Citation Nr: 1120062 Decision Date: 05/24/11 Archive Date: 06/06/11 DOCKET NO. 08-28 282 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for an acquired psychiatric disability other than PTSD, to include depression, panic disorder, mood disorder, and obsessive compulsive disorder, including as secondary to service-connected PTSD. 3. Entitlement to service connection for a respiratory disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had a period of active duty for training (ACDUTRA) in the U.S. Army Reserves from March to July 1977 and active service in the U.S. Air Force from November 1990 to May 1991, including in the Persian Gulf War. She also had U.S. Air Force Reserve (USAFR) service. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a September 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied, in pertinent part, the Veteran's claims of service connection for PTSD, a total hysterectomy, and for a respiratory disability (which it characterized as allergic rhinitis/sinusitis). The Veteran disagreed with this decision in August 2007. When she perfected a timely appeal in July 2008, she limited her appeal to the denial of service connection for PTSD and for a respiratory disability, however. A Travel Board hearing was held at the RO in October 2010 before the undersigned Veterans Law Judge and a copy of the hearing transcript has been added to the record. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. The Board acknowledges that, at the beginning of the hearing, the VLJ confirmed that the Veteran was withdrawing a claim of service connection for a total hysterectomy. As noted above, the Veteran had limited her appeal to the issues listed on the title page of this decision, so withdrawal of the issue of service connection for a total hysterectomy on the record at the hearing was not required. See 38 C.F.R. § 20.204(b) (2010). In any event, during the hearing, the VLJ noted the basis of the prior determination and noted the element of the claims that was lacking to substantiate the claims for benefits. The VLJ specifically noted the issues as service connection for PTSD and for a respiratory disability. The representative and the VLJ then asked questions to ascertain whether the Veteran had submitted evidence linking her PTSD and/or respiratory disability to active service. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. The representative specifically asked the Veteran about continuity of her PTSD and respiratory symptomatology since active service. He also asked the Veteran to discuss her claimed in-service stressors. Moreover, neither the Veteran nor her representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims and the Veteran, through her testimony, demonstrated that she had actual knowledge of the elements necessary to substantiate her claims for benefits. The Veteran's representative and the VLJ asked questions to draw out the evidence linking PTSD and a respiratory disability to active service, the elements of the claims in question. As such, the Board finds that, consistent with Bryant, and especially in light of the decision below reopening and granting the Veteran's claim of service connection for PTSD, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that any error in notice provided during the Veteran's hearing constitutes harmless error. The Board notes that, in Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Court held that claims for service connection for PTSD also encompass claims for service connection for all psychiatric disabilities afflicting a Veteran based on a review of the medical evidence. The medical evidence indicates that, in addition to PTSD, the Veteran has been diagnosed as having depression, panic disorder, mood disorder, and obsessive compulsive disorder. This evidence also shows that the Veteran's service-connected PTSD caused or aggravated (permanently worsened) his acquired psychiatric disability other than PTSD. Thus, the claims of service connection for PTSD and for an acquired psychiatric disability other than PTSD, to include depression, panic disorder, mood disorder, and obsessive compulsive disorder, including as secondary to service-connected PTSD, are as stated on the title page of this decision. The issues of entitlement to service connection for a disability manifested by chronic fatigue, joint pain, muscle pains, memory loss, and insomnia, to include as due to an undiagnosed illness, entitlement to a total disability rating based on individual unemployability (TDIU), and whether new and material evidence has been submitted to reopen a claim of service connection for hypertension have been raised by the record but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). The Veteran filed a claim of service connection for a disability manifested by chronic fatigue, joint pain, muscle pains, memory loss, and insomnia, to include as due to an undiagnosed illness, and requested that his previously denied service connection claim for hypertension be reopened in April 2004. A TDIU claim also has been reasonably raised by a review of the record. Because these claims have not been adjudicated by the AOJ, the Board does not have jurisdiction over them and they are referred to the AOJ for appropriate action. As will be explained below, the Board finds that additional development is necessary before the claim of service connection for a respiratory disability can be adjudicated on the merits. This claim is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. The Veteran's service personnel records show that she served in the southwest Asia theater of operations during the Persian Gulf War. 2. The Veteran has reported that her in-service stressors are related to fear of hostile military or terrorist activity. 3. The competent evidence shows that the Veteran's PTSD is related to active service. 4. The competent evidence shows that the Veteran's acquired psychiatric disability other than PTSD, to include depression, panic disorder, mood disorder, and obsessive compulsive disorder, is related to her service-connected PTSD. CONCLUSIONS OF LAW 1. PTSD was incurred in active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.304 (2010). 2. An acquired psychiatric disability other than PTSD, to include depression, panic disorder, mood disorder, and obsessive compulsive disorder was caused or aggravated by the service-connected PTSD. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board grants entitlement to service connection for PTSD and for an acquired psychiatric disability other than PTSD, to include depression, panic disorder, mood disorder, and obsessive compulsive disorder, including as secondary to service-connected PTSD. This action constitutes a complete grant of the Veteran's claims. Therefore, no discussion of VA's duty to notify or assist is necessary. The Veteran contends that she incurred PTSD and an acquired psychiatric disability other than PTSD, to include depression, panic disorder, mood disorder, and obsessive compulsive disorder, during active service. She specifically contends that in-service stressors during her active service in the Persian Gulf War contributed to or caused her PTSD. She also contends that in-service personal trauma contributed to or caused her PTSD. She has asserted that she has experienced PTSD symptoms continuously since active service. She contends further that she has been diagnosed as having PTSD based on an in-service stressor corroborated by a VA psychiatrist or psychologist on outpatient treatment. She also contends further that her acquired psychiatric disability other than PTSD, to include depression, panic disorder, mood disorder, and obsessive compulsive disorder, was caused or aggravated (permanently worsened) by her PTSD. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In the case of any Veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. Every reasonable doubt shall be resolved in favor of the Veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with VA regulations; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). See 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) (pertaining to combat Veterans). If, however, 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. Examples of such evidence include, but are not limited to, statements from family members, and evidence of behavior changes following the claimed assault. 38 C.F.R. § 3.304(f)(3). In Patton v. West, 12 Vet. App. 272 (1999), the Court held that special consideration must be given to personal assault PTSD claims. In particular, the Court held in Patton that the provisions in M21-1, Part III, 5.14(c), which address PTSD claims based on personal assault, are substantive rules which are the equivalent of VA regulations and must be considered. See also YR v. West, 11 Vet. App. 393, 398-99 (1998). The Board notes that M21-1, Part III, Chapter 5, has been rescinded and replaced, in relevant part, by M21-1MR, Part III, Subpart iv, Chapter 4, Section H30. See generally M21-1MR, Part III, Subpart iv, Chapter 4, Section H30. These M21-1MR provisions on personal assault PTSD claims require that, in cases where available records do not provide objective or supportive evidence of the alleged in-service stressor, it is necessary to develop for this evidence. As to personal assault PTSD claims, more particular requirements are established regarding the development of "alternative sources" of information as service records may be devoid of evidence because many victims of personal assault, especially sexual assault and domestic violence, do not file official reports either with military or civilian authorities. See M21-1MR, Part III, Subpart iv, Chapter 4, Section H30b. Further, the relevant provisions of M21-1MR indicate that behavior changes that occurred around the time of the incident may indicate the occurrence of an in-service stressor and that "[s]econdary evidence may need interpretation by a clinician, especially if the claim involves behavior changes" and "[e]vidence that documents behavior changes may require interpretation in relation to the medical diagnosis by a neuropsychiatric physician". See M21-1MR, Part III, Subpart iv, Chapter 4, Section H30c. The Board observes here that the Veteran has asserted that her PTSD is due to a variety of in-service stressors, including witnessing enemy Scud missile attacks during the Persian Gulf War and in-service personal assault. The RO appears to have developed the Veteran's PTSD claim, in part, as a claim based on an in-service personal assault; however the competent evidence (service personnel records and service treatment records) does not show that she experienced a personal assault during active service. Instead, it appears that the Veteran contended on her February 2006 VA Form 21-0781a, "Statement In Support Of Claim For Service Connection For Posttraumatic Stress Disorder (PTSD) Secondary To Personal Trauma," that her in-service stressors related to several enemy Scud missile attacks during the Persian Gulf War. No information concerning an alleged in-service personal assault was provided on this form. Although the RO concluded that the M21-MR provisions concerning personal assault PTSD claims were applicable in this case, and although it appears that the RO complied with the required development outlined in the M21-MR provisions governing personal assault PTSD claims in this case, the Board finds that the Veteran's service connection claim for PTSD should be analyzed under the relaxed evidentiary standards for verification of in-service stressors found in the revised § 3.304(f) rather than under the M21-MR provisions governing personal assault PTSD claims. See 38 C.F.R. § 3.304(f) (effective July 13, 2010). See also M21-1MR, Part III, Subpart iv, Chapter 4, Section H30. On July 13, 2010, VA published a final rule that amended its adjudication regulations governing service connection for PTSD by relaxing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. 75 Fed. Reg. 39843 (July 13, 2010) as amended by 75 Fed. Reg. 41092 (July 15, 2010) (providing the correct effective date of July 13, 2010 for the revised 38 C.F.R. § 3.304(f)). Specifically, the final rule amends 38 C.F.R. § 3.304(f) by redesignating current paragraphs (f)(3) and (f)(4) as paragraphs (f)(4) and (f)(5), respectively, and by adding a new paragraph (f)(3) that reads as follows: (f)(3) If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See 75 Fed. Reg. 39843 (July 13, 2010) as amended by 75 Fed. Reg. 41092 (July 15, 2010) (providing the correct effective date of July 13, 2010 for the revised 38 C.F.R. § 3.304(f)). The revised § 3.304(f) applies to claims of service connection for PTSD that were appealed to the Board before July 13, 2010, but have not been decided by the Board as of July 13, 2010. Because the Veteran's appeal for service connection for PTSD was pending at the Board before July 13, 2010, the Board finds that the revised 38 C.F.R. § 3.304(f) is applicable to the Veteran's claim. See 38 C.F.R. § 3.304(f) (effective July 13, 2010). Service connection also may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). See Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition also is compensable under 38 C.F.R. § 3.310(a). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. The Board finds that the evidence supports granting the Veteran's claim of service connection for PTSD. The Veteran's service treatment records do not show that she was diagnosed as having PTSD at any time during active service. The Veteran has contended that she was in combat while on active service in the Persian Gulf War. The Veteran's DD Form 214 shows that she served in Operation Desert Shield/Desert Storm from November 26, 1990, through May 15, 1991, and her military occupational specialty (MOS) was hospital administration. The Board acknowledges that, in April 2005, the National Personnel Records Center in St. Louis, Missouri (NPRC) informed VA that the Veteran's service personnel records from her period of active service in the U.S. Air Force, including in the Persian Gulf War, were missing. The Veteran has contended that her in-service stressors include witnessing Scud missile attacks at the King Khalid International Airport in Riyadh, Saudi Arabia, while she was on active service. The Veteran specifically reported on an October 2009 VA Form 21-0781a that, in January 1991 while she was assigned to the 1611th Aeromedical Evacuation Support Group at the King Khalid International Airport in Riyadh, Saudi Arabia, several Scud missiles were fired directly over the staging area of one of the medical aeromedical facilities where she worked. After patients were unloaded from an inbound C-130 aircraft, the alarm sounded for a Scud missile attack and the Veteran was required to take cover. A Patriot missile was fired and intercepted the Scud missile over the flight line. The Veteran stated, " The earth shook as it was going to open up, the building that we were secure in shook and swayed a little[,] and glass [was] heard cracking, [with] people yelling and screaming, including me." Later in January 1991, the Veteran stated that the alarm sounded for another Scud missile attack while she was taking a shower and she had to take cover immediately until another Patriot missile intercepted the incoming Scud missile. She also testified credibly regarding these in-service stressors at her October 2010 Board hearing. Given the foregoing, and although the Veteran's service personnel records do not show that she received any combat awards or citations during active service, the Board finds that the Veteran's reported in-service stressors are consistent with the facts and circumstances of her active service in the Persian Gulf War and persuasively suggest that she saw combat during this period of service. See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The Board also finds that the Veteran's reported in-service stressors clearly include fear of hostile military activity. See 38 C.F.R. § 3.304(f) (effective July 13, 2010). The competent evidence also contains a diagnosis of PTSD based on the Veteran's reported in-service stressors from her active combat service in the Persian Gulf War. In a May 2004 letter, a Vet Center Readjustment Counseling Specialist stated that the Veteran had been seen initially at the Vet Center in July 1992 "shortly after she returned from serving in Operation Desert Storm." This counselor also stated that the Veteran had begun regular treatment in December 2003 for PTSD "resulting from her experiences in Operation Desert Storm." It was noted that the Veteran had presented with "isolation, depression, intrusive thoughts, retarded social skills, hypervigilance, poor sleep patterns[,] and poor anger control." The Veteran also had been diagnosed as having chronic and severe PTSD. In an outpatient treatment note dated in August 2004 and included in the Veteran's VA outpatient treatment records, her VA treating psychiatrist stated that, based on an outpatient treatment visit in January 2004, the Veteran had been diagnosed as having PTSD "related to her service in Desert Storm combat operation[s]." On VA outpatient treatment in August 2006, the Veteran's complaints included anxiety, an inability to control her emotions, and claustrophobia. She reported that she was feeling emotional after the deaths of some relatives. She denied feeling depressed, hopeless, helpless, or worthless. She also denied any suicidal or homicidal ideation. Her panic attacks were stable. The Veteran's Global Assessment of Functioning (GAF) score was 49, indicating serious symptoms or any serious impairment in social, occupational, or school functioning. The assessment included chronic PTSD. On VA examination in June 2010, the Veteran complained of PTSD. The VA examiner reviewed the Veteran's claims file, including her service treatment records and post-service VA treatment records. The Veteran denied experiencing any sexual abuse prior to active service. She reported that her in-service duties in the U.S. Air Force included coordinating airlifts of medical patients. She also reported having combat experience while serving from January to March 1991 in the Persian Gulf War. She was close to her family and friends although she never married and had no children. She rarely socialized and remained isolative watching television at home. Mental status examination of the Veteran showed she was clean and casually dressed with unremarkable psychomotor activity and speech, an inability to complete serial 7's, and inability to spell a word backwards, full orientation, unremarkable thought process and content, no delusions, hallucinations, obsessive/ritualistic behavior, suicidal or homicidal ideation, and severe panic attacks a few times a week which lasted for 30 minutes. There was good impulse control and no episodes of violence or problems with activities of daily living. The Veteran described her in-service stressor as witnessing a Scud missile explode overhead. She also stated that her PTSD symptoms were daily and moderate to severe in intensity. The VA examiner opined that the Veteran's PTSD most likely was caused by or a result of her in-service combat exposure due to being one of the few females being in a war zone and actually being fired upon by the enemy. The diagnosis was chronic PTSD. The evidence shows that the Veteran was in combat in the Persian Gulf War. She has reported that her in-service stressors, including the fear of hostile military activity, were related to her active combat service in the Persian Gulf War. The competent evidence also shows that the Veteran has been diagnosed as having PTSD and she reported her in-service stressors, including the fear of hostile military activity, to the VA examiners who rendered this diagnosis. In summary, after resolving all reasonable doubt in the Veteran's favor, and especially in light of the relaxed evidentiary standards for PTSD claims found in the revised 38 C.F.R. § 3.304(f), the Board finds that the evidence supports granting service connection for PTSD. The Board also finds that the evidence supports granting the Veteran's claim of service connection for an acquired psychiatric disability other than PTSD, to include depression, panic disorder, mood disorder, and obsessive compulsive disorder, as secondary to her service-connected PTSD. The Veteran does not contend, and the competent evidence does not show, that she incurred an acquired psychiatric disability, to include depression, panic disorder, mood disorder, and obsessive compulsive disorder during active service. Nor does she contend that her current acquired psychiatric disability is related directly to active service or any incident of service. See 38 C.F.R. §§ 3.303, 3.304. The Veteran has contended instead that her service-connected PTSD caused or aggravated (permanently worsened) her acquired psychiatric disability (variously diagnosed as depression, panic disorder, mood disorder, and obsessive compulsive disorder) and she is entitled to service connection on a secondary service connection basis. See 38 C.F.R. § 3.310. The Board already has found that service connection is warranted for the Veteran's PTSD. The competent evidence (in this case, the Veteran's VA outpatient treatment records) shows that the Veteran has been diagnosed as having and treated as an outpatient for a variety of acquired psychiatric disabilities (variously diagnosed as depression, panic disorder, mood disorder, and obsessive compulsive disorder) since her service separation. The competent evidence also shows that the Veteran's service-connected PTSD caused or aggravated (permanently worsened) her acquired psychiatric disability. For example, on VA outpatient treatment with her VA treating psychiatrist in January 2009, the Veteran's complaints included irritability, crying spells after nightmares 2-3 times per week, checking doors and windows every night, and feeling angry at times. She denied any suicidal or homicidal ideation or plan. Mental status examination of the Veteran showed no psychomotor agitation or retardation, a clean appearance, coherent and goal-oriented speech, no suicidal or homicidal ideation, no "voices" or delusions, and full orientation. The diagnoses included panic disorder related to PTSD, depression, not otherwise specified, related to PTSD, and obsessive compulsive disorder related to PTSD. There is no competent contrary opinion of record. In summary, after resolving all reasonable doubt in the Veteran's favor, the Board finds that the evidence supports granting service connection for an acquired psychiatric disability other than PTSD, to include depression, panic disorder, mood disorder, and obsessive compulsive disorder, as secondary to service-connected PTSD. Id. ORDER Entitlement to service connection for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to service connection for an acquired psychiatric disability other than PTSD, to include depression, panic disorder, mood disorder, and obsessive compulsive disorder, as secondary to service-connected PTSD, is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND The Veteran also has contended that she incurred a respiratory disability (which she characterized as sinusitis and allergic rhinitis) during active service. She specifically contends that in-service exposure to fumes from burning oil wells and desert dust while serving in the southwest Asia theater of operations during the Persian Gulf War caused her current respiratory disability. As noted above, the Veteran's service personnel records clearly show that she had active service in the southwest Asia theater of operations during the Persian Gulf War. The Veteran testified credibly as to the continuity of her respiratory symptomatology since active service at her Board hearing in October 2010. A review of the claims file also shows that she was treated for sinusitis/allergic rhinitis during active service and since her service separation, including in October 2010 at Bayfront Medical Center. The Board notes that, because VA's duty to assist under the VCAA includes obtaining an examination or medical opinion when necessary, and because the Veteran has not been provided with a VA examination which addresses the contended causal relationship between a respiratory disability and active service, on remand, she should be scheduled for appropriate examination(s). 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) ; McLendon v. Nicholson, 20 Vet. App. 79 (2006). The RO/AMC also should attempt to obtain the Veteran's up-to-date VA and private treatment records. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and/or her service representative and ask them to identify all VA and non-VA clinicians who have treated her for a respiratory disability since her separation from active service. Obtain all VA treatment records which have not been obtained already. Once signed releases are received from the Veteran, obtain all private treatment records which have not been obtained already. A copy of any records obtained, to include a negative reply, should be included in the claims file. 2. Schedule the Veteran for appropriate examination(s) to determine the current nature and etiology of her respiratory disability. The claims file and a copy of this remand must be made available to the examiner in conjunction with the examination. All appropriate tests and studies should be accomplished. Based on a review of the Veteran's claims file and the results of her physical examination, the examiner(s) is asked to opine whether it is at least as likely or not (i.e., a 50 percent or greater probability) that any current respiratory disability, if diagnosed, is related to active service or any incident of service, to include in-service treatment for sinusitis/allergic rhinitis. A complete rationale must be provided for any opinions expressed. 3. Thereafter, readjudicate the Veteran's claim of service connection for a respiratory disability. If the benefits sought on appeal remain denied, the Veteran and her service representative should be provided a supplemental statement of the case. An appropriate period of time should be allowed for response. 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. 2010). ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs