Citation Nr: 1015656 Decision Date: 04/29/10 Archive Date: 05/06/10 DOCKET NO. 07-07 436 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for sarcoidosis. 2. Entitlement to service connection for an acquired psychiatric disorder, to include major depression and post traumatic stress disorder (PTSD). 3. Entitlement to service connection for a sexually transmitted disease (STD). 4. Entitlement to service connection for a low back disorder. 5. Entitlement to service connection for a right ankle disorder. 6. Entitlement to service connection for a left ankle disorder, including as secondary to low back and right ankle disorders. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Carole R. Kammel, Counsel INTRODUCTION The Veteran had active service from January 1995 to August 1997. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. By that rating action, the RO denied service connection for chronic major depression, low back disorder and right and left ankle disorders. The Veteran appealed the RO's August 2005 rating action to the Board. This appeal also stems from a December 2007 rating action. By that rating action, the RO denied service connection for sarcoidosis, post traumatic stress disorder (PTSD) and STD. The Veteran appealed the RO's December 2007 rating action to the Board. In February 2010, the Veteran testified before the undersigned Veterans Law Judge at the Portland, Oregon RO. A copy of the hearing transcript is of record. At the hearing, the Veteran submitted additional evidence (e.g., VA treatment records and a statement, prepared by T. M.G.), along with a waiver of initial RO consideration of this evidence. 38 C.F.R. § 20.1304 (2009). The Veteran initially claimed service connection, in part, for major depression. She subsequently amended her claim to include service connection for PTSD. The United States Court of Veterans Claims (Court) has recently held that claims for service connection for PTSD encompass claims for service connection for all psychiatric disabilities. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Thus, the Veteran's claims for service connection for major depression and PTSD are most appropriately adjudicated as a single issue and it has been framed as that listed on the title page. In light of the award of service connection for an acquired psychiatric disorder, to include major depression and PTSD in the decision below, the issue of entitlement to service connection for a STD as secondary to PTSD has raised by the record (see, Transcript (T.) at page. (pg.) 16), but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to ). 38 U.S.C.A. § 7107(a)(2) (West 2002); 38 C.F.R. § 20.900(c) (2009). The issues of entitlement to service connection for a STD, low back disorder, right ankle disorder and left ankle disorder, to include as secondary to the low back and right ankle disorders are addressed in the REMAND portion of the decision below and are REMANDED to the RO/Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. In February 2010, prior to the promulgation of a decision in the appeal, the Board received written notification from the Veteran of her desire to withdraw the appeal for service connection for sarcoidosis. 2. The Veteran did not engage in combat with the enemy. 3. The weight of the competent evidence of record shows that the Veteran's currently diagnosed acquired psychiatric disorder (PTSD, major depressive disorder, and generalized anxiety disorder) is related to an in-service sexual assault. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a Substantive Appeal on the claim for service connection for sarcoidosis by the Veteran have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2009). 2. With resolution of the doubt in the Veteran's favor, an acquired psychiatric disorder (PTSD, major depressive disorder and generalized anxiety disorder) was incurred in service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.304(f) (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawal of Appeal-Service Connection for Sarcoidosis An appeal consists of a timely filed Notice of Disagreement in writing, and after a Statement of the Case has been furnished, a timely filed Substantive Appeal. 38 U.S.C.A. § 7105(a) (West 2002); 38 C.F.R. § 20.200 (2009). A Substantive Appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. §§ 20.202, 20.204(b) (2009). Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. 38 C.F.R. § 20.204(b) (2009). The record reflects that the Veteran perfected an appeal of a December 2007 rating decision. By that rating action, the RO denied, in part, service connection for sarcoidosis. Thereafter, in February 2010, the Board received written notification from the Veteran of her desire to withdraw the appeal for service connection for this disability. The Board finds that this written statement qualifies as a valid withdrawal of the issue of entitlement to service connection for sarcoidosis. See 38 C.F.R. § 20.202. Accordingly, this claim will be dismissed. II. Service Connection-Acquired Psychiatric Disorder, to include Major Depression and PTSD In general, service connection will be granted for disability resulting from injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303. If a condition noted during service is not determined to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). There must be medical evidence of a current disability, medical or lay evidence of in-service incurrence or aggravation of a disease or injury, and medical evidence linking the current disability to that in-service disease or injury. Pond v. West, 12 Vet. App. 341, 346; Hickson v. West, 12 Vet. App. 247, 253. A specific VA regulation applies to PTSD claims. In order for service connection to be awarded for PTSD, three elements must be present: (1) a current medical diagnosis of PTSD; (2) credible supporting evidence that a claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between the current PTSD symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (2007); Moreau v. Brown, 9 Vet. App. 389 (1996). If a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. 38 C.F.R. § 3.304(f)(3). However, VA will not deny such claims without: (1) first advising veterans that evidence from sources other than a veteran's service medical records, including evidence of behavior changes, may constitute supporting evidence of the stressor; and (2) allowing him the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. Id. The regulation specifically provides that VA "may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred." Id. See also Patton v. West, 12 Vet. App. 272 (1999) (Observing special development considerations in claims for PTSD based on sexual assault); M21-1, Part III, 5.14(c)(8)and (9) of Section 5.14 which state that "[b]ehavior changes that occurred at the time of the incident may indicate the occurrence of an in-service stressor." The Court in Patton stated that such changes in behavior should be examined and clinically interpreted to determine whether they constitute evidence of "[v]isits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment." The Veteran contends that she has PTSD as a result of an- service sexual assault that occurred while stationed in Naples, Italy in 1995. She maintains that while she was at a civilian party with several other United States Navy personnel, she became intoxicated and was dated raped by another soldier. She contends that she reported the sexual assault one week later at the same time she sought treatment for a STD. (See VA Form 21-0781a, Statement in Support of Claim for Service Connection for PTSD, received by VA in June 2007). The Veteran submitted a statement, dated in January 2010, prepared by T. M. G., a fellow United States Navy service comrade, who indicated that she had attended the party where the Veteran was sexually assaulted and, while she did not the witness event, she remembered the Veteran telling her about it afterward. The Veteran's service personnel records show that she was stationed in the Naples/Gaeta area of Italy in support of visiting and homeported SIXTH Fleet units and shore-based personnel from late April 1995 to mid-January 1997. These reports also show that the Veteran's overall individual trait average declined from 3.29 in early April 1995 to 2.83 in mid-January 1997. The Veteran's service treatment records (STRs) show that she was found to have been psychiatrically "normal" when examined for service entrance in November 1994. In late January 1997, the Veteran was diagnosed as having a probable urinary tract infection (UTI). A gynecological examination of the Veteran performed the following day was found to have been "normal." In mid-June 1997, the Veteran presented to the mental health clinic with a history of self-mutilation, possible borderline traits and significant distress over spousal separation. The Veteran indicated that while stationed in Italy, she drank alcohol on a daily basis. A sexual assault was not reported. After a mental status evaluation of the Veteran, she was diagnosed with adjustment disorder and borderline personality disorder. It was recommended that the Veteran be administratively separated from active duty based on her level of past and current instability. On DD Form 2697, Report of Medical Assessment, dated in early July 1997, the Veteran indicated that she was "THE SAME" since her previous medical assessment/physical examination. The examining physician noted that the Veteran had been evaluated at the mental health clinic for an adjustment disorder with depressed mood. A Report of Medical Examination, dated in early July 1997, reflects that the Veteran was psychiatrically evaluated as "abnormal." The examining physician diagnosed the Veteran with an adjustment disorder with depressed mood and borderline personality disorder was to be ruled out. On a July 1997 Report of Medical History, the Veteran reported that she had had frequent trouble sleeping and depression or excessive worry. She denied having any loss of memory or amnesia or nervous trouble of any sort. The examiner reported that she had recently been diagnosed with an adjustment disorder with depressed mood on recent evaluation. There was no evidence of major depression. When seen in the medical clinic in late July 1997, it was noted that the Veteran had met the criteria for alcohol dependence and that she had a history of self-mutilation when she abstained from drinking. Assessments of alcohol dependence and self mutilation were recorded. The first post-service evidence of an acquired psychiatric disorder and report of the in-service personal assault was during a June 2005 VA examination. A review of that examination report reflects that the examiner had reviewed the Veteran's claims files. The Veteran reported having experienced a violent family background that was infused with instability and illicit drug abuse. She gave a childhood history of self-mutilation (e.g., cutting her wrists and arms). The Veteran also reported having contracted Chlamydia after she was date raped while intoxicated during military service. The examiner gave a history of the Veteran's STRs, which is consistent with that previously reported herein. After a mental status examination of the Veteran in June 2005, the VA examiner entered diagnoses of depressive disorder, not otherwise specific, and alcohol and substance abuse in remission. The examiner opined that the Veteran did not currently exhibit signs of an adjustment disorder with depressed mood or borderline personality disorder. The examiner concluded that the Veteran's major depression was not caused by, or a result of, her military service. (See June 2005 VA mental disorders examination report). In contrast to the foregoing VA opinion, is a February 2009 VA treatment record that is supportive of the Veteran's claim. A review of that report shows that the Veteran had become increasingly anxious and depressed since she began to talk with a close friend about her [in-service] rape. After a mental status evaluation of the Veteran, the psychiatrist entered assessments of: PTSD, Recurrent and Moderate Major Depressive Disorder, Generalized Anxiety Disorder, and Military Sexual Trauma (MST)-Rape in Military. The Board has reviewed the evidence of record in association with the Veteran's contentions and hearing testimony before the undersigned. As noted above, there are special criteria for PTSD cases based on stressors that involved personal assaults or trauma. In this case, like most personal assault cases, the evidence is not unequivocal. Nonetheless, there is indication within the claims folders, including service personnel records, which pertinently reflect that the Veteran's overall individual trait average had declined from 3.29 in early April 1995, when she first arrived in Italy, to 2.83 in January 1997. In addition, her STRS show that after the Veteran returned stateside, she sought psychiatric treatment, albeit, in part, due to spousal-separation anxiety. The Veteran, as well as a fellow service comrade, have consistently provided an unwavering written and oral account of the in-service personal assault. Finally, as recited above, there are VA opinions against and in support of the Veteran's claim. A June 2005 VA examiner concluded that the Veteran's major depression was not caused by, or a result of, her military service. In contrast, a March 2009 VA psychiatrist assessed the Veteran as having PTSD, Recurrent and Moderate Major Depressive Disorder, Generalized Anxiety Disorder, as well as MST-rape in service. There can be no doubt that further medical inquiry could be undertaken with a view towards development of the claim. However, under the "benefit-of-the-doubt" rule, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). The mandate to accord the benefit of the doubt is triggered when the evidence has reached such a stage of balance. In this matter, the Board is of the opinion that this point has been attained. Because a state of relative equipoise has been reached in this case, the benefit of the doubt rule will therefore be applied. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996); Brown v. Brown, 5 Vet. App. 413, 421 (1993). Under the law set forth in the evaluation of personal assault claims, and recognizing the credible allegations raised by the Veteran in association with the evidence of record, that reasonable doubt must be resolved in her favor. Service connection for an acquired psychiatric disorder (PTSD, major depressive disorder and generalized anxiety disorder) is granted. The Board has considered whether further development and notice under the Veterans Claims Assistance Act of 2000 or other law should be undertaken. However, given the results favorable to the Veteran, further development under the VCAA or other law would not result in a more favorable result for the veteran, or be of assistance to this inquiry. ORDER The claim of service connection for sarcoidosis is dismissed. Service connection for an acquired psychiatric disorder (PTSD, major depressive disorder and generalized anxiety disorder) is granted. REMAND The Board finds that the claims for service connection for residuals of a STD, low back disorder, right ankle disorder, and left ankle disorder, to include as secondary to low back and right ankle disorders must be remanded, in part, for VA medical opinions to clarify whether the claimed disorders are etiologically related to the Veteran's period of military service. 38 C.F.R. § 3.159(c)(4) (2008); McLendon v. Nicholson, 20 Vet. App. 79 (2006) (discussing circumstances when a VA examination is required). The Veteran contends that after she was sexually assaulted during military service, she contracted a STD that has caused post-service genitourinary problems, such as having to undergo a loop electrosurgical excision procedure (LEEP). (T. at pg.) 15). She also maintains that her current low back and right ankle disorders had their onset during military service and have continued since service discharge. Finally, she maintains that she developed a left ankle disorder as a result of having to overcompensate for a weak right ankle. (T. at pg. 21). Service treatment records pertinently reflect that in January 1995, prior to her service in Italy, the Veteran was diagnosed with Chlamydia. In February 1995, the Veteran twisted her right ankle. She related that she had stepped on another soldier's foot while marching four days previously. The Veteran was diagnosed, in part, with mild right ankle sprain. In January 1997, the Veteran was diagnosed as having a probable UTI. A gynecological examination of the Veteran performed the following day was "normal." In late June 1997, the Veteran complained of low back pain that had its onset three days previously after she bent over to tie her shoe. The Veteran was diagnosed with lower back muscle strain. A service discharge examination report, dated in early July 1997, reflects that the Veteran's genitourinary and musculoskeletal systems were evaluated as "normal." On a Report of Medical History, dated in July 1997, the Veteran denied having any venereal disease, bone, joint or other deformity and recurrent back pain. In the notes section of the report, the examining physician indicated that the Veteran had a history of a UTI and Chlamydia. The first post-service evidence of any STD residuals, right ankle and low back disorders was in October and December 2005 and March 2009, respectively. In October 2005, the Veteran was status post LEEP for a history of "CIN III/CIS." (See August 2006 VA outpatient report, reflecting that in October 2005, the Veteran had undergone a LEEP procedure). In December 2005, the Veteran sought treatment at a private emergency room for complaints of right ankle edema that had its onset two weeks previously. She was diagnosed with erythema nodosum, the etiology of which was unclear. VA interpretations of a March 2009 magnetic resonance imaging (MRI) scan of the lumbar spine contained an impression of early degenerative disk disease with a radial tear at L4-5. In sum, the record shows that the Veteran received treatment in service for Chlamydia, a UTI, mild right ankle sprain, and lower back muscle strain. The Veteran has maintained, in written statements and testimony provided throughout the appeal, that she has experienced a continuation of symptomatology associated with these disorders since service separation. (See June 2005 VA mental disorders examination report). As indicated above, the Veteran has maintained that due to financial and geographical reasons, she did not initially seek treatment for the claimed disorders after service discharge. In this instance, the lay and medical evidence shows symptoms of sexually transmitted diseases (STDs), right ankle and low back problems during active military service and current diagnoses, or residuals thereof, of these disorders. Thus, the claims for service connection for a STD, low back disorder and right ankle disorder must be remanded, in part, for VA medical opinions to clarify whether the claimed disorders are etiologically related to, or had their onset during, the Veteran's period of military service. Id. Regarding the Veteran's claim for service connection for a STD, in its December 2007 rating action, the RO referenced a "discharge examination dated June 29, 1997," showing that the Veteran had received treatment for a STD, Chlamydia, from her first [sexual] partner. (See December 2007 rating action). A review of the Veteran's STRS, is devoid of the above-cited report. VA has a duty to obtain a copy of the above-cited discharge examination report and associated with the claims files. 38 U.S.C.A. § 5103A(b), (c) (West 2002). In addition, during the hearing before the undersigned, she testified that she had sought treatment for various STDs from Planned Parenthood. As these private treatment records might contain information regarding the etiology of any diagnosed STD, or residuals thereof, they should be obtained on remand. Id. Concerning the claim for service connection for a left ankle disorder, the Veteran has maintained that she currently has a left ankle disorder that is secondary to having to overcompensate for a weak right ankle. (See VA Form 21-4138, Statement in Support of Claim, dated and signed by the Veteran in November 2005, and T. at pg. 21). The RO has not provided the Veteran with complete notice under the VCAA with respect to this claim. Specifically, she has not been informed of the information and evidence necessary to substantiate her claim for service connection for a left ankle disorder on a secondary basis. This must be completed on remand to the RO/AMC. As any decision with respect to the claims for service connection for low back and right ankle disorders may affect the Veteran's claim for service connection for a left ankle disorder, which has been claimed as secondary to these disorders, these claims are, therefore, inextricably intertwined. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). Thus, any decision on the claim for service connection for a left ankle disorder, to include as secondary to low back and right ankle disorders would be premature. Hence, a remand of this matter is also warranted. As evidenced by a March 2009 VA treatment record, the Veteran has applied for Social Security Administration (SSA) disability benefits. These records have not been associated with the claims files. The Board finds that a remand is necessary to obtain such records and associate them with the Veteran's claims files. VA has a duty to obtain SSA records when they may be relevant. See Voerth v. West, 13 Vet. App. 117, 121 (1999); Baker v. West, 11 Vet. App. 163, 169 (1998); Murincsak v. Derwinski, 2 Vet. App. 363, 370-72 (1992). Accordingly, the RO should contact the SSA and obtain and associate with the claims files copies of the Veteran's records regarding SSA benefits, including the complete medical records upon which any decision was based. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c)(2) (2009). Finally, in a March 2009 statement to the RO, the Veteran indicated that she had continued to seek treatment for the claimed disorders on appeal from VA Medical Centers (VAMCs) in Roseburg and Eugene, Oregon. Treatment records from these VAMCs dating up to March 2009 are contained in the claims files. Because VA has a duty to obtain all relevant VA and Governmental records prior to adjudication of a claim, updated records should be obtained prior to any further appellate review of the instant service connection claims. 38 U.S.C.A § 5103A(c)(3) (West 2002 & Supp. 2009); see Bell v. Derwinski, 2 Vet. App. 611 (1992) (Observing that any VA treatment records that have been generated up to and including the date of the Board's decision, whether or not filed in the claims folder, are in the constructive possession of the Board and must be considered). see also 38 C.F.R. § 3.159(c)(2) (2009). Upon completion of the remand directives as below and readjudication of the Veteran's claims, the RO/AMC will also ascertain whether service connection may be granted for any currently present non-service-connected left ankle disorder on direct (i.e., non-secondary) and secondary bases. Schroeder v. West, 212 F.3d 1265 (Fed. Cir 2000); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994) (Both for the general proposition that in claims involving presumptive service connection, the Board must also examine the evidence of record to ascertain if there is any other basis upon which to develop or grant the claim, including direct service connection). (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). Expedited handling is requested.) 1. The Veteran should be provided the notice required under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), to include notice concerning her claim of entitlement to service connection for a left ankle disorder as secondary to low back and right ankle disorders. 2. Associate with the claims files a copy of the Veteran's "discharge examination dated June 29, 1997" referred to in the appealed December 2007 rating action. If this document can not be obtained, all requests and responses must be clearly documented in the claims folders. 3. Provide the Veteran with the necessary authorizations for the release of any treatment records from Planned Parenthood that are not currently of record. The RO/AMC should then obtain these records and associate them with the claims folders. All requests for records and their responses should be clearly delineated in the claims folders. 4. Obtain all treatment records pertaining to the Veteran from the VAMCs in Roseburg and Eugene, Oregon, dated from March 2009 to the present. All information should be associated with the claims folders. All requests for records and their responses should be clearly delineated in the claims folders. 5. Request that the SSA produce all records associated with the award of any Social Security benefits (Supplemental Security Income or Supplemental Security Disability Income) pertaining to the Veteran, including copies of any and all award letters and all medical records associated with those award letters. If such records are unavailable, obtain a written response from SSA indicating that these records were lost, destroyed, or were otherwise unavailable. 6. After the development requested above has been completed and any additional medical evidence has been associated with the claims folders, the RO/AMC must schedule the Veteran for VA examinations by the appropriate examiners to determine the etiology of any STD, or residuals thereof, low back disorder and right and left ankle disorders found on examination. The following considerations will govern the examinations: a. The claims folders must be provided to and reviewed by the examiners in conjunction with their respective examinations. The examiners must indicate that a review of the claims folders was made. Each examiner must respond to the following question(s) as it pertains to their respective physical disorder(s) and provide a full statement of the basis for the conclusions reached: (i) Does the Veteran currently have an STD, or residuals thereof, low back disorder and right and left ankle disorders that are etiologically related to, or had their onset during, her period of active military service or within a year of service discharge in August 1997? and; (ii) If it is determined that the Veteran currently has low back and/or right ankle disorder(s) that is/are a result of her military service, should the respective examiner answer the following question: Does the Veteran currently have a left ankle disorder that is secondary to, or has been permanently worsened by, the low back and/or right ankle disorder(s) ? b. All opinions expressed must be accompanied by supporting rationale, with reference to the documented clinical history. c. In formulating the foregoing respective opinions, all examiners must comment on the following service and post-service treatment records, as it pertains to their respective physical disorder(s): (i) January 1995 STR, reflecting that the Veteran was diagnosed with Chlamydia; (ii) February 1995 STR, showing that the Veteran complained of having twisted her right ankle. A diagnosis of mild right ankle sprain was entered. (iii) January 1997 STR, reflecting that the was diagnosed with a probable UTI. A gynecological examination performed the following day was "normal;" (iv) A June 1997 STR, showing that the Veteran complained of low back pain that had its onset three days previously after she bent over to tie her shoe. A diagnosis of lower back muscle strain was entered. (v) Service discharge examination report, dated in early July 1997, reflecting that the Veteran's genitourinary and musculoskeletal systems were evaluated as "normal." (vi) A July 1997 Report of Medical History, showing that the Veteran denied having any venereal disease, bone, joint or other deformity and recurrent back pain. A history of UTI and Chlamydia were noted.; (vii) June 2005 VA treatment record, showing that the Veteran had complained of low back pain that had its onset three to five years previously; (viii) December 2005 report, prepared by Sacred Heart Medical Center, reflecting that the Veteran had sought emergency room treatment for complaints of right ankle edema that had its onset two weeks previously. A diagnosis of erythema nodosum, the etiology of which was unclear, was recorded. (ix) August 2006 VA treatment record, showing that in October 2005, the Veteran underwent a LEEP for a history of "CIN III/CIS;" (x) VA interpretations of a March 2009 MRI of the lumbar spine containing an impression of early degenerative disk disease with radial tear at L4- 5. 7. Thereafter, review the Veteran's claims for service connection for residuals of a STD, low back disorder, right ankle disorder, and left ankle disorder, to include as secondary to low back and right ankle disorders. If the service connection claims are denied, issue a supplemental statement of the case to the Veteran and her representative, and provide an opportunity to respond, before the case is returned to the Board. The purposes of this remand are to ensure that notice is complete with respect to the claim for service connection for a left ankle disorder, to include as secondary to low back and right ankle disorder and to assist the Veteran with the substantive development of her claims for service connection for a STD, low back disorder and right and left ankle disorders. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. The Board takes this opportunity, however, to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of her claims. Her cooperation in VA's efforts to develop her claims, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of her claims. 38 C.F.R. § 3.655 (2009). (CONTINUED ON NEXT PAGE) These claims 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. 2009). ______________________________________________ VITO A. CLEMENTI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs