Citation Nr: 1124238 Decision Date: 06/24/11 Archive Date: 06/29/11 DOCKET NO. 06-20 174 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for residual gynecological disabilities, to include endometriosis, status post hysterectomy with bilateral oophrectomy, claimed as due to medication prescribed for a skin disability. 2. Entitlement to service connection for a mouth disability, claimed as secondary to a skin disability. 3. Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Jennifer R. White, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1974 to June 1977. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada. In June 2006, the Veteran requested a hearing before the Board via video conference. However, in April 2007, she withdrew her request for a hearing. The Board, then, finds that all due process has been satisfied with respect to the Veteran's right to a hearing. In November 2009, the Board remanded the case to the RO, via the Appeals Management Center (AMC) for further development and adjudicative action. All required development with respect to the Veteran's claim of service connection for PTSD has been completed by the AMC and the case has been returned to the Board for further appellate review. The issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) has been raised by the record, 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. Notably, the U.S. Court of Appeals for Veterans Claims (Court) recently held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). However, in this case, the Veteran was granted service connection for an acquired psychiatric disorder, namely depression, in a November 2009 Board decision. The Veteran did not subsequently appeal the rating subsequently determined by the AMC. Thus, the Board finds that the only psychiatric disability currently on appeal is the claim of service connection for PTSD. The issues of entitlement to service connection for a mouth disability and residual gynecological disabilities are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will provide notification if further action is required on the part of the Veteran. FINDING OF FACT There is no credible supporting evidence to corroborate the Veteran's claimed stressor. CONCLUSION OF LAW The Veteran's PTSD was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim. Accordingly, notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters in July 2004 and January 2007 that fully addressed all notice elements of a claim for PTSD based on in-service assault. The letters provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. Moreover, the January 2007 letter informed the Veteran of what type of information and evidence was needed to establish a disability rating and effective date. Although the second correspondence was subsequent to the adverse rating decision on appeal, it was followed by a readjudication of the claim, most recently in March 2011. Accordingly, any timing deficiency has been cured, and no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. 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). The Board notes that the claim was remanded for records to be associated from the claims file from the Fort Shafter Military Police. Unfortunately, a reply from Headquarters, U.S. Army Criminal Investigation Command dated January 2010 indicates that no such records were found in their search. Thus, no further development is required in this regard. Further regarding the duty to assist, the claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. 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). Analysis The Veteran contends, in essence, that she has PTSD due to traumatic experiences in service, specifically a rape by an unknown assailant. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2010). Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between the veteran's current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). In Zarycki v. Brown, 6 Vet. App. 91 (1993), the Court held that the presence of a recognizable stressor is the essential prerequisite to support the diagnosis of PTSD. However, if the claimed stressor is not combat-related, the veteran's lay testimony regarding the in-service stressor is insufficient, standing alone, to establish service connection, and must be corroborated by credible evidence. Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996); Duran v. Brown, 6 Vet. App. 283, 289 (1994). If, as in this veteran's case, 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)(4)(redesignated effective July 13, 2010). The determination as to whether the requirements for service connection have been met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a) (2010). When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. § 3.102 (2010). If the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz at 1365. The Board has reviewed all the evidence in the Veteran's claims file. Although there is an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the veteran or obtained on his behalf be discussed in detail. Rather, the analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In this case, the Veteran is not claiming, nor does the evidence show, that she was engaged in combat with the enemy while in service. Instead, the Veteran has asserted that she has PTSD as a result of a personal assault that occurred during military service. While it has been difficult for the Veteran to recall and discuss this issue, she has reported that she was raped by a civilian sometime between June and August 1976, while working alone as a medical records technician at Tripler Army Hospital. The Veteran reported that the civilian used force and hit her head on the filing cabinet, causing head trauma and severe lacerations. She has indicated that, since the incident, she has had frequent episodes of anxiety and panic attacks, as well as gynecological, stomach, and intestinal problems, which she attributes to PTSD. The Veteran has asserted that, following the personal assault, she was taken to the emergency room where X-rays and blood tests were performed. She also reported that she was given a shift change following the incident, and that her request to see a counselor following the incident was denied by her superiors. The Veteran reports that her superiors removed the pertinent medical records from her file and threatened that she would not be promoted if she reported the incident to anyone. Nevertheless, the Veteran reported that the Military Police came to the hospital, made a report on the incident, and eventually apprehended the civilian. However, she was told that the civilian was released by the Military Police about two weeks later because they did not have jurisdiction over a civilian. He was not turned over to civilian authorities. In a statement received at the RO in July 2004, the Veteran indicated that relatives to whom she had confided details of her sexual assault were deceased and other enlisted members with whom she served were aware of the attack but were afraid to come forth due to threats made against them by superiors. The Veteran has additionally indicated in a March 2007 statement that her behavior changes include nightmares and flashbacks and her inability to be in a relationship led, which led to her divorce in 1979. Service treatment records dated July and August 1976 indicate the Veteran had acne which she had been treated for prior to active service. A March 1976 treatment record indicates that the Veteran had eczema for which she had been treated on numerous occasions. Service treatment records dated in June 1976 reflect treatment for a vaginal infection. Pelvic examination was normal and she was advised to change to cotton underwear. In an additional report dated in June 1976, the Veteran wanted to change her birth control due to mid-cycle bleeding. She was treated in July and August 1976 for colds with an ear infection and received treatment at the dermatology clinic for acne and eczema. An additional August 1976 treatment note indicates a diagnosis of herpes simplex of the mouth. Also, she was treated for eye irritation in August 1976. Laboratory tests from June 1976 to August 1976 are all indicated as being for the acute minor illness clinic. There are none from the emergency room for this time period and none indicating testing for pregnancy or venereal disease. The Board additionally observes the Veteran's lengthy history of treatment for gynecological problems both before and after June to August 1976. A November 1974 treatment note indicates that the Veteran had irregular periods. A February 1975 GYN clinic note relates an excess of estrogen. An April 1975 note indicates abdominal pain secondary to ovulation. A November 1975 cytology result indicates minimal dysplasia. A December 1975 provider's impression was one of rule out nonspecific vaginitis. A January 1976 GYN clinic note states the Veteran mid-cycle break through bleeding. A March 1976 treatment note indicates severe menstrual cramping after missing two periods. A June 1976 treatment note indicates a vaginal infection with a watery yellow discharge. An October 1976 treatment note says the Veteran had a vaginal discharge for two weeks. A December 1976 note from the OB/GYN emergency clinic indicates that the Veteran wanted an IUD (inter-uterine device) inserted. A February 1977 notes indicates that the IUD became displaced and half of it was expelled. The remainder was subsequently pulled out. A February 1977 treatment note indicates an adnexal mass on the right side of the uterus. A March 1977 lab report reflects a negative gonorrhea test. In March 1977, the Veteran had a foul smelling discharge, with the impression being vaginitis. Additionally, the Veteran was treated for acne and skin problems just after induction in July 1974 which continued until the time of her discharge. She also began treatment in April 1975 for abdominal pain which was treated on a regular basis until the time of her discharge. The Veteran's separation examination dated January in 1977 indicates no significant history since the Veteran's last examination in March 1975, but indicated that she had been followed in the dermatology clinic. The Veteran had a post-service examination dated in November 1978, as she was trying to re-enlist in the Army. The Veteran noted that she had been operated on at age 5 when she had her tonsils removed and she had childhood diseases. She also indicated that she had a broken nose in September 1978 while living in Genoa, Illinois. The medical examiner noted vaginitis due to yeast in the past. In the Veteran's service personnel records, an enlisted evaluation report covering the time period from January 1975 to November 1975 indicates that she exceeded or met duty requirements, was superior to most or ranks with the very best on all of her duty performance traits. Her ranks with very best ratings were in the area of personal behavior and taking pride in dress and appearance. She was rated as superior to most in working with others and being physically fit. She received a rating of 33 from her rater and a rating of 38 from her indorser for demonstrated overall performance of assigned duties. Advancement potential was at 28, promote ahead of peers. The comment from her rater was that the Veteran had performed the duties of the next higher rank since March 1975. The indorser's comment indicated that the Veteran's performance since March 1975 had been equaled by few if any young soldier that he knew. An enlisted evaluation report covering the time period from December 1975 to August 1976 indicates that the Veteran was superior to most in all areas. She received a rating of 38 from both her rater and her indorser. Advancement potential was 26, promote ahead of peers. The comments from both her rater and indorser indicate that the Veteran had the potential to assume the responsibilities of the next higher rank. An enlisted evaluation report covering the time period from September 1976 to April 1977 indicates that the Veteran was superior to most in all areas with the exception of taking pride in dress and appearance for which she got a rank with the very best from the indorser. The demonstrated overall performance was a 42 from both the indorser and the rater. Advancement potential was 22, promote with peers. The Veteran's rater made no comments. The indorser indicated that the Veteran was intelligent, efficient, and dedicated and that she could "get the job done under trying conditions." Additionally, he indicated her pleasant personality and willingness to put in long hours made her an asset to Tripler Army Medical Center. A January 1979 request for discharge from the delayed entry program, created post-service as the Veteran attempted to re-enlist, reports from the Area Commander that the Veteran appeared to be dangerously close to a nervous breakdown and could easily slip into hysteria. The Veteran was afforded a VA psychiatric examination in March 2004. She indicated that she had been sexually assaulted while on active duty and that she had told no one about it since it happened. The examiner indicated that she examined the claims file and that there was no record of a rape or Emergency Room visit. The Veteran stated that she married just after service and that her husband was abusive and broke her nose. The examiner indicated that the Veteran did not come to the session knowing what PTSD was or with an intention to claim service connection for the disability. The examiner diagnosed the Veteran with PTSD related to military sexual trauma. The examiner provided additional information in a letter dated February 2005 in which she reiterated that the Veteran did not come to the psychiatric evaluation claiming PTSD due to sexual assault. The examiner indicated that it is no surprise there was no evidence of such stressor twenty-nine years after the assault. The examiner also reiterated her report from March 2004 indicating that she hoped the Veteran's contentions would be taken seriously. The Board notes that the Veteran has submitted various medical literature printed from the internet indicating general information regarding PTSD. There is no specific information about the Veteran's circumstance and no corroboration of her stressor contained in the documents. Thus, the articles are entitled to little, if any, probative weight. See Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (finding that generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case does not provide competent evidence to establish a nexus between current disability and military service). The controlling issue in this case is whether there is independent, credible supporting evidence to corroborate the Veteran's statements as to the occurrence of the claimed stressors. See Doran, supra; 38 C.F.R. § 3.304(f). There is no indication of an assault with injuries consistent with the Veteran's report of the assault contained in her service treatment records. Her contentions that her service treatment records from the time of the attack were destroyed by her supervisor but that lab reports should show treatment between June 1976 and August 1976 with various pregnancy tests and tests for sexually transmitted diseases (STDs) are acknowledged. However, the Board observes that there were no laboratory tests found in the service treatment records which indicate pregnancy or testing for STDs during the relevant time period. In fact, the laboratory testing in the claims file from the time period designated are consistent with the Veteran's medical treatment of record from June 1976 to August 1976. Moreover, there is no indication in the Veteran's service personnel records that she requested a transfer to another unit as she contended in her statement submitted to the RO in April 2007. As indicated above, in a PTSD claim 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. Here, the Board is precluded from granting service connection as there is no corroboration of the Veteran's account of the stressor incident, such as records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; or statements from family members, roommates, fellow service members, or clergy. There is also no objective evidence of behavior changes following the claimed assault to include 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. Although the Veteran has submitted lengthy statements contending that she has had all of the behavior changes indicated, there is no objective evidence of such in the period of time immediately following the alleged sexual assault. As discussed previously, she continued to perform her job functions at a level superior to the majority of her peers. Additionally, the Board notes that pregnancy tests or tests for sexually transmitted diseases can be used as corroboration of a sexual assault. However, in this case, there is no notation of such in the Veteran's service treatment records for the time period which she indicates that the sexual assault occurred. The Veteran contends that her skin and gynecological conditions, documented in her service treatment, records resulted from the trauma of her sexual assault. However, the Board notes that the Veteran was treated for such conditions multiple times prior to the time period of the alleged assault. Although the Veteran has a diagnosis of PTSD, this diagnosis must be connected to a verified or corroborated in-service traumatic event in order to be service connected. There has been no such verification of a stressor in this case. As the Veteran's claim is not substantiated by credible supporting evidence that the claimed in-service stressor occurred, the criteria for a grant of service connection are not met, and the claim for service connection for PTSD must be denied. In reaching the conclusion above the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to service connection for PTSD is denied. REMAND Review of the record reveals a diagnosis of endometriosis in March 1999 following consistent complaints of abdominal pain. Subsequent treatment records show diagnoses of ovarian cysts and suspected small fibroid, and the Veteran was eventually prescribed a hysterectomy to treat the endometriosis. Despite the medical records showing the development of endometriosis and eventual need for a hysterectomy, such evidence does not identify the cause of the Veteran's gynecological problems. In this regard, the Veteran was afforded a VA examination in March 2004 to determine the etiology of her endometriosis and hysterectomy; however, the examiner limited her discussion to the potential relationship between the Veteran's problems and medication given at the San Francisco VA Medical Center (VAMC) Women's Clinic after service. While the examiner found no "legitimate claim" of endometriosis and hysterectomy due to medications given at the VAMC Women's clinic after service, she did not address the Veteran's contentions regarding the relationship between her gynecological problems and the in-service prescription and continued use of birth control pills and/or medication used to treat her service-connected skin disability. Moreover, she did not articulate any rationale for the conclusion she did reach, but instead noted that she had reviewed the claims folder and "research literature" in forming her opinion. This is not deemed to be an adequate supporting rationale and thus further commentary was requested on this point in the prior remand. The Board notes that the Veteran was afforded a VA gynecological examination pursuant to the previous remand in April 2010. The examiner indicated that endometriosis is a condition which is due to a genetic predisposition and is not altered by environmental or occupational circumstances. The examiner provided appropriate citations to empirical evidence. However, the examiner did not consider the Veteran's extensive treatment for gynecological problems in-service and whether the Veteran's endometriosis and ovarian cysts, diagnosed post-service with a resultant hysterectomy, is related to in-service gynecological treatment and complaints. In this regard, service treatment records reveal gynecological treatment basically throughout the Veteran's period of active duty. Specifically, a November 1974 treatment note indicates that the Veteran had irregular periods. A February 1975 GYN clinic note relates an excess of estrogen in the Veteran. An April 1975 note indicates abdominal pain secondary to ovulation. A November 1975 cytology result indicates minimal dysplasia. A December 1975 provider's impression was one of rule out nonspecific vaginitis. A January 1976 GYN clinic note states the Veteran mid-cycle break through bleeding. A March 1976 treatment note indicates severe menstrual cramping after missing two periods. A June 1976 treatment note indicates a vaginal infection with a watery yellow discharge. An October 1976 treatment note says the Veteran had a vaginal discharge for two weeks. A December 1976 note from the OB/GYN emergency clinic indicates that the Veteran wanted an IUD (inter-uterine device) inserted. A February 1977 notes indicates that the IUD became displaced and half of it was expelled. The rest of it was subsequently pulled out. A February 1977 treatment note indicates that the Veteran had an adnexal mass on the right side of her uterus. A March 1977 lab report indicates that the Veteran had a gonorrhea test which was negative. A March 1977 note indicates that the Veteran had a foul smelling discharge with the impression being vaginitis. Likewise, the April 2010 examiner did not indicate whether the Veteran's claimed oral lesions are related to her in-service treatment for the oral herpes simplex virus. Specifically, in August 1976, the Veteran was treated for fever blisters to include painful sores in the mouth and on the lips with an assessment of herpes simplex. Prior VA examinations dated March 2004 and June 2007 noted intermittent papular lesions in the Veteran's mouth but also did not indicate whether such lesions were related to in-service treatment for such condition. The Board finds that an additional VA medical opinion to determine if the sores the Veteran was treated for in August 1976 are related to her current oral lesions. Accordingly, the case is REMANDED for the following action: 1. Request that a VA physician examine the Veteran and review the claims file in order to provide an opinion as set forth below. The claims file must be made available to the examiner for review in conjunction with the examination, and the examination report should reflect that such review is accomplished. The examiner is requested to provide an opinion as to whether it is at least as likely as not (i.e., to a 50-50 degree of probability), or unlikely (i.e., less than a 50-50 probability) that the Veteran's residual gynecological condition, including endometriosis and hysterectomy, is causally related to 1) the Veteran's active military service to include treatment for various gynecological abnormalities initially found while she was on active duty, 2) medication for any service-related condition to include the various medications the Veteran has taken for her skin disorder or 3) due to medications (Depo-Provera) provided at the San Francisco VA Medical Center's Women's clinic following service. The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather 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 causation as it is to find against it. A rationale should be provided for any opinion offered. If any opinion cannot be rendered without resort to speculation, the examiner should state why this is so. 2. Request that a VA physician examine the Veteran and review the claims file in order to provide an opinion as set forth below. The claims file must be made available to the examiner for review in conjunction with the examination, and the examination report should reflect that such review is accomplished. The examiner should be requested to provide an opinion as to whether it is at least as likely as not (i.e., to a 50-50 degree of probability), or unlikely (i.e., less than a 50-50 probability) that the Veteran's oral lesions are related to herpes diagnosed while she was on active service or her service-connected skin disability. The examiner should address whether the oral lesions are simply manifestations or a progression of the service-connected skin disability and/or whether the oral lesions are secondary to the medication prescribed to treat the service-connected skin disability, to include whether the oral lesions are the proximate cause, aggravated by, or the result of the medications. In this context, "aggravated" is defined as a permanent worsening beyond the natural progression of the disability. A rationale should be provided for any opinion offered. If any opinion cannot be rendered without resort to speculation, the examiner should state why that is so. Additionally, if that examiner is no longer available, then another comparably qualified examiner may respond in his place, following review of the record. 3. Following the above actions, the issues on appeal should be readjudicated. If the benefits sought on appeal are not granted to the Veteran's satisfaction, the Veteran should be provided with a supplemental statement of the case and afforded the appropriate opportunity to respond thereto. The Veteran 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. 2010). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs