Citation Nr: 1314079 Decision Date: 04/29/13 Archive Date: 05/15/13 DOCKET NO. 10-49 320 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Wichita, Kansas THE ISSUES 1. Entitlement to an increased rating for chronic low back strain, currently rated as 10 percent disabling. 2. Entitlement to an increased rating for residuals of cold injury of the right hand, currently rated as 10 percent disabling. 3. Entitlement to an increased rating for residuals of a cold injury of the left hand, currently rated as 10 percent disabling. 4. Entitlement to a compensable rating for migraine headaches. 5. Entitlement to service connection for a sleep disorder. 6. Whether new and material evidence has been received to reopen the claim for entitlement to service connection for exposure to tuberculosis. 7. Whether new and material evidence has been received to reopen the claim for entitlement to service connection for shin splints. 8. Whether new and material evidence has been received to reopen the claim for entitlement to service connection for a bilateral foot disability. ATTORNEY FOR THE BOARD A. Adamson, Counsel INTRODUCTION The Veteran served on active duty from November 1992 to August 2008. This case is before the Board of Veterans' Appeals (Board) on appeal of a March 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. In addition to the paper claims files, there is an electronic claims file associated with the Veteran's claims. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims files or are irrelevant to the issues on appeal. The issues of entitlement to an increased ratings for chronic low back strain, and residuals of cold injuries of the hands and whether new and material evidence has been received to reopen the claims for entitlement to service connection for exposure to tuberculosis, shin splints, and bilateral foot disability are addressed in the REMAND that follows the order section of this decision. FINDINGS OF FACT 1. Throughout the entire period on appeal, the Veteran's headaches have been characterized by prostrating headaches occurring every other month. 2. No sleep disorder has been present during the pendency of this claim. CONCLUSIONS OF LAW 1. The criteria for a 10 percent rating, and not higher, for migraine headaches, beginning August 1, 2009, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.124a, Diagnostic Code 8100 (2012). 2. A sleep disorder was not incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2002), requires that notice to a claimant pursuant to the VCAA be provided 'at the time' that or 'immediately after' VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). With respect to the issues decided herein, the record reflects that the Veteran was provided all required notice in a letter mailed in September 2009, prior to the initial adjudication of the claims in March 2010. All appropriate development to obtain the Veteran's pertinent, available service treatment records (STRs) and post-service VA medical records has been completed. The Veteran has not identified any pertinent, outstanding records that could be obtained to substantiate her claims. The Board is also unaware of any such records. Moreover, the Veteran has been afforded an appropriate VA examination as to her migraine headache disorder. The Board acknowledges that the Veteran has not been afforded a VA examination and that no VA medical opinion has been obtained in response to her sleep disorder claim, but has determined that VA has no duty to provide an examination or obtain a medical opinion in response to this claim. In this regard the Board notes that VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A (d)(2) , 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. In this case, as discussed in more detail below, there is no competent evidence reflecting a diagnosis, either in service or since, of a sleep disorder. In the September 2009 notice, the Veteran was requested to provide any evidence showing that she currently has a sleep disorder. She did not submit or identify any evidence showing a diagnosis of a sleep disorder, or treatment for symptoms outside of those associated with her service-connected major depressive disorder. As the low threshold in McLendon has not been met, a remand for an examination or opinion is not required at this point. See 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). See also Wells v. Principi, 326 F. 3d. 1381, 1384 (Fed. Cir. 2003); Duenas v. Principi, 18 Vet. App. 512 (2004) (per curiam). Accordingly, the Board concludes that VA has complied with its duty to assist the Veteran. The Board will now address the merits of these claims. II. Burdon of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. III. Increased Rating - Migraine Headaches A. Legal Criteria Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). The Veteran's service-connected headaches are rated under 38 C.F.R. § 4.124a, Diagnostic Code 8100, for migraine headaches. The maximum schedular disability rating of 50 percent is warranted for migraine headaches with very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. A 30 percent disability rating is warranted for migraine headaches with characteristic prostrating attacks occurring on an average once a month over the last several months. A 10 percent disability rating is warranted for migraine headaches with characteristic prostrating attacks averaging one in two months over the last several months. A noncompensable disability rating is warranted for migraine headaches with less frequent attacks. The rating criteria do not define "prostrating," nor has the United States Court of Appeals for Veterans Claims (Court). Cf. Fenderson v. West, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack.). By way of reference, the Board notes that according to WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, "prostration" is defined as "utter physical exhaustion or helplessness." A very similar definition is found in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st Ed. 2007), in which "prostration" is defined as "extreme exhaustion or powerlessness." 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In addition, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2012). B. Factual Background and Analysis In accordance with 38 C.F.R. §§ 4.1 , 4.2 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the Veteran's service-connected migraine headache disability. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disabilities under review. The Veteran was originally awarded service connection for her migraine headaches in the November 2008 rating decision. The Veteran was notified of this decision in January 2009. A noncompensable rating was assigned, effective September 1, 2008. She did not file any statement indicating disagreement with the initial rating assigned, but then filed a VA Form 21-526 in August 2009, which included migraines. This is construed as a claim for an increased rating for the already service-connected migraine headaches. Following her request for increase, the Veteran was afforded a VA general medical examination in October 2009. The Veteran reported that she had most recently had a migraine two weeks prior to the examination. She reported that she becomes nauseated and her vision becomes blurry just prior to the onset of a migraine. She reported that she goes into a dark and quiet room to lay down when her headaches occur, and that sometimes the headaches last seven days. She reported no weakness or fatigue. Based upon this, the examiner concluded that the Veteran's migraine headaches are prostrating in nature and ordinary activity is not possible. In April 2010, the Veteran submitted a written statement in which she reported having a migraine headache every other month during which she is sick and nauseous. She reported requiring a cool room to lie down in, and that the medication prescribed, Imitrex, does not work. There is no additional medical evidence available related to the Veteran's headaches. Nonetheless, this limited available evidence establishes that the Veteran's migraine headaches are prostrating in nature and occur every other month. This disability picture most closely approximates the rating criteria for a 10 percent rating under diagnostic code 8100 (with characteristic prostrating attacks averaging one in 2 months over the last several months). There is no suggestion in the record that these prostrating headaches have occurred once per month, thus the rating criteria for a 30 percent rating are not met. Consideration has been given to assigning staged ratings for the Veteran's migraine headaches; however, at no time during the period in question has the headache disability warranted more than the schedular rating awarded here. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered whether this case, or any component thereof, should be referred to the Director of the Compensation and Pension Service for extra-schedular consideration. In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case the manifestations of the service-connected migraine headaches are contemplated by the schedular criteria. In fact, the criteria for the next higher rating are discussed in the analysis, above. The Board has therefore determined that referral of this case for extra-schedular consideration under 38 C.F.R. § 3.321(b) is not in order. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). Accordingly, in arriving at the determination above the Board has considered not only the medical evidence but also the lay evidence presented by the Veteran in the form of her correspondence to VA and her reports in conjunction with her VA examination. However, even affording this lay evidence full competence and credibility, such lay evidence does not support a schedular rating higher than the 10 percent rating granted herein. IV. Service Connection - Sleep Disorder A. General Legal Criteria Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). B. Factual Background and Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this claim. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. A review of the Veteran's service treatment records (STRs) fails to reveal any diagnosis of a sleep disorder during service. She was noted as having problems with sleep onset, noted as dyssomnia, at the time of a February 2008 psychiatric medical evaluation board. In August 2007, she was noted as having trouble sleeping due to worry related to her son's deployment. She was noted as being prescribed with zolpidem tartrate, one tablet at bedtime for insomnia, in October 2007. Prior to that, in July 2004, the Veteran was noted as presenting with difficulty sleeping, loss of appetite, and a report of work becoming overwhelming. She was diagnosed as having an adjustment disorder with depressed mood and insomnia at that time. Earlier in her service, however, no such symptoms were reported. For instance, August 1992 and April 1998 Reports of Medical History show that she replied "No" to whether she had frequent trouble sleeping. Thus, the service treatment records are devoid of evidence related to a sleep disorder, but show that the Veteran experienced trouble sleeping associated with her psychiatric problems. Post-service records also indicate no diagnosis of a sleep disorder outside of symptoms associated with a psychiatric disorder. At the time of the July 2008 VA mental disorders examination, the Veteran reported that she was prescribed medication in service at the time she was first seen in the mental health clinic and that the medication was for anxiety and insomnia. She reported that she currently experienced "weird dreams" with associated difficulty falling and staying asleep. The Veteran was diagnosed as having major depressive disorder and difficulty falling and staying asleep was noted as a symptom. In an April 2008 VA general medical examination report, just three months prior, there was no mention of insomnia, and no diagnosis related to any sleep disorder was assessed. At the time of her August 2009 claim, the Veteran clearly stated that she has sleep problems due to her deployment and her worry that she would not see her sons again. Shortly thereafter, the Veteran was afforded another VA general medical examination, at which time she again reported insomnia. The general medical examiner did not discuss this disability, and instead referred to her mental examination. In June 2010, the Veteran underwent VA mental disorders examination. At this time, sleeping less was noted as a symptom of the Veteran's depressive disorder. The examiner diagnosed generalized anxiety disorder, panic disorder, agoraphobia, and depressive disorder not otherwise specified. There was no indication in this report that a separate sleep disorder diagnosis was appropriate. Rather, the Veteran's trouble sleeping was listed as a symptom of her depression. In October 2010, the RO increased the Veteran's rating for her service-connected mental disorder, explicitly noting sleep disturbance as a symptom. Thus, the Veteran is shown to have experienced insomnia associated with worry and depression since service, and is now compensated for that insomnia as part of her rating for her service connected major depressive disorder with anxiety. There is no suggestion in the record, either during the Veteran's active service or at any time since, that she has a sleep disorder in and of itself, such as sleep apnea or a diagnosed fatigue disorder such as chronic fatigue syndrome, outside the realm of her mental disorder symptoms, for which service connection can be considered. In sum, the evidence shows that the veteran's sleep symptoms are manifestations of her already service-connected psychiatric disability and that she does not have a separate sleep disorder. In reaching this decision, the Board has considered the Veteran's statements. The Board acknowledges that the Veteran is competent to describe her sleep disturbances. However, whether those disturbances are due to a sleep disorder or her service-connected psychiatric disability is a medical question that the Veteran, as a layperson, is not competent to answer. As discussed above, the medical evidence shows that she does not have a sleep disorder separate from her service-connected psychiatric disability. The Board has duly considered the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim, so that doctrine is not applicable to this claim. The claim must be denied. ORDER The Board having determined that the Veteran's headaches warrant a 10 percent rating, but not higher, throughout the period of the claim, the benefit sought on appeal is granted to this extent and subject to the criteria applicable to the payment of monetary benefits. Service connection for a sleep disorder is denied. REMAND The Board finds that further development is required before the claims of entitlement to an increased rating for chronic low back strain, and residuals of cold injury of the right and left hands, each currently rated as 10 percent disabling, and the issues of whether new and material evidence was received to reopen the claims for entitlement to service connection for exposure to tuberculosis, shin splints, and a bilateral foot disability are adjudicated. Low Back Strain The Veteran's 2009 claim for a rating in excess of 10 percent for low back strain was received and shortly thereafter, the Veteran was afforded a VA general medical examination, which assessed her lumbar spine. At the time of the October 2009 examination, the Veteran reported daily low back pain with nightly flare-ups. Examination, however, was reported to show no objective evidence of painful motion, spasm, weakness, tenderness, atrophy or guarding. She was noted to be able to forward flexion to 70 degrees, with the limitation reported to be due to pain. Since that time, the Veteran has reported symptoms suggestive of a worsening of the lumbar spine disability. In particular, in April 2010, she submitted a written statement requesting to be reevaluated as her daily and nightly pain has reached a level where she is unable to sit down properly, and cannot lie down without the use of either a heating pad or medication. The Veteran has not been afforded a new VA spine examination since October 2009. Thus, more than three years have passed and the Veteran has reported symptoms indicative of a worsening of the service-connected lumbar spine disability. Where a veteran asserts that a disability has worsened since her last VA examination, and the last examination is too remote to constitute a contemporaneous examination, a new examination is required. See 38 U.S.C.A. § 5103A (d); 38 C.F.R. § 3.159(c)(4). See also Snuffer v. Gober, 10 Vet. App. 400 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991). Thus, a new VA examination is required to determine the current disability level for the Veteran's lumbar spine strain. Cold Injury Residuals - Left and Right Hands The Veteran's cold injury residuals of her left and right hands are currently evaluated as 10 percent disabling for each hand under 38 C.F.R. § 4.114, Diagnostic Code 7122. This rating is assigned with arthralgia or other pain, numbness, or cold sensitivity. For a higher rating, 20 percent, the arthralgia or other pain, numbness, or cold sensitivity must be present, plus tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or X-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis). For a 30 percent rating, there must be arthralgia or other pain, numbness, or cold sensitivity, plus two of the following: tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, or X-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis). The Veteran's hands were examined one time during the course of this claim. At the time of the October 2009 examination, the Veteran reported that her hand condition causes her to refrain from carrying or lifting too heavy of items, and that the pain in her hands and fingers flares-up approximately five to six times in a thirty-day time. Physical examination revealed that her hands were pink with normal capillary refill bilaterally, and that there was no evidence of edema, erythema, heat or deformity. Motor and sensory function and neurovascular function were noted as intact bilaterally. Bilateral hand grasp was normal. Right and left hand X-rays yielded a normal study at that time. More recently, in April 2010, the Veteran submitted a statement indicating that when it is cold, her fingers feel sore, tender and painful to the touch. She also reported that she walks around with gloves on at all times. While not an extraordinarily clear depiction of a worsening in symptoms, this description by the Veteran does indicate a possibility that "painful to the touch" may indicate locally impaired sensation, and thus a worsening. Moreover, the Board notes that the October 2009 VA examination report does not discuss the existence of nail abnormalities, or the lack thereof. Thus, more than three years has passed and the Veteran has reported symptoms potentially indicative of a worsening of the service connected cold injury residuals. Moreover, the October 2009 examination report is partially incomplete in that it fails to discuss the state of the Veteran's nails. Again, where a veteran asserts that a disability has worsened since her last VA examination, and the last examination is too remote to constitute a contemporaneous examination, a new examination is required. See 38 U.S.C.A. § 5103A (d); 38 C.F.R. § 3.159(c)(4). See also Snuffer v. Gober, 10 Vet. App. 400 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991). Thus, a new VA examination is required to determine the current disability level for the Veteran's cold injury residuals of the right and left hands. New and Material Evidence Claims Historically, in a November 2008 rating decision, the RO denied the Veteran's claims related to exposure to tuberculosis, shin splints, and a bilateral foot disability. The Veteran was notified of the decision in a letter sent in January 2009. In particular, the tuberculosis claim was denied on the basis that the Veteran's exposure to tuberculosis is not a disability. The shin splint and foot claims were both denied on the basis that, while symptoms were noted in service, there was no evidence of current disability for either. The Veteran did not file any statement within one year of January 2010 indicating disagreement with the decision. Moreover, there was no pertinent evidence received within that year that can be construed as evidence pertinent to the original claim, thus alleviating the requirement to reopen under 38 C.F.R. § 3.156(b). The August 2009 VA Form 21-526 and accompanying statement by the Veteran were the only items received during the one year following the January 2009 notice. These items merely listed the disabilities and restated the claim. Thus, the August 2009 VA Form 21-526 and accompanying statement are deemed attempts to reopen these previously denied claims, rather than being deemed a notice of disagreement or evidence to alleviate the need for new and material evidence. The Veteran did not appeal the RO's determinations related to exposure to tuberculosis, shin splints, and bilateral foot disability, and they became final. The issues on appeal have been characterized accordingly. The Board further notes that in March 2006, the Court held that because the terms "new" and "material" in a new and material evidence claim have specific, technical meanings that are not commonly known to VA claimants, when providing the notice required by the VCAA, it is necessary, in most cases, for VA to inform claimants seeking to reopen a previously and finally disallowed claim of the unique character of the evidence that must be presented. Kent v. Nicholson, 20 Vet. App. 1, 9-10 (2006). In this case, the record does not reflect that the Veteran has been provided adequate notice in response to the claims to reopen. The Veteran's current claims (filed in August 2009) were adjudicated by way of the March 2010 rating decision. While the RO noted in the decision that the "previous denial of service connection...is confirmed and continued" with regard to each claim, the RO did not provide the Veteran with notice as it relates to new and material evidence claims, and also did not adjudicate the claims on a new and material evidence basis in the December 2010 statement of the case. Thus, the Veteran has not received proper notice and has not received the relevant regulations related to these claims. For this reason, remand is necessary. All Claims - Records Finally, the Board recognizes that the Veteran's paper claims files include VA outpatient treatment notes dated through December 3, 2010, from the Eastern Kansas Healthcare System of the Topeka, Kansas VA Medical Center (VAMC) Division. The Veteran's electronic (Virtual VA) claims file was reviewed and, at this time, does not include additional treatment records. There is no indication in the record that the Veteran currently receives treatment outside the VA healthcare system for any of her claimed disabilities. Thus, on remand, development to obtain any outstanding, pertinent VA records, to include records since December 3, 2010, from the Eastern Kansas Healthcare System of the Topeka, Kansas VAMC, should be completed. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, this case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. The RO or the AMC should provide the Veteran with appropriate notice regarding her request to reopen the claims of entitlement to service connection for exposure to tuberculosis, shin splints and a bilateral foot disability. 2. The RO or the AMC should undertake appropriate development to obtain a copy of any outstanding records pertinent to the Veteran's claims, including the VA treatment records dating since December 3, 2010, from the Eastern Kansas Healthcare System of the Topeka, Kansas VAMC. 3. If any requested records related to remand instruction 2 are not available, the claims files should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 4. Once the record is developed to the extent possible, afford the Veteran a VA spine examination by an examiner with the sufficient expertise to ascertain the current severity and manifestations of her service-connected lumbar spine strain. The claims files and any pertinent evidence in Virtual VA that is not contained in the claims files must be made available to and reviewed by the examiner, and any indicated studies should be performed. The RO or the AMC should ensure that all information required for rating purposes is provided by the examiner. The rationale for all opinions expressed must also be provided. 5. Once the record is developed to the extent possible, afford the Veteran a VA cold injuries examination by an examiner with the sufficient expertise to ascertain the current severity and manifestations of her service-connected cold injury residuals of the right and left hands. The claims files and any pertinent evidence in Virtual VA that is not contained in the claims files must be made available to and reviewed by the examiner, and any indicated studies should be performed. The RO or the AMC should ensure that all information required for rating purposes is provided by the examiner. In particular, the examiner should report as to whether the Veteran's cold injury residuals of either hand are manifested by tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, and/or X-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis). The rationale for all opinions expressed must also be provided. 6. The Veteran must be given adequate notice of the date and place of any requested examination. A copy of all notifications, including the address where the notice was sent, must be associated with the record if the Veteran fails to report for any examination. The Veteran is to be advised that failure to report for a scheduled VA examination without good cause may have adverse effects on her claims. 7. The RO or the AMC should also undertake any other development it determines to be warranted. 8. Then, the RO or the AMC should readjudicate the Veteran's claims of entitlement to an increased rating for lumbar spine strain, entitlement to increased ratings for right and left hand cold injury residuals, and whether new and material evidence has been received to reopen the claims for service connection for exposure to tuberculosis, shin splints, and a bilateral foot disability. If the benefits sought on appeal are not granted to the Veteran's satisfaction, a supplemental statement of the case should be issued to the Veteran, and she should be afforded the requisite opportunity to respond. In particular, with regard to the new and material evidence claims, the Veteran must be informed, in the SSOC, of the legal criteria pertinent to claims to reopen. Thereafter, the case should be returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran need take no action until she is 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). This REMAND must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the Court 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). ______________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs