Citation Nr: 1627475 Decision Date: 07/11/16 Archive Date: 07/22/16 DOCKET NO. 10-41 610 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for myotonic dystrophy. 2. Entitlement to service connection for a psychiatric disorder, to include an anxiety/depression disorder. 3. Whether new and material evidence has been received to reopen a previously denied claim of service connection for a gastrointestinal disorder, characterized as chronic pancreatitis (previously claimed as intestinal disorder, irritable bowel syndrome, gastritis) secondary to chemical exposure to include JP-4 jet fuel. 4. Whether new and material evidence has been received to reopen a previously denied claim of service connection for a dermatological and/or allergic disorder characterized as bilateral hand dermatitis allergies, bilateral hand swelling and skin rashes secondary to chemical exposure to include JP-4 jet fuel JP-4 fuel. 5. Whether new and material evidence has been received to reopen a previously denied claim for service connection for a neurological disorder characterized as paralysis agitans, previously claimed as distal polyneuropathy and benign essential tremors. 6. Entitlement to compensation for additional disability under 38 U.S.C. 1151 for pancreas procedure and/or surgery complications to include necrotizing pancreatitis disease, splenic vein thrombosis, muscle wasting, shaking, tremors and inability to walk. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran served on active duty from April 1978 to September 1982. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Regional Office (RO) of the Department of Veterans Affairs (VA) in San Diego, California. These include an October 2009 rating that denied service connection for myotonic dystrophy, an anxiety/depression disorder and a left knee disorder. Also on appeal is a September 2010 rating decision, which confirmed and continued previous denials of claims of service connection for a gastrointestinal disorder classified as chronic pancreatitis; a dermatological and/or allergic disorder classified as bilateral hand dermatitis allergies, bilateral hand swelling and skin rashes and a neurological disorder classified as paralysis agitans. Finally, this appeal comes from an October 2013 rating which denied the 1151 claim. The Board notes that in an October 2012 rating the RO granted service connection for left knee disorders of chondromalacia patella and patellar subluxation; the Veteran did not appeal the effective date or the ratings assigned thus this matter is no longer on appeal. The Veteran testified before the undersigned Veterans Law Judge at a hearing held at the RO in March 2016. A transcript of this hearing is associated with the record. The issue of entitlement to service connection for a dental disorder has been raised in statements made in his Board hearing testimony (see Transcript at page 67), but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). The reopened claims for service connection for a gastrointestinal disorder, a skin/allergic disorder affecting the hands and a neurological disorder, plus the claims for service connection for a psychiatric disorder and myotonic dystrophy are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. In July 1999, the RO denied the Veteran's claim of service connection for a gastrointestinal disorder. The Veteran failed to file a timely notice of disagreement, and no new and material evidence was received within a year of the rating decision's issuance. 2. Certain evidence received since the July 1999 decision is neither cumulative nor redundant of the evidence of record at the time of the July 1999 denial and, by itself or in conjunction with the evidence previously assembled, relates to an unestablished fact necessary to substantiate the claim of service connection for a gastrointestinal disorder. 3. In July 1999, the RO denied the Veteran's claim of service connection for a dermatological and/or allergic disorder affecting the bilateral hands. The Veteran failed to file a timely notice of disagreement, and no new and material evidence was received within a year of the rating decision's issuance. 4. Certain evidence received since the July 1999 decision is neither cumulative nor redundant of the evidence of record at the time of the July 1999 denial and, by itself or in conjunction with the evidence previously assembled, relates to an unestablished fact necessary to substantiate the claim of service connection for a dermatological and/or allergic disorder affecting the bilateral hands. 5. In July 1999, the RO denied the Veteran's claim of service connection for a neurological disorder. The Veteran failed to file a timely notice of disagreement, and no new and material evidence was received within a year of the rating decision's issuance. 6. Certain evidence received since the July 1999 decision is neither cumulative nor redundant of the evidence of record at the time of the July 1999 denial and, by itself or in conjunction with the evidence previously assembled, relates to an unestablished fact necessary to substantiate the claim of service connection for a neurological disorder. CONCLUSIONS OF LAW 1. The July 1999 RO rating decision denying the Veteran's claim of service connection for a gastrointestinal disorder is final. 38 U.S.C.A. § 7105 (West 2014). 2. Evidence received since the July 1999 RO rating decision is new and material; accordingly, the claim of service connection for a gastrointestinal disorder is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2015). 3. The July 1999 RO rating decision denying the Veteran's claim of service connection for a dermatological and/or allergic disorder affecting the bilateral hands is final. 38 U.S.C.A. § 7105 (West 2014). 4. Evidence received since the July 1999 RO rating decision is new and material; accordingly, the claim of service connection for a dermatological and/or allergic disorder affecting the bilateral hands is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2015). 5. The July 1999 RO rating decision denying the Veteran's claim of service connection for a neurological disorder is final. 38 U.S.C.A. § 7105 (West 2014). 6. Evidence received since the July 1999 RO rating decision is new and material; accordingly, the claim of service connection for a neurological disorder is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015). As the claim is being reopened, the Veteran is being granted the full benefit sought with regard to the lone issue being decided herein. Thus, there is no need to undertake any review of compliance with the VCAA. See generally 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). New and Material Evidence Despite the determination made by the RO, the Board must find new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. See Jackson v. Principi, 265 F. 3d 1366 (Fed. Cir. 2001); see also VAOPGCPREC 05-92. Following notification of an initial review and adverse determination by the Regional Office (RO), a notice of disagreement must be filed within one year from the date of notification thereof; otherwise, the determination becomes final and is not subject to revision except on the receipt of new and material evidence. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. § 3.156. Following receipt of a notice of a timely disagreement, the RO is to issue a statement of the case. 38 C.F.R. § 19.26. A substantive appeal must be filed within 60 days from the date that the agency of original jurisdiction mails the statement of the case to the appellant, or within the remainder of the 1-year period from the date of mailing of the notification of the determination being appealed, whichever period ends later. 38 C.F.R. § 20.302(b). Otherwise, the determination becomes final and is not subject to revision except on the receipt of new and material evidence. 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. § 3.156. When a claim to reopen is presented, a two-step analysis is performed. The first step of which is a determination of whether the evidence presented or secured since the last final disallowance of the claim is "new and material." See Elkins v. West, 12 Vet. App. 209, 218-19 (1999) (en banc); see also 38 U.S.C. § 5108; Hodge v. West, 155 F.3d 1356, 1359-60 (Fed. Cir. 1998). The provisions of 38 C.F.R. § 3.156 (which define "new and material evidence") state as follows: New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2015). Additionally, if VA determines that the evidence is new and material, the VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist has been fulfilled. See Winters v. West, 12 Vet. App. 203, 206 (1999) (en banc) (discussing the analysis set forth in Elkins), overruled on other grounds sub nom. Winters v. Gober, 219 F.3d 1375, 1378 (Fed. Cir. 2000); Elkins, supra. The second step becomes applicable only when the preceding step is satisfied. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 325 (1999). In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is not material, the inquiry ends and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). In Evans v. Brown, 9 Vet. App. 273 (1996), the Court held that to reopen a previously and finally disallowed claim, there must be new and material evidence presented or secured since the time that the claim was finally denied on any basis. Additionally, evidence considered to be new and material sufficient to reopen a claim should be evidence that tends to prove the merits of the claim that was the specified basis for the last final disallowance of the claim. In Justus v. Principi, 3 Vet. App. 510 (1992), the Court held that for new and material evidence purposes only, new evidence is presumed to be credible. The only exception would be where evidence presented is either (1) beyond the competence of the individual making the assertion or (2) inherently incredible. If new and material evidence has been received with respect to a claim that has become final, then the claim is reopened and decided on a de novo basis. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. Gastrointestinal Disorder In its July 1999 rating decision, the RO denied a claim for a gastrointestinal disorder, conceding that there had been treatment in service for acute viral gastroenteritis during active duty but finding no evidence of any chronic gastrointestinal (GI) disorder due to chemical exposure, including from JP-4 jet fuel which he was conceded to have been exposed to in service. The Veteran did not file a notice of disagreement with this decision after receiving notice of it in August 1999. As such, the decision became final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. § 3.156(b) (2014) (new and material evidence received within the appeal period after a decision is considered as having been received in conjunction with the prior claim); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011) (VA must determine whether evidence received during the appeal period after a decision contains new and material evidence per 3.156(b) and failure to readjudicate the appeal after receipt of such evidence renders the decision non-final). The evidence before the RO in July 1999 is noted to include service treatment records (STRs) that revealed no evidence of GI problems on entry in April 1978. See 63 pg STRs at p 3, 48. In March 1979 he went to the emergency room (ER) in March 1979 for stomach pains and lightheadedness, with findings of tenderness in the midline umbilical area with an assessment of dyspepsia versus muscle strain. See 63 pg STRs at pgs 18-19. Other records from March 1979 show that he was hospitalized for abdominal pain to rule out appendicitis, and developed diarrhea while hospitalized. He was diagnosed with gastroenteritis. See 12 pg STRs pg 12. In April 1979 he was placed under observation for questionable abdominal pain. See 63 pg STRs at pg 42. There is no separation examination shown to be of record. The service treatment records confirmed that he was exposed to chemicals from fuels and printing chemicals per records dated in February 1981 noting allergy to fuels with a 3 year history of working with fuel, and a March 1982 record noting contact dermatitis due to printing chemicals. See 18 pg STRS pg 7, 13. Post-service evidence before the RO in July 1999 reveals no evidence of GI problems until several years after service. VA records obtained in July 1999 included records of repeated treatments throughout 1998 and 1999 for GI symptoms of abdominal pain, frequent heartburn, and bowel issues that included changes in bowel patterns, diarrhea and bloody stools. He was assessed with various GI problems most frequently diagnosed as irritable bowel syndrome (IBS), but also with other possible diagnoses including Crohn's disease and Celiac disease in these records dated from April 1998 to January 1999. See 92 pages VA records up to 1999, received July 13, 1999 at pages 2, 4, 5, 9, 10, 12, 16, 18, 19, 22, 25, 39, 41, 48, 59, 73, 78. These records included an April 1998 record that gave a history of IBS disease dating back to 1993. A June 1998 record suggested a possible psychiatric component to his abdominal symptoms, with other records from the same month suggesting that intestinal disease dated back to 1992 or 1993 and the Veteran complained of multiple Social Security denials. A September 1998 record noted that there was no resolution of IBS symptoms following a gallbladder removal by a private medical provider, Kaiser, and diagnosed IBS versus sprue. Id at pages 2, 9, 12, 59. None of the records contained a positive link between the GI symptoms noted and any incidents in service. Also before the RO was the report of an October 1998 VA examination that addressed the etiology of his gastrointestinal symptoms noting that most of his GI symptoms began in the 1990s and noted symptoms of diarrhea, weight loss, GI bleeding, with a history of gallbladder removal in 1994 and stomach ulcers and small intestinal inflammation in 1995. Following examination the examiner diagnosed IBS but suggested he had a very unusual bowel syndrome with difficulty absorbing and thought it was more of a malabsorption syndrome than IBS. As to whether his GI disorder was as likely as not related to service, including exposure to chemicals and toxic substances 15 years earlier, the examiner stated that this question could not be easily answered. The examiner opined that he should have shown symptoms long before this time and it would have been a little unusual to be showing symptoms from exposure to a toxic substance in the 1980s this late. Evidence after the July 1999 rating decision includes records and examinations from the 1990s through 2015 continuing to document ongoing GI problems. These records include additional records from private medical provider Kaiser documenting GI symptoms treated as early as 1994 with persistent abdominal pain/right upper quadrant pain prompting workup that revealed a gallstone in March 1994 which was removed by cholecystectomy in April 1994. See 75 pg Kaiser records from 1990s pages 16, 27-31. His symptoms persisted and he later underwent a colonoscopy in November 1996 that was essentially normal. Id at p 6. He was assessed with severe IBS in April 1997. Id at pages 3-4. The post July 1999 records include records from January 2008 showing that he persisted with intermittent abdominal pain along with alternating constipation and diarrhea and abdominal CT done in February 2008 was notable for a pancreatic mass, questionable pseudocyst. See 73 pages VA records from 1998-2008 at pages 32, 35. The records indicate that he later underwent surgery at the VA in March 2008 to remove and biopsy the cyst with endoscopic retrograde cholangiopancreatography (ERCP) done, but with complications of a leak into the abdomen resulting in 2 lengthy hospitalizations from March to April and April to May of 2008. Subsequently, he required hospitalization at a private hospital (Kaiser) in June and July of 2008 for hypotension, with findings of necrotizing pancreatitis as well as new onset portal vein thrombosis with additional splenic vein thrombosis. See Kaiser records 75 pages incl summer 2008 tx at pgs 18-22, 69, 72. He persisted with the diagnosis of chronic necrotizing pancreatitis in VA treatment records from August 2008. See 73 pg VA records received 6/29/10, at pg 12. This chronic necrotizing pancreatitis was confirmed on CT in August 2009. See 75 pgs VA records 2009-2010 entered 12/22/10 at p 44. Subsequent post July 1999 VA records from 2010 through 2014 continued to confirm the Veteran as having continued GI symptoms, with a diagnosis of chronic pancreatitis along with symptoms of persistent abdominal pain, with CT findings showing atrophic pancreas likely secondary to the chronic pancreatitis. See Id at page 37 (June 2010 record noting atrophic pancreas and partial splenic vein thrombosis on CT). See also 203 pages CAPRI in Virtual VA at p 189 (February 2011 abdominal CT scan showing the same findings) and page 15 (August 2013 record showing chronic abdominal pain with continued complaints of bloating and abdominal pain). He has continued with regular GI consults for his chronic pancreatitis and symptoms of persistent abdominal pain. See 310 page CAPRI in Virtual VA at pages 140-147, 249, 267 (October 2013, February 2014, and August 2014 GI consults for chronic pancreatitis). VA examinations conducted after the July 1999 rating include VA examinations from July 2010 and January 2015. While containing unfavorable etiology opinions, these examinations confirmed persistent symptoms of abdominal pain, weight loss and alternating constipation diarrhea and confirmed a diagnosis of residual chronic pancreatitis status post necrotizing pancreatitis secondary to ERCP. Also received after July 1999 was the Veteran's testimony both in a hearing held before a DRO in December 2010 which described his heavy exposure to various chemicals while serving in his MOS as a fuel specialist and later after being transferred to a graphics position repairing printing presses. See 12/10 Hearing Transcript pages 5-8. See also 3/16 Travel Board Hearing Transcript pages 62-63. He has argued that he was exposed to numerous chemicals besides JP-4 fuel. Id at 63. He also has submitted numerous documents detailing the various chemicals he was exposed to as well as treatises regarding the medical consequences of such exposure. He has testified as to continued GI symptoms after service and reported having treated privately at Kaiser for intestinal problems back in the 1980's. Id at p 5. In addition the evidence received after July 1999 includes a September 2009 opinion from M.B., M.D., who examined the Veteran and reviewed pertinent medical records including service treatment records, service personnel records and post service records. Dr. M.B. provided an opinion that it was reasonably probable that the exposures to such chemicals as JP-4 was a reasonable probable contributor to the Veteran's chronic pancreatitis. See Dr. B Opinion 9/2/09 at pg 17. The Board notes that the Court has interpreted the language of 38 C.F.R. § 3. 156(a) as creating a low threshold and viewed the phrase "raises a reasonable possibility of substantiating the claim" as enabling rather than precluding the reopening of a claim. The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which does not require new and material evidence as to each previously unproven element of a claim. It was indicated that it would be illogical to require that a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element, as it would force the Veteran to provide medical nexus evidence to reopen the claim so that the Veteran could be provided with a medical nexus examination by VA. Shade v. Shinseki, No. 08-3548 (U.S. Vet. App. Nov. 2, 2010). In determining whether the submitted evidence is new and material, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). Thus, pursuant to Shade, evidence is new if it has not been previously submitted to agency decisionmakers and is material if, when considered with the evidence of record, would at least trigger VA's duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Id. The Board finds that the evidence now showing continuity of GI symptoms treated after service with a diagnosis of chronic pancreatitis, along with the Veteran's lay evidence further describing the nature and extent of his in-service chemical exposures, combined with the favorable opinion from Dr. B as to the pancreatitis having a high probability of being related to the Veteran's chemical exposures in service, meet the low threshold of 38 C.F.R. § 3.156(a) and are new and material evidence to reopen the Veteran's claim; because they indicate that the Veteran's post service gastrointestinal symptoms may be related to his conceded exposure to various toxic chemicals in service. As new and material evidence has been received to reopen the claim, the claim for entitlement to service connection for a gastrointestinal disorder is reopened. Dermatological and/or Allergic disorder --Bilateral Hands In its July 1999 rating decision, the RO denied a claim for a disorder classified as "allergies, hands swelling and skin rashes" conceding that there had been treatment in service in February 1981 for questionable contact dermatitis with very dry hands and a history of working with fuel for 3 years and washing his hands frequently. Also noted was a March 1982 examination that showed skin rashes assessed as contact dermatitis on his hands due to printing chemicals. The RO noted that a VA examination was unremarkable for residuals scarring or skin problems. The RO concluded that although there was a record of treatment in service for allergies, hands swelling and rashes in service due to JP-4 exposure, no permanent residuals or chronic disability was shown by the STRS or demonstrated by evidence after service. The Veteran did not file a notice of disagreement with this decision after receiving notice of it in August 1999. As such, the decision became final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. § 3.156(b) (2014) (new and material evidence received within the appeal period after a decision is considered as having been received in conjunction with the prior claim); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011) (VA must determine whether evidence received during the appeal period after a decision contains new and material evidence per 3.156(b) and failure to readjudicate the appeal after receipt of such evidence renders the decision non-final). The evidence before the RO in July 1999 is noted to include STRs that revealed no evidence of skin problems on entry in April 1978. See 63 pg STRs at p 3, 48. In December 1980 he injured his right hand with swelling and was diagnosed with a contusion of the right fifth finger. The swelling later resolved. See 63 pg STRS at p 7; see also 18 pg STRS at pg 15. In January 1981 he was seen in the ER for rash on his hands assessed as contact dermatitis. In February 1983 he complained of having an allergy to fuel. See 18 pg STRS at pg 13. In March 1982 he was treated for a skin rash on his hands assessed as contact dermatitis. 18 pg STRS at pg 7. There is no separation examination shown to be of record. The service treatment records confirmed that he was exposed to chemicals from fuels and printing chemicals per records dated in February 1981 noting allergy to fuels with a 3 year history of working with fuel, and a March 1982 record noting contact dermatitis due to printing chemicals. See 18 pg STRS pg 7, 13. Another March 1982 record disclosed duty restrictions of no contact with chemicals for a month due to contact dermatitis. An undated record disclosed a prescription of Lanolin hand cleaner and Eucerin. See 63 pg STRS at pg 30, 63. Post-service evidence before the RO in July 1999 reveals no evidence of skin issues on his upper extremities or other hands problems such as swelling in the VA records received prior to this decision. However, there were some skin issues involving a facial rash for 1 year as noted in a June 1998 record. See 92 pages VA records up to 1999 received July 13, 1999. The report of a September 1998 VA skin examination noted the history of rash in 1981, which was described as occurring after the Veteran came into contact with some chemicals. The rash was said to have resolved after he was removed from exposure, without recurrence. Examination was said to have shown unremarkable hands without residual atrophy or other skin problems. Evidence after the July 1999 rating does not include any mention of issues with his hands, including the skin of his hands. However, he is noted to have sought treatment sporadically for skin issues elsewhere on his body including on his head/ face, legs or stomach. See 203 page CAPRI in Virtual VA at p 100 (showing treatment in October 2003 for peeling/cracking of skin on his forehead for 2 months with a prior history of dermatology treatment for this problem). See also 73 page VA records received 6/29/09 at pg 50 (treatment for skin on abdomen having turned yellow). See also 75 pg VA recs 2009-2010 at page 18-20 (treatment in July 2010 for red spots on his thighs diagnosed as cherry angiomas and moles diagnosed as nevi). See also 240 pg VA recs at pages 101, 119 (dermatology treatment in September 2012 and October 2012 for peeling of the forehead/scaling of his scalp and red spots on his thighs and moles diagnosed cherry angiomas and nevi). Also received after the July 1999 rating is the report of a July 2010 VA examination addressing his claimed skin disorder/allergies claimed as secondary to exposure to aviation fuel (JP-4). On physical examination, there was no rash or swelling of the hands or upper extremities. The examiner did find that the Veteran had contact dermatitis secondary to exposure to jet fuels and recurrence on exposure to chemicals used in the printing process, but without subsequent recurrence. The examiner noted that while in the service, the Veteran clearly developed a swelling, erythema and rash in his hands when he was exposed in the course of his job to jet fuels, and again this happened after he was exposed to chemicals and in the printing lab after he changed jobs in the service. This examiner stated that the Veteran had resolution of the hand swelling after he was no longer exposed to the fuels and chemicals. The examiner noted that he had nasal allergies and skin issues of cherry angiomas and nevi of various morphologies and an atypical nevus, but no allergic-type rashes. Also received after the July 1999 are the Veteran's lay descriptions of symptoms he described affecting his hands and arms, with his December 2010 hearing testimony describing his arms and hands swelling after exposure to chemicals in service. 12/10 DRO Transcript at page 7. More recently he described in detail at his March 2016 hearing that he has had continued swelling of his limbs and rashes since service after he was exposed to chemicals. His representative suggested that the rashes were well documented in service after exposure to chemicals in service and indicated that the Veteran had received post service treatment for them at Kaiser in the 1980s. His representative also thought the skin and swelling manifestations could potentially be related to his pancreatitis issues. 3/16 Travel Board Transcript at pgs 29-36. In addition, the evidence received after July 1999 includes a September 2009 opinion from M.B., M.D. who examined the Veteran and reviewed pertinent medical records including service treatment records, service personnel records and post service records. Dr. M.B. provided an opinion that described a host of medical issues including skin rashes on hands and arms, chemical allergy and skin problems as linked to exposure to chemicals in Kerosene based Jet Fuels. See Dr. B Opinion 9/2/09 at pg 16. The Board finds that the evidence now including lay evidence suggestive of continuity of symptoms of swelling and rashes involving his upper extremities, combined with the evidence suggesting this is linked to his inservice chemical exposure including the September 2009 opinion from Dr. B and the July 2010 VA examiner's opinion that such symptoms were likely caused by his exposure to chemicals in service, although this examiner thought the symptoms had resolved, meet the low threshold of 38 C.F.R. § 3.156(a) and are new and material evidence to reopen the Veteran's claim; because they indicate that the symptoms of swelling of the upper extremities and rashes continued after service with the Veteran found to be competent to report such continuity of symptoms. See Walker supra; see also Jandreau, supra, 492 F.3d 1372 (Fed. Cir. 2007). As new and material evidence has been received, the claim for entitlement to service connection for the dermatological/allergic disorder affecting his hands is reopened. Neurological Disorder In its July 1999 rating decision, the RO denied a claim for a disorder classified as benign essential tremors. They were deemed familial in origin and the claim was denied as there was no showing of a chronic acquired neurologic disability. The Veteran did not file a notice of disagreement with this decision after receiving notice of it in August 1999. As such, the decision became final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. § 3.156(b) (2014) (new and material evidence received within the appeal period after a decision is considered as having been received in conjunction with the prior claim); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011) (VA must determine whether evidence received during the appeal period after a decision contains new and material evidence per 3.156(b) and failure to readjudicate the appeal after receipt of such evidence renders the decision non-final). The evidence before the RO in July 1999 is noted to include STRs that revealed no evidence of neurological problems on entry in April 1978. See 63 pg STRs at pg 3, 48. In June 1981 while being evaluated for persistent and constant headaches, he was noted to have an essential tremor, said to be familial in nature. See 13 pg. STRs at pg 9. The essential tremor was again noted in February 1982. Id at p. 3. The findings from a brain CT done in September 1981 for headaches was noted to not be able to exclude the possibility of a vascular brain lesion such as AVM. See 18 pg STRS at pg 13. Post service treatment records before the RO in July 1999 included findings in October 1998 of cogwheeling in the elbows and a postural tremor, with etiology including essential tremor. The possibility of multiple sclerosis was raised but was viewed as doubtful. Later in January 1999 he was seen by the VA for neuro degenerative disease and was again noted to have essential tremor, but no other significant neurological findings. The impression was of essential tremor, with no evidence of any other neurological disorder. See 92 pages VA records up to 1999, received July 13, 1999 at pages 53, 54, 71. The report of an October 1998 brain and spinal cord VA examination noted the Veteran's diagnosis of essential tremors and a history of taking Inderal, although it was unclear whether this was for tremors or his headaches. He did have a tremor on examination that did not occur at rest. The tremor was shown on coordination testing of finger to nose, but other findings were normal. The diagnosis was essential tremor. The examiner opined that this seemed to be a constant condition. A brain MRI done at the time of this examination was normal. Evidence received after the July 1999 rating decision includes records and examinations through 2015, which continue to document ongoing neurological problems including essential tremor. This was noted in the problem lists repeatedly throughout the VA records and was observed on repeated examinations. This includes primary care notes from October 2003 and September 2004 with a problem list noting a questionable history of essential tremor with evaluation for neurogenic disease last seen in January 1999, with no history of neurological disease. See 73 pages VA records from 1998-2008 at pages 47, 50. This medical history was repeated throughout the rest of the records. A March 2009 VA neurology record drafted by Dr. D. described his reports of tremors in his hands for over 25 years, worsened by rushing or anxiety and a history of the same symptoms in his father. Following examination which confirmed bilateral tremor in both arms with postural component, the assessment was of presentation of myotonic dystrophy with essential postural tremor with myoclonus. Additionally the Veteran was diagnosed with some distal polyneuropathy as well. See 2 pg VA records-tremor 3/4/09. Bilateral hand tremors were also noted in a June 2009 VA record addressing low back pain. See 39 pg VA records received 10/10/09 at page 35. The July 2010 VA examination assessed benign essential tremors, described as familial in nature and said to pre-date service. A December 2010 VA neurology record confirmed a diagnosis of postural and action tremor consistent with essential tremor, but no signs of Parkinson's. See 65 pg VA records 2009-2010 received 1/25/11 at page 1. Later in April 2013 and August 2013 VA neurology records continued to address neurological complaints of tremors and abnormal leg movements, which continued to be consistent with essential tremor, although the nature of leg movements were unclear, with the April 2013 record describing them as probably dystonic in nature. See 203 pages CAPRI in Virtual VA pg 20-22, 50-52. He continued to carry an assessment of essential tremor shown in records from November 2003. See 310 pg CAPRI in Virtual VA at pgs 24, 54. Also received after July 1999 was the Veteran's testimony both in a hearing held before a DRO in December 2010 which described his heavy exposure to various chemicals while serving in his MOS as a fuel specialist and later after being transferred to a graphics position repairing printing presses. See 12/10 Hearing Transcript pages 5-8. See also 3/16 Travel Board Hearing Transcript pages 62-63. He has argued that he was exposed to numerous chemicals besides JP-4 fuel. Id at 63. He also has submitted numerous documents detailing the various chemicals he was exposed to as well as treatises regarding the medical consequences of such exposure. In addition the evidence received after July 1999 includes a September 2009 opinion from M.B., M.D. who examined the Veteran and reviewed pertinent medical records including service treatment records, service personnel records and post service records. Dr. M.B. provided an opinion that linked the Veteran's neurological symptoms to the exposures to various chemicals from jet fuel and solvents. Dr. M.B. commented that the VA physician, Dr. D. who recently examined the Veteran (in March 2009) had noted the presence of a distal neuropathy, and this examiner described this as a condition that can be caused by solvent exposure. See Dr. B Opinion 9/2/09 at pg 14. Dr. B. further described the chemical components of JP-4 (jet fuel) as highly neurotoxic and can lead to peripheral neuropathy. Id at pg 16. The Board finds that the evidence now showing continuity of neurological symptoms treated after service with diagnoses that include essential tremor, and distal neuropathy, along with the Veteran's lay evidence further describing the nature and extent of his in-service chemical exposures, combined with the favorable opinion from Dr. B as to the likelihood of neurological manifestations being related to the Veteran's chemical exposures in service, meet the low threshold of 38 C.F.R. § 3.156(a) and are new and material evidence to reopen the Veteran's claim; because they indicate that the Veteran's post service neurological symptoms may be related to his conceded exposure to various toxic chemicals in service. As new and material evidence has been received to reopen the claim, the claim for entitlement to service connection for a neurological disorder is reopened. ORDER New and material evidence having been received, the petition to reopen a claim of service connection for a gastrointestinal disorder is granted. New and material evidence having been received, the petition to reopen a claim of service connection for dermatological and/or allergic disorder involving the bilateral hands is granted. New and material evidence having been received, the petition to reopen a claim of service connection for a neurological disorder is granted. REMAND With regard to the reopened claims for a GI disorder, dermatological and/or allergic disorder, and a neurological disorder, as well as the claims for service connection for the disorders of myotonic dystrophy and a psychiatric disorder, and for the 1151 claim, additional development is needed. Of note, the claims file contains multiple references to the Veteran having claimed and eventually being granted Social Security Disability (SSD) benefits. The Veteran's December 2010 testimony described being granted SSD benefits for depression around 1995 after appealing denials of it. 12/10 DRO hearing at pg 18. He again confirmed receipt of SSD benefits for depression in his March 2016 hearing. BVA hearing transcript at p 26. There is noted to be a copy of an August 1998 SSD decision of record entered into the electronic record in December 2013 that granted disability benefits effective May 1995. However other than an August 1998 psychiatric examination, there are no medical records, including disability examinations, and other records presumed to be used in this decision. Elsewhere there are not shown to be SSA records. As such records could particularly prove pertinent to all the claimed issues besides the 1151 claim, particularly if they include older records dating back to the 1980s, an effort should be made to obtain such records. With regard to the 1151 claim, the Veteran alleges additional disability, including his chronic necrotizing pancreatitis, portal vein thrombosis and additional splenic vein thrombosis. The Board notes that there are records addressing a possible GI workup in March 2008 for pancreatic cyst on CT in February 2008, and additional post-surgery records showing complications from the surgery in 2008 as pointed out in the above decision addressing the reopening of his service connection claim for GI disability. See Kaiser records 75 pages including summer 2008 at pgs 18-22, 69, 72. He persisted with the diagnosis of chronic necrotizing pancreatitis in VA treatment records from August 2008. See 73 pg VA records received 6/29/10, at pg 12. This chronic necrotizing pancreatitis was confirmed on CT in August 2009. See 75 pgs VA records 2009-2010 entered 12/22/10 at p 44. However, the Board notes that the many volumes of VA and private records do not actually include reports of the actual surgeries forming the basis of his 1151 claim. Such procedures were said to have taken place at the San Diego VAMC in March 2008. See 310 pg VAMC in Virtual VA at p 52. This would include no actual records of the biopsy procedure of the pancreatic cyst or the ERCP resulting in complications of a leak into the abdomen or the subsequent lengthy hospitalizations from March to April and April to May of 2008. Additionally, the release form is not shown to be in the current records, although this as well as the surgical records were apparently available to the January 2015 VA examiner who addressed the 1151 claim. An effort must be made to obtain the VA records not already of record that are in the VA's constructive possession. See Bell v. Derwinski, 2 Vet. App. 611 (1992). Although the Veteran underwent multiple VA examinations to address the etiologies of all claimed disorders, the opinions obtained by these examinations are inadequate for the purposes of adjudicating these claims. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board notes that this appeal regarding all the claimed disorders, with the exception of the psychiatric disorder, which is contended to be secondary to his other claimed disorders, are based on the premise that exposure to various toxins in JP-4 jet fuel and other chemicals while serving as a fuel specialist and later while repairing printing machines. The Board concedes such exposure as both the STRs and service personnel records corroborate his claims of such exposures. In regard to the claimed GI disorder, with current evidence of chronic pancreatitis and a past history of IBS, with the GI disorder claimed to be directly related to service as well as an additional disability under 38 C.F.R. § 1151 based on medical treatment at the VA, the VA examinations addressing this were conducted in October 1998, July 2010 and January 2015. None of these examinations included consideration of the lay evidence from the Veteran regarding continued symptomatology after service, and he is noted in his March 2016 testimony to have reported having had medical treatment shortly after service in the 1980s. The Board notes that the October 1998 examiner suggested that symptoms from toxic exposure should have been manifested earlier in time than was indicated by the evidence considered at the time. Likewise, the July 2010 VA examiner appeared to rely heavily on the lack of medical evidence of GI symptoms to support an unfavorable opinion regarding the link between the Veteran's GI disability and incidents in service including chemical exposure. The January 2015 examination focused more on the 1151 claim but did note that the Veteran's current abdominal pain symptoms were due not only to the preexisting irritable bowel syndrome but also to some (likely) ongoing contribution from the 2008 episode of severe necrotizing pancreatitis that led to development of an atrophic pancreas that likely contributes to chronic abdominal pain symptoms. This opinion suggests the possibility of chronic GI symptoms from IBS continuing through the present, but did not clearly answer whether the IBS was incurred in service including through the conceded chemical exposure. Regarding the GI disorder as it relates to the 1151 claim, although the January 2015 examiner answered this question in the negative stating that the subsequent pancreatitis was noted to be a potential complication of the abdominal cyst surgery, the Board again points to these records not currently being associated with the claims file. The Board further notes that the Veteran's March 2016 testimony raises further questions regarding the 1151 claim that need further examination to properly address. Of note, the Veteran has now alleged that the pancreas condition should have been properly diagnosed by the VA earlier than it was, so that early treatment could have potentially avoided the surgery and subsequent complications. Additionally the Veteran indicated in his testimony that his surgical consent was limited only to the needle biopsy, not for the further procedures he subsequently underwent. 3/16 Travel Board Transcript pages 46-52, 55-60. Thus, additional examination of the Veteran's GI disorders should include consideration of these contentions made in his lay testimony and written statements in addition to the available evidence of record. Further, if the examiner does find that the Veteran has additional disability subject to an award under 1151, the examiner should specify the nature of each disability claimed as complications as the Veteran has set forth a litany of medical complaints alleged to have been caused by his complications from the 2008 pancreas surgery at the VA. Id at p 55. Regarding the neurological disorders, the Veteran underwent examinations in October 1998, July 2010 and January 2010, with the general consensus that he had essential tremors that were familial (congenital) in nature. However, none of these addressed whether the essential tremors were aggravated by intercurrent injury (including the chemical exposures). Again, the records confirm treatment for these tremors in service and continuing after service. Further regarding the claimed neurological disorder(s), additional examination by a neurological specialist should clearly determine the nature and etiology of all neurological manifestations in light of the very complicated neurological history shown in the records which includes records suggesting the Veteran had Parkinson's disease; records refuting a diagnosis of Parkinson's disease, and records suggesting the presence of a polyneuropathy, in addition to the essential tremors. With respect to the claimed myotonic dystrophy, the RO has denied this disorder based on it being congenital in nature, having relied upon a medical treatise from the Myotonic Dystrophy Foundation submitted by the Veteran. See 9/10/10 e-mail correspondence. Again, the Board notes that even if congenital, it must be determined whether intercurrent injury in service caused it to worsen beyond normal progression. Additionally, the Veteran has made allegations that he has muscle wasting as additional disability from the surgery on his pancreas per his 1151 claim. See January 2015 VA examination at page 1. Thus, further examination should address whether there was intercurrent inservice injury or additional disability by the VA treatment of the Veteran's pancreatic cyst superimposed onto a congenital disorder of genetic myotonic dystrophy (if found to be present in the Veteran). Regarding the claimed skin disorder/allergic disorder affecting the hands, the Veteran underwent examinations in September 1998 and July 2010. These examinations found no evidence of a current disability regarding the hands. However the Veteran's lay testimony in his March 2016 hearing was not considered. Given this fact and in light of his contentions that the claimed symptoms include swelling of the upper extremities, further examination is warranted. As to the Veteran's claimed psychiatric disorder, the Veteran is claiming that he has symptoms of anxiety and depression secondary to the above discussed disorders including his GI symptoms, neurological disorder, myotonic dystrophy and skin disorder. The evidence reflects that he has sought psychiatric treatment due to chronic pain issues with records showing such treatment as early as June 1999. He has continued to seek psychiatric treatment for pain management issues, with a June 2008 record noting a diagnosis of adjustment disorder with anxiety and depressed mood depression due to multiple medical issues, including chronic pain. Among the areas of chronic pain, he is shown in a June 2009 pain clinic to have pain complaints that include his knees, back and intestines. See 73 pg VA recs pg 1, 16, 58, 60. He continued to have psychiatric treatment related to pain and somatic issues in November 2009 and in March and April 2010. See 75 page VA records (2009-2010, 2nd entry) at pg 36-38. See also 75 pgs VA records (2009-2010) at pgs 39, 62, 72. He has continued to have psychiatric issues and testified as to these in his January 2016 hearing, where he alleged that he started having psychiatric symptoms in service although they were untreated at the time. See March 2016 Travel Board Transcript at p 17-27. The Board notes that service connection is presently in effect for migraines and left knee disorders of chondromalacia patella and patellar subluxation. Thus, a VA examination is indicated in this matter regardless of the outcome of the other claims, as it must be addressed whether he has a psychiatric disorder being caused or aggravated by these painful disorders in light of the evidence of psychiatric treatment related to painful conditions (including his knee). Accordingly, the case is REMANDED for the following action: 1. The RO should contact the Social Security Administration (SSA) and obtain and associate with the claims file copies of the Veteran's records regarding SSA benefits, including any SSA administrative decisions (favorable or unfavorable) and the medical records upon which the decisions were based. 2. Obtain and associate with the claims file all outstanding VA treatment records, to include all records of treatment from the San Diego VAMC pertaining to the surgical procedures addressing the 2008 pancreatic cyst biopsy and the ERCP procedure, and records of treatment both leading up to these procedures and the post-surgical hospitalizations for complications following the surgical procedures on the pancreas (noted to include leaking into the abdomen, the development of chronic necrotizing pancreatitis and new onset portal vein thrombosis and splenic vein thrombosis). 3. The Veteran should be afforded a VA examination by a medical expert or a panel of experts with specialties in GI and pancreatic disorders and/or in toxicology for the purpose of determining the nature, etiology and severity of his claimed GI disorder to include chronic pancreatitis with complications including portal vein thrombosis and splenic vein thrombosis and/or irritable bowel syndrome (IBS), as well as any other complications from this surgery. The claims file must be made available to the examiner(s) for review in connection with the examination. Following a review of the relevant evidence, to include the claims file, service treatment records, post-service treatment records; a history obtained from the Veteran, the clinical evaluation, and any tests that are deemed necessary, the examiner(s) should opine whether it is at least as likely as not (a 50 percent or greater probability) that a GI disorder to include IBS and/or a pancreatic disorder began during or is causally related to service, to include whether such disorder(s) is/are the result of conceded exposures to various chemicals including those shown in jet fuel (JP-4) and other chemicals routinely encountered by him while serving both as a fuel specialist as well as servicing printing machinery in service. The examiner(s) should note the Veteran's lay hearing testimony from his hearings held in December 2010 and March 2016 and written statements (including in his June 2012 VA Form I-9) pertaining to continuity of symptoms reported by him after service. Consider all relevant lay and medical evidence (to include all previous VA examinations addressing his GI/pancreatic disorders; the September 2, 2009 OCCEMED opinion on Internal Consultation and Toxicology Consult by M.B.B. MD, MPH; and medical treatises submitted regarding chemical exposures including the multiple treatises submitted on October 22, 2010 and the Web HTML docs of the Subcommittee on Permissible Exposure Levels for Military Forces submitted on December 22, 2010) and provide reasons and bases for the opinion. Provide rationale for any conclusions. If the examiner cannot provide an opinion without resort to speculation, the examiner should explain whether the limitation is due to the lack of evidence or scientific/medical knowledge. The examiner(s) should additionally provide an opinion for the following: (a) Is it at least as likely as not (50 percent or greater) that the Veteran incurred additional disability as a result of VA medical care, including treatment and medical procedures performed on the pancreas following the February 2008 CT findings of a pancreatic cyst, with treatment including biopsy and the ERCP procedure? If additional disability exists, the examiner is to note the nature of such additional disability. (b) If additional disability exists, is it at least as likely as not (50 percent or greater) that such was due to carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA? In answering this question the examiner should address not only the available records addressing the surgical and post-surgical treatments for the pancreas and subsequent complications (including in 2008 as well as any medical releases pertaining to these procedures, but should also address the Veteran's contentions in his March 2016 hearing suggesting that the pancreatic disorder that was surgically treated was not diagnosed in a timely fashion). See March 2016 BVA hearing transcript at pg 46. (c) If additional disability exists, is it at least as likely as not (50 percent or greater) that such was due to an event not reasonably foreseeable? A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. Thereafter and following the completion of the above development Veteran should be afforded a VA examination by a medical expert or a panel of experts with specialties in neuro-muscular disorders and in toxicology for the purpose of determining the nature, etiology and severity of his claimed neurological and muscular disorders to include myotonic dystrophy (or other muscle wasting disorder) and any neurological disorder(s) to include one manifested by essential tremors; paralysis agitans and/or distal polyneuropathy. The claims file must be made available to the examiner(s) for review in connection with the examination. Following a review of the relevant evidence, to include the claims file, service treatment records, post-service treatment records; a history obtained from the Veteran, the clinical evaluation, and any tests that are deemed necessary, the examiner(s) should opine whether it is at least as likely as not (a 50 percent or greater probability) that any neuromuscular disorder began during or is causally related to service, or if shown to be congenital was aggravated by intercurrent injury to include whether such disorder(s) is/are the result of conceded exposures to various chemicals including those shown in jet fuel (JP-4) and other chemicals routinely encountered by him while serving both as a fuel specialist as well as servicing printing machinery in service. The examiner(s) should note the Veteran's lay hearing testimony from his hearings held in December 2010 and March 2016 and written statements (including in his June 2012 VA Form I-9) pertaining to continuity of symptoms reported by him after service. Consider all relevant lay and medical evidence (to include all previous VA examinations addressing his neuro-muscular/neurological disorders; the September 2, 2009 OCCEMED opinion on Internal Consultation and Toxicology Consult by M.B.B. MD, MPH; and medical treatises submitted regarding chemical exposures including the multiple treatises submitted on October 22, 2010 and the Web HTML docs of the Subcommittee on Permissible Exposure Levels for Military Forces submitted on December 22, 2010) and provide reasons and bases for the opinion. Provide rationale for any conclusions. If the examiner cannot provide an opinion without resort to speculation, the examiner should explain whether the limitation is due to the lack of evidence or scientific/medical knowledge. The examiner should specifically offer opinions on the following: (a) Are any of the Veteran's claimed disorders affecting the muscular or neurological system, to include myotonic dystrophy (or other muscle wasting disorder) and any neurological disorder(s) to include one manifested by essential tremors; paralysis agitans and/or distal polyneuropathy shown to be a developmental defect or a developmental disease? For VA purposes, a defect differs from a disease in that the former is "more or less stationary in nature" while the latter is "capable of improving or deteriorating." Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009). (b) If any diagnosed claimed disorders affecting the muscular or neurological system is/are a developmental defect(s), please opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran incurred any superimposed disease or injury on such congenital defect during his military service (including by exposure to the above discussed toxic chemicals in service). If the answer to the above question is "Yes," please describe the resultant disability. (c) If the answer to question (a) is that the Veteran's has a disease or disorder affecting the muscular or neurological system that is not of a congenital or developmental origin, please provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that such disease or disorder affecting the muscular or neurological system was incurred in or aggravated beyond the normal course of the condition by his active service, to include by his conceded exposure to the above discussed toxic chemicals in service. (d) The examiner(s) should also review the findings from the GI/pancreatic disorders examination(s) (detailed in paragraph #3 above) pertaining to the questions of whether there is additional disability as a result of VA medical care involving treatment and medical procedures performed on the pancreas following the February 2008 CT findings of a pancreatic cyst, with treatment including biopsy and the ERCP procedure. Specifically, the examiner(s) should clarify whether any additional disability from such procedures includes any claimed neuro-muscular disorder(s) and state the nature of such neurological and/or muscular disorders affected by such VA medical procedures performed on the pancreas. In rendering the requested opinions, the examiner(s) should consider all pertinent evidence, to include the above cited medical and lay evidence pertaining to his neuro-muscular disorders and chemical exposures, and the findings of essential tremors noted in the service treatment records and post service records. The examiner(s) should set forth all examination findings, along with complete rationale for the conclusions reached. If the examiner cannot provide any of the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 5. The Veteran should be afforded a VA examination by a medical expert or a panel of experts with specialties in dermatological/allergic disorders and in toxicology for the purpose of determining the nature, etiology and severity of his claimed dermatological and/or allergic disorder classified as bilateral hand dermatitis allergies, bilateral hand swelling and skin rashes. The claims file must be made available to the examiner(s) for review in connection with the examination. Following a review of the relevant evidence, to include the claims file, service treatment records, post-service treatment records; a history obtained from the Veteran, the clinical evaluation, and any tests that are deemed necessary, the examiner(s) should opine whether it is at least as likely as not (a 50 percent or greater probability) that any a dermatological and/or allergic disorder classified as bilateral hand dermatitis allergies, bilateral hand swelling and skin rashes secondary began during or is causally related to service, to include whether such disorder(s) is/are the result of conceded exposures to various chemicals including those shown in jet fuel (JP-4) and other chemicals routinely encountered by him while serving both as a fuel specialist as well as servicing printing machinery in service. The examiner(s) should note the Veteran's lay hearing testimony from his hearings held in December 2010 and March 2016 and written statements (including in his June 2012 VA Form I-9) pertaining to continuity of symptoms reported by him after service. Consider all relevant lay and medical evidence (to include all previous VA examinations addressing his neuro-muscular/neurological disorders; the September 2, 2009 OCCEMED opinion on Internal Consultation and Toxicology Consult by M.B.B. MD, MPH; and medical treatises submitted regarding chemical exposures including the multiple treatises submitted on October 22, 2010 and the Web HTML docs of the Subcommittee on Permissible Exposure Levels for Military Forces submitted on December 22, 2010) and provide reasons and bases for the opinion. Provide rationale for any conclusions. If the examiner cannot provide an opinion without resort to speculation, the examiner should explain whether the limitation is due to the lack of evidence or scientific/medical knowledge. 6. Thereafter, following completion of the above development, the Veteran should be afforded a VA mental disorders examination for the purpose of determining the nature, etiology and severity of the Veteran's claimed psychiatric disorder(s). The claims file must be made available to the examiner for review in connection with the examination. Following a review of the relevant evidence, to include the claims file, service treatment records, post-service treatment records; a history obtained from the Veteran, the clinical evaluation, and any tests that are deemed necessary, the examiner should opine: (a) Whether it is at least as likely as not (a 50 percent or greater probability) that a psychiatric disorder to include an anxiety/depression disorder began during or is causally related to service, to include whether it was caused, or aggravated by any service connected disorder to include the currently service connected disabilities of migraines, and left knee disorders of chondromalacia patella and patellar subluxation. (b) If the above development results in a finding that service connection is warranted, pursuant to 38 U.S.C. § 1151 or otherwise, for any or all of the following: Disorders of the GI system (including IBS and any disorder(s) of the pancreas including complications from pancreas surgery in 2008), neurological and/or neuromuscular disorder (including myotonic dystrophy, muscle wasting, paralysis agitans, distal polyneuropathy and essential tremor) and a dermatological/allergic disorder affecting the bilateral hands with manifestations including dermatitis, swelling and skin rashes), the examiner should give an opinion stating whether it is as likely as not that any psychiatric disorder to include an anxiety/depression disorder was caused or aggravated by any of these aforementioned disorders of the GI system, neurological/neuromuscular system and or dermatological/immune system claimed as affecting the hands. 7. If any claim remains denied issue a supplemental statement of the case. Thereafter, return the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). 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). (CONTINUED ON NEXT PAGE) 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). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs