Citation Nr: 1336790 Decision Date: 11/13/13 Archive Date: 11/26/13 DOCKET NO. 10-13 850 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to a higher initial rating for posttraumatic stress disorder (PTSD), from June 8, 2007, to March 22, 2012. 2. Entitlement to a higher initial rating for posttraumatic stress disorder (PTSD), since March 22, 2012. 3. Entitlement to a higher initial rating for traumatic arthritis, left knee, currently rated as 10 percent disabling. 4. Entitlement to service connection for hypertension. 5. Entitlement to service connection for a respiratory disorder, to include sinusitis. ATTORNEY FOR THE BOARD S. Coyle, Counsel INTRODUCTION The Veteran served on active duty from July 1974 to June 1977, and from March 2003 to May 2004, with additional service in the Army National Guard. This matter is before the Board of Veterans' Appeals (Board) on appeal of a May 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. The issues of entitlement to higher initial ratings for PTSD have been recharacterized to comport with the medical evidence of record. The issue of entitlement to a higher initial rating for traumatic arthritis, left knee, and the claims for service connection for hypertension and a respiratory disorder, 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. From June 8, 2007, to March 22, 2012, PTSD has been manifested by symptoms approximating occupational and social impairment, with deficiencies in most areas. 2. Since March 22, 2012, PTSD has resulted in symptoms approximating total occupational and social impairment. CONCLUSIONS OF LAW 1. From June 8, 2007, to March 22, 2012, the criteria for a 70 percent rating for PTSD are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.130, Diagnostic Code 9411 (2013). 2. Since March 22, 2012, the criteria for a 100 percent rating for PTSD are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist The appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection for PTSD. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial and will not be discussed. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Veteran's service treatment records and VA treatment records have been obtained; he did not identify any additional records pertinent to the appeal, and no such records are reasonably identified by the record. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. VA examinations were conducted in April 2008, October 2010, March 2012, and April 2013; the record does not reflect that these examinations are inadequate for rating purposes, because each provides sufficient evidence and opinion to make a fully informed assessment as to the nature, extent and severity of the service-connected PTSD. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). There is no indication that any additional evidence, relevant to the issues decided, is available and not part of the record. Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Dingess/Hartman, 19 Vet. App. at 486. Legal Criteria Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disability. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to apply to the veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). The Veteran is appealing the initial assignment of a disability rating, and the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. Id. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim, or whether a preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A May 2008 rating decision assigned an initial 10 percent disability rating for PTSD, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, effective June 8, 2007, the date of the claim. A July 2013 decision assigned a 70 percent rating, effective November 4, 2011. Diagnostic Code 9411 provides that a 70 percent disability rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. A 100 percent disability rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased disability rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. A Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). A higher GAF score reflects less impairment. A February 2008 VA clinical note reflects that the Veteran sought out mental health counseling, stating that he had been "maintaining, but lately it's been going down." He denied suicidal or homicidal ideation, but did report anhedonia, depression, insomnia, nightmares, flashbacks, intrusive memories, hypervigilance, increased anxiety, and a significant amount of alcohol consumption, which included a pint of whiskey and several beers each day or every other day. He indicated that he had a "pattern of suppressing traumatic stress symptoms and self-medicating with alcohol." There was a history of fleeting suicidal ideation without plan; the Veteran's love for his family kept him from considering seriously the thought of suicide. However, his wife, who was present, indicated that the Veteran had had suicidal thoughts as recently as two months prior to the interview. The Veteran's wife had the only access to the couple's sole firearm and medications. Later in February 2008, the Veteran underwent a psychiatric evaluation for the purposes of determining his eligibility to participate in a clinical research trial of a psychiatric drug meant to alleviate the symptoms of PTSD. He told the psychiatrist that his goal was to feel like himself again, that he wanted to meet new people, and "put things behind me." His reported symptoms included depression, anxiety, sleep impairment, low energy, "fleeting suicidal and homicidal thoughts," a "lack of anger control," and "relationship problems." He slept only 3 hours a night due to nightmares which occurred 4 to 5 times a week. He also experienced intrusive memories and flashbacks of his combat service which resulted from emotional triggers. He no longer went to church or large department stores. He was hypervigilant and had an increased startle response. He reported that his symptoms began after his return from Iraq in 2004. Other symptoms included tobacco and alcohol abuse; the Veteran stated that he was drinking a pint of whiskey 4 to 5 times a week. The Veteran had been married for many years and maintained full-time employment; however, the examiner stated that "these symptoms appear to be globally moderate to severe, and make it difficult for [the Veteran] to function socially, interpersonally and emotionally." A mental status examination was essentially normal. The Veteran ultimately decided not to enroll in the trial because of the potential negative interaction between the researched drug and his chronic alcohol abuse. In March 2008, he contacted VA addiction treatment staff about getting treatment for alcoholism. He stated that he drank a pint of whiskey and a beer approximately 4 to 5 times a week to "block out his feelings" and help him sleep. The staff felt that he "may be minimizing his use" of alcohol. The Veteran underwent a psychosocial assessment in April 2008 in preparation for addiction treatment and PTSD counseling. He reported the same symptoms as he had in February 2008, but went into greater detail, describing a lack of patience and easy irritability. He also reported that his alcohol abuse was having a negative impact on his relationship with his wife. He reported that his excessive use of alcohol began during his tour of duty in Iraq and accelerated after his return. He did not go out to many places or talk when drinking. He cared for his young nephew with his wife, but had little contact with his siblings, because he wanted to hide his drinking from them. In May 2008, the Veteran approached a VA psychologist with whom he had had no previous contact (he, literally, just walked into her office unannounced). He was "tearful and upset" after attending a memorial service. He stated that the service triggered his PTSD symptoms and that he had been "suffering emotionally for several days." The counselor advised him on coping strategies and advised the Veteran to continue with treatment for alcohol abuse. Notwithstanding, the Veteran ultimately dropped out of the alcohol abuse program. In July 2008, the Veteran stated that he was "struggling." His symptoms had increased in severity, and he had had suicidal thoughts for 1 to 2 months; however, he denied having a plan or intent to commit suicide. He had "panicky feelings in public places." He did leave the house daily, but avoided crowds. He had loud verbal outbursts without physical violence approximately twice a week. He was drinking a half a pint to a pint of whiskey a day, and his tobacco use had increased. The Veteran also approached his former addiction counselor and stated that his employment requirements prevented his continuing with treatment, but he was hopeful that antidepressants would improve his symptoms. He was looking forward to playing golf again, since his participation had been limited recently due to his increased PTSD symptoms, which included anhedonia. In November 2008, the Veteran underwent a VA mental health consult. He was not entirely compliant with his antidepressant regimen, but reported that his mood and sleep impairment were improving. The remainder of his symptoms, including his alcohol abuse, were unchanged. In January 2009, the Veteran's wife contacted VA mental health staff, stating that her husband had become upset and grabbed a gun while intoxicated. She intimated that it was a suicidal gesture, although she stated that the Veteran did not make any statements specifically about suicide, and she was able to take the firearm from him. She reported that the Veteran contacted the VA suicide hotline that day. The Veteran then came to the phone, reporting symptoms of increased depression. He denied feeling suicidal, but did admit to suicidal thoughts on the day that his wife described. He insisted that he had no plan to commit suicide and that his thoughts that day were influenced by alcohol. In February 2009, the Veteran reported that his symptoms were back to baseline, and had not improved or deteriorated. He continued to state that he had no suicidal intent at that time. He also approached his addiction counselor about the possibility of rejoining the treatment program. In August 2009, the Veteran's wife stated that he drank a pint of whiskey every day and isolated himself from her. He also seemed very restless when sleeping, and became angry with her when she tried to encourage him to get help for his drinking. In September 2009, the Veteran enrolled in treatment for alcohol abuse, but never started the program. Mental health treatment notes in October 2009 and December 2009 show that the Veteran's symptoms were essentially unchanged, although he was drinking more. The Veteran did seek mental health treatment intermittently throughout 2010, with symptoms unchanged. The Veteran underwent a PTSD examination in October 2010. His symptoms were reported as they usually were. He had worked in aircraft maintenance for 25 years, but that he was "not as motivated and gets irritable." The examiner stated that the veteran's "employment and social life [are] affected by his tendency to isolate and irritability." He had had increased depression, with suicidal thoughts 2 weeks prior to the examination. He did not get along with his wife or engage in social events, but he did play golf a couple of times a week. A mental status examination was normal. A GAF score of 55 was assigned. The examiner described the Veteran as having a "fair to good" capacity for adjustment, with no time lost from work due to his mental health symptoms. The examiner also stated that the Veteran's alcohol abuse was not the result of his PTSD, but did not provide a rationale for that conclusion. He described the impact of the Veteran's PTSD symptoms on his social and occupational functioning as "moderate." During a June 2011 hearing before a Decision Review Officer, the Veteran reported that his symptoms were again unchanged. His wife stated that his alcohol abuse was negatively impacting their relationship, and reported that he became "out of control" when drinking. His drinking was impacting their finances as well. They did nothing they had once done as a couple together. They never went anywhere or visited family. Their young nephew still came to the house, but had become aware of the Veteran's impairment from alcohol and had decreased the frequency of his visits. The Veteran isolated himself on the back porch of his home after work and smoked and drank. He also did not eat properly. The Veteran stated that if he went to the store, it had to be at 4 AM so he did not encounter crowds. The Veteran also stated that his symptoms affected his employment and that he was trying to get time off of work to take care of himself. He stated that sometimes he liked living and sometimes he didn't, but felt that he was better off away from everything, where he could live with his own misery and not make his family and friends miserable as well. He stated that he had not "had it together since Iraq." In August 2011, the Veteran filed for disability benefits with the Social Security Administration. Although he reported that his musculoskeletal disabilities were the primary cause of his inability to work, the Veteran did report that he had had PTSD since his return from Iraq, that he did not handle stress well, and that he had to stick to a routine in order to cope. Disability benefits were granted on the basis of his cardiomyopathy; psychiatric symptomatology was not considered to be a factor, since the Veteran did not submit any medical evidence regarding his mental health symptoms or treatment for PTSD. In February 2012, the Veteran reported that he drank every day to help him sleep and to block out unwanted memories of Iraq. He stated that his alcohol abuse had caused relationship problems and difficulties with his siblings because of his irritability. A March 22, 2012 PTSD examination described the Veteran's symptoms as productive of "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation." However, the Veteran stated that he had decreased concentration; that he ruminated over things; and that he had insomnia. His self-care was decreased, as he had lost 15 pounds because of poor appetite. He felt hopeless and had fatigue. A mental status examination reflected "concrete thought" and suicidal ideation with plan, but no intent. A GAF score of 50, indicative of serious symptoms, was assigned. The examiner also noted "limitations in [the Veteran's] ability to maintain/gain employment; the veteran's serious symptoms may also prevent him from engaging in gainful employment with physical or sedentary work." The Veteran underwent another VA examination in April 2013. The examiner stated that the Veteran's "PTSD is clearly [worse] than his current 10% rating evidenced by his depression, suicidal ideation and violent urges ... along with his preoccupation with the Iraq War." His symptoms were unchanged from those reported on his previous examination. He was still drinking excessively, although the examiner stated that his alcohol use was a separate disorder from his PTSD, because PTSD resulted in preoccupation with the Iraq War and alcohol abuse resulted in overuse of alcohol. He and his wife were afraid that he would "misuse" a firearm because of his chronic suicidal ideation. A GAF score of 55, indicative of moderate symptomatology, was assigned; however, the examiner described the Veteran's symptoms as productive of "severe occupational and social impairment," with "deficiencies in most areas." From June 8, 2007, to March 22, 2012, the Veteran's symptoms most closely approximate severe occupational and social impairment with deficiencies in most areas. The Veteran's symptoms include suicidal ideation, with a suicidal gesture in January 2009. Both he and his wife reported that he began using alcohol to great excess after his return from Iraq. The Veteran and his wife are competent to report the onset and frequency of the Veteran's alcohol abuse. Layno v. Brown, 6 Vet. App. 465, 467-69 (1994). Although VA examiners have indicated that the Veteran's alcohol abuse is a separate disease process from his PTSD, his VA clinical treatment providers have tended to view his alcohol use as a symptom of his PTSD, rather than a separate disorder. The Veteran has indicated that he uses alcohol to help him sleep and to block out unwanted memories. As the VA examiners have provided no real rationale for their finding that the Veteran's alcohol abuse is a separate disorder from PTSD, their opinions as to the etiology of the Veteran's alcohol abuse are of limited probative value. The reports from the Veteran's clinicians are of greater probative weight, as they are uncontradicted by any other competent evidence of record. Both the Veteran and his wife stated that the Veteran's common routine was to come home from work, sit on the back porch of his home and drink and smoke until late at night. His actions negatively impacted his relationship with his wife and family. He rarely engaged in the community, except to go to work as an aircraft mechanic and play golf. Prior to March 22, 2012, the Veteran's overall clinical picture indicates that his psychiatric manifestations impaired his ability to function appropriately and effectively. His symptomatology most closely approximates a 70 percent disability rating for this period of time. The Veteran is not entitled to a 100 percent disability rating prior to March 22, 2012. The Veteran is consistently shown to be oriented in all spheres and there is no demonstration of grossly inappropriate behavior(s). Following his leaving his job as an aircraft mechanic, he applied for disability from the Social Security Administration in August 2011; notably failing to disclose his psychiatric symptomatology. Additionally, he was able to maintain some relationship, albeit a strained one, with his wife. However, the March 22, 2012 VA examiner found that the Veteran's symptoms were of such severity that they alone might preclude his participation in substantially gainful employment. Additionally, the Veteran's reported symptoms reflect an increase in severity from his previous baseline. Specifically, his ability to engage in activities of self-care was decreasing, as evidenced by poor appetite and weight loss, and the frequency and severity of his suicidal ideation was increasing. In March 2012, the Veteran indicated that he did have a plan to commit suicide, and on VA examination in April 2013, reported a fear that he might "misuse" a firearm, even though all of his firearms were purportedly hidden away. While the GAF scores reflect no more than moderate to serious symptoms, they are inconsistent with the overall clinical picture consistently presented by virtually every clinician. Accordingly, the Board assigns more probative value to the narratives describing the Veteran's symptoms. Resolving all doubt in the Veteran's favor, since March 22, 2012, his symptoms are of such severity that they result in total occupational impairment. A disability evaluation of 100 percent for PTSD from March 22, 2012, is warranted. Other Considerations Consideration has also been given regarding whether the schedular evaluation of 70 percent prior to March 22, 2012, is inadequate, requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The schedular evaluation of 70 percent prior to March 22, 2012, is adequate. The Veteran was employed on a full-time basis until 2011, and there is no indication of record prior to March 2012 that the Veteran's PTSD resulted in marked interference with employment. The diagnostic criteria adequately describe the severity and symptomatology of the Veteran's PTSD and extraschedular consideration is not required. As a 100 percent evaluation has been granted for PTSD from March 22, 2012, the application of 38 C.F.R. § 3.321(b)(1) is moot with respect to that period of time. TDIU was granted effective November 4, 2011, although there is no evidence that the Veteran's service-connected disabilities, by themselves, rendered him unemployable as of that date. The Veteran did not assert, at any point prior to his March 2012 VA examination, that his PTSD resulted in an inability to maintain substantially gainful employment. Moreover, although the Veteran received disability benefits from the SSA effective May 2011, those benefits were awarded for cardiomyopathy, a disability that is not service-connected. Thus, entitlement to a TDIU prior to November 4, 2011, has not been raised in connection with the claim on appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Entitlement to an initial rating of 70 percent for PTSD from June 8, 2007, to March 22, 2012, is granted. Entitlement to an initial rating of 100 percent for PTSD since March 22, 2012, is granted. REMAND In March 2013, the Veteran submitted written authorization to obtain updated treatment records from Dr. M.B. and Dr. S.J., who have treated him for hypertension and left knee pain, respectively. The most recent records from Dr. M.B. are dated January 2012, and the most recent records from Dr. S.J. are dated March 2012. Remand is required so that updated treatment records may be obtained. 38 C.F.R. § 3.159(c)(1). Updated VA treatment records must also be requested. In January 2012, a nurse practitioner in Dr. M.B.'s practice provided a letter indicating that the Veteran's hypertension may be the result of exposure to asbestos. The record contains evidence, in the form of emails from officers with the Veteran's unit to other Army officials, that significant quantities of asbestos were present in broken ceiling tiles located near the Veteran's barracks in Iraq. The Veteran's service treatment records also corroborate the potential exposure to asbestos. Clinical notes from Dr. M.B.'s practice also indicate that there may be a link between the Veteran's hypertension and his PTSD. A VA examination must be scheduled to determine the etiology of the Veteran's hypertension. In the years immediately following his return from Iraq, the Veteran was intermittently diagnosed with sinusitis. He asserts that he had symptoms of sinusitis during service. His service treatment records reflect that he was treated on one occasion for symptoms that were assessed as possible allergies. A VA examination is also necessary to determine the etiology of the Veteran's respiratory disorder. Accordingly, the case is REMANDED for the following action: 1. Obtain all VA treatment records since July 2013. 2. Provide the Veteran with VCAA notice on the claim for hypertension as secondary to PTSD. 3. After obtaining any necessary updated authorization from the Veteran, obtain all treatment records from Dr. M.B. since January 2012, and from Dr. S.J. since March 2012. 4. After the aforementioned development has been completed, schedule the Veteran for a VA hypertension examination by an appropriate medical professional. The entire claim file (i.e., the paper claim file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claim file so they can be available to the examiner for review. The examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that hypertension is related to the Veteran's service, to include exposure to asbestos, or, alternatively, whether it is caused or aggravated by his PTSD symptoms. The examiner must reconcile his or her finding with the January 2012 letter purporting to link the Veteran's hypertension with exposure to asbestos, as well as the private treatment records indicating a potential link between the Veteran's hypertension and his PTSD symptoms. The term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 5. Then, schedule the Veteran for a VA respiratory disorders examination by an appropriate medical professional. The entire claim file (i.e., the paper claim file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claim file so they can be available to the examiner for review. The examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any respiratory disorder, to include rhinitis and/or sinusitis, is related to the Veteran's service, to include exposure to asbestos. The examiner must reconcile his or her finding with the 2004 service treatment record documenting coughing, sneezing, and similar complaints, which were assessed as possible allergies, as well as the Veteran's statements that he experienced symptoms similar to sinusitis during service, which are to be presumed true for purposes of this examination. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 6. Then, readjudicate the issues on appeal. If any benefit sought continues to be denied, issue a supplemental statement of the case and return the case to the Board. The appellant has the right to submit additional evidence and argument on the 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 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. 2013). ______________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs