He was diagnosed with lumbosacral sprain, chronic with right and left radiculitis, L-5 spondylosis, and grade 1 L5-S1 spondylolisthesis. Also, in July 2002, the Veteran was given medication for back pain. A private treatment record, dated in 2002, reveals that the Veteran was diagnosed with lumbar spine spondylosis, stable spondylolisthesis and multiple disc bulges and a central disc protrusion at L3-L4. A February 2015 treatment record reveals a diagnosis of lumbar DDD and lumbago. The Veteran was afforded a VA examination in June 2016. Upon examination, the Veteran complained of sharp, stabbing pains in his low back. The Veteran denied significant traumatic events to his back following military service. The examiner diagnosed the Veteran with mild L5 spondylosis, stable L5-S1 spondylolisthesis and bilateral sacroiliac arthrosis, with an onset date of 2015. The examiner noted the Veteran’s multiple episodes of back injuries in 1977, 1981, and 1989. The examiner also stated that the Veteran’s record is silent for a low back condition from 1990 to 2002, at which time he sustained a low back injury secondary to a heavy load falling on him. Following the injury, x-rays and an MRI revealed mild degenerative changes (bilateral spondylosis at L5) and a repeat MRI in 2015 revealed no significant degenerative changes and a stable L5-S1 spondylisthesis. The examiner opined that it was less likely than not that the Veteran’s back disorder was incurred in or caused by an in-service injury, event, or illness. The rationale provided was that a history of significant low back injuries during military service would likely manifest as posttraumatic degenerative changes of the lumbar spine by 2002, a period of 12 years, and by 2015, a period of 25 years. Further, the examiner noted that the Veteran’s back pain from 2002 forward was more likely attributable to a back injury in 2002. Therefore, the examiner concluded that the Veteran’s current back condition was not incurred or caused by the lower back strain and pain sustained during service. Based on the above, the Board finds that the most competent and credible evidence of record is against a finding of service connection for a low back disorder. In this regard, the Board finds the June 2016 VA opinion to be highly probative to the issue at hand. The Board notes that the probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, his knowledge and skill in analyzing the data, and his medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the examiner acknowledged the Veteran’s lay statements and in-service back injuries but opined that his current back injury was related to an interceding post-service injury, rather than service. Here, the June 2016 examiner possesses the necessary education, training, and expertise to provide the requested opinions. Additionally, the opinion is shown to have been based on a review of the Veteran’s claims file and is accompanied by sufficient explanations. The opinion is also consistent with the other medical evidence of record, to include the Veteran’s service treatment records, post-service treatment records, and the Veteran’s lay statements. The Board thus finds the June 2016 VA examination is dispositive of the nexus issue in this case. The Board considered the Veteran’s lay statements in evaluating his claim. The Board acknowledges the Veteran’s assertions that he has experienced a low back disorder since service and his assertions that his current low back disorder is related to his injuries sustained in service. In this regard, he is competent to report symptoms, such as pain, that require only personal knowledge as they come to him through his senses as well as any diagnosis reported to him by a medical professional. See Layno v. Brown, 6 Vet. App. 465, 47 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Veteran, as a lay person, is generally not competent to link his symptoms to a specific diagnosed disability or to relate them to any instance of his military service. While it is in error to categorically reject layperson evidence as incompetent, the Board is allowed to consider the facts of a particular case to determine the layperson’s competence. See Davidson v. Nicholson, 581 F.3d 1313 (Fed. Cir. 2009). One factor to consider is the complexity of the question to be determined. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (providing an example at footnote 4 that a layperson would be competent to diagnose a simple condition such as a broken leg but not to diagnose a form of cancer.). In this regard, the Veteran’s statements as to the relationship between his current low back disorder and injuries sustained in service is not within the realm of knowledge of a layperson. Rather, the nature and causation of arthritis is a complex question that requires expertise. There is no indication that the Veteran possesses such specialized knowledge, and therefore, he is not competent in this regard. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board accords his statements regarding the nature and etiology of his low back disorder no probative weight. As a preponderance of the evidence is against entitlement to service connection for a low back disorder, denial of the benefit sought is required and the benefit of the doubt doctrine does not apply. 38 U.S.C. § 5107 (b); see generally Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); see Gilbert, supra. 2. Entitlement to service connection for a left hip disorder The Veteran contends that service connection is warranted for a left hip disorder. Specifically, the Veteran contended that he sustained two bad hip injuries as a result of a fall from the flight deck into the cat walk and the other a fall down the stairs aboard a ship. See September 2012 Statement in Support of Claim. The Veteran’s service treatment records are silent as to complaints, treatment, and diagnosis of a hip disorder or hip pain. Additionally, the Veteran’s hips were deemed clinically normal upon separation, as indicated in his June 1990 separation examination. In a June Report of Medical History, the Veteran did not identify any hip disorder or pain. In April 2002, the Veteran complained of right hip pain for two days, which was thought to be musculoligamentous. He did not complain of left hip pain. In May 2002, the Veteran was evaluated for bilateral hip pain; degenerative hip disease was ruled out. X-rays revealed no significant degenerative changes of the bilateral hips. In July 2002, an MRI revealed normal evaluations of the bilateral hips. The Veteran was afforded a VA examination in June 2016. The Veteran reported stabbing lateral and deep hip pain which occurred randomly 2-3 times a day. Upon examination, the Veteran denied significant bilateral hip injuries during his military service and denied being seen or evaluated for a hip condition since service. The examiner diagnosed the Veteran with osteoarthritis of the bilateral hips with an onset date of June 2016 and moderate bilateral sacroiliac joint arthrosis with an onset date of 2014. The examiner opined that it was less likely than not that the Veteran’s hip pain was incurred in or caused by an in-service injury, event, or illness. The rationale provided was that the Veteran’s service treatment records were silent as to hip pain and a review of his civilian medical records showed episodes of hip pain, diagnosed as musculoligamentous hip pain) in 2002 (12 years following service). X-rays revealed at that time revealed no significant bilateral hip degenerative joint disease. The examiner also noted that the Veteran had a history of hip pain, but stated that there was no evidence of ongoing evaluation or treatment of a left hip condition. Based on the above, the Board finds that the most competent and credible evidence of record is against a finding of service connection for a left hip disorder. In this regard, the Board finds the June 2016 VA opinion to be highly probative to the issue at hand. The Board notes that the probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, his knowledge and skill in analyzing the data, and his medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the June 2016 examiner possesses the necessary education, training, and expertise to provide the requested opinions. Additionally, the opinion is shown to have been based on a review of the Veteran’s claims file and is accompanied by sufficient explanations. The opinion is also consistent with the other medical evidence of record. The Board notes the Veteran’s assertions that he suffered a hip injury in service, which the Board notes was not documented; however, the Board finds that the June 2016 examiner’s opinion is not based solely on a lack of treatment during service. Instead, the VA examiner based the opinion on service treatment records and post-service treatment records, which are absent of a diagnosis or treatment of a left hip disorder. The Board thus finds the June 2016 VA examination is dispositive of the nexus issue in this case. The Board considered the Veteran’s lay statements in evaluating his claim. The Board acknowledges the Veteran’s assertions that he has experienced hip pain since service and his assertions that his left hip disorder is related to his period of service. In this regard, he is competent to report symptoms, such as pain, that require only personal knowledge as they come to him through his senses as well as any diagnosis reported to him by a medical professional. See Layno v. Brown, 6 Vet. App. 465, 47 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the Veteran, as a lay person, is generally not competent to link his symptoms to a specific diagnosed disability or to relate them to any instance of his military service. While it is in error to categorically reject layperson evidence as incompetent, the Board is allowed to consider the facts of a particular case to determine the layperson’s competence. See Davidson v. Nicholson, 581 F.3d 1313 (Fed. Cir. 2009). One factor to consider is the complexity of the question to be determined. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (providing an example at footnote 4 that a layperson would be competent to diagnose a simple condition such as a broken leg but not to diagnose a form of cancer.) Here, the Veteran’s service treatment records are replete with complaints of in-service incidents and resulting injuries. However, the record is largely silent as to complaints of hip pain. In this regard, the Veteran’s statements as to the relationship between his current hip disorder is not within the realm of knowledge of a layperson. Rather, the nature and causation of arthritis is a complex question that requires expertise. There is no indication that the Veteran possesses such specialized knowledge, and therefore, he is not competent in this regard. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Therefore, the Board accords his statements regarding the nature and etiology of his left hip disorder no probative weight. As a preponderance of the evidence is against entitlement to service connection for a left hip disorder, denial of the benefit sought is required and the benefit of the doubt doctrine does not apply. 38 U.S.C. § 5107 (b); see generally Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); see Gilbert, supra. 3. Entitlement to service connection for right and left lower extremity radiculopathy, to include as secondary to a service-connected cervical spine disorder The Veteran contends that service connection is warranted for bilateral lower extremity radiculopathy, to include as secondary to a service-connected cervical spine disorder. The Veteran’s service treatment records are silent as to complaints, treatment, or diagnosis of radiculopathy affecting the right and left lower extremities. Additionally, the Veteran’s bilateral lower extremities were deemed clinically normal upon separation, as indicated in his June 1990 separation examination. In an August 2013 VA examination, the Veteran did not complain of radiculopathy of the bilateral lower extremities. A post-operative note, dated in November 2014, reveals that there were new neurological symptoms consisting of decreased sensation along the left hemibody and new left lower extremity proximal weakness could be attributed to ischemic insult during the procedure. In a 2015 treatment record, the Veteran complained of bilateral leg pain following his November 2014 cervical spine surgery. An EMG, dated in February 2015, notes evidence of radiculopathy of the left lower extremity. A diagnosis of lumbar radiculopathy was noted. The Board also acknowledges numerous VA treatment reports indicating complaints of lower extremity pain associated with decreased sensation following his November 2014 surgery. In a June 2016 VA examination, the examiner noted that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy in his right or left lower extremity. In an October 2016 NOD, the Veteran contended that following an August 2014 MRI of the cervical spine, his doctor told him that there was a blockage in his spinal canal extending from C-3 to T-3 that was preventing spinal fluid from reaching below the level of blockage and that had caused a partial paralysis of the radicular lower extremity nerves rooted in his spine below that level. The Board notes, however, that the MRI report specifies finding down to the T-1 level with posterior disc protrusion/extrusion. In a June 2017 VA Form 9, the Veteran contended that he planned to submit a statement of a treating physician supporting the fact that he was told that he had chronic nerve impairments of both of his legs due to the cut-off of spinal fluid that his service-connected cervical spine disorder caused. Yet, no additional medical evidence has been submitted or identified, to this extent, in support of his claim. The Board finds that service connection is not warranted on a direct or secondary basis. Here, the Veteran’s service treatment records are silent as to a lower extremity disorder. Further, the evidence of record does not reveal a diagnosis of right or left lower extremity radiculopathy. Notably, in June 2016, the examiner noted that the Veteran did not have radicular pain or radiculopathy in his bilateral lower extremities. Because the VA examination contains competent examination results, the Board gives greater weight to that medical evidence than to the Veteran’s lay statements. A VA examination is necessary when there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; there is evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability; but, insufficient competent medical evidence exists on file for the Secretary to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to and mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Here, there is no competent evidence of record of bilateral lower extremity radiculopathy and the Veteran has provided no competent evidence indicating that his right and left lower extremity radiculopathy are secondary to his service-connected cervical spine disorder. As such, the claim is denied. REASONS FOR REMAND 1. Entitlement to service connection for a chronic respiratory disorder (claimed as diminished breathing and tiredness and asbestosis) is remanded. The Veteran contends that service connection is warranted for a chronic respiratory disorder. The Veteran’s service treatment records show that in December 1988, while being evaluated for bronchitis, a chest x-ray revealed a calcified granuloma at the extreme right apex. An October 2002 private treatment record reveals that the Veteran had a 5-mm calcification superimposed over the right upper lobe. The physician noted that it represented a small calcified granuloma. The physician also stated that he did not see any acute lung infiltrates or lung masses. An October 2005 private treatment record indicates that the Veteran had a 5- mm calcified granuloma in the right upper lobe, as well as strand-like increased markings in both lung bases. The physician noted that there was no pleural effusion or pneumothorax. The physician also noted that the Veteran’s lungs were well-inflated. The Veteran was afforded a VA examination in August 2013. Upon examination, the examiner noted that the Veteran did not have any pulmonary condition. The examiner also noted that the Veteran did not have any plaque or nodules to correlate with asbestosis. The examiner also stated that the Veteran’s mild restriction on PFT was not diagnostic in and of itself of a lung condition, disease, or asbestosis. The examiner further opined that it was less likely than not that the Veteran’s lung condition was related to or caused by his documented asbestosis exposure based on the Veteran’s military occupational specialty. The Veteran’s VA treatment records dated in July 2014, August 2014, September 2014, October 2014, and November 2014 reveal a calcified granuloma in the right lung/right upper lobe. The Veteran was afforded another VA examination in March 2016. The Veteran reported that he had difficulty completing his in-service running exercises in the mid-1980s. The Veteran reported using albuterol in the past and noted that he had elevated left hemidiaphragm on CXR in the past with a mild restrictive defect on PFT testing without reversibility on bronchodilator testing. The examiner noted a March 2016 x-ray which revealed moderately expanded lungs and a stable focus of a calcified granuloma in the right apex. The examiner noted that the Veteran had a 5-mm granuloma in the extreme right apex, and that the lungs and mediastinum appeared otherwise normal. The examiner noted that the Veteran’s condition did not impact his ability to work. The examiner opined that the claimed condition was less likely than not related to service. The rationale provided for the opinion was that the Veteran was noted to have an old granuloma of the right upper lobe on chest radiograph with no evidence consistent with asbestosis (plaque or fibrosis). The examiner also noted that the Veteran had a restrictive defect on his PFTs which was not indicative of lung disease or a lung condition. In correspondence, dated in October 2016, the Veteran’s representative noted that the Veteran has chronicity of the calcified granuloma of the right lung apex which was detected on a chest x-ray examination performed during his military service in December 1988. The representative also noted that the August 2013 examiner’s reading of the chest x-ray as normal was in error and that the April 2016 VA examiner did not specifically mention calcified granuloma or history of a calcified granuloma. It is still unclear whether the Veteran has a chronic respiratory disability manifested by a right lung apex nodule which is related to service, to include that of a calcified granuloma detected by x-ray examination in December 1988. As such, a remand is necessary. 2. Entitlement to a disability rating in excess of 20 percent for a cervical spine disorder is remanded. The Veteran contends that a rating in excess of 20 percent is warranted for his service-connected cervical spondylosis. In December 2015, the Veteran was granted a 20 percent disability evaluation, effective June 6, 2012. A temporary 100 percent evaluation from November 25, 2014 to May 15, 2014 due to surgery was also granted. In October 2016, the Veteran disagreed with the rating assigned and specifically requested a 30 percent evaluation retroactive to May 14, 2015. See October 2016 NOD. The Veteran was afforded a VA examination in June 2017 to assess the severity of his condition. The Veteran reported that his neck pain was slightly better since surgery in 2014. The Veteran also stated that he takes medication, does massage therapy, and uses a cane. The Veteran reported that he had chronic neck pain, as well as numbness and tingling down both arms into his fingers. Regarding functional impact, the Veteran reported that he had difficulty turning his neck from side to side, driving, and difficulty with lifting heavy objects. The examiner noted diagnoses of degenerative arthritis of the spine, as well as cervical spondylosis, status post decompression and fusion from C3-T1 with anterior cervical fusion at C4-6. Range of motion testing revealed forward flexion to 40 degrees, extension to 20 degrees, right lateral flexion to 15 degrees, right lateral flexion to 35 degrees, and left lateral rotation to 35 degrees. The examiner noted that there was pain with active/passive range of motion upon all planes of motion. The examiner noted that the Veteran did not report flare-ups of the cervical spine and that no ankylosis was present upon examination. The examiner noted that the Veteran had IVDS, but that it did not require bed rest prescribed by a physician and treatment by a physician in the past 12 months. Following the examination, in a June 2017 VA Form 9, the Veteran reported that he had almost no movement in his neck as a result of its surgical stabilization with two titanium rods. The Board acknowledges that the Veteran’s statements were approximate in time to his last VA examination; however, due to evidence of a possible worsening (i.e. reduced range of motion and possible ankylosis) of the Veteran’s neck condition since the Veteran’s most recent June 2017 VA cervical spine examination; an updated VA examination is required. 3. Entitlement to TDIU is remanded The Veteran contends that TDIU is warranted. Specifically, the Veteran noted in an October 2016 NOD that he could not work due to his cervical spine disability, nerve damage in his extremities, and heart condition. The claim for TDIU is inextricably intertwined with the increased rating claim remanded herein. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc). Additionally, on remand the Veteran should be given a final opportunity to complete and return VA Form 21-8940 (Veteran’s Application for Increased Compensation Based on Unemployability). The matters are REMANDED for the following action: 1. Request that the Veteran complete a VA Form 21-8940. 2. Schedule the Veteran for a VA examination to determine the current severity of his neck disability. The examiner must also describe the functional impact of such disability. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. 3. After the foregoing record development is complete, schedule the Veteran for a respiratory VA examination by an examiner who has never examined the Veteran. The claims file should be made available to the examiner in conjunction with the examination. All necessary testing should be conducted. The examiner is asked to identify/diagnose any chronic respiratory disability, that presently exists or has existed during the pendency of the appeal. Then, for any diagnosed respiratory disorder, provide an opinion as to whether it is at least as likely as not (probability of 50 percent or more), that it had its onset during service or is causally and etiologically related to service, to specifically include the December 1988 findings of a calcified granuloma in right lung. In making this determination the examiner should address (i) the Veteran’s competent reports that he has experienced diminished breathing and tiredness, (ii) the Veteran’s December 1988 service treatment records indicating a calcified granuloma, (iii) the Veteran’s past use of albuterol, (iv) as well as the elevated left hemidiaphragm on CXR in the past with a mild restrictive defect on PFT testing. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be acknowledged and considered in formulating any opinion. A complete rationale for all conclusions expressed should be set forth in the report of examination. If the examiner is unable to provide the requested opinions without resort to undue speculation, he or she should explain why this is the case. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Tiffany N. Hanson, Associate Counsel