Citation Nr: 1330527 Decision Date: 09/24/13 Archive Date: 09/30/13 DOCKET NO. 08-33 198 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for alcohol abuse. 2. Entitlement to service connection for fatty deposits of the liver. 3. Entitlement to service connection for high cholesterol. 4. Entitlement to service connection for joint pain, other than of the left knee and bilateral hips. 5. Entitlement to service connection for hemorrhoids. 6. Entitlement to service connection for colon polyps, claimed as diverticulitis. 7. Entitlement to service connection for joint pain of the left knee and bilateral hips. 8. Entitlement to service connection for chest pain, to include a heart disorder. 9. Entitlement to service connection for a cervical spine disorder, claimed as a pinched neck nerve. 10. Entitlement to service connection for hypertension. 11. Entitlement to service connection for a respiratory condition, to include as secondary to tuberculosis residuals. 13. Entitlement to service connection for gastroresophageal reflux disorder (GERD), to include as secondary to a service-connected disability. 13. Entitlement to service connection for a peptic ulcer or antritis, to include as secondary to a service-connected disability. 14. Entitlement to an initial compensable evaluation for residuals of tuberculosis. 15. Entitlement to an initial compensable evaluation for residuals of a left varicocelectomy. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and Friend ATTORNEY FOR THE BOARD H. Bunker, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1979 to July 1990 with service in the Army Reserve as well. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The Veteran and his friend testified before a Decision Review Officer (DRO) at the RO in Indianapolis, Indiana in May 2009. The Veteran also testified at a Board hearing at the RO in June 2012. These transcripts have been associated with the file. Also at the June 2012 Board hearing and in September 2012 the Veteran submitted additional evidence. However, the Veteran and his representative waived RO review of this evidence and therefore, Board adjudication of the current appeal may go forward without remanding the appeal for a supplemental statement of the case. See 38 C.F.R. § 20.1304(c)(2012). In a June 2010 rating decision the Veteran was granted service connection for a bilateral hearing loss disability, tinnitus, and a sinus condition. The Veteran has not disagreed with the assigned disability ratings or the effective dates. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection.) Therefore, the matters are considered resolved and are not in appellate status. Although in May 2012 the Veteran stated that he wished to withdraw the claims of entitlement to service connection for hemorrhoids and asthma, he presented testimony on these issues at his June 2012 Board hearing. Accordingly, the Board will continue adjudication of the issues as it appears the Veteran did not wish to withdraw them. The Veteran was afforded a VA examination in August 2009 for residuals of a left hand injury from service. X-rays showed a metallic object in the first metacarpal. The issue of entitlement to service connection for a scar status post left varicocelectomy has also been raised. These issues have never been adjudicated by the RO, and therefore, are REFERRED to the RO for proper adjudication. The issues of entitlement to service connection for hypertension, alcohol abuse, fatty deposits of the liver, high cholesterol, and joint pain, other than of the left knee and bilateral hips are addressed in this decision. The remaining issues are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In May 2012, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that a withdrawal of the appeal for entitlement to service connection for alcohol abuse, fatty liver deposits, high cholesterol, and joint pain other than the left knee and bilateral hips was requested. 2. The Veteran's hypertension is not related to service, nor may be presumed to be so. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran have been met for the issues of entitlement to service connection for alcohol abuse, fatty liver deposits, high cholesterol, and joint pain other than the left knee and bilateral hips. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 2. Hypertension did not manifest within one year of service and was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1112, 1113, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to review the entire record, the Board does not have to discuss each piece of evidence reviewed. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The notice requirements were met in this case by a letter sent to the Veteran in September 2006. This letter advised the Veteran of the information necessary to substantiate his claims and of his and VA's respective obligations for obtaining specified types of evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). This letter also advised the Veteran of how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran has not alleged that VA failed to comply with the notice requirements of the VCAA, and he was afforded a meaningful opportunity to participate effectively in the processing of his claim, and has in fact provided additional arguments at every stage. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005). The notice required by 38 U.S.C.A. § 5103(a) should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005). That was done in this case. The Veteran's service treatment records and VA treatment records are in the file. The VA has also obtained private treatment records and associated them with the claims file. The Veteran has not indicated that there are any additional outstanding records to be obtained. The duty to assist with obtaining medical records has been satisfied. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. A VA examination was not provided in conjunction with the Veteran's claim for hypertension, and, as discussed below, the evidence of record does not warrant one. See 38 C.F.R. § 3.159(c)(4). In the present case, there is no competent evidence of record to support a finding that the Veteran's hypertension is related to service. The Veteran himself has provided statements that his hypertension is related to service, and although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, determining the etiology of hypertension, this falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also Waters v. Shinseki, 601 F.3d 1274, 1279 (Fed. Cir. 2010) (the Veteran's conclusory lay statement is insufficient to trigger VA's duty to provide an examination with an opinion). The Veteran has not satisfied all the elements of McLendon; therefore, VA is not required to provide him with a VA examination in conjunction with his claim. In light of the foregoing, all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be granted for a chronic disease, including hypertension, when it is manifested to a compensable degree within one year of separation from 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). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a 'competent' source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. In certain instances, however, lay evidence has been found to be competent with regard to a disease with 'unique and readily identifiable features' that is 'capable of lay observation.' See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the 'authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence'). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Withdrawn Issues The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2012). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. The Board received notice in May 2012 from the Veteran that he was withdrawing the appeal of entitlement to service connection for alcohol abuse, fatty liver deposits, high cholesterol, and joint pain other than the left knee and bilateral hips and, hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review these issues on appeal and they are dismissed. Hypertension The Veteran contends that his hypertension began in service when he was "borderline," although it was not officially diagnosed at that time. See June 2012 Board hearing transcript. For VA rating purposes, 'hypertension' means that diastolic blood pressure is predominately 90 millimeter (mm) or greater; 'isolated systolic hypertension' means that the systolic blood pressure is predominately 160 mm or greater with a diastolic blood pressure of less than 90 mm. 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. At entrance to service in October 1984 the Veteran's blood pressure was recorded as 120/70. In a March 1984 dental record the Veteran's blood pressure was 142/78. It was noted he had his blood pressure checked for 3 consecutive days and it was within normal limits. In a December 1986 treatment record his blood pressure was 128/74. In a May 1989 record it was 122/84, but in November 1989 it was recorded as 130/98. Two weeks later it was recorded as 120/84. In December 1989 it was recorded as 158/90. The Board acknowledges this meets the numerical requirements to be considered for hypertension for VA purposes. However, under 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 the Veteran's blood pressure readings must be confirmed by readings taken two or more times on at least three different days. There is no evidence this finding was confirmed by additional readings. At his separation examination in June 1990 the Veteran denied high or low blood pressure and recordings showed it was 130/70. In a June 1996 examination for the Reserves the Veteran denied high or low blood pressure. His blood pressure was recorded as 128/82 and 134/80. In a May 2002 record the Veteran's blood pressure readings were 148/99, 138/82, and 132/83; hypertension was not diagnosed, nor did the Veteran indicate he was being treated for hypertension. Again, under 38 C.F.R. § 4.104, Diagnostic Code 7101, Note 1 the Veteran's blood pressure readings must be confirmed by readings taken two or more times on at least three different days. There is no evidence this finding was confirmed by additional readings. Although the Veteran was treated for multiple health complaints while in service and in the Reserves, he was not diagnosed with hypertension at any point. Post-service private treatment records indicate that the Veteran is receiving prescription medication for his hypertension. A February 2005 record indicated that it was under good control. At the Veteran's August 2008 VA examination his blood pressure was123/76. At the Veteran's August 2009 VA examinations his blood pressure was recorded as 107/69. At his May 2009 DRO hearing the Veteran testified that he was currently being treated for hypertension. At his June 2012 Board hearing he testified that he had "borderline" hypertension in service, although it was not diagnosed at that time. He also testified to taking prescription medication now, but none was taken in service. The Board finds that the preponderance of the evidence is against the Veteran's claim for service connection. The Veteran and his friend have provided statements and testimony attesting to his symptoms of hypertension. See e.g., May 2009 DRO hearing transcript. The Veteran is competent to report observable symptoms such as what medication he takes and what his blood pressure is, if he records it himself. Layno v. Brown, 6 Vet. App. 465 (1994). However, the most probative evidence of record shows that the Veteran's hypertension is not related to service. The Board acknowledges that the Veteran credibly believes he his hypertension began in service when he was borderline hypertensive. As discussed, although lay persons are competent to provide opinions on some medical issues, determining the etiology of a condition like hypertension is outside the realm of common knowledge of a lay person. See Kahana, supra. In this case, given the Veteran's lack of medical expertise, his assertions that he currently has hypertension that is related to service are beyond his competence. With regard to the presumption of service connection, the Veteran must be diagnosed with hypertension which manifested to a degree of 10 percent or more within 1 year from service for the presumption to apply. 38 C.F.R. § 3.307 (a)(3). There is no evidence he was diagnosed with hypertension within one year of discharge. As such, the presumption of service connection does not apply in the instant case. 38 C.F.R. §§ 3.307, 3.309(a). Accordingly, the Board concludes that the preponderance of the evidence is against the claim of service connection for hypertension and the benefit of the doubt rule does not apply. See 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). ORDER The appeal for entitlement to service connection for alcohol abuse is dismissed. The appeal for entitlement to service connection for fatty liver deposits is dismissed. The appeal for entitlement to service connection for high cholesterol is dismissed. The appeal for entitlement to service connection for joint pain, other than of the left knee and bilateral hips, is dismissed. Entitlement to service connection for hypertension is denied. REMAND The Veteran indicated that he is receiving benefits from the Social Security Administration (SSA) and has undergone a physical examination. See e.g., June 2012 Board hearing testimony. On remand the Agency of Original Jurisdiction (AOJ) should request any available SSA records. The Veteran was afforded a VA examination in August 2009 for his left knee and bilateral hip disorders; however the examiner did not offer an opinion as to the likelihood that the Veteran's left knee, bilateral hips, or cervical spine disorders were related to service. A new opinion should be obtained on remand. The Veteran was diagnosed with costochondritis in service in November 1984. He also reported chest pain on his separation examination. He testified he has experienced continued chest pain after separation from service and has been diagnosed with an enlarged heart. An opinion should be provided as to whether the Veteran has a heart disorder that is related to service. The Veteran has claimed multiple gastrointestinal disorders to include colon polyps, diverticulitis, GERD, hemorrhoids, a peptic ulcer, and antritis. The Veteran should be afforded a new VA examination to determine what disorders he currently has, or had at some point during the appeal period, and whether it is at least as likely as not that these disorders are related to service. An opinion should also be given as to whether any gastrointestinal disorder was caused, or aggravated by, medication prescribed for service-connected scrotal pain. Finally, the Veteran was afforded VA examinations in August 2008 and August 2009 for his tuberculosis residuals. The Veteran also has a claim pending for asthma or another respiratory condition, which may be secondary to the tuberculosis residuals. The August 2009 VA examiner did not adequately discuss these conditions, to include whether asthma was caused, or aggravated by service-connected tuberculosis residuals. Accordingly, a new examination should be scheduled. The AOJ should also obtain all outstanding VA treatment records and associate them with the claims file. Accordingly, the case is REMANDED for the following action: 1. Request from the SSA complete copies of any disability determination(s) it has made concerning the Veteran and copies of the medical records that served as the basis for any such decision(s). If these records are not available, a negative reply is required. 2. Obtain all of the Veteran's outstanding VA treatment records through the present. All information which is not duplicative of evidence already received should be associated with the claims file. If the AOJ is unable to obtain any of the relevant records sought, it shall notify the Veteran that it has been unable to obtain such records by identifying the specific records not obtained, explaining the efforts used to obtain those records, and describing any further action to be taken with respect to the claim. 38 U.S.C. § 5103A(b)(2) (West 2002). 3. After completing the directives above, have an appropriate VA physician provide an opinion to determine the likelihood that the Veteran's left knee, bilateral hip, or cervical spine disorders are related to service. The entire claims file must be reviewed by the examiner in conjunction with the opinion. The examiner should confirm in the examination report that (s)he has reviewed the folder in conjunction with the examination. The examiner should provide the following opinions: a) Is the Veteran's left knee disorder at least as likely as not related to service? The examiner should note the Veteran complained of left knee pain while in service in January 1980 and has submitted statements indicated he jumped on and off of Bradley Fighting vehicles for 12 years. b) Does the Veteran have a cervical spine disorder? If so, is it at least as likely as not related to service? The examiner should note the Veteran has testified he was moving furniture in service when he felt pain in his neck which radiated to his left side and saw a flash. See December 1988 service treatment record. c) Is the Veteran's bilateral hip disorder at least as likely as not related to service? d) Was the Veteran's bilateral hip disorder caused, or aggravated by (worsened) by his service-connected tuberculosis? If so, please state, to the extent possible, the baseline level of severity of the hip disorder before the onset of aggravation. The examiner should specifically comment on the February 2011 statement from the Veteran's private physician that his avascular necrosis of the hips was due to steroid use for tuberculosis. The supporting rationale for all opinions expressed must be provided. If the examiner is unable to provide any opinion as requested, the examiner should fully explain the reason why such opinion could not be rendered. If further examination of the Veteran is necessary to provide the requested opinion, the Veteran should be scheduled for an additional examination. It is the Veteran's responsibility to report for any examination scheduled, and to cooperate in the development of the case; the consequences of failing to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158, 3.655 (2012). 4. After completing the first two directives, have an appropriate VA physician provide an opinion to determine the likelihood that the Veteran's claimed heart disorder is related to service. The entire claims file must be reviewed by the examiner in conjunction with the opinion. The examiner should confirm in the examination report that (s)he has reviewed the folder in conjunction with the examination. The examiner must provide an opinion as to whether it is at least as likely as not (50% or greater probability) that any current heart disorder had its clinical onset during active service. The examiner should specifically review service treatment records noting diagnoses of costochondritis and post service treatment records. See e.g., September 2002 discharge summary and March 2006 stress echo test. The supporting rationale for all opinions expressed must be provided. If the examiner is unable to provide any opinion as requested, the examiner should fully explain the reason why such opinion could not be rendered. If further examination of the Veteran is necessary to provide the requested opinion, the Veteran should be scheduled for an additional examination. It is the Veteran's responsibility to report for any examination scheduled, and to cooperate in the development of the case; the consequences of failing to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158, 3.655 (2012). 5. After completing the first two directives, schedule the Veteran for a VA examination to determine what gastrointestinal conditions the Veteran has and whether any were caused or aggravated by his medication taken for his service-connected left varicocele. The entire claims file must be reviewed by the examiner in conjunction with the opinion. The examiner should confirm in the examination report that (s)he has reviewed the folder in conjunction with the examination. The examiner should provided diagnoses for the current gastrointestinal conditions the Veteran has, or had at any point during the appeal period. The examiner should then offer the following opinions: a) Whether it is at least as likely as not that a gastrointestinal condition, to include colon polyps, diverticulitis, GERD, hemorrhoids, a peptic ulcer, or antritis is related to service? The examiner should consider the Veteran's testimony that he had complaints of constipation in service as well as the service treatment records showing diagnoses of stomach pain, gastritis, and antritis. b) Whether it is at least as likely as not that the medication provided for the Veteran's service-connected scrotal pain caused or aggravated a gastrointestinal condition? If so, please state, to the extent possible, the baseline level of severity of the gastrointestinal condition before the onset of aggravation. The supporting rationale for all opinions expressed must be provided. If the examiner is unable to provide any opinion as requested, the examiner should fully explain the reason why such opinion could not be rendered. 6. After completing the first two directives, schedule the Veteran for a VA examination to determine what respiratory conditions the Veteran currently has and whether his service-connected tuberculosis residuals are causing or aggravating another respiratory condition. The entire claims file must be reviewed by the examiner in conjunction with the opinion. The examiner should confirm in the examination report that (s)he has reviewed the folder in conjunction with the examination. The examiner must provide the diagnoses for any current respiratory disorder. After doing so the examiner should provide the following opinions. a) Whether it is at least as likely as not that a respiratory condition other than tuberculosis residuals is related to service? The examiner should consider the Veteran's testimony that he was exposed to motor pool fumes and dust and uses an inhaler. b) Whether it is at least as likely as not that the Veteran's service-connected tuberculosis residuals caused or aggravated another respiratory condition? If so, please state, to the extent possible, the baseline level of severity of the respiratory disorder before the onset of aggravation. The supporting rationale for all opinions expressed must be provided. If the examiner is unable to provide any opinion as requested, the examiner should fully explain the reason why such opinion could not be rendered. 7. Ensure that all of the foregoing development actions have been completed. If any development is incomplete, take corrective action. 38 C.F.R. § 4.2. This includes ensuring the examination reports contain adequate responses to the specific questions asked. 8. After undertaking any additional development deemed necessary, readjudicate the remaining issues on appeal. If the benefits sought on appeal remain denied, in whole or in part, the Veteran and his representative must be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case must then be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs