Citation Nr: 1756830 Decision Date: 12/08/17 Archive Date: 12/15/17 DOCKET NO. 14-37 005 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for a skin disability. 2. Entitlement to service connection for a respiratory disability, to include sinusitis/chronic allergies. 3. Entitlement to service connection for an acquired psychiatric disability other than PTSD, to include mood disorder, including as due to service-connected migraine headaches. 4. Entitlement to service connection for erectile dysfunction. 5. Entitlement to service connection for fibromyalgia. 6. Entitlement to service connection for temporomandibular joint (TMJ) syndrome. 7. Entitlement to service connection for right L5-S1 radiculopathy. 8. Entitlement to service connection for radiculopathy of the left lower extremity. 9. Entitlement to service connection for radiculopathy of the bilateral upper extremities. 10. Entitlement to service connection for bilateral tarsal tunnel syndrome. 11. Entitlement to service connection for a cervical spine disability. 12. Entitlement to service connection for a lumbosacral spine disability. 13. Entitlement to service connection for tinnitus. 14. Entitlement to service connection for obstructive sleep apnea. 15. Entitlement to service connection for a right shoulder disability. 16. Entitlement to an initial rating greater than 10 percent for a gastrointestinal disability. 17. Entitlement to an initial rating greater than 30 percent for migraine headaches. REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from February 1991 to August 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico, which granted, in pertinent part, of service connection for migraine headaches, assigning a 30 percent rating effective April 22, 2011, and denied claims of service connection for a lumbosacral spine disability (which was characterized as subligamentous disc protrusion L5-S1 claimed as lumbar degenerative disc disease, herniated disc, and lumbar condition), an acquired psychiatric disability other than PTSD, to include mood disorder (which was characterized as major depressive disorder with psychotic features also claimed as panic attacks, bipolar disorder, and sleep disorder), right L5-S1 radiculopathy, radiculopathy of the left lower extremity, radiculopathy of the bilateral upper extremities (which was characterized as separate service connection claims for radiculopathy of the left upper extremity and for radiculopathy of the right upper extremity), bilateral tarsal tunnel syndrome (which was characterized as separate service connection claims for left tarsal tunnel syndrome and for right tarsal tunnel syndrome), and for a right shoulder disability (which was characterized as right shoulder tear superior glenoid labrum). The Veteran disagreed with this decision in January 2013 with respect to these claims, although a copy of his notice of disagreement is not associated with his claims file. He perfected a timely appeal in September 2014. This matter next is on appeal from a March 2014 rating decision in which the RO granted, in pertinent part, a claim of service connection for a gastrointestinal disability (which was characterized as dyspepsia (claimed as gastroesophageal reflux/irritable bowel syndrome) secondary to medications taken for service connected disability of migraine headaches), assigning a 10 percent rating effective September 30, 2013, and denied claims of service connection for a cervical spine disability (which was characterized as cervical conditions), fibromyalgia, erectile dysfunction, a skin disability (which was characterized as tinea versicolor (claimed as skin condition)), a respiratory disability, to include sinusitis/chronic allergies (which was characterized as sinusitis/chronic allergies), tinnitus, obstructive sleep apnea, and for TMJ syndrome. A videoconference Board hearing was held in June 2015 before the undersigned. In a March 2015 statement and on the record at his June 2015 Board hearing, the Veteran withdrew his appeal for service connection for fibromyalgia, TMJ syndrome, right L5-S1 radiculopathy, radiculopathy of the left lower extremity, radiculopathy of the bilateral upper extremities, and for bilateral tarsal tunnel syndrome. The issues of entitlement to service connection for a cervical spine disability, a lumbosacral spine disability, tinnitus, obstructive sleep apnea, and for a right shoulder disability, entitlement to an initial rating greater than 10 percent for a gastrointestinal disability, and entitlement to an initial rating greater than 30 percent for migraine headaches are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. The record evidence shows that the Veteran's current skin and respiratory disabilities are related to active service. 2. The record evidence is in equipoise as to whether the Veteran's service-connected migraine headaches caused or aggravated his current acquired psychiatric disability other than PTSD, to include mood disorder. 3. The record evidence shows that the Veteran does not experience any current disability due to his claimed erectile dysfunction which could be attributed to active service or any incident of service. 4. In statements made on the record at his June 3, 2015, Board hearing, prior to the promulgation of a decision in the appeal, the Veteran withdrew his appeal for service connection for fibromyalgia, TMJ syndrome, right L5-S1 radiculopathy, radiculopathy of the left lower extremity, radiculopathy of the bilateral upper extremities, and for bilateral tarsal tunnel syndrome. CONCLUSIONS OF LAW 1. A skin disability was incurred in active service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 2. A respiratory disability was incurred in active service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 3. An acquired psychiatric disability other than PTSD, to include mood disorder, was incurred in service as due to service-connected migraine headaches. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). 4. Erectile dysfunction was not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 5. The criteria for withdrawal of an appeal on the issue of service connection for fibromyalgia by the appellant (or his or her authorized representative) have been met. 38 U.S.C. §§ 7105(b)(2), (d)(5) (West 2012); 38 C.F.R. § 20.204 (2017). 6. The criteria for withdrawal of an appeal on the issue of service connection for TMJ syndrome by the appellant (or his or her authorized representative) have been met. 38 U.S.C. §§ 7105(b)(2), (d)(5) (West 2012); 38 C.F.R. § 20.204 (2017). 7. The criteria for withdrawal of an appeal on the issue of service connection for right L5-S1 radiculopathy by the appellant (or his or her authorized representative) have been met. 38 U.S.C. §§ 7105(b)(2), (d)(5) (West 2012); 38 C.F.R. § 20.204 (2017). 8. The criteria for withdrawal of an appeal on the issue of service connection for radiculopathy of the left lower extremity by the appellant (or his or her authorized representative) have been met. 38 U.S.C. §§ 7105(b)(2), (d)(5) (West 2012); 38 C.F.R. § 20.204 (2017). 9. The criteria for withdrawal of an appeal on the issue of service connection for radiculopathy of the bilateral upper extremities by the appellant (or his or her authorized representative) have been met. 38 U.S.C. §§ 7105(b)(2), (d)(5) (West 2012); 38 C.F.R. § 20.204 (2017). 10. The criteria for withdrawal of an appeal on the issue of service connection for bilateral tarsal tunnel syndrome by the appellant (or his or her authorized representative) have been met. 38 U.S.C. §§ 7105(b)(2), (d)(5) (West 2012); 38 C.F.R. § 20.204 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran contends that he incurred a skin disability, a respiratory disability, to include sinusitis/chronic allergies, an acquired psychiatric disability, and erectile dysfunction during active service and experienced continuous disability due to each of these claimed disabilities since his service separation. Factual Background and Analysis The Board finds that the evidence supports granting the Veteran's claims of service connection for a skin disability and for a respiratory disability, to include sinusitis/chronic allergies. The Veteran contends that he incurred both of these claimed disabilities during active service. The evidence supports finding an etiological link between the Veteran's current skin disability, his current respiratory disability, and active service. For example, on VA skin diseases Disability Benefits Questionnaire (DBQ) in March 2014, the Veteran's complaints included frequent episodes of skin itching and rash since active service. The examiner reviewed the claims file, including service and post-service VA treatment records. Physical examination showed no skin condition. The VA examiner opined that it was less likely than not that the Veteran's claimed skin condition was related to active service. T The rationale for this opinion was that, although there was evidence of in-service complaints of and treatment for tinea versicolor, the Veteran's more recent medical records were "silent" for any complaints of or treatment for a skin condition. The rationale also was that there was no evidence of a skin condition on physical examination of the Veteran. The diagnosis was tinea versicolor, resolved. On VA sinusitis DBQ in March 2014, the Veteran complained of sinusitis and chronic allergies since active service. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. This examiner found that the Veteran did not have a sinus condition. He also opined that it was less likely than not that the Veteran's claimed sinus condition was related to active service. The rationale for this opinion was that, although there was evidence of in-service complaints of and treatment for upper respiratory symptoms, these complaints had been resolved with treatment and without residuals. The rationale also was that the Veteran's more recent medical records were "silent" for complaints of or treatment for a sinus condition. The Court has held that the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. Wilson v. Derwinski, 2 Vet. App. 614 (1992). The Court also has held that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). Accordingly, because the March 2014 VA examiner's opinions violated the Court's holdings in Buchanan and Barr, the Board finds that they are entitled to no probative value on the issues of whether the Veteran experiences any current skin disability or respiratory disability which is related to active service. The remaining medical evidence supports granting the Veteran's service connection claims for a skin disability and for a respiratory disability, to include sinusitis/chronic allergies. See generally 38 C.F.R. §§ 3.303, 3.304. For example, on private outpatient treatment in March 2014, the Veteran complained of a pruritic rash when exposed to the sun. A history of chronic tinea versicolor and atopic dermatitis was noted. Objective examination showed xerosis, dry skin, and hypopigmented patches on the trunk. The assessment was chronic tinea versicolor. In April 2014, the Veteran complained of a pruritic rash when sweating and on sun exposure. Objective examination showed mild eczema, xerosis, and hypopigmented patches on the trunk, arms, and neck. The assessment was rule-out tinea versicolor and rule-out atopic dermatitis. A private pathology report dated in September 2014 shows a diagnosis of tinea versicolor. On private outpatient treatment that same month, physical examination showed pruritic eruption on the neck, arms, and trunk. The assessment was tinea versicolor. On VA skin diseases DBQ in October 2014, the Veteran's complaints included intermittent itching and pain (which he rated as 5/10 on a pain scale, with 10/10 being the worst imaginable pain) and daily severe itching and pain (which he rated as 7/10 on a pain scale) in the previous 6 months on his chest, neck, upper back, and arms not relieved by daily constant use of creams and lotions. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records, and noted in-service complaints of and treatment for a skin condition. Physical examination showed scattered multiple areas of raised erythema with inner discoloration and moderate scaling on the chest (right and left), neck, upper back, and right and left arms. The Veteran's skin conditions required the constant or near-constant use of antihistamines and other oral medications (Meloxicam), topical corticosteroids (desonide lotion and triamcinolone cream), and constant or near-constant use of other topical medications (pramoxine lotion and econzaole cream). The VA examiner stated that 20 to 40 percent of the Veteran's total body area and 5 to 20 percent of the exposed area of the body was affected by his skin infection. The September 2014 pathology report was reviewed. The VA examiner opined that it was at least as likely as not that the Veteran's tinea versicolor was related to active service. The rationale for this opinion was a review of the medical evidence of record, the Veteran's reported medical history, and physical examination findings. The diagnoses included tinea versicolor (dermatophytosis of body). On VA sinusitis DBQ in October 2014, the Veteran's complaints included persistent daily nasal congestion, sneezing, and nasal secretions which were not relieved by daily constant use of an cetirizine and patanase inhaler. He also complained of intermittent episodes of sore throat which he rated as 4/10 on a pain scale partially alleviated with the use of Meloxicam or baclofen. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records, and noted in-service complaints of and treatment for a respiratory condition. Physical examination showed permanent hypertrophy and hyperemia of both nasal turbinates, a 50 percent obstruction of both nasal passages due to rhinitis, no evidence of nasal polyps, mild evanescent erythema of the pharynx, and no evidence of tonsil swelling or exudates. The VA examiner opined that it was at least as likely as not that the Veteran's allergic rhinitis and pharyngitis were related to active service. The rationale for this opinion was a review of the medical evidence of record, the Veteran's reported medical history, and physical examination findings. The diagnoses were allergic rhinitis and pharyngitis. On VA sinusitis DBQ in May 2015, the Veteran's complaints included recurring episodes of sinusitis. The Veteran experienced 6 non-incapacitating episodes of sinusitis per year which required antibiotic treatment on more than 4 occasions which each episode characterized by headaches, pain, and purulent discharge or crusting. Physical examination showed chronic sinusitis, headaches, pain and tenderness of the sphenoid sinuses, greater than 50 percent obstruction of the bilateral nasal passages due to rhinitis, permanent hypertrophy of the nasal turbinates, no nasal polyps. A magnetic resonance imaging (MRI) scan of the sinuses taken in June 2014 showed mucoperiosteal thickening in the sphenoid sinus. The diagnoses were chronic sinusitis and allergic rhinitis. The Veteran contends that his current skin disability and respiratory disability, to include sinusitis/chronic allergies, are related to active service. The Board agrees, finding that the medical evidence demonstrates an etiological link between both of these disabilities and active service. The VA examiner specifically found in October 2014 that the Veteran's current skin disability (which was diagnosed as tinea versicolor) and his current respiratory disability (which was diagnosed as allergic rhinitis and pharyngitis) were related to active service. These opinions were fully supported. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In summary, and after resolving any reasonable doubt in the Veteran's favor, the Board finds that service connection for a skin disability and for a respiratory disability, to include sinusitis/chronic allergies, is warranted. The Board next finds that the evidence supports granting the Veteran's claim of service connection for an acquired psychiatric disability other than PTSD, to include mood disorder, as due to service-connected migraine headaches. The Veteran contends that he incurred an acquired psychiatric disability other than PTSD (which he described as depression) during active service. He alternatively contends that his service-connected migraine headaches caused or aggravated (permanently worsened) his current acquired psychiatric disability other than PTSD. The record evidence supports the Veteran's assertions concerning an etiological link between his service-connected migraine headaches and his current acquired psychiatric disability other than PTSD (diagnosed as mood disorder, not otherwise specified). See 38 C.F.R. § 3.310. Service connection is in effect for migraine headaches. The medical evidence shows that, on private psychiatric evaluation in February 2011, the Veteran's complaints included feeling depressed "constantly," sadness, "terrible mood changes," and difficulty sleeping. He was unable to control "explosive outbursts...at home with his wife and children." He also had outbursts at work with his boss and had been aggressive with his friends. The Veteran also experienced "severe anxiety and thoughts that lead into panic attacks." At a mental status examination of the Veteran in February 2011, the Axis I diagnoses included chronic major depression with psychotic features. On VA mental disorders examination in May 2013, the examiner opined that it was at least as likely as not that the Veteran's current acquired psychiatric disability was due to, or the result of, his service-connected migraines. The rationale was that it was "well known that a chronic medical condition associated with chronic pain can increase the risk, exacerbate, or aggravated a mood disorder." The rationale also was a review of the medical evidence of record. The Axis I diagnose included mood disorder, not otherwise specified, and a history of depression. VA outpatient treatment records dated in 2013 and 2014, which the Veteran submitted to VA in June 2014, show ongoing complaints of, and treatment for, a variety of acquired psychiatric disabilities other than PTSD. On VA mental disorders examination in October 2014, the examiner opined that it was less likely than not that the Veteran's current acquired psychiatric disability other than PTSD was caused or aggravated by a service-connected disability. The rationale for this opinion was: After reviewing the longitudinal psychiatric history, including the social history and occupational history, and performing a mental examination, it is determined that the Veteran's mental condition is remarkable for a long standing, enduring pattern of inner experience and behavior that is inflexible and pervasive across a broad range of personal and social situations. The diagnosis was mood disorder, not otherwise specified. There is evidence both in support of and against the Veteran's contentions regarding an etiological relationship between migraines and a current psychiatric disability. In other words, the evidence is in relative equipoise as to whether the Veteran's service-connected migraine headaches caused or aggravated (permanently worsened) his acquired psychiatric disability other than PTSD. On the one hand, the May 2013 VA examiner found that it was at least as likely as not the Veteran's service-connected migraine headaches caused or aggravated his current acquired psychiatric disability other than PTSD (diagnosed as mood disorder, not otherwise specified). On the other hand, a different VA examiner concluded in October 2014 that it was not at least as likely as not that a service-connected disability caused or aggravated the Veteran's current acquired psychiatric disability other than PTSD (diagnosed as mood disorder, not otherwise specified). Resolving all reasonable doubt in the Veteran's favor, the Board finds it reasonable to conclude that the record evidence sufficiently supports an actual causal relationship between the Veteran's service-connected migraine headaches and his current acquired psychiatric disability other than PTSD, to include mood disorder. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(d), 3.310. Accordingly, the criteria for establishing service connection for an acquired psychiatric disability other than PTSD, to include mood disorder, as due to service-connected migraine headaches have been met. The Board finally finds that the preponderance of the evidence is against granting the Veteran's claim of service connection for erectile dysfunction. The record shows that, in fact, he does not have that disability. The post-service evidence shows that, on VA male reproductive systems DBQ in March 2014, the Veteran reported that he could sustain an erection and did not experience any current erectile dysfunction. At that examination, the examiner stated that he had reviewed the claims file, including service treatment records and post-service VA treatment records. This examiner observed that the Veteran had not been diagnosed as having any condition of the male reproductive system. The Veteran also reported "that he lacks the motivation to engage in sexual intercourse." He denied complaining about erectile dysfunction or being seen by a primary care physician for erectile dysfunction. Physical examination showed a normal penis. The VA examiner concluded that no opinion concerning the etiology of the Veteran's claimed erectile dysfunction was necessary because he did not meet the criteria for a diagnosis of erectile dysfunction. A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). Service connection is not warranted in the absence of proof of current disability. The Board has considered whether the Veteran experienced erectile dysfunction at any time during the pendency of this appeal. Service connection may be granted if there is a disability at some point during the claim even if it later resolves or becomes asymptomatic. McClain v. Nicholson, 21 Vet. App. 319 (2007). Here, the evidence shows that the Veteran has not experienced erectile dysfunction at any time during the appeal period. The Veteran also has not identified or submitted any evidence demonstrating his entitlement to service connection for erectile dysfunction. In summary, the Board finds that service connection for erectile dysfunction is not warranted. Dismissal of Claims The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (West 2012). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2017). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. As noted above, in statements made on the record at his June 2015 Board hearing, the Veteran, through his service representative, requested that his appeal for service connection for fibromyalgia, TMJ syndrome, right L5-S1 radiculopathy, radiculopathy of the left lower extremity, radiculopathy of the bilateral upper extremities, and for bilateral tarsal tunnel syndrome be withdrawn. See Board hearing transcript dated June 3, 2015, at pp. 3-4. Thus, there remain no allegations of errors of fact or law for appellate consideration with respect to these claims. Accordingly, the Board does not have jurisdiction to review the claims of service connection for fibromyalgia, TMJ syndrome, right L5-S1 radiculopathy, radiculopathy of the left lower extremity, radiculopathy of the bilateral upper extremities, and bilateral tarsal tunnel syndrome and they are dismissed. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for a skin disability is granted. Entitlement to service connection for a respiratory disability, is granted. Entitlement to service connection for an acquired psychiatric disability other than PTSD, is granted. Entitlement to service connection for erectile dysfunction is denied. Entitlement to service connection for fibromyalgia is dismissed. Entitlement to service connection for TMJ syndrome is dismissed. Entitlement to service connection for right L5-S1 radiculopathy is dismissed. Entitlement to service connection for radiculopathy of the left lower extremity is dismissed. Entitlement to service connection for radiculopathy of the bilateral upper extremities is dismissed. Entitlement to service connection for bilateral tarsal tunnel syndrome is dismissed. REMAND With respect to the Veteran's service connection claims for a cervical spine disability, a lumbosacral spine disability, tinnitus, obstructive sleep apnea, and for a right shoulder disability, the Board notes that the record evidence shows that he experiences current disability due to each of these claimed disabilities. Unfortunately, although the Veteran has been diagnosed as having each of these claimed disabilities, none of the medical evidence currently of record contains a nexus opinion linking any of these disabilities to active service or any incident of service. Accordingly, the Board finds that, on remand, the Veteran should be scheduled for appropriate examinations to determine the current nature and etiology of his cervical spine disability, lumbosacral spine disability, tinnitus, obstructive sleep apnea, and right shoulder disability. With respect to the Veteran's higher initial rating appeals for a gastrointestinal disability and for migraines, he essentially testified at his June 2015 hearing that both of these disabilities had worsened since his most recent VA examinations. His most recent VA examination for a gastrointestinal disability occurred in March 2014 and his most recent VA examination for migraines occurred in October 2014. The Court has held that when a Veteran alleges that his service-connected disability has worsened since he was examined previously, a new examination may be required to evaluate the current degree of impairment. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); but see Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (finding "mere passage of time" does not render old examination inadequate). Given the Veteran's contentions, and given the length of time which has elapsed since his most recent VA examinations, the Board finds that, on remand, he should be scheduled for updated VA examinations to determine the current nature and severity of his service-connected gastrointestinal disability and his service-connected migraine headaches. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for examination for cervical spine disability. The claims file should be provided for review. The examiner should opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that a cervical spine disability, if diagnosed, is related to active service or any incident of service. The examiner should provide reasons for the opinions. If any requested opinion(s) cannot be provided without resorting to speculation, then the examiner should explain why this is so. 3. Schedule the Veteran for examination for a lumbosacral spine disability. The claims file should be provided for review. The examiner should opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that a lumbosacral spine disability, if diagnosed, is related to active service or any incident of service. The examiner should provide reasons for the opinions. If any requested opinion cannot be provided without resorting to speculation, the examiner should explain why this is so. 4. Schedule the Veteran for examination for tinnitus. The claims file should be provided for review. The examiner should opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that tinnitus, if diagnosed, is related to active service or any incident of service. The examiner should record the Veteran's reports as to the onset of symptoms and any continuity. The examiner should provide reasons for the opinions. If any requested opinion(s) cannot be provided without resorting to speculation, the examiner should explain why this is so. 5. Schedule the Veteran for examination to determine the nature and etiology of any obstructive sleep apnea. The claims file should be provided for review. The examiner is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that obstructive sleep apnea, if diagnosed, is related to active service or any incident of service. A rationale also should be provided for any opinions expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the examiner should explain why this is so. 6. Schedule the Veteran for examination to determine the nature and etiology of any right shoulder disability. The claims file should be provided for review. The examiner is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that a right shoulder disability, if diagnosed, is related to active service or any incident of service. A rationale also should be provided for any opinions expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the examiner should explain why this is so. 7. Schedule the Veteran for an updated examination to determine the current nature and severity of his service-connected gastrointestinal disability. 8. Schedule the Veteran for an updated examination to determine the current nature and severity of his service-connected migraine headaches. 9. Readjudicate the appeal. 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. §§ 5109B, 7112 (West 2012). ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs