Citation Nr: 21001860 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 15-05 985 DATE: January 12, 2021 REMANDED Entitlement to service connection for a respiratory condition is remanded. Entitlement to service connection for a headache disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Marine Corps for twenty days from July 1976 to August 1976. The Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge in October 2020. A transcript of the hearing has been associated with the claims file. 1. Entitlement to service connection for a respiratory condition is remanded. The Veteran contends that he began experiencing a respiratory condition while in service, misdiagnosed as a headache disability. See October 2020 Board hearing transcript. Service treatment records include the results of a January 1976 enlistment physical examination. In a concurrent medical history questionnaire, the Veteran reported a history of frequent or severe headaches but denied any sinusitis, frequent colds, asthma or shortness of breath. However, in a July 1976 dental questionnaire, he reported current “sinus trouble.” Service treatment records (STRs) reflect that the Veteran was admitted to a medical ward following a severe headache in July 1976. Several days later, a clinician in the hospital dispensary noted that medication for headaches was not effective. There were no notations regarding respiratory distress. An August Aptitude Board Report noted that the Veteran was not in need of hospitalization, that an unspecified condition pre-existed service and was not aggravated, and that his discharge was for unsuitability and not for medical reasons. The Veteran attended a VA examination in July 2014. Following an examination and review of the claims file, an examiner concluded that the Veteran’s respiratory condition was less likely than not related to service because there was no documentation while on active duty. The Veteran submitted a private opinion in October 2014, which stated that the Veteran’s exposure to potential triggers during service coincided with the onset of symptoms and was therefore at least a plausible explanation for the development of his respiratory condition. He did not explain what triggers the Veteran was exposed to that would have led to a respiratory condition. The Veteran testified during his October 2020 Board hearing that he started experiencing respiratory symptoms almost immediately upon arriving at basic training, and that he was sent to sick bay. He testified that whenever he was in air conditioning, his symptoms would subside, only to reappear when he went back outside. The Veteran stated that by the time he returned home, he was hospitalized with pneumonia and chronic bronchitis. He reported using rescue inhalers from that point forward. The Board finds that a supplemental VA examination and opinion are warranted, as the 2014 examiner failed to consider the Veteran’s contention that a respiratory condition was caused or aggravated by exposure to the climate at basic training. She also did not explain why the Veteran’s respiratory condition was unrelated to his in-service hospital admission of migraines, or comment on the October 2014 opinion. 2. Entitlement to service connection for a headache disability is remanded. The Veteran contends that his time at basic training aggravated his pre-existing headache disability. See October 2020 Board hearing transcript. Service treatment records include the results of a January 1976 enlistment physical examination. In a concurrent medical history questionnaire, the Veteran reported a history of frequent or severe headaches. In July 1976, the Veteran sought treatment for a headache that he had experienced for seven days and reported a history of migraine headaches for the previous four years. The headache interfered with sleep and was aggravated by noise and tension. The clinician noted that the Veteran responded to treatment and was assigned light duty for 48 hours. However, over the next several days, the headaches did not improve. The Veteran attended a VA examination in July 2014. Following an examination and review of the claims file, an examiner concluded that the Veteran’s pre-existing headache disability was not incurred in or caused by service because it was reported at his enlistment and there were no aggravating factors noted. The Veteran submitted a private opinion in October 2014, which stated that the Veteran’s exposure to potential triggers during service coincided with the onset of symptoms and was therefore at least a plausible explanation for the development of his chronic headache condition. He did not comment on the fact that the Veteran’s headache disability pre-existed his service. The Board finds that a supplemental VA examination and opinion are warranted, as the 2014 examiner failed to consider the Veteran’s contention that his pre-existing headache disability was aggravated by his basic training. She also did not comment on the October 2014 opinion. The matters are REMANDED for the following action: 1. Ensure all available service treatment and personnel records are associated with the claims file, to include any hospitalization records between July and August 1976 at Naval Hospital Beaufort in Parris Island. Document all requests for information as well as all responses in the claims file. 2. Ask the Veteran to complete a VA Form 21-4142 for any treatment received for respiratory or headache conditions, to include any treatment received shortly following discharge. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for a VA examination for his respiratory disability. The examiner must review the claims file. The examiner is asked to provide an opinion on whether the Veteran’s current respiratory disabilities are at least as likely as not caused or aggravated by service, including his in-service exposure to the climate at Parris Island. In providing the requested opinion, consider the Veteran’s description of his in-service symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? The examiner is also asked to comment on the October 2014 private opinion in any opinion rendered. 4. Schedule the Veteran for a VA examination for his headache disability. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a.) Did the Veteran’s headache disability, which existed prior to service increase in severity during service? (b.) If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? The examiner is asked to comment on the August 1976 personnel record which reflects that the Veteran believed his headaches were caused by nerves and the noise in recruit training. The examiner is also asked to comment on the October 2014 private opinion. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Fitzgerald, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.