Citation Nr: 9901570 Decision Date: 01/22/99 Archive Date: 02/01/99 DOCKET NO. 96-02 296 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for skin rashes, to include as an undiagnosed illness. 2. Entitlement to service connection for blood clots in the nose with shortness of breath, to include as due to an undiagnosed illness. 3. Entitlement to service connection for heart problems, to include as due to an undiagnosed illness. 4. Entitlement to service connection for hepatitis, to include as due to an undiagnosed illness. 5. Entitlement to service connection for memory loss, to include as due to an undiagnosed illness. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Michael A. Holincheck, Associate Counsel INTRODUCTION The veteran served on active duty from November 1975 to November 1979, January 1980 to January 1982 and from November 1990 to April 1991. He had active service in the Southwest Asia theater in support of Operations Desert Shield and Desert Storm from December 1990 to April 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 1995 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky, which denied the benefits sought on appeal. The issue of entitlement to service connection for memory loss will be addressed in the remand portion of this decision. CONTENTIONS OF APPELLANT ON APPEAL The veteran essentially contends that the RO erred in not granting the benefits sought on appeal. The veteran maintains, in substance, that he was in perfect health before his service in the Persian Gulf and that his health deteriorated after he returned from service in the Persian Gulf. He further contends that his current medical conditions are directly related to his service in the Persian Gulf. Therefore, a favorable determination is requested. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1998), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the veteran’s claims of entitlement to service connection for skin rashes, blood clots in the nose with shortness of breath, heart problems, and hepatitis, to include as due to an undiagnosed illness, are not well grounded. FINDINGS OF FACT 1. Disability due to an undiagnosed illness was not shown to be first manifest during service in the Southwest Asia theater of operations during the Persian Gulf War nor is there evidence of compensable disability attributable to an undiagnosed illness after service discharge. 2. The claims of entitlement to service connection for skin rashes, blood clots in the nose with shortness of breath, heart problems and hepatitis, to include as due to an undiagnosed illness, are not supported by cognizable evidence showing that the claims are plausible or capable of substantiation. CONCLUSIONS OF LAW 1. Disability alleged to be due to an undiagnosed illness is not shown to have been incurred during the veteran’s period of active duty in the Southwest Asia theater of operations during the Persian Gulf War nor shown to a compensable level after service discharge. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.317 (1998). 2. The claims of entitlement to service connection for skin rashes, blood clots in the nose with shortness of breath, heart problems, and hepatitis, to include as due to an undiagnosed illness, are not well grounded. 38 U.S.C.A. § 5107(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Background The veteran served two periods of active duty from November 1975 to November 1979 and from January 1980 to January 1982 prior to service in the Southwest Asia theater of operations. The RO made several attempts to obtain the veteran’s service medical records (SMRs) for the earlier periods of active duty. In August 1997, the RO made a formal finding of unavailability of service records and conveyed the finding to the veteran by way of a letter dated that same month. The only records for the veteran’s prior periods of service associated with the claims file consist of copies of two physical examinations. The first physical was dated in December 1975. There were no abnormalities or defects noted pertinent to the claims on appeal. The second physical was dated in January 1980 with no pertinent problems noted. There were SMRs available for the period from February 1989 to September 1991. These records covered part of the veteran’s service in the Marine Corps Reserve as well as his period of active duty from November 1990 to April 1991. The SMRs, including a release from active duty physical examination dated in March 1991, are silent with respect to treatment for conditions related to the issues on appeal. The records show that the veteran received some burns on his legs as the result of a civilian work-related accident in May 1989. A February 1990 physical examination reported no findings pertinent to the issues on appeal and the veteran’s accompanying medical history made no reference to any problems other than a longstanding eye problem. In November 1990 the veteran completed two NAVMED 6120/3, Annual Certificate of Physical Condition, slips wherein he indicated that he had not required hospitalization or missed school/work for any injury, illness or disease for more than three consecutive days within the past 12 months. The veteran was treated in December 1990 for complaints of sinus pain and congestion. The assessment was rule out sinusitis, viral syndrome and fever. The March 1991 physical noted some scars on the veteran’s left arm and lower leg. The veteran indicated no problems, other than his eye problem, on his medical history form also dated in March 1991. Associated with the claims files are private medical records provided by the veteran for several sources of care. These sources were listed on the veteran’s VA form 21-526 that was received in January 1995. The first records were from a F. Malubay, M.D., dated in August 1992. Dr. Malubay treated the veteran on two occasions for a probable spider bite in the right axilla. The veteran later developed an abscess from the bite. The next records are from V. Soni, M.D., and covered a period from November 1989 to June 1993. In September 1992 the veteran was treated for the insect bite. The veteran was diagnosed with cellulitis in the right axilla and underwent an incision and drainage of the area in September 1992. In May 1993, Dr. Soni treated the veteran after he had been seen in a local emergency room (ER). The veteran had a history of swelling of the face and nose and was diagnosed in the ER with an allergic reaction. He responded to Benadryl and steroid injection. His Lyme test was negative. Upon physical examination Dr. Soni noted that there was no tenderness or swelling of the face or nose. The inside of the nostrils seemed to be red, swollen, and congested consistent with allergic rhinitis with some cellulitis. He was seen again in June 1993 with complaints of not being able to breath through his nose. Physical examination found the veteran to have swollen mucosa on the left that almost filled the nostril and on the right. Dr. Soni opined that the veteran’s condition was an allergy-type problem. Associated with the claims file are the ER records referred to by Dr. Soni. The veteran was treated at the Union County Methodist Hospital on May 23, 1993. The treatment report indicates that the veteran noticed a tick on himself approximately one week earlier and came to the ER with progressive swelling since the previous Friday. He had noticed that his nose and eyes had begun swelling and he had trouble breathing through his nose. He had a fever up to 100 degrees but had not noticed any rash. He had had diffuse myalgias with no arthralgias noted. No productive cough and no nasal drainage. Physical examination found the facial area around the mid-face and nose to be markedly swollen, tender and erythematous as well as warm. There was marked edema noted around the nose and under the eyes. Nasal mucosa was boggy and there was green exudate in the nares. The turbinates were markedly swollen. A Lyme titer (later reported as negative) and a fluorescent antibody to R. Rickettsii were drawn and were to be forwarded to Dr. Soni. The treating physician’s impression was facial edema, unknown etiology, rule out infectious process. In June 1993, the veteran received follow-up treatment for complaints of nasal obstruction. He was treated by T. B. Logan, M.D., at the Community Methodist Hospital. Dr. Logan noted that the veteran was seen with a complaint of nasal obstruction and that he had recently been treated for a facial abscess. He said that the veteran described several other abscesses about his body, particularly the posterior neck and axillary regions. The veteran said that he thought all of this had happened since he had returned from Desert Storm. Upon physical examination, Dr. Logan noted the presence of a mass involving the nasal septum. He said that it was difficult to tell if it was an abscess or a hematoma. Dr. Logan performed surgery on the nasal mass several days later. The operative report noted that the nasal septum was opened and bloody clots were present as well as fibrin and these were removed. The veteran was seen several days later and his hematoma drained. Dr. Logan said the culture was negative and that he still did not have an etiology for the hematoma. The veteran was treated one last time two days later and noted to be doing well and to return whenever needed. The veteran was afforded a VA Persian Gulf War Protocol examination in December 1993. The veteran listed his several chief complaints. He said that he had skin rashes which seemed to have occurred underneath both axillae areas and on the posterior neck region. The last time it was prominent was the summer of 1992. He described a hematoma on the right side of his nose, which had been removed earlier in 1993. He said that he continued to have trouble breathing through his nose since the surgery, a problem that he did not have prior to surgery. He also complained of shortness of breath (SOB). He said that while physically exerting himself in the yard using a shovel he would get short of breath. Physical examination of the skin was negative except for minor abrasion on the right lateral knee. There was no evidence of a rash. Examination of the face and head found that the right nares seemed to be flatter than the left but the turbinates on both sides were edematous and somewhat injected. The heart had a regular rate and rhythm with a grade I-II/VI murmur best heard at the base. The examination was to include x-rays of the sinuses, nasal bones and pulmonary function tests. No diagnoses were provided with the protocol examination. Chest x-rays from December 1993 were interpreted to show no evidence of acute pulmonary cardiac disease. X-rays of the nasal bones were interpreted to show the nasal bones within normal limits. X-rays of the paranasal sinuses were reported to show normal paranasal sinuses. The veteran was notified by the RO, in a letter dated in March 1994, that some of his liver tests were mildly elevated and that follow-up treatment was being arranged. The veteran was notified of an upcoming appointment at the VA Medical Center (VAMC) in Louisville, Kentucky. Treatment records from the VAMC, for the period from April 1994 to September 1994, show that the veteran was seen in April to review the results of his serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase (SGPT) tests. He also was scheduled for a pulmonary function test (PFT) and echocardiogram as a result of the detection of a heart murmur on his protocol examination. An April 1994 PFT indicated that the veteran had a mild decrease in ventilation with a forced expiratory volume in one second (FEV1) of 92 percent and a ratio of FEV1 to forced vital capacity (FVC) of 86 percent. The results of a May 1994 Doppler echocardiogram were interpreted to show that the veteran had a moderate to severe aortic insufficiency and trivial mitral regurgitation. A May 1994 clinical entry noted that the veteran’s laboratory test was positive for presence of the Hepatitis C antibody. A second clinical entry from May 1994 reported the veteran’s liver function tests to be within normal limits and the positive test for the Hepatitis C antibody. An August 1994 entry noted the results of the echocardiogram and the veteran’s complaints of dyspnea for the past year. The assessment was aortic insufficiency of unknown etiology. The veteran was to be scheduled to undergo an exercise stress test. The veteran was afforded a VA examination in February 1995 to evaluate the conditions claimed on appeal. The veteran said that in September 1991 he had several skin lesions under the left arm and on the back of the neck which appeared to ulcerate. He said that he thought that he was told that they were spider bites. He was treated at Union County Hospital in 1992 when the areas did not heal and they were then excised. The areas were now healed. He also described an incident of his face swelling up in 1993. He was treated with steroids and told that this was probably an allergic reaction. He related that he had continued problems with nasal swelling and had surgery to remove a blood clot from his nose. He had not had any problems breathing after his surgery. The veteran further related that he was diagnosed with aortic insufficiency and Hepatitis C at the Louisville VAMC. The veteran gave a history of exposure to a number of environmental hazards while serving in the Persian Gulf. He admitted to having memory loss at the time of the examination. He said that he was in perfect health before his service in the Persian Gulf. The examiner noted that, after reviewing the history, physical examination, laboratory and special studies performed, it seemed unusual for a 37- year old man to have such unusual extensive chronic obstructive pulmonary disease (COPD) and multiple abnormal problems. The veteran had present complaints of marked SOB, either at rest or upon exertion. He denied any cough. He said that he did not breath completely right at night. He had occasional leading sharp pains in the substernal area that would come and go and were not related to exercise. He tired very easily. His face felt flushed at times. He had daily headaches in the frontal areas of the face that were relieved by Tylenol and not associated with activity. He had no visual disturbances but his headaches sometimes would last all day. He had body aches all over and he would forget very easily. His symptomatology was very vague but the examiner said that the veteran impressed him as a very honest and sincere person in trying to answer questions. He described vague aching in the knees, neck, shoulders, and arms, but range of motion of all joints was fairly well within normal limits. In February 1995, physical examination of the skin revealed three well-healed scars of one-half centimeter (cm) in size, round and flat, on the posterior of the neck area. The head, face, and neck were normal. Examination of the noses, sinuses, mouth and throat were normal with clear air passage. The veteran had a regular heart rate and rhythm. There was a loud diastolic murmur in the aortic area, but it did not appear to be transmitted to the carotid area. Point of maximum impulse was in the 4th interspace left mid-clavicular line. The carotid pulses were normal with no bruits. The femoral, popliteal, and dorsalis pedis pulses were normal bilaterally. The veteran was not exercised due to a lack of need for cardiac stress testing due to his lung condition. The lungs had markedly diminished breath sounds with a few scattered rhonchi. A chest x-ray was interpreted as showing clear lungs and a normal heart. X-rays of the sinuses were interpreted as showing the sinuses as normally developed; there were no fluid levels or bony abnormalities. A blood test was positive for the Hepatitis C antibody. A PFT demonstrated a change from the April 1994 PFT. The results of the February 1995 PFT revealed an FEV1 of 34 percent and an FEV1/FVC ratio of 49 percent. The examiner’s diagnoses were: aortic insufficiency, compensated at present; COPD, severe; Persian Gulf Syndrome; scars, three on neck, status post excision of unknown type lesions, presumed to be benign; status post excision of hematoma from right nasal cavity; Hepatitis C, presently inactive because of normal liver enzymes. In August 1995, along with his notice of disagreement, the veteran requested that he be afforded a hearing with RO personnel in Evansville, Indiana. In a September 1995 reply, the RO informed the veteran that hearings were only held in regional offices. The veteran was informed of the nearest RO’s which included: Louisville; Indianapolis, Indiana; St. Louis, Missouri; and, Nashville, Tennessee. He was informed that he would be provided with a statement of the case (SOC) and informed of his hearing options and that if he wanted to request a personal hearing to notify the RO. The veteran was provided with an SOC in September 1995; however, there is no indication in the file that he ever requested a hearing at any subsequent time. There is no other medical evidence of record following the February 1995 VA examination. The RO notified the veteran in July 1996 that he should forward records of any medical treatment that he may have. The veteran was also informed that he could submit non-medical evidence in support of his claims and what types of evidence would be of benefit to him. There is no indication in the record that the veteran submitted any further evidence, either medical or non- medical. Nor is there any evidence in the record that the veteran said that he had received additional treatment for his claimed conditions and notified the RO of that development. Analysis The veteran is seeking service connection for skin rashes, blood clots in the nose with shortness of breath, heart problems, and hepatitis. The legal question to be answered initially is whether the veteran has presented evidence of well-grounded claims; that is, claims that are plausible. If he has not presented well-grounded claims, his appeal must fail with respect to these claims and there is no duty to assist him further in the development of his claims. 38 U.S.C.A. § 5107(a) (West 1991). As will be explained below, the Board finds that these claims are not well grounded. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303(a) (1998). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b) (1998). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1998). However, “[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service.” Watson v. Brown, 4 Vet. App. 309, 314 (1993). Three discrete types of evidence must be present in order for a veteran’s claim for benefits to be well grounded: (1) There must be competent evidence of a current disability, usually shown by medical diagnosis; (2) There must be evidence of incurrence or aggravation of a disease or injury in service. This element may be shown by lay or medical evidence; and (3) There must be competent evidence of a nexus between the inservice injury or disease and the current disability. Such a nexus must be shown by medical evidence. See Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Service connection may also be established for chronic disability resulting from an undiagnosed illness which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2001. 38 C.F.R. § 3.317(a)(1) (1998). Objective indications of a chronic disability include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first become manifest. A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from part 4 of chapter 38, Code of Federal Regulations, for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability referred to in this section shall be considered service- connected for purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(2-5). Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b) (1998). In the alternative, the chronicity provisions of 38 C.F.R. § 3.303(b) are applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service, or during an applicable presumptive period, and still has such condition. Such evidence must be medical unless it relates to a condition as to which under case law of the Court, lay observation is competent. If chronicity is not applicable, a claim may still be well grounded on the basis of 38 C.F.R. § 3.303(b) if the condition is noted during service or during an applicable presumptive period, and if competent evidence, either medical or lay, depending on the circumstances, relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488, 498 (1997). The veteran’s service medical records show no indication of any treatment for, or diagnoses of, skin rashes, blood clots in the nose with shortness of breath, heart problems, or hepatitis during his period of service. His physical examinations do not report any related conditions. He was treated on one occasion in December 1990 for a sinus problem with no indication of any sequelae in service. Various private treatment records show that the veteran was seen following his separation from service for complaints of an insect bite and cellulitis in the right axilla, and a hematoma in the right nasal cavity, with complaints of difficulty breathing through his nose. However, none of these conditions were related to any incident of service, especially during the veteran’s period of service in the Persian Gulf. Dr. Logan noted that the veteran attempted to connect his nasal hematoma to service in the Persian Gulf. However, in a June 15, 1993, clinical entry, Dr. Logan noted the etiology as unknown. Moreover, the veteran’s cellulitis in his right axilla was attributed to an insect bite that occurred in 1992. There is no medical evidence of record that shows that the veteran had any lesions on his neck that were removed. There are scars present with only the veteran’s description of what caused the scars. The February 1995 VA examination noted that the veteran’s skin was normal, except for scars on the neck. There was no evidence of lesions or a rash. Further, examination of the veteran’s nose and sinuses reported that he had a clear air passage. Establishment of service connection for skin rashes and blood clots in the nose with shortness of breath must be denied. There is no evidence of treatment for the claimed conditions in service. There is no evidence of any type of rash present post-service, only the 1992 treatment for cellulitis due to an insect bite, a diagnosed condition. The veteran’s nasal surgery was due to a diagnosed condition of a hematoma in the right nasal cavity. There is no evidence linking this condition to any incident of service. Moreover, as a diagnosed condition, it cannot be considered for service connection under 38 C.F.R. § 3.317. The Board notes that the veteran was diagnosed with COPD, as early as April 1994 based on evidence of record. It is not clear from the record if the veteran attributed his shortness of breath to his COPD or to the earlier difficulty he had in breathing through his nose. To the extent that the claim involved COPD, there is no basis to establish service connection for the condition. Clearly, COPD is a diagnosed condition and not for consideration for service connection under 38 C.F.R. § 3.317. Further, there is no evidence of record to show any nexus between the diagnosis of COPD and any incident of service. Nor does the evidence show development of COPD within one year after the veteran’s last period of service to warrant consideration on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309 (1998). The Board does acknowledge the development of the condition following the veteran’s last period of active duty and the change in PFT results between April 1994 and February 1995, which indicate a worsening of the condition. However, without competent medical evidence providing a nexus between the COPD and the veteran’s active military service, there is no basis for service connection. The veteran’s heart problems were first identified in May 1994 based on follow-up tests conducted in conjunction with his Persian Gulf protocol examination in December 1993. The veteran was diagnosed with aortic insufficiency and trivial mitral regurgitation. No nexus between any incident of service and the veteran’s heart diagnoses was made. The conditions were diagnosed in 1994, approximately three years after the veteran was released from active duty, well beyond the one year presumptive period for service connection for heart conditions. 38 C.F.R. §§ 3.307, 3.309. Accordingly, there is no nexus to establish service connection on a direct, or presumptive, basis. Further, as diagnosed conditions, there is no basis to establish service connection under 38 C.F.R. § 3.317. The veteran’s hepatitis C condition is, by definition, a diagnosed condition, and not eligible for consideration under 38 C.F.R. § 3.317. Moreover, there is no evidence of a finding of hepatitis C in service or linking the development of hepatitis C to any incident of service. Accordingly, the veteran’s claim for service connection must be denied. While the veteran claims that he developed skin rashes, blood clots in the nose with shortness of breath, heart problems, and hepatitis C as a result of his service in the Persian Gulf, he has offered no competent evidence to establish such a relationship, other than his own unsubstantiated contentions. While the veteran is certainly capable of providing evidence of symptomatology, “the capability of a witness to offer such evidence is different from the capability of a witness to offer evidence that requires medical knowledge...” Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Causative factors of a disease amount to a medical question; only a physician’s opinion would be competent evidence. Gowen v. Derwinski, 3 Vet. App. 286, 288 (1992). A well-grounded claim requires more than a mere assertion; the claimant must submit supporting evidence. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Since the service medical records do not show the veteran with any of the claimed conditions during service and as he has not submitted any medical opinion or other competent evidence to show the claimed conditions in service or to support a finding that his current conditions are in anyway related to his periods of service, the Board finds that he has not met the initial burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that his claims are well grounded. 38 U.S.C.A. § 5107. Hence, the benefits sought on appeal are denied. Although the Board has disposed of the claim of entitlement to service connection for skin rashes, blood clots in the nose with shortness of breath, heart problems, and Hepatitis on a ground different from that of the RO, that is, whether the veteran's claims are well grounded rather than whether he is entitled to prevail on the merits, the veteran has not been prejudiced by the Board's decision. In assuming that the claim was well grounded, the RO accorded the veteran greater consideration than his claim warranted under the circumstances. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). Finally, as the foregoing explains the need for competent evidence of a current disability which is linked by competent evidence to service, the Board views its discussion above sufficient to inform the veteran of the elements necessary to complete his application for service connection for the claimed disabilities. Robinette v. Brown, 8 Vet. App. 69, 79 (1995). ORDER Service connection for skin rashes, blood clots in the nose with shortness of breath, heart problems and hepatitis, to include as due to an undiagnosed illness, is denied. REMAND The veteran’s remaining claimed condition of memory loss was never evaluated. Memory loss was referred to as a current complaint at the veteran’s February 1995 VA examination. A brief summary of an examination of the nervous system, to include psychiatric and personality, was provided, however, the claimed condition of memory was not examined. In view of the state of the record, further development, as specified below, is required. Accordingly, the case is REMANDED to the RO for the following action: 1. The veteran should be requested by VA to provide the names, addresses and approximate dates of treatment for any health care providers, including VA, who may possess records since February 1995 that are pertinent to the claim still on appeal. After obtaining any necessary consent forms for the release of the veteran's private medical records, the RO should obtain, and associate with the file, any records noted by the veteran that are not currently on file. 2. After the above has been completed, the veteran should be afforded VA neurological and psychiatric examinations by board certified specialists, if available, to determine the nature, extent, and etiology of any memory loss. The claims file must be made available to the examiners for study prior to the examinations. Any necessary tests or studies should be conducted, and all findings should be reported in detail. The rationale for any opinion expressed should be explained. 3. The RO should then review the examination reports to ensure that they are in complete compliance with the directives of this REMAND. If the reports are deficient in any manner, the RO must implement corrective procedures at once. 4. Thereafter, the RO should again consider the claim of entitlement to service connection for memory loss, to include as due to an undiagnosed illness, based on all the pertinent evidence of record, and all applicable laws and regulations. If the benefit sought is not granted, the veteran and his representative should be furnished with a supplemental statement of the case and provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration. By this action, the Board intimates no opinion, legal or factual, as to the ultimate disposition warranted. This case must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans’ Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1997) (Historical and Statutory Notes). In addition, VBA’s ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. JAMES W. LOEB Acting Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1998), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. Appellate rights do not attach to the issue addressed in the remand portion of the Board’s decision, because a 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) (1998). - 2 -