Citation Nr: 1308983 Decision Date: 03/18/13 Archive Date: 03/25/13 DOCKET NO. 09-47 864 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder to include major depressive disorder and PTSD. 2. Entitlement to an initial compensable disability rating for service-connected gastroesophageal reflux disease (GERD) prior to March 26, 2012. 3. Entitlement to an initial disability rating in excess of 10 percent for service-connected GERD as of March 26, 2102. 4. Entitlement to an initial compensable disability rating for service-connected stress headaches. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD B. Berry, Counsel INTRODUCTION The Veteran served on active duty from November 2001 to August 2007. These matters come to the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in August 2007 by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran indicated in the December 2009 substantive appeal that she wanted a travel Board hearing. The Veteran informed VA in a written statement dated in January2010 that she requested a local hearing with a Decision Review Officer (DRO) instead of a travel Board hearing. Thereafter, the Veteran withdrew her requested for the DRO hearing in a March 2012 written statement. Therefore, the requests for a hearing is deemed withdrawn. See 38 C.F.R. § 20.704(d), (e) (2012). The Board observes that the Veteran specifically filed a claim for service connection for insomnia/depression. The United States Court of Appeals for Veterans Claims (Court) has held that when a claimant identifies a mental health disability without more, it cannot be considered a claim limited only to that diagnosis, but rather must be considered a claim for any mental disability that may reasonably be encompassed by several factors including the claimant's description of the claim, the symptoms the claimant describes, and the information the claimant submits or that VA obtains in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In this case, the Veteran has also been diagnosed with PTSD. Based on the Veteran's description of her symptoms it appears that her claim would also include the diagnosis of PTSD. As such, the Board has re-characterized the issue as entitlement to an acquired psychiatric disorder, as shown on the title page of this decision. The issue of entitlement to an increased rating for stress headaches 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. FINDINGS OF FACT 1. The competent and credible evidence establishes that the Veteran has been diagnosed with PTSD by a VA psychologist and that such diagnosis is due to a stressor that is based on "fear of hostile military or terrorist activity" while serving in Iraq between October 2006 and May 2007. 2. The evidence of record indicates that the Veteran's GERD is characterized by abdominal and chest pain, heartburn, regurgitation, nausea and vomiting throughout the appeal period with no evidence of dysphagia, material weight loss, hematemesis or melena with moderate anemia indicating considerable or severe impairment of health. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are met. 38 U.S.C.A. §§ 1110, 1154 (b), 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. The criteria for a 10 percent disability rating, and no higher, for service-connected GERD prior to March 26, 2012 have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1-4.14, 4.114, Diagnostic Code 7346 (2012). 3. The criteria for a disability rating in excess of 10 percent for service-connected GERD as of March 26, 2012 have not been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1-4.14, 4.114, Diagnostic Code 7346 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA) imposes a duty on the United States Department of Veterans Affairs (VA) to notify and assist a claimant in developing a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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 and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). With respect to the Veteran's service connection claim for a psychiatric disorder, the Board is granting in full the benefit sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. Regarding the Veteran's increased rating claim, she is appealing the initial disability rating assignment as to GERD. The August 2007 rating decision granted the Veteran's claim of entitlement to service connection and therefore, such claim is now substantiated. Her filing of a notice of disagreement as to the initial rating assigned in the August 2007 determination does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3). Rather, the Veteran's appeal as to the initial rating assignment here triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. Under 38 U.S.C.A. § 7105(d), upon receipt of a notice of disagreement in response to a decision on a claim, the agency of original jurisdiction must take development or review action it deems proper under applicable regulations and issue a statement of the case if the action does not resolve the disagreement either by grant of the benefits sought or withdrawal of the notice of disagreement. If VA receives a notice of disagreement in response to notice of its decision on a claim that raises a new issue, section 7105(d) requires VA to take proper action and issue a statement of the case if the disagreement is not resolved; however, section 5103(a) does not require VA to provide notice of the information and evidence necessary to substantiate the newly raised issue. See VAOPGCPREC 8-03 (December 22, 2003); 69 Fed. Reg. 25180 (2004); 38 C.F.R. § 3.159(b)(3) (2012). As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here. The October 2009 statement of the case, under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," set forth the relevant diagnostic code for rating hiatal hernia, and included a description of the rating formula for all possible schedular ratings under this diagnostic code. Therefore, the Veteran was informed of what was needed not only to achieve the next-higher schedular ratings, but also to obtain all schedular ratings above the initial evaluation that the RO assigned. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve a higher rating for the service-connected disability on appeal. Regarding VA's duty to assist, the Board finds that VA has fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the Veteran's claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The claims file contains the Veteran's service treatment records, lay statements from the Veteran and VA examination reports dated in July 2007 and March 2012. The July 2007 and March 2012 VA examination report reflects that the examiner conducted a review of the Veteran's claims file in addition to obtaining an oral history and an evaluation of the Veteran with respect to symptoms of her GERD. The examiners documented in detail the claimed symptoms. The March 2012 examiner discussed the effect those symptoms have on her occupational functioning. Accordingly, the Board concludes that the examinations are adequate for rating purposes. Additionally, the claims file contains the Veteran's statements in support of her claim. The Veteran has not identified, and the record does not otherwise indicate, any existing, pertinent evidence, such as current treatment records, that have not been obtained. The record also presents no basis for further development to create any additional evidence to be considered in connection with the matter currently under consideration. Under these circumstances, the Board finds that the Veteran is not prejudiced by appellate consideration of the claim on appeal at this juncture, without directing or accomplishing any additional notification and/or development action. II. Merits of the Claim for Service Connection The Veteran contends that she has insomnia and depression due to her military service. See September 2008 notice of disagreement. She notes that ever since she returned from Iraq she has experienced difficulty sleeping and nightmares. Her nightmares consist of watching bombs being dropped in Iraq and playing dead as Iraqis with guns search for people who are still alive. Service connection for PTSD requires medical evidence establishing a diagnosis of the disorder, credible supporting evidence that the claimed in-service stressor(s) occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor(s). 38 C.F.R. § 3.304(f) (2012). With regard to the second PTSD element as set forth in 38 C.F.R. § 3.304(f), evidence of an in-service stressor, the evidence necessary to establish the claimed stressor varies depending on the circumstances of the stressor and the nature of a veteran's service. If the evidence establishes that a 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 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(f)(2) (2012). Additionally, if a stressor claimed by a veteran is related to the veteran's "fear of hostile military or terrorist activity" and a VA or VA-contracted psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor so long as there is not 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. 38 C.F.R. § 3.304(f)(3). For purposes of this section, "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,..., and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror." Id. The Veteran's DD Form 214 and service treatment records show that the Veteran served on active duty from November 2001 to August 2007 with service with the A company 27th Brigade Support Battalion in Iraq as part of Operation Iraqi Freedom from October 2006 to May 2007. The records reveal that her military occupational specialty (MOS) during this period was an ammunition specialist. While none of the evidence of record supports the conclusion that the Veteran directly engaged in combat with the enemy, it does show that she served in Iraq during Operation Iraqi Freedom. The Veteran has also presented lay evidence that she heard constant shooting at night and that she was in fear that the enemy would come over the hill close to her camp and start shooting. The Board finds the reported stressor event, if credible, is consistent with a stressor based on "fear of hostile military activity" as defined above. In the instant case, there is nothing in the record which tends to refute the Veteran's assertion that she served in an area where the enemy was present, thereby placing her and her unit under the threat of fire. Moreover, such circumstances would seem consistent with service in Iraq during an era of conflict. Absent clear and convincing evidence to the contrary, the Board finds the Veteran's lay assertion regarding fearing for her life to be credible. Given that the Veteran's stressor is based on "fear of hostile military or terrorist activity," the critical remaining element of this PTSD claim is whether she has been diagnosed with PTSD by a VA or VA-contracted psychiatrist or psychologist based on this stressor. In this regard, the Veteran was evaluated by a VA psychologist in March 2012 for mental health disorders other than PTSD. The examiner determined that the Veteran is experiencing symptoms consistent with a diagnosis of PTSD. The examiner also provided the opinion that the Veteran's symptoms of depression are secondary to her PTSD and the Veteran's symptoms of PTSD include chronic sleep impairment. The examiner noted that the current examination was for Mental Disorders (other than PTSD) and therefore, that the Veteran should be referred for additional testing for PTSD. Nonetheless, she noted that the Veteran related several stressors to include the following: while her squad accompanied another convoy, the first and second truck was blown up by an IED and she assisted in picking up the remains of the soldiers killed in the explosion; she heard constant shooting at night and she feared that the enemy would come over the hill close to camp and start shooting; and sexual harassment from superiors and fellow noncommissioned officers. The psychologist provided a diagnosis of PTSD due to these military traumas. The examiner also determined that the Veteran's PTSD was at least as likely as not incurred in or caused by the claimed in-service events as the records indicate that her symptoms appeared following her tour of Iraq where she experienced combat conditions. Therefore, the Board finds that the VA psychologist provided the Veteran with a diagnosis of PTSD related to the fact that she had been exposed to a traumatic event while stationed in Iraq, which involved threatened death or threat to the physical integrity of the claimant and threat to the physical integrity of others and the appellant responded with intense fear. Based on the foregoing, the Board concludes that the Veteran has a current diagnosis of PTSD from a VA psychologist. Moreover, this diagnosis is at least in part the result of a stressor that is based on "fear of hostile military activity." Under these circumstances, the Board finds that service connection is warranted for PTSD. The appeal is therefore granted. III. Merits of the Claims for an Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C.A. § 5107(b). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where, as in the instant case, the appeals arise from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Thus, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Id. Disabilities involving the digestive system are evaluated under the regulatory criteria found at 38 C.F.R. §§ 4.110- 4.114 (2012). The Veteran's service-connected GERD has been rated under the provisions of 38 C.F.R. § 4.114, Diagnostic Code 7399-7346. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27 (2012). The additional code is shown after the hyphen. In this case, Diagnostic Code 7399 is used to identify disabilities of the digestive system that are not specifically listed in the schedule, but are rated by analogy to similar disabilities under the schedule. See 38 C.F.R. §§ 4.20, 4.27. The assignment of Diagnostic Code 7346 shows that the Veteran's service-connected GERD is rated as analogous to hiatal hernia. The symptoms of the Veteran's GERD are similar to the symptoms of hiatal hernia. Thus, the Board concludes that the Veteran's GERD is properly rated by analogy under Diagnostic Code 7346. Under Diagnostic Code 7346, a 10 percent evaluation is assigned when there is evidence of two or more of the symptoms for the 30 percent evaluation of less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346. A 30 percent evaluation is assigned when there is evidence of persistently recurrent epigastric distress with dysphasia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. During the pendency of this appeal, the RO increased the disability rating assigned to the Veteran's GERD from noncompensable to 10 percent under Diagnostic Code 7346, effective March 26, 2012. The Board will therefore consider whether the Veteran is entitled to a higher disability rating under both stages of this appeal. Additionally, the Board has considered whether additional staging is appropriate. For reasons discussed in more detail below, the Board finds that the stages created by the RO are not appropriate in light of the lay and medical evidence of record and that the Veteran is entitled to a 10 percent disability rating for the entire appeal period. The Veteran was provided with a general VA examination in July 2007. The Veteran reported that she developed heartburn in 2002. She explained that whenever she ate something spicy, she had problems with heartburn. She was prescribed Aciphex and since then the problems of heartburn have subsided. She has also had relief from heartburn after avoiding spicy food and sweets. The Veteran explained in her September 2008 notice of disagreement that in 2002 she would have chest pains that would not stop until she vomited. She went to the doctor and she was prescribed Aciphex for reflux. She asserted that she still has the same problem with chest pain and vomiting. The Veteran revealed in the December 2009 substantive appeal that her prescription was changed to Prilosec in 2008; however, that did not relieve her problems of chest pains and vomiting. The Veteran was provided with another VA examination in March 2012. The Veteran reported that she has a diagnosis of GERD and it is being treated with Prilosec 20 mg daily. She noted that the Prilosec is not very effective and she continues to have a burning sensation to the epigastric area, regurgitation, nausea and vomiting, approximately three times per week. The examiner noted that the Veteran had recurring episodes of severe symptoms due to her stomach condition with four or more episodes of symptom recurrence per year, which last less than one day. The examiner documented that the Veteran has pronounced abdominal pain that is unrelieved by standard ulcer therapy. She has recurrent nausea and vomiting that occur more than four times per year and that last less than one day. The examiner determined that the Veteran did not have any incapacitating episodes due to signs and symptoms of a stomach condition. The examiner noted that the Veteran had an upper endoscopy in October 2009, which revealed mild hyperemia and gastritis. Based on the evidence of record, the most pertinent of which is discussed above, the Board finds that the Veteran's GERD symptoms most closely approximate a 10 percent disability rating for the entire appeal period. In this regard, the Veteran's GERD is manifested by heartburn, chest pain, reflux, regurgitation, nausea and vomiting. See September 2008 notice of disagreement, December 2009 substantive appeal and March 2012 VA examination. These symptoms occur intermittently, approximately three times a week with each occurrence lasting less than a day. See VA examination dated in March 2012. The frequency of episodes of abdominal/chest pain, nausea and vomiting is more than four episodes a year lasting last than a day. Id. The VA examiner in March 2012 determined that the Veteran did not have any incapacitating episodes due to signs and symptoms of her GERD and it did not impact her ability to work. There is no evidence of dysphagia, material weight loss, hematemesis or melena with moderate anemia and the lay and medical evidence of record do not indicate that the symptoms of GERD result in considerable impairment of health. Accordingly, the overall evidence of record shows that the Veteran's symptoms of GERD result in two or more of the symptoms for the 30 percent evaluation but of less severity. In granting the Veteran a 10 percent disability rating for the entire appeal period, the Board recognizes that there is no medical evidence between July 2007 and March 2012 that shows that the Veteran's symptoms of GERD consisted of two or more of the symptoms listed in the 30 percent evaluation. Nonetheless, the Veteran reported symptoms of chest pain and vomiting in the September 2009 notice of disagreement and the December 2009 substantive appeal. These statements reveal that she has had these symptoms since they first appeared in 2002 and medication did not provide relief from these symptoms. The Veteran did not indicate the frequency or duration of these symptoms; however, this information was obtained in the March 2012 VA examination. The Veteran has consistently reported that her symptoms of GERD include chest pain and vomiting. The Veteran's statements about the symptoms of her condition, such as chest pain and vomiting, are the type of evidence that is within the knowledge and experience of a lay person. See Falzone v. Brown, 8 Vet. App. 398, 405-06 (1995) (lay statements about a person's own observable condition or pain are competent evidence); Layno v. Brown,6 Vet. App. 465, 369-70 (1994) (lay testimony is competent when it regards features or symptoms of injury or illness). The Board also finds the record does not indicate that her statements are not credible. The VA examiner in March 2012 was able to elicit from the Veteran the needed information to fully evaluate the severity and frequency of her symptoms. The symptoms reported and found in the March 2012 VA examination are consistent with the Veteran's prior lay statements. Therefore, in considering all of the evidence of record, the Board concludes that the Veteran's disability picture more closely approximates the 10 percent disability rating for the entire appeal period. According to VA regulation, in exceptional cases where schedular ratings are found to be inadequate, the RO may refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and it is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. In this case, the evidence does not show such an exceptional disability picture that the available schedular evaluation for the service-connected GERD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's GERD with the established criteria found in the rating schedule for hiatal hernia shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. The Board notes that the record reveals that the Veteran's symptoms do not affect her ability to work and there is no evidence of record to suggest that her GERD has caused marked interference with employment that is not already contemplated by the rating criteria. Furthermore, the medical record does not show that the Veteran's GERD has necessitated frequent periods of hospitalization during the appeal period or otherwise rendered impracticable the regular schedular standards for rating such disability. Under these circumstances, and in the absence of factors suggestive of an unusual disability picture, further development in keeping with the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) is not warranted. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). ORDER Service connection for PTSD is granted. An initial disability rating of 10 percent, and not in excess thereof, for service-connected GERD, from August 16, 2007 to March 25, 2012, is granted. Entitlement to an initial disability rating in excess of 10 percent for service-connected GERD since March 26, 2012 is denied. REMAND After a review of the claims file, the Board concludes that a remand for further development of the remaining issue on appeal is necessary. With respect to the Veteran's initial increased rating claim for headaches, the Board observes that the Veteran contends that the VA examiner in March 2012 did not accurately report her symptoms of headaches. Furthermore, the Board finds that the March 2012 VA examination is inadequate for rating purposes. In this regard, the examiner did not describe how the Veteran's daily headaches affect her daily life including her ability to perform her current job as an administrative support assistant. The examiner also did not discuss the symptoms of the Veteran's prostrating headaches versus other headaches of a lesser severity. In this regard, the examiner noted that the Veteran had daily severe stabbing type pain that last up to two to three hours and that she has nausea and vomiting during the headaches. She also indicated that the Veteran gets "fainty." However, she then determined that the Veteran had characteristic prostrating attacks less than once every two months. It is unclear what symptoms on which the examiner used to make the determination that the Veteran had prostrating attacks and the frequency of those attacks. Based on the foregoing, the Board finds that the Veteran should be provided with another VA examination to determine the manifestations and severity of her service-connected stress headaches. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the manifestations and current level of severity of her service-connected stress headaches. The claims file must be made available to and reviewed by the examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests that are deemed necessary for an accurate assessment must be conducted. The examiner must record all pertinent medical complaints, symptoms and clinical findings in detail. Specifically, the examiner must describe in detail the symptoms of the Veteran's stress headaches and the frequency of such headaches. The examiner should specifically discuss whether the Veteran experiences such symptoms has nausea, vomiting, phonophobia, photophobia, mental or physical exhaustion or powerlessness and the frequency of such symptoms. The examiner should also state whether the Veteran experiences any prostrating attacks. If the Veteran experiences prostrating attacks, the examiner must describe the symptoms of the prostrating attacks, the frequency of such attacks and indicate whether the attacks would reasonably be described as "very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability," or would better be characterized as some lesser degree of severity or frequency. The examiner is requested to provide findings as to the impact of the service-connected headaches on the Veteran's social and occupational functioning and her ordinary activities of daily life. 2. Upon completion of the foregoing, readjudicate the Veteran's claim based on a review of the entire evidentiary record. If the benefit sought on appeal remains denied, provide the Veteran and her representative with a supplemental statement of the case and the opportunity to respond thereto. Thereafter, subject to current appellate procedure, the case should be returned to the Board for further consideration, if in order. 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). _____________________________________________ M.G. MAZZUCCHELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs