Citation Nr: 21026931 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 13-02 748 DATE: May 4, 2021 REMANDED Entitlement to service connection for tremors is remanded. Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1973 to May 1975. The Veteran testified at a hearing with the undersigned in January 2018. The matter was most recently remanded in June 2020. There has not been substantial compliance with the remand directives and the claims must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). In a December 2020 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection and assigned a rating for the Veteran's dysphagia disability, effective date of April 4, 2019. The grant of service connection for a dysphagia disability the represents a full grant of benefits sought for that issue. Entitlement to service connection for tremors Entitlement to service connection for hypertension. The Veteran contends that his current tremors started in service after he underwent a tracheostomy and have continued since then. His wife testified that she has witnessed the tremors since they married. The Veteran is service-connected for several residuals of an in-service tracheostomy and a pneumothorax. The claim is remanded again to obtain an adequate medical opinion that considers a connection to either event. The September 2020 VA examiner concluded the tremors were not related to the tracheostomy because there is no support for such a connection in medical literature. In a December 2020 addendum, the examiner noted that tremors are a neurosystem (neurological) disorder and there is no medical literature supporting tremors causing hypertension. The opinions are inadequate because the examiner did not address the significance of the Veteran and his wife lay assertions that he has had tremors since the tracheostomy and whether the lack of medical literature supporting a connection is the same as precluding such a connection. Pertinent service treatment records detail the tracheostomy and related findings. Post-service treatment records include an August 1984 hospital admission record that detailed the Veteran's report that during service he gave himself a drug injection, which resulted in a coma, and he was told he may have sustained brain damage. The opinion on remand should consider the Veteran's report that he was told he may have suffered brain damage in service related to a coma and that he's had tremors since the in-service tracheostomy. The opinion should also clarify whether or not the lack of medical literature supporting a connection also precludes a connection. The hypertension claim is intertwined with the claim for tremors and must be remanded. The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate clinician, preferably a neurologist, on the likely etiology of the Veteran's tremors and hypertension. Copies of all pertinent records must be made available to the examiner for review. The examiner must answer the following: (a) Is it at least as likely as not that the current tremors began during service or are otherwise related to an in-service injury, event, or disease, to include the tracheostomy and/or pneumothorax? In offering the opinion, the examiner must specifically discuss (i) whether the in-service pneumothorax could have led to a potential brain injury that may have caused tremors; (ii) testimony of the Veteran and his wife that the tremors began after the tracheotomy procedure and have continued; (iii) whether the lack of medical literature supporting a connection between tracheostomy and tremors is the same as precluding a connection, and if so, why. (b) Is it at least as likely as not that the Veteran's hypertension was incurred in service? (c) Is it at least as likely as not that the Veteran's hypertension is (i) caused by or (ii) aggravated by the tremors? In answering these questions, the examiner must discuss the in-service pneumothorax and tracheostomy. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge; the examiner's own expertise, or; whether additional facts are required and note what, if any, additional evidence would permit such an opinion to be made. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Jarman, 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.