Citation Nr: 1756617 Decision Date: 12/07/17 Archive Date: 12/15/17 DOCKET NO. 11-07 875 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a right knee disorder. 2. Entitlement to service connection for a right elbow disorder. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for an acquired psychiatric disorder. 5. Entitlement to service connection for chronic fatigue syndrome or fibromyalgia as due to Southwest Asia Service. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD C. Smith, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1976 to July 1979, August 1997 to April 1998, and October 2004 to January 2006, with additional service in the Army Reserves. This case comes to the Board of Veterans' Appeals (Board) on appeal from December 2009 and April 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In November 2014 the Veteran testified at a hearing before the undersigned Veterans Law Judge and a transcript of that proceeding is of record. This matter was previous remanded by the Board in January 2015, and has since been returned for further appellate review. Prior to the issue being recertified to the Board, the Veteran's prior representative withdrew their representation and to date the Veteran has not appointed another representative. The Legacy Content Manager contains additional VA treatment records from 2003 to 2006 from the Charleston VA Medical Center (VAMC), the November 2014 VA hearing transcript, a July 2015 VA mental disorders examination report, records from December 2015 to April 2016 from the Bay Pines VAMC, and an April 2017 addendum opinion. The issues of entitlement to service connection for a right knee disorder, service connection for a right elbow disorder, service connection for hypertension, and service connection for an acquired psychiatric disorder are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War. 2. The Veteran does not have a diagnosis of fibromyalgia or chronic fatigue syndrome. 3. The Veteran's joint pain, muscle pain, and fatigue have been attributed to diagnosed conditions. CONCLUSIONS OF LAW 1. The criteria for service connection for fibromyalgia, to include as due to service in Southwest Asia, are not met. 38 U.S.C. §§ 1110, 1117, 1131 (2012); 38 C.F.R. §§ 3.303, 3.317 (2017). 2. The criteria for service connection for chronic fatigue syndrome, to include as due to service in Southwest Asia, are not met. 38 U.S.C. §§ 1110, 1117, 1131 (2012); 38 C.F.R. §§ 3.303, 3.317 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Neither the Veteran nor his attorney has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Board acknowledges that the Veteran's service treatment records (STRs) are incomplete and additional STRs may be added to the record following this remand; however the relevant STRs from the Veteran's period of service in Southwest Asia pertaining to the Veteran's claim for service connection for chronic fatigue syndrome or fibromyalgia are associated with the claims file. The Veteran also offered testimony before the undersigned Veterans Law Judge at a Board hearing in November 2014. The Board finds that all requirements for hearing officers have been met. 38 C.F.R. § 3.103 (c)(2) (2017); Bryant v. Shinseki, 23 Vet. App. 488 (2010). To the extent that any evidentiary deficiency was noted, the Board finds that it has been cured on remand. For the issue decided below, the Board also finds that there has been compliance with the prior January 2015 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Law Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498 (1995). In addition, service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a) (2017); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although 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. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War. The Southwest Asia Theater of operations refers to 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. 38 C.F.R. § 3.317(e). For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1). 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 VA determines in regulations warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). An undiagnosed illness is a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317(a)(1). A medically unexplained chronic multisymptom illnesses is 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 VA determines meets the criteria in paragraph 3.317(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). 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Analysis The Veteran seeks entitlement to service connection for fibromyalgia, also claimed as chronic fatigue syndrome, due to his service in Southwest Asia. The Veteran's DD214 shows he had active service in Kuwait during the Persian Gulf War, and thus the Veteran is a Persian Gulf Veteran. On a December 2005 post deployment questionnaire following his return from Kuwait, the Veteran reported he had symptoms of swollen, stiff, or painful joints, and muscle aches. The Veteran has also claimed entitlement to service connection for right knee and elbow disorders, and he asserts that those joint pains began in service. An October 2008 VA psychiatry note documents an Axis III diagnosis of chronic pain; however it was related to the right knee. November 2009 VA treatment record documents the presence of chronic pain related to the elbow, knee, and back. Chronic pain appears in the Veteran's problem list with a diagnosis date of November 2009. In his December 2009 notice of disagreement, the Veteran wrote that he had been diagnosed with fibromyalgia at the Bay Pines VAMC from September 2008 to present, which the Veteran related to his service in Southwest Asia. A review of Bay Pines VAMC records fails to show a diagnosis of fibromyalgia. An April 2011 VA treatment record documented the Veteran had pain in his right shoulder attributed to tendonitis. A September 2011 VA treatment record documented the Veteran complained of muscle pain with a sudden onset three days prior. He reported pain in the left flank that radiated to both shoulders, then to knees and ankles. There was no known mechanism of injury. The assessment was myalgias secondary to a viral infection or reaction to an influenza vaccination. A May 2013 VA emergency department note reported the Veteran had left shoulder pain for a few days. The assessment was cervical radiculopathy. VA treatment records show an October 2013 diagnosis of arthralgia, but it was specified as chronic pain in right knee and right elbow. May and June 2014 VA treatment records document the Veteran complained of left shoulder pain after a March 2014 injury at work where his left upper extremity was caught in an elevator door. He denied previous shoulder injuries. The impression was left acromioclavicular joint inflammation and possible partial rotator cuff tear. An MRI report showed a small low-grade partial thickness articular surface tear, infraspinatus and subscapularis tendinopathy, mild to moderate acromioclavicular degenerative changes, and mild sub-acromial and sub-deltoid bursitis. VA medical records document that the Veteran was prescribed medication for muscle spasms in October 2014. At the November 2014 hearing, the Veteran reported that he experiences bilateral shoulder pain and back spasms for which he takes medication, and that he occasionally felt tired. A November 2015 VA internal medicine note reports the Veteran had chronic back pain caused by degenerative joint disease and improved by pain medication. A November 2015 VA primary care letter documents the Veteran had marked spasm in the right lumbar and thoracic region muscles associated with low back strain. The Veteran underwent a VA examination in February 2017 upon a review of the claims file. The examiner stated that the Veteran did not have a diagnosis of chronic fatigue syndrome, as his fatigue was related to his mental health disorder and chronic pain that required sedating medications for maintenance. The examiner stated that there was no evidence to support a diagnosis of chronic fatigue syndrome or fibromyalgia. The foregoing evidence establishes that service connection under the presumptive provisions of 38 C.F.R. § 3.317 as the Veteran does not have a diagnosis of chronic fatigue syndrome or fibromyalgia. While the Veteran has claimed symptoms of fatigue, muscle pain, and joint pain; those symptoms have been attributed to known diagnoses, to include diagnoses of the right knee, right elbow, bilateral shoulders, and back. Regarding the documented reports and treatment for joint pain, chronic pain has been specified as related to chronic pain in the right knee, right elbow, and back. See October 2008 VA psychiatry note; See November 2009 VA treatment record. The Veteran had diagnoses of right knee degenerative joint disease and sprain; right elbow epicondylitis and osteophyte; and lower back strain and degenerative changes. See November 2015 VA primary care letter. The reported pain in the right and left shoulders has been attributed to tendonitis or to cervical radiculopathy, articular surface tear, tendinopathy, acromioclavicular degenerative changes, and mild bursitis. See April 2011 VA treatment record. Left shoulder symptoms of pain and tingling have been attributed to cervical radiculopathy, articular surface tear, tendinopathy, acromioclavicular degenerative changes, and mild bursitis. See May 2013 VA emergency department record; see May and June 2014 VA treatment records. Regarding reports of muscle pain, the record shows that the Veteran has back spasms associated with degenerative joint disease and low back strain. See November 2015 VA records. Other noted myalgia was secondary to a viral infection or reaction to an influenza vaccination. See September 2011 VA treatment record. The Veteran's reported fatigue has been attributed to diagnosed psychiatric disorders and as a side effect of pain medication. See February 2017 VA examination report. All of the Veteran's symptoms are attributable to known diagnoses that are not presumptively related to Southwest Asia service. In sum, the Veteran does not have a medically unexplained chronic multisymptom illness or undiagnosed illness, thus the presumptive provisions of 38 C.F.R. § 3.317 are not for application. The Board has also considered the statements of the Veteran and his representative. The Veteran is certainly competent to report as to the observable symptoms he experiences and their history. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, the ultimate questions of diagnosis and etiology in this case are beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. See Jandreau, 492 F.3d at 1377, n.4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Here, the Veteran has not been shown to be competent to diagnose fibromyalgia, and to the extent he is reporting a contemporaneous diagnosis, there is not documentation in the medical records to support his assertion. The Board finds the objective medical treatment records to be more probative on the issue of whether the Veteran has a diagnosis of fibromyalgia. Accordingly, service connection is not warranted. ORDER Entitlement to service connection for chronic fatigue syndrome or fibromyalgia is denied. REMAND First, remand is again required to verify all periods of ACDUTRA and INACDUTRA in the Army and Army Reserves as requested in the Board's January 2015 Remand. While the AOJ uploaded a summary of the Veteran's periods of service in the Army and Army Reserves that showed an additional period of active duty service in the Army from August 1997 to April 1998, there is nothing of record verifying the Veteran's periods of ACDUTRA and INACDUTRA. Thus, remand is again necessary. Stegall v. West, 11 Vet. App. 268 (1998). Second, remand is required to obtain outstanding federal records. VA's duty to assist claimants to obtain evidence needed to substantiate a claim includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, the Social Security Administration (SSA). 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In a June 2017 statement the Veteran reported that he is now in receipt of Social Security Disability benefits. October 2015 VA treatment records document the Veteran had been off work in part due to right knee problems. Thus, the Board finds that the SSA records are potentially relevant to the Veteran's right knee service connection claim and they should be obtained on remand. Additionally, of record are VA treatment records through April 2016. On remand all outstanding VA treatment records from April 2016 onward should be associated with the claims folder. Also, the January 2015 Remand also directed the AOJ to make efforts to obtain treatment records from Fort Eustis. The Veteran reported being treated for his right knee at Fort Eustis in approximately 1993. The AOJ specifically requested records from the Personnel Information Exchange System (PIES) for Fort Eustis from January through December 1993, and received a negative response for records from 1989, which was not the date requested. The Veteran's representative submitted records reportedly from Joint Base Langley-Eustis that showed treatment from November 2004 to December 2005, and August 2002 right knee x-ray results. There were no records submitted regarding the reported treatment in 1993, and the PIES response addressed the incorrect year. Thus, on remand another request should be made to obtain any outstanding treatment records from Fort Eustis, to specifically include records from 1993. Third, remand is required to secure adequate VA examinations and opinions regarding the Veteran's remaining service connection claims. When VA undertakes to obtain an examination or opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Opinions, which typically concern service connection issues, must be based on accurate facts and supported by a fully articulated rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Reonal v. Brown, 5 Vet. App. 458 (1993). With regard to the Veteran's claims for service connection for right knee and elbow disorders, August 2002 STRs document the Veteran had right knee pain from a previous injury when he was walking and stepped in hole and heard a "pop." The Veteran reported his right knee had bothered him one month and assessment was right knee pain, lateral collateral ligament injury versus spur. The Veteran had an August 2002 physical profile for elbow pain and knee pain, and was exempt from pullups, sit ups, or running. A May 2003 VA emergency department note documents the Veteran had a past medical history of tendinitis of the knee and elbow. An August 2003 treatment record documents the Veteran had chronic right arm and right knee pain since a 1991 injury. December 2004 military treatment records document the Veteran tendonitis of the right elbow and right knee and needed braces for both. November 2008 VA radiographs were significant for minimal bony degenerative change of the right knee. November 2008 VA radiographs of the right elbow were significant for a tiny focus of early developing non-inflammatory enthesophyte at the distal attachment of the triceps tendon. A January 2014 physical therapy note documents a history of right knee pain since 1993 when he injured knee during a hard run for a physical test in the military. January 2014 MRI studies showed a discoid variant of the lateral meniscus and anterior cruciate ligament thinning proximally which may be related to a remote injury. The Veteran underwent a VA joints examination in December 2009. The Veteran reported that he was taking a physical test in 1998 and heard something pop in his right knee. He denied any other right knee incidents in service, and reported progressively worse right knee symptoms since. With regard to the right elbow, the Veteran reported that the injury occurred in 1991 while he was in the Reserves. He reported he was a passenger in a truck when the hood flew open. His elbow became swollen and he was seen by a medical provider the following day and was treated with cortisone injections. The examiner diagnosed right knee sprain and degenerative joint disease and right elbow epicondylitis and osteophyte. The examiner opined that the Veteran's right elbow and right knee conditions were not related to service. The examiner explained that there were no STRs relating to the Veteran's reported in-service right elbow and right knee injuries. There was only an October 2002 STR that mentioned elbow pain and a history of right knee pain for one month after stepping into a hole. The examiner then stated that the most recent records from October 2008 which revealed a negative musculoskeletal review of systems. The Board notes that the December 2009 opinion is inadequate as VA treatment records do show right knee and elbow symptoms and diagnoses prior to and during 2008. Further, there are STRs documenting in-service right knee and elbow symptoms. In a February 2017 addendum opinion, a VA examiner opined that it was less than a 50 percent probability that the Veteran's right knee and right elbow disorders were related to his period of active service, ACDUTRA, or INACDUTRA. In support of that opinion, the examiner stated that the available medical evidence showed the Veteran did not complain about right knee or elbow pain until 2014, so there was no evidence of continuity of symptoms. In another April 2017 addendum opinion, the examiner stated that he reviewed an August 2002 record documenting the Veteran had a physical profile for right elbow and right knee pain, but stated there was no permanent profile found and no continuity of symptoms since service so his opinion remained unchanged. The addendum opinions of the 2017 examiner are also inadequate for failure to address other August 2002 or the December 2005 military records documenting tendonitis of the right elbow and right knee, and an assessment of right knee lateral collateral ligament injury versus spur. Additionally, VA treatment records from 2003 onward document the Veteran's reports of chronic right knee and right elbow symptoms since his reported in-service injuries. The 2017 examiner failed to adequately address these records, or consider the Veteran's competent reports of onset and continuity of symptoms. Regarding the Veteran's claim of service connection for hypertension, April 2004 VA treatment records document the Veteran had elevated blood pressure and was taking blood pressure medication. December 2005 STRs document the Veteran was taking atenolol, which is commonly used for treatment of hypertension. A March 2006 VA treatment record documents a current diagnosis of hypertension. A July 2015 General Medical Pension DBQ documented the Veteran had a diagnosis of hypertension since 1998. The Veteran gave a history of high blood pressure for 11 years that was controlled with medication. In February 2017, a VA examiner opined that the Veteran's hypertension was not related to his period of service as there was no evidence of the condition in the STRs, at separation, or evidence of continuity of symptoms. The examiner stated "I believe there is neither evidence in the medical literature, consensus in the medical community or evidence in this specific case that supports a causal/aggravation relationships between these conditions." The examiner's opinion is based on an inaccurate reporting of the facts as the Veteran had elevated blood pressure readings in April 2004 prior to his final period of active service and may have been treated for hypertension during service in 2005. Further, the Veteran reports that his hypertension had on onset in 1998 and the Veteran was on a period of active duty through April 1998. Thus, remand is required for an adequate opinion. Lastly, with regard to the Veteran's claim for a psychiatric disorder, a November 2009 VA psychiatry record documents an assessment of major depressive disorder, adjustment disorder with anxiety, pain disorder secondary to general medical condition, and alcohol and cannabis abuse by history. A July 2010 VA treatment record shows the Veteran reported witnessing suicide in the military. A January 2015 VA mental health assessment report documents the Veteran reported nightmares related to his deployments. The Veteran reported symptoms suggestive of trauma or stress related anxiety disorder and chronic insomnia. The Veteran underwent a VA PTSD evaluation in February 2015. At that time he reported trauma in Kuwait when the truck behind him got in an accident and fell off a bridge, he also reported being fired at, and an incident where a man forced the Veteran to wait in the heat for a long time for a container and the Veteran got so angry he threatened to shoot the man. The Veteran reported that his psychiatric symptoms began after he threatened to shoot the fellow service-member. Specifically, he stated that he lost the ability to focus and the ability to sleep. The Veteran underwent a VA mental disorder examination in February 2017. The examiner noted current diagnoses of severe bipolar disorder, and alcohol and cannabis abuse in remission. The Veteran had a history dating back to 2005 of inpatient and outpatient psychiatric treatment within the VA, and he had been hospitalized 6 times due to depression and suicidal ideation. His symptoms appeared to be aggravated by financial and interpersonal stressors. The examiner stated that based on review of the available treatment records, the Veteran's bipolar disorder was related to the Veteran's period of INACDUTRA as his first psychiatric treatment was in December 2006, 11 months after separation from active service. The examiner stated the Veteran had denied the presence of mental health symptoms prior to this. The examiner did not address the February 2015 PTSD evaluation at which the Veteran reported his symptoms had their onset during his final period of active service, specifically related to the incident with threatening to shoot a fellow service-member. Also, despite the examiner's finding that there were no psychiatric symptoms prior to December 2006, the examiner did not otherwise explain why the Veteran's diagnosed psychiatric disorders were not related to a period of active duty service in light of the VA treatment records indicating stressful or traumatic in-service events and deployment related nightmares. Last, the examiner failed to address the other mental health diagnoses of record, or otherwise explain why those diagnoses were no longer applicable. Thus, remand is required to secure another VA examination and opinion. Last, on remand appropriate efforts should be made to identify and obtain all outstanding and relevant VA and private treatment records. Accordingly, the case is REMANDED for the following action: 1. Contact the National Personnel Records Center, the Records Management Center, the Veteran's unit(s), or any other appropriate entity to verify the dates of the Veteran's periods of ACDUTRA and INACDUTRA The AOJ must identify each verified period of ACDUTRA and INACDUTRA in a memorandum to the file that should then be associated with the claims folder for the examiners review. Summarize the findings and all actions taken, and include a copy of the summary in the claims file. 2. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment from April 2016 onward. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 3. Contact the SSA and obtain a copy of that agency's decision concerning the Veteran's claim for disability benefits, including any medical records used to make the decision. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 4. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 5. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination with an examiner qualified to opine on the etiology of the Veteran's claimed right knee and right elbow disorders. The entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide the following opinions: a) Is it at least as likely as not (50 percent or greater probability) that any diagnosed right knee or right elbow disorders is due to an injury incurred in a period of INACDUTRA? b) Is it at least as likely as not (50 percent or greater probability) that any diagnosed right knee or right elbow disorders are due to disease or injury incurred in a period of ACDUTRA? c) Is it at least as likely as not (50 percent or greater probability) that any diagnosed right knee or right elbow disorders were incurred in or otherwise related to a period of active duty service? d) Is it at least as likely as not (50 percent or greater probability) that right knee or right elbow arthritis developed to a compensable degree within one year of separation from active duty service? In providing the above opinion, the examiner must consider the following: 1) August 2002 and December 2005 service records documenting right knee and right elbow pain, and treatment for right knee and right elbow tendinitis; 2) 2003 VA treatment records documenting a history of right knee and right elbow pain and tendinitis; 3) November 2008 VA x-rays significant for degenerative changes of the right knee; and 4) January 2014 VA MRI results showing a discoid variant of the lateral meniscus and anterior cruciate ligament thinning proximally which may be related to a remote injury. 6. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his hypertension. The entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. a) Is it at least as likely as not (50 percent or greater probability) that hypertension is due to an injury incurred in a period of INACDUTRA? b) Is it at least as likely as not (50 percent or greater probability) that hypertension is due to disease or injury incurred in a period of ACDUTRA? c) Is it at least as likely as not (50 percent or greater probability) that hypertension was incurred in or otherwise related to a period of active duty service? d) Is it at least as likely as not that hypertension manifested to a compensable degree within one year of separation from active duty service? In providing the above opinion, the examiner must consider the following: 1) April 2004 VA treatment records documenting the Veteran had elevated blood pressure; 2) December 2005 STRs noting the Veteran was prescribed atenolol; 3) March 2006 VA treatment records noting a current diagnosis of hypertension; and 4) a July 2015 disability benefits questionnaire documenting a diagnosis of hypertension since 1998. 7. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his claimed psychiatric disorder. The entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. a) Identify all psychiatric disorders previously diagnosed and currently diagnosed. If a previously diagnosed disorder is no longer present, the examiner must explain why and reconcile any conflicting medical evidence. b) Is it at least as likely as not (50 percent or greater probability) that any diagnosed psychiatric disorders are due to an injury incurred in a period of INACDUTRA? c) Is it at least as likely as not (50 percent or greater probability) that any diagnosed psychiatric disorders are due to disease or injury incurred in a period of ACDUTRA? d) Is it at least as likely as not (50 percent or greater probability) that any diagnosed psychiatric were incurred in or otherwise related to a period of active duty service? The examiner must consider the following: 1) November 2009 VA treatment records noting diagnoses of major depressive disorder, adjustment disorder with anxiety, pain disorder secondary to general medical condition; 2) a July 2010 VA treatment record noting the Veteran witnessed a suicide in the military; 3) a January 2015 VA mental health assessment reporting nightmares related to deployment; and 4) a February 2015 VA PTSD evaluation. 8. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 9. Ensure that compliance with the directives of this remand. If a report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 10. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter or 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 2014). ______________________________________________ K. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs