Citation Nr: 1801035 Decision Date: 01/09/18 Archive Date: 01/19/18 DOCKET NO. 13-27 518 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for lupus, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 2. Entitlement to service connection for a low back disorder, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 3. Entitlement to service connection for headaches, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 4. Entitlement to service connection for a right foot disorder, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 5. Entitlement to service connection for a digestive disorder, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, and to include as secondary to nonsteroidal anti-inflammatory agents (NSAIDs) taken for low back pain. REPRESENTATION Veteran represented by: Florida Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD P.S. Rubin, Counsel INTRODUCTION The Veteran had active military service in the United States Army from September 1986 to February 1992. Subsequently, the Veteran served with the Florida Army National Guard and Army Reserve from 1992 to 2001, with various periods of Active Duty Training (ACDUTRA) and Inactive Duty Training (INACDUTRA). This matter comes to the Board of Veterans' Appeals (Board) on appeal from April 2010 and October 2010 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In September 2016, the Veteran presented testimony at a Board videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. After this hearing, the Veteran was given 60 days to submit additional evidence. See 38 C.F.R. § 20.709 (2017). However, after the expiration of the 60-day period, the Veteran did not submit any additional evidence of record. Therefore, the Board will proceed with consideration of the appeal. In an earlier September 1993 rating decision, the RO denied service connection for a low back disorder, a digestive disorder, and headaches. The Veteran did not appeal the September 1993 rating decision, such that it became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.302, 20.1103. The Veteran submitted a claim to reopen these three service connection issues in February 2010. On this basis, the RO characterized these three issues on appeal as "new and material evidence" issues. In this regard, generally, a claimant may reopen a finally adjudicated claim by submitting new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). However, in November 2001, the law affecting compensation for disabilities occurring in Persian Gulf War veterans was amended, effective March 1, 2002. See 38 U.S.C. §§ 1117, 1118. The law provides for compensation for Persian Gulf veterans suffering from a chronic disability resulting from an undiagnosed illness or medically unexplained chronic multi-symptom illness that became manifest during active duty in the Southwest Asia theater of operations or became manifest to a compensable degree within the prescribed presumptive period. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. As this liberalizing law creates a new basis of entitlement, new and material evidence is not required to reopen the Veteran's previously denied claims. See Spencer v. Brown, 4 Vet. App. 283, 288-89 (1993), aff'd 17 F.3d 368 (Fed. Cir. 1994). Therefore, the issues of service connection for a low back disorder, a digestive disorder, and headaches may be reviewed on a de novo basis. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND First, VA is generally required to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim. 38 U.S.C. § 5103A(a) (2012). Specifically, VA is required to obtain the Veteran's STRs or other relevant service records held or maintained by a government entity. 38 U.S.C. § 5103A(c). When VA attempts to obtain records from a federal department or agency, the efforts to obtain those records must continue until the records are obtained unless it is reasonably certain that such records do not exist or that further efforts to obtain those records would be futile. 38 U.S.C. § 5103A(b); 38 C.F.R. § 3.159(c)(2), (c)(3). In this regard, the record contains several medical and personnel records from the Florida Army National Guard and Army Reserve dated from 1992 to 2001. The Veteran's unit is listed as Company A, 146th Signal Battalion. However, it appears that only limited medical or personnel records from his period of National Guard service are present in the claims file. Therefore, the AOJ should contact the National Personnel Records Center (NPRC), the Records Management Center (RMC), the State Adjutant General, the Commander of the Veteran's National Guard Unit, the Army Human Resources Command, or any other appropriate Federal or State custodian, to secure any additional medical or personnel records dated from 1992 to 2001 for his Florida Army National Guard and Army Reserve service. Any additional National Guard or Army Reserve medical or personnel records, if available, may provide more information on the existence of the disorders on appeal. (In fact, at the September 2016 videoconference hearing (pages 3-5), the Veteran testified that he was treated in the National Guard for low back problems in 1995 and 1996 - but any such records are not present in the claim file). If these National Guard or Army Reserve records are unavailable or do not exist, a negative reply to this effect is required from the appropriate custodian. Second, as the appeal is already being remanded for further development, the Board sees the Veteran's VA treatment records on file for the Gainesville, Florida VA healthcare system date to July 2013. Significantly, at the September 2016 videoconference hearing (page 17), the Veteran testified that he has received additional VA treatment in June 2016 for his right foot. Thus, as the Veteran has since received additional VA treatment since July 2013 for the right foot issue on appeal, these VA treatment records should be obtained. VA's duty to assist includes obtaining records of VA medical treatment identified by the Veteran, regardless of their relevance. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016). VA must continue to obtain such records unless it is documented that the records do not exist or that further efforts would be futile. 38 U.S.C. § 5103A(c)(2); 38 C.F.R. § 3.159(c)(2), (c)(3). See Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA is charged with constructive knowledge of evidence generated by VA). Third, the Veteran should be scheduled for the appropriate VA examinations and opinions to determine the etiology of any current lupus, low back, headache, right foot, and digestive disorders. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). Because the Veteran served in the Persian Gulf, the issue is raised as to whether any of his symptoms are due to a chronic disability pattern resulting from an undiagnosed illness or from a diagnosable but medically unexplained multi-symptom illness of unknown etiology. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(2)(i), (ii). An opinion is also needed to address whether his digestive problems are secondary to NSAIDs taken for low back pain. The Board acknowledges that the RO secured earlier August 2010 VA examinations and opinions for all disabilities on appeal. However, these August 2010 VA examinations and opinions were flawed because they were not fully compliant with the Persian Gulf illness protocols. Also, at several of these VA examinations, the VA examiner failed to consider or address certain probative evidence of record. When VA provides a VA examination or obtains a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the case is REMANDED for the following action: 1. The AOJ should contact the NPRC, the RMC, the State Adjutant General, the commander of the Veteran's Florida Army National Guard Unit (Company A, 146th Signal Battalion), the Army Human Resources Command, or any other appropriate Federal or State custodian, in order to secure any additional medical and personnel records from the Veteran's time in the Florida Army National Guard and Army Reserve from 1992 to 2001. Such records would include line of duty determinations, point statements, hospital records, examinations, etc. The Veteran served with the Florida Army National Guard from 1992 to 2001, with various periods of ACDUTRA and INACDUTRA. However, at present, it appears that only limited medical and personnel records from his period of National Guard / Army Reserve service are present in the claims file. (In fact, at the September 2016 videoconference hearing (pages 3-5), the Veteran testified that he was treated in the National Guard for low back problems in 1995 and 1996 - but any such records are not present in the claim file). If these National Guard and Army Reserve records are secured, the AOJ should verify and document all periods of active duty for the Veteran including periods of ACDUTRA or INACDUTRA dated from 1992 to 2001. If these National Guard records are unavailable or do not exist, a negative reply to this effect is required from the appropriate custodian. 2. The AOJ should obtain complete VA treatment records from the Gainesville, Florida VA healthcare system dated from July 2013 to the present, and associate them with the claims file. (At the September 2016 videoconference hearing (page 17), the Veteran testified that he has received additional VA treatment in June 2016 for his right foot.). All attempts to secure these VA records, and any response received, must be documented in the claims file. If no VA records are available, a response to that effect is required and should be documented in the file. 3. After completion of steps 1 - 2 above, the AOJ should schedule the Veteran for the appropriate VA Gulf War examination (Disability Benefits Questionnaire - DBQ) to determine the etiology of the Veteran's claimed lupus disorder. Access to the electronic claims file must be made available to the examiner for review. The examination should include any diagnostic testing or evaluation deemed necessary, including X-rays. The Veteran must be interviewed. The VA examiner must provide a clear explanation for the opinion, to include any comment on any credibility issues raised by the record from a medical perspective. THE VA EXAMINER MUST RESPOND TO THE FOLLOWING INQUIRIES: (A) The examiner should state whether the Veteran's lupus is an undiagnosed illness, a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, a diagnosable chronic multisymptom illness with a partially explained etiology, or a disease with a clear and specific etiology and diagnosis. (B) For any lupus disorder that the examiner determines is either a diagnosable chronic multi-symptom illness with a partially explained etiology or a disease with a clear and specific etiology and diagnosis, the examiner should state whether it is at least as likely as not (i.e., 50 percent or more probable) that the lupus disorder is related to the Veteran's active service from 1986 to 1992, including the assumed environmental Persian Gulf hazards. (C) In answering the questions above, the VA examiner is advised of the following: * STRs dated from 1986 to 1992 are negative for any complaint, treatment, or diagnosis of a lupus disorder. However, STRs do show treatment for frequent cold symptoms. In addition, a December 1990 STR documented three blisters on the left side of the Veteran's cheek. * (Post-service, any further National Guard records dated from 1992 to 2001, secured during the course of this remand, should be reviewed for lupus symptoms). * Post-service, at a March 1993 National Guard report of medical history at enlistment - the Veteran denied any skin diseases. All findings at the March 1993 National Guard enlistment examination were normal. However, at a May 1993 VA examination, the Veteran complained of chronic nasal stuffiness and frequent clearing of his throat. He had a history of very mild epistaxis dating back to childhood. He had a history of having coughed up blood on one occasion with a severe upper respiratory infection. Upon examination, there were no abnormalities in the nose or throat. * Post-service, a June 2003 private Flagler Family Medicine record revealed a diagnosis of alopecia. The Veteran had bald spots on the top of his head. A February 2006 private Flagler Family Medicine record documented a diagnosis of possible lupus erythematosus. Private treatment records dated from 2007 to 2009 from Flagler Family Medicine are negative for skin problems, but do record treatment for a sore throat. * Post-service, an August 2010 VA examiner noted that an office note of 02/21/2006 reported the Veteran as having a positive antinuclear antibody. There was a diagnosis of possible lupus erythematosus. The August 2010 VA examiner rendered a negative opinion on the issue of a nexus between lupus and the Veteran's military service. * Post-service, an August 2010 VA preventive medicine education note showed a diagnosis of lupus - skin lesions to scalp x 3 were observed. * Post-service, an October 2010 VA scanned report discussed private progress notes dated in February 2006. Dermatology notes and pathology notes confirmed discoid lupus erythematosus from biopsies obtained of the Veteran's scalp. Dermatology at that time noted that, as the disease was rather quiescent, they "would prescribe Lidex rather than plaque was nil." * Post-service, the Veteran states that his lupus disorder includes symptoms of hair loss and skin problems. It is noted for the record that discoid lupus erythematosus (DLE) is a form of lupus erythematosus marked by chronic skin eruptions. It is a chronic skin condition of sores with inflammation and scarring favoring the face, ears, and scalp and at times on other body areas. 4. After completion of steps 1 - 2 above, the AOJ should schedule the Veteran for the appropriate VA Gulf War examination (Disability Benefits Questionnaire - DBQ) to determine the etiology of the Veteran's claimed low back disorder. Access to the electronic claims file must be made available to the examiner for review. The examination should include any diagnostic testing or evaluation deemed necessary, including X-rays. The Veteran must be interviewed. The VA examiner must provide a clear explanation for the opinion, to include any comment on any credibility issues raised by the record from a medical perspective. THE VA EXAMINER MUST RESPOND TO THE FOLLOWING INQUIRIES: (A) The examiner should state whether the Veteran's low back disorder is an undiagnosed illness, a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, a diagnosable chronic multisymptom illness with a partially explained etiology, or a disease with a clear and specific etiology and diagnosis. (B) For any low back disorder that the examiner determines is either a diagnosable chronic multi-symptom illness with a partially explained etiology or a disease with a clear and specific etiology and diagnosis, the examiner should state whether it is at least as likely as not (i.e., 50 percent or more probable) that the low back disorder is related to the Veteran's active service from 1986 to 1992, including his documented in-service treatment for low back pain, and including the assumed environmental Persian Gulf hazards. (C) In answering the questions above, the VA examiner is advised of the following: * A January 1990 STR documented low back pain x 1 day and a cold. A May 1990 STR recorded groin and back pain after heavy lifting. A left inguinal disorder was assessed. STRs dated in December 1990 noted two weeks of low back pain after lifting sand bags. The Veteran was placed on light duty for two weeks. Finally, STRs dated in January 1991 mentioned several instances of low back treatment, after the Veteran was injured when a vehicle tumbled over multiple times. Decreased range of motion for the low back was observed. The diagnosis was low back pain, worsened by the MVA. He was given medication. * (Post-service, any further National Guard records dated from 1992 to 2001, secured during the course of this remand, should be reviewed for any low back complaints. The Veteran testified at his hearing that he was treated in 1995 and 1996 while in the National Guard for low back pain). * Post-service, a March 1993 National Guard enlistment examination revealed a normal spine. However, at an April 1993 VA neurological examination, the Veteran stated that he injured his lower back in January of 1991 during active duty when he turned over a fuel truck. He commented that he continued to have some lower back pain. At a May 1993 VA examination, the Veteran continued to report chronic back trouble, which he dated to his 1991 in-service MVA in the Persian Gulf. He is on Motrin. It was noted at the May 1993 VA examination that the Veteran is currently employed as a laborer, handling steel rods that go up the manufacturing line. He added that his back pain is definitely aggravated by working in a bent over position. The May 1993 VA examiner diagnosed chronic low back pain, musculoskeletal in origin. X-rays of the low back were normal. * Post-service, a June 2007 private Flagler Family Medicine record noted low back pain for two days, new onset lumbar, with a constant dull ache. The Veteran was started on Advil and heat. An August 2010 VA examiner rendered a negative nexus opinion for the low back. * Post-service, the Veteran contends he experienced intermittent, recurrent low back pain, but for many years he did not seek medical treatment for his low back due to a lack of health insurance coverage. 5. After completion of steps 1 - 2 above, the AOJ should schedule the Veteran for the appropriate VA Gulf War examination (Disability Benefits Questionnaire - DBQ) to determine the etiology of the Veteran's claimed headache disorder. Access to the electronic claims file must be made available to the examiner for review. The examination should include any diagnostic testing or evaluation deemed necessary, including X-rays. The Veteran must be interviewed. The VA examiner must provide a clear explanation for the opinion, to include any comment on any credibility issues raised by the record from a medical perspective. THE VA EXAMINER MUST RESPOND TO THE FOLLOWING INQUIRIES: (A) The examiner should state whether the Veteran's headache disorder is an undiagnosed illness, a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, a diagnosable chronic multisymptom illness with a partially explained etiology, or a disease with a clear and specific etiology and diagnosis. (B) For any headache disorder that the examiner determines is either a diagnosable chronic multi-symptom illness with a partially explained etiology or a disease with a clear and specific etiology and diagnosis, the examiner should state whether it is at least as likely as not (i.e., 50 percent or more probable) that the headache disorder is related to the Veteran's active service from 1986 to 1992, including the documented in-service January 1991 MVA, and including the assumed environmental Persian Gulf hazards. (C) In answering the questions above, the VA examiner is advised of the following: * STRs dated from 1986 to 1992 are negative for any complaint, treatment, or diagnosis of a headache disorder. A December 1990 STR specifically stated the Veteran did not have headaches at that time. (The Veteran testified at his videoconference hearing that he complained to military medical personnel more than 20 times about headaches during service, but when he was in the Persian Gulf, he was simply provided medicine, but not formally treated). * (Post-service, any further National Guard records dated from 1992 to 2001, secured during the course of this remand, should be reviewed for any headache complaints). * Post-service, in March 1993, approximately one year after separation from active duty, the Veteran filed his original service connection claim for headaches. * Post-service, at an April 1993 VA neurological examination, the Veteran complained of intermittent bitemporal headaches approximately every other day since returning from Saudi Arabia in September of 1991. The headaches are of a constant pressure type pain and are relieved with Ibuprofen. His neurological examination of the head was normal. The VA examiner endorsed headaches, most consistent with intermittent muscle contraction headaches. The VA examiner suggested that the Veteran continue with the Ibuprofen. The VA examiner added he found no evidence of a neurological disability. A May 1993 examiner remarked the Veteran's headaches are relieved by Ibuprofen - he presently takes 600mgs. His headaches have not been helped in the past by Tylenol with Codeine or aspirin. There is no associated nausea or vomiting with these headaches. * Post-service, in a private July 2003 Flagler Family Medicine treatment record, the Veteran denied current headaches. His neurological examination was normal. In an August 2003 Baker and Gilmour, MD., treatment report, the Veteran denied any new or unusual headaches. An August 2010 VA examiner rendered a negative nexus opinion for the Veteran's alleged headache disorder. * Post-service, an October 2010 VA nursing telephone encounter note and a November 2010 VA preventive care education note mentioned a chief complaint of chronic migraine headaches. * Post-service, the Veteran contends he experienced recurrent migraine-type headaches, but for many years he did not seek medical treatment for his headaches due to a lack of health insurance coverage. Instead, he self-treated with Aspirin or Advil. 6. After completion of steps 1 - 2 above, the AOJ should schedule the Veteran for the appropriate VA Gulf War examination (Disability Benefits Questionnaire - DBQ) to determine the etiology of the Veteran's claimed right foot disorder. Access to the electronic claims file must be made available to the examiner for review. The examination should include any diagnostic testing or evaluation deemed necessary, including X-rays. The Veteran must be interviewed. The VA examiner must provide a clear explanation for the opinion, to include any comment on any credibility issues raised by the record from a medical perspective. THE VA EXAMINER MUST RESPOND TO THE FOLLOWING INQUIRIES: (A) The examiner should state whether the Veteran's right foot disorder is an undiagnosed illness, a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, a diagnosable chronic multisymptom illness with a partially explained etiology, or a disease with a clear and specific etiology and diagnosis. (B) For any right foot that the examiner determines is either a diagnosable chronic multi-symptom illness with a partially explained etiology or a disease with a clear and specific etiology and diagnosis, the examiner should state whether it is at least as likely as not (i.e., 50 percent or more probable) that the right foot disorder is related to the Veteran's active service from 1986 to 1992, including having to wear tight boots while in-service, and including the assumed environmental Persian Gulf hazards. (C) In answering the questions above, the VA examiner is advised of the following: * STRs dated from 1986 to 1992 are negative for any complaint, treatment, or diagnosis of a right foot disorder. * (Post-service, any further National Guard records dated from 1992 to 2001, secured during the course of this remand, should be reviewed for right foot symptoms). * Post-service, at a March 1993 National Guard report of medical history at enlistment - the Veteran denied any foot trouble, swollen or painful joints, or skin problems. All lower extremity findings at the March 1993 National Guard enlistment examination were normal. * Post-service, private Flagler Family Medicine records dated throughout 2007 document treatment for right foot calluses. The initial January 2007 treatment report from this provider recorded an increased callus formation of the right plantar foot, for the past two months. The impression of January 2007 X-rays of the right foot was no radiographic foreign bodies found, no fractures or dislocation, and no significant osseous abnormality identified. An August 2010 VA examiner indicated the Veteran has diminished reflexes in the lower extremities. * A November 2010 VA podiatry consult described the Veteran's complaints of painful calluses on the right foot "for several years." The Veteran reported he files the calluses down with a sharp instrument at home and this lasts him about two months. The diagnoses were pes planus and right foot calluses. He was prescribed cream and custom orthotics. As to etiology, the Veteran thought he may have stepped on something at some point on his right foot, perhaps causing the callus. The November 2010 VA provider discussed with Veteran the possible etiologies, including previous puncture causing hyperkeratotic scar, plantar flexed/hypertrophic met head, parakeratosis, or retained foreign body (not radio-opaque.) * Post-service, VA podiatry notes dated from 2011 to 2013 reflected treatment for right foot pain with diagnoses of pes planus and calluses of the right foot. At his September 2016 videoconference hearing, the Veteran testified that he was recently treated by the VA for his right foot at St. Augustine in June 2016. The Veteran also asserted in his testimony that his right foot problems were caused by wearing "jungle" or "tiger" boots during his military service in the Persian Gulf in 1990 and 1991. 7. After completion of steps 1 - 2 above, the AOJ should schedule the Veteran for the appropriate VA Gulf War examination (Disability Benefits Questionnaire - DBQ) to determine the etiology of the Veteran's claimed digestive disorder. Access to the electronic claims file must be made available to the examiner for review. The examination should include any diagnostic testing or evaluation deemed necessary, including X-rays. The Veteran must be interviewed. The VA examiner must provide a clear explanation for the opinion, to include any comment on any credibility issues raised by the record from a medical perspective. THE VA EXAMINER MUST RESPOND TO THE FOLLOWING INQUIRIES: (A) The examiner should state whether the Veteran's digestive disorder is an undiagnosed illness, a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, a diagnosable chronic multisymptom illness with a partially explained etiology, or a disease with a clear and specific etiology and diagnosis. (B) For any digestive disorder that the examiner determines is either a diagnosable chronic multi-symptom illness with a partially explained etiology or a disease with a clear and specific etiology and diagnosis, the examiner should state whether it is at least as likely as not (i.e., 50 percent or more probable) that the digestive disorder is related to the Veteran's active service from 1986 to 1992, including the assumed environmental Persian Gulf hazards. (C) Is it at least as likely as not (i.e., 50 percent or more probable) that any current digestive disorder is caused by, proximately due to, or the result of NSAIDs taken for low back pain? (D) Is it at least as likely as not (i.e., 50 percent or more probable) that any current digestive disorder is aggravated by or worsened by NSAIDs taken for low back pain? Both the causation and aggravation facets of secondary service connection should be addressed by the VA examiner. (E) In answering the questions above, the VA examiner is advised of the following: * STRs dated from 1986 to 1992 are negative for any complaint, treatment, or diagnosis of a digestive disorder. (The Veteran testified at his videoconference hearing that he took antacid many times during active duty to calm his gastritis). * (Post-service, any further National Guard records dated from 1992 to 2001, secured during the course of this remand, should be reviewed for digestive / stomach symptoms). * Post-service, at a May 1993 VA examination, the Veteran reported anorexia beginning in October 1990 during his service in the Persian Gulf. He has also experiences frequent indigestion, heartburn, and episodes of diarrhea since that time. The diagnosis was gastritis, probably secondary to NSAIDs taken for his low back pain. The Veteran was advised to stop Ibuprofen to see if his GI symptoms improve with Aspirin or Tylenol instead. * Post-service, under reported GI symptoms, a private July 2003 Flagler Family Medicine report noted no abdominal pain, no constipation, no diarrhea, no nausea, no vomiting, no rectal bleeding, and no melena. In an August 2003 Baker and Gilmour, MD., report, for GI symptoms, the Veteran denied nausea, reflux, change in bowel habits, or melena. In private treatment records from Flagler Family Medicine, dated 2007 to 2009, the Veteran repeatedly denied symptomatology for nausea or vomiting. A May 2012 VA nutrition consult revealed no nausea, no vomiting, no diarrhea, and no constipation. An August 2010 VA examiner opined that a nexus between gastritis and the Veteran's military service would be "speculative." * Post-service, an August 2010 VA preventive medicine education note reported a bowel problem. An August 2012 VA primary care note assessed persistent loose stools since 1992, based on the Veteran's reported history. The Veteran says his stools are more like water, with blood sometimes. Stool culture laboratory testing was negative in August 2012. * Post-service, the Veteran contends he experiences intermittent, recurrent digestive / stomach problems including loose stools, but for many years he did not seek medical treatment for his stomach due to a lack of health insurance coverage. Instead, he self-medicated. 8. After completion of steps 1 - 7 above, the AOJ should review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 9. After completion of steps 1 - 8 above, the AOJ should consider all of the evidence of record and readjudicate the appeal. If the benefit sought is not granted, the AOJ should issue a Supplemental Statement of the Case (SSOC) and allow the Veteran and his representative an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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). _________________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).