Citation Nr: 1316409 Decision Date: 05/20/13 Archive Date: 05/29/13 DOCKET NO. 09-27 939A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado THE ISSUES 1. Entitlement to an initial rating higher than 30 percent for the service-connected sinusitis with associated headaches. 2. Entitlement to pseudogout of the left foot. 3. Entitlement to service connection for a deviated septum. 4. Entitlement to service connection for a bilateral hearing loss. 5. Entitlement to service connection for eczema. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Mac, Counsel INTRODUCTION The Veteran served on active duty from October 1978 to July 1996 and from November 2004 to June 2008. He also served in the Army Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision of the RO. The Board notes that the September 2008 rating decision granted service connection for sinusitis with associated headaches and assigned a noncompensable rating, effective on July 1, 2008, the day after the Veteran was separated from service. During the current appeal period, in a rating decision in April 2010, the RO increased the rating to 30 percent effective on July 1, 2008 and thus the issue on appeal is characterized as entitlement to an initial rating higher than 30 percent for sinusitis associated with headaches. A rating decision in January 1999 denied service connection for dermatophytosis and granted service connection for pseudofolliculitis barbae and tinea versicolor. The Veteran's claim for the issues currently on appeal was received on March 24, 2008, while he was still on active duty, when he specifically claimed service connection for eczema. The Court of Appeals for Veteran Claims has held (in the context of a claim for service connection for a psychiatric disorder) that a claim for service connection encompasses all pertinent symptomatology, regardless of how that symptomatology is diagnosed. Clemons v. Shinseki, 23 Vet. App. 1 (2009). However, as the RO developed the current claim as service connection for eczema and there is no skin disability during the current appeal period, the issue on appeal continues to be characterized as service connection for a eczema. In March 2013, the Veteran withdrew his earlier request for a videoconference hearing with the Board. In September 2010, the VA treatment records dated from 1999 to 2010 were associated with the Virtual VA paperless claims processing system. While these records were received after the last Supplemental Statement of the Case (SSOC) dated in July 2010, the records are found to be cumulative or duplicative of the evidence of record at the time of the July 2010 SSOC, and a waiver of initial RO consideration is not needed. See 38 C.F.R. § 20.1304. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this case should take into consideration the existence of this electronic record. In March 2008, the Veteran also filed a claim of service connection for pes planus. It is unclear whether this claim has been adjudicated, and it is referred to the RO for appropriate action. The issues of service connection for pseudogout of the left foot and a deviated septum and an initial rating higher than 30 percent for the service-connected sinusitis with associated headaches are being remanded to the RO. FINDINGS OF FACT 1. The Veteran is not shown to have a current bilateral hearing loss disability for VA compensation purposes. 2. The Veteran is not shown to have a skin condition manifested by eczema that is due to service. CONCLUSIONS OF LAW 1. The Veteran's claim for a bilateral hearing loss must be denied by operation of law. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.159, 3.303, 3.307, 3.309, 3.385 (2012). 2. The Veteran does not have a disability manifested by eczema due to disease or injury that was incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102 , 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. The VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided post-adjudication VCAA notice by letter dated in August 2009. The Veteran was notified of the evidence needed to substantiate the claim for service connection, as well as what information and evidence must be submitted by the Veteran, what information and evidence would be obtained by VA, and the provisions for disability ratings and for the effective date of the claims. While the VCAA notice specifically referred to the Veteran's claim for malunion of the maxilla (which is not in appellate status), under a reasonable person standard, the Veteran could be expected to understand from the notice that the five elements of a claim of service connection for malunion of the maxilla also would apply to his claim of service connection for bilateral hearing loss and eczema. To the extent that the August 2009 VCAA came after the initial adjudication, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The procedural defect was cured as after the RO provided substantial content-complying VCAA notice, the claim of service connection was readjudicated as evidenced by the SSOC dated in April 2010 and in July 2010. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.) Duty to Assist VA has fulfilled its duty to assist in obtaining the identified evidence needed to substantiate the claims. The service treatment records, post-service treatment records, and lay statements have been associated with the record. Additionally, the Veteran was afforded VA examinations in May 2008, while the Veteran was still on active duty service. In particular, the VA examiners reviewed the Veteran's claims file and provided detailed medical histories, clinical evaluations, and opinions. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Thus, with respect to the Veteran's claims, there is no additional evidence which needs to be obtained. Legal Criteria Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). For a showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. If the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including (organic disease of the nervous system) are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101(3), 1112(a)(1), 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). See also Memorandum, Characterization of High Frequency Sensorineural Hearing Loss, Under Secretary for Health, October 4, 1995 (sensorineural hearing loss is an organic disease of the nervous system). Whether service connection is claimed on direct, presumptive, or secondary basis, a necessary element for establishing such a claim is the existence of a current disability. See Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) Hearing Loss There are specific requirements regarding what constitutes a hearing loss disability under VA law. The threshold for normal hearing is from 0 to 20 decibels. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran contends that he has a hearing loss that is related to service. The service treatments records in March 2006 and in May 2008 show that the Veteran complained of hearing loss. In a statement in May 2010, the Veteran reported having a hearing loss as a result of the exposure to acoustic trauma during service. He claimed that his numerous assignments during service exposed him to noise, to include as a truck driver and dental assistant. The Veteran asserted that he made dentures during service without hearing protection. The personnel records show that the Veteran was a dental assistant and supply clerk/driver. Therefore, the Board concedes that the Veteran was exposed to hazardous noise in service. See 38 U.S.C.A. § 1154(a). The service treatment records are replete with audiograms, which are presented in detail below. However, none of the audiograms show that the Veteran had impaired hearing in either ear for the purpose of the applying the law administered by VA pursuant to 38 C.F.R. § 3.385. The auditory threshold was not 40 decibels or greater in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz; nor were the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz 26 decibels or greater; nor was speech recognition scores using the Maryland CNC Test less than 94 percent. See 38 C.F.R. § 3.385. The service treatment records shows that on enlistment examination in December 1977, puretone thresholds in decibels were the following: in the right ear at 500 Hertz - 10, 1000 Hertz - 5, 2000 Hertz - 5, 3000 Hertz - 5, 4000 Hertz - 10; and in the left ear at 500 Hertz - 10, 1000 Hertz - 10, 2000 Hertz - 5, 3000 Hertz - 10, 4000 Hertz - 15. An in-service audiogram shows that in February 1983 puretone thresholds in decibels were as follows: in the right ear at 500 Hertz - 5, 1000 Hertz - 5, 2000 Hertz - 5, 3000 Hertz - 5, 4000 Hertz - 5; and in the left ear at 500 Hertz - 10, 1000 Hertz - 10, 2000 Hertz - 0, 3000 Hertz - 5, 4000 Hertz - 15. An in-service audiogram in September 1988 shows that puretone thresholds in decibels were the following: in the right ear at 500 Hertz - 0, 1000 Hertz - 5, 2000 Hertz - 0, 3000 Hertz - 15, 4000 Hertz - 15; and in the left ear at 500 Hertz - 0, 1000 Hertz - 0, 2000 Hertz - 0, 3000 Hertz - 15, 4000 Hertz - 10. In September 1988, an in-service audiogram shows that puretone thresholds in decibels were: in the right ear at 500 Hertz - 0, 1000 Hertz - 5, 2000 Hertz - 0, 3000 Hertz - 15, 4000 Hertz - 15; and in the left ear at 500 Hertz - 0, 1000 Hertz - 0, 2000 Hertz - 0, 3000 Hertz - 15, 4000 Hertz - 10. An in-service audiogram in August 1994 shows that puretone thresholds in decibels were as follows: in the right ear at 500 Hertz - 5, 1000 Hertz - 0, 2000 Hertz - 0, 3000 Hertz - 10, 4000 Hertz - 25; and in the left ear at 500 Hertz - 5, 1000 Hertz - 5, 2000 Hertz - 5, 3000 Hertz - 20, 4000 Hertz - 10. An audiogram dated in November 1996, during a period of non-active duty service, shows that puretone thresholds in decibels were as follows: in the right ear at 500 Hertz - 0, 1000 Hertz - 0, 2000 Hertz - 0, 3000 Hertz - 10, 4000 Hertz - 15; and in the left ear at 500 Hertz - 0, 1000 Hertz - 0, 2000 Hertz - 0, 3000 Hertz - 10, 4000 Hertz - 0. An audiogram dated in October 1998, during a period of non-active duty service, shows that puretone thresholds in decibels were as follows: in the right ear at 500 Hertz - 15, 1000 Hertz - 15, 2000 Hertz - 15, 3000 Hertz - 30, 4000 Hertz - 35; and in the left ear at 500 Hertz - 15, 1000 Hertz - 10, 2000 Hertz - 15, 3000 Hertz - 30, 4000 Hertz - 30. Speech recognition in both ears was 100 percent. An audiogram in March 2003, during a period of non-active duty service, shows that puretone thresholds in decibels were as follows: in the right ear at 500 Hertz - 0, 1000 Hertz - 0, 2000 Hertz - 0, 3000 Hertz - 15, 4000 Hertz - 20; and in the left ear at 500 Hertz - 0, 1000 Hertz - 0, 2000 Hertz - 0, 3000 Hertz - 15, 4000 Hertz - 15. The service treatment records include an audiogram in November 2004 that shows that puretone thresholds in decibels were the following: in right ear at 500 Hertz - 0, 1000 Hertz minus 5, 2000 Hertz - 0, 3000 Hertz - 10, 4000 Hertz - 30; and in the left ear at 500 Hertz - 5, 1000 Hertz - 5, 2000H - 0, 3000 Hertz - 20, 4000 Hertz - 15. A March 2006 audiogram shows that puretone thresholds in decibels were as follows: in the right ear at 500 Hertz - 25, 1000 Hertz - 10, 2000 Hertz - 5, 3000 Hertz - 10, 4000 Hertz - 0; and in the left ear at 500 Hertz - 15, 1000 Hertz - 10, 2000 Hertz - 5, 3000 Hertz - 0, 4000 Hertz - 15. An uninterpreted audiogram in September 2007 does not show hearing loss per VA criteria. Speech recognition was 96 percent at 55 decibels (right ear)and 100 percent at 55 decibels (left ear). An undated in-service audiogram shows that puretone decibels were: in the right ear at 500 Hertz - 15, 1000 Hertz - 10, 2000 Hertz - 10, 3000 Hertz - 20, 4000 Hertz -20; and in the left ear at 500 Hertz - 15, 1000 Hertz - 5, 2000 Hertz - 10, 3000 Hertz - 20, 4000 Hertz - 20. On VA examination in May 2008, while the Veteran was still on active duty, the examiner noted that he had been exposed to acoustic trauma during service due to his duties as a truck driver, teletype operator and dental assistant. He was exposed to loud noises from tanks, weapons, field unit and trucks. The audiogram shows that puretone thresholds in decibels were as follows: in the right ear at 500 Hertz - 10, 1000 Hertz - 5, 2000 Hertz - 15, 3000 Hertz - 25, 4000 Hertz - 30; and in the left ear at 500 Hertz - 15/10, 1000 Hertz - 10, 2000 Hertz - 15/10, 3000 Hertz - 30/25, 4000 Hertz - 30/20. Word recognition score was 100 percent at 60 dBHL in both ears. The Veteran is competent to report that which he has personally experienced, such as noise exposure and hearing problems. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Furthermore, the Board finds the Veteran's statements concerning his experiences in service and difficulties hearing to be credible. The Veteran, however, is not competent to state whether his hearing loss meets VA's requirements for a disability pursuant to 38 C.F.R. § 3.385. See Jandreau v. Nicholson, 492 F. 3d 1372. The question of disability in this instance requires specialized training, which the Veteran does not have. In this case, the above-cited testing results do not establish bilateral hearing loss disability as required by 38 C.F.R. § 3.385, as the auditory thresholds were not 40 decibels or greater at any of the frequencies, the auditory thresholds at minimum of three frequencies were not 26 decibels or greater, and the Maryland CNC speech recognition scores were not less than 94 percent. See 38 C.F.R. § 3.385. Moreover, neither the Veteran nor his representative has presented or identified existing audiometric testing results that meet the requirements of that regulation for bilateral hearing loss. Nor have they contended that he has experienced a decreased in hearing acuity during the period of the appeal. It is the Veteran's general evidentiary burden to establish all elements of the claim. 38 U.S.C.A. § 5107(a); Fagan v. Shinseki, 573 F.3d. 182, 1287 (Fed. Cir. 2009). Hence, on this record, the Veteran is not shown to have a bilateral hearing loss disability for VA purposes. The test results are controlling and clearly more probative than his lay evidence. For this reason, the Board finds that the claim of service connection for bilateral hearing loss must be denied by law. Eczema The Veteran's claim of service connection for eczema was received on March 24, 2008, while he was still on active duty. His service treatment records show treatment for various skin problems. In October 1979, the Veteran was treated for a groin rash. In January 1980, he was treated for allergic urticaria. In June 1980, he was treated for a rash on his trunk, arms, back, chest and face. The assessment was that of allergic reaction due to an unknown cause. In June 1981, the Veteran was treated for a rash on the chest and back (which the examiner noted had been there since the Veteran was 16 years old). In February 1983, the records show that the Veteran had questionable dermatitis and urticaria by history. Subsequent service treatment records show that the Veteran was treated for seborrheic dermatitis in October 1989, May 1990, August 1991 and November 1994. On the report of medical history in March 2003, the Veteran indicated that he had had eczema. On the report of medical assessment on March 13, 2008, psoriasis was noted. In May 2008, while still in service, the Veteran was afforded a VA examination. The examiner reviewed the claims folder in conjunction with the examination. The Veteran reported that he had eczema during service in 1987 while he was in Germany. He stated that it covered all of his body and was treated with daily special baths. He stated that, in 1982, he had his first attack of eczema which affected his hands and at the time was also associated with some type of fungus. The examiner noted that the Veteran currently was in complete remission and did not have any eczema. He also had a history of onychomycosis that affected his left great toe. The examination showed that there was no evidence of any rashes or deformities. The Veteran's skin was perfectly normal-looking skin. His toenails healed up and responded very well to Lamisil. The examiner was of the opinion that the Veteran's eczema was completely in remission and appeared to have been associated with some type of fungal infection. The examiner concluded that it was currently in complete remission without any adverse residual. When a claimant's medical history indicates that his condition undergoes periods of remission and recurrence, VA may be required to provide a medical examination during the period of recurrence in order to provide a proper disability rating. Ardison v. Brown, 6 Vet. App. 405, 407. While the service treatment records show a notation of psoriasis on March 13, 2008, shortly before the Veteran's claim was received, there is no current showing of eczema. The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Here, as there has been no competent evidence of eczema, the current disability requirements as articulated by the Court in McClain have not been met. The Board has considered the Veteran's statements with regard to his eczema; although he is competent to describe symptoms observable to a lay person and his statements are credible, the Veteran is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis of the specific disability at issue. See Bostain v. West, 11 Vet. App. 124, 127 (1998). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). Should the Veteran have a recurrence of eczema, he is welcome to reopen his claim. In sum, the preponderance of the evidence does not show that the Veteran has eczema. In the absence of proof of a present disability due to disease or injury that occurred in service, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Sanchez-Benitez v. Principi, 259 F.3d 1356 (2001). Under the circumstances, the Board finds that the preponderance of the evidence is against the claim and service connection for eczema must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Service connection for a bilateral hearing loss is denied. Service connection for eczema is denied. REMAND An initial rating higher than 30 percent for sinusitis with associated headaches The Veteran's last VA examination was in April 2010. At that time, he complained of having headaches, postnasal drainage and intermittently treatment with antibiotics. The service treatment records show that, in January 1984, the Veteran underwent an osteotomy whereby his maxillary sinus was lifted. On VA examination in April 2010 he stated that, since his 1984 surgery, bone spurs had developed and caused difficulty breathing. Subsequently, in a statement in June 2010, the Veteran's representative stated that a higher rating for the service-connected sinusitis with headaches was warranted as he has chronic osteomyelitis and constant headaches, pain, and tenderness of the affected sinus, purulent discharge and crusting after repeated surgeries. While the Veteran had an osteotomy affecting his maxillary sinus during service and subsequently experienced bone spurs, it is unclear whether he has osteomyelitis. As the Veteran may be entitled to a higher rating under Diagnostic Code 6513 (for chronic maxillary sinusitis), a VA examination is warranted to determine the current level of severity of the service-connected sinusitis with associated headaches. Service connection for deviated septum The service treatment records in September 2006, December 2006, January 2008, and in March 2008 showed that the Veteran had a deviated nasal septum. On VA examination in May 2008, the examiner noted that the Veteran had a history of a septum deviation to the right due to a previous injury. The assessment was that of deviated septum. The RO, in the September 2008 rating decision, denied service connection for a deviated septum on the basis that it was a congenital or developmental defect and that the service treatment records did not show that the Veteran sustained an injury to the nose during service. To the extent that the medical evidence tends to show that the deviated nasal septum is due to an injury, a VA examination is needed to determine the nature and likely etiology of the deviated septum. Service connection for pseudogout of the left foot The service treatment records dated in February 2008 show a notation of pseudogout. On the report of medical assessment in March 2008, gout of the left foot was noted. On VA examination in May 2008, while still on active duty, the examiner indicated that the Veteran had had 6 bouts of pseudogout since 2005. At the time of the examination, he was responding very well to Lodine and was in complete remission without any evidence of any deformities. As the evidence suggests that the Veteran may have pseudogout due to service, another VA examination is necessary to determine whether the Veteran currently is suffering for a chronic disease. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 C.F.R. § 3.159(c)(4)(i). Accordingly, these remaining matters are REMANDED for the following action: 1. The RO should have the Veteran scheduled for a VA examination to determine the current severity of the service-connected sinusitis with associated headaches. The claims file must be provided to and be reviewed by the examiner in conjunction with the examination. The examination report should include a detailed account of the history and pathology associated with the service-connected sinusitis. The examiner should document all surgeries the Veteran has had on his sinuses. All tests or studies deemed necessary should be conducted, and the results should be reported in detail. The examiner must address whether the Veteran has chronic osteomyelitis following radical surgery or near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. The RO then should have the Veteran scheduled for a VA examination to determine the nature and likely etiology of the claimed deviated nasal septum. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. After examining the Veteran and reviewing the entire record, the examiner should opine as to whether it is at least as likely as not that he has a disability manifested by a deviated nasal septum is due to an injury or other event or incident of his military service. The examiner should be informed that the Veteran is competent to describe observable symptoms and injuries that he experienced. 3. The RO then should have the Veteran scheduled for a VA examination to determine the nature and likely etiology of the claimed pseudogout of the left foot. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. After examining the Veteran and reviewing the entire record, the examiner should opine as to whether it is at least as likely as not that he has a disability of the left foot including any due to pseudogout that is due to an injury or other event or incident of his military service. The examiner should be informed that the Veteran is competent to describe observable symptoms and injuries that he experienced. 4. After completing all indicated action, the RO should readjudicate the Veteran's claims remaining on appeal in light of all the evidence of record. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a fully responsive SSOC and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran 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). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs