Citation Nr: 1303433 Decision Date: 01/31/13 Archive Date: 02/05/13 DOCKET NO. 11-17 853 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for carpal tunnel syndrome. 2. Entitlement to service connection for a back disability. 3. Entitlement to service connection for a gynecological disability, to include anemia. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD G. E. Wilkerson, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1985 to April 1991. These matters come before the Board of Veterans' Appeals (Board) from a September 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. In October 2011, the Veteran testified at a hearing before the undersigned Veterans Law Judge in Washington, D.C.; a transcript of the hearing is of record. The Board remanded the claims to the RO, via the Appeals Management Center (AMC), in January 2012, for additional development. For the reasons stated below, the RO/AMC complied with the Board's remand instructions with respect to the claims for service connection for carpal tunnel syndrome and back disability. Stegall v. West, 11 Vet. App. 268, 271 (1998). In a December 2012 rating decision, the AMC granted service connection for depressive disorder, not otherwise specified. As this represents a full grant of a benefit previously sought on appeal, it is no longer before the Board. A review of the Veteran's Virtual VA electronic claims file reveals outstanding VA outpatient treatment records from the Baltimore VA Medical Center, to include the Glen Burnie Clinic. As these records have been considered by the RO-as noted in the December 2012 supplemental statement of the case-remand for initial consideration of these records is not warranted. In a statement dated in January 2013, the Veteran indicated that her heart problems, including high blood pressure and a heart murmur, began in service. The Board notes that service connection for heart murmur was denied in the September 2010 rating decision, but the Veteran did not appeal this issue. Service connection for a heart disability is not otherwise before the Board. As such, this matter is referred to the RO for development. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to service connection for gynecological disability, to include anemia, is addressed in the REMAND portion of the decision below and is again REMANDED to the RO via the AMC, in Washington, DC. FINDINGS OF FACT 1. The Veteran's carpal tunnel syndrome did not manifest in service and is unrelated to service. 2. The Veteran's current back disability did not manifest in service, within the one year of service, and is unrelated to service, to include the November 1986 assessment of lumbosacral strain. CONCLUSIONS OF LAW 1. Carpal tunnel syndrome was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. A back disability was not incurred in or aggravated by service and arthritis may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a Mach 2010 pre-rating letter, the RO notified the Veteran of the evidence needed to substantiate the claim for entitlement to service connection for carpal tunnel syndrome and a back disability. Additionally, the March 2010 letter provided her with the general criteria for the assignment of an effective date and initial rating. Id. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate her claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to her claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, VA obtained the Veteran's service treatment records (STRs) and all of the identified post-service private and VA treatment records. Pursuant to the Board's January 2012 remand instructions, the RO/AMC requested from the Baltimore VA Medical Center and Glen Burnie Clinic, and copies of these records are associated with the Veteran's electronic claims file. In addition, the Veteran was afforded VA examinations in February 2012, October 2012, and December 2012 to determine the etiology of the claimed back disability and carpal tunnel syndrome, as instructed in the Board's January 2012 remand. The examiner provided the requested opinions thus complied with the Board's remand instructions in this regard as well. Stegall, 11 Vet. App. at 271. The Board has considered the Veteran's January 2013 statement to the effect that the December 2012 VA neurology examination was inadequate because the examination was less than one hour and the examiner "looked like an intern," and "did not seem to know what he was doing at all." A review of the December 2012 examination report reflects that the examiner was the attending physician in neurology services, and not an intern. Moreover, the report reflects that the examiner conducted a complete physical and neurological examination and provided a diagnosis rationale for all opinions. Therefore, the Board finds this examination adequate for adjudication purposes. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The claims for entitlement to service connection for carpal tunnel syndrome and back disability are thus ready to be considered on the merits. II. Analysis The Veteran seeks service connection for carpal tunnel syndrome and a back disability. As an initial matter, the Board notes that the Veteran did not engage in combat with the enemy. Therefore, the combat provisions of 38 U.S.C.A. § 1154 (West 2002) are not applicable. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A claimant can establish continuity of symptomatology with competent evidence showing: (1) that a condition was "noted" during service; (2) post-service continuity of the same symptomatology; and (3) a nexus between a current disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-96 (1997); 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease first 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 addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101(3), 1112(a)(1); 38 C.F.R. §§ 3.307(a), 3.309(a). A. Carpal Tunnel Syndrome The Veteran contends that she is entitled to service connection for carpal tunnel syndrome, as she believes that this disability had its onset in service. The Veteran's service treatment records do not reflect any complaint, treatment, or diagnosis with respect to the claimed carpal tunnel syndrome. There were no abnormalities with respect to this claimed disability noted on the Veteran's March 1991 discharge examination. The upper extremities and the neurologic systems were normal. She denied a history of neuritis and paralysis. Post service, a November 2010 VA outpatient treatment report reflects that the Veteran complained of bilateral wrist pain and shaking. She was issued wrist splints. In a December 2010 statement, the Veteran's friend, D. S. indicated that she served with the Veteran with the Personnel Support Detachment in Philadelphia. She noted that, during service, the Veteran complained of pain in both wrists and indicated that her wrists would shake and stiffen without warning. She reported that the Veteran's duties required her to type about 6 to 7 hours per day. The Veteran's mother also submitted a statement in December 2010 noting that the Veteran had discussed her carpal tunnel syndrome since 1991. On VA treatment in January 2011, symptoms of numbness, shaking, and pain at the wrists were indicated. The Veteran underwent nerve conduction and EMG studies, and was diagnosed with mild carpal tunnel syndrome. During the Veteran's October 2011 Board hearing, she testified that she worked in personnel during service and her duties consisted of frequent typing. She reported that she experienced cramping of the hands, numbness, and shaking during service. She indicated that these symptoms continued following her discharge from service, leading to her eventual diagnosis in 2010. On VA examination in February 2012, the Veteran reported that she had difficulty during service and since service related to pain after repetitive motion of the hand and wrist. After physical examination, the examiner, a nurse practitioner, diagnosed carpal tunnel syndrome. She noted that she reviewed the Veteran's claims file, and opined that the Veteran's carpal tunnel syndrome is at least as likely as not related to or caused by service. She noted that, during service, the Veteran's duties included clerical work, and while deployed she worked on the dock line drove speed boats, and worked the tug boat assisting with line handling. The examiner pointed out that this type of manual labor consistently required the use of hands and wrists to complete the duties. After years of this constant pulling and strain on the hands and wrists, a normal progression would be to have pain in the wrist and hands. On VA neurology examination in December 2012, the Veteran reported that her current symptoms included numbness and pain in her forearms without much involvement of the hands or wrists. She stated that she experienced symptoms of aching in the wrist since 1990. After physical and neurological examination, the examiner diagnosed carpal tunnel syndrome. The examiner, the neurology service attending physician, indicated that he reviewed the entire claims file, including service treatment records and post service records. He noted that the Veteran complained of wrist symptoms since 1990 and there were attestations in the claims file that she had these complaints in service. The examiner pointed out that after the Veteran was discharged in 1991, she sought part-time work including housekeeping and clerical work that included repetitive wrist movements. From 2000 to 2010 she was employed doing a significant amount of computer work. The Veteran also reported that her symptoms became very problematic 5 years prior to examination and she first sought medical care for these complaints in 2011. Her examination showed no evidence of severe or advanced carpal tunnel, with no wasting and no Phalens or Tinnels signs. She demonstrated weakness in the left hand on initial exam, but on encouragement or with distraction, the best-effort strength was normal in almost all muscle groups. The electrodiagnostic studies confirmed median nerve slowing consistent with carpal tunnel syndrome. However, the examiner found it less likely than not that this was a service-related condition. The examiner noted that this conclusion was supported that the Veteran's attestations that she not seek attention for her condition until 2011. Moreover, she continued to work with her hands in a similar capacity as during her military service, for almost 20 years. The record reflects a current diagnosis of carpal tunnel syndrome. However, given the evidence outlined above, the Board finds that the weight of the evidence is against the claims for service connection for carpal tunnel syndrome. The Board acknowledges that there are competing opinions with respect to whether the Veteran's current carpal tunnel syndrome is related to service. While the February 2012 examiner opined that such a relationship was likely, the December 2012 VA examiner found it less likely than not that the Veteran's current carpal tunnel syndrome is related to service. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Board finds that the December 2012 VA examiner's opinion is more probative. In so finding, the Board points out that the December 2012 is supported by medical rationale-such as the fact that the Veteran's carpal tunnel is not advanced-and is consistent with the medical evidence of record. Unlike the December 2012 examiner, the February 2012 VA examiner failed to address relevant the Veteran's pertinent work history following service, her report of onset of treatment of the disability, and the number of years between the Veteran's alleged onset and the first indication of treatment and diagnosis. Furthermore, the Board points out that the December 2012 VA examiner is a physician who specializes in neurology, whereas the February 2012 examiner is a nurse practitioner. Although both are competent to render medical opinions, a physician has more medical training and expertise. Thus, the most persuasive opinion on the question of whether there exists a medical nexus between the Veteran's current carpal tunnel syndrome and service weighs against the claim. The Board has also considered the Veteran's written statements and hearing testimony, as well as those statements from her mother and from D. S., to the effect that her carpal tunnel syndrome first manifest in service with symptoms of wrist pain and stiffness, and that she has experienced these symptoms continuously since service. The Veteran is competent to testify as to her observations, but this testimony must be weighed against the other evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). In this case, her statements as to continuity of symptomatology are outweighed by the other evidence of record. The separation examination report was normal with regard to the hand and wrists, and the neurologic evaluation was normal. Normal findings are not consistent with her report of an in-service abnormality. In addition, there were no complaints with regard to the hand or wrists in service or for many years thereafter. Rather, at separation she denied a pertinent history to include neuritis, paralysis, and painful joints. When the Veteran initially sought treatment in 2010, she did not express continuous problems wrist or hand symptoms service. To the extent that the Veteran advances her own interpretation of her medical condition indicating that her current carpal tunnel syndrome is related to the alleged in service manifestations of wrist symptoms, the Board acknowledges that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau). In any event, the probative value of the Veteran's general assertions in this regard is outweighed by the probative value of the specific, reasoned opinion of the physician who performed the December 2012 VA examination. Furthermore, we find the lay evidence, to include that of her friend and a family member, to be inconsistent with her own report at separation and the normal findings at separation. Such lay evidence is not credible. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for carpal tunnel syndrome. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). B. Back Disability The Veteran likewise contends that she is entitled to service connection for a back disability, as she believes that this disability originated during her active duty service. The Veteran's service treatment records reflect that she sought treatment for back complaints in November 1986. There was mild to moderate tenderness and spasm in the right lumbosacral region without radicular pain. She was assessed with lumbosacral strain and place on limited duty. It was also noted that the Veteran was 5 months pregnant at the time with a due date in March 1987. Outside of a complaint of low back and abdominal pain associated with gynecological symptoms in May 1989, there is no other indication in the record of complaint or treatment with respect to the back. There were no abnormalities related to the claimed disability found on March 1991 discharge examination. The spine was normal and she denied a history of recurrent back pain. Following service, a December 2009 radiology report reflects an impression of L4-5 discal space narrowing. IT was noted that there was a 1 year history of back pain and no trauma. A December 2009 treatment report from private physician Dr. P. reflects a complaint of lower back pains. A March 2010 report reflects that the Veteran went to physical therapy and her back condition was improving. Physical therapy treatment reports dated in March and April 2010 reflect an assessment of lumbar muscle strain. She did not report a specific injury to the lumbar region, but indicated that she spent a lot of time on her feet and had experienced past discomfort in the lumbar region. Onset of current symptoms was within the previous 3 three months, but was noted to be an exacerbation of a pre-existing injury, though the previous injury was not identified. In a December 2010 statement, the Veteran's friend, D.S., indicated that the Veteran complained of back pain while they served together at the Personnel Support Detachment Center in Philadelphia. The Veteran's mother also submitted a statement indicating that the Veteran had complained of low back pain since 1991. During the Veteran's December 2011 Board hearing, she testified that she had experienced back pain since service and continuously since service. She reported that the pain was subtle at first, but progressed into more severe pain. She reported that she was a boatswain mate right after her enlistment, which required a lot of heavy lifting. On VA examination in February 2012, the Veteran reported that she experienced a number of episodes of back pain in service, but she did not report the condition. The examiner indicated that mild to moderate tenderness and spasm of the right lumbosacral region was noted in service in November 1986. After physical examination, the examiner diagnosed lumbosacral strain. The examiner, a nurse practitioner, indicated that she reviewed the Veteran's claims file. She determined that the Veteran's current back condition is at least as likely as not related to the back condition in service. She noted that, once the lumbosacral area is affected, there are usually long-term residual effects. The affects may not be felt for many years, however the pain can return usually affected the same site as the initial indicated. The examiner noted that, while the Veteran was deployed, she worked on docks line handling, drove speed boats, and worked the tug boat in assisting with line handling. She found that this type of manual labor consistently put a strain on the low back and a normal progression would be to have residuals of back strain long term. On VA examination in October 2012, the Veteran reported that she was a boatswain mate and also worked in personnel during service. She stated that she experienced back pain while pulling some rope in November 1986. Following physical examination, the examiner diagnosed lumbosacral strain. An x-ray of the lumbosacral spine was normal. The examiner, a physician, determined that the Veteran current low back discomfort is not caused by or a result of military service. She noted that there is no medical nexus to establish causality between the current complaints and service. Although there is a record of treatment in service for lumbosacral strain, she noted that there was no permanent residual or chronic disability subject to service connection shown by the service medical records or demonstrated by evidence following service. She noted that the Veteran was treated in November 1986 for lumbosacral strain and was 5 months pregnant at the time, and she gave birth in March 1987. These treatment records reflect that she was treated with moist heat and instructed to return after delivery in March 1987. There is no other record of back treatment in service. She worked for 17 years following service. The record reflects a current diagnosis of back disability, characterized as lumbosacral strain. However, given the evidence outlined above, the Board finds that the weight of the evidence is against the claims for service connection for a back disability. The Board acknowledges that there are competing opinions with respect to whether the Veteran's current back disability is related to service. While the February 2012 examiner opined that such a relationship was likely, the October 2012 VA examiner found it less likely than not that the Veteran's current back complaints are related to service. As noted above, when reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens, 7 Vet. App. at 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert, 5 Vet. App. at 30; see also Colvin, 1 Vet. App. at 171. In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens, 11 Vet. App. at 382. Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean, 13 Vet. App. at 448-49. A medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez, 22 Vet. App. at 304. In this case, the Board finds that the October 2012 VA examiner's opinion is more probative. In so finding, the Board points out that the October 2012 opinion is supported by medical rationale and is consistent with the medical evidence of record. The October 2012 VA examiner based her opinion on the entirety of the Veteran's service treatment records as well as post-service treatment records. Unlike the December 2012 examiner, the February 2012 VA examiner failed to address relevant points including the Veteran's pregnancy at the time of initial complaint and the lack of findings with respect to the back in service after the pregnancy, and the number of years between the Veteran's alleged onset and the first indication of treatment and diagnosis in 2009. Furthermore, the Board points out that the December 2012 VA examiner is a physician, whereas the February 2012 examiner is a nurse practitioner. Although both are competent to render medical opinions, a physician has more medical training and expertise. Thus, the most persuasive opinion on the question of whether there exists a medical nexus between the Veteran's current back disability and service weighs against the claim. The Board has also considered the Veteran's written statements and hearing testimony, as well as those statements from her mother and from D. S., to the effect that her back problems first manifest in service with symptoms of back pain, and that she has experience these symptoms continuously since service. The Veteran is competent to testify as to her observations, but this testimony must be weighed against the other evidence of record. See Jandreau, 492 F.3d at 1376-77; Buchanan, 451 F.3d at 1336. In this case, the Board finds the other evidence of record more probative. The separation examination report was normal with regard to the back, and there were no complaints with regard to the back outside of the November 1986 report in service or for many years thereafter. In fact, the spine was normal at separation and she denied a pertinent history at that time. When the Veteran initially sought treatment in 2009, she did not express continuous back symptoms service or indicate prior injury in service. Rather, she reported a 1 year history of back pain rather than a history dating to service. To the extent that the Veteran advances her own interpretation of her medical condition indicating that her current back symptoms are related to the alleged in service complaints, the probative value of the Veteran's general assertions in this regard is outweighed by the probative value of the specific, reasoned opinion of the physician who performed the October 2012 VA examination. To the extent that she and the lay informants attempt to report continuity, such lay evidence is inconsistent with the service treatment records, the normal findings at separation, and her denial of pertinent pathology at separation. She and the lay informants are not credible. We find her contemporaneous in-service statements to be more credible than the lay evidence advanced in support of a claim for monetary benefits. The above evidence also reflects that there was neither a diagnosis of arthritis within the one year appeal period or symptoms that were early manifestations of arthritis. See 38 C.F.R. § 3.307(c); Traut v. Brown, 6 Vet. App. 495 (1994) (establishing service connection on a presumptive basis does not require that a chronic disease be diagnosed within the applicable time period; rather, symptoms that manifest within this time period may subsequently be determined to have been early manifestations of a chronic disease). Therefore, entitlement to service connection for a back disability is not warranted on a presumptive basis. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for a back disability. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Fagan, 573 F.3d at 1287. ORDER Entitlement to service connection for carpal tunnel syndrome is denied. Entitlement to service connection for a back disability is denied. REMAND The Veteran contends that she is entitled to service connection for a gynecological disability, to include anemia, as she believes that this disability had its onset in service. In the January 2012 remand, the Board instructed that the Veteran be afforded an examination to determine the etiology of any current gynecological disabilities, to include anemia. The examiner was asked to address whether it is at least as likely as not that such disability is related to service, to include in-service gynecological symptoms. The Veteran was subsequently afforded an examination in February 2012. At that time, the examiner noted that there were no current gynecological diagnoses following the Veteran's November 2009 hysterectomy. Even though she found no evidence of a current gynecological disability, she opined that "these conditions" are at least as like as not related to or caused by the in-service gynecological conditions. The examiner also indicated that the Veteran had a current diagnosis of anemia, and referenced VA blood screening results dated in June 2011 as supportive of the diagnosis. However, the examiner did not address whether the Veteran's anemia is related to service. Moreover, it is unclear as to whether February 2012 examiner, in noting that "these conditions" are related to service, meant that the November 2009 hysterectomy was due to disease incurred in or aggravated by active military service. For all the foregoing reasons, the Board finds that the February 2012 examination is inadequate. Accordingly, the Board finds that the claim must be remanded for a new VA examination and clinical opinion as to the nature and etiology of the Veteran's current gynecological disability, to specifically include anemia. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). Expedited handling is requested.) 1. The AOJ should arrange for the Veteran to undergo examination by a qualified examiner. The entire claims file should be made available to the examiner designated to examine the Veteran. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should clearly identify all current gynecological disabilities, to include anemia. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that a current gynecological disability, to include the November 2009 hysterectomy and anemia, was incurred in service or is otherwise medically related to service. In providing the requested opinion, the examiner is asked to consider and address the Veteran's contentions as to onset of gynecological disability and anemia in service. The examiner should set forth all examination findings, along with the complete rationale for any conclusions reached. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should clearly so state, and the reasons and bases for the inability to provide the opinion must be included in the examination report. 2. Then, the AOJ should readjudicate the Veteran's claims. If the benefits sought on appeal are not granted, the Veteran and her representative should be provided a Supplemental Statement of the Case and afforded the requisite opportunity to respond before the case is returned to the Board. 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. 2012). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs