Citation Nr: 1323930 Decision Date: 07/26/13 Archive Date: 08/06/13 DOCKET NO. 09-21 802 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a skin disorder, claimed as dermatitis and/or skin cancer, to include as the residual of exposure to Agent Orange. 2. Entitlement to service connection for a chronic pulmonary disorder. 3. Entitlement to service connection for peripheral neuropathy of the hands and legs, to include as the residual of exposure to Agent Orange. 4. Entitlement to service connection for benign prostatic hypertrophy, to include as the residual of exposure to Agent Orange. 5. Entitlement to service connection for a chronic bladder disorder. 6. Entitlement to service connection for right and left knee disabilities. 7. Entitlement to service connection for a disorder of the colon, claimed as colon cancer and/or colonic polyps, to include as the residual of exposure to Agent Orange. 8. Entitlement to service connection for a disorder characterized by fatigue. 9. Entitlement to service connection for an eye disorder, claimed as visual impairment. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs WITNESS AT HEARINGS ON APPEAL The appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The Veteran served on active duty from May 1968 to May 1970, with service in the Republic of Vietnam from November 1968 to October 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal of a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The case comes to the Board from the Montgomery, Alabama RO. In a rating decision of April 2012, the RO granted entitlement to service connection for hernias of the right and left lower extremities. Accordingly, those issues, which were formerly on appeal, are no longer before the Board. In a decision of November 2012, the Board denied entitlement to service connection for bilateral hearing loss. At that same time, the Board remanded for additional development the remaining issues currently before the Board. The case is now, once more, before the Board for appellate review. Finally, for reasons which will become apparent, the appeal as to the issues of service connection for a skin disorder (including dermatitis and/or skin cancer), peripheral neuropathy of the hands and legs, a bladder disorder, a disorder of the colon (including colon cancer and/or colonic polyps), and an eye disorder is once again being REMANDED to the RO via the Appeals Management Center (AMC) in Washington, D.C. VA will notify you if further action is required on your part. FINDINGS OF FACT 1. A chronic pulmonary disorder is not shown to have been present in service, or at any time thereafter. 2. Benign prostatic hypertrophy is not shown to have been present in service, or for many years thereafter, nor is it the result of any incident or incidents of the Veteran's period of active military service, to include exposure to Agent Orange. 3. Chronic right and left knee disorders are not shown to have been present in service, or for many years thereafter, nor are they the result of any incident or incidents of the Veteran's period of active military service. 4. A chronic disorder characterized by fatigue is not shown to have been present in service, or at any time thereafter. CONCLUSIONS OF LAW 1. A chronic pulmonary disorder was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. Benign prostatic hypertrophy was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 3. Chronic right and left knee disabilities were not incurred in or aggravated by active military service, nor may osteoarthritis of the bilateral knees be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 4. A chronic disorder characterized by fatigue was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) In the case at hand, the requirements of the Veterans Claims Assistance Act of 2000 (VCAA) have been met. There is no issue as to whether the Veteran was provided an appropriate application form, or the completeness of his application. VA notified the Veteran in December 2007 and December 2012 of the information and evidence needed to substantiate and complete his claims, to include notice of what part of that evidence was to be provided by him, and what part VA would attempt to obtain. VA has also fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claims, and, as warranted by law, affording VA examinations. Currently, there is no evidence that additional records have yet to be requested, or that additional examinations are in order. Moreover, there is currently no error or issue which precludes the Board from addressing the merits of the Veteran's appeal. Finally, in reaching this determination, the Board has reviewed all the evidence in the Veteran's claims file, to include testimony presented at an RO hearing in October 2011, as well as testimony at a hearing before the undersigned, service treatment records, various articles, and both VA (including Virtual VA) and private treatment records and examination reports. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claims, and what the evidence in the claims file shows, or fails to show, with respect to those claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000), and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection The Veteran in this case seeks entitlement to service connection for a chronic pulmonary disorder, as well as for benign prostatic hypertrophy, right and left knee disabilities, and a disorder characterized by fatigue. In pertinent part, it is contended that all of the aforementioned disabilities had their origin during the Veteran's period of active military service, to include, in the case of the Veteran's benign prostatic hypertrophy, as the result of exposure to Agent Orange in the Republic of Vietnam. In that regard, service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (2012). In order to establish service connection for a claimed disability, there must be competent evidence of that disability; medical, or in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and competent evidence of a nexus between the claimed inservice disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see also Hickson v. West, 12 Vet. App. 247, 253 (1999). Where a Veteran served for ninety (90) days or more during a period of war, and osteoarthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Finally, where a Veteran was exposed to an herbicide agent during active military, naval, or air service in the Republic of Vietnam, the following diseases shall be service connected, even though there is no record of such disease during service: chloracne or other acneform disease consistent with chloracne, Type II diabetes (also known as Type II diabetes mellitus, or adult-onset diabetes), Hodgkin's disease, ischemic heart disease, including, but not limited to, acute, subacute, and old myocardial infarction, atherosclerotic cardiovascular disease, including coronary artery disease (as well as coronary spasm) and coronary bypass surgery, and stable, unstable, and Prinzmetal's angina, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease; acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (i.e., cancers of the lung, bronchus, larynx, or trachea); all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); or soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (2012). [Note (3): For purposes of this section, the term ischemic heart disease does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease.] The aforementioned disease shall become manifest to a degree of 10 percent or more anytime after service, except that chloracne, acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall become manifest to a degree of 10 percent or more within a year after the last day on which the Veteran was exposed to an herbicide agent during active military, naval, or air service. For purposes of this section, the term "herbicide" means a chemical or an herbicide used in support of the United States and Allied Military Operations in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975. 38 U.S.C.A. § 1116 (West 2002); 38 C.F.R. § 3.307(a)(6)(ii) (2012). Service in the Republic of Vietnam includes service in the waters offshore or service in other locations if the conditions of service include duty or visitation in the Republic of Vietnam. 38 U.S.C.A. § 501 (West 2002); 38 C.F.R. §§ 3.307, 3.313 (2012). In the present case, service treatment records are negative for history, complaints, or abnormal findings indicative of the presence of a pulmonary disorder, benign prostatic hypertrophy, right and/or left knee disabilities, or a disorder characterized by fatigue. In point of fact, at the time of a service separation examination in February 1970, the Veteran denied any of the aforementioned problems. A physical examination was essentially unremarkable, and no pertinent diagnoses were noted. The earliest clinical indication of the presence of benign prostatic hypertrophy is revealed by private outpatient treatment records dated in October 2007, more than 37 years following the Veteran's discharge from service, at which time it was noted that his medication (Flomax) was "not working well." Significantly, while during the course of VA outpatient treatment in 2009, there was once again noted the presence of benign hypertrophy of the prostate, at no time was that pathology attributed to the Veteran's period of active military service, to include as the result of exposure to Agent Orange. In like manner, while at the time of a Social Security Administration disability determination in July 2009, there was noted the presence of osteoarthritis in both knees "since 1999" (once again, many years following the Veteran's discharge from service), at no time was such pathology determined to be of service origin. Significantly, there is no indication that, either in service, or thereafter, the Veteran has suffered from a chronic pulmonary disorder or other chronic disorder characterized by fatigue. The Board notes that, at the time of a VA genitourinary examination in January 2013, which examination involved a full review of the Veteran's claims folder, the Veteran reported the gradual onset of urinary frequency since leaving Vietnam. Reportedly, the Veteran had been diagnosed with benign prostatic hypertrophy approximately 10 years earlier, and currently took medication for his hesitancy symptoms. In the opinion of the examiner, the Veteran's benign prostatic hypertrophy was less likely than not incurred in or caused by an inservice injury, event, or illness. This was felt to be the case given that the Veteran had served on active duty from May 1968 until 1970, at which time he was in his late teenage years and early twenties. According to the examiner, the Veteran's benign prostatic hypertrophy was not the likely cause of his reported frequent urination during active duty, inasmuch as the condition was usually seen in aging men. Accordingly, it was not likely that the onset of the Veteran's current benign prostatic hypertrophy was during active military service. On VA examination of the Veteran's knees, likewise conducted in January 2013, it was noted that the Veteran's claims folder was available, and had been reviewed. When questioned, the Veteran indicated that his knees first began to hurt in basic training when he was running with another soldier on his back while leaving the mess hall. According to the Veteran, he experienced continued pain when carrying heavy radios, or jumping out of helicopters. Current symptoms consisted of constant, moderately severe bilateral knee pain and stiffness, in conjunction with an intermittent feeling of "giving way." Radiographic studies of the bilateral knees were consistent with very minimal, early degenerative changes at the left patellofemoral space, as well as tiny right patellar osteophytes. There appeared to be a small right suprapatellar effusion, though no significant bone or joint abnormalities were otherwise evident. The pertinent diagnosis noted was bilateral knee degenerative joint disease. In the opinion of the examiner, the Veteran's bilateral knee disability was less likely than not incurred in or caused by a claimed inservice injury, event, or illness. This was felt to be the case given that the Veteran had no documented chronic history of knee problems until approximately 2001, at which time he reportedly underwent left knee surgery. While current imaging revealed evidence of minimal degenerative joint disease, in the opinion of the examiner, this joint disease would most likely be more advanced in an individual who had experienced trauma 30 to 40 years earlier. At the time of a VA respiratory examination, likewise conducted in January 2013, it was once again noted that the Veteran's claims folder was available, and had been reviewed. Significantly, when questioned, the Veteran denied any known respiratory condition. Moreover, according to the Veteran, he had never been diagnosed with such a respiratory condition. Radiographic studies of the Veteran's chest showed the lungs to be clear of any focal consolidation. No large effusion or pneumothorax was in evidence, nor was there any significant change from previous studies. At the time of examination, no pertinent diagnosis was noted. On VA chronic fatigue examination conducted in January 2013, which examination involved a full review of the Veteran's claims folder, it was noted that, by the Veteran's report, he had been treated for "combat fatigue" while in Vietnam. Moreover, according to the Veteran, he had experienced both syncopal episodes and episodes of low body temperature in 1969. Reportedly, at that time, the Veteran was treated at an aid station, and told that he had "battle fatigue." When questioned, the Veteran indicated that he continued to experience severe fatigue, as well as dyspnea on mild exertion. Additionally noted were problems with nightmares, consistent with the Veteran's being treated for (service-connected) posttraumatic stress disorder. According to the Veteran, he had no known lung or cardiac diagnoses, to include asthma, chronic obstructive pulmonary disease, sarcoidosis, or coronary artery disease. Nor did he have any history of sleep apnea, or the use of pulmonary medication or oxygen. In the opinion of the examiner, the Veteran's claimed fatigue was less likely than not incurred in or caused by a claimed inservice injury, event, or illness. This was felt to be the case given that the Veteran's separation examination in February 1970 showed negative responses for goiter, tuberculosis, asthma, shortness of breath, or chronic cough. According to the examiner, the Veteran currently had no known pulmonary condition or diagnosis of chronic fatigue syndrome. Rather, multiple factors likely contributed to the Veteran's complaint of fatigue. In that regard, a review of the Veteran's laboratory testing showed impaired glucose, with a glucose of 160 and an A1C of 5.4 percent in conjunction with a mildly elevated TSH. According to the examiner, the Veteran's conditions might initially present with a complaint of fatigue during onset. Significantly, the Veteran was additionally being treated for post-traumatic stress disorder, which, in the opinion of the examiner, might be contributing to his complaints of fatigue. The Board finds the aforementioned opinions of a VA nurse practitioner highly probative, because those opinions were based upon a review of the Veteran's entire claims folder, as well as other pertinent medical records, and full examinations, including both history and clinical findings. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion are the examiner's access to the claims file, and the thoroughness and detail of the opinion). The VA nurse practitioner reviewed the Veteran's claims folder, discussed the Veteran's medical history, provided well-reasoned medical opinions, and alluded to the evidence which supported those opinions. See Hernandez-Toyens v. West, supra. Under the circumstances, the Board is of the opinion that the probative medical evidence of record fails to establish that the Veteran suffers from a chronic pulmonary disorder or chronic fatigue, or that his benign prostatic hypertrophy or bilateral knee disabilities are in any way related to active military service. In evaluating the Veteran's claims, the Board has a duty to assess the credibility and weight to be given to the evidence of record. See Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). In that regard, the Veteran has attributed the disabilities at issue to his period of active military service, to include, in the case of benign prostatic hypertrophy, exposure to Agent Orange during his period of service in the Republic of Vietnam. However, not until November 2009, many years following his discharge from service, did the Veteran file a claim for service connection for any of those disabilities. As noted above, there is no evidence that the Veteran currently suffers from a clinically identifiable pulmonary disorder, or, for that matter, a disorder characterized by chronic fatigue. Moreover, to the extent that the Veteran does, in fact, suffer from benign prostatic hypertrophy and osteoarthritis of the bilateral knees, pertinent evidence of record is to the effect that such pathology is unrelated to the Veteran's period of active military service. Significantly, the passage of many years between discharge from service and medical documentation of a claimed disability is a factor which tends to weigh against a claim for service connection. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In this case, there is no medical evidence suggesting a link between the Veteran's benign prostatic hypertrophy and osteoarthritis of the bilateral knees and his period of active military service, or, in the case of benign prostatic hypertrophy, exposure to Agent Orange. Nor has it been demonstrated that the Veteran has in the past or presently suffers from a chronic pulmonary disorder or disorder characterized by chronic fatigue. Under the circumstances, the Veteran's claims for service connection must be denied. The Board acknowledges the Veteran's testimony regarding the origin of the disabilities at issue. However, the Board rejects those assertions to the extent that they seek to etiologically relate the disabilities at issue to the Veteran's period of active military service (including Agent Orange exposure in the Republic of Vietnam). The Veteran's statements and history, when weighed against the objective evidence of record, are neither credible nor of particular probative value. Moreover, the Veteran, as a layperson, is not competent to create the requisite causal nexus for the disabilities at issue. Rather, evidence which requires medical knowledge must be provided by someone qualified as an expert by knowledge, skill, experience, training, or education, none of which the Veteran possesses. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Based on the aforementioned, the Board is unable to reasonably associate the Veteran's benign prostatic hypertrophy or osteoarthritis of the knees with any incident or incidents of service, including, in the case of benign prostatic hypertrophy, exposure to Agent Orange. Nor is there persuasive evidence that, either in service, or thereafter, the Veteran has suffered from a chronic pulmonary disorder or a disorder characterized by chronic fatigue. Significantly benign prostatic hypertrophy is not one of those disabilities for which service connection might be granted on a presumptive basis based on inservice exposure to Agent Orange. Accordingly, the Veteran's claims for service connection must be denied. ORDER Entitlement to service connection for a chronic pulmonary disorder is denied. Entitlement to service connection for benign prostatic hypertrophy, to include as the residual of exposure to Agent Orange, is denied. Entitlement to service connection for chronic right and left knee disabilities is denied. Entitlement to service connection for a disorder characterized by fatigue is denied. REMAND In addition to the above, the Veteran in this case seeks entitlement to service connection for a chronic skin disorder (including dermatitis and/or skin cancer), peripheral neuropathy of the hands and legs, a bladder disorder, a disorder of the colon (including colon cancer and/or colonic polyps), and a chronic eye disorder characterized by loss of vision. However, a review of the record raises some question as to the exact nature and etiology of those disabilities. In that regard, service treatment records disclose that, in December 1969, the Veteran received treatment for what was described as dermatitis. However, as of the time of a service separation examination in February 1970, a physical examination of the Veteran's skin was within normal limits. Significantly, while at the time of a recent VA examination in January 2013, the Veteran received diagnoses of dermatitis, skin cancer, and lipomas, a physical examination of the Veteran's skin was essentially unremarkable. Noted at the time was that the Veteran had apparently previously undergone the surgical removal of various benign malignant skin lesions. Nonetheless, based on examination findings, it is currently unclear whether the Veteran does, in fact, suffer from a chronic skin disorder, to include dermatitis, skin cancer, or various lipomas. Significantly, in rendering her opinion, the examiner indicated that skin cancers are usually the result of sun exposure, in particular, beginning at an early age. Given that the Veteran would presumably have experienced considerable exposure to the sun during his service as a young man in Vietnam, additional development of the evidence is necessary prior to a final adjudication of his claim for service connection for a chronic skin disorder. Turning to the issue of service connection for peripheral neuropathy of the hands and lower extremities, the Board notes that service treatment records are entirely negative for any such disability. However, at the time of a service separation examination in February 1970, the Veteran gave a history of having been paralyzed in a "car wreck" in 1965, at which time he suffered a concussion and "muscle spasms." Significantly, following a Social Security disability examination in October 2008, the Veteran received a diagnosis of "peripheral neuropathy secondary to Agent Orange exposure." While it is true that, following a VA peripheral nerve examination in January 2013, the Veteran once again received a diagnosis of peripheral neuropathy of the bilateral hands and feet, it was the opinion of the examiner that the Veteran's lower extremity symptoms were likely the residuals of previous neurological injuries sustained at the time of the Veteran's preservice motor vehicle accident, while his upper extremity symptomatology ("numbness and tingling") had its origin no earlier than 1995, resulting in a left carpal tunnel release in approximately 1997. Given the apparently contradictory conclusions, the Board is of the opinion that further development of the evidence would be appropriate prior to a final adjudication of the Veteran's claim. Turning to the issue of service connection for a chronic bladder disability, the Board notes that the Veteran has complained of various genitourinary symptomatology which has reportedly been present since the time of his active service. In that regard, during the course of private outpatient treatment in March 2007, it was noted that the Veteran had recently been seen by his physician for "bladder outlet obstruction." However, as of June 2009, the Veteran was noted to be suffering from benign prostatic hypertrophy "without urinary obstruction." Significantly, while following a VA genitourinary examination in January 2013, there was once again noted the presence of benign prostatic hypertrophy, no opinion was offered as to whether the Veteran was, in fact, suffering from bladder outlet obstruction. Under the circumstances, additional development will be undertaken prior to a final adjudication of the Veteran's claim. As regards the Veteran's claim for service connection for a disorder of the colon (to include colon cancer and/or colonic polyps), it would appear that, based on the evidence of record, the Veteran has no history of colon cancer. However, that same evidence would appear to indicate that the Veteran has in the past suffered from colonic polyps. While in January 2013, the Veteran underwent a VA gastrointestinal examination for the purpose of determining the nature and etiology of his claimed disorder of the colon, no opinion was offered regarding the relationship, if any, between the Veteran's colonic polyps and his period of active military service, to include exposure to Agent Orange. Such an opinion is necessary prior to a final adjudication of the Veteran's claim. Turning to the issue of service connection for a chronic eye disorder characterized by visual impairment, the Board notes that, while at the time of a VA eye examination in December 2012, the Veteran was felt to have suffered from superficial injuries to his eyes from debris which had healed without residual disability, it was additionally noted that he suffered from bilateral cortical cataracts and bilateral dry eye syndrome. Significantly, no opinion was offered as to whether the Veteran's cataracts or dry eye syndrome were in any way related to his period of active military service. Such an opinion is necessary prior to a final adjudication of the Veteran's claim for service connection. Finally, the Board notes that, during the course of a Supplemental Statement of the Case dated in May 2013, it was noted that a VA eye examination conducted in August 2010 showed evidence of an internal hordeolum, blepharitis, dry eye, and meibomitis. Moreover, treatment records dated in November 2011 reportedly showed evidence of dry eye syndrome, retinal drusen, and refractive error with presbyopia. Significantly, such records are not at this time a part of the Veteran's claims folder, and must be obtained prior to a final adjudication of his claim for service connection for a chronic eye disorder. Accordingly, in light of the aforementioned, the case is once again REMANDED to the RO/AMC for the following actions: 1. The RO/AMC should attempt to obtain the aforementioned VA records reflecting diagnoses of and/or treatment for various eye disabilities in August 2010 and November 2011. Once obtained, such records should be made a part of the Veteran's claims folder. Should such records prove unavailable, the RO/AMC should specifically so state. 2. Any pertinent VA or other inpatient or outpatient treatment records, subsequent to January 2013, the date of the most recent VA examinations of record, should be obtained and incorporated in the claims folder. The Veteran should be requested to sign the necessary authorization for release of any private medical records to the VA. All attempts to procure such records should be documented in the file. If the RO/AMC cannot obtain records identified by the Veteran, a notation to that effect should be included in the claims file. In addition, the Veteran and his representative should be informed of any such problem. 3. The Veteran should then be afforded additional VA dermatologic, neurologic, genitourinary, gastroenterologic, and ophthalmologic examinations in order to more accurately determine the exact nature and etiology of his claimed skin disorder, peripheral neuropathy of the hands and lower extremities, bladder outlet obstruction, colonic polyps, and eye disorder. These examinations should be conducted by physicians who have not heretofore seen or examined the Veteran. The Veteran is hereby notified that it is his responsibility to report for the examinations, and to cooperate in the development of his claims. The Veteran is further to be advised that the consequences for failure to report for a VA examination without good cause may include denial of his claims. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for the aforementioned examinations, documentation should be obtained which shows that notice scheduling the examinations was sent to his last known address. It should also be indicated whether any notice sent was returned as undeliverable. Following completion of the dermatologic examination, the examining physician should specifically comment as to whether the Veteran currently suffers from a chronic, clinically-identifiable skin disorder, to include dermatitis, skin cancer, and/or lipomas, and, if so, whether such pathology at least as likely as not had its origin during, or is in some way the result of, the Veteran's period of active military service, to include exposure to sunlight and/or Agent Orange. Following completion of the neurologic examination, the examining neurologist should specifically comment as to whether the Veteran's peripheral neuropathy of the hands and legs at least as likely as not had its origin during, or is in some way the result of, the Veteran's period of active military service, to include exposure to Agent Orange. Following completion of the genitourinary examination, the examining urologist should specifically comment as to whether the Veteran currently suffers from chronic, clinically-identifiable disorder of the bladder, to include bladder outlet obstruction, and, if so, whether that pathology at least as likely as not had its origin during, or is in some way the result of, the Veteran's period of active military service. Following completion of the gastroenterologic examination, the examining gastroenterologist should specifically comment as to whether the Veteran currently suffers from recurrent colonic polyps, and, if so, whether such pathology at least as likely as not had its origin during, or is in some way the result of, the Veteran's period of active military service, to include exposure to Agent Orange in the Republic of Vietnam. Upon completion of the aforementioned, the Veteran's entire claims folder should be furnished to the same VA ophthalmologist who conducted the Veteran's December 2012 eye examination, or some other VA ophthalmologist should that ophthalmologist prove unavailable. Following a review of the Veteran's entire claims folder, that ophthalmologist should offer a supplementary opinion as to whether any clinically-identified chronic eye disorder (excluding refractive error, but including cortical cataracts and dry eye syndrome) at least as likely as not had its origin during, or is in some way the result of, the Veteran's period of active military service. A complete rationale must be provided for any opinion offered, and all information and opinions, once obtained, must be made a part of the Veteran's claims folder. The claims folder must be made available to and reviewed by the dermatologic, neurologic, genitourinary, and gastroenterologic examiners prior to completion of their examinations. In addition, the examiners must specify in their reports that the claims file and Virtual VA records have been reviewed. 4. The RO/AMC should then review the examination reports to ensure that they are in complete compliance with the directives of this REMAND, and that the examiners have documented their consideration of all records contained in Virtual VA. If the reports are deficient in any manner, the RO/AMC must implement corrective procedures. 5. The RO/AMC should then readjudicate the Veteran's claims for service connection for a chronic skin disorder (claimed as dermatitis and/or skin cancer, to include as a residual of exposure to Agent Orange), peripheral neuropathy of the hands and legs (to include as a residual of exposure to Agent Orange), a bladder disorder, disorders of the colon (claimed as colon cancer and colonic polyps, to include as the residual of exposure to Agent Orange), and a chronic eye disorder (claimed as visual impairment). Should the benefits sought on appeal remain denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case (SSOC). The SSOC must contain notice of all relevant action taken on the claims for benefits since the issuance of the most recent SSOC in May 2013. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome in this case. The Veteran need take no action unless otherwise notified. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs