Citation Nr: 1329649 Decision Date: 09/16/13 Archive Date: 09/20/13 DOCKET NO. 06-39 227 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder. 2. Entitlement to service connection for right ear hearing loss. 3. Entitlement to service connection for left ear hearing loss. 4. Entitlement to service connection for a skin disorder other than chloracne. REPRESENTATION Veteran represented by: Carolyn J. Kerr ATTORNEY FOR THE BOARD S. Becker, Associate Counsel INTRODUCTION The Veteran served on active duty in the Army from March 1964 to April 1970 and in the Army Reserve on various periods of active duty for training (ACDUTRA), to include from June to October 1983 and inactive duty for training (INACDUTRA). This matter comes before the Board of Veterans' Appeals (Board) from a September 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. Among other things, service connection for posttraumatic stress disorder (PTSD), rash/boils, and left ear hearing loss was denied therein. It also was determined that new and material evidence had not been received sufficient to reopen a previously denied claim for service connection for right ear hearing loss. The RO in Louisville, Kentucky, notified the Veteran of the rating decision, and he appealed. Jurisdiction of this appeal has remained with the Louisville, Kentucky, RO. Of note is that a hearing before a Veterans Law Judge was scheduled pursuant to the Veteran's request, but was not conducted because he submitted a statement cancelling it. His hearing request is considered withdrawn. 38 C.F.R. § 20.704(e). In November 2010, the Board recharacterized the issue of entitlement to service connection for PTSD as one for service connection for an acquired psychiatric disorder which includes PTSD and all other psychiatric disorders claimed or diagnosed. A psychiatric claim indeed must be construed liberally to encompass claimed and diagnosed disorders. Clemons v. Shinseki, 23 Vet. App. 1 (2009). This issue and all the others comprising this matter were remanded for additional development. Also in November 2010, the Board determined that new and material evidence sufficient to reopen the previously denied claim for service connection for right ear hearing loss had been received. In December 2012, the Board denied service connection for a skin disorder. All the other issues comprising this matter once again were remanded for additional development. The Veteran appealed the aforementioned denial to the Court of Appeals for Veterans Claims (Court). Service connection for a skin disorder was remanded back to the Board via a June 2013 Order of the Court, which granted a Joint Motion for Partial Remand (JMPR). This issue is remanded to the RO via the Appeals Management Center (AMC) in Washington, D.C., based on this JMPR as well as review of the Veteran's paper claims file and his Virtual VA electronic claims file. It is recharacterized at this time to exclude chloracne because service connection for chloracne was denied in an unappealed July 2008 rating decision. Service connection for right ear hearing loss and left ear hearing loss also are remanded based on such review, while it leads to the conclusion that adjudication may proceed with respect to service connection for an acquired psychiatric disorder. Finally, acknowledgement is given to the Veteran's change of representative in June 2013. The most recent letter from VA regarding service connection for a skin disorder was sent to his new representative. However, the most recent VA letter regarding service connection for an acquired psychiatric disorder, right ear hearing loss, and left ear hearing loss was sent to his former representative. There nevertheless is no detriment to the Veteran. As noted above, service connection for right ear hearing loss and left ear hearing loss is remanded rather than adjudicated herein. Service connection for an acquired psychiatric disorder is adjudicated herein, but it is granted and not denied. FINDING OF FACT The Veteran's acquired psychiatric disorder includes anxiety not otherwise specified (NOS), anxiety disorder NOS, depression, depression NOS, depressive disorder NOS, major depressive disorder, adjustment disorder with depressed mood, mood disorder, mood disorder NOS, and insomnia, of which anxiety disorder NOS has been attributed to his service and deemed to aggravate major depressive disorder, but does not include PTSD. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, specifically anxiety disorder NOS and major depressive disorder, have been met. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 1153, 1154, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.2, 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310, 3.384, 4.125, 4.130, Diagnostic Codes 9201-9211 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist Service connection for an acquired psychiatric disorder characterized as an anxiety disorder NOS and a major depressive disorder is granted herein. Service connection for PTSD and for any other diagnosed acquired psychiatric disorder is not granted herein. Separately diagnosed psychiatric disorders can be service-connected. Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009). Thus, it is possible for the Veteran to be awarded service connection for anxiety disorder NOS, major depressive disorder, and one or more other diagnosed acquired psychiatric disorders. That the acquired psychiatric disorder claimed by the Veteran is different than those for which service connection is awarded for is of no consequence. The benefit sought, service connection for an acquired psychiatric disorder, is granted. VA has a duty to notify and a duty to assist claimants in substantiating entitlement to VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Discussion of these duties is not necessary because the determination made herein is fully favorable to the Veteran. It follows that any errors made regarding the duties were harmless. Any errors made with respect to ensuring at least substantial compliance with the Board's previous remands also were harmless for this same reason. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999), aff'd Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). II. Service Connection Service connection means that the facts, shown by evidence, establish that an injury or disease resulting in disability was incurred in service, or if preexisting service, was aggravated therein. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). To establish service connection, there generally must be (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus between the current disability and the in-service disease or injury. Hickson v. West, 12 Vet. App. 247 (1999); Barr v. Nicholson, 21 Vet. App. 303 (2007). Establishing service connection specifically for PTSD requires (1) a diagnosis in conformity with the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), (2) an in-service stressor, and (3) a nexus between the diagnosis and the in-service stressor. 38 C.F.R. §§ 3.304(f), 4.125(a); Cohen v. Brown, 10 Vet. App. 128 (1997). If the claimed in-service stressor concerns combat with the enemy, lay evidence from the Veteran is sufficient unless the stressor is inconsistent with the circumstances, conditions, or hardships of service or there is clear and convincing evidence to the contrary. 38 C.F.R. § 3.304(f)(2); Zarycki v. Brown, 6 Vet. App. 91 (1993). If the claimed in-service stressor concerns fear of hostile military or terrorist activity, lay evidence from the Veteran is sufficient provided that a VA or VA-contracted psychologist or psychiatrist confirms that the manifested symptoms are related to a stressor that is adequate to support a diagnosis of PTSD or the stressor is inconsistent with the places, types, and circumstances of service or there is clear and convincing evidence to the contrary. 38 C.F.R. § 3.304(f)(3). If the claimed in-service stressor does not concern combat with the enemy or fear of hostile military or terrorist activity, there must be evidence other than lay evidence from the Veteran or after-the-fact medical evidence of nexus. Zarycki, 6 Vet. App. at 91; Cohen, 10 Vet. App. at 142; Moreau v. Brown, 9 Vet. App. 389 (1996); Dizoglio v. Brown, 9 Vet. App. 163 (1996). Service connection may be established for a disease in a variety of additional manners. A psychosis is a chronic disease. 38 U.S.C.A. § 1101(3); 38 C.F.R. § 3.309(a). Psychosis includes brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified (NOS), schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. 38 C.F.R. §§ 3.384, 4.130, Diagnostic Codes 9201-9211. For any disease that is diagnosed after discharge, service connection is established when the evidence shows it was incurred in service. 38 C.F.R. § 3.303(d). For chronic diseases, service connection may be established through chronicity or continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A chronic disease during service is shown when there is a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). Merely isolated findings are insufficient, as is a diagnosis including the word chronic. Id. Subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected unless clearly attributable to intercurrent causes. Id.; Barr, 21 Vet. App. at 303. Continuity of symptomatology after service is required if the disease is noted during service but is not chronic, or where a determination that it is chronic may legitimately be questioned. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Finally, service connection is presumed for chronic diseases when service was for 90 days or more during a period of war or after December 31, 1946, and the disease manifested, whether or not it was diagnosed, to a compensable degree within one year from the date of discharge. 38 U.S.C.A. § 1112(a); 38 C.F.R. §§ 3.307(a), (c). Evidence rebutting in-service incurrence or aggravation of the disease must be taken into consideration, however. 38 U.S.C.A. §§ 1113, 1153; 38 C.F.R. §§ 3.307(d), 3.309(a). Secondary service connection means that a current nonservice-connected disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). To establish service connection on a secondary basis, there must be a current disability proximately caused or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). With respect to aggravation, the baseline level of disability pre-aggravation must be compared to the current level of disability. 38 C.F.R. § 3.310(b). Compensation is paid only for the degree of disability over and above the baseline plus natural progression. 38 C.F.R. § 3.310(b); Allen, 7 Vet. App. at 439. There must be a permanent worsening beyond natural progression of the disorder, rather than temporary or intermittent flare-ups. Davis v. Principi, 276 F.3d 1341 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292 (1991). The Board must identify the evidence it finds to be persuasive and unpersuasive and explain why any favorable evidence is unpersuasive. Gabrielson v. Brown, 7 Vet. App. 36 (1994), Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Both medical and lay evidence may be discounted in light of inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). When there is an approximate balance of positive and negative evidence, any reasonable doubt is resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. The claimant thus prevails when the evidence supports the claim or is in relative equipoise but does not prevail when the preponderance of the evidence is against the claim. Only the most salient and relevant evidence must be discussed, although all the evidence must be reviewed. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). The Board finds that service connection for an acquired psychiatric disorder is warranted. A current disability exists when there is a disability at the time a claim is filed or at any time during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The Veteran filed the instant claim in January 2005. It was determined upon VA medical examination in December 2010 that he did not have any psychiatric disorder. Indeed, the only diagnosis made was bereavement. Yet VA treatment records dated since January 2005 contain diagnoses of anxiety NOS, depression, depression NOS, depressive disorder NOS, adjustment disorder with depressed mood, mood disorder, mood disorder NOS, and insomnia. Anxiety disorder NOS and major depressive disorder further were diagnosed at a June 2013 VA medical examination. The Veteran, in sum, has an acquired psychiatric disorder. However, this acquired psychiatric disorder does not include PTSD. There can be no valid claim if there is no current disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). VA treatment records document a diagnosis only of rule out PTSD. One of the diagnoses rejected at the December 2010 VA medical examination was PTSD. It particularly was determined that the in-service stressors reported by the Veteran at that time did not meet the DSM-IV criteria for PTSD. Of note is that the Board indicated in its December 2012 remand that not all of his claimed in-service stressors had been considered at this examination. Yet, a diagnosis of PTSD again was rejected at the June 2013 VA medical examination which did consider all of his claimed in-service stressors. In particular, it was determined that the Veteran's symptoms do not meet the DSM-IV criteria for PTSD. This determination was made following diagnostic testing. That VA treatment records contain numerous PTSD screenings, some of which were positive and some of which were negative was acknowledged. They were described as often helpful but never sufficient to establish a diagnosis of PTSD. Here, many of the screenings were noted to be not very thorough and all were noted to be based on the Veteran's self-report. That he exhibited significant indicators of exaggeration on one occasion was referenced. Acknowledgement is given to the Veteran's belief that he has PTSD. As there is no indication that he has a medical background, he is a lay person. A lay person is competent to diagnose a condition only when the lay person is competent to identify it, is reporting a contemporaneous medical diagnosis, or describes symptoms supporting a later medical diagnosis. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Conditions such as flat feet, a dislocated shoulder, certain skin ailments, tinnitus, and varicose veins are examples of conditions a lay person is competent to identify. Jandreau, 492 F.3d at 1372; Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Charles v. Principi, 16 Vet. App. 370 (2002); Falzone v. Brown, 8 Vet. App. 398 (1995). PTSD, in contrast, is not a condition a lay person is competent to identify. As noted above, specific DSM-IV criteria must be met. Diagnostic testing often is needed to confirm a diagnosis. It is impossible for the Veteran to have reported a contemporaneous medical diagnosis or to describe symptoms supporting a later medical diagnosis. Indeed, it is reiterated that PTSD never has been diagnosed. None of the diagnoses comprising the Veteran's acquired psychiatric disorder constitute a psychosis. He does not have a chronic disease, in other words. Chronicity and continuity of symptomatology therefore cannot be established. Presumptive service connection based on manifestation within one year of the Veteran's discharge in April 1970 also cannot be established, notwithstanding that he served for more than 90 days during the Vietnam era period of war which occurred after December 31, 1946. 38 U.S.C.A. § 101(29); 38 C.F.R. § 3.2(f). That leaves for consideration service connection in general and secondary service connection. During his service, the Veteran contends that he was exposed to blasts and enemy fire, had to recover human body parts following engagements with the enemy, and witnessed a soldier commit suicide. Among his contentions is that he engaged in combat with the enemy. A veteran engaged in combat with the enemy if he personally participated in an actual fight or encounter with the enemy, to include receipt of fire from the enemy. Sizemore v. Principi, 18 Vet. App. 264 (2004); VAOPGCPREC 12-99 (October 18, 1999). Here, the Veteran's DD-214 shows that he served in Vietnam from October 1967 to October 1968. It cannot be presumed that he engaged in combat there, as he did not receive any medals indicative of such. VA Adjudication Procedure Manual, Part IV, Subpart ii, Chapter 1, Section D, Part 13.e. Yet, his engagement in combat is consistent with the circumstances, conditions, and hardships of serving there. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). There further is no evidence, let alone clear and convincing evidence, to the contrary. Id. The Veteran's DD-214 denotes that he was a welder. This supports his recount of repairing equipment. Further, it is common knowledge that soldiers in Vietnam often performed duties outside the scope of their specialty. The Veteran's recounts of delivering supplies and recovering human body parts also therefore are conceded, as they were in the Board's November 2010 and December 2012 remands. Each of these activities is consistent with exposure to enemy fire, as they required him to travel around. He indeed also recounted acting as a gunner in response to such enemy fire, which additionally was conceded in the Board's remands. VA treatment records do not shed light onto whether or not any of the diagnoses comprising the Veteran's acquired psychiatric disorder are related to his engagement in combat during service. Neither does the December 2010 VA medical examination. At the June 2013 VA examination, it was determined that his anxiety disorder NOS, in contrast, is related to his combat during service. That he has several longstanding trauma-based symptoms falling under this diagnosis was noted. It was determined that the Veteran's major depressive disorder is not related to his combat during service but rather is related to the impairment caused by his stroke about 10 years ago, the death of his brother, and his trauma-based symptoms. In other words, his major depressive disorder is aggravated beyond natural progression partially by his anxiety disorder NOS. That these symptoms increased once his lifestyle slowed down and he was no longer distracted by employment following his stroke was noted. Factors in assessing a medical opinion include the qualifications and expertise of the examiner, access to the claims file or other pertinent evidence, the scope of the examination, the accuracy of the factual premise underlying the opinion, the rationale offered for it, and the degree of certainty provided. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Prejean v. West, 13 Vet. App. 444 (2000); Black v. Brown, 10 Vet. App. 297 (1997); Ardison v. Brown, 6 Vet. App. 405 (1994); Sklar v. Brown, 5 Vet. App. 140 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993); Guerrieri v. Brown, 4 Vet. App. 467 (1993). None of these factors is problematic here. A psychologist rendered each of the aforementioned opinions after reviewing the claims file and other VA treatment records as well as interviewing and thoroughly assessing the Veteran. There is no indication that either opinion was based on an inaccurate factual premise. The Veteran's manifestation of trauma-related symptoms since his engagement in combat during service forms the basis, or rationale, for the anxiety disorder NOS opinion. The rationale of the major depressive disorder opinion was his manifestation of depressive symptoms in response to events about 10 years prior, or well after his engagement of combat during service, with exacerbation thereof attributable to his increasing trauma-related symptoms. Ambiguous language finally was not used in either opinion, and hesitancy otherwise is not apparent. Given the foregoing, general service connection for anxiety disorder NOS is established based on the preponderance of the evidence. Service connection for major depressive disorder as secondary to anxiety disorder NOS also is established based on the preponderance of the evidence. This benefit sought thus is granted, without application of reasonable doubt, for these disorders alone out of the several comprising the Veteran's acquired psychiatric disorder. ORDER Service connection for an acquired psychiatric disorder, specifically anxiety disorder NOS and major depressive disorder, is granted. REMAND The Board sincerely regrets the delay another remand entails, but adjudication of the Veteran's entitlement to service connection for right ear hearing loss, left ear hearing loss, and a skin disorder other than chloracne cannot be undertaken as of yet. More development is needed to ensure he is afforded every possible consideration. VA's duty to assist him in substantiating entitlement to VA benefit indeed is reiterated in this regard. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. This duty includes a mandate that any VA medical opinion obtained be adequate. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Hayes v. Brown, 9 Vet. App. 67 (1996). A VA medical opinion is adequate when it allows the Board to perform a fully informed evaluation. Barr, 21 Vet. App. at 303. Consideration must be given to the Veteran's entire medical history. Stefl v. Nicholson, 21 Vet. App. 120 (2007); Ardison v. Brown, 6 Vet. App. 405 (1994). This helps ensure that the factual premises underlying the opinion are accurate, as is required. Reonal v. Brown, 5 Vet. App. 458 (1993). The rationale for the opinion also must be clearly and fully articulated. Nieves-Rodriguez, 22 Vet. App. at 295; Stefl, 21 Vet. App. at 120. In its November 2010 and December 2012 remands, the Board determined that all VA medical opinions that had been rendered regarding the Veteran's right ear hearing loss as well as his left ear hearing loss were inadequate. Another VA medical examination complete with medical opinion thus was directed. This opinion specifically was to include several subparts. First, the examiner was to opine as to whether or not the Veteran's right ear hearing loss preexisted his service. Comment was to be made concerning the significance of his March 1964 entrance examination recording a right ear auditory threshold at 6000 Hertz of 30 decibels pursuant to standards set by the American Standards Association (ASA) and of 40 decibels pursuant to standards set by the International Standards Organization (ISO)-American National Standards Institute (ANSI), which have been used since November 1, 1967, as such was characterized as mild hearing loss at a previous VA medical examination. If preexisting right ear hearing loss was found, the examiner second was to opine as to whether or not it increased beyond natural progression during service. If preexisting right ear hearing loss was not found, the examiner was to opine as to whether it is at least as likely as not that the Veteran's current right ear hearing loss had its onset during or otherwise is related to his active duty, ACDUTRA, or INACDUTRA service. This same opinion was to be made with respect to left ear hearing loss. Comment was to be made on the impact of any post-service noise exposure. Finally, it was indicated that support for the opinion must be provided. This was to include reference to medical principles as well as the medical and lay evidence. Specific reasons were to be provided if it was found that delayed onset hearing loss weighs against a relationship to service. The Veteran underwent a VA audiological examination in June 2013. Afterward, the examiner opined that the Veteran did not have right ear hearing loss prior to his service. The rationale provided was a quotation from a previous VA medical opinion to the effect that his auditory thresholds were within normal limits between 500 and 4000 Hertz at his entrance examination. The examiner further opined both that the Veteran's current right ear hearing loss and that his current left ear hearing loss is less likely as not related to his service. The rationale provided included a list of pertinent information, to include his dates of active duty service and report of post-service noise exposure in addition to military noise exposure. It additionally included the conclusions that he already had hearing loss by October 1980 and that it did not change significantly thereafter during his service, as shown upon examinations. A Board remand confers upon the Veteran the right to compliance with the directives therein. Stegall, 11 Vet. App. at 268. Strict compliance is not necessary, but there must be at least substantial compliance. Dyment, 13 Vet. App. at 141, aff'd, Dyment, 287 F.3d at 1377. Here, there has not been even substantial compliance with the Board's directives. The opinions requested were rendered. Yet, there was no comment on the Veteran's right ear auditory threshold at 6000 Hertz at his March 1964 entrance examination. Indeed, there was no mention in this regard whatsoever. There also was no comment on the impact of the Veteran's post-service noise exposure. Such exposure instead simply was noted. Further, none of the opinions was supported by a clear and complete rationale. It is unclear why the examiner merely quoted a previous opinion when all previous opinions had been deemed inadequate with respect to the opinion concerning preexisting right ear hearing loss. Simply listing the evidence is not the same as referencing it in explaining why the opinions reached regarding current right ear hearing loss and left ear hearing loss were made. To cure the aforementioned deficiencies, arrangements now must be made for a new VA medical opinion to be rendered. In denying service connection for a skin disorder, the Board relied on a January 2011 VA medical opinion. The examiner, who essentially diagnosed current seborrheic dermatitis and eczema/dermatitis of both anterior legs, opined that it is less likely than not that either condition was due to the Veteran's service. That he did not have a specific complaint but multiple vague complaints from his discharge to present was noted as rationale. It also was noted that neither of the aforementioned conditions was related to his exposure to Agent Orange during service. The JMPR indicated that the Board failed to explain how this rationale concerning in-service exposure to herbicides was sufficient. A directive either for the examiner to addend his opinion or, if this examiner is unavailable, for another VA medical examination complete with opinion was made. Compliance with the terms of the JMPR thus is required. Forcier v. Nicholson, 19 Vet. App. 414 (2006). As such, arrangements must be made as aforementioned. Reasonable efforts must be made by VA to assist in the procurement of pertinent records. 38 U.S.C.A. § 5103A(b); 38 C.F.R. § 3.159(c). Reasonable efforts with respect to records in Federal custody consist of making as many requests as are necessary to obtain them unless it is concluded that they do not exist or that further requests would be futile. 38 U.S.C.A. § 5103A(b)(3); 38 C.F.R. § 3.159(c)(2). The claimant shall be notified if requested records cannot be or are not obtained. 38 U.S.C.A. § 5103A(b)(2); 38 C.F.R. § 3.159(e)(1). Here, VA treatment records dated as recently as June 2013 are available. Such records plausibly could be expected to be before the Board, and thus the Board has constructive notice of them. Bell v. Derwinski, 2 Vet. App. 611 (1992). As many requests as are necessary thus must be made for any dated from June 2013 to present. This must be completed prior to any VA medical opinions being rendered. It indeed is reiterated that the Veteran's entire medical history must be considered in an effort to ensure that the factual premises underlying these opinions are accurate. Given the above, a REMAND is directed for the following: 1. Make as many requests as necessary to obtain the Veteran's VA treatment records dated from June 2013 to present. Associate all records received with the paper claims file or Virtual VA electronic claims file. If requested records ultimately are not received or are received but are incomplete, notify the Veteran and his representative. Document the paper claims file or Virtual VA electronic claims file as appropriate in this regard. 2. After completion of the above, arrange for another VA medical opinion to be rendered regarding the Veteran's right ear hearing loss and left ear hearing loss by an audiologist or similar medical professional specializing in the ears, whether the June 2013 examiner or otherwise. Review of the paper claims file and Virtual VA electronic claims file must be undertaken, with such documented in a report to be placed in the paper claims file or Virtual VA electronic claims file. If deemed necessary, the Veteran may be scheduled for another VA medical examination. Details of the interview of him and the results of all tests conducted at such an examination must be included in the report. Opinions thereafter shall be rendered in the report as to the following: a) Did the Veteran have right ear hearing loss that pre-existed his entry into active duty service in March 1964? b) If there was preexisting right ear hearing loss, was is permanently aggravated (increased beyond natural progression) during active duty, ACDUTRA, or INACDUTRA service? c) If there was not preexisting right ear hearing loss, is it at least as likely as not (a 50 percent or greater probability) that the Veteran's current right ear loss hearing loss had its onset during his active duty, ACDUTRA, or INACDUTRA service, onset to a degree of at least 10% within one year of his active duty service, or otherwise is related to his active duty, ACDUTRA, or INACDUTRA service? d) Is it at least as likely as not that the Veteran's current left ear loss hearing loss had its onset during his active duty, ACDUTRA, or INACDUTRA service, had its onset to a degree of at least 10% within one year of his active duty service, or otherwise is related to his active duty, ACDUTRA, or INACDUTRA service? Consideration shall be given to the Veteran's conceded military noise exposure in opining as aforementioned. A clear and complete rationale (explanation of how the opinion was reached) shall be provided for every opinion in the report. This includes a discussion of the pertinent medical principles, with a citation for or the attachment of any literature referenced, as well as the pertinent medical and lay (non-medical) evidence. The Veteran's right ear auditory threshold at 6000 Hertz of 30 decibels pursuant to standards set by the ASA and of 40 decibels pursuant to standards set by the ISO-ANSI at his entrance examination therefore shall be addressed, as shall the fact that this was characterized as mild hearing loss at a previous VA medical examination. The impact of the Veteran's reported post-service noise exposure also shall be addressed. If delayed onset of the hearing loss forms the partial or complete basis for a negative opinion, the rationale must additionally include discussion of why delayed onset weighs against a nexus to service. The medical journal article and presentation to the contrary, which were submitted by the Veteran's then representative in November 2012 must be addressed in this discussion. If an opinion cannot be provided without resort to speculation, the rationale shall include a discussion of whether this is because more information is needed, information that cannot be obtained is needed, the limits of current medical knowledge have been exhausted, there are multiple possible etiologies with none more likely than not the cause, or some other reason. 3. Also, arrange for another VA medical opinion to be rendered regarding a skin disorder other than chloracne by the January 2011 examiner. If deemed necessary, this examiner may schedule the Veteran for another appropriate VA medical examination. If the January 2011 examiner is not available, arrange for another appropriate VA medical examination and medical opinion by a qualified physician. Review of the paper claims file and Virtual VA electronic claims file must be undertaken, with such documented in a report to be placed in the paper claims file or Virtual VA electronic claims file, regardless of whether the January 2011 examiner or another examiner is involved. If the Veteran is examined, details of the interview of him and the results of all tests conducted must be included in the report. An opinion thereafter shall be rendered in the report for each diagnosed disorder (to include seborrheic dermatitis and eczema/dermatitis of both anterior legs as well as any other disorder diagnosed upon examination) as to whether it is at least as likely as not (a 50 percent or greater probability) that it had its onset during or otherwise is related to the Veteran's active duty or ACDUTRA service. In answering this question, the examiner must consider whether the Veteran's conceded exposure to an herbicide agent such as Agent Orange during active duty service caused his skin problems. Of note is that service connection as due to herbicide exposure can be granted on a direct basis, if warranted given the specifics of the Veteran's case, even if service connection cannot be presumed to be due to such exposure. A clear and complete rationale (explanation of how the opinion was reached) shall be provided for every opinion in the report. This includes a discussion of the pertinent medical principles, with a citation for or the attachment of any literature referenced, as well as the pertinent medical and lay (non-medical) evidence. If an opinion cannot be provided without resort to speculation, the rationale shall include a discussion of whether this is because more information is needed, information that cannot be obtained is needed, the limits of current medical knowledge have been exhausted, there are multiple possible etiologies with none more likely than not the cause, or some other reason. 4. Lastly, readjudicate the issue of entitlement to service connection for right ear hearing loss, left ear hearing loss, and a skin disorder other than chloracne. For determinations favorable to him, issue a rating decision. If any determinations remain adverse to the Veteran, furnish him and his representative with a supplemental statement of the case (SSOC) and allow them the requisite time period to respond. A copy of the SSOC shall be placed in the paper claims file or electronic claims file. All issues addressed in the SSOC then shall be processed for return to the Board. No action is required of the Veteran until he is notified by the RO or AMC, but he is advised that his failure to report for a scheduled VA medical examination may result in denial of the benefit(s) sought. 38 C.F.R. § 3.655 (2012). He also is advised that he has the right to submit additional evidence and argument regarding any remanded issue. Kutscherousky v. West, 12 Vet. App. 369 (1999). This matter must be afforded prompt treatment. The law indeed requires that all matters remanded by the Board or by the Court be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs