Citation Nr: 1310396 Decision Date: 03/29/13 Archive Date: 04/09/13 DOCKET NO. 10-09 590 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California THE ISSUES 1. Entitlement to service connection for right knee disability, claimed as patellofemoral syndrome. 2. Entitlement to service connection for left knee disability, claimed as patellofemoral syndrome. 3. Entitlement to service connection for recurrent sinusitis. 4. Entitlement to service connection for a gastrointestinal disability, claimed as ulcer. 5. Entitlement to service connection for disability manifested by recurrent urinary/kidney infections. 6. Entitlement to service connection for chronic cervicitis. 7. Entitlement to service connection for a chronic neck disability. 8. Entitlement to an initial disability rating greater than 10 percent for dysthymic disorder. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD April Maddox, Counsel INTRODUCTION The Veteran served on active duty from November 1996 to November 2001. This appeal to the Board of Veterans' Appeals (Board) arose from September 2008 and December 2009 rating decisions. In the September 2008 rating decision, the RO, inter alia, denied service connection for patellofemoral syndrome of both knees, recurrent sinusitis, a gastrointestinal disorder (claimed as ulcer), recurrent urinary/kidney infections, chronic cervicitis, and a chronic neck disability. In October 2008 the Veteran filed a notice of disagreement (NOD). The RO issued a statement of the case (SOC) in December 2009, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in January 2010. In the December 2009 rating decision, the RO awarded service connection and assigned an initial 10 percent rating for dysthymic disorder, effective September 22, 2007, the date of the Veteran's claim. As explained in more detail below, the Veteran filed an NOD as to the assigned rating, but no further action has been taken with respect to this claim. In August 2012, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge at the RO; a transcript of that hearing is of record. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The Board's decision on the claims for a gastrointestinal disorder and a chronic neck disability is set forth below. The remaining claims for service connection on appeal, along with the matter of a higher initial rating for dysthymic disorder-for which the Veteran has completed the first of two actions required to place this matter is appellate status-are addressed in the remand following the order; these matters are being remanded to the RO, via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran when further action, on his part, is required. As a final preliminary matter, it is noted that, during the August 2012 Board hearing, the Veteran raised the issue of entitlement to service connection for residuals of a hysterectomy secondary to recurrent urinary tract infections and kidney infections during her military service. This issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ), here the RO. Therefore, the Board does not have jurisdiction over the matter, and it is referred to the RO for appropriate action. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim herein decided have been accomplished. 2. Collectively, pertinent lay and medical evidence of record indicates that the Veteran's duodenal ulcer was first manifest and treated during active service, and has continued to date, with at least one reoccurrence at a time frame pertinent to this appeal. 3. Collectively, pertinent lay and medical evidence of record indicates that the Veteran's chronic cervical strain was first manifest and treated during active service, and has continued to date (although asymptomatic in August 2009). CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for duodenal ulcer are met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for chronic cervical strain are met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist 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, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Given the favorable disposition of the claims for service connection for a gastrointestinal disability, and for a chronic neck disorder, the Board finds that all notification and development actions needed to fairly adjudicate these claims have been accomplished. II. Analysis Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active peacetime service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). In general, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disease must be shown to be of a chronic nature in service, or if not chronic, then seen in service with continuity of symptomatology demonstrated after discharge from service. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494- 97 (1997). Disorders diagnosed after discharge may still be service-connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Certain chronic diseases may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. See 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C.A. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In its evaluation, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Id. Another way stated, VA has an equipoise standard akin to the rule in baseball that "the tie goes to the runner." Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Notably, the benefit of the doubt doctrine is not applicable based on pure speculation or remote possibility. See 38 C.F.R. § 3.102. A lay claimant is competent to provide testimony concerning factual matters of which he or she has firsthand knowledge (i.e., reporting something seen, sensed or experienced). Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Under certain circumstances, lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In Barr, the United States Court of Appeals for Veterans Claims (Court) emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of the presence of the claimed symptomatology. However, there are clearly limitations regarding the competence of a lay claimant to speak to certain matters, such as those involving medical diagnosis and etiology. See Jandreau, 492 F.3d at 1377 (Fed. Cir. 2007) (noting that a layperson not competent to diagnose a form of cancer). As reflected in Fed.R.Evid 701, lay witness testimony is permissible in the form of opinions or inferences when (a) rationally based on the perception of the witness and (b) helpful to a clear understanding of the witness' testimony or the determination of a fact in issue. Otherwise, in matters involving scientific, technical or other specialized knowledge, Fed.R.Evid 702 requires that an opinion be provided by a witness qualified as an expert by knowledge, skill, experience, training or education. A. Gastrointestinal disability The Veteran claims that she was diagnosed with gastrointestinal disability (to include ulcers) was first diagnosed and treated during active service. Service treatment records confirm that the Veteran was diagnosed and treated for gastroenteritis, gastroesophageal reflux disease (GERD), and an ulcer during her military service. Specifically, records show that the Veteran was first treated for gastroenteritis in May 1997 and was first diagnosed with g GERD in August 1999. Records also show several gastrointestinal complaints in May 1997, May 1999, June 1999, July 1999, August 1999, September 1999, and March 2001. The Veteran filed a claim for service connection for ulcers in September 2007 and she was afforded a VA general examination in August 2009. With regard to the Veteran's gastrointestinal complaints, the examiner noted that a review of the claims file shows that the Veteran had gastroenteritis in 1999 and H-pylori positive with GERD. The examiner could not find any service treatment records that could substantiate that the Veteran had an ulcer in service, but noted that she was told that she had an ulcer in 1999 when she was experiencing epigastric pain as a result of emotional disturbances while going through her first divorce. She had an EGD (esophagogastroduodenoscopy), was placed on Prilosec, and was told that she had a small ulcer. Reportedly, the conditions abated after she took the Prilosec along with Bismuth Subsalsalate, Amoxicillin, and Clarithromycin. She did well with no symptoms whatsoever until July 2009 when she presented with severe abdominal pain in the middle of the night and was seen at Coalinga District Hospital. The Emergency Room physician believed that this was a urinary tract infection. The Veteran returned, insisting on a more thorough examination. A CT (computed tomography) scan was obtained, which revealed evidence of an acute abdomen with perforated duodenal ulcer. She was transferred to Hanford Community Hospital for stabilization and later transferred to Clovis Community Hospital where she had an operative procedure performed by Dr. S., a physician who she knew who provided bypass surgery for bariatric purposes years earlier. The Veteran did well and avoided transfusions. The Veteran reported that she still suffered abdominal pain but that it was kept in check by Nexium. She did not have any difficulties swallowing or keeping food down in spite of having bariatric surgery as mentioned above. The Veteran's H-pylori had, reportedly been eradicated. She was not known to have other problems in the gut, none such as chronic loose stools, blood in the stools, or gallbladder or liver disease. The examiner again noted that the Veteran had surgery for perforated duodenal ulcer in July 2009. She had not had malignancy of the gastrointestinal tract and did not have peritoneal tuberculosis. On physical examination, she had no ventral hernia, wore no truss, and had no residuals of malignancy. The examiner noted that, in service, the Veteran was known to have GERD symptoms, which was treated with Prilosec and H-pylori were eradicated. The Veteran had a recurrence of her symptoms leading to ulcer disease without NSAIDs (non-steroidal anti-inflammatory drugs) implicated as she had stopped these medications years earlier because of dyspepsia in the past. Thus, the examiner opined that the Veteran's post-service July 2009 duodenal ulcer was a recurrence from her original ulcer disease established when she was in the service years earlier. The examiner noted that the Veteran was clinically asymptomatic and that physical examination revealed no anemia. As demonstrated above, the Veteran was diagnosed with gastrointestinal problems (including an ulcer) during active service and treated for gastrointestinal problems from May 1997 through March 2001. The Veteran has alleged continuous gastrointestinal symptoms since service discharge which is corroborated by the August 2009 VA examination showing a continued diagnosis of gastrointestinal problems, most recently a duodenal ulcer in July 2009. Furthermore, the August 2009 VA examiner opined that the Veteran's post-service July 2009 duodenal ulcer was a recurrence from her original ulcer disease established when she was in the service years earlier. 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. 38 C.F.R. § 3.102. See also 38 U.S.C.A. § 5107; Gilbert, supra. In light of the foregoing, the Board finds that, collectively, pertinent lay and medical evidence of record indicates that the Veteran's duodenal ulcer was first manifest and treated during active service, and has continued to date, with at least one reoccurrence during a time frame pertinent to this appeal. Accordingly, and with resolution of all reasonable doubt in the Veteran's favor, the criteria for service connection for duodenal ulcer are met. B. Chronic Neck Disability The Veteran claims that her currently diagnosed chronic cervical strain was first diagnosed and treated during active service. Service treatment records confirm that the Veteran was diagnosed and treated for chronic cervical strain during the military service. Specifically, records show that the Veteran first complained of right sided neck pain in September 1998 and then began complaining of neck pain from both sides in June 2001 and was, at that time, diagnosed with cervical muscle strain. The Veteran filed a claim for service connection for chronic neck problems in September 2007, and she was afforded a VA general examination in August 2009. With regard to the Veteran's neck complaints the Veteran reported that she was diagnosed with cervical strains on several occasions during her military service from 1996 to 2001. No cervical strain was noted to be accompanied by any significant injury, or to occur traumatically. She reported that she would episodically and randomly have severe neck pain radiating to the left or right shoulder, which would be present anywhere from two to five days. She claimed this pain was very severe from six to eight on a scale of ten and worse with moving from left to right or from right to left. She claimed that it was a pinching sort of pain and that the pain was localized in the neck area and did not radiated towards the shoulder or upper arms. The Veteran did not believe she had ever had radiographs to see whether or not she had any bony injuries but she claimed that she had seen a chiropractor at least once but did not receive relief with his care. Her current treatments included narcotic medication as well as long acting Flexeril. The examiner noted that service treatment records revealed a history of cervical strains as early as September 1998. The examiner also noted an in-service history of lumbar strain. On physical examination, the Veteran had cervical flexion from 0 to 45 degrees and cervical extension from 0 to 45 degrees. Rotary movements to the left and right were also 0 to 45 degrees and left and right rotations were from 0 to 80 degrees bilaterally, respectively. After three repetitions, there was no reduction in joint excursion, weakness, pain, fatigability, and no loss of coordination. X-ray examination of the cervical spine was within normal limits. The examiner diagnosed chronic cervical strain, currently asymptomatic, with a normal physical examination and full range of motion at the time of the examination. As demonstrated above, the Veteran was diagnosed with cervical muscle strain during active service and treated for neck pain on several occasions from 1998 through 2001. The Veteran has alleged continuous neck pain since service discharge which is corroborated by the August 2009 VA examination showing a continued diagnosis of chronic cervical strain. In light of the above, the Board finds that, collectively, pertinent lay and medical evidence of record indicates that the Veteran's chronic cervical strain was first manifest and treated during active service, and has continued to date. Therefore, with \resolution of all reasonable doubt in the Veteran's favor, the criteria for service connection for chronic cervical strain are met. ORDER Service connection for a duodenal ulcer is granted. Service connection for a chronic cervical strain is granted. REMAND The Board's review of the claims file reveals that additional RO action on the claims for service connection remaining on appeal is warranted. As regards the claims for knee disabilities, the Board notes that service treatment records reveal that the Veteran was diagnosed and treated for patellofemoral syndrome of the knees during the military service. Specifically, records show that the Veteran first complained of left knee pain in October 1999 and then began complaining of bilateral knee pain in January 2000 and was, at that time, diagnosed with patellofemoral syndrome of the knees. May 2001, July 2001, and October 2001 service treatment records show continued treatment for patellofemoral syndrome of the knees. The Veteran filed a claim for service connection for bilateral knee disability claimed as bilateral patellofemoral syndrome in September 2007; she was afforded a VA general examination in August 2009. With regard to the Veteran's bilateral knee complaints, the examiner noted that the Veteran's service treatment records show that she was diagnosed with bilateral patellofemoral syndrome in 2001. The examiner also noted that, around 1999 the Veteran indicated that she twisted her right knee, causing some injury. Radiographs were obtained. She was given NSAIDs (non-steroidal anti-inflammatory drugs) including Motrin and Feldene and given modified duty. Post-service, the Veteran severely injured the right knee in 2003 when she was on the dance floor and tripped over another dancer's shoes that were taken off and were laying on the dance floor. This resulted in a severe catastrophic failure to the right knee with a ruptured anterior cruciate ligament, which required cadaveric replacement in 2003. The examiner noted that bilateral patellofemoral syndrome was diagnosed in 2001 and that the Veteran was also status post cadaveric anterior cruciate ligament for traumatic rupture involving the right knee. However, the examiner also noted that physical examination of the knees was normal, and that the Veteran had full range of motion of the knees. X-rays revealed a normal left knee and post-surgical changes of the right knee. Unfortunately, the Board finds that the August 2009 VA examination is inadequate as it is unclear as current diagnosis(es) and etiology of disability(ies) affecting each knee whether the Veteran has a current diagnosis of bilateral patellofemoral syndrome. Notably, the August 2009 VA examiner indicated that "bilateral patellofemoral syndrome was diagnosed in 2001" but did not indicate whether the Veteran had a current diagnosis of bilateral patellofemoral syndrome. Also, the examiner did not comment upon the etiology of the Veteran's right knee status post cadaveric anterior cruciate ligament for traumatic rupture. Moreover, with regard to the claimed recurrent sinusitis, recurrent urinary/kidney infections, and chronic cervicitis issues, the Board notes that the Veteran was treated for each of these claimed conditions on several occasions in service but it is unclear whether these conditions have resulted in any current disabilities. The Veteran was afforded a VA general examination in August 2009. With regard to the claimed recurrent sinusitis disorder the examiner diagnosed "sinusitis, resolved with no evidence of sequela of chronic infection and with normal examination." With regard to the claimed recurrent urinary/kidney infections the examiner diagnosed "urinary tract infection, uncomplicated." Currently quiescent without any chronic renal disease." With regard to the chronic cervicitis the examiner diagnosed "cervical dysplasia, status post colposcopic procedure with normal PAP smears following this procedure." Unfortunately, the August 2009 examiner did not specifically address the Veteran's contentions in reaching a determination as whether the Veteran currently has recurrent sinusitis, recurrent urinary/kidney infections, and/or chronic cervicitis. While, arguably, the Veteran's assertions of experiencing sinus, urinary/kidney, and cervicitis problems that started at the time of her military service and that have continued to date are factors for consideration in whether there exists a medical nexus between current disability and service, persistent or recurrent symptoms-which the Veteran is certainly competent to assert-may be indicative of current disability. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Under these circumstances, the Board finds that further VA examination and medical opinion-based on full consideration of the Veteran's documented medical history, her lay assertions, including the contention that the bilateral knee, sinus, urinary/kidney, and cervicitis problems started during her military service and have continued to date, and supported by clearly-stated rationale-is needed to resolve the claim for service connection for bilateral patellofemoral syndrome, recurrent sinusitis, recurrent urinary/kidney infections, and chronic cervicitis. See 38 U.S.C.A. § 5103A ; 38 C.F.R. § 3.159; McLendon, 20 Vet. App. at 83. Hence, the RO should arrange for the Veteran to undergo VA examination, by an appropriate physician, at a VA medical facility. The Veteran is hereby advised that failure to report to the scheduled examination, without good cause, may result in denial of the claims for service connection (as the claims will be considered on the basis of the evidence of record). See 38 C.F.R. § 3.655 (2012). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. If the Veteran fails to report to the scheduled examination, the RO should obtain and associate with the claims file copy(ies) of the notice(s) of the date and time of the examination sent to her by the pertinent VA medical facility. Prior to arranging for the examination, the RO should give the Veteran another opportunity to supplement the record. In the Veteran's January 2010 VA Form 9, she wrote that VA has not reviewed current and past treatment records from her civilian doctors from the time of her discharge from military service to the present time. During the August 2012 Board hearing, the Veteran reiterated this argument and the undersigned held the record open for 60 days so that the Veteran could submit any post-service treatment records. However, the 60-day period has since expired and the Veteran has yet to submit any post-service treatment records. Therefore, on remand, the RO should send the Veteran a letter giving her an opportunity to present additional information and/or evidence pertinent to the claims remaining on appeal. The RO's letter to the Veteran should explain that she has a full one-year period for response. See 38 U.S.C.A § 5103(b)(1)(West 2002); but see 38 U.S.C.A. § 5103(b)(3) (West Supp. 2012) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). In its letter, the RO should request that the Veteran provide any records (or necessary releases to obtain records) related to post-service medical treatment that she has received, particularly regarding the claimed disorders. The RO should also inform her that she can submit lay statements by her and others who have observed her claimed disabilities. The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). However, identification of specific actions requested on remand does not relieve the RO of the responsibility to ensure full VCAA compliance. Hence, in addition to the actions requested above, the RO should also undertake any other development or notification action deemed warranted by the VCAA prior to adjudicating the remaining claims for service connection on appeal. The RO's adjudication of the claim should include consideration of all evidence added to the record since the RO's last adjudication of the claims. As a final matter, the Board notes that in a December 2009 rating decision, the RO granted service connection for dysthymic disorder and assigned a 10 percent disability rating effective September 22, 2007, the date of the Veteran's claim. In January 2010 the Veteran filed a notice of disagreement (NOD) indicating her disagreement with the disability rating assigned for her dysthymic disorder. However, the RO has yet to issue a SOC with respect to the Veteran's claim for an initial disability rating greater than 10 percent for dysthymic disorder, the next step in the appellate process. See 38 C.F.R. § 19.29 (2012); Manlincon v. West, 12 Vet. App. 238, 240-41 (1999); Holland v. Gober, 10 Vet. App. 433, 436 (1997). Consequently, this matter must be remanded to the RO for the issuance of a SOC. Id. The Board emphasizes, however, that to obtain appellate review of any issue not currently in appellate status, a perfected appeal must be filed. See 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.200 , 20.501, 20.502 (2012). On remand, the appellant will have the opportunity to file a timely substantive appeal if she wishes to complete an appeal as to this matter. Accordingly, these matters are hereby REMANDED for the following action: 1. Furnish to the Veteran an SOC on the matter of an initial rating in excess of 10 percent for dysthymic disorder, along with a VA Form 9, and afford her the appropriate opportunity to submit a substantive appeal perfecting an appeal on this issue. The Veteran is hereby reminded that to obtain appellate review of any matter not currently in appellate status, a timely appeal must be perfected-here, as regards the matter of entitlement to an initial disability rating greater than 10 percent for dysthymic disorder, within 60 days of the issuance of the SOC. 2. Send to the Veteran a letter requesting that she provide sufficient information and, if necessary, authorization to enable it to obtain any additional evidence pertinent to the appeal that is not currently of record. Specifically request that the Veteran furnish to the RO any records (or necessary releases to obtain records) related to private treatment records or lay statements relating to the Veteran's claimed disabilities. Clearly explain to the Veteran that she has a full one-year period to respond (although VA may decide the claim within the one-year period). 3. If the Veteran responds, assist her in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After all records and/or responses received from each contacted entity have been associated with the claims file, or, a reasonable time period for the Veteran's response has expired, arrange for the Veteran to undergo VA examination, by an appropriate physician, at a VA medical facility. The entire claims file must be made available to the physician designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented medical history and her lay assertions. All indicated tests and studies should be accomplished (with all results made available to the examining physician prior to the completion of his or her report), and all clinical findings should be reported in detail. The physician should clearly identify all current, chronic disability (ies) affecting each knee (to include patellofemoral syndrome), the sinuses (to include recurrent sinusitis), the kidneys/urinary tract (to include recurrent infections), the cervix (to include chronic cervicitis). Then, with respect to each diagnosed disability, the physician should render an opinion, consistent with sound medical judgment, as to whether it is as least as likely as not (i.e., there is a 50 percent or greater probability) that the disability had its onset in or is otherwise medically related to service. In rendering the requested opinions as to diagnosis and etiology, the physician should consider and discuss all pertinent medical and lay evidence of record, to include the Veteran's oral and written assertions that she began experiencing bilateral knee, sinus, urinary/kidney, and cervicitis problems during her military service and continues to suffer from these problems. The examiner should set forth all examination findings, together with the complete rationale for the conclusions reached, in a printed (typewritten) report. 4. If the Veteran fails to report to the scheduled examination, the RO must obtain and associate with the claims file a copy of any notice(s) of the date and time of the examination sent to her by the pertinent VA medical facility. 5. To help avoid future remand, the RO must ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 6. After completing the requested actions, and any additional notification and/or development deemed warranted, the RO should readjudicate the claims on appeal in light of pertinent evidence (to particularly include all evidence contained in the temporary file(s) or otherwise added to the claims file since the RO's last adjudication of the claims) and legal authority. 7. If any benefit sought on appeal remain denied, the RO must furnish to the Veteran an appropriate SSOC that includes citation to and discussion of all additional legal authority considered, along with reasons and bases for all determinations, and afford her the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication, and it is not the Board's intent to imply whether the benefits requested should be granted or denied. The Veteran need take no action until otherwise notified, but she may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This REMAND must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs