Citation Nr: 1754084 Decision Date: 11/28/17 Archive Date: 12/07/17 DOCKET NO. 13-22 415 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection, to include on a secondary basis, for papillary adenocarcinoma of the thyroid, right lower lobe. 2. Entitlement to service connection, to include on a secondary basis, for papillary adenocarcinoma of the thyroid, right lower lobe. 3. Entitlement to service connection for coronary artery disease, claimed as ischemic heart disease, to include as due to in-service herbicide exposure. 4. Entitlement to a disability rating in excess of 30 percent for PTSD prior to September 1, 2011. 5. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) from September 1, 2011. 6. Entitlement to a disability rating in excess of 40 percent for a low back disability. 7. Entitlement to a disability rating in excess of 10 percent for residuals of a fragment wound to the neck. 8. Entitlement to a disability rating in excess of 10 percent for residuals of a shell fragment wound to the left hand. 9. Entitlement to a compensable rating for residuals of a shell fragment wound to the forehead. 10. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and his son ATTORNEY FOR THE BOARD D. Houle, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1966 to June 1969, including service in the Republic of Vietnam. His decorations include the Purple Heart medal. These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2009 and August 2011 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In July 2017, the Veteran testified at a travel Board hearing before the undersigned at the St. Petersburg RO. The Board notes that the Veteran was previously represented by Christopher Loiacono, an agent. In February 2017, the Veteran submitted a VA Form 21-22a in favor of Disabled American Veterans (thereby revoking the power of attorney of Mr. Loiacono). See 38 C.F.R. § 14.631(f)(1)(2017). The Board recognizes the change in representation. The issues of whether new and material evidence has been received to reopen a claim for service connection for papillary adenocarcinoma of the thyroid, right lower lobe and entitlement to a TDIU are addressed in the decision below. The remaining issues on appeal, including entitlement to service connection for papillary adenocarcinoma of the thyroid, right lower lobe on a de novo basis, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A July 2003 rating decision denied service connection for papillary adenocarcinoma of the thyroid, right lower lobe; the Veteran was notified of the decision and of his appellate rights, but he did not appeal. 2. Evidence received since the July 2003 rating decision is new and material and sufficient to reopen the claim of entitlement to service connection for papillary adenocarcinoma of the thyroid, right lower lobe. 3. The Veteran's service-connected disabilities preclude him from securing and following a substantially gainful occupation consistent with his education and work experience. CONCLUSIONS OF LAW 1. The July 2003 rating decision in which the RO denied service connection for papillary adenocarcinoma of the thyroid, right lower lobe, is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 2. New and material evidence has been received since the July 2003 rating decision and the requirements to reopen the claim of entitlement to service connection for papillary adenocarcinoma of the thyroid, right lower lobe, have been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 3. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA provided the Veteran with 38 U.S.C. § 5103(a)-compliant notice in May 2009, October 2010, May 2011, and October 2011. The record also shows that VA has fulfilled its obligation to assist the Veteran in developing the claims, including with respect to VA examinations of the Veteran. Neither the Veteran nor his representation has identified any deficiency in VA's notice or assistance duties. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). II. Claim to Reopen Rating actions from which an appeal is not perfected become final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing, and after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. In order to reopen a claim which has been denied by a final decision, new and material evidence must be received. 38 U.S.C. § 5108. New and material evidence means evidence not previously submitted to agency decision makers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is 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 which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether that low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA's duty to assist or through consideration of an alternative theory of entitlement. In a July 2003 rating decision, the RO denied service connection for papillary adenocarcinoma of the thyroid, right lower lobe, based on a lack of evidence showing a correlation between the Veteran's service-connected shell fragment wound to the neck and his diagnosis of papillary adenocarcinoma of the thyroid. The pertinent evidence of record at the time of the July 2003 rating decision consisted of the Veteran's service treatment records (STRs), military personnel records (MPRs), and hospital reports from Amsterdam Memorial Hospital from September 1983 to December 1983. The Veteran was notified of the July 2003 rating decision, but he did not file a timely appeal, and no new and material evidence was received within a year of the rating decision. Therefore, the July 2003 rating decision is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104(a), 3.156(b), 3.160(d), 20.302, 20.1103 (2017). The pertinent evidence received since the July 2003 rating decision includes the Veteran's July 2017 travel Board hearing testimony. During the Veteran's July 2017 travel Board hearing, the Veteran testified that during service, he suffered a shell fragment wound to his neck, which created a goiter that became infected and required removal shortly after separation from service. The Veteran testified that his doctor stated that the goiter resembled cancer and sent a section off to Air Force pathology for further review. He stated that he never heard anything further regarding the pathology results. When the Veteran's thyroid was removed, he was put on the medication synthroid, which he currently still takes. He testified that he receives treatment at the Lakeland VA Medical Center, which monitors the proper dosage of thyroid replacement medication. Additionally, the Veteran testified at his travel Board hearing that he believes there could also be a correlation between his exposure to water at Camp Lejeune and his thyroid disorder. He stated that he was stationed at Camp Lejeune during his first year in service. As he was often moving around the location, he was given portable water to drink. The Veteran believes the water he drank was contaminated and that this may have contributed to his thyroid disorder. The Board finds that new and material evidence has been presented to reopen the claim. The Veteran's July 2017 travel Board hearing testimony is new since it is neither cumulative nor redundant of the evidence that was of record in July 2003. This evidence is also material because, accepting the evidence as credible for the purpose of reopening the claim, the evidence tends to show the onset of the Veteran's thyroid disorder during service or as a result of his service-connected shell fragment wound to the neck. New evidence may be found to be material if it provides a ?more complete picture of the circumstances surrounding the origin of the Veteran's injury or disability, even where it will not eventually convince the Board of Veterans' Appeals to alter its decision." See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). Thus, the Board finds that new and material evidence has been submitted and the petition to reopen the claim of entitlement to service connection for papillary adenocarcinoma of the thyroid, right lower lobe, must be granted. III. Entitlement to a TDIU A. Legal Principles It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled. 38 C.F.R. § 4.16 (2017). Substantially gainful employment is employment that is ordinarily followed by the nondisabled to earn their livelihoods with earnings common to the particular occupation in the community where the veteran resides. Moore v. Derwinski, 1 Vet. App. 356 (1991). Marginal employment will not be considered substantially gainful employment. 38 C.F.R. § 4.16(a) (2017). The central inquiry is, ?whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16(a) (2017). In determining whether unemployability exists, consideration may be given to a veteran's level of education, special training, and previous work experience, but not to any non-service-connected condition or advancing age. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017). B. Factual Background and Analysis At the time the Veteran filed his claim for entitlement to a TDIU in September 2010, his service-connected disabilities included PTSD, rated 30 percent; a low back disability, rated 40 percent; residuals of a shell fragment wound to the neck, rated 10 percent; residuals of a shell fragment wound to the left hand, rated 10 percent; and residuals of a shell fragment wound to the forehead, noncompensable. The Veteran's combined service-connected disability rating at this time was 70 percent. A review of the Veteran's application for a TDIU shows that he ceased working full-time in February 2006. Prior to this period, he was employed as a sales representative for aluminum goods. The Veteran completed one year of college and six years of training in aluminum processing. In January 2011, the Veteran was found disabled by the Social Security Administration (SSA), effective September 2010. The disability transmittal lists degenerative disc disease as the primary diagnosis for the award of disability benefits, as well as essential hypertension as the secondary diagnosis. During a September 2011 VA examination for the Veteran's PTSD, the examiner noted that this disability impacted the Veteran's ability to work, specifically, his ability to concentrate and work around other people . The examiner stated the Veteran had a history of poor relationships and an inability to control his anger. He had increased irritability which caused him to flare-up at people. The examiner found the Veteran to be unemployable. In a September 2011 general VA examination, the Veteran's neck, left hand scar, forehead scar, and back were evaluated. The examiner noted that the Veteran's neck disability had significant effects on the Veteran's occupational activities, specifically, that the Veteran had difficulty lifting, carrying, and reaching for objects. With regard to the Veteran's left hand and forehead scars, the examiner stated that the Veteran's scars had no significant effect on occupation. With regard to the Veteran's back disability, the examiner stated the disability caused pain, decreased mobility, and problems lifting, carrying, or reaching for objects in relation to occupational activities. Overall, the examiner opined that it was less likely as not that the Veteran's neck disability, shrapnel fragment wounds to the left hand and forehead, and back disability prevented him from working and that the Veteran should be able to perform sedentary office tasks that allow him to take frequent breaks, as needed. In a September 2012 psychological impairment questionnaire, the Veteran's private psychiatrist, Dr. J. L., found that the Veteran was incapable of performing full-time competitive work, citing to the Veteran's symptoms unprovoked hostility, deficiencies in judgment, limited ability to concentrate for extended periods of time, limited ability to sustain an ordinary routine without supervision, limited ability to interact with the general public, and a limited ability to get along with co-workers. VA treatment records document a December 2012 opinion from Dr. P. G., the Veteran's primary care physician with the Lakeland VA Clinic. Dr. P. G. noted that the Veteran suffered from chronic neck and back pain as well as PTSD and chronic depression. Dr. P. G. opined that the Veteran was unemployable due to his service-connected disabilities. In a March 2016 PTSD disability benefits questionnaire, Dr. J. L. found the Veteran to have occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood, citing to the Veteran's symptoms of anxiety, suspiciousness, weekly panic attacks, near-continuous depression, mild memory loss, impaired judgement, and the inability to establish and maintain relationships. During his March 2017 travel Board hearing, the Veteran testified that his service-connected disabilities prevented him from working. With regard to his last job as a sales engineer for foundry products, the Veteran stated that his job required him to be on the road quite often, driving for long periods of time. He testified that his PTSD caused him to have difficulty concentrating and that he was easily agitated and argued with others. He stated that in the past, he experienced problems with his supervisors and co-workers. With regard to his low back disability, the Veteran testified that he often called out of work because driving and sitting aggravated his back. He was eventually let go by his company because he could not physically perform his job. The Veteran testified that he attempted to secure employment again, but his disabilities prevented him from being able to travel for work, which is a requirement for the type of sales job he had with his prior employer. He stated that he is only able to walk approximately 15 feet before gasping for air due to pain in his lower back. With regard to his neck disability, the Veteran testified that he is unable to bend over without his carotid gland trapping blood and swelling to the size of a tangerine. To prevent this type of occurrence, he has to remain in an upright position and cannot bend over or lie down flat. The Veteran's son also testified at the Veteran's March 2017 travel Board hearing. His son stated that he lives with the Veteran to help him with daily activities such as getting dressed, shaving, and tying his shoes, as well as cooking meals. The Veteran's son stated that the Veteran is always in pain and requires help walking and standing up from a seated position. He testified that the Veteran falls every few days due to his physical disabilities. Upon review of the record, the Board finds that entitlement to a TDIU is warranted. The symptoms documented throughout his VA examinations, VA and private treatment records, and his travel Board hearing testimony as associated with his service-connected PTSD, neck disability, and low back disability, include physical symptoms with regard to difficulty lifting, carrying, and reaching for objects, and difficulty sitting, standing up from a seated position, and walking, as well as psychological symptoms of depression, anxiety, memory loss, poor concentration, reduced productivity, inability to work with others, and irritability. The evidence shows that the Veteran's PTSD, neck disability, and low back disability impeded his ability to work as a sales representative because of his physical limitations as well as impairment in social and occupational areas of functioning. Resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for entitlement to TDIU have been met. While the September 2011 general VA examination opinion weighs against the claim of entitlement to TDIU, there is competent and credible evidence which weighs in favor of the claim. The September 2011 VA examiner who evaluated the Veteran for PTSD found that the Veteran's PTSD impacted his ability to concentrate and work around other people due to his inability to control his anger. The examiner opined that the Veteran's PTSD rendered him unemployable. Additionally, in a December 2012 note in the Veteran's VA treatment records, Dr. P. G., the Veteran's treating physician for his service-connected disabilities, stated that it was her opinion that the Veteran is unemployable due to his PTSD, low back disability, and neck disability. Corroborating these opinions, the Veteran consistently and credibly described severe symptoms related to his PTSD, low back disability, and neck disability. These statements were consistently and credibly reiterated by the Veteran and his son in the July 2017 travel Board hearing, and they further showed that the Veteran would experience significant amounts of pain and discomfort while sedentary. In light of the Veteran's occupational background and the functional limitations described, the Board finds that the evidence is in equipoise as to whether the Veteran is unable to obtain and maintain substantially gainful employment in accordance with his background and education level as a result of combined symptoms of the service-connected disabilities. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to TDIU is warranted. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER As new and material evidence has been received, the claim of entitlement to service connection for papillary adenocarcinoma of the thyroid, right lower lobe is reopened; the appeal is granted to this extent only. Entitlement to a TDIU is granted. REMAND The Board finds that additional development is required before the remaining claims on appeal are decided. Papillary Adenocarcinoma of the Thyroid, Right Lower Lobe During his July 2017 travel Board hearing, the Veteran alleged that his thyroid disorder is either caused by his service-connected neck disability or as a result of consuming contaminated water while stationed at Camp Lejeune. The Board notes that the Veteran has not been provided with an examination addressing his claimed thyroid disorder. VA's duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d). The Board finds that an examination is necessary to determine whether the Veteran has a thyroid disability that either incurred in or is related to service or is caused or aggravated a by service-connected disability. Additionally, while the record reflects that the Veteran served for some period of time at Camp Lejeune, the exact dates of service are not specified. Therefore, the AOJ should verify the dates of the Veteran's service at Camp Lejeune. Coronary Artery Disease, Claimed as Ischemic Heart Disease During his July 2017 travel Board hearing, the Veteran indicated that he received treatment from the Albany VA Medical Center shortly after separation from service, as well as from the private Heart of Florida Hospital in 2005. These records are not in the Veteran's claims file, nor does it appear that VA attempted to obtain them. These records appear relevant to the Veteran's claim because they relate to whether the Veteran was diagnosed with and treated for a heart disability and they may include further information pertaining to the Veteran's history of symptoms. VA has a duty to seek these records. 38 U.S.C. § 5103A(b)(1). Additionally, the June 2011 VA examination report notes that a diagnosis of ischemic heart disease is purely speculative, as the examiner was unable to verify any of the Veteran's reported history of symptoms and treatment in the Veteran's claims file, suggesting that she had access to an incomplete claims file. Further, it appears that the examiner completed the examination report based solely on the Veteran's reported history, rather than conducting the appropriate diagnostic testing necessary to evaluate the Veteran for ischemic heart disease. For these reasons, the Board finds that the June 2011 VA examination is inadequate. A new VA examination, therefore, is necessary to adjudicate the claim. 38 U.S.C. § 5103A(d) (2012); 38 C.F.R. § 3.159(c)(4) (2017); See McLendon v. Nicholson, 20 Vet App. 79, 81 (2006). PTSD During his July 2017 travel Board hearing, the Veteran indicated that he receives treatment from a private psychiatrist, Dr. J. L., for his PTSD. These records are not in the Veteran's claims file, nor does it appear that VA attempted to obtain them. These records appear relevant to the Veteran's claim because they may relate to a worsening in the Veteran's PTSD symptoms. VA has a duty to seek these records. 38 U.S.C. § 5103A(b)(1). Low Back Disability The Veteran last underwent a VA examination for his service-connected low back disability in September 2011. During the examination, the Veteran reported constant pain and stiffness in his lower back, as well as daily flare-ups of a severe nature. The examiner noted there were no signs of incapacitating episodes of spine disease, nor was cervical or thoracolumbar ankylosis found. The examiner stated the Veteran experienced decreased mobility and problems with lifting, carrying, and reaching due to pain in his lower back. During his July 2017 travel Board hearing, the Veteran asserted that his low back disability had worsened since his September 2011 VA examination. Specifically, the Veteran contended that he has experienced incapacitating episodes where he is unable to pick himself up from the floor. He testified that he falls every few days and is able to walk approximately 15 feet before gasping for air due to pain in his lower back. The Veteran stated that he currently experiences pain running down both of his legs and has been informed by his physician that his back is ankylosed and is fusing together. In consideration of the Veteran's report of a worsening in his service-connected disability, and the six-year time lapse since the last VA examination, the Board finds that the medical evidence is not sufficient upon which to decide these aspects of the claim and a remand is warranted for a new VA examination to ensure the record contains evidence reflecting the current severity of the Veteran's service-connected low back disability. Residuals of a Fragment Wound to the Neck The Veteran last underwent a VA examination for his service-connected neck wound disability in September 2011. During the examination, the Veteran reported increased tightness in his neck muscle and pain in his neck when he coughs or sneezes. The examiner noted there were no residuals of nerve damage, tendon damage, bone damage, muscle herniation, and loss of deep fascia or muscle substance. Regarding his neck scar, there was no evidence of skin breakdown over the scar and no reports of pain. The examiner stated the Veteran experienced problems with lifting, carrying, and reaching for objects. During his July 2017 travel Board hearing, the Veteran asserted that his neck wound disability had worsened since his September 2011 VA examination. Specifically, the Veteran contended that every time he bends over, his carotid gland swells to the size of a tangerine and that he has to sleep upright to prevent further swelling. He stated that his neck scar is painful and tender to touch. In consideration of the Veteran's report of a worsening in his service-connected disability, and the six-year time lapse since the last VA examination, the Board finds that the medical evidence is not sufficient upon which to decide these aspects of the claim and a remand is warranted for a new VA examination to ensure the record contains evidence reflecting the current severity of the Veteran's service-connected neck wound disability. Residuals of a Shell Fragment Wound to the Left Hand The Veteran last underwent a VA examination for his service-connected left hand scar wound disability in September 2011. The VA examination report shows the Veteran's left thumb scar and left wrist scar are well-healed with no breakdown over the scars. No pain was reported by the Veteran. During his July 2017 travel Board hearing, the Veteran asserted that his left hand scar wound disability had worsened since his September 2011 VA examination. Specifically, the Veteran contended that he experiences numbness in his left hand as well as his entire left arm. He stated that his left hand scars are painful and tender to touch. In consideration of the Veteran's report of a worsening in his service-connected disability, and the six-year time lapse since the last VA examination, the Board finds that the medical evidence is not sufficient upon which to decide these aspects of the claim and a remand is warranted for a new VA examination to ensure the record contains evidence reflecting the current severity of the Veteran's service-connected left hand scar wound disability. Residuals of Shell Fragment Wound to the Forehead The Veteran last underwent a VA examination for his service-connected forehead scar wound disability in September 2011. The VA examination report shows the Veteran's forehead scar is well-healed with no breakdown over the scar. No pain was reported by the Veteran. During his July 2017 travel Board hearing, the Veteran asserted that his forehead scar wound disability had worsened since his September 2011 VA examination. Specifically, the Veteran contended that he experiences headaches and pain near the shell fragment wound site. He stated that his forehead scar is painful and tender to touch. In consideration of the Veteran's report of a worsening in his service-connected disability, and the six-year time lapse since the last VA examination, the Board finds that the medical evidence is not sufficient upon which to decide these aspects of the claim and a remand is warranted for a new VA examination to ensure the record contains evidence reflecting the current severity of the Veteran's service-connected forehead scar wound disability. Accordingly, the case is REMANDED for the following action: 1. With any necessary identification of sources and authorization by the Veteran, request all VA and private treatment records for the Veteran not already associated with the file, to specifically include VA treatment records from the Albany VA Medical Center, private treatment records from Heart of Florida Hospital, and private treatment records from Dr. J. L, all referenced in the Veteran's July 2017 travel Board hearing transcript. Copies of any outstanding VA and private treatment records should be added to the Veteran's electronic claims file. 2. Determine the dates the Veteran served at Camp Lejeune. 3. Thereafter, schedule the Veteran for a VA examination by an appropriate examiner to determine the nature and etiology of any diagnosed thyroid disability. A complete history from the Veteran should be obtained and recorded. All testing deemed necessary by the examiner should be performed and the results reported in detail. The rationale for all opinions expressed should be provided. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination. Following the review of the claims file and examination of the Veteran, the examiner is then requested to respond to the following: a) Is it at least as likely as not (a 50 percent probability or greater) that any diagnosed thyroid disability is etiologically related to the Veteran's active service, to include exposure to contaminated drinking water at Camp Lejeune. b) Is it at least as likely as not (50 percent probability or greater) that any diagnosed thyroid disability is caused by the Veteran's service-connected disabilities, to include residuals of a fragment wound to the neck. c) Is it at least as likely as not (50 percent probability or greater) that any diagnosed thyroid disability is aggravated by the Veteran's service-connected disabilities, to include residuals of a fragment wound to the neck. If an opinion cannot be expressed without resort to speculation, discuss why such is the case. In this regard, indicate whether the inability to provide a definitive opinion is due to a need for further information or because the limits of medical knowledge have been exhausted regarding the etiology of the disability at issue or because of some other reason. 4. Schedule the Veteran for a VA examination by a physician with appropriate expertise to determine the nature and etiology of any diagnosed heart disability. A complete history from the Veteran should be obtained and recorded. All testing deemed necessary by the examiner should be performed and the results reported in detail. The rationale for all opinions expressed should be provided. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination. Following the review of the claims file and examination of the Veteran, the examiner is then requested to respond to the following: a) The examiner should diagnose or rule out ischemic heart disease and coronary heart disease. b) Is it at least as likely as not (a 50 percent or greater probability) that any diagnosed heart disability is etiologically related to the Veteran's active service. In providing this opinion the examiner should discuss the Veteran's presumed exposure to herbicides. In rendering the requested opinions, the examiner should consider the March 2012 VA treatment record diagnosis of transient ischemic attack. If an opinion cannot be expressed without resort to speculation, discuss why such is the case. In this regard, indicate whether the inability to provide a definitive opinion is due to a need for further information or because the limits of medical knowledge have been exhausted regarding the etiology of the disability at issue or because of some other reason. 5. Schedule the Veteran for a VA examination to determine the current severity of his service-connected low back disability, including whether there is ankylosis or incapacitating episodes. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The examiner must provide a complete rationale for any opinions expressed. 6. Schedule the Veteran for a VA examination to determine the current severity of his service-connected neck wound disability. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The examiner must provide a complete rationale for any opinions expressed. 7. Schedule the Veteran for a VA examination to determine the current severity of his service-connected left hand scar wound disability, including whether the scars are manifested by pain, loss of skin covering or limitation of motion. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The examiner must provide a complete rationale for any opinions expressed. 8. Schedule the Veteran for a VA examination to determine the current severity of his service-connected forehead scar wound disability. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The examiner must provide a complete rationale for any opinions expressed. 9. After completing all indicated development, the AOJ should readjudicate the Veteran's claims. If the benefits sought on appeal remain denied, the Veteran should be furnished with a supplement statement of the case, given the opportunity to respond, and the case should be thereafter returned to the Board for further appellate review, if warranted. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case 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. §§ 5109B, 7112 (2012). ______________________________________________ Thomas H. O'Shay Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs