Citation Nr: 1324911 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 10-29 712 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Whether a previously denied claim for service connection for chronic fatigue syndrome should be reconsidered. 2. Whether a previously denied claim for service connection for suprapatellar ligament calcification should be reconsidered. 3. Whether a previously denied claim for service connection for a disability characterized by upper extremity and waist pain should be reconsidered. 4. Entitlement to service connection for bilateral hearing loss. 5. Entitlement to service connection for chronic fatigue syndrome. 6. Entitlement to service connection for a knee disorder, to include suprapatellar ligament calcification, claimed as leg pain. 7. Entitlement to service connection for a disability characterized by upper extremity and waist pain, to include a wrist disorder, claimed as arm pain. 8. Entitlement to service connection for a respiratory condition, to include as due to undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C.A. § 1117. 9. Entitlement to service connection for erectile dysfunction. REPRESENTATION Veteran represented by: Alberto Torrado Delgado, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from September 1962 to September 1964, and from September 1990 to May 1961, including service in the Persian Gulf in support of Operations Desert Shield/Desert Storm, with subsequent Reserve service. This appeal to the Board of Veterans' Appeals (Board) arose from a December 2008 rating decision in which the RO denied the Veteran's claims for service connection for bilateral hearing loss, erectile dysfunction and a respiratory condition. In addition, his requests to reopen his claims for service connection for chronic fatigue syndrome, suprapatellar ligament calcification and upper extremity and waist pain were denied. In December 2009, the Veteran filed a notice of disagreement (NOD). The RO issued a statement of the case (SOC) in June 2010, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in July 2010. In January 2011, the Veteran testified before the undersigned at a hearing (Travel Board) at the RO. A transcript of that hearing has been associated with the claims file. Subsequent to the January 2011 hearing, the Veteran submitted additional evidence in support of his claims. The Veteran's representative submitted a waiver of initial RO consideration of this evidence in April 2011. See 38 C.F.R. §§ 20.800, 20.1304 (2012). A review of the paperless, electronic (Virtual VA) claims processing system reveals additional adjudicatory documents pertinent to the claims on appeal, to include a December 2012 rating decision. As a final preliminary matter, the Board notes that a December 2012 rating decision granted the Veteran's claim for service connection for an acquired psychiatric disorder, namely depressive disorder, and assigned a total initial rating. As the December 2012 decision represents a full grant of the benefits sought with respect to this issue, this matter is no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). The Board's decision addressing granting reconsideration of the Veteran's claims for service connection for chronic fatigue syndrome, suprapatellar ligament calcification and a disability characterized by upper extremity and waist pain as well as his claim for service connection for hearing loss is set forth below. The remaining claims on appeal are addressed in the remand following the order; this matter is being remanded to the RO, via the Appeals Management Center (AMC), in Washington, D.C. VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the matters herein decided have been accomplished. 2. In a February 2004 rating decision, the RO denied service connection for chronic fatigue syndrome, claimed as general body tardiness; although notified of the denial in a March 2004 letter, the Veteran did not initiate an appeal. 3. New evidence associated with the claims file since the February 2004 denial of the claim for service connection for chronic fatigue syndrome includes relevant official service department records not previously considered. 4. In a February 2004 rating decision, the RO denied service connection for suprapatellar ligament calcification, claimed as lower extremity (knee) pain; although notified of the denial in a March 2004 letter, the Veteran did not initiate an appeal. 5. New evidence associated with the claims file since the February 2004 denial of the claim for service connection for suprapatellar ligament calcification includes relevant official service department records not previously considered. 6. In a February 2004 rating decision, the RO denied service connection for upper extremity and waist pain; although notified of the denial in a March 2004 letter, the Veteran did not initiate an appeal. 7. New evidence associated with the claims file since the February 2004 denial of the claim for service connection for upper extremity and waist pain includes relevant official service department records not previously considered. 8. Although no specific incident of acoustic trauma is reflected in the Veteran's service treatment records, the Veteran's assertions of in-service noise exposure are credible and consistent with the circumstances of his service. 9. The Veteran currently has bilateral hearing loss to an extent recognized as a disability for VA purposes, and competent opinion evidence indicates that there is at least as likely as not a relationship between the current bilateral hearing loss and in-service noise exposure. CONCLUSIONS OF LAW 1. As evidence received since the RO's unappealed February 2004 denial includes service department records not previously considered, the criteria for reconsideration of the claim for service connection for chronic fatigue syndrome are met. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2012). 2. As evidence received since the RO's unappealed February 2004 denial includes service department records not previously considered, the criteria for reconsideration of the claim for service connection for suprapatellar ligament calcification, claimed as lower extremity pain, are met. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2012). 3. As evidence received since the RO's unappealed February 2004 denial includes service department records not previously considered, the criteria for reconsideration of the claim for service connection for upper extremity and waist pain are met. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2012). 4. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for a bilateral hearing loss are met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Given the Board's favorable disposition of the decision to reconsider the claims for service connection for chronic fatigue syndrome, suprapatellar ligament calcification and upper extremity and waist pain, as well as his claim for service connection for bilateral hearing loss, the Board finds that all notification and development actions needed to fairly adjudicate these matters have been accomplished. II. Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or from aggravation of a preexisting injury suffered or disease contracted in line of duty. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). With respect to the Veteran's Reserve service, the applicable laws and regulations permit service connection only for disability resulting from disease or injury incurred or aggravated while performing active duty for training (ACDUTRA) or for injury incurred or aggravated while performing inactive duty training (INACDUTRA). See 38 U.S.C.A. § 101(22), (24); 38 C.F.R. § 3.6. In order to establish service connection on a direct basis, there must be competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). See also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The determination as to whether elements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Certain chronic diseases, including organic diseases of the nervous system (interpreted to include sensorineural hearing loss), shall be presumed to have been incurred in service if manifested to a compensable degree within a prescribed period post service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit recently clarified that the provisions of 38 C.F.R. § 3.303(b) pertaining to the award of service connection on the basis of continuity of symptomatology, alone (in lieu of a medical nexus opinion) is limited to chronic diseases as defined in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Persian Gulf Veteran is defined as a veteran who served on active duty in the Armed Forces in the Southwest Asia Theater of operations during the Persian Gulf War. See 38 U.S.C.A. § 1117(f); 38 C.F.R. § 3.317(d). Under 38 U.S.C.A. § 1117(a)(1), compensation is warranted for a Persian Gulf veteran who exhibits objective indications of a 'qualifying chronic disability' that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. A "qualifying chronic disability" includes (a) undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. At the time the Veteran filed his claim for benefits, 38 C.F.R. § 3.317(a)(1)(i) listed the cutoff date for manifesting such a disability as December 31, 2011; that date has subsequently been extended to December 31, 2016. See Extension of Statutory Period for Compensation for Certain Disabilities Due to Undiagnosed Illnesses and Medically Unexplained Chronic Multi-Symptom Illnesses, 76 Fed. Reg. 81,834 -81,836 (Dec. 29, 2011) (now codified at 38 C.F.R. § 3.317(a)(1)(i)) (2012). For purposes of 38 U.S.C.A. § 1117, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a), (b). Specific to claims for service connection, impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000 or 4000 Hertz is 40 decibels of greater; the thresholds for at least three of these frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. A. Chronic Fatigue Syndrome, Suprapatellar Ligament Calcification and Upper Extremity and Waist Pain The Veteran's initial claims for service connection for chronic fatigue syndrome, suprapatellar ligament calcification and upper extremity and waist pain were denied in a February 2004 rating decision. The evidence of record at the time included the Veteran's service treatment records and VA treatment records dated through September 2003, which were silent for any complaints, diagnosis, or treatment for chronic fatigue syndrome, a knee disorder or an upper extremity disorder. Also of record were VA examinations dated in December 2003, which indicated that the Veteran's symptoms did not meet the requirements for a chronic fatigue syndrome diagnosis and contained a diagnosis of left knee suprapatellar ligament calcification. The basis for the RO's March 2004 denial was that the record did not document a diagnosis of chronic fatigue syndrome or a disability characterized by upper extremity and waist pain. It also found that the evidence of record was insufficient to demonstrate a relationship between the Veteran's diagnosed suprapatellar ligament calcification and service. Although notified of the denial in an April 2004 letter, the Veteran did not initiate appeals of the March 2004 RO decision denying service connection for chronic fatigue syndrome, suprapatellar ligament calcification and upper extremity and waist pain. Typically, this fact would render the decision final as to the evidence then of record, and not subject to revision on the same factual basis. See 38 U.S.C.A. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. Under such circumstances, VA could only reopen and review such claim if new and material evidence is submitted by or on behalf of the Veteran. See 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a); see also Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). However, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim, notwithstanding the requirement that new and material evidence must first be received. 38 C.F.R. § 3.156(c). In this case, additional evidence was associated with the claims file following the March 2003 denial-namely, official service department records-that are relevant to the Veteran's present claims on appeal. Such records, which include the Veteran's service treatment records from the Veteran's second period of active duty service as well as his service in the Reserves. Such records reflect that the Veteran sustained a trauma to his right wrist during a period of "active training" in July 1988 and complaints of left knee pain in July 1988. This additional evidence is relevant to the matters under consideration, as it documents possible in-service injury and complaints. Here, although it is not clear exactly when the treatment records related to the Veteran's second period of service as well as his Reserves service were first received by VA, these documents were listed as evidence in the December 2012 rating decision and were submitted by the Veteran following his January 2011 hearing. As, pursuant to 38 C.F.R. § 3.156(c), these additional service records received require reconsideration of the claims for service connection, analysis of the claims in light of 38 C.F.R. § 3.156(a) is unnecessary. [The Board further notes, parenthetically, that if the reconsidered claim is ultimately granted all or in part on the basis of the additional service records received, the effective date of such award is the date entitlement arose, or the date of receipt of the previously denied claim, whichever is later. See 38 C.F.R. § 3.156(c)(iii)(3).] B. Hearing Loss The Veteran contends that his current hearing loss is related to his exposure to noise during his service, including noise exposure from heavy machines and the infantry. In the present case, the Veteran's service treatment records do not reflect audiometric testing results indicating that the Veteran had hearing loss to an extent recognized as a disability for VA purposes. The Veteran's September 1962 entrance examination report reflects no audiometric findings. The Veteran's July 1964 separation examination report indicates audiometric findings that were within normal limits. While still relevant to the current appeal, the Board notes that the absence of in-service evidence of a hearing loss disability is not fatal to a claim for service connection. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). In this regard, evidence of a current hearing loss disability (i.e., one meeting the requirements of section 3.385, as noted above) and a medically sound basis for attributing such disability to service may serve as a basis for a grant of service connection for hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993); see also 38 C.F.R. § 3.303(d). After filing his August 2008 claim for service connection for hearing loss, the Veteran was evaluated by an audiologist in May 2011. Testing performed at the examination showed that the Veteran has bilateral hearing loss that meets the criteria for a hearing loss disability. See 38 C.F.R. § 3.385. Specifically, testing revealed pure tone thresholds at 30 decibels or greater in all relevant frequencies in both the right and left ears (even though speech recognition testing revealed speech recognition ability of 100 percent in both al ears). Therefore, inasmuch as the Veteran has demonstrated that he has a current bilateral hearing loss disability, the relevant inquiry is whether such hearing loss may be etiologically linked to some event, injury, or disease incurred in or aggravated by service. First, addressing the matter of in-service injury, the Board notes that the Veteran's service treatment records do not document the occurrence of, or treatment for, any specific incident of acoustic trauma. However, the Veteran is competent to assert the occurrence of an in-service injury, to include in-service noise exposure. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1991). The Board notes that the Veteran's Form DD-214 shows that his military occupational specialty was heavy weapons infantryman and that he served in the United States Army Pacific (USARPAC) for more than one year. In addition, his second From DD-214 shows that his military occupational specialty was fabric repair specialist, that he served in support of combat operations in Southwest Asia for approximately six months and that he had earned a Marksman badge for the M-1/Cal 30. Given the circumstances of the Veteran's duties in service, the Board finds that he was likely exposed to some noise in service. Thus, although there is no objective evidence to support a specific incident of acoustic trauma in service, the Board accepts the Veteran's assertions of in-service noise exposure as credible and consistent with the circumstances of his service. See 38 U.S.C.A. § 1154. Turning to the issue of whether the Veteran's current hearing loss is related to in-service noise exposure, the Board notes the opinion of the May 2011 VA examiner, who opined that the Veteran's hearing loss was at least as likely as not related to his service. The examiner further opined that the Veteran had a presenting history of fluctuating hearing loss for many years and that he had been exposed to significant high intensity noise levels, which were known to cause damage to inner ear structures. This is the only etiological opinion of record. In sum, the Veteran has current bilateral hearing loss to an extent recognized as a disability for VA purposes, likely in-service noise exposure, and a medical opinion indicating that the evidence on the question of whether there exists a medical nexus between current bilateral hearing loss and in-service noise exposure is, at least, in relative equipoise. While the examiner's clearly was based in part, upon the Veteran's unsubstantiated assertions, such is significant only if the Board rejects such assertions as not credible (which is not the case here). Moreover, although the opinion is not definitive, it was written in terms sufficient to permit application of the benefit-of-the-doubt doctrine. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. See 38 C.F.R. § 3.102. See also 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Therefore, given the facts of this case, and resolving all reasonable doubt in the Veteran's favor, the Board concludes that the criteria for service connection for bilateral hearing loss are met. ORDER The request to reconsider the claim for service connection for chronic fatigue syndrome is granted. The request to reconsider the claim for service connection for suprapatellar ligament calcification is granted. The request to reconsider the claim for service connection for upper extremity and waist pain is granted. Service connection for bilateral hearing loss is granted, subject to the legal authority governing the payment of VA compensation. REMAND The Board's review of the claims file reveals that further RO action on the remaining claims on appeal is warranted. The Veteran has submitted copies of his service treatment records, including records from his period of Reserve service, and which suggest that he may have sustained injuries during a period of ACDUTRA. On remand, the RO/AMC should attempt to verify all periods of ACDUTRA and INACDUTRA. The RO/AMC is reminded that, in requesting records from Federal facilities, efforts to assist should continue until either the records are obtained, or sufficient evidence indicating that the records sought do not exist, or that further efforts to obtain those records would be futile, is received. See 38 C.F.R. 3.159(c)(2). If the Veteran's periods of ACDUTRA and INACDUTRA are unverifiable, such a fact should be documented in the record. The Veteran has asserted that he sustained a knee injury and a wrist injury during service, resulting in his current left knee and wrist disorder. He has also alleged that his in-service penis lesions and warts resulted in his current erectile dysfunction. The Board notes that the Veteran's service treatment records document complaints of venereal warts and lesions on his foreskin in June and July 1963, that he sustained an injury to his right wrist in July 1988 and that he complained of left knee pain in July 1988 and October 1990. The Board also notes that a November 2012 VA examiner provided an etiological opinion as to the relationship between the Veteran's erectile dysfunction and fibromyalgia only. In addition, although the Veteran has reported respiratory symptoms, the clinical evidence does not reflect a currently diagnosed respiratory disorder. As previously indicated, the Veteran had documented service in Southwest Asia and consideration of the provisions of 38 U.S.C. § 1117(a)(1), for objective indications of a qualifying chronic disability, is warranted. In addition, although the December 2003 and August 2008 VA examiners found that the Veteran's symptoms did not meet the diagnostic criteria for chronic fatigue syndrome, a private physician issued such a diagnostic impression in January 2005. On remand, the Veteran should be afforded a VA Gulf War examination to determine whether his reported symptoms were attributable to a known clinical diagnosis, to include chronic fatigue syndrome, and to provide an etiological opinion for each diagnosed condition. Accordingly, and given the other development being accomplished, the Board finds that further medical opinion with sufficient findings-based on full consideration of the Veteran's documented medical history and assertions, and supported by a thorough, clearly-stated rationale-is needed to resolve the claims for service connection for chronic fatigue syndrome, a respiratory disorder, a knee disorder, a wrist disorder, and erectile dysfunction. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006). Hence, the RO/AMC should arrange for the Veteran to undergo VA orthopedic, genitourinary and Gulf War examinations, each by an appropriate medical professional, at a VA medical facility. The Veteran is hereby notified that failure to report to any scheduled examination, without good cause, may result in denial of the claim(s) for service connection. See 38 C.F.R. § 3.655 (2012). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. If the Veteran fails to report to any scheduled examination(s), the RO/AMC should obtain and associate with the claims file (a) copy(ies) of the notice(s) of the date and time of the examination sent to him by the pertinent VA medical facility. As regards VA records, the claims file currently includes outpatient treatment records from the VA Medical Center (VAMC) in San Juan, Puerto Rico dated through May 2011. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). To ensure that all outstanding VA records are obtained, the RO/AMC should obtain from the San Juan VAMC all pertinent, outstanding records of evaluation and/or treatment of the Veteran since May 2011, following the current procedures prescribed in 38 C.F.R. § 3.159(c) with regard to requests for records from Federal facilities. Prior to obtaining further opinions, to ensure that all due process requirements are met and the record is complete, the RO/AMC should give the Veteran another opportunity to provide information and/or evidence pertinent to the claim on appeal. The RO/AMC's letter to the Veteran should explain that he has a full one-year period for response. See 38 U.S.C.A § 5103(b)(1); but see also 38 U.S.C.A. § 5103(b)(3) (West Supp. 2012) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). The RO should specifically request that the Veteran provide, or provide appropriate authorization for it to obtain any outstanding private medical records. Thereafter, the RO/AMC should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5103, 5103A ; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the RO/AMC of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the RO/AMC should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claims remaining on appeal. Accordingly, these matters are hereby REMANDED for the following action: 1. Contact the National Personnel Records Center, the Department of the Army, the Veteran's Army Reserves unit, and any other appropriate source(s) to verify the Veteran's periods of ACDUTRA and INACDUTRA. In making these requests, use the Veteran's complete last name, as listed on his Form DD-214. Follow the procedures set forth in 38 C.F.R. § 3.159(c) as regards requesting records from Federal facilities. Continue efforts to obtain records and verify service until either the evidence/information is received, or until specific information that the evidence/information sought does not exist or that further efforts to obtain it/them would be futile is obtained. All records and/or responses received should be associated with the claims file. 2. Obtain from the San Juan VAMC all outstanding, pertinent records of evaluation and/or treatment of the Veteran, dated since May 2011. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with regards to requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 3. Furnish to the Veteran and his attorney a letter requesting that the Veteran provide information and, if necessary, authorization, to enable it to obtain any additional evidence pertinent to the claims remaining on appeal that is not currently of record. Specifically request that the Veteran provide, or provide appropriate authorization for it to obtain, any outstanding private medical records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 4. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 5. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo VA orthopedic examination, by a physician, at a VA medical facility, to determine the current nature and etiology of his claimed knee and wrist disorders. The entire claims file, to include a complete copy of this REMAND, must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented medical history and assertions. All indicated tests and studies should be accomplished (with all results made available to the requesting physician prior to the completion of his or her report), and all clinical findings should be reported in detail. a) Identify diagnoses for all disabilities of the Veteran's knees and wrists that have been present at any time since August 2008. b) For each diagnosed disability, the physician should render an opinion as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the disability had its onset in or is otherwise medically related to service, to include any period of ACDUTRA. In rendering each requested opinion, the examiner should consider and discuss all relevant evidence, to include medical documents, and all lay assertions. The examiner should specifically address the significance, if any, of the noted right wrist trauma in July 1988 as well as the complaints related to his left knee in July 1988 and October 1990. The examiner should set forth all examination findings and testing results (if any), along with the complete rationale for the conclusions reached, in a printed (typewritten) report. 6. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo VA genitourinary examination, by a physician, at a VA medical facility, to determine the current nature and etiology of his claimed erectile dysfunction. The entire claims file, to include a complete copy of this REMAND, must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented medical history and assertions. All indicated tests and studies should be accomplished (with all results made available to the requesting physician prior to the completion of his or her report), and all clinical findings should be reported in detail. With regards to the Veteran's erectile dysfunction, the physician should render an opinion as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the disability had its onset in or is otherwise medically related to service, to include any period of ACDUTRA, to include venereal warts diagnosed in June 1963 and lesions on the foreskin noted in July 1963. In rendering each requested opinion, the examiner should consider and discuss all relevant evidence, to include medical documents, and all lay assertions. The examiner should specifically address the Veteran's contentions that his erectile dysfunction was related to his in-service venereal warts and foreskin lesions. The examiner should set forth all examination findings and testing results (if any), along with the complete rationale for the conclusions reached, in a printed (typewritten) report. 7. After all available records and/or responses from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo VA Gulf War examination, by an appropriate physician, at a VA medical facility. This 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), at a VA medical facility. As indicated below, additional specialist examination(s) should be conducted as needed. The entire claims file, to include a complete copy of this REMAND, must be made available to each physician designated to examine the Veteran, and the examination report(s) should include discussion of the Veteran's documented medical history and assertions. Each physician should set forth all examination findings, along with the complete rationale for the conclusions reached (to include citation to specific evidence and/or medical authority, as appropriate) in a typewritten report a) The primary Gulf War examiner should note and detail all reported symptoms of a respiratory disorder and/or chronic fatigue syndrome. The examiner should conduct a comprehensive general medical examination, and provide details about the onset, frequency, duration, and severity of all symptoms of respiratory symptoms and/or chronic fatigue syndrome and state what precipitates and what relieves them. b) The examiner should list all diagnosed disabilities and state which symptoms of a respiratory disorder and/or chronic fatigue syndrome are associated with each disability. If all symptoms (such as joint pain or fatigue) are associated with diagnosed condition(s), additional specialist examinations for diagnostic purposes are not needed. c) If any symptoms of a respiratory disorder and/or chronic fatigue syndrome have not been determined to be associated with a known clinical diagnosis, further specialist examination(s) will be required to address these findings, and should be ordered by the primary examiner. d) If any specialist examination(s) is/are warranted, the primary examiner should provide the specialist with all examination reports and test results, specify the relevant symptoms that have not been attributed to a known clinical diagnosis and request that the specialist determine which of these, if any, can be attributed in this Veteran to a known clinical diagnosis and which, if any, cannot be attributed in this Veteran to a known clinical diagnosis. e) For each diagnosed respiratory disorder, the physician should render an opinion as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the disability had its onset in or is otherwise medically related to service. If sacroidsois is diagnosed, the physician should state whether it was manifested to a compensable degree within one year of service discharge (i.e., May 1991). 8. If the Veteran fails to report to any scheduled examination(s), obtain and associate with the claims file (a) copy(ies) of any notice(s) of the date and time of the examination sent to him by the pertinent VA medical facility. 9. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 10. After completing the requested actions, and any additional notification and/or development deemed warranted, readjudicate the claims on appeal in light of all pertinent evidence and legal authority. 11. If any benefit sought on appeal remains denied, furnish to the Veteran and his attorney an appropriate SSOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefits requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This REMAND must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs