Citation Nr: 0005597 Decision Date: 03/01/00 Archive Date: 03/14/00 DOCKET NO. 98-10 435 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, Puerto Rico THE ISSUES 1. Entitlement to service connection for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for bilateral elbow medial and lateral epicondylitis. 3. Entitlement to service connection for shortness of breath due to undiagnosed illness. 4. Entitlement to service connection for fatigue and tiredness due to undiagnosed illness. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD William L. Pine, Counsel INTRODUCTION The appellant had active service from November 1963 to December 1965 and from January 1991 to July 1991, with active duty in the Southwest Asia theater of operations from February 14, 1991, to June 25, 1991. In this decision, Southwest Asia, the Persian Gulf, and the Gulf are used interchangeably for the general geographical area of the appellant's overseas service during the Persian Gulf War. Names of countries are used specifically, and are reported as they are used in the various documents of record. This appeal is from a March 1998 rating decision of the Department of Veterans Affairs (VA), San Juan, Puerto Rico, regional office (RO) that denied the claims stated as issues, supra, as well as for anxiety and memory loss, issues that the appellant withdrew in a written statement received September 18, 1998. Evidence pertinent to anxiety and memory or other cognitive problems is mentioned in this decision in the context of the Board's discussion of the issues currently on appeal. For reasons explained in the remand appended to this decision, the Board will defer review on the merits of the claim for service connection for PTSD. FINDINGS OF FACT 1. The appellant has submitted competent medical evidence of a current diagnosis of PTSD, testimony of psychic trauma (stressors) incurred in service, and competent medical evidence of a nexus between the currently diagnosed PTSD and the stressors incurred in service. 2. VA has not assisted the appellant to develop certain facts pertinent to the claim of entitlement to service connection for PTSD. 3. The appellant has not submitted competent medical evidence of nexus between bilateral elbow medial and lateral epicondylitis and a disease or injury incurred or aggravated in service or with a symptomatology continuous with a condition noted in service. 4. The appellant's shortness of breath has been attributed to diagnoses of REM (rapid eye movement)-related sleep disordered breathing and asthma. 5. The appellant's fatigue and tiredness have been attributed to diagnoses of insomnia, insufficient sleep syndrome, and dyssomnia associated with mood disorder. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for PTSD is well grounded, and VA has not discharged its duty to assist the appellant to develop facts pertinent to the claim. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim of entitlement to service connection for bilateral elbow medial and lateral epicondylitis is not well grounded, and VA has no duty to assist the appellant to develop facts pertinent to the claim. 38 U.S.C.A. § 5107(a) (West 1991). 3. The claim of entitlement to service connection for shortness of breath due to an undiagnosed illness is legally insufficient. 38 U.S.C.A. § 1117 (West Supp. 1999); 38 C.F.R. § 3.317 (1999). 4. The claim of entitlement to service connection for fatigue and tiredness claimed as due to an undiagnosed illness is legally insufficient. 38 U.S.C.A. § 1117 (West Supp. 1999); 38 C.F.R. § 3.317 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Background Service medical records predating February 1991 are negative for any complaint, diagnosis, or treatment for mental, elbow, or breathing condition. In February 1991, the appellant complained of difficulty breathing, numbness in the left arm, chest pressure, and rapid heart rate with a history of high blood pressure. The assessment was rule out myocardial infarction, which, upon evaluation by internal medicine was found to be chest wall pain. In May 1991, he complained of frequent chest pain and spells of awakening at night with shortness of breath, numbness in the left arm, and a heartburn sensation. The complaints were assessed as hyperdynamic heart syndrome by history, consider panic disorder, and other possible diagnoses. In June 1991, the appellant complained of chest pain and shortness of breath. He was assessed as having supraventricular tachycardia and hypertension. He was admitted to the intensive care unit, and on examination had no shortness of breath. A nursing report noted there was no dyspnea. Medical evaluation found no chronic condition. The appellant was referred to psychiatry, which noted complaints of feeling tired, sad, and missing his family. The impression was depression and adjustment disorder with mixed emotional features. An undated medical document shows a diagnosis of anxiety disorder. The June 1991 medical history for separation from the service was positive for palpitation or pounding heart, recent weight loss, frequent trouble sleeping, depression or excessive worry, and nervous trouble. The physician's comment noted development of anxiety in Saudi Arabia and diagnosis of hyperkinetic heart syndrome. The June 1991 separation physical examination was essentially negative. The examiner noted observation for anxiety in the summary of defects. The appellant had a VA Persian Gulf protocol examination in July 1994 in which he reported depression, flashbacks, hair loss, and insomnia as complaints. The diagnoses were major depression, PTSD, hair loss, and high blood pressure. VA outpatient records of July 1994 to August 1998 show multiple psychiatric diagnoses of which PTSD was predominant. Other diagnoses included depression, dysthymia, and anxiety. The initial diagnosis, in July 1994, was major depression. The appellant complained of no sleep and being very anxious. He reported that since 1993 he had had severe anxiety, nightmares, irritability, insomnia, anhedonia, and flashbacks. The diagnosis was rule out PTSD. When evaluated in November 1994 for participation in VA PTSD Clinical Team (PCT) group and individual therapy, the appellant reported stressful events he experienced while in Southwest Asia. He stated that he was among a group of 10 military police (MP) lost in the desert for two and a half weeks and he felt abandoned. He reported an occasion on which he was going to Kuwait looking for snipers and he saw badly damaged enemy bodies. He reported that war recollections were triggered by visual stimuli. Upon completion of the clinical interview and mental status examination, the assessment was PTSD and dysthymia. In July 1995, he reported that the worst thing that happened was that three officers died and his team had to deal with it. On VA orthopedic examination in May 1995, the appellant complained of pain in both sides of his elbows with a tired sensation for the past six months. Physical examination was negative except for tenderness to palpation of the lateral and medial epicondyles, bilaterally. The diagnosis was bilateral elbow medial and lateral epicondylitis. On VA psychiatric examination in May 1995, the appellant gave a history of referral to a psychologist while on active service. He reported duty in Kuwait and Saudi Arabia as an MP during the Gulf War. Current complaints were of irritability, tenseness, aggressiveness, forgetfulness, inability to get involved in past interests, and occasional violence at home. He reported that in the Gulf "they killed a black man that was robbing things," and that memory was always on his mind. He reported he was exposed to extreme situations in the desert; one night the wind blew up his tents in the dunes. Upon completion of clinical interview and mental status examination, the examiner diagnosed anxiety disorder, not otherwise specified (NOS). In June 1997 at the VA primary care clinic, the appellant complained of pain and discomfort in all joints. In a July 1997 letter, the Department of Defense (DoD) informed the appellant that his unit was near Khamisiyah, Iraq, in early March 1991 when rockets were destroyed, which may have resulted in the release of the nerve agents sarin and cyclosarin into the air. The appellant may have been exposed at a very low level, if he was with his unit at that time. DoD noted that little is known about the long-term effects of such a brief, low-level exposure, but current medical evidence was that long-term health effects were unlikely. On VA psychiatric examination in November 1997, the appellant reported he served as an MP in Saudi Arabia and Kuwait during the Persian Gulf War. He reported his current complaints, including forgetfulness, irritability, anxiety, desire to run out of his home, depression, and expectation of bad things to happen, all of which had persisted since he returned from the Gulf. Upon completion of clinical interview and objective observation, the diagnosis was dysthymia. In November 1997, the RO requested information from the appellant necessary to develop his claim for PTSD. The appellant responded in December 1997. He reported his unit of assignment. Regarding stressors, he reported the following: Around the end of February 1991, while on a reconnaissance mission near Kugi, a rocket exploded "close to us." He reported seeing enemy soldiers being attacked by our Air Force, and hundreds of enemy corpses were spread all around in pieces at the "Kuait [sic]" zone. While in Dhahran, Saudi Arabia, a SCUD hit a compound and blew it to pieces, killing about 20 men in a barracks. He saw SCUD missiles intercepted and blown up by our rockets on several occasions. Take-quarters alarms activated several times a day for months. He reported that "we" were generally on our own with no backup of superior officers, working 24 hours a day during the week, without appropriate food. He reported having too many hours alone in the desert in his Humvee in very hot or very cold conditions. He reported an occasion of getting lost in the desert with no radio and the light that was to guide him went out, so he had no reference point. The appellant testified at a hearing before a VA hearing officer in September 1998. He asserted that all of his claimed disabilities were a consequence of his service in the Persian Gulf. He reported he was in Saudi Arabia and Kuwait. He reported he first had a breathing problem when he arrived in Saudi Arabia, noticing it first in February or March 1991. He also could not sleep and felt agitated. He reported a second episode of breathing problems in April or May 1991. He stated that his first post-service medical treatment was in 1994 at a VA hospital, and he had had no private medical treatment prior to that. He reported being treated currently for PTSD and not having current treatment for shortness of breath, for which he had never been treated or told what condition that could be. He reported that now trouble breathing disrupted his sleep at night. Regarding PTSD, he reported the first diagnosis was in 1994 by a VA doctor. The appellant's representative asked the appellant to report the stressors he experienced in service, noting that the appellant's December 1997 report of stressors in service was incomplete and insufficient. The appellant reported that as an MP, he had to catch prisoners of war, find and identify dead bodies. He made a vague statement about four Americans who had lost their lives, but he did not articulate an intelligible context for the reference. He stated he had had only VA treatment for PTSD. He described his current symptomatology. Regarding his elbows, the appellant reported having no treatment for either of them in service. He said he was already starting symptoms when he returned from the war to Puerto Rico. Treatment started in 1994. He stated he did not know the origin of the condition, which he had never had before, and he planned therapy to start in late 1997 or 1998. When seen as an outpatient in July 1998, the appellant complained of pain in his elbows. There were no other symptoms, and the impression was rule out osteoarthritis. On VA respiratory examination in November 1998, the appellant gave a history of onset of shortness of breath in service, evaluated twice with findings of high blood pressure and anxiety. He reported currently awakening at night with shortness of breath and occasional cough about once a week. He reported having sweats nightly. There was no history of hypersomnolence or hemoptysis. The appellant was under no treatment for any respiratory condition. Examination revealed no evidence of pulmonary hypertension, right ventricular hypertrophy, cor pulmonale, congestive heart failure, pulmonary embolism, respiratory failure, or pulmonary thromboembolism. Chest x-ray in September 1998 was negative for the lungs. There is reference in the report to a pulmonary function test report that is not of record. The diagnosis was asthma. On VA psychiatric examination in November 1998, the examiner reviewed the appellant's VA claims file and hospital records. The examiner summarized the medical records and noted the appellant's current complaints of poor sleep, nightmares, forgetfulness, expectation of bad occurrences, depression, desire to cry, and unwelcome recollections of the past. Upon completion of the clinical interview and objective observations, the examiner diagnosed dysthymia and opined that based on the appellant's history, records, present, and previous evaluations, dysthymia was the correct diagnosis, and the appellant did not fulfill the diagnostic criteria for PTSD. The appellant was evaluated at the Houston VA Medical Center (VAMC) Gulf War Referral Center for two weeks in August 1999. A social work record noted that the appellant vigorously held the perception that his predicament is linked solely to exposures while deployed in the Gulf conflict and his frustration over the lack of precise and clear external explanations for his difficulties. On intake into the evaluation program, exposures related to and in Southwest Asia were listed as immunizations prior to and during the war, one SCUD, oil well fires, "positive P.B for one week-no problems," ate local food and water, was in combat zone, "no DO exposure," cleaned trucks, and disposed of captured weapons. The DoD letter regarding Khamisiyah was noted. On systems review, he reported dyspnea on exertion, awakening at two a.m., fatigue, night sweats, snores, and jumps for breath. A pulmonary function test revealed FEV1 (forced expiratory volume in one second) before administration of a bronchodilator that was 87 percent of that predicted and FEV1 after administration of a bronchodilator that was 90 percent of that predicted; oxygen saturation was 96 percent before pre-bronchodilator and 90 percent of that predicted. On psychiatric evaluation, the appellant reported he was an army guard and staff sergeant during the war. He stated he witnessed horrendous sights of dead corpses. He said he was called upon to identify dead bodies on occasion. He reported he saw two Puerto Ricans being killed by mine explosions, and he constantly lived in fear of death. He reported having emotional changes when he returned from the war. The examiner listed the appellant's current symptoms and diagnosed PTSD, depression NOS, and cognitive disorder NOS. The examiner noted that cognitive problems, depression, and anger dyscontrol could be caused by chemical exposure during the war and that white matter changes in the brain shown by MRI (magnetic resonance imaging) could contribute to his problems. In a follow-up psychiatric examination and report, the examiner restated the PTSD diagnosis as due to Persian Gulf related experiences. He also diagnosed unexplained illness since Persian Gulf, reported exposure to multiple chemicals in Persian Gulf, including vaccinations, smoke from oil fires, pesticides, and possible chemical warfare agents. He commented that anxiety, depression, irritability, and cognitive problems may occur after exposure to neurotoxic chemicals. On neuropsychiatric clinical interview related to cognitive dysfunction, the appellant reported that he had been in combat in the Persian Gulf for two years beginning in January 1991. He stated he was stationed in Iraq, where he was responsible for "cleanup" following bombardment of the Iraqi countryside. Neuropsychiatric testing revealed severely impaired attention and concentration as well as emotional variables, primarily depression and anxiety, delimited the appellant's performance across all tests. It was recommended he have a repeat evaluation once the depressed and anxious affect had been effectively treated. The appellant had a sleep disorder study, which noted the number of episodes of sleep apnea and of hypopnea. The appellant reported multiple sleep related dysfunctions, certain of which were characterized as psychophysiological insomnia features. He stated he did not have excessive daytime sleepiness. The diagnosis related to breathing was REM-related sleep-disordered breathing, which was felt to be at a level that did not warrant continuous positive airway pressure (CPAP) therapy. Other sleep study diagnoses included psychophysiological insomnia; insufficient sleep syndrome; and dyssomnia associated with mood disorder. The appellant was discharged with the following pertinent final diagnoses: PTSD, depression NOS, rule out cognitive disorder NOS, REM-related sleep-disordered breathing, psychophysiological insomnia, insufficient sleep syndrome, and dyssomnia associated with mood disorder. II. Analysis In seeking VA disability compensation, the appellant seeks to establish that current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 1991). Such a disability is called "service connected." 38 U.S.C.A. § 101(16) (West 1991). Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. 38 C.F.R. § 3.303(a) (1999). Before the Board may consider the merits of the claim, preliminary determinations are required. First, it must be determined that the application for benefits is complete, and if not, whether VA has discharged any duty it may have to so inform the claimant. 38 U.S.C.A. § 5103(a) (West 1991). The appellant has provided no information indicating a source of evidence not of record. His application for disability compensation is complete, and VA has no duty to inform him of the necessity to submit any evidence to complete it. Second, "a person who submits a claim for benefits under a law administered by the Secretary [of Veterans Affairs] shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded." 38 U.S.C.A. § 5107(a) (West 1991). If the appellant does not meet that burden, the Board will not consider the merits of the underlying claim. Grottveit v. Brown, 5 Vet. App. 91 (1993). "For a claim to be well grounded, there must be (1) a medical diagnosis of a current disability; (2) medical, or in certain circumstances, lay evidence of in[-]service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service [disease or injury] and the current disability." Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997) (quoting Epps v. Gober, 9 Vet. App. at 343-44 (citations and quotations omitted)); see Grottveit, 5 Vet. App. 91 (characterizing the type of evidence, lay versus medical, necessary to well ground a claim as dependent on the nature of the matter to be proven); see also Espiritu v. Derwinski, 2 Vet. App. 492 (1992) (lay individuals are competent to testify about matters of common experience, but expert qualification is necessary for VA to take cognizance of testimony that is rendered reliable only by expertise pertinent to object of inquiry). Evidence is presumed true for the limited purpose of determining if a claim is well grounded. Robinette v. Brown, 8 Vet. App. 69, 75-76 (1995). Alternatively, a claim may be well-grounded by evidence of continuity of symptomatology with a condition noted in service, 38 C.F.R. § 3.303(b) (1999), and a competent medical opinion that there is a nexus between a currently diagnosed disorder and the symptomatology for which there is continuity with the condition noted in service. Savage v. Gober, 10 Vet. App. 488 (1997). Additionally, a veteran of active service in the Southwest Asia theater of operations during the Persian Gulf War may establish service connection for certain disabilities due to undiagnosed illness. 38 U.S.C.A. § 1117 (West Supp. 1999); 38 C.F.R. § 3.317 (1999). Thus, such a veteran may have a well-grounded claim in the absence of a current diagnosis to explain the claimed disability. A. PTSD The appellant has submitted evidence of a current diagnosis of PTSD, which satisfies the first element of a well-grounded claim. Epps, 126 F.3d at 1468. He has reported and testified under oath to having certain experiences while in the Southwest Asia theater of operations, and the testimony is presumed true. Robinette, 8 Vet. App. 69. These statements satisfy the second criterion of a well-grounded claim. 126 F.3d at 1468. Finally, the Houston VAMC record showed that a competent expert linked the PTSD to his experiences in the Persian Gulf. In short, the claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). Where a claim is well grounded, VA has a duty to assist the appellant to develop facts pertinent to the claim. As is discussed in more detail in the remand, infra, the record reveals that VA has not discharged its duty to assist the appellant to develop his claim. Id. B. Bilateral Elbow Epicondylitis The appellant has submitted a current diagnosis of bilateral elbow medial and lateral epicondylitis. Thus he has satisfied the first element of a well-grounded claim. Epps, 126 F.3d at 1468. He has not submitted any evidence that bilateral elbow conditions were incurred in service. He has not submitted evidence that the condition was noted during service. His hearing testimony that symptoms were already starting when he returned home could arguably be liberally construed as the noting of a condition in service. His testimony could also be liberally construed as evidence of continuity of symptomatology. So liberally construed, the appellant has satisfied the second element of a well-grounded claim. 38 C.F.R. § 3.303(b) (1999); Savage, 10 Vet. App. 488. However, neither the May 1995 VA examiner who diagnosed bilateral epicondylitis nor the August 1999 VA radiologist who noted spurs at the olecranon processes indicated a nexus between the current findings and any symptoms that have been continuous with the symptoms noted by the appellant during service. Id. The appellant has not presented a well-grounded claim for service connection for bilateral elbow medial and lateral epicondylitis. Absent a well-grounded claim, VA has no duty to assist the appellant to develop facts pertinent to the claim, Morton v. West, 12 Vet. App. 477 (1999), and the Board does not have jurisdiction to adjudicate the claim on the merits. Boeck v. Brown, 6 Vet. App. 14 (1993). C. Shortness of Breath Due to Undiagnosed Illness The appellant has reported shortness of breath in two functional contexts, as dyspnea on exertion, and during sleep. The Board will consider both. The appellant has not submitted evidence that he has a current disability due to an undiagnosed illness. The appellant has submitted competent medical evidence of two diagnoses that involve respiratory function, i.e., shortness of breath, as a symptom of asthma and REM-related sleep- disordered breathing. Whereas his breathing complaints have been shown related to diagnosed conditions, he cannot establish the claim as well-grounded despite the absence of a diagnosis. See 38 U.S.C.A. § 1117 (West Supp. 1999); 38 C.F.R. § 3.317 (1999). Thus, even if the Board interprets the complaints in service that were then evaluated in the context ruling out a cardiac condition as manifestations in service of the current condition, see 38 C.F.R. § 3.317(a)(1)(i) (1999), the existence of current diagnoses precludes the application of the regulation. Moreover, the Houston VAMC psychiatric examiner who commented that the appellant had unexplained illness since his service in the Persian Gulf did not relate shortness of breath to the unexplained illness, and the report is not evidence of shortness of breath as a symptoms of an undiagnosed illness or of disability due to undiagnosed illness. Thus, as a matter of law, the appellant seeks a VA benefit on legally insufficient grounds. Such a claim is properly denied because of such legal insufficiency, rather than as not well grounded. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). D. Fatigue and Tiredness Due to Undiagnosed Illness The veteran's complaints of fatigue and tiredness have not been identified by competent medical authority as symptomatic of any undiagnosed illness. On the contrary, the veteran's symptoms may be associated with diagnoses given on examination. They have been related to insomnia, mood disorder, and insufficient sleep syndrome. Accordingly, as there are diagnoses to account for the symptoms, they cannot be said to be symptoms of undiagnosed illness. See 38 U.S.C.A. § 1117 (West Supp. 1999); 38 C.F.R. § 3.117 (1999). In this case, the facts are not in dispute, and application of the law to the facts is dispositive. Where there is no entitlement under the law to the benefit sought, the appeal must be terminated. See Sabonis v. Brown, 6 Vet. App. 426 (1994). ORDER The appellant has presented a well-grounded claim of entitlement to service connection for PTSD, and to that extent the claim is granted. Whereas the appellant has not submitted a well-grounded claim of entitlement to service connection for bilateral elbow medial and lateral epicondylitis, the claim is denied. Service connection for shortness of breath due to undiagnosed illness is denied. Service connection for fatigue and tiredness claimed as due to undiagnosed illness is denied. REMAND VA must assist the appellant to develop his well-grounded claim for PTSD. 38 U.S.C.A. § 5107(a) (West 1991). Specifically, the appellant has reported his unit of assignment during the Persian Gulf War and the unit to which his unit was attached. He has reported numerous incidents as stressors, but he has provided insufficient detail to enable VA to assist him by verifying that the stressors occurred. He has reported events that should be verifiable if the appellant provides sufficiently detailed information about the time, location, and persons involved in those events. "The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The appellant has reported generally the area of the Southwest Asia theater in which certain event occurred. He has reported duty in Saudi Arabia, mentioning specifically the city of Dhahran, and in Kuwait and Iraq. It may considerably assist his claim for VA to obtain his personnel records, unit histories, and morning reports showing in the greatest available detail the appellant's assignments and his and his unit's movements while in the Southwest Asia theater of operations. In Cohen v. Brown, 10 Vet. App. 128 (1997), the claimant had reported multiple stressors, and a VA diagnosis of PTSD was based on the reported stressors. Certain of the stressors were verified and others were not. The diagnosing physician had not identified which stressor or stressors among those the veteran reported had precipitated PTSD. The Court remanded for the physician to identify the stressors on which the diagnosis was based. Likewise in the instant case, no physician diagnosing PTSD has identified the precipitating stressor or stressors. Clearly it would greatly assist the appellant's claim if a diagnosing physician identified the stressor or stressors upon which the diagnosis was based. Accordingly, the case is REMANDED for the following action: 1. Request the appellant to provide additional details regarding the following incidents: (a) The beginning and ending dates of the two and a half week period during which he and 10 other MPs were lost in the desert, the names of the others with him, and the command to which they reported at the end of that period; (b) the date and location when and where his unit had to deal with the three dead officers, and the names and units of those officers; (c) the date and location at which a black man was killed for stealing, whether he witnessed the killing or had any role in the event in his capacity as an MP; (d) the date of the incident in Dhahran in which a SCUD missile hit a barracks, whether he was a witness, and his distance from the event; (e) the dates and places he was assigned to identify dead, and the name and unit of any dead U.S. soldier he identified, including the four individuals about whom he testified; (f) the date and place he saw a Puerto Rican being killed in a mine explosion, and the name and unit of the person killed; (g) the dates he was in Iraq, and specifically, whether he was with his unit on March 10, 1991. Associate any information obtained with the claims folder. 2. Obtain from the appropriate archives the appellant's personnel records and any available unit histories and morning reports for the 716th battalion, 89th MP brigade, 301st MP Company, attached to the 716th battalion for the period February 14, 1991, to June 25, 1991. Refer the case to U.S. Armed Services Center for Research of Unit Records (USASCRUR) for any possible assistance verifying any stressors about which the appellant provides sufficient detail to permit the assistance of USASCRUR. Associate any information obtained with the claims folder. 3. Request the PCT psychiatrist and the VAMC Houston psychiatrist who diagnosed PTSD to review their treatment and examination records and report which incident or incidents as reported by the appellant precipitated PTSD. Provide each the claims folder for review if their records are insufficient to permit a response. Each responding physician should identify the precipitating incident or incidents with sufficient detail to enable RO personnel and the reviewing member of the Board to identify from the claims folder the incidents to which the examiners' reports refer. Associate any information obtained with the claims folder. 4. Readjudicate the claim for service connection for PTSD. If the claim remains denied, provide the appellant and his representative a supplemental statement of the case and afford them an appropriate amount of time to respond. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The appellant need take no further action until he is further informed. The purpose of this REMAND is to obtain additional information and to afford due process. No inference should be drawn regarding the final disposition of the claim because of this action. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. 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 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. 1999) (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. J. SHERMAN ROBERTS Member, Board of Veterans' Appeals