Citation Nr: 1805382 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 10-25 070 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas THE ISSUES 1. Entitlement to service connection for skin disability of the feet. 2. Entitlement to service connection for a gastrointestinal (GI) disability, claimed as a gastric ulcer, to include as secondary to service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Leifert, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1966 to July 1968. The Veteran's military decorations include the Purple Heart, among others. This appeal to the Board of Veterans' Appeals (Board) arose from an April 2009 rating decision in which the RO, inter alia, denied a petition to reopen claims for service connection for gastroenteritis/ulcer disabilities and a bilateral foot condition. In June 2009, the Veteran filed a notice of disagreement (NOD) as to the denial of his gastroenteritis/ulcer and bilateral foot disability claims. A statement of the case (SOC) was issued in April 2010, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in June 2010. In April 2014, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge at the San Antonio satellite office of the RO; a transcript of that hearing is associated with the electronic Virtual VA record. In September 2014, the Board determined that the Veteran had submitted new and material evidence sufficient to reopen the claim for service connection for a GI disability. As for the bilateral foot/skin claim on appeal, the Board noted that, because new service treatment records were associated with the claims file after the issuance of the March 1981 rating decision that denied service connection for a bilateral foot condition (claimed as jungle rot), the claim would be reconsidered on a de novo basis, in accordance with 38 C.F.R. § 3.156(c).. The Board remanded both claims to the agency of original jurisdiction (AOJ) for further action, to include additional development of the evidence. After accomplishing further action, the AOJ continued to deny the claims (as reflected in a November 2014 supplemental SOC (SSOC)) and returned the matters to the Board. In April 2016, the Board again remanded the claims for further development. After accomplishing further action, the AOJ continued to deny both claims (as reflected in a January 2017 supplemental SOC (SSOC)), and returned these matters to the Board. The Board's decision addressing the claim for service for a skin disorder of the feet is set forth below. The s claim for service connection for a GI disability is addressed in the remand following the order; this matter is being remanded to the agency of original jurisdiction. VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim herein decided have been accomplished. 2. The Veteran first manifested callous formation and pitted keratolysis service, he has credibly asserted continuing experience symptoms consistent with callous formation and pitted keratolysis, intermittently, since service; and competent, probative medical opinion evidence essentially indicates that the Veteran as likely as not has current callous formation and pitted keratolysis that had its onset during service.. 3. No other currently diagnosed skin disorder of the feet-to include onychomycosis and maceration between the fourth and fifth digits-was shown in service or for years thereafter, and the only medical opinion evidence to address the medical relationship addressing the relationship between any such other skin disability affecting the bilateral feet and service weighs against the claim. CONCLUSION OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for callus formation and pitted keratolysis of the bilateral feet are met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. § § 3.102, 3.303 (2017). 2. The criteria for service connection for any other diagnosed skin disability of the feet are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. § § 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). After a complete or substantially complete application for benefits is received, notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Pelegrini v. Principi, 18 Vet. App. 112 (2004) and Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)). VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA compliant notice must be provided to a claimant before an unfavorable decision on a claim for VA benefits by the AOJ. Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In an October 2008 pre-rating letter, the AOJ provided notice to the Veteran explaining what information and evidence was needed to substantiate his claim for service connection, what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. The letter further provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. The record also reflects that, consistent with applicable duty-to-assist provisions, VA has made reasonable efforts to develop each claim herein decided, to include obtaining or assisting in obtaining all relevant records and other evidence pertinent to this matter. Pertinent medical evidence associated with the claims file consists of service treatment records (STRs), VA treatment records, private treatment records, and VA examination reports. Also of record is the transcript of the Veteran's Board hearing, along with various written statements by the Veteran and his representative, on his behalf. The Board finds that no further AOJ action on the claim herein decided, prior to appellate consideration, is required. As noted, the Veteran had an opportunity to orally advance his contentions during an April 2014 Board hearing. During the hearing, the undersigned identified the claims on appeal, and with respect to service connection, information was elicited regarding the nature and onset of the Veteran's symptoms, current disability and treatment, as well as the basis for Veteran's belief that service connection is warranted. Although the undersigned did not explicitly suggest the submission of any specific additional evidence, on these facts, such omission was harmless. Following the hearing, the Board sought additional development of the evidence, as the result of which additional evidence was added to the record. Thus, the hearing was legally sufficient. See 38 C.F.R. § 3.103(c)(2) (2017); Bryant v. Shinseki, 23 Vet. App. 488 (2010). In summary, the duties imposed by the VCAA have been considered and satisfied. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim herein decided. As such, the Veteran is no prejudiced by the Board proceeding to a decision on the claim on appeal, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or from aggravation of a pre-existing injury suffered or disease contracted in the line of duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). To establish entitlement to direct service connection, there must be: (1) competent and credible evidence confirming the Veteran has manifested the claimed disability at some point since the filing of the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). See also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The determination as to whether elements are met is based on an analysis of all the evidence of record and the evaluation of its competency, credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The Veteran contends that he has a skin condition affecting the bilateral feet that is due to his service in Vietnam. STRs dated in June 1967 document that the Veteran had chronic problems with callous formation on his bilateral feet, which was treated with salicylic acid for eight days with no improvement. The examiner noted that the Veteran's feet became tender after continuous walking, and that there were granular-appearing callouses on the soles of the feet under the heel. In July 1967, STRs reflect diagnosis of pitted keratolysis, and that there was no good treatment for the condition except drying the feet in a temperate climate. The examiner noted that the Veteran was given a different military physical profile as he was serving in Vietnam, which had humid tropical conditions. A May 1969 VA examination report reflects a normal evaluation of the skin and feet. In a May 2014 statement, the Veteran reported that he developed callouses on both feet due to the humid and wet conditions in Vietnam to the point where he could not walk without feeling excruciating pain. He explained that he developed cuts under the callouses once the disease became acute, and that he continued to experience the same symptoms to the present. A January 2015 VA examination report documents the Veteran's complaints of "jungle rot" that started while in Vietnam. He described his symptoms as peeling of the skin and burning on the sole of both feet with callouses. The Veteran reported that he was treated with a cream with some improvement, but that he relapsed on-and-off. He also stated that the condition continued intermittently and that he had not been evaluated by a medical provider for his condition since he left service. He explained that he self-treated with foot powder, moisturizing creams, and resting his feet. A physical examination of the feet was negative for any active or abnormal skin lesions even though the Veteran contended current symptoms. The examiner stated that as there was no current evidence of an active disease, he was unable to render a diagnosis, and as such a medical opinion was not deemed necessary. An April 2015 VA examination report documents maceration between the bilateral small web of the fourth and fifth digits, and great toe nail brittle and cracked with a diagnosis of onychomycosis. The examiner noted the Veteran's contentions that his bilateral foot problems began during service as a result of the wet environment and constant walking. The examiner also noted the Veteran's move to an administrative position in November or December 1967 due to his bilateral foot condition. Nevertheless, the examiner found that the condition was asymptomatic since 1967 as the history of flare-ups was solely based on the Veteran's self-reporting. While the examiner noted that the Veteran served in a humid, tropical environment, which predisposed him to developing pitted keratolysis, it was also noted that the July 1968 separation examination was silent for foot issues. As for onychomycosis, while the examiner noted that the condition most often occurred with repeated exposure to moisture and was exacerbated by low atmospheric humidity, he noted that it was also caused by thyroid disease and nutritional deficiency. The examiner also seemed to suggest that the Veteran was diagnosed with tinea cruris affecting his groin, which was easily transferable to his fingers and feet. However, the examiner noted that the Veteran had pre-metabolic disease, if not diabetes, which was also a cause for fungal nail and superficial infections (such as tinea cruris affecting the groin). As such, the VA examiner opined that the Veteran's bilateral foot condition was not related to service. VA treatment records dated in July 2015 document red itchy rash on the right lower foot on the later malleolus, with slight relief with hydrocortisone. The Veteran did not report any oozing from any of the sites. An October 2016 VA examiner noted that there was no in-service diagnosis for callous formation of the feet or pitted keratolysis, but also noted the Veteran's statements concerning his bilateral foot problems and his Vietnam service, and his statements that he continued to experience bilateral foot pain since his in-service callous and pitted keratolysis . Physical examination of the Veteran revealed mild onychomycosis of the lesser toes with severe cracking disease involving the right greater than left great toenails; there was no callous formation, pitted, keratolysis, or maceration between the fourth and fifth digits. He had subjective discomfort with palpation of the mid-plantar surface of the calcaneus and plantar surface beneath the second and third metatarsal heads. In addition, x-rays revealed bilateral plantar heel spurs. The examiner noted that the Veteran had never sought medical attention for his foot pain. The examiner explained that pitted keratolysis was a skin disorder characterized by crateriform pitting that primarily affected the pressure-bearing aspects of the plantar surface of the feet and that the manifestations of pitted keratolysis were due to a superficial cutaneous bacterial infection. The examiner also stated that pitted keratolysis could be symptomatic with painful feet, which could limit function. The examiner explained that fungal infection, also called onychomycosis and tinea unguium, of the toenails or fingernails was caused by a fungal microbe that invaded the nail bed. This caused the fingernails or toenails to thicken, discolor, disfigure, and split. In addition, the examiner noted that the Veteran also had mild to moderate degenerative changes involving the left first metatarsal phalangeal joint and interphalangeal joints with sesamoid spurring. He explained that osteoarthritis gradually wore away at the cartilage in the joint, which became frayed and rough, and decreased the protective space between the bones. This, in turn, could result in bone rubbing on bone, and produce painful osteophytes (bone spurs). The examiner found that the Veteran did not have a currently diagnosed bilateral foot condition. Furthermore, based on review of the Veteran's STRs and treatment records, the examiner opined that it was less likely than not that onychomycosis, heel spurs, and foot arthropathy had their onset or were medically related to the Veteran's service, to include the chronic callous formation and pitted keratolysis reported in the STRs. In connection with providing a November 2016 addendum opinion, the October 2016 VA examiner reviewed the Veteran's June 1967 STRs documenting diagnosed chronic callous and pitted keratolysis. The examiner then opined that it was at least as likely as not (50 percent or greater probability) that the Veteran had current callous formation of the feet and pitted keratolysis that was e incurred during service as noted in the June 1967 STRs. In a December 2016 addendum opinion, the October 2016 VA examiner noted no in-service complaints or treatment of onychomycosis, maceration between the fourth and fifth digits, or bilateral heel/calcaneal spurring. The examiner noted that post-service VA examinations revealed maceration between the fourth and fifth digits with great toe onychomycosis in April 2015, and x-rays revealed small bilateral heel spurs in April 2015 and October 2016. Thus, the examiner opined that it was less likely than not that onychomycosis, maceration between the fourth and fifth digits; osteoarthritis of the first metatarsal phalangeal joint and bilateral heel/calcaneal spurring were related to service as there were no in-service complaints. Considering the totality of the lay and medical evidence of record, and with resolution of all reasonable doubt in the Veteran's favor, the Board finds that the record presents a plausible basis for awarding service for callous formation and pitted keratolysis of the bilateral feet, but that the preponderance of the evidence is against an award of service connection for any other currently diagnosed foot condition, to include onychomycosis and maceration between the fourth and fifth digits. First addressing the matter of callous formation and pitted keratolysis, the Veteran's STRs document that he first manifested such in service. While not an identified chronic disease subject to presumptive service, the Veteran has asserted continuing to experience symptoms consistent with callous formation and pitted keratolysis, intermittently, since service-matters within his personal knowledge that he is competent to assert. See 38 C.F.R. 3.159 (a)(2) (2017); see also Charles v. Principi, 16 Vet. App. 370 (2002); Layno v. Brown, 6 Vet. App. 465, 470 (1994). Furthermore, although the record is devoid of documented evidence of treatment for such problems for years after service, the Veteran has asserted continuity of self of treatment post service, and the Board has no reason to question the veracity of his assertions in this regard. The Board further notes that, in the in the November 2016 addendum opinion, a the October 2016 VA examiner opined that the Veteran has current callous formation and pitted keratolysis, which is at least as likely as not related to service, specifically, the e June 1967 in-service diagnosis of pitted keratolysis. The Board acknowledges that the VA examiner initially found no current diagnosis, and that no skin diagnosis was noted on the September 2014 VA examination; October 2016 VA examiner also initially rendered a negative etiology opinion. However, considering the nature of skin disabilities (i.e., they wax and wane), review of the Veteran's STRs, and the Veteran's assertions, the recent VA examiner not only found current disability of callus formation and pitted keratolysis, but also opined that there is as likely as not a nexus between such disability and service. The Board emphasizes that VA is not free to ignore a medical opinion or pertinent medical findings (see Owens v. Brown, 7 Vet. App. 429, 433 (1995)), or to reject a medical opinion based on its own medical judgment (see Obert v. Brown, 5 Vet. App. 30 (1993) and Colvin v. Derwinski, 1 Vet. App. 171 (1991)), even if the opinion is based on lay assertions. Notably, the fact that the November 2016 addendum opinion by the October 2016 examiner was largely based on the Veteran's lay assertions as to continuing to experiencing callus formation and pitted keratolysis intermittently since service does not diminish the probative value of the opinion unless the lay statements are deemed not credible. Such is not the case here. Moreover, while the opinion was not definitive, it was expressed in terms sufficient to warrant application of the benefit-of-the-doubt doctrine. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. See 38 C.F.R. § 3.102; see also 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Given the totality of the competent lay and probative medical evidence of record, and with resolution of all reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for callous formation and pitted keratolysis are met. However, the record presents no basis for an award of service connection for any other diagnosed skin disability of the feet, to include onychomycosis and maceration between the fourth and fifth digits. The Board notes that STRs are silent as to any complain, finding or diagnosis with respect to any of these diagnoses, which were not shown until years post service. Moreover, the only medical opinion evidence addressing the etiology of such diagnosed disorders-in particular, the December 2016 addendum opinion from the October 2016 VA examiner, weighs against a finding of service connection. Furthermore, while the Veteran has asserted continuity of symptoms of callous formation and pitted keratolysis since service, no similar arguments have been advanced with respect to any other diagnosed skin disability of the feet, and the Veteran has not otherwise asserted the existence of a medical relationship between any such disability and service. For all the foregoing reasons, the Board concludes that service connection for callous formation and pitted keratolysis , but no other skin disability affecting the bilateral feet, is warranted. The Board has resolved all reasonable doubt in the Veteran's favor in reaching the decision to award service connection for callous formation and pitted keratolysis but finds that the preponderance of the evidence is against awarding service connection for any other diagnosed skin disorder of the feet. See 38 U.S.C.§ 5107(b) (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Service connection for callous formation and pitted keratolysis of the bilateral feet is granted. Service connection for any other diagnosed skin disability of the bilateral feet is denied. REMAND The Board's review of the claims file reveals that further AOJ action is warranted for the claim of service connection for a GI disability. The January 2015 and May 2015 VA examination reports reflect a current diagnosis of GERD and nexus opinions that GERD was less likely than not related to service. Further, the May 2015 VA examiner found that the Veteran's May 2014 statements regarding his in-service symptoms were not consistent with the circumstances, conditions, or hardships of his service as noted in the available clinical evidence. However, an October 2015 VA treatment record reflects chronic active gastritis, H. pylori, intestinal metaplasia in separate fragment, and no evidence of malignancy or dysplasia; a GI junction biopsy revealed squamous and gastric-type mucosa with intestinal metaplasia with no evidence of malignancy of dysplasia; and a colonoscopy showed very small scattered sigmoid diverticulitis but an otherwise normal examination. Further, a July 2016 VA examination report reflects diagnoses of pyloric deformity/dysfunction/stenosis, chronic gastritis, and mild distal esophagitis. Nevertheless, the July 2016 VA examiner only opined as to whether the Veteran's current diagnoses were secondary to his service-connected PTSD. The Board finds that the record does not include an adequate medical opinion addressing the existence of a relationship between any diagnosed GI disability and service. In this regard, in a May 2014 statement, the Veteran contended that he experienced stomach cramps, diarrhea, upset stomachs accompanied with vomiting and headaches, constipation from eating dry canned c-rations, hunger and thirst during major troop movements, and stomachaches from eating and drinking contaminated and spoiled water and food during service. Further, while the May 2015 VA examiner found that the Veteran's May 2014 statements were not consistent with the circumstances, conditions, or hardships of his service, the Board notes that the Veteran is competent to describe his in-service symptom, and that there is no evidence to directly contradict the Veteran's assertions as to his in-service symptoms. Accordingly, on remand, the AOJ should arrange to obtain from an appropriate physician addendum opinions addressing the etiology of all diagnosed GI disorders. The AOJ should only arrange for the Veteran to undergo a VA examination, by an appropriate physician, if one is deemed necessary in the judgment of the physician designated to provide the addendum opinions. The Veteran is hereby notified that failure to report to any scheduled examination, without good cause, may result in denial of the claim. 38 C.F.R. § 3.655 (2017). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. Prior to undertaking action responsive to the above, to ensure that all due process requirements are met, and that the record is complete, the AOJ should undertake to obtain and associate with the claims file all outstanding, pertinent records. As for VA records, the claims file includes VA treatment records from the South Texas VA Medical Center (VAMC) dated through January 2017. The Board emphasizes that records generated by VA and federal facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Accordingly, the AOJ should obtain from the South Texas VAMC all records of pertinent treatment since January 2017, following the current procedures prescribed in 38 C.F.R. § 3.159(c) (2017) with regard to requests for records from Federal facilities. The AOJ should also give the Veteran another opportunity to provide additional information and/or evidence pertinent to the remaining claim on appeal (particularly as regards outstanding private (non-VA) treatment), explaining that he has a full one-year period for response. See 38 U.S.C. § 5103(b)(1) (2012); but see also 38 U.S.C. § 5103(b)(3) (clarifying that VA may make a decision on a claim before the expiration of the one-year notice period). Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159 (2017). The actions identified herein are consistent with the duties imposed by the VCAA. See 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full VCAA compliance. Hence, in addition to the actions requested above, the AOJ should also undertake any other development or notification action deemed warranted prior to adjudicating the remaining claim on appeal. The AOJ's adjudication of the claim g should include consideration of all pertinent evidence added to the record since the last adjudication. Accordingly, this matter is hereby REMANDED for the following action: 1. Obtain from the South Texas VAMC (and any associated facility(ies)) all outstanding records of VA evaluation and/or treatment of the Veteran, dated since January 2017. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with respect to requesting records from Federal facilities. All records/responses received should be associated with the claims file. 2. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization to enable VA o obtain any additional evidence pertinent to the claims on appeal that is not currently of record. Specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private (non-VA) records-to include records of a private psychiatric hospitalization in Portsmouth, Virginia, within 120 days of his service discharge . Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 3. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After all records/responses from each contacted entity have been associated with the claims file, arrange to obtain from an appropriate physician and addendum opinion addressing the etiology of all diagnosed GI disorders. Only arrange for the Veteran to undergo VA examination, by an appropriate physician, if one is deemed necessary in the judgment of the physician designated to provide the addendum opinion, The contents of the entire, electronic claims file (in VBMS and Virtual VA (Legacy Content Manager)), to include a complete copy of this REMAND, must be made available to the designated individual, and the addendum opinion/examination report should include discussion of the Veteran's documented medical history and assertions. If the Veteran is examined, all indicated tests and studies should be accomplished (with all results made available to the requesting physician prior to the completion of his or her report), and all clinical findings should be reported in detail. With respect to diagnosed GERD, pyloric deformity/dysfunction/stenosis, chronic gastritis, and mild distal esophagitis, for each such diagnosed disorder, the physician should provide an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) the disability had its onset during service or is otherwise medically related to service. In addressing the above, the physician must consider and discuss all pertinent in- and post-service medical and other objective evidence, include with respect to the Veteran's May 1969 admission for gastroenteritis, which occurred within the first year after discharge from service. The physician must also consider and discuss all lay assertions, to include the Veteran's assertions as to the nature, onset, and continuity of gastrointestinal (GI) symptoms of stomach cramps, diarrhea, upset stomach, vomiting , headaches and constipation, as well as his assertions that his GI problems were not documented while in Vietnam because they were considered minor ailments, Notably, the lack of medical treatment for or diagnosis of a GI disability during service or shortly thereafter should not, alone, form the sole basis for a negative opinion. In this regard, the physician is advised that the Veteran is competent to report his symptoms and history, and his assertions in this regard should be considered in formulating the requested opinions. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why All examination findings/testing results (if any), along with complete, clearly-stated rationale for the conclusions reached, must be provided. 5. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 6. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the remaining claim on appeal in light of all pertinent evidence (to include all that added to the VBMS and/or Virtual VA (Legacy Content Manager) file(s) since the last adjudication (to include all evidence received pursuant to this remand) and legal authority. 7. If the benefit sought on appeal remains denied, furnish to the Veteran and his representative an SSOC that reflects consideration of all additional evidence received, and includes clear reasons and bases for all determinations, and afford them an appropriate time period for response. The purpose of this REMAND is to afford due process, and to accomplish additional development and adjudication; it is not the Board's intent to imply whether any benefit requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs