Citation Nr: 0814489 Decision Date: 05/02/08 Archive Date: 05/12/08 DOCKET NO. 03-08 753A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for degenerative arthritis and disc disease of the cervical spine, to include as due to an undiagnosed illness. 2. Entitlement to service connection for degenerative joint disease of both wrists, to include as due to an undiagnosed illness. 3. Entitlement to service connection for degenerative joint disease of both hips, to include as due to an undiagnosed illness. 4. Entitlement to service connection for gastroesophageal reflux disease (GERD) to include gastrointestinal symptoms as due to an undiagnosed illness. REPRESENTATION Appellant represented by: Kentucky Department of Veterans Affairs ATTORNEY FOR THE BOARD K. Hudson, Counsel INTRODUCTION The veteran had active service from March 1989 to June 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from regional office (RO) rating decisions of August 2000, which originally denied the claims on appeal, and December 2002, which again denied the claims in the course of a de novo review pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000). The veteran failed to report for a Travel Board hearing scheduled in September 2007. The issue of entitlement to service connection for GERD is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. FINDINGS OF FACT 1. The veteran was diagnosed with degenerative arthritis of the cervical spine several years after service, and degenerative disc disease of the cervical spine after a post- service injury; both of these conditions are unrelated to service. 2. The veteran does not have an undiagnosed illness of the cervical spine. 3. The veteran does not have an undiagnosed illness involving the wrists, and currently shown degenerative changes are unrelated to service. 4. The veteran does not have an undiagnosed illness involving the hips, and currently shown degenerative joint disease of both hips is unrelated to service. CONCLUSIONS OF LAW 1. Degenerative arthritis and disc disease of the cervical spine were not incurred in or aggravated by active military service, including as an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1111, 1112, 1113, 1117 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.317 (2007). 2. Degenerative joint disease of both wrists was not incurred in or aggravated by active military service, including as an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1111, 1112, 1113, 1117 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.317 (2007). 3. Degenerative joint disease of both hips was not incurred in or aggravated by active military service, including as an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1111, 1112, 1113, 1117 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.317 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified at 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2005)), imposes obligations on VA in terms of its duties to notify and assist claimants. Prior to the post-VCAA readjudication of his claim in December 2002, the veteran was informed, in a letter dated in March 2001, of the information necessary to substantiate a claim for service connection based on direct service incurrence. He was also informed of his and VA's respective obligations for obtaining specified different types of evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). In September 2002, he was advised of the information necessary to substantiate a claim for service connection for an undiagnosed illness based on Gulf War service, and of his and VA's respective obligations for obtaining specified different types of evidence. In February 2007, he was provided complete, content-compliant VCAA notice in a single document. Specifically, he was advised of the information necessary to substantiate a claim for service connection both on a direct basis and as an undiagnosed illness based on Gulf War service, and of his and VA's respective obligations for obtaining specified different types of evidence. He was also told to provide any relevant evidence or information in his possession. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). In addition, he was provided with information regarding assigned ratings and effective dates. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The claim was subsequently readjudicated by means of a supplemental statement of the case in April 2006. Therefore, any timing defect in the provision of this aspect of the notice was harmless error. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). Hence, the VCAA notice requirements have been satisfied. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159. With respect to the duty to assist, the service medical records have been obtained, as have identified post-service private and VA medical records. A VA examination as to nexus was provided, and, later, an opinion was obtained to reconcile apparently conflicting opinions. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4); see McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Dalton v. Nicholson, 21 Vet.App. 23 (2007). In a statement signed in July 2006, the veteran said he had no other information of evidence to give VA to substantiate his claim. He has not identified the existence of any potentially relevant evidence which is not of record. Thus, the Board also concludes that VA's duty to assist has been satisfied. Thus, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). Significantly, neither the appellant nor her representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Merits of Service Connection Claims The veteran contends that he began experiencing cervical spine pain in service, which has been increasing in severity since that time. He states that he slowly began to have wrist pain, which gradually increased in severity, and that now his hips are getting stiff as well. His wife and some co-workers have written regarding their observations of the veteran's condition. Service connection may be established for chronic disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted on a presumptive basis for certain chronic diseases, if the disability was manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1110, 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). If there is no showing of a chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Generally, to establish service connection, there must be (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be granted to a Persian Gulf veteran for objective indications of chronic disability resulting from an illness or combination of illnesses, provided that such disability became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2011, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis, unless there is affirmative evidence that the undiagnosed illness was not incurred during Persian Gulf service, or resulted from the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317 (2006). A qualifying chronic disability may also include a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2)(B); 38 C.F.R. § 3.317(a)(2). Such undiagnosed or medically unexplained chronic multisymptom illnesses can include joint pain, neurologic signs or symptoms signs, and/or gastrointestinal signs and symptoms. 38 C.F.R. § 3.317(b)(8). However, chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Service connection for an undiagnosed illness presumptively based on qualifying Persian Gulf service will not be granted if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness. 38 C.F.R. § 3.317(c). Several examinations have addressed more than one of the conditions at issue, and these will be summarized in this section, to avoid unnecessary duplication and to retain the context of the reports. The evidence specific to only one claim will be addressed in the discussion pertaining to that issue. On a VA Persian Gulf Registry examination in February 1999, the veteran complained of neck pain, wrist pain, and joint pain. He reported five to six years of wrist pain without injury. Joints were noted to be normal on examination. In a November 1999 letter to the veteran, summarizing the results of the examination, it was noted that there had been no diagnosis for neck pain from the rehabilitation medicine clinic. He was informed that the examination indicated that there were undiagnosed illnesses for the neck and for pain and numbness in the wrists. X-rays of the wrists taken in February 1999 were normal. X-rays of the cervical spine disclosed degenerative changes at C5-6. VA treatment records show the veteran was evaluated by his primary care physician in March 2000, as a new patient. He reported that in 1993, he had noted joint pain in his hands and neck without swelling, and the impression was polyarthralgia. On a VA neurology examination in May 2000, it was noted that an electromyogram and nerve conduction study had been performed in August 1999, and had been interpreted as normal bilaterally. The veteran reported a history of neck soreness without radiation since 1991, and stiffness in the wrists since 1993. On examination, he reported decreased sensation in the hypothenar region of both arms. The examiner noted that the distribution of the sensory changes would be most suggestive of an ulnar neuropathy, but the examiner was unable to find any objective findings to support a diagnosis of ulnar neuropathy. On VA examination of the joints in June 2000, the veteran complained of pain in his neck, which radiated from the neck into the shoulders. He also said he had bilateral wrist stiffness, with occasional pain. The diagnosis was degenerative arthritis of the cervical spine, and wrist and hand arthralgias, with no evidence of arthritis on examination or by X-rays. (However, there is no evidence that new X-rays were conducted in connection with this examination.) A VA examination in October 2002 noted that the veteran complained of ongoing neck and wrist pain. He said he had pain but primarily stiffness in his neck and shoulders. He also had pain in the wrists, and stiffness in the hands. He had a feeling of stiffness from time to time in his hips. Examination of the wrists revealed tenderness to deep palpation bilaterally, and crepitus with range of motion. Phalen's and Tinel's signs were negative. Grip strength was 5/5, but he reported fatiguing of both hands with overuse. Examination of the cervical spine disclosed tenderness. Examination of the hips revealed no crepitus and no tenderness. The examination report noted that nerve conduction studies of the upper extremities were normal and ruled out carpal tunnel, but there is no indication in the record that new nerve conduction studies were obtained for the examination. X-rays of the wrists and hips showed mild degenerative arthritis. The diagnoses were degenerative arthritis and degenerative disc disease of the cervical spine; bilateral wrist and hip pain and mild arthritis. The examiner stated that there were no undiagnosed illnesses found on that examination. A December 2001 social work note regarding billing for certain treatment of the veteran noted that the veteran's primary care physician was adamant that the veteran's treatment was all for Gulf War related illnesses. In January 2001 and again in February 2004, this physician wrote that the veteran's medical conditions included polyarthralgias with negative evaluation for diagnosable conditions, limiting his activities of daily living due to pain and requiring daily narcotic pain medication. His multiple joint pain was consistent with findings seen in many other Gulf War veterans he had followed. They had remained undiagnosable and the etiology remained elusive, and thus it was reasonable to conclude the conditions were directly related to exposures or events in military service. A VA opinion was obtained in July 2006, to reconcile the conflicting evidence. The examiner noted that the February 2004 opinion noted that the veteran had polyarthralgias with negative evaluation for diagnosable conditions, limiting his activities of daily living due to pain and requiring daily narcotic pain medication. The October 2002 VA Gulf War examination noted that he identified pain and/or stiffness in his shoulders, both wrists, and hips. X-rays showed minimal degenerative joint disease in both wrists, and mild degenerative joint disease in both hips. Therefore, the polyarthralgias had clearly defined diagnoses. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). A layman, such as the veteran, is competent to give evidence about what he experienced; for example, he is competent to report that he had certain injuries during service or that he experienced certain symptoms. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). A layman, however, is not competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because he does not have the requisite medical expertise. See, e.g., See Routen v. Brown, 10 Vet. App. 183, 186 (1997); Espiritu v. Derwinski, 2 Vet.App. 492 (1992). Additionally, competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). A. Cervical Spine Service medical records do not show any complaints or abnormal findings pertaining to the cervical spine. In this regard, although on the separation examination, the veteran responded "yes" to a question of whether he had now, or had ever had, recurrent back pain, he explained this as back pains across his shoulder (which he said he had had his whole life), and did not indicate the neck area. As noted above, in November 1999, the veteran was informed that a VA Persian Gulf Registry examination had indicated that there was an undiagnosed illness for neck pain. In addition, a May 2000 rheumatology clinic evaluation, obtained due to complaints including neck pain, which he said had been present for 9 years, resulted in an impression of myofascial pain. Statements from his primary care physician dated in 2001 and 2004, as well as treatment records, note polyarthralgia. However, X-rays in February 1999 disclosed degenerative changes in the cervical spine, at C5-6. In addition, the VA examination in June 2000 resulted in a diagnosis of degenerative arthritis of the cervical spine. Likewise, a physical medicine and rehabilitation clinic record dated in June 2001, as well as an X-ray report at that time, noted degenerative disc space narrowing at C4-5 with degenerative spurs causing some foraminal narrowing at C4-5 and to a lesser extent C3-4. The veteran was hospitalized in Chandler Medical Center in August 2001, for treatment of injuries sustained in a fall approximately 15-18 feet out of a barn loft, landing on his neck, back, and right arm. He had a past medical history of chronic neck pain. A computerized tomography (CT) scan disclosed a C5 lamina fracture. VA records dated from September to December 2001 show follow-up treatment for the injuries sustained in the fall. A VA examination in October 2002 noted that the veteran complained of ongoing neck, with pain but primarily stiffness in his neck. Examination of the cervical spine disclosed tenderness. The diagnosis was degenerative arthritis and degenerative disc disease of the cervical spine; the examiner stated that there were no undiagnosed illnesses found on that examination. An MRI of the cervical spine in May 2006 disclosed mild degenerative changes within the cervical spine. While the degenerative disc disease shown in October 2002 may be associated with the fracture, even before the fracture of the cervical spine, degenerative changes had been shown on X- rays on several occasions. Thus, the evidence clearly shows that the veteran had degenerative changes in the cervical spine-a diagnosed disease-prior to the 2001 fall which resulted in additional cervical spine disability. X-rays since 1999 have shown the presence of degenerative changes. The July 2006 VA opinion also noted that the veteran had a clearly defined diagnosis. As the evidence establishes that the veteran's cervical spine symptoms are due to a diagnosed condition, the weight of the evidence is against the claim for service connection for an undiagnosed disability manifested by cervical spine pain. Moreover, the diagnosed condition was first shown several years after service. While the veteran contends that the neck pains began in service, service medical records do not show any cervical spine pain, nor is there any other contemporaneous evidence of cervical spine pain or disability until the 1999 VA Gulf War Registry examination. Thus, the Board finds that the evidence against the claim outweighs the positive evidence. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); see Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Bilateral Wrists Service medical records do not show any complaints or abnormal findings pertaining to the wrists in service. Private treatment records dated from June 1996 to April 1997 show that in April 1997, the veteran complained of pain in both wrists, which had been present for about 1 1/2 years. He had a job which required repetitive motion of the wrists, and involving the manipulation of tubes of paper which weighed a lot. There was tenderness over the extensor tendons and metacarpophalangeal joint of both wrists, just distal to the radius. He was not tender over the median nerve, and there was no numbness in that distribution. The impression was over-use syndrome and bilateral extensor tendonitis secondary to that. When seen for follow-up after having been off work for a week, he reported a lot of improvement. On examination, Tinel and Phalen signs were negative, and he had full range of motion in both wrists. X-rays of the wrists were normal. He was advised to pursue another job, due to bilateral wrist tendonitis. It was noted that his employer had agreed to switch him to a different position. The last record notes that the condition was still improving, and he was recommended to continue with Advil, and to start physical therapy. Thus, prior to the February 1999 Persian Gulf Registry examination, which resulted in a conclusion that the evidence indicated that there was undiagnosed illness manifested by numbness in the wrists, the veteran had been diagnosed with tendonitis of the wrists, and his job responsibilities had been changed as a result. Moreover, this repetitive motion injury was not reported on the VA examination, which noted a history of five to six years of wrist pain without injury. An occupational therapy note dated in May 1999 related that the veteran had some repetitive motions on his job, but not as much as in the past. He was educated as to carpal tunnel syndrome, but it was noted that an electromyogram would provide more conclusive evidence of CTS. Later evidence indicates that electrodiagnostic tests in August 1999 were negative. For instance, the October 2002 VA examination report noted that nerve conduction studies of the upper extremities were normal and ruled out carpal tunnel, but there is no indication in the record that new tests had been conducted since 1999. After the March 2000 primary care clinic evaluation, which resulted in an impression of polyarthralgia, and the neurology evaluation in May 2000, which failed to disclose any objective findings to support a diagnosis of ulnar neuropathy, the veteran was referred for an evaluation in a VA rheumatology clinic in May 2000. The veteran's complaints included bilateral wrist pain, which he said had been present for six years. He denied any numbness or tingling. He said the pain was constant. He said nerve conduction tests and electromyogram had been negative for median neuropathy of the wrists. The impression was myofascial pain. Examination of the wrists during the August 2001 hospitalization after the fall from the barn loft disclosed normal findings, with 5/5 wrist extensors and wrist flexors. The October 2002 VA examination disclosed mild degenerative changes in the wrists. Additionally, VA treatment records show that in August 2003, the veteran complained of left arm pain and numbness for 2 1/2 months, and in September 2003, electromyogram disclosed compression of the median nerve at the right/left/both wrists (noted to reflect carpal tunnel syndrome), electrophysiologically mild on the right, moderate on the left. In October 2003, he was educated regarding carpal tunnel syndrome in the occupational therapy clinic, and provided heavy duty wrist supports. In March 2007, the primary care problem list included carpal tunnel syndrome. Thus, degenerative changes in the wrists have been demonstrated on X-rays, and the veteran currently has carpal tunnel syndrome confirmed on electrodiagnostic studies. While these studies were negative in August 1999, it must be noted that in 1997, the veteran had tendonitis of the wrists, attributed to repetitive motions, which symptoms of which were reduced but not eliminated when he switched to other job duties. Moreover, this history was not before any of the physicians who later evaluated his condition. As noted above, affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between his Persian Gulf service and the onset of the condition rebuts the presumption of service connection. See 38 C.F.R. § 3.317(c). In this case, in 1997, the veteran's symptoms were attributed by his doctor to the repetitive motions of his job at that time. Moreover, tendonitis was diagnosed. The history he provided on his VA evaluations did not mention these factors, but the length of time extended back several years, to encompass this time period. This contemporaneous medical evidence of a diagnosed condition outweighs the later opinions of arthralgia due to Persian Gulf service, which were based on an inaccurate history. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005). In addition, the veteran currently has diagnosed carpal tunnel syndrome and degenerative changes of the wrists. Thus, the evidence establishes that the veteran, in 1997, had repetitive motion injuries to the wrists, diagnosed as tendonitis, and that he continued to experience wrist pain, eventually developing carpal tunnel syndrome and degenerative arthritis in both wrists. These conditions were not due to service, nor does he have an undiagnosed illness involving the wrists. Thus, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C. § 5107(b); see Ortiz, supra; Gilbert, supra. C. Bilateral Hips With respect to the veteran's claim pertaining to his hips, no complaints specific to the hips were noted in the medical records until the October 2002 VA examination, when the veteran said he had a feeling of stiffness from time to time in his hips. X-rays at that time showed mild degenerative arthritis in the hips. Accordingly, the veteran has a diagnosed illness involving the hips. Moreover, there is no indication of this condition in service; the veteran himself states that the hip pain developed some time after his wrist and cervical spine pain, and service medical records do not show hip pain. Thus, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is inapplicable, and the claim must be denied. 38 U.S.C. § 5107(b); see Ortiz, supra; Gilbert, supra. ORDER Service connection for degenerative disc disease of the cervical spine, to include as due to an undiagnosed illness, is denied. Service connection for degenerative joint disease of both wrists, to include as due to an undiagnosed illness, is denied. Service connection for degenerative joint disease of both hips, to include as due to an undiagnosed illness, is denied. REMAND The Board finds that additional development is required prior to an appellate decision as to the issue of service connection for GERD. The Board regrets the delay necessitated by a remand, but there is insufficient evidence to grant the claim, and the veteran has not been afforded an adequate examination as to this issue. VA medical records show that the veteran has been diagnosed with GERD since 2000, and has been treated with medication for the condition. However, there is no evidence of any specific symptoms or diagnostic studies that resulted in this diagnosis. In March and April 2006, the veteran underwent an upper gastrointestinal series and an endoscopic evaluation, which did not disclose any reflux or esophageal abnormalities. The Board may not make any unsubstantiated medical conclusions, and the evidence does not show whether or not these studies ruled out the presence of GERD. See Jones v. Principi, 16 Vet. App. 219, 225 (2002) (Board must provide a medical basis other than its own unsubstantiated conclusions to support its ultimate decision); Colvin v. Derwinski, 1 Vet.App. 171 (1991) (Board is prohibited from making conclusions based on its own medical judgment). If GERD has been ruled out, the veteran must be afforded an examination to determine whether he has gastrointestinal symptoms of an undiagnosed illness. If, on the other hand, the veteran has GERD, the question of whether GERD is related to gastrointestinal symptoms in service must be addressed in an examination. Specifically, in July 1990, upper abdominal pain was noted. In July 1991, the veteran complained of gastrointestinal pain for 1.5 months, and the possibility of a stomach ulcer was raised, and, although when examined his symptoms were thought to be due to gastroenteritis secondary to virus/stress, no tests were actually conducted. These incidents of in-service symptoms are sufficient to trigger a VA examination specifically addressing the matter of a nexus to service. See Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, 20 Vet. App. 79 (2006); Charles v. Principi, 16 Vet.App. 370, 374-75 (2002); 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Accordingly, the case is REMANDED for the following action: 1. Schedule the veteran for an appropriate examination, to determine whether he has GERD or other symptoms related to service. The entire claims folder and a copy of this REMAND must be made available to the examiner prior to the examination. The examiner is asked to review the service medical records, post- service treatment records, in particular, the reports of an upper gastrointestinal series obtained March 27, 2006, and an EGD performed April 25, 2006, and, with the addition of any other needed tests and an examination, determine the following: * Does the veteran have GERD? * If he does have GERD, is it etiologically related to gastrointestinal symptoms shown in service (July 1990, July 1991)? * If he does not have GERD, does he have objective indications of upper gastrointestinal manifestations of a chronic disability which are signs and symptoms of an undiagnosed illness, that by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis? For this purpose, a "chronic disability" is defined as a disability that has existed for six months or more. The complete rationale for all opinions expressed should be provided. It would be helpful if the physician would use the following language in his or her opinion, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 2. After completion of the above and any additional development deemed necessary, readjudicate the claim of service connection for GERD, including as an undiagnosed illness based on service in the Persian Gulf War. See 38 C.F.R. § 3.317. If the benefit sought remains denied, the veteran and his representative should be furnished an appropriate supplemental statement of the case, and afforded an opportunity to respond, before the case is returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters 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 of Veterans' Appeals 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 Supp. 2007). _________________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2007). Department of Veterans Affairs