Citation Nr: 1601681 Decision Date: 01/14/16 Archive Date: 01/21/16 DOCKET NO. 10-46 902 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a heart condition, to include a stroke, secondary to the service-connected duodenal ulcer. 2. Entitlement to service connection for a hiatal hernia secondary to the service-connected duodenal ulcer. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. Muetzel, Associate Counsel INTRODUCTION The Veteran had active duty service from October 1968 to October 1970. This appeal comes to the Board of Veterans' Appeals (Board) from a November 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran filed a Notice of Disagreement (NOD) in March 2010 and the RO issued a Statement of the Case (SOC) in October 2010. In November 2010, the Veteran filed a VA Form 9, Substantive Appeal. The Veteran appealed, and in April 2014, the Board denied the claims. The appellant appealed to the U.S. Court of Appeals for Veterans Claims (Court). In November 2014, while his case was pending at the Court, the VA's Office of General Counsel and appellant's representative filed a Joint Motion for Remand (JMR) requesting that the Court vacate the Board's April 2014 decision. In January 2015, the Board remanded the claims for the development required by the JMR. In reviewing this case the Board has reviewed files on the Veterans Benefits Management System (VBMS) and the "Virtual VA" system. The issue of entitlement to service connection for a heart condition, to include a stroke, is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT A hiatal hernia did not manifest in service or for many years thereafter, and is not shown to be related to or aggravated by a disease or injury of service origin, to include the service-connected duodenal ulcer. CONCLUSION OF LAW A hiatal hernia was not incurred in or aggravated by active service, and is not proximately due to, the result of, or aggravated by a service-connected condition. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implantation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2014). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2015). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Prinicipi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. The RO provided pre-adjudication VCAA notice by letters dated in March 2009 and June 2009. The notice included the types of evidence needed to substantiate the underlying claims of service connection, namely, evidence of an injury or disease or event, causing an injury or disease, during service; evidence of a current disability; and evidence of a relationship between the current disability and the injury or disease or event, causing the injury or disease, during service. The notice identified the evidence needed to substantiate a claim and the relative duties of VA and the Veteran to obtain evidence. The Veteran was notified of what information and evidence he needed to submitted and of what information and evidence would be obtained by VA. The notice included the provisions for the effective date of a claim and for the degree of disability assignable. VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The RO has obtained service treatment records and VA records, and provided the Veteran with VA examinations. The reports of the VA examination included a review of the Veteran's medical history, including his service treatment records, an interview and examination of the Veteran, as well as sufficient clinical and diagnostic findings for purposes of determining the nature and etiology of the Veteran's hiatal hernia. Therefore, the Board concludes that the VA examinations are adequate. 38 C.F.R. § 4.2 (2015); see Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide an examination or obtain a VA opinion, it must ensure that examination or opinion is adequate). Additionally, the RO substantially complied with prior remand instructions. In January 2015 the Veteran's claims for service connection for a heart condition, to include a stroke, and a hiatal hernia were remanded in order to obtain a medical opinion concerning the etiology of both disorders. In accordance with the remand instructions, the Veteran was provided VA examinations in September 2015. Opinions were provided regarding both claims, to include whether either condition was caused or aggravated by the Veteran's service-connected peptic ulcer disease or peptic ulcer disease treatment. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate this claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 539, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Factual Background and Analysis Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. 1110, 1131 (West 2014); 38 C.F.R. 3.303(a) (2015). Service connection may be established for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that disease was incurred in service. 38 C.F.R. § 3.303(d) (2015). Generally to establish entitlement to service connection, a Veteran must show (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the current disability and an in-service injury or disease. All three elements must be proved. See generally Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A disability which is proximately due to or the result of a service-connected disease or injury shall be service-connected. 38 C.F.R. § 3.310(a) (2014). Any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury, will be service-connected. 38 C.F.R. § 3.310(b) (2014). When considering evidence supporting a service-connection claim, the Board must consider, on a case-by-case basis, the competence and sufficiency of lay evidence offered to support a finding of service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (reiterating that "'[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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.'") (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 Fed. Cir. 2007)). Competency is a question of fact, which is to be addressed by the Board. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and weight, factual determinations going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). When the evidence is admissible, the Board must determine whether the evidence is credible. "Credible evidence" is that which is plausible or capable of being believed. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (the determination of credibility is a finding of fact to be made by the Board in the first instance). If the evidence is credible, the Board, as the fact finder, must determine the probative value or weight of the admissible evidence, that is, does the evidence tend to prove a material fact. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). If the evidence is not credible, the evidence has no probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). The Veteran is seeking service connection for a hiatal hernia, which he believes has either been caused by his military service or is secondary to his service connected duodenal ulcer or its treatment. Service treatment records do show complaints of epigastric pain, but a hiatal hernia was never diagnosed in service. On a physical in August 1970, the Veteran was found to have epigastric pain on deep palpation. In September 1970, he presented with complaints of stomach cramps, and was noted to be on Maalox which had reportedly not helped. An Upper GI Series was conducted to rule out peptic ulcer disease; and the medical officer indicated that fluoroscopically the Veteran's esophagus and stomach appeared normal. The duodenal cap was irritable and deformed and a persistent collection of barium was noted in the center of the duodenal cap that was thought to represent an ulcer crater. Ten days later it was noted that the Veteran had a probable ulcer crater. However, again, at no time was a hiatal hernia diagnosed. Following service, the Veteran underwent a VA examination in December 1971. It was noted that around the final month of his service, the Veteran's stomach started hurting. He saw doctors who diagnosed a duodenal ulcer. An Upper GI Series was conducted. The esophagus, stomach and duodenal cap were noted to have been "carefully" studied by means of image amplification. The esophagus and stomach were entirely normal. The cap showed some degree of deformity and possibly a small amount of irritability, but the deformity was far out of proportion to the degrees of irritability and if the Veteran had any residual activity from his old ulcer, the examiner felt it was minimal in degree. The examiner noted that there was scarring and deformity which was probably on the basis of the old ulcer, but no single penetrating crater was seen. The examiner conceded that with the degree of irritability it was possible that the Veteran might have some continued ulcer activity. The examiner found that the digestive system was normal and there was no evidence of a hernia. In March 2009, the Veteran filed a claim seeking service connection for a hiatal hernia that had worsened. The first evidence of a hiatal hernia was provided by a CT scan in April 2009 which revealed a small hiatal hernia. As such, it was not shown that the Veteran had a hiatal hernia for nearly 40 years after he separated from service. In a second letter in April 2009, the Veteran stated that he was enclosing a copy of a letter of appreciation while serving at Fort Ord where he came in contact with some metal containers from a paint locker which he suggested could have contributed to his health issues. He stated that he was of the opinion that his duodenal ulcer was a major contributor to the severity of his hiatal hernia. The letter of commendation is of record and notes that he was in the "Receiving Company" at Fort Ord, but it does not show any in-service exposures. Moreover, the Veteran has not suggested that any medical professional has ever endorsed the suggestion that in-service exposure might have caused a hiatal hernia to develop decades later. To investigate the Veteran's allegation that his hiatal hernia was caused by his duodenal ulcer, a VA examination was provided in October 2009. The examiner noted that the Veteran was being treated by VA for a hiatal hernia, and the Veteran stated that he had been diagnosed with the condition three to four years earlier. He complained of periodic burning and regurgitation that would awaken him from sleep. Having reviewed the claims file and examined the Veteran, the examiner opined that the Veteran's hiatal hernia was a separate condition from his ulcer disease and was not caused by or otherwise the result of his military service. The examiner indicated that her opinion was based on a review of the medical literature, her clinical experience and her review of the record. In his November 2010 substantive appeal, the Veteran stated that he had been dealing with hernia conditions for the past 41 years and he felt that it was all related to the ulcer condition. He stated that when he was initially examined for on active duty at Fort Ord, he did not believe that a complete examination was conducted was sufficient to reveal the true condition that was at hand. He reported that he believes that the hiatal hernia should have been part of the primary diagnosis. Then, as discussed, the Board remanded the claims in accordance with the JMR in order to afford the Veteran an additional VA examination. The examination was provided in September 2015; the examiner reviewed the Veteran's records in conjunction with the examination. The examiner noted the history of hiatal hernia and opined that it is less likely as not that the hiatal hernia had its clinical onset during the Veteran's active service. He also opined that it is less likely as not that the hiatal hernia was caused by, or aggravated by, the Veteran's service-connected duodenal ulcer or its treatment. By way of rationale, the examiner indicated that the Veteran was diagnosed with and treated for a peptic ulcer in the military and that he was diagnosed with a hiatal hernia in 2006. He stated that a hiatal hernia is a physiological condition, not a worsening of the peptic ulcer disease. Additionally, he noted that the hiatal hernia did not result from the treatment of the peptic ulcer disease. The Board has reviewed the evidence the Veteran has put forth in support of his claim that his hiatal hernia is related to, or aggravated by, his duodenal ulcer or its treatment. The Veteran and his wife have also submitted statements regarding his hiatal hernia. The Board finds the VA examiners' opinions to be highly probative to the questions at hand. The examiners were clinicians who possess the necessary education, training, and expertise to provide the requested opinions. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In addition, the VA examiners collectively provided adequate rationales in determining that the Veteran's current hiatal hernia was less likely as not caused or aggravated by his period of active service or his service-connected duodenal ulcer disease. Their opinions were based, at least in part, on examination and interview of the Veteran. Additionally, the VA examination reports and opinions expressly demonstrate the examiners' review of the Veteran's medical history, both during service and after separation. The examiners' opinions, taken together, considered all of the relevant evidence, to include the lay evidence submitted by the Veteran, which purports that his hiatal hernia is related to his service, or is caused or aggravated by his duodenal ulcer disease, or to the medication that treats his duodenal ulcer disease. Clearly, the examiners took into consideration all relevant medical facts, both favorable and unfavorable, in giving their opinions. The Board notes that the contrary opinion of record comes from the Veteran himself, who maintains that his hiatal hernia is related to his period of active service, or in the alternative, to his peptic ulcer disease. While the Board recognizes that the Veteran, as a lay person, is competent to report what comes to him through his senses, and he may therefore provide information about the gastrointestinal symptoms he experiences. See Layno v. Brown, 6 Vet. App. 465 (1994). However, once again, he lacks the medical training and expertise to provide a complex medical opinion such as determining the etiology of a hiatal hernia. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As such, the Veteran's contention that his hiatal hernia is either related to his service or caused or aggravated by his duodenal ulcer disease or its medication is not competent evidence. Additionally, the Veteran's assertions that medical testing in service was insufficient to detect a hiatal hernia or that his duodenal ulcer caused or aggravated his hiatal hernia are taken as limited medical evidence. The persuasive value of his lay contentions is low because the overall factual picture is complex. The Veteran simply does not have the medical expertise to opine as to the etiology of a hiatal hernia. As the evidence does not show the Veteran has expertise in medical matters, the Board concludes that the Veteran's nexus opinions in this regard are not competent and therefore is not probative of whether his hiatal hernia is related to his period of service, or was caused or aggravated by his duodenal ulcer or its medication. The Board has reviewed the claims file, but finds that there is no evidence that any medical professional has ever endorsed the Veteran's assertions. Moreover, there is little to support the Veteran's contention that testing in service was incomplete; as testing was conducted both while the Veteran was in service and approximately one year after separation, but none of the tests led to the diagnosis of a hiatal hernia. There is neither competent nor credible evidence linking the hiatal hernia to service, and the most probative evidence establishes that this condition was not caused or aggravated by his duodenal ulcer disease or its medication. For these reasons, the Board finds that a hiatal hernia did not manifest during service and is not proximately due to, the result of, or aggravated by the service-connected duodenal ulcer. While the Veteran asserts that his current hiatal hernia is related to service, or in the alternative, was caused or aggravated by his duodenal ulcer, or the medication that treats his peptic ulcer condition, the VA examiners who have examined the Veteran and reviewed his claims file have considered and addressed these contentions, and have ultimately concluded that the Veteran's hiatal hernia is not a result of his service, and is not in any way caused or aggravated by his duodenal ulcer. In sum, the weight of the competent and probative evidence does not establish that the Veteran's hiatal hernia is related to his military service, including on a secondary basis. The Board has determined, therefore, that the preponderance of the evidence is against the claim, and that service connection is not warranted for a hiatal hernia on any basis. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Service connection for a hiatal hernia, to include as secondary to the service-connected duodenal ulcer, is denied. REMAND While further delay is regrettable, the Board observes that additional development is required prior to adjudicating the issue of entitlement to service connection for a heart condition, to include a stroke. In March 2009, the Veteran reported getting treated for a heart condition which he suggested might also be service related. Service treatment records show that on a periodic physical in in March 1970 the Veteran's heart was found to be normal. On a second physical in August 1970, the Veteran's heart was again found to be normal on examination, and the Veteran denied any shortness of breath, chest pain, or high blood pressure on a medical history survey completed in conjunction with the physical. As such, no heart condition was noted in service. In December 1971, approximately one year after service, the Veteran underwent a VA examination at which his cardiovascular system was found to have normal thrust, rate, and rhythm. No murmurs or valvular accentuations were noted and the Veteran's peripheral vessels were soft and compressible. No heart condition was diagnosed. As such, no heart condition was diagnosed within a year of the Veteran's separation from service. In April 2009, there was nothing found to explain the Veteran's complaints of chest pain; in May 2009, a cardiac silhouette was within normal limits, an ECG was normal, and the Veteran was noted to have a normal sinus rhythm. In June 2010, testing showed that the Veteran had a generally normal sinus rhythm, with one very brief run of atrial tachycardia, for which no specific treatment was recommended. The medical professional explained that atrial tachycardia simply meant a rapid heartbeat for several minutes, which could be caused by caffeine, anxiety, stress or thyroid problems (and it was noted that a recent thyroid test had been normal). In February 2010 and May 2010, the Veteran also sought treatment for palpitations. In May 2010, the Veteran was diagnosed with a right occipital stroke, and ongoing stroke and stroke prevention treatment continued after that time. In June 2014, the Veteran sought treatment for rapid heart rate and chest pain. VA treatment records from July 2014 show that the Veteran was provided a diagnostic test on his heart which revealed that the left ventricular function was normal, the left ventricular wall motion abnormalities were not seen and he head normal valvular structures and function. There was no pericardial effusion and no evidence of an intracavitary mass or thrombus noted. The diastolic function as moderately impaired and there was mild aortic root dilatation. In January 2015, per the instructions of the remand required by the JMR, the Board remanded the claim to provide the Veteran with a VA examination. The examination was provided in September 2015. The examiner noted the Veteran's diagnosis of supraventricular arrhythmia. The Veteran reported difficulty with his heart rate, which he stated he believed to be related to his peptic ulcer medication. He stated that he went to the hospital in June 2014 because his heart was beating "out of rhythm." He also reported that he felt that his heart problem had begun in 1972, but that neither VA nor his private doctor found anything wrong at the time. The Veteran also relayed information about his stroke, indicating that his low blood pressure is related to his peptic ulcer. He indicated that his stroke occurred in 2011, when he woke up with a headache and left eye difficulty. He indicated that he has a shadow in his upper left quadrant of his eye; he also reported pain and light sensitivity. The examiner noted that the Veteran's supraventricular tachycardia is intermittent and that the Veteran had approximately four episodes in the last 12 months. The Veteran's heartrate was regular on examination, and the point of maximal impact was the fourth intercostal space. His heart sounds were normal without jugular-venous distension. The peripheral pulses and peripheral edema were normal. The examiner noted that previous diagnostic testing had shown that the Veteran had supraventricular tachycardia in June 2014 and left ventricular ejection fraction in June 2015. In September 2015, the Veteran underwent an interview-based METs test, which was shown to be >5-7 METs, which was consistent with activities such as walking one flight of stairs, golfing, mowing the lawn, or doing heavy yard work. The examiner was asked to provide an opinion as to whether the Veteran's heart condition, to include the stroke he suffered, was related to the Veteran's period of active duty, or to his peptic ulcer disease or its treatment. The examiner opined that the Veteran's atrioventricular node reentry tachy arrhythmia is not caused by or a result of the Veteran's military service. The examiner noted that the Veteran's heart condition did not have its clinical onset during active duty service or within one year of separation from the service. The examiner also noted that the Veteran's heart condition is not caused by or a result of the Veteran's peptic ulcer disease or its treatment. Finally, the examiner opined that the Veteran's stroke was not caused by the Veteran's period of active service and that it did not manifest during service or within one year of separation from service; the examiner also opined that the stroke was not caused by or related to the Veteran's peptic ulcer or its treatment. By way of rationale, the examiner explained that the Veteran's heart condition is an electrical conduction disease of the heart. It was not diagnosed in the military and is not a known complication of peptic ulcer disease or treatment for peptic ulcer disease. Additionally, the examiner opined that there is no known association of stroke and peptic ulcer disease. The Veteran submitted evidence, including medical research, which suggests that there is a link between a bacterium that causes ulcers and the incidence of strokes. See October 2015 submission of medical evidence and research. While the examiner adequately addressed the etiology of the Veteran's heart condition and relayed that it is related to an electrical conduction disease, the newly-submitted evidence provides support for the Veteran's claim that his stroke was related to his duodenal ulcer. The Board notes in this regard that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998). Therefore, while the evidence is not sufficient to grant the claim of service connection, the Board finds that a remand is required so that the examiner may address the relationship between the Veteran's ulcer and his stroke and provide an opinion regarding the etiology of the Veteran's stroke, with due consideration given to the medical treatises and research provided by the Veteran. Relevant ongoing medical records should also be requested. 38 U.S.C.A. § 5103A(c) (West 2014); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for his heart condition and stroke. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. Appropriate efforts must be made to obtain all available VA treatment records. All attempts to procure records should be documented in the file. If the AMC/RO cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. 2. Thereafter, return the September 2015 examination report to the VA examiner for an addendum opinion. If the examiner is unavailable, forward the claims folder to a similarly qualified physician. The need for additional examination of the Veteran is left to the discretion of the examiner. The entire claims file, to include a complete copy of the REMAND, must be made available to the examiner, and the examination report should include discussion of the Veteran's documented medical history and assertions. Any indicated evaluations, studies, and tests deemed to be necessary by the examiner should be accomplished. The examiner should state whether it is at least as likely as not (50 percent or greater probability) that the Veteran's stroke was caused by, or aggravated by, the Veteran's service-connected duodenal ulcer or the medication with which it is treated. If aggravation by a service-connected disability is found, then the examiner should quantify the degree of such aggravation beyond the baseline of the disability. The examiner is asked to specifically address the medical and lay evidence submitted by the Veteran, including the medical research and treatises that suggest a link between ulcers and strokes. A fully articulated medical rationale for each opinion expressed must be set forth in the medical report. The examiner should discuss the particular of this Veteran's medical history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. The examiner should provide a rationale that fully explains the basis for the conclusions reached. 3. Review all evidence received since the last prior adjudication and readjudicate the Veteran's claim of service connection. If the determination remains unfavorable to the Veteran, then the RO should issue a supplemental statement of the case that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issues. An appropriate period of time should be allowed for response by the Veteran and his service representative. Thereafter, the case should be returned to the Board for further appellate consideration, if 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 2014). ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs