Citation Nr: 1525429 Decision Date: 06/15/15 Archive Date: 06/26/15 DOCKET NO. 13-24 417 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Honolulu, Hawaii THE ISSUES 1. Entitlement to service connection for a left ankle disorder. 2. Entitlement to a disability rating in excess of 10 percent for a service-connected low back disability. 3. Entitlement to service connection for a gastrointestinal disorder (to include irritable bowel syndrome (IBS), acid reflux, and gastroesophageal reflux disease (GERD)), to include as secondary to the Veteran's service-connected back disability. 4. Entitlement to service connection for a cough, to include as secondary to a service-connected gastrointestinal disorder. 5. Entitlement to service connection for an acquired psychiatric disorder, to include depression and insomnia. 6. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to a service-connected acquired psychiatric disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD G.R. Waddington, Associate Counsel INTRODUCTION The Veteran had active duty from November 2001 to April 2008. This matter is before the Board of Veteran's Appeals (Board) on appeal from a March 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii. The Veteran's claim of service connection for depression has been re-characterized as a claim of service connection for an acquired psychological disorder, to include depression and insomnia. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that VA must construe a claim for service connection to include any disability that may reasonably be encompassed by the claimant's description of the claim, the symptoms the claimant describes, and the information the claimant submits or the Secretary obtains in support of the claim). The Veteran's claims of entitlement to service connection for IBS and acid reflux have also been recharacterized; they have been combined into a claim of entitlement to service connection for a gastrointestinal disorder, to include IBS, acid reflux, and GERD, to include as secondary to the Veteran's service-connected back disability. Id. The Veteran testified before the undersigned at a November 2014 video-conference hearing. The undersigned noted the issues on appeal and engaged in a colloquy with the Veteran toward substantiation of the claim. See Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). A transcript of the hearing is in the claims file. This appeal was processed using the Virtual VA paperless claims processing system. Any future consideration of this case should account for the electronic record. The issues of entitlement to a disability rating in excess of 10 percent for a service-connected low back disability and entitlement to service connection for a gastrointestinal disorder (to include as secondary to the Veteran's service-connected back disability), a cough (to include as secondary to a gastrointestinal disorder), an acquired psychiatric disorder (to include depression and insomnia), and ED (to include as secondary to an acquired psychiatric disorder) are addressed in the REMAND section of the decision and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The Veteran's left ankle disorder does not relate to service. CONCLUSION OF LAW The criteria for entitlement to service connection for a left ankle disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2014). REASONS AND BASES FOR FINDING AND CONCLUSION VA has satisfied its duties under The Veteran's Claims Assistance Act of 2000 to notify and assist. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2014). A November 2010 letter notified the Veteran of the elements of service connection and informed him of his and VA's respective responsibilities for obtaining relevant records and other evidence in support of his claims. The duty to notify is satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). VA's duty to assist under the VCAA includes helping claimants to obtain service treatment records (STRs) and other pertinent records. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The claims file contains the Veteran's STRs, private medical records (PMRs), and VA medical records (VAMRs). The duty to obtain relevant records is satisfied. See 38 C.F.R. § 3.159(c). VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The June 2013 VA examiner reviewed the Veteran's relevant medical history, examined the Veteran, and provided an opinion (with rationale) that is sufficiently clear to enable the Board to make a fully informed decision. The July 2013 VA examination report is adequate to decide the Veteran's claim. VA has satisfied its duties to notify and assist and the Board may proceed with appellate review. Merits of the Claim The Veteran alleges that his left ankle disorder relates to an in-service injury. STRs document that the Veteran injured his left foot-ankle in service; however, the medical evidence does not suggest that the Veteran's current left foot-ankle disorder was caused or aggravated by his in-service injury or otherwise relates to service. The claim is denied. Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2014). Entitlement to service connection may be established on a direct basis with evidence showing (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement).). 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In December 2006, the Veteran injured his left foot-ankle after he fell from his upper bunk during active duty. December 2006 Service Treatment Records (STRs). A physical examination revealed that the left foot was painful and swollen and the Veteran was diagnosed as having an abrasion and sprain. X-rays taken at the time (December 2006) revealed a normal left foot and ankle (i.e., no fracture, dislocation, arthritics, or inflammatory changes). The Veteran had not injured his left foot-ankle prior to December 2006. See October 2001 Report of Medical History; August 2005 STRs (denying previous trauma to the left leg). STRs from July 2007 indicate no bone, joint, or muscle problems that prevented the Veteran from doing physical activity of any kind and/or performing his military duties. See October 2007 Report of Medical History (denying foot or joint trouble upon separation from service). The Veteran's March 2008 Reports of Medical Assessment and History indicate that he may have had an ankle problem in service, but do not specify the affected ankle. A June 2008 VA Examination Report noted that the Veteran injured his right ankle in service when he slipped and hit a bunk bed while serving aboard the U.S.S. Crommelin in 2006. The examiner observed problems with the Veteran's right ankle, knees (bilaterally), and spine, but not his left ankle. Post-service medical records indicate that the Veteran did not experience left foot-ankle problems for several years after service. In January 2010, a VA physical examination found normal reflexes and mobility of the joints in the Veteran's upper and lower extremities. Similarly, the October 2010 VA Joints Examiner found that the Veteran had no restrictions on standing or walking, a normal gait, and no need for assistive devices. See also December 2010 VA Spine Examination Report (noting no limitations on walking). In April 2012, the Veteran was evaluated for left dorsal foot pain a day after walking on the beach in sandals. He reported intermittent, sharp pain in his left foot (third and fourth digit flexor longus tendons dorsally), denied trauma to the left foot-ankle, and was diagnosed as having flexor longus tendon sprain. VAMRs from October 2012 document a history of foot pain (unspecified). In June 2013, a VA examiner opined that the Veteran's reported left foot-ankle disorder was not caused by the sprain that resulted from his in-service left foot-ankle injury. She noted that the Veteran required emergency medical care after he slipped and twisted his left foot in service and used crutches for a few days to support his weight. However, she also noted that the Veteran did not receive any follow-up care for his in-service left foot injury, that at the time (December 2006) the Veteran was diagnosed as having "left foot contusion-resolved," and that his separation examination did not indicate any problems with the left foot-ankle. The VA examiner explained that an ankle sprain that resulted in problems several years after service would have required ongoing medical treatment and that the Veteran's post-service medical treatment records do not show any treatment for left foot-ankle pain until six years after service. Physical examination revealed no swelling or deformity of the left foot and slight tenderness to palpation. The examiner found no evidence of arthritis. June 2013 VA Examination Report. The June 2013 VA examination report constitutes probative evidence that weighs against the Veteran's claim. The examination was performed by a medical doctor who reviewed the pertinent medical evidence, considered the Veteran's self-reported medical history, and provided a clear rationale for why the Veteran's current left foot-ankle disorder is not consistent with his in-service injury. The Board has considered the Veteran's statements regarding the etiology of his current left foot-ankle disorder. During the June 2013 VA examination, the Veteran reported that he experiences left foot-ankle pain when running/walking on uneven ground and when he twists his foot and that his prescription medications for back pain control his left foot-ankle pain. June 2013 Report of Medical Examination. In November 2014, the Veteran testified that he injured his left foot-ankle in service and was treated for a left ankle sprain and placed on profile. He also testified that he has experienced intermittent left foot-ankle pain since service and that he requires treatment for his disorder. See also December 2013 Statement of Representative in Appeals Case. The Veteran's separation examination of medical examination constitutes probative evidence that he did not experience any left foot-ankle problems on separation from service. The Veteran's March 2008 medical assessment was performed to ascertain the Veteran's state of physical health and is equivalent to statements of diagnosis and/or treatment. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that recourse to the Federal Rules of Evidence may be appropriate to assist in the articulation of the Board's decision); see also LILLY'S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (observing that statements made to physicians for purposes of diagnosis and/or treatment are often exempted from the general prohibition of hearsay because the declarant has a strong motive to tell the truth in order to receive proper medical care). Similarly, the October 2007 and March 2008 Report of Medical History constitutes a complete assessment of the Veteran's medical problems at separation from service. See AZ v. Shinseki, 731 F. 3d 1303, 1315 (Fed. Cir. 2013) (finding that the absence of an entry in a record may be considered evidence that a fact did not occur if the fact would have been recorded if present); Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (holding that silence in the STRs can constitute "contradictory" evidence weighing against the credibility of a claimant's testimony if the STRs are complete "in relevant part," and there is competent evidence that the claimed "injury, disease, or related symptoms would ordinarily have been recorded had they occurred"). In addition, the Veteran completed over a year of service after his December 2006 left foot-ankle injury with no indication of ongoing foot or ankle problems. Thus, the Veteran's STRs suggest that the Veteran's left foot-ankle injury was acute and resolved prior to separation from service. Although the Veteran is competent to identify symptoms such as pain and swelling, he is not competent to determine if his left foot-ankle disorder was caused or aggravated by service. Whether the Veteran's left foot-ankle disorder relates to his in-service left foot-ankle injury is a medically complex determination that cannot be based on lay observation alone. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77, n.4 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet. App. 303, 309. Such a determination must be made by a medical professional with appropriate expertise. Id. Because the Veteran's statements are not based on medical training and/or experience, his assertion that his left foot-ankle disorder relates to service does not constitute competent evidence and is therefore outweighed by the VA examiner's opinion, which was rendered by a medical expert and is based on the Veteran's medical history. See Layno v. Brown, 6 Vet. App. 465, 470-71 (1994). The preponderance of the evidence is against the Veteran's claim. The benefit-of-the-doubt rule does not apply and service connection for a left foot-ankle disorder is denied. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55. ORDER Service connection for a left ankle disorder is denied. REMAND The Veteran's increased rating claim is remanded for a new VA examination to assess the severity of the Veteran's service-connected back disability. The Veteran's service-connection claims are also remanded for VA examinations with opinions as to whether the Veteran's gastrointestinal disorder, cough, acquired psychiatric disorder, and/or ED relate to service. The case is REMANDED for the following actions: 1. Provide the Veteran with release forms and request that he identify any relevant private medical records (PMRs) that are not in the claims file. If the Veteran returns the forms, attempt to obtain the identified PMRs and associate them with the claims file. If any records are unavailable, document their unavailability within the claims file and provide the Veteran with notice of this fact in compliance with 38 C.F.R. § 3.159(e)(1). 2. Obtain any outstanding VA medical records (VAMRs) from May 2013 onwards and associate them with the claims file. 3. Return the claims file to the VA examiner who performed the September 2013 VA examination for a new medical examination to assess the severity of the Veteran's service-connected spine disability. If that examiner is not available, a similarly qualified examiner may conduct the examination. The entire claims file, to include a copy of this remand, must be made available to the examiner, who must note its review. a. The VA examiner must conduct a complete back examination and provide a comprehensive assessment of the severity of the symptoms associated with the Veteran's low back disability. The assessment must: Provide the range of motion of the Veteran's thoracolumbar or entire spine expressed in degrees. Conduct repetitive motion testing and note any decrease of range of motion (in degrees) after repetitive use. Determine whether the back exhibits any weakened movement, excess fatigability with use, incoordination, painful motion, and/or pain with use and express any additional limitation of motion in terms of additional degrees of motion lost. State whether there is any ankylosis of the thoracolumbar spine or whether the Veteran experienced any incapacitating episodes related to intervertebral disc syndrome expressed in days and/or weeks. Also state whether the Veteran experiences muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. If possible, the examiner should determine the duration of the Veteran's current symptoms and any resulting limitations in range of motion within the claims period. b. The examiner has an independent responsibility to review the entire record for pertinent evidence, INCLUDING ANY PERTINENT EVIDENCE ADDED TO THE RECORD AS A RESULT OF THIS REMAND. The examiner's attention is called to: June 2008 VA Examination Report, documenting the range of spinal motion and finding that the Veteran's thoracolumbar strain affected his occupational and daily activities. See also December 2009 VA Examination Report (finding that the Veteran's thoracolumbar spine was normal). January 2010 PMRs, reporting a 10 percent improvement in the symptoms associated with the Veteran's diagnosed chronic lumbosacral strain but also reporting constant pain and a new complaint of mid-back pain. January 2010 VA Medical Records (VAMRs), noting that the Veteran's back disability improved with physical therapy after he injured his back in service in 2004, but that his symptoms are worsening and he has begun to see a chiropractor. May 2010 VAMRs, reporting back pain that worsens during the course of the day. December 2010 VA Examination Report, documenting the range of spinal motion, no ankylosis, and no muscle spasm, guarding, weakness, or localized tenderness that results in an abnormal gait. February 2012 VAMRs, reporting increased low back pain. See also December 2011 VAMRs (reporting limited ability to run or play golf as well as pain with bending and prolonged sitting); January 2012 VAMRs (noting the recent onset of lower thoracic pain with a long history of lumbar pain). April 2012 VAMRs, noting full forward flexion and extension, no pain with range of motion, and chronic back pain. September 2013 VA Thoracolumbar Spine Examination Report, recording the Veteran's range of spinal motion and the functional limitations associated with his service-connected low back disability. September 2014 Disability Benefits Questionnaire, documenting the Veteran's range of spinal motion and the functional limitations associated with the Veteran's service-connected low back disability. 4. After the passage of a reasonable amount of time or upon the Veteran's response to remand directive one (1), schedule an examination with an opinion as to whether the Veteran's gastrointestinal disorders relate to service, to include as secondary to a service-connected low back disability. The entire claims file, to include a copy of this REMAND, must be provided to the VA examiner, who must note its review. The following considerations must govern the examination: a. The VA examiner must diagnose the Veteran's specific gastrointestinal disorders, before determining whether any of the diagnosed disorders relate to service. Specifically, the examiner should diagnose IBS, acid reflux, and/or GERD. If the examiner is unable to provide the requested diagnoses, he or she must explain why diagnosis is not possible and address any medical evidence that is contrary to this finding. b. The VA examiner must opine as to whether any or all of the Veteran's diagnosed gastrointestinal disorders are caused or AGGRAVATED (I.E., PERMANENTLY WORSENED) by service. c. The VA examiner must also opine as to whether any or all of the Veteran's gastrointestinal disorders are caused or AGGRAVATED (I.E., PERMANENTLY WORSENED) by the medications prescribed for the Veteran's service-connected back disability. d. The examiner has an independent responsibility to review the entire record for pertinent evidence, INCLUDING ANY PERTINENT EVIDENCE ADDED TO THE RECORD AS A RESULT OF THIS REMAND. The examiner's attention is called to: October 2001 Reports of Medical Examination and History, indicating that the Veteran was in good health and had no ongoing medical problems upon entrance to service. See also December 2002 Reports of Medical Examination and History. October 2006 Chronological Record of Medical Care, indicating that the Veteran did not have any ongoing medical problems and was in good health. October 2007 Report of Medical History, denying stomach, liver, and/or intestinal troubles as well as an ulcer disorder. January 2010 VAMRs, noting that the Veteran's back disability does not result in incontinence. May 2010 through July 2010 VAMRs, documenting a history of alcohol abuse, to include binge drinking. See also May 2012 VAMRs (noting that the Veteran had reduced his drinking). July 2010 VAMRs: presenting with severe abdominal pain and cramping that has been ongoing for several years; reporting that the Veteran's gastrointestinal symptoms are not associated with particular foods and that he occasionally has loose stools. May 2013 VAMRs, reporting that the Veteran's gastritis improved with prescription ranitidine, that he has reduced his alcohol intake, and that his bowels remain unpredictable. Also, noting that the Veteran "feels like he has IBS [irritable bowel syndrome]" and continues to experience symptoms such as increased gas, alternating diarrhea and constipation, and "churning." November 2014 Hearing Transcript, testifying that the Veteran's stomach problems relate to the medications prescribed to manage his back pain. 5. After the gastrointestinal examination required by remand directive four (4) is completed (and the Veteran's specific gastrointestinal disorders identified), schedule another VA examination with an opinion as to whether the Veteran's reported cough disorder relates to service, to include as secondary to a gastrointestinal disorder. ALTERNATIVELY, the requested opinion may be provided by the VA examiner who performed the gastrointestinal examination and as part of the gastrointestinal examination. The entire claims file, to include a copy of this REMAND, must be provided to the VA examiner, who must note its review. The following considerations must govern the examination: a. The VA examiner must diagnose the Veteran's specific cough disorder. If the examiner is unable to provide the requested diagnosis, he or she must explain why diagnosis is not possible (e.g., the cough is an acute disorder that has resolved or is a symptom of a separate disorder). b. The VA examiner must opine as to whether the Veteran's cough disorder was caused or AGGRAVATED (I.E., PERMANENTLY WORSENED) by service. c. The VA examiner must also opine as to whether the Veteran's cough disorder was caused or AGGRAVATED (I.E., PERMANENTLY WORSENED) by any of his diagnosed gastrointestinal disorders. d. The examiner has an independent responsibility to review the entire record for pertinent evidence, INCLUDING ANY PERTINENT EVIDENCE ADDED TO THE RECORD AS A RESULT OF THIS REMAND. The examiner's attention is called to: October 2001 Reports of Medical Examination and History, indicating that the Veteran was in good health and had no ongoing medical problems upon entrance to service. See also December 2002 Reports of Medical Examination and History. December 2001 and 2002 STRs, documenting treatment for nasal congestion, sore throat, and a cough. December 2002 Reports of Medical Examination and History, indicating that the Veteran was in good health and had no ongoing medical problems. See also October 2006 Chronological Record of Medical Care. October 2007 Report of Medical History, denying cough or any breathing problems. June 2008 VA Examination Report, finding normal nose, sinuses, mouth, and throat. May 2010 VAMRs, documenting constant throat irritation and clearing of the throat. October 2010 VAMRs, reporting that the Veteran often feels like he needs to clear his throat and that he produces a lot of mucous when he runs. November 2014 Hearing Transcript, testifying that the Veteran's cough results from his stomach problems. e. The examiner must provide a complete explanation of his or her opinion, based on his or her clinical experience and medical expertise and on established medical principles. If the requested medical opinion cannot be given, the examiner must state the reason(s) why. 6. After the passage of a reasonable amount of time or upon the Veteran's response to remand directive one (1), schedule a mental health examination with an opinion as to whether the Veteran's acquired psychiatric disorder, to include depression and insomnia, relates to service. The entire claims file, to include a copy of this REMAND, must be provided to the VA examiner, who must note its review. The following considerations must govern the examination: a. The VA examiner must diagnose the Veteran's individual mental health disorders. If the examiner is unable to provide the requested diagnosis, he or she must explain why diagnosis is not possible and address any medical findings that are contrary to the examiner's opinion. b. The VA examiner must opine as to whether the Veteran's acquired psychiatric disorder was caused or AGGRAVATED (I.E., PERMANENTLY WORSENED) by service. c. The examiner has an independent responsibility to review the entire record for pertinent evidence, INCLUDING ANY PERTINENT EVIDENCE ADDED TO THE RECORD AS A RESULT OF THIS REMAND. The examiner's attention is called to: October 2001 Reports of Medical Examination and History, indicating that the Veteran was in good health and had no psychiatric problems upon entrance to service. See also December 2002 Reports of Medical Examination and History. October 2006 Chronological Record of Medical Care, indicating that the Veteran did not have any ongoing psychiatric problems. October 2007 Report of Medical History, denying depression. October 2009 VAMRs (initial mental health evaluation): diagnosing anxiety and depression; assigning a Global Assessment of Functioning (GAF) score of 60; noting that the Veteran saw a psychiatrist for depression when he was 18 years old and that his current depression manifested after he and his long-time girlfriend broke up in July 2006; observing symptoms such as social avoidance, angry outbursts, and racing thoughts; and noting that the results of a mental health screening test suggested that the Veteran had severe depression. October 2009 VAMRs, reporting that the Veteran has experienced depression with brief episodes of elevated mood throughout much of his life and assigning a GAF score of 69. April 2010 VAMRs (initial mental status examination), documenting heavy drinking in the U.S. Navy, a history of mental health problems (e.g., mood swings since the Veteran was young and the use of prescription Ritalin at age 13/14 and Paxil at age 16), and a possible relationship between the Veteran's mood swings and alcohol use. October 2012 VAMRs, reporting that the Veteran has had problems with depression for the past four to five years related to feelings of lack of accomplishment and personal relationships, suggesting that his depression may be related to back pain and noting problems with authority figures but no traumatic experiences in the Navy. May 2010 VAMRs, reporting that the Veteran has not had a depressive episode since July 2009, noting a history of binge drinking, and diagnosing alcohol abuse, bipolar disorder, malaise and fatigue, and major depressive disorder. Also, noting insomnia, frequent night time waking, and daytime somnolence. July 2010 VAMRs, diagnosing bipolar disorder, major depressive disorder, and alcohol abuse. July 2010 VAMRs, documenting a negative PTSD screen and suggesting that the Veteran's depression is related to his relationship with a former girlfriend and that his disorder minimally affects his job performance. October 2012 VAMRs, diagnosing insomnia and reporting that the Veteran gets about 5 hours of sleep a night. May 2013 VAMRs, reporting that the Veteran's prescription citalopram makes him feel tired and "flat" and that he is not sleeping well due to possible sleep apnea. June 2013 VAMRs, diagnosing major depressive disorder and substance/alcohol dependence (binge drinking) in possible remission. December 2013 Statement of Representative in Appeals Case, claiming that the Veteran has posttraumatic stress disorder (PTSD). May 2014 Mental Disorders VA Examination, opining that the Veteran's insomnia does not relate to service and finding that his insomnia and depressive disorder do not satisfy the DSM IV/V diagnostic criteria due to insufficient clinical impairment in functioning. November 2014 Hearing Transcript, testifying that the Veteran has been depressed since the end of his career in the U.S. Navy. d. The examiner must provide a complete explanation of his or her opinion, based on his or her clinical experience and medical expertise, and on established medical principles. If the requested medical opinion cannot be given, the examiner must state the reason(s) why. 7. After the mental health examination required by remand directive six (6) is completed, schedule another VA examination with an opinion as to whether the Veteran's erectile dysfunction (ED) relates to service, to include as secondary to any acquired psychiatric disorders identified on the mental health examiner. ALTERNATIVELY, the requested opinion may be provided by the same VA examiner who performed the mental health examination and as part of that same examination. The entire claims file, to include a copy of this REMAND, must be provided to the VA examiner, who must note its review. The following considerations must govern the examination: a. If the VA examiner must diagnoses ED, he or she must express an opinion as to whether the Veteran's ED relates to service. If the examiner is unable to provide the requested diagnosis, he or she must explain why diagnosis is not possible (e.g., examination findings do not support a diagnosis of ED). b. The VA examiner must opine as to whether the Veteran's ED was caused or AGGRAVATED (I.E., PERMANENTLY WORSENED) by service. c. The VA examiner must also opine as to whether the Veteran's ED was caused or AGGRAVATED (I.E., PERMANENTLY WORSENED) by any of his mental health disorders. d. The examiner has an independent responsibility to review the entire record for pertinent evidence, INCLUDING ANY PERTINENT EVIDENCE ADDED TO THE RECORD AS A RESULT OF THIS REMAND. The examiner's attention is called to: October 2006 Chronological Record of Medical Care, indicating that the Veteran did not have any ongoing medical or psychological problems and was in good health during service. See also October 2001 Reports of Medical Examination and History; December 2002 Reports of Medical Examination and History. May 2010 VAMRs, reporting difficulty maintaining an erection but not with ejaculation. October 2010, reporting "some ED" and difficulty sustaining erections with drive/libido variable. November 2012 VAMRs, noting that lab results indicate normal testosterone levels and that the Veteran makes a normal amount of sexual hormones. November 2014 Hearing Transcript, testifying that the Veteran's diagnosed ED is due to his depression/depression medications. e. The examiner must provide a complete explanation of his or her opinion, based on his or her clinical experience and medical expertise and on established medical principles. If the requested medical opinion cannot be given, the examiner must state the reason(s) why. 8. Then, review the medical examination reports to ensure that they adequately respond to the above instructions, including providing adequate explanations in support of the requested opinions. If a report is deficient in this regard, return the case to the appropriate VA examiner for further review and discussion. 9. After the above development, and any other development that may be warranted based on additional information or evidence received, is completed, readjudicate the issues of 1) entitlement to an increased disability rating for a service-connected low back disability and 2) entitlement to service connection for a) a gastrointestinal disorder, b) a cough disorder, to include as secondary to gastrointestinal problems, c) an acquired psychiatric disorder, to include depression and insomnia, and d) ED, to include as secondary to an acquired psychiatric disorder. The RO should carefully consider any additional functional loss due to pain, weakened movement, excess fatigability, and/or incoordination when rating the Veteran's low back disability. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); see also 38 C.F.R. §§ 4.40 and 4.45. If the benefits sought are not granted, the Veteran and his representative should be furnished with a Supplemental Statement of the Case (SSOC) and afforded a reasonable opportunity to respond to the SSOC before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs