Citation Nr: 1315136 Decision Date: 05/08/13 Archive Date: 05/15/13 DOCKET NO. 11-05 854 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for a subdural hematoma. 4. Entitlement to service connection for degenerative joint disease of the right knee (a right knee disability). 5. Entitlement to service connection for erectile dysfunction, to include as secondary to hypertension or neuropathy of the lower extremities. 6. Entitlement to service connection for neuropathy of the lower extremities, to include as secondary to left and right knee disabilities, or in the alternative, as due to a qualifying chronic disability. 7. Entitlement to service connection for left ear hearing loss. 8. Entitlement to service connection for ocular hypertension with mild hypertensive retinopathy, glaucoma, and cataracts of the left eye (a left eye disability). 9. Service connection for a qualifying chronic disability, claimed as Gulf War Syndrome, to include weight loss, chronic fatigue syndrome, fibromyalgia, weakness in muscles and joints, chronic tremors and nervousness, brittle bones, nerve damage, and memory loss. 10. Whether new and material evidence has been received to reopen service connection for degenerative joint disease of the left knee (a left knee disability). 11. Whether new and material evidence has been received to reopen service connection for obstructive sleep apnea. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD L.M. Yasui, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from January 1969 to September 1971, and from November 1990 to June 1991. The record reflects that the Veteran had National Guard service from November 1990 to June 1991 and was ordered to active duty in support of Desert Shield/Storm under 10 U.S.C. § 672. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In October 2012, the Veteran testified in a Travel Board hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is associated with the claims file. The Board notes that other service connection claims for acquired psychiatric disabilities, to include alcohol abuse and major depression (diagnosed as dysthymic disorder), were adjudicated in the August 2010 rating decision. The Veteran did not initiate the appeals process as to those issues; therefore, the issues of service connection for an acquired psychiatric disability, other than PTSD, including alcohol abuse and major depression are not in appellate status, and are not before the Board at this time. See 38 U.S.C.A. § 7105(a) (West 2002). The Board also notes that the RO originally identified an issue on appeal as whether new and material evidence has been received to reopen service connection for restrictive lung disease with obstructive sleep apnea. In August 2010, the RO denied service connection for chronic obstructive pulmonary disease (COPD). The Veteran did not initiate the appeals process as to that issue; therefore, the issue of service connection for COPD (as a restrictive lung disease) is not in appellate status, and is not before the Board at this time. Id. In addition, in a January 2011 VA treatment report, it was noted that the Veteran's erectile dysfunction is likely secondary to vascular disease and/or neuropathy. Here, the record raises another theory of entitlement - service connection for erectile dysfunction as secondary to hypertension or neuropathy. While the Veteran is not seeking service connection on a secondary basis, all theories of entitlement - direct and secondary - must be considered. See Hodge v. West, 155 F.3d 1356, 1362-1363 (Fed. Cir. 1998) (noting that Congress expects the VA "to fully and sympathetically develop the veteran's claim to its optimum before deciding it on the merits"). As such, after reviewing the contentions and evidence of record, the Board finds that the issues on appeal are more accurately stated as listed on the title page of this decision. In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the Veteran's file on the "Virtual VA" system to ensure a complete assessment of the evidence. The issues of service connection for PTSD, hypertension, erectile dysfunction, neuropathy of the lower extremities, and a qualifying chronic disability, and new and material evidence for a left knee disability and obstructive sleep apnea are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran did not sustain an injury or disease of the brain, right knee or left ear, or experience head or acoustic trauma in service. 2. Symptoms of a subdural hematoma, a right knee disability, and left ear hearing loss were not chronic in service and were not continuous after service separation. 3. Symptoms of a subdural hematoma, a right knee disability and left ear hearing loss did not manifest to a compensable degree within one year of separation from service. 4. A subdural hematoma, a right knee disability, and left ear hearing loss are not related to an in-service injury, disease, or event. 5. The Veteran did not sustain an injury or disease of the left eye in service. 6. The current left eye disability is not related to an in-service injury, disease, or event. CONCLUSIONS OF LAW 1. The criteria for service connection for a subdural hematoma are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 2. The criteria for service connection for a right knee disability are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 3. The criteria for service connection for left ear hearing loss are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 4. The criteria for service connection for a left eye disability are not met. 38 U.S.C.A. §§ 1101, 1110, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In timely letters dated in March 2009, May 2009, October 2009, and November 2009 the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate claims for service connection, as well as what information and evidence must be submitted by the Veteran, and what evidence VA would obtain. All four letters included provisions for disability ratings and for the effective date of the claims. During the October 2012 Board hearing, to assist the Veteran, the undersigned asked questions to help direct the Veteran's testimony, and specifically advised the Veteran (see hearing transcript at 2-3) of the necessity to demonstrate evidence of some injury, disease, or event that happened in service, a currently diagnosed disability, and a relationship between service and the current disability. The undersigned also indicated that the record would be held open for 30 days in an effort to enable the Veteran to obtain additional evidence in support of his claims. These actions fulfilled the duties under 38 C.F.R. § 3.103 (2012). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). With regard to the duty to assist, VA has made reasonable efforts to obtain relevant records and evidence with respect to the issues adjudicated herein. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's post-service VA treatment records and the Veteran's statements, to include his testimony during the October 2012 Board hearing. As fully discussed in the Remand section below, the RO did not obtain the Veteran's service treatment records, both from active duty and from National Guard duty, from the NPRC, or other appropriate facility. However, with respect to the service connection claims for a subdural hematoma, a right knee disability, left ear hearing loss, and a left eye disability, the Veteran has not asserted that these disabilities had onset in service or are related to an in-service injury, disease, or event. As such, the Board finds that there is no reasonable possibility that remanding these issues would aid in substantiating these claims. See 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d). The Board nevertheless recognizes that it has a heightened duty to explain its findings and conclusions to the extent that there are, in fact, missing records, and to carefully consider the benefit-of-the-doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992). Also as discussed below, the Veteran indicated that he applied for Social Security Administration (SSA) benefits in 2009. While the Board is remanding the claims of service connection for PTSD, hypertension, erectile dysfunction, neuropathy of the lower extremities, and Gulf War Syndrome, and of new and material evidence for a left knee disability and obstructive sleep apnea, in part, to obtain any outstanding SSA records, with respect to the claims adjudicated herein, the Board does not find that these records are pertinent. In light of the Veteran's contentions that a subdural hematoma, a right knee disability, left ear hearing loss, and a left eye disability did not have onset in service or are related to an in-service injury, disease, or event, such records would not pertain to service or include an opinion of nexus to service, but would only tend to substantiate current diagnosis or show treatment for current disability, which element of the service connection claim has already been substantiated. As the additional evidence in the SSA records would only pertain to elements of service connection that have already been substantiated, there is no reasonable possibility that these records would further substantiate the claims for service connection for these claimed disorders. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) (holding that VA is not required to obtain SSA records in all cases but only where potentially relevant to the claims on appeal). For these reasons, as to the adjudicated issues of a subdural hematoma, a right knee disability, left ear hearing loss, and a left eye disability, the Board finds that obtaining service treatment records and SSA records are unnecessary, particularly in light of the fact that the Veteran has not contended that these conditions had onset in service or manifested in service. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran should be avoided). In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran has not been afforded VA medical examinations with respect to his claims of service connection for a subdural hematoma, a right knee disability, left ear hearing loss, and a left eye disability. In this case, because the weight of the evidence demonstrates that there was no injury to, or disease of, the brain, right knee, left ear, or left eye in service, and these claimed disabilities had their onset years after service separation, there is no duty to provide a VA medical examination. Additionally, the Board finds that the weight of the evidence demonstrates no chronic symptoms in service and no continuity of symptoms of a subdural hematoma, a right knee disability, or left ear hearing loss since service separation. There is no reasonable possibility that a VA examination or opinion could aid in substantiating the current claims for service connection for a subdural hematoma, a right knee disability, left ear hearing loss, and a left eye disability because there is nothing in service to which any current disabilities could be related by competent opinion. See 38 U.S.C.A. § 5103A(a)(2) (West 2002) (VA "is not required to provide assistance to a claimant . . . if no reasonable possibility exists that such assistance would aid in substantiating the claim"); 38 C.F.R. § 3.159(d) (VA to discontinue assistance where there is "no reasonable possibility that further assistance would substantiate the claim"). See also Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010) (holding that a layperson's assertions indicating exposure to gases or chemicals during service are not sufficient evidence alone to establish that such an event actually occurred during service; where the evidence has failed to establish an in-service injury, disease, or event, VA is not obligated to provide a medical examination). The Board has considered the decision in Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); however, in the absence of evidence in-service disease or injury, or even persistent symptoms of a subdural hematoma, a right knee disability, left ear hearing loss, or a left eye disability, referral of these issues to obtain an examination and/or an opinion as to the etiology of the Veteran's subdural hematoma, right knee disability, left ear hearing loss, and left eye disability would in essence place the examining physician in the role of a fact finder, would suggest reliance on an inaccurate history of occurrence of an in-service injury or disease, and could only result in a speculative opinion or purported opinion of no probative value. In other words, any medical opinion which purported to provide a nexus between the Veteran's claimed disabilities and his military service would necessarily be based on an inaccurate history regarding what occurred in service, so would be of no probative value. The Court has held on a number of occasions that a medical opinion premised upon an unsubstantiated account of a claimant is of no probative value. See, e.g., Swann v. Brown, 5 Vet. App. 229, 233 (1993) (generally observing that a medical opinion premised upon an unsubstantiated account is of no probative value, and does not serve to verify the occurrences described); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (the Board is not bound to accept a physician's opinion when it is based exclusively on the recitations of a claimant that have been previously rejected). The holding in Charles was clearly predicated on the existence of evidence of both in-service injury or event and a current diagnosis. Referral of these issues of a subdural hematoma, a right knee disability, left ear hearing loss, and a left eye disability for an examination or to obtain medical opinions would be a useless act. The duty to assist by providing a VA examination or opinion is not invoked in this case regarding the claims of a subdural hematoma, a right knee disability, left ear hearing loss, and a left eye disability because there is no reasonable possibility that such assistance would aid in substantiating these claims. See 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d). As such, the RO has provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claims. Service Connection - Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). In this case, subdural hematoma (as a brain hemorrhage), degenerative joint disease of the right knee (as arthritis), and left ear hearing loss (as an organic disease of the nervous system) are "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. 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). However, ocular hypertension with mild hypertensive retinopathy, glaucoma, and cataracts of the left eye are not "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply. Id. Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as, subdural hematoma, arthritis, or sensorineural hearing loss, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. a 303. Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A veteran as a lay person is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau at 1372). The Board notes that in cases where a veteran's service treatment records are unavailable through no fault of his own, a heightened duty exists to assist the veteran in the development of the case and to provide reasons or bases for any adverse decision rendered without these records. See O'Hare, 1 Vet App. at 365; Layno at 469. In this case, as mentioned above, the Veteran's service treatment records are not of record; however, the Veteran has not contended that the disabilities adjudicated herein had onset in service or that symptoms of those conditions manifested in service. Thus, the Board concludes that VA's heightened duty to assist the Veteran is satisfied with respect to the claims of a subdural hematoma, a right knee disability, left ear hearing loss, and a left eye disability. The Board is also mindful of the heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Service Connection for a Subdural Hematoma, a Right Knee Disability, and Left Ear Hearing Loss After a review of all the evidence, the Board first finds that the Veteran has current disabilities of a subdural hematoma, a right knee disability, and left ear hearing loss. Most recently, in a January 2011 VA treatment report, the Veteran's medical problem list included subdural hematoma, bilateral degenerative joint disease of the knees, and bilateral mixed hearing loss. Parenthetically, while it is unclear whether the Veteran has a left ear hearing loss "disability" under 38 C.F.R. § 3.385 that is required for VA disability compensation purposes, even assuming, arguendo, that the Veteran has a left ear hearing loss "disability," as fully discussed below, the evidence is against the claim of service connection for left ear hearing loss. The Board finds that the evidence of record, lay and medical, demonstrates that the Veteran did not sustain any injury or disease of the brain, right knee, or left ear in service, to include head and acoustic trauma, and that a subdural hematoma, right knee, and left ear hearing loss symptoms were not chronic in service. In fact, the Veteran himself has not claimed that these symptoms manifested in service or had onset in service. During the Board hearing before the undersigned, the Veteran testified that he could not recall a specific incident or event in service with respect to the subdural hematoma. Hearing transcript at 12. When asked to explain what happened in service to his knees, the Veteran only testified as to an injury to his left knee, not the right knee. Hearing transcript at 13. Indeed, the Veteran has consistently asserted that he sustained a left knee injury in service and yet has never contended such an injury to the right knee or symptoms of a right knee condition in service. Similarly, the Veteran testified that he first began to notice hearing loss symptoms 15 years prior to the Board hearing, which is approximately seven years after separation from active service. Id. at 17. Parenthetically, in a Gulf War examination from June 1995, the Veteran reported that he had a history of head injury; however, upon explanation, the report also indicated that the Veteran was in a motor vehicle accident as a child and hit his head on the left. Indeed, in June 1995, the examination report revealed a normal clinical evaluation of the Veteran's head and neurologic system. The Board next finds that the weight of the evidence demonstrates that subdural hematoma, a right knee disability, and left ear hearing loss symptoms have not been continuous since service separation in June 1991. As stated, the Veteran first noticed hearing loss symptoms approximately seven years after service separation. He was first diagnosed with a subdural hematoma in June 2001 and symptoms of arthritis of the knees, bilaterally, in March 2001. Importantly, the Veteran himself does not contend that a subdural hematoma, a right knee disability, or left ear hearing loss symptoms were continuous since service. Also, during the Gulf War examination in June 1995, the Veteran reported that he had a history of painful or swollen joints, and bone, joint, or other deformity; however, he did not specify which joints were painful or swollen, or which bones or joints were deformed. Regardless, the examination report indicated a normal clinical evaluation of the Veteran's lower extremities. The Board also finds that the weight of the evidence demonstrates that symptoms of a subdural hematoma, a right knee disability, or left ear hearing loss were not continuous after service, including that a subdural hematoma, a right knee disability, and left ear hearing loss did not manifest to a compensable degree within one year of service separation. The weight of the evidence demonstrates no subdural hematoma, arthritis of the right knee, or left ear hearing loss symptoms during the one year period after service, and no diagnoses or findings of subdural hematoma, arthritis of the right knee, or left ear hearing loss of any severity during the one year post-service presumptive period. See 38 C.F.R. § 4.124a, Diagnostic Code 8009 (hemorrhage from brain vessels is rated 10 percent for residuals of hemorrhage from brain vessels); see also 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012) (degenerative arthritis is rated 10 percent when there is X-ray evidence of involvement of a major joint with objective evidence of pain and noncompensable limitation of motion); see also 38 C.F.R. § 4.85, Diagnostic Code 6100 (hearing loss is rated at 10 percent when a non-service-connected ear is assigned a Roman Numeral designation for hearing impairment of I, and the service-connected ear is assigned a Roman Numeral designation for hearing impairment of X). The competent medical evidence shows the first diagnosis of a subdural hematoma in June 2001 and right knee degenerative joint disease in August 2001. The first assessment of left ear hearing loss is shown in January 2010. Also for these reasons, the Board finds that a subdural hematoma, a right knee disability, and left ear hearing loss did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for a subdural hematoma, a right knee degenerative joint disease, and left ear hearing loss as chronic conditions are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309(a). The Board finds that the weight of the evidence further demonstrates that the Veteran's subdural hematoma, right knee disability, and left ear hearing loss are not otherwise related to service. With respect to the etiology of the subdural hematoma, in a June 2001 VA treatment report, the Veteran was admitted for hospitalization for a near-syncope event. At that time, results of a magnetic resonance imaging (MRI) revealed subdural hematoma. The most recent VA treatment record from January 2011 indicated that the Veteran's subdural hematoma is secondary to head trauma from the June 2001 syncopal event. Regarding the Veteran's at least implicit assertions as to the cause of the current subdural hematoma, right knee disability, and left ear hearing loss, the Board recognizes that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, 581 F.3d at 1316 (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau, 492 F.3d at 1372.) In this case, the causes of the Veteran's subdural hematoma, right knee disability and left ear hearing loss involve complex medical etiological questions because they pertain to the origin and progression of the Veteran's brain, right knee, and left ear hearing. The Veteran is competent to relate symptoms of a subdural hematoma, a right knee disability, and left ear hearing loss that he experienced at any time, but he is not competent to opine on whether there is a link between the current subdural hematoma, right knee disability, and left ear hearing loss, and active service because such a conclusion regarding causation requires specific, highly specialized, medical knowledge and training regarding the unseen and complex processes of the brain, musculoskeletal system, and ear, knowledge of the various risk factors and causes of a subdural hematoma, arthritis, and hearing loss, specific clinical testing for a subdural hematoma, arthritis, and hearing loss that indicate onset, and knowledge of the incubation period or ranges of progression of such disorders that the Veteran is not shown to possess. See Rucker, 10 Vet. App. at 74 (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). Based on the evidence of record, the weight of the competent and credible evidence demonstrates no relationship between the Veteran's current subdural hematoma, right knee disability, and left ear hearing loss, and active duty service, including no credible evidence of chronic symptoms of a subdural hematoma, a right knee disability, and left ear hearing loss in service, of a subdural hematoma, a right knee disability, and left ear hearing loss to a compensable (10 percent) degree within one year of service separation, or continuity of symptomatology of a subdural hematoma, a right knee disability, and left ear hearing loss since service that would serve either as a nexus to service or as the basis for a medical nexus opinion. Charles, 16 Vet. App. at 374. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claims for service connection for a subdural hematoma, a right knee disability, and left ear hearing loss, including presumptively as chronic diseases, and the claims must be denied. Because the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for a Left Eye Disability The Veteran contends that he has a vision disorder that is related to service, although he did not claim service connection for a vision disorder when he first filed a claim for VA compensation in January 2005, or during subsequent claims for service connection in January 2008, February 2009, March 2009, and April 2009. It was not until May 2009 that he added visual loss in the left eye as a claimed disorder for which he was seeking service connection. After a review of all the evidence, the Board first finds that the Veteran has a current disability of the left eye. Most recently, in a January 2011 VA treatment report, the Veteran's medical problem list included glaucoma and cataracts of the eyes. The Board finds that the evidence of record, lay and medical, demonstrates that the Veteran did not sustain any injury or disease of the left eye in service. In fact, the Veteran himself has not claimed that these symptoms manifested in service or had onset in service. During the Board hearing before the undersigned, when asked to explain what happened in service regarding this current left eye condition, the Veteran was mostly unresponsive and could not recall details regarding the claimed eye disability and service. Hearing transcript at 15-16. Indeed, the Veteran has not asserted that there was any injury, disease, or symptoms of a left eye disability in service. The Board notes that there are no post-service treatment records indicating complaints of, diagnosis of, or treatment for, a left eye disability (specifically, ocular hypertension with mild hypertensive retinopathy of the eyes) until November 2003. The absence of post-service complaints, findings, diagnosis, or treatment of a left eye disability after service for over a decade until 2003 is one factor, considered in addition to the other factors stated in this decision, that tends to weigh against the Veteran's claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is one factor that tends to weigh against a claim for service connection). Importantly, in this case, the Veteran has not asserted that he has had left eye disability symptoms since service separation. The Board finds that the weight of the evidence further demonstrates that the Veteran's left eye disability is not related to service. Regarding the Veteran's at least implicit assertion regarding the relationship between his service and his current left eye disability, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, he is not shown to be competent to render medical opinions on such complex disorders as ocular hypertension with mild hypertensive retinopathy, glaucoma, and cataracts. See Jandreau at 1372; see also Barr at 303 (lay testimony is competent to establish the presence of observable symptomatology). As such, as a lay person, he is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the etiology of a specific condition. As to the specific issue in this case, the etiology of a left eye disability falls outside the realm of common knowledge of a lay person. See Jandreau at 1377 n.4 (lay persons not competent to diagnose cancer)." Such disorders of the eye, including ocular hypertension with mild hypertensive retinopathy, glaucoma, and cataracts, are diagnosed not by symptoms alone but by specialized testing such as eye examinations or other testing, is not diagnosed only on symptoms, such as fuzzy vision, to which a lay person is competent to report, and rendering an etiology opinion would require knowledge of the various causes or risk factors for ocular hypertension with mild hypertensive retinopathy, glaucoma, and cataracts, and knowledge of periods of incubation or progression of disease processes. The question of causation, in this case, involves a complex medical question that the Veteran is not competent to address. Jandreau at 1372. As such, his lay opinion does not constitute competent medical evidence and lacks probative value. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a). Based on the evidence of record, there is no competent or credible evidence of a relationship between the Veteran's current left eye disability and active duty service. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a left eye disability and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for a subdural hematoma is denied. Service connection for a right knee disability is denied. Service connection for left ear hearing loss is denied. Service connection for a left eye disability is denied. REMAND A remand is required in this case to ensure that there is a complete record upon which to decide the Veteran's claims of service connection for PTSD, hypertension, erectile dysfunction, neuropathy of the lower extremities, and a qualifying chronic disability, and claims to reopen service connection based on new and material evidence for a left knee disability and obstructive sleep apnea. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2002); 38 C.F.R.§ 3.159(c), (d) (2012). With respect to these remanded issues, in contrast to the issues adjudicated above, the Veteran has contended that these conditions had onset in service and are related to his military service. During the October 2012 Board hearing, the Veteran testified that, while in Korea (between January 1969 to September 1971), he experienced two stressors that he alleges caused his claimed PTSD (see full discussion below). Hearing transcript at 5-8. He also alleged that his hypertension had onset during active service due to the stress he experienced in Korea. Id. at 15. As to the left knee disability, the Veteran stated that he testified that he first injured the left knee while in the National Guard in 1985 or 1986 during leadership school training, and reinjured it a few weeks later. Id. at 13-14. He also testified that his obstructive sleep apnea symptoms had onset in 1991, while in service, and noticed breathing problems. Shortly after he returned from active service in 1991, the Veteran sought treatment for sleep apnea. Id. at 18. While the Veteran's dates of active service are of record (from January 1969 to September 1971, including an order to active duty from November 1990 to June 1991 in the Army National Guard), it appears that the Veteran has had other periods of National Guard service. As noted above, the Veteran testified that he first injured the left knee while in the National Guard in 1985 or 1986 during leadership school training, and reinjured it a few weeks later. It appears that the RO did not attempt to obtain the Veteran's service treatment records during his National Guard Service. Additionally, an attempt was made to the Records Management Center to obtain the Veteran's service treatment records during his periods of active service (from January 1969 to September 1971, and from November 1990 to June 1991); however, no attempts were made to procure these records from the National Personnel Records Center (NPRC), or other appropriate government entity. There is no formal finding of record regarding the unavailability of the Veteran's service treatment records, including the efforts made in order to obtain the service treatment records. VA's duty to assist the Veteran particularly applies to relevant evidence known to be in the possession of the Federal Government, such as VA or Social Security records. See 38 C.F.R. § 3.159(c)(2) (2012). Also in this regard, SSA records are relevant to a claim and VA must obtain them where either (1) there is an SSA decision pertaining to a medical condition related to the one for which the veteran is seeking service connection or (2) there are specific allegations "giv[ing] rise to a reasonable belief" that the SSA records may pertain to the claimed disability. Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010). Here, the Veteran testified that in 2009, he applied for SSA benefits. Hearing transcript at 16. It is unclear from his testimony whether the SSA disabilities for which he applied are the same as the conditions claimed for VA compensation purposes. Id. The Veteran stated "that's when I applied for Social Security disability and I applied for these things that's wrong with me in the military." The SSA records are potentially pertinent to the Veteran's claims (service connection for PTSD, hypertension, erectile dysfunction, neuropathy of the lower extremities, and a qualifying chronic disability, and new and material evidence for a left knee disability and obstructive sleep apnea) because the disabilities that gave rise to SSA disability are not indicated; therefore, in this regard, the significance of the SSA records, including whether they involve the remanded claims, cannot be determined. Accordingly, upon remand, the RO should attempt to obtain a copy of any decision granting or denying SSA disability benefits and all supporting medical documentation. As to the PTSD claim, the record reflects that the Veteran has been treated by VA for PTSD; however, it is unclear whether the Veteran has a diagnosis of PTSD for VA compensation purposes. See 38 C.F.R. § 3.304(f); see also 38 C.F.R. § 4.125(a) (2012) (stating that the diagnosis of PTSD must comply with the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, of the American Psychiatric Association (DSM-IV). Establishing service connection for PTSD requires specific findings. These are (1) a current medical diagnosis of PTSD; (2) credible supporting evidence that the claimed in- service stressor actually occurred; and (3) medical evidence of a causal nexus between current symptomatology and the specific claimed in- service stressor. See 38 C.F.R. § 3.304(f) (2012). During the pendency of this appeal, the regulations applicable to service connection for PTSD have been amended. Specifically, effective July 13, 2010, VA amended 38 C.F.R. § 3.304(f) by liberalizing, in certain circumstances, the evidentiary standards for establishing the occurrence of an in-service stressor for non-combat Veterans. See 75 Fed. Reg. 39,843 -39,852 (effective July 13, 2010). Previously, VA was required to undertake extensive development to determine whether a non-combat Veteran actually experienced the claimed in-service stressor and lay testimony, by itself, was not sufficient to establish the occurrence of the alleged stressor. Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Instead, credible supporting evidence of a corroborated in-service stressor was required. Credible supporting evidence was not limited to service department records, but could be from any source. See YR v. West, 11 Vet. App. 393, 397 (1998); see also Moreau v. Brown, 9 Vet. App. 389, 395 (1996). Further, credible supporting evidence of the actual occurrence of an in-service stressor could not consist solely of after-the-fact medical nexus evidence. See Moreau, 9 Vet. App. at 396. The amended version of 38 C.F.R. § 3.304(f)(3) eliminated the need for stressor corroboration in circumstances in which the service member's claimed in-service stressor is related to "fear of hostile military or terrorist activity." Specifically, the amended version of 38 C.F.R. § 3.304(f)(3) states that, if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See 38 C.F.R. § 3.304 (f)(3) (2012). In this case, there is no evidence of record that the Veteran engaged in combat with the enemy, nor does he so contend. In addition, his alleged in-service stressors have not been corroborated. However, the Veteran has presented statements concerning his in-service stressors. During the October 2012 Board hearing, the Veteran testified that while in Korea, he was ordered to transport an ordnance for destruction. During transport, in a jeep, a fellow serviceman who was carrying the ordnance fell out of the jeep with the ordnance as the driver was driving faster than he should have been. The Veteran testified that he did not know whether the ordnance would go off and stated that it, "scare me so bad. It scared me extremely bad. And it stayed with me." Hearing transcript at 6-7. The Veteran also testified that, also while in Korea, he was involved in a motor vehicle accident, which also scared him. Id. at 8. In his February 2009 informal claim for service connection, the Veteran stated that while in Saudi Arabia in the 176 Engineer unit he witnessed dead bodies, some of which were dismembered. In an April 2009 statement, the Veteran alleged that while in Saudi Arabia he witnessed a fellow serviceman picked up a hand grenade that he believed was safe as a souvenir. The Veteran reported that the grenade was live and, when he was startled, the serviceman dropped the grenade, which exploded. The Veteran asserted that the serviceman and a few others were injured. These experiences, particularly his claimed stressor involving the ordnance and grenade, appear to meet the new criteria that the Veteran must have experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device. Accordingly, in light of the amendment to VA regulations discussed above, a remand is necessary to afford the Veteran a VA examination with a VA psychiatrist or psychologist or a psychiatrist or psychologist with whom VA has contracted. With respect to the claim for a qualifying chronic disability, claimed as Gulf War Syndrome, to include weight loss, chronic fatigue syndrome, fibromyalgia, weakness in muscles and joints, chronic tremors and nervousness, brittle bones, nerve damage, and memory loss, the Veteran was afforded a Gulf War examination in June 1995, nearly 15 years prior to his claim for service connection. The Board finds, however, that a new VA Gulf War examination is warranted. Service connection may be established on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that 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, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317(a)(1) (2012) (VA has issued an interim final rule extending this date to December 31, 2016). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Guiterrez v. Principi, 19 Vet. App. at 8-9. Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more, the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location, or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-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 became manifest. 38 C.F.R. § 3.317(a)(4) . "Objective indications of 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. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). The term "Persian Gulf Veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(e)(2). The Persian Gulf War period runs from August 2, 1990, and ending on the date thereafter prescribed by Presidential proclamation or by law. 38 U.S.C.A. § 101(33). In this case, personnel records reflect that that the Veteran has confirmed service in Southwest Asia from December 1990 to May 1991. As such, he has qualifying service in the Southwest Asia theater of operations as defined by 38 C.F.R. § 3.317 as a "Persian Gulf veteran." With respect to the Veteran's chronic fatigue syndrome and fibromyalgia service connection claims, which are examples of medically unexplained chronic multisymptom illnesses, the Board finds the June 1995 Gulf War examination inadequate. For VA purposes, a diagnosis of chronic fatigue syndrome requires: (1) the new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least 6 months, and (2) the exclusion, by history, physical examinations, and laboratory tests, of all other clinical conditions that may produce similar symptoms, and (3) 6 or more of the following: (i) acute onset of the condition, (ii) low grade fever, (iii) nonexudative pharyngitis, (iv) palpable or tender cervical or axillary lymph nodes, (v) generalized muscle aches or weakness, (vi) fatigue lasting 24 hours or longer after exercise, (vii) headaches (of a type, severity or pattern that is different from headaches in the pre-morbid state), (viii) migratory joint pains, (ix) neuropsychologic symptoms, and (x) sleep disturbance. 38 C.F.R. § 4.88a. Here, while the Veteran's records repeatedly indicate a complaint of fatigue, they do not indicate whether the Veteran has chronic fatigue syndrome for VA compensation purposes. While the June 1995 Gulf War examiner did not render a diagnosis of chronic fatigue syndrome, he made no findings regarding attribution of complaints of fatigue to a known diagnosis, or whether such complaints constitute a chronic disability. In sum, there is competent evidence of current chronic fatigue that has not been attributed to a specific known diagnosis, and that may be attributed to an undiagnosed illness. As such, a medical opinion is necessary. The Board also observes that, in this case, the Veteran has been shown to have two or more signs or symptoms that may be manifestations of an undiagnosed illness or a medically unexplained chronic multi-symptom illness. These include weight loss, weakness in muscles and joints, chronic tremors and nervousness, brittle bones, nerve damage, and memory loss. The June 1995 Gulf War examiner gave provisional diagnoses of fatigue, transient ischemic attack versus reversible ischemic neurologic defect, insomnia, right lateral epicondylitis (an elbow disability for which the Veteran does not currently claim), and possible high blood pressure; however, results of a chest X-ray revealed a normal heart, and no radiographic evidence for acute cardiopulmonary disease. In addition, a neurologic examination was normal. The June 1995 Gulf War examiner made no findings regarding whether such complaints of weight loss, weakness in muscles and joints, chronic tremors and nervousness, brittle bones, nerve damage, and memory loss constitute a qualifying chronic disability. While the etiology of these symptoms may be suggested by the record, the Board is not free to substitute its own judgment for that of an expert. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Indeed, when the medical evidence of record is insufficient, in the opinion of the Board, or of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions. Id; see also Hatlestad v. Derwinski, 3 Vet. App. 213 (1992); see also 38 C.F.R. § 3.159(c)(4) (a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim). Additionally, the outcome of the claims for service connection for erectile dysfunction, to include as secondary to hypertension or neuropathy of the lower extremities, and neuropathy of the lower extremities, to include as secondary to left and right knee disabilities, or in the alternative, as due to a qualifying chronic disability, could be affected by the results of the development ordered on remand. Thus, the erectile dysfunction and neuropathy of the lower extremities claims are inextricably intertwined, and the proposed development will encompass those issues. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). Accordingly, the issues of service connection for PTSD, hypertension, erectile dysfunction, neuropathy of the lower extremities, and a qualifying chronic disability, and new and material evidence for a left knee disability and obstructive sleep apnea are REMANDED for the following action: 1. Contact the Veteran and request information regarding dates and specific information pertaining to his National Guard Service. Request any information regarding the Veteran's dates of service in the National Guard, to include all periods of ACDUTRA or INACDUTRA, and the specific unit(s) to which the Veteran was assigned. 2. Then, attempt to verify the dates of the Veteran's service in the National Guard, to include all the periods of ACDUTRA and INACDUTRA. If such verification of National Guard, ACDUTRA, or INACDUTRA service is unobtainable, a negative reply must be noted in writing and associated with the claims file. 3. Request all service treatment records for the Veteran's service with the National Guard from the NPRC and any other appropriate source, to include the headquarters of the National Guard with which the Veteran served. All requests for records and their responses should be associated in the claims folder. Any records obtained should be associated with the claims file. 4. Request all service treatment records for the periods of the Veteran's verified active duty service (from January 1969 to September 1971 and from November 1990 to June 1991) from the NPRC and any other appropriate source. All requests for records and their responses should be associated in the claims folder. Any records obtained should be associated with the claims file. 5. Obtain a copy of any SSA decision awarding or denying disability benefits for the Veteran, copies of all medical records upon which any such SSA disability benefit award was based, and a copy of any medical records associated with any subsequent disability determinations by the SSA for the Veteran. All requests for records and their responses should be associated in the claims folder. Any records obtained should be associated with the claims file. 6. Notify the Veteran, in accordance with 38 C.F.R. § 3.159(e), if the service treatment records (both from active duty and National Guard service) and/or SSA records are unavailable. 7. After the above actions have been completed, schedule the Veteran for a VA psychiatric (mental disorders) examination to assist in determining whether there is PTSD and, if so, the etiology of PTSD. The relevant documents in the claims file should be made available to the VA examiner. The examiner (a VA psychiatrist or psychologist or a psychiatrist or psychologist with whom VA has contracted) should note the diagnosis of PTSD if it complies with the criteria set forth in the DSM-IV. If the Veteran does not have a diagnosis of PTSD that complies with the criteria set forth in the DSM-IV, the examiner should so explicitly state. Following the examination, if there is a diagnosis of PTSD, the VA examiner is asked to render an opinion as to whether it is at least as likely as not (fifty percent or greater) that: a) the Veteran experienced, witnessed, or was confronted by an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, and the Veteran's response to that event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror; b) that the claimed stressor is adequate to support a diagnosis of PTSD; and c) that the Veteran's PTSD symptoms are related to the claimed stressor; and d) whether any currently diagnosed PTSD first manifested during the Veteran's periods of active service from January 1969 to September 1971 and from November 1990 to June 1991, and/or (if possible) whether any currently diagnosed PTSD is causally related to events during a period of active service. The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. A rationale should be given for all opinions and conclusions rendered. The opinions should address the particulars of this Veteran's medical history and the relevant medical science as applicable to this claim. If an opinion cannot be rendered without resorting to speculation, the examiner should state whether the inability to provide an opinion was due to a need for further information (with said needed information identified) or because the limits of medical knowledge had been exhausted regarding the etiology of the disorder. 8. Schedule the Veteran for an appropriate VA examination to assist in determining the nature and etiology of his complaints of weight loss, chronic fatigue syndrome, fibromyalgia, weakness in muscles and joints, chronic tremors and nervousness, brittle bones, nerve damage, and memory loss. The examination should conform to the guidelines for conducting Gulf War examinations set forth in the Under Secretary for Health's Information Letter, dated April 28, 1998 (IL 10-98- 010). The purpose of the examination is to obtain information as to the nature and etiology of claimed symptoms. The relevant documents in the claims file should be made available to the VA examiner. All necessary tests should be accomplished. After the review of the claims file, an interview with the Veteran, a physical examination, and any further development as deemed appropriate, the VA examiner should render diagnoses that correlate with the reported symptoms of weight loss, fatigue, weakness in muscles and joints, chronic tremors and nervousness, brittle bones, nerve damage, and memory loss (to the extent possible), then offer the following opinions: a) Does the Veteran have a diagnosis of chronic fatigue syndrome under VA regulation? See 38 C.F.R. § 4.88a. If chronic fatigue syndrome is diagnosed, has it existed for six months or more? b) Does the Veteran have a diagnosis of fibromyalgia? If fibromyalgia is diagnosed, has it existed for six months or more? c) Are the Veteran's claimed weight loss, fatigue, weakness in muscles and joints, chronic tremors and nervousness, brittle bones, nerve damage, and memory loss associated with a diagnosable illness? d) If the symptomatology is attributable to a known clinical diagnosis, is it as least as likely as not (50 percent or greater likelihood) that the Veteran's clinically diagnosed disabilities (manifested by weight loss, fatigue, weakness in muscles and joints, chronic tremors and nervousness, brittle bones, nerve damage, and memory loss) are related to service? e) If the Veteran's weight loss, fatigue, weakness in muscles and joints, chronic tremors and nervousness, brittle bones, nerve damage, and memory loss are not due to a specific disease entity, do they represent an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's Persian Gulf War service, or a medically unexplained chronic multisymptom illness, which is defined by a cluster of signs or symptoms, as detailed above? The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. A rationale should be given for all opinions and conclusions rendered. The opinions should address the particulars of this Veteran's medical history and the relevant medical science as applicable to this claim. If an opinion cannot be rendered without resorting to speculation, the examiner should state whether the inability to provide an opinion was due to a need for further information (with said needed information identified) or because the limits of medical knowledge had been exhausted regarding the etiology of the disorder. 9. After completion of the above and any additional development deemed necessary, such as a VA examination, the claims for service connection for service connection for PTSD, hypertension, erectile dysfunction, neuropathy of the lower extremities, and a qualifying chronic disability, and new and material evidence for a left knee disability and obstructive sleep apnea, should be readjudicated in light of all the evidence of record. If the determination remains adverse to the Veteran, he and his representative should be furnished with a Supplemental Statement of the Case. An appropriate period of time should then be allowed for a response before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs