Citation Nr: 21026447 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 19-29 795 DATE: May 3, 2021 REMANDED 1. Entitlement to service connection for a nasal disability is remanded. 2. Entitlement to service connection for emphysema, chronic obstructive pulmonary disease (COPD), and a pulmonary nodule is remanded. 3. Entitlement to service connection for right upper extremity dystonic tremor is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from September 1957 to October 1960 and had service in the Naval Reserve until September 1963. These matters are before the Board of Veterans' Appeals (Board) on appeal from a December 2018 Department of Veterans Affairs (VA) rating decision. In January 2021, a virtual hearing was held before the undersigned; a transcript is in the record. The Veteran requested, and was granted, a 90-day abeyance period for the submission of additional evidence. [A May 2017 private medical treatment record was received.] On review of the record, the Board finds that further development of medical evidence is necessary to comply with VA's duty to assist the Veteran in the development of facts pertinent to his claims of service connection for the disabilities here at issue. The Naval Reserve medical records (to include reports of any periodic examinations) are not associated with the claims file, may contain pertinent information, are of record, and must be obtained. 38 C.F.R. § 3.159(c). At the January 2021 hearing, the Veteran identified records of private treatment that remain outstanding and may be pertinent evidence in all three claims on appeal. Remand development to obtain those records (any available) is necessary. Sullivan v. McDonald, 815 F.3d 786 (2016). 1. Entitlement to service connection for a nasal disability. On September 2018 Sinusitis, Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire (DBQ), the examiner noted a diagnosis of deviated nasal septum (traumatic) (DNS) in 2013 and that the Veteran underwent nasal septum repair (NSR) in 2003. The examiner also noted the Veteran's report of being punched in the face (causing nose injury) while boxing in the Navy. The Veteran reported that after separation from service, he underwent surgery on his nose (but does not know what was done or why he needed the surgery). He indicated he currently did not have complaints pertaining to his nose injury. In an October 2019 VA Form 9, the Veteran stated that he was on the boxing team while serving in the Navy and his nose was broken during service. At the January 2021 hearing, the Veteran testified that he sustained a nose injury while boxing in service when his opponent "bonked [him] under the eye and on the corner of the nose." He stated that he had a nose operation at St. Margaret's Hospital, and he currently does not have any difficulty with his nose. Records from St. Margaret's Hospital are not associated with the claims file and are pertinent evidence in this claim. The Board notes that while the Veteran has indicated his nose trauma residuals do not cause current impairment, he may nonetheless have current residuals of a nasal fracture and repair surgery that may be discernable on diagnostic studies. Therefore, any existing medical records of his reported nose surgery at St. Margaret's hospital must be obtained. 2. , 3. Entitlement to service connection for a variously diagnosed lung disability and for a right upper extremity tremor. On July 2017 Otolaryngology Consult, the Veteran reported that he was a 50-pack year smoker; he denied having any significant history of alcohol use. In a February 2019 Notice of Disagreement (NOD) and October 2019 VA Form 9, the Veteran related that he had lung surgery for cancer, and was told following the surgery that he what he had was a lung virus (not lung cancer), possibly from an environmental exposure in service in Africa. He also stated that a surgeon told him that the surgeon who performed his lung surgery mistakenly cut a muscle and nerve in his back (causing his right upper extremity tremor), thus alleging a secondary service connection theory of entitlement for the tremor. In a July 2020 letter, Dr. F. stated that he was the Veteran's primary care provider (and that the Veteran suffered a myocardial infarction in January 2020 and recently received a diagnosis of small cell lung cancer). At the January 2021 hearing, the Veteran testified he upon chest X-ray before retirement from active duty in 1960 he was told to see a doctor immediately for suspected lung cancer. He saw Dr. O. (who said there was nothing wrong with him because the prior chest X-ray showed the shadow of a collarbone). At the West Penn Hospital, Dr. L. (a pulmonologist) told him he had lung cancer and operated on him immediately. After the surgery, Dr. L. and a Disease Control Center physician told him that he did not have cancer but had tuberculosis (from a possible exposure to a virus in Africa), and he was kept in isolation for eight days. After his release, he went to Allegheny County for tuberculosis treatment, but the doctors said he did not have tuberculosis. A primary care provider (based on his complaints of being unable to lift his right arm seamlessly (lift it above his chin, with an eight-pound weight limit on lifting the right arm over his head)), sent him to an orthopedic surgeon (who noticed that his rotator cuffs were in shreds, and performed right arm, surgery). Thereafter, he saw a neurologist (who told him that he had Parkinson's Disease), a young surgeon (who said he had a frozen shoulder which would improve), and (another) orthopedic surgeon (who said that a surgeon had cut a nerve in the muscle in his back (during his lung surgery)). He finally gave up seeking treatment and learned to live with his right arm and hand tremors. He also testified that he worked at Glenshaw Glass for 40 years and was finishing up with lung chemotherapy. (Dr. R. informed him that his lung cancer [was in remission].) Private treatment records from Dr. O., Dr. L, the Allegheny County primary care provider, the orthopedic surgeon (who performed rotator cuff surgery), the noted neurologist, the surgeons (including the one who told the Veteran that a lung surgeon had cut a nerve in back muscle in his back, causing the claimed tremors), Dr. R,, and Dr. F. are not associated with the claims file, and are likely to contain pertinent (to the Veteran's stated theory of entitlement) information, and must be obtained As noted above, the Veteran has stated that Dr. L. and a Disease Control Center doctor advised him he had tuberculosis (from an exposure to a virus in Africa). He has also stated that an orthopedic surgeon informed him that his lung surgery caused his right arm/right hand tremors. Considering his statements, the Board cannot make a fully-informed decision on these matters without first obtaining pertinent medical records from the providers identified. A September 2018 VA examiner provided a negative nexus [to service] opinion in these matters noting that the Veteran's STRs are unavailable. Under the circumstances presented, development for alternate source information that might support the Veteran's claims is necessary. The matters are REMANDED for the following: 1. Arrange for exhaustive development for service personnel records that may confirm the Veteran's reported service in Africa (where, when, and in what capacity he served there, and the types of exposures he may have experienced. Also secure for the record any STRs pertaining to his post-active duty service in the Naval Reserves to September 1963, including reports of any periodic examinations he may have been afforded. If any such records cannot be located because they have been irretrievably lost or destroyed (or did not exist), it should be so certified; the scope of the search for the records should be described; and the appellant should be so notified. He should be asked to provide copies of any pertinent STRs (not already in his claims file) he may have in his possession, and to assist with this development by providing any identifying information needed. 2. Ask the Veteran to identify all providers of private evaluations or treatment he has received for nasal disability, a lung disability, and right upper extremity tremors, and to submit authorizations for VA to secure for the record complete records from the private providers identified, (to specifically include from the St. Margaret's Hospital nose surgeon, Dr. O., Dr. L., the Allegheny County primary care doctor, the orthopedic surgeon who performed rotator cuff surgery, the neurologist he mentioned, the other surgeons (including the one who told the Veteran that a the lung surgeon had cut back muscle and nerve, Dr. R, Dr. F., and the providers of the 2013 DNS diagnosis and NSR surgery. Obtain those records (all available). 3. After the development requested above is completed, arrange for the Veteran's record to forwarded to an appropriate clinician for review and an advisory medical opinion regarding the existence, nature, and likely etiology of his claimed nasal disability. [If further examination is deemed necessary (e.g., if records received the Veteran underwent nasal septum deviation (that may have been due to boxing trauma) repair surgery, but the information in the record in the record is insufficient to determine whether there is any residual pathology), such should be arranged. The opinion should include responses to the following: (a.) Identify any post-operative (from repair/corrective surgery) residuals (pathology and manifestations) of DNS shown by the record or found on examination. If no current pathology or impairment is identified, but DNS and surgical repair are shown, explain why that is so (e.g., healed with no discernable, by examination or diagnostic studies, residuals). (b.) Identify the likely etiology for any residuals of DNS and surgery for repair of DNS found. Specifically, is it at least as likely as not (a 50% or better probability) that the manifestations and any impairment are etiologically related to the Veteran's, and trauma from boxing in service? (c.) If a nasal disability is found to be unrelated to service, identify the etiology that is considered to be more likely, an explain why that is so. All opinions must include rationale that cites to supporting factual data and medical principles. The rationale must acknowledge/address the Veteran's lay statements and testimony noted above. 4. Review the records received pursuant to development sought above. If they show (a) service in Africa and exposures therein, and (b) that the Veteran has/has had a lung disability due to an exposure in Africa (as alleged, e.g. TB or a virus possibly incurred therein) arrange for the record to be forwarded to an appropriate clinician for review and an advisory medical opinion addressing the nature and likely etiology of the claimed lung and right upper extremity tremors disabilities. [If further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged.] The opinion should include responses to the following: (a.) Identify all lung disability entities shown, or found on examination, if one is conducted, by diagnosis. (b) Identify the likely etiology for each diagnosed ling disability. Specifically, is it at least as likely as not (a 50% or better probability) that it is etiologically related to an exposure during service in Africa, such as to TB or a virus? (c) If the lung condition is determined to be unrelated to service/exposures therein, identify the etiology for the disability that is considered to be more likely, and explain why that is so. (d) If it is determined that a diagnosed lung disability is related to the Veteran's service) identify (by diagnosis) the disability underlying the Veteran's right upper extremity tremors., and the likely etiology for the tremors. Specifically, is it at least as likely as not that the right upper extremity tremors were caused or aggravated by (the opinion must address aggravation) his lung surgery, as alleged. All opinions must include rationale that cites to supporting factual data and medical principles. The rationale must acknowledge/address the Veteran's lay statements and testimony. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Chu, 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.