Citation Nr: 1803156 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 12-33 493A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for dysentery, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 2. Entitlement to service connection for a skin condition, to include rash and skin cancer, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 3. Entitlement to service connection for chronic fatigue, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 4. Entitlement to service connection for muscle aches and joint pain, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 5. Entitlement to service connection for trouble sleeping, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 6. Entitlement to service connection for brain fog, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 7. Entitlement to service connection for hearing loss. 8. Entitlement to service connection for tinnitus. 9. Entitlement to service connection for traumatic arthritis of the low back. 10. Entitlement to service connection for hypertension. 11. Entitlement to service connection for Crohn's disease. 12. Entitlement to service connection for traumatic arthritis, right foot. 13. Entitlement to service connection for traumatic arthritis, left foot. 14. Entitlement to service connection for kidney cancer. 15. Entitlement to service connection for loss of nails, right foot. 16. Entitlement to service connection for loss of nails, left foot. 17. Entitlement to service connection for a bladder condition. 18. Entitlement to service connection for residual scar, stomach. 19. Entitlement to service connection for a prostate condition. 20. Entitlement to service connection for a ureteral condition, to include as secondary to a kidney disorder. 21. Entitlement to an increased (compensable) disability rating for an intestinal bowel disorder, also claimed as intestinal blockage. 22. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD C. Bosely, Counsel INTRODUCTION The Veteran had active service from July 1972 to June 1976 and from October 1990 to March 1991. He served in Southwest Asia from October 1990 to March 1991. He also had service in the Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2010 and April 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in a videoconference hearing from the RO in June 2017. In June 2017 and July 2017, the Veteran submitted additional evidence. He waived initial RO consideration of the additional evidence. See 38 C.F.R. § 20.1304(c). The issues of service connection for a skin condition, toe nail conditions, a psychiatric condition, trouble sleeping, brain fog, traumatic arthritis, right foot, a bladder condition, and a prostate condition are addressed in the decision below. The remaining claims are addressed in the remand section. FINDINGS OF FACT 1. At the June 2017 Board hearing, which was prior to the promulgation of a decision in the appeal, the Veteran informed the Board that a withdrawal of the appeal concerning the issue of traumatic arthritis, right foot, was requested. 2. The Veteran's multiple skin conditions, diagnosed as basal cell carcinoma excision; actinic keratosis, multiple scars; dermatitis not otherwise specified, lesion on right anterior chest; and dyshidrotic eczema bilateral feet with overlying tinea pedis, started during or are related to his service. 3. A psychiatric disorder, to include PTSD, depression, and anxiety, claimed as trouble sleeping and brain fog, is a result of stressful events during service, including in the Persian Gulf War. 4. A bladder condition or prostate condition did not start during or result from service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran have been met as to the issue of traumatic arthritis, right foot. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. The criteria to establish service connection for a skin condition, to include basal cell carcinoma excision; actinic keratosis, multiple scars; and dermatitis not otherwise specified, lesion on right anterior chest, are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. The criteria to establish service connection for dyshidrotic eczema, right foot, with overlying tinea pedis, claimed as loss of nails, right foot, are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. The criteria to establish service connection for dyshidrotic eczema, left foot, with overlying tinea pedis, claimed as loss of nails, left foot, are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 5. The criteria to establish service connection for a psychiatric disorder, to include PTSD, depression, and anxiety, claimed as trouble sleeping and brain fog, are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, (2017). 6. The criteria to establish service connection for a bladder condition are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 7. The criteria to establish service connection for a prostate condition are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Withdrawal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. Id. In the present case, the Veteran withdrew his appeal at the June 2017 Board hearing as it concerns the issue of service connection for traumatic arthritis, right foot. Board Hr'g Tr. 3. Hence, there remain no allegations of errors of fact or law for appellate consideration with regard to that issue. Accordingly, the Board does not have jurisdiction to review the appeal as to that issue, and it is dismissed. II. Service Connection The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). A. Applicable Law Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, a veteran must show: "(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"-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Active Duty for Training (ADT) is defined as full-time duty in the Armed Forces performed by Reserves for training purposes. 38 U.S.C.A. § 101(22). Service connection may be granted for injury or disease incurred or aggravated in ADT. 38 U.S.C.A. § 101(24). Inactive Duty Training (IADT) is defined as other than full-time training performed by Reserves. 38 U.S.C.A. § 101(23). Service connection may be granted for injuries incurred or aggravated in IADT, but not for disease (except from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training). 38 U.S.C.A. § 101(24). Service connection may be granted for certain disabilities occurring in Persian Gulf veterans. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. The term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The Southwest Asia theater of operations 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)(2). Service connection may be established where a Persian Gulf veteran exhibits objective indications of a qualifying chronic disability, provided that such disability: (i) became manifest either during active military, naval, or air service in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2016; and (ii) by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1). For purposes of this section, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (b) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders (excluding structural gastrointestinal diseases). 38 C.F.R. § 3.317(a)(2)(i). The term "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. 38 C.F.R. § 3.317(a)(2)(ii). Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. "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). Non-medical indicators include evidence such as time lost from work, the veteran having sought treatment for his symptoms, and changes in the veteran's appearance, physical abilities, and mental or emotional attitude. Joyner v. McDonald, 766 F.3d 1393, 1395 (Fed. Cir. 2014) Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). A qualifying chronic disability referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a)(5). Service connection may not be established under 38 C.F.R. § 3.317 for a chronic disability: (i) if there is affirmative evidence that the disability was not incurred during active military, naval, or air service in the Southwest Asia theater of operations; or (ii) if there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations and the onset of the disability; or (iii) if there is affirmative evidence that the disability is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(a)(7). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurological 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). Pain, such as muscle pain or joint pain, may also establish an undiagnosed illness that causes a qualifying chronic disability. Joyner, 766 F.3d at 1395. Presumptive service connection may also be established under 38 C.F.R. § 3.317 for certain infectious diseases, which are listed in 38 C.F.R. § 3.317(c). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. B. Discussion Relevant to the claims decided herein, the Veteran is a Persian Gulf War Veteran as defined in § 3.317. His service records confirm service in Southwest Asia from October 1990 to March 1991. Skin & Toenails The Veteran maintains that he has a skin condition since returning from the Persian Gulf War. Board Hr'g Tr. 17. He has had foot fungus, or "foot rot," since that time, which he maintains advanced into skin cancer. See May 2009 statement, June 2013 statement. He has since been treated for different types of skin cancers. Board Hr'g Tr. 17. He has also had a problem with his toenails falling out since 1991. Board Hr'g Tr. 30. As confirmed on VA examination in April 2010, the Veteran has been diagnosed with basal cell carcinoma excision; actinic keratosis, multiple scars; dermatitis not otherwise specified, lesion on right anterior chest; and dyshidrotic eczema bilateral feet with overlying tinea pedis. In July 2017, the Veteran's private treating dermatology provider (PA-C) gave an opinion that the Veteran's environmental exposures in Southwest Asia, including desert sun exposure, contributed more likely as not to his history of skin cancers. She explained the basis for this opinion as radiation from the sun being a primary cause of skin cancers. Service connection for skin cancer is warranted in light of this opinion, which is clear and well supported. With regard to the remaining diagnoses, the evidence does not contain a similar opinion from a medical professional relating the conditions to his service. However, the Veteran's own statements, which are credible, describe an onset of symptoms since service. Those symptoms are uniquely within his own capacity to recognized and observe and medical evidence is not categorically necessary to substantiate a claim. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In fact, the Veteran submitted copies of letters he wrote to his wife while in Southwest Asia. These include an October 1990 letter where he specifically complained that his toenails were turning colors, becoming brittle, and cracking. Accordingly, his lay statements are sufficiently competent to bring the evidence into a state of relative equipoise in establishing a nexus to service. Accordingly, service connection is granted for these skin conditions as well. Trouble Sleeping/Brain Fog The Veteran also maintains that he has had trouble sleeping and brain fog, as manifestations of posttraumatic stress disorder (PTSD), due to service in the Persian Gulf War. To establish entitlement to disability compensation specifically for PTSD, a claimant must present (1) evidence of a current diagnosis of PTSD; (2) evidence of an in-service stressor, with credible supporting evidence that the claimed in-service stressor occurred; and (3) evidence of a causal nexus between the current symptomatology and the in-service stressor. 38 C.F.R. § 3.304(f). The Veteran separately filed a claim of service connection for PTSD, which was denied in the May 2010 rating decision on appeal. The Veteran filed a notice of disagreement (NOD) in June 2010 specifically disagreeing with the denial of service connection for PTSD. A statement of the case (SOC) was not issued. The Board finds that this is nonprejudicial, however, as the scope of the instant claims is reasonably shown to include all psychiatric conditions. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). On the title page of this decision, the Board maintained the RO's original characterization only for purposes of clarity. The Veteran is currently diagnosed with PTSD. A VA examiner reached such a diagnosis in April 2010, as did a private examiner in February 2009 and his treating VA providers including in July and July 2017. The evidence is consistent with fear of hostile military action during service in Southwest Asia. For instance, an August 2010 VA Mental Health Record notes that he had been "often terrified and horrified." He also had other stressful events consistent with his service in the Persian Gulf War. In a March 2009 stressor statement, he wrote about an enemy jet flying over his position and receiving SCUD missile attacks. In his letters to home, he specifically wrote about these two events. First, in two January 1991 letters, he wrote about incoming SCUD missiles. Second, in a separate January 1991 letter, he wrote about "an Iraq MIG fighter" doing a "recon mission on us today." This evidence establishes stressful events during service. Finally, the Veteran's PTSD is shown to be related to these events. His treating VA psychotherapist diagnosed "severe and chronic PTSD caused by military service in the Gulf War" in June 2017. A different VA provider in July 2017 diagnosed PTSD from the Gulf War and major depressive disorder and anxiety disorder. Accordingly, service connection is granted is granted for PTSD. The symptoms of "brain fog" and trouble sleeping are shown to be related to the Veteran's PTSD. As such, those two claims are granted as symptoms of the PTSD. Bladder & Prostate The Veteran maintains that he has bladder and prostate conditions that are either due to his service in Southwest Asia or are otherwise due to the cumulative impact of his service over the years. Board Hr'g Tr. 31-32. With regard to the bladder, the medical records show a diagnosis of bladder calculi (stones), which were found in March 2011 and treated in May 2011. With regard to the prostate, the Veteran was found to have elevated laboratory readings in September 2010. A biopsy was done in October 2010, which was negative. On CT scan in March 2011, he was found to have an enlarged prostate gland. An ultrasound in April 2011 showed a cyst in the prostate. He underwent a second procedure in August 2013, which was negative for cancer. There is insufficient evidence to show that the bladder or prostate conditions started during or otherwise resulted from his service. Additionally, as clinical diagnoses are shown, the conditions are not undiagnosed illnesses. There is also no indication that these conditions represent a medically unexplained chronic multisymptom illness as defined in § 3.317(a)(2)(ii). The Veteran himself feels that the conditions resulted from service. However, this question is not one that is capable of lay observation, within the common knowledge of a lay person, or otherwise within the competence of a non-medical expert. See Fountain v. McDonald, 27 Vet. App. 258, 274-75 (2015); Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). Otherwise, as his hearing testimony shows, he has no factual basis to support his belief. Board Hr'g Tr. 31-32. Thus, his conclusory statements do not indicate a nexus to service. See Fountain, 27 Vet. App. at 274-75; see also Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010). Because the evidence does not indicate a nexus to service, there is no basis to undertake any further development. Although the Board is remanding the remaining issues for further development, remand is not necessary for these two claims as there is no reasonable possibility that further assistance would substantiate this claim. See 38 C.F.R. § 3.159(d). As the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine is not applicable, and service connection is not warranted for a bladder or prostate condition. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. ORDER The appeal regarding the issue of traumatic arthritis, right foot, is dismissed. Service connection for a skin condition, to include basal cell carcinoma excision; actinic keratosis, multiple scars; and dermatitis not otherwise specified, lesion on right anterior chest is granted. Service connection for dyshidrotic eczema, right foot, with overlying tinea pedis, claimed as loss of nails, right foot, is granted. Service connection for dyshidrotic eczema, left foot, with overlying tinea pedis, claimed as loss of nails, left foot, is granted. Service connection for a psychiatric disorder, to include PTSD, depression, and anxiety, claimed as trouble sleeping and brain fog, is granted. Service connection for a bladder condition is denied. Service connection for a prostate condition is denied. REMAND The Board has conducted a preliminary review of the remaining issues, but has found that further evidentiary development is warranted. Dysentery, Crohn's Disease, & Intestinal Bowel Disorder The three claims of involving dysentery, Crohn's disease, and intestinal bowel disorder (IBD) must be remanded for further development. With regard to Crohn's disease, a new VA examination is needed. An April 2010 VA examiner summarized that the condition was diagnosed in 1980, he had surgery in 1987, and it flared up when deployed in Southwest Asia from 1990 to 1991. (The contemporaneous medical records from 1980 and 1987 are not in the claims file.) The April 2010 VA examiner opined that the irritable bowel syndrome is not a risk factor for Crohn's disease. The Veteran underwent a second VA examination in January 2014. This VA examiner cited a WebMD.com article explaining that inflammatory bowel disease (IBD) is not the same thing as IBS. These examinations are incomplete as the question is not whether the Veteran's Crohn's disease is secondary to IBD, but whether Crohn's disease, which was diagnosed in close temporal proximity to his first period of active service, had its actual onset during that period of service separate and apart from IBD. Separately, there is a question as to whether the condition, which preexisted his second period of active duty service, was aggravated therein. A new VA examination is needed to address these complex medical questions. The claim of service connection for dysentery is intertwined with the claim of service connection for Crohn's disease. With regard to the claim for an increased rating for IBD, there are outstanding private medical records. The private medical records were identified at a September 2013 VA Rheumatology appointment, where it was noted that he was followed by a "civilian" gastrointestinal physician. Because these records have been reasonably identified as potentially relevant, the Veteran should be given the opportunity to obtain them for review or request VA to obtain them on his behalf. A new VA examination is also needed. The Veteran last underwent a VA examination in January 2014. The VA examiner commented that "the majority of his current symptoms are due to Crohn's disease and unrelated to irritable bowel syndrome." (The VA examiner appears to have substituted the term "irritable bowel syndrome" for the service-connected IBD.) The examiner also wrote that "[t]o the best of my ability, this examiner has attempted to associate only the [V]eteran's current symptoms associated with his service-connected condition (durable [sic] bowel syndrome) for purposes of this report." Nonetheless, in light of the development on the claim of service connection for Crohn's disease, together with the outstanding private medical records, the Board finds that a new VA examination is needed to more accurately evaluate the ongoing severity of the disability. See 38 C.F.R. §§ 3.326, 3.327 (2015); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995). Chronic Fatigue & Muscle Aches and Joint Pain The Veteran maintains that he has chronic fatigue and muscle aches and joint pain resulting from his service in Southwest Asia. A VA examination is needed as the Veteran is shown to have complained of fatigue and muscle aches and joint pain, but the Board cannot determine with any degree of certainty whether these symptoms are undiagnosed illnesses within the meaning of § 3.317. For instance, a VA examiner in April 2010 diagnosed chronic fatigue. But, the Veteran complained of fatigue as early as January 1987 and February 1987, which was before his service in Southwest Asia. More recently, he complained of fatigue in February 2009 in connection with a course of medication for an intestinal condition. A private provider in July 2012 noted that the Veteran's fatigue had been eliminated with testosterone treatment for hypogonadism. He complained of decreased energy in January 2017 after stopping testosterone. These medical records indicate that the Veteran's complaints of fatigue may be symptoms of a separate medical condition. Similarly, the evidence shows muscle and joint pain, but it is not clear whether these symptoms are associated with other diagnoses. For instance, the April 2010 VA examiner diagnosed muscle and joint pain at the hand and wrist at the time of the examination. During his service in Southwest Asia, he wrote four letters to his wife in February 1991 indicating "more body ailments," especially numbness and tingling in the hand. More recently, a February 2011 VA Rheumatology consultation resulted in an assessment of chronic bilateral hand paresthesias with positive Tinel sign consistent with carpal tunnel syndrome (CTS). Subsequent VA Rheumatology appointments, such as in November 2012, March 2013, and September 2013, show "polyarthralgias" with complaints involving the low back, right elbow, right foot, left knee, bilateral shoulders, and right great toe. He has been diagnosed with specific conditions in those joints, but also gout. More recently, he had a gout flare in November 2014 involving the left foot, heel and great toe, plus likely rotator cuff tendonitis in the shoulder. Based on this current evidence, the Board cannot determine with any degree of certainty whether the muscle and joint pains representative a qualifying chronic disability under § 3.317 instead of symptoms of other diagnoses. A VA examination is needed to address these questions. Hearing Loss & Tinnitus The claims of service connection for hearing loss and tinnitus must be remanded for a new VA examination. With regard to hearing loss, the Veteran underwent a VA examination in April 2010. The VA examiner gave a negative opinion, but the examiner's supporting rationale is confusing. First, the VA examiner reasoned that the "slight changes in hearing from 1978 to 2001 over a period of 20 years are more than likely due to the natural aging process." Next, the VA examiner reasoned that the hearing loss shown at that examination was "not due to military service, but more than likely due to civilian noise exposure (law enforcem[e]nt) and/or some other etiology." This explanation is confusing because the Veteran had Reserve service after the 2001 hearing examination cited by the examiner. That service was concurrent with his civilian law enforcement job. It is not clear from the VA examiner's opinion why it would only be the civilian law enforcement noise, but not the military service noise, that would have caused the hearing loss. It is common sense within common experience to recognize that military noise exposure is as severe as, or worse, than civilian noise exposure as a law enforcement officer. Thus, it is not clear to the Board why the examiner attributed the Veteran's hearing loss to one type of noise exposure (law enforcement) instead of another (military) when the Veteran was being exposed to both types of noise exposure during the same time periods. With regard to tinnitus, the Veteran has given somewhat differing statements. He informed the April 2010 VA examiner that his tinnitus "started shortly after his return from overseas in 1991." At the Board hearing, by comparison, he testified that the tinnitus symptoms started "probably right after I got discharged from the Navy," which was in June 1976. Board Hr'g Tr. 8. He further testified that the symptoms were not "to the point that it was so annoying until I came back from Desert Storm." Board Hr'g Tr. 8. Reconciling these two accounts, he appears to be contending that the condition began at some point after his first period of service, but became worse during his second period of service. The April 2010 VA Audiology examiner concluded that the record contained "no documentation of any tinnitus." Therefore, the VA examiner reasoned, "[s]ince there was no change in hearing while on active duty and it is more than 19 years since he was on active duty, in my opinion the tinnitus is not due to military service but more than likely due to some other etiology." Earlier in the report, the examiner wrote "Yes" where asked if tinnitus was likely a symptom of hearing loss. The VA examiner did not give a medical reason justifying why contemporaneous medical documentation was needed. For instance, the VA examiner did not identify any specific instances in the STRs where the Veteran was asked during service whether he had symptoms of tinnitus or where, even if not specifically asked, he was reasonably expected to have reported symptoms of tinnitus. Thus, it is not clear to the Board why the VA examiner was equating an absence of documented symptoms during service with affirmative evidence of absence. See Fountain, 27 Vet. App. at 274 (a medical report stating that the "veteran did not report tinnitus" cannot be considered evidence of a denial of tinnitus during service or after service.). Moreover, the VA examiner did not address whether tinnitus, if preexisting his second period of service, was aggravated therein. Low Back A new VA examination is needed to resolve the complex medical questions raised by the low back claim. The Veteran previously underwent a VA examination in July 2012. The VA examiner gave a negative opinion. The VA examiner reasoned that there was no documented medical evidence of chronicity to support the Veteran's claim; he had a diagnosis of minimal degenerative changes per x-ray dated in November 2010; and he marked having "No" recurrent back pain on a March 1992 Airborne examination. At his Board hearing, the Veteran testified that he started having low back problems since he came back from Southwest Asia in 1991. This would imply that his low back symptoms started after such service. However, he also testified that his symptoms were due to carrying heavy equipment and parachuting during service. Board Hr'g Tr. 4. Consistent with his latter testimony, the claims file contains letters the Veteran wrote home to his wife during his service in Southwest Asia. In a January 1991 letter, he complained that this "lower back is killing me from digging and filling sand bags." Then in February 1991, he again complained that his "body is killing me, esp[ecially] my lower back." Then, during VA Rheumatology treatment in November 2010, the Veteran complained of "chronic [low back pain], was paratrooper in Army, sustained multiple injuries as paratrooper." The Board notes that the July 2012 VA examiner cited a March 1992 Airborne examination, but a later Individual Jump Record in his personnel file shows that he had subsequent jumps after the March 1992 examination. In a May 2015 VA Form 9, the Veteran identified the most traumatic jump landing as occurring in 2003. (He is currently service-connected for a hip disability related to this event.) At his Board hearing, he described a later parachute landing fall on tar mac, which "messed up" his whole body on the left side. Board Hr'g Tr. 24. Overall, the evidence does not currently answer whether the low back symptoms, even if they started after his Persian Gulf War service, were nonetheless due to the cumulative joint trauma experienced throughout his service, such as those documented in his letters home, or his later parachute jumps. A new VA examination is needed to address these questions. Left Foot A VA examination is needed to address the left foot claim. The Veteran maintains that he injured the left foot when he hit the side of the ankle, causing an inverted sprain, while parachuting. Board Hr'g Tr. 24. The Veteran's STRs show that he was put on profile in August 2003 for left leg inverted sprain. No details are provider, and there are no other STRs reflecting treatment for this injury. The Air Force Base at which this injury occurred informed the RO in February 2009 that it had no records on file for the Veteran. However, there is a private x-ray from March 2003. It does not state why the x-ray was taken other than to note "trauma." There were no acute osseous abnormalities found. He had follow-up treatment with a private provider approximately 14 days later, which noted he had fallen on the left lower leg and had a left ankle sprain. This evidence does not confirm the parachute injury. However, the Veteran's testimony is competent and credible and is consistent with this evidence, including the August 2003 profile. A VA examination has not been conducted. The Board finds that one is necessary. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i); McLendon, 20 Vet. App. at 83. Hypertension A new VA examination is needed to address the Veteran's hypertension. The Veteran maintains that he was diagnosed with high blood pressure in February 2002 after complaining of chest pain during Reserve service. See May 2015 VA Form 9. According to an April 2010 examination, the onset was in 2000 or 2001, according to the Veteran's report. The VA examiner could not give an opinion without resort to speculation because his blood pressure was elevated during ADT in November 2001, but there were no preceding records. The VA examiner concluded that it was not possible to state that the hypertension did or did not exist prior to those two weeks. The VA examiner went on to state that "if medical records for the months to a year before November 2001 can be obtained, the case should be reviewed." At present, it does not appear that the records identified by the April 2010 VA examiner exist or are obtainable. Thus, further action is not needed on this basis, and the VA examiner's opinion appears to be adequate. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). However, the Veteran's VA medical records repeatedly describe the Veteran's hypertension as difficult to control even with medication. Of particular note, a September 2012 VA Telecare note reflects the Veteran's complaints that his blood pressure went "wacky" before going to therapy for PTSD. Because the Board herein above grants service connection for PTSD, this raises a secondary theory of entitlement. An opinion has not been obtained to address this theory. Accordingly, remand for an opinion is needed. Kidney, Urethral, Scar The claim of service connection for kidney cancer must be remanded as it is intertwined with the claim of service connection for hypertension and the claimed joint disorders. The Veteran's kidney cancer was diagnosed in January 2010; he had surgery in February 2010. The private medical records, such as April 2009, and an April 2010 VA examination, indicate that the Veteran had chronic renal insufficiency secondary to poorly controlled hypertension. Similarly, a November 2012 letter from the Veteran's VA medical center states that his kidney function was worse due to taking Aleve. To the extent the remanded development results in a grant of service connection for hypertension, a VA examination will be needed to address to what extent the poorly controlled hypertension and/or pain medication played a role in the development of his kidney cancer. As stated in a September 2015 VA Form 9, the Veteran maintains that the urethral condition is secondary to kidney corrective surgery. Similarly, he testified at the Board hearing that the claimed stomach scar is a result of surgery for Crohn's disease. As such, these claims are intertwined and must be remanded together. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). TDIU The claim for a TDIU is intertwined with the remanded claims and will also be remanded. Accordingly, these issues are REMANDED for the following actions: 1. Send the Veteran a letter requesting that he submit or authorize VA to obtain all private (non-VA) health care providers who may have additional records pertinent to the remanded claims, to specifically include treatment for his intestinal bowel condition. Make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. 2. Obtain all outstanding VA treatment records. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. Thereafter, arrange for the Veteran to undergo a VA examination to address the claimed dysentery and Crohn's disease. The relevant information in the claims file must be made available to the examiner for review. The examiner is asked to review the pertinent evidence, including the Veteran's lay assertions regarding the history of his symptomatology, and undertake any indicated studies. Based on the examination results, the examiner is asked to provide an expert medical opinion on each of the following questions: (a) Provide a current diagnosis for any and all disorders found extant, including any current manifestations of dysentery. If the Veteran previously had any such medical condition, but it is no longer extant, when did that condition resolve? (b) For each diagnosed disorder, is it at least as likely as not (i.e., at least equally probable) that the disorder had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service? In answering question (b), the examiner is particularly asked to address whether Crohn's disease started during the Veteran's first period of active duty from July 1972 to June 1976 even though the diagnosis was not made until after that period of service. In answering these questions, please articulate the reasons underpinning each conclusion. That is, (1) identify what facts and information, whether found in the record or outside the record, support the conclusion, and (2) explain how that evidence justifies the conclusion. 4. Also, arrange for the Veteran to undergo a VA examination to address the claimed chronic fatigue and muscle aches and joint pain. The examiner is asked to review the pertinent evidence, including the Veteran's lay assertions regarding his symptomatology, and undertake any indicated studies. Then, based on the results of the examination, the examiner is asked to address each of the following questions: (a) Please state whether the symptoms of each claimed condition are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had any such condition, when did that condition resolve? (b) Is the Veteran's disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis. (c) If, after examining the Veteran and reviewing the claims file, you determine that the Veteran's disability pattern is either (2) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis, then please provide an expert opinion as to whether it is related to a presumed environmental exposures experienced by the Veteran during service in Southwest Asia. (d) Is it at least as likely as not that any diagnosed disorder had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War? In answering all questions (a) to (d), please articulate the reasons underpinning your conclusions. That is, (1) identify what facts and information, whether found in the record or outside the record, support your opinion, and (2) explain how that evidence justifies your opinion. 5. Also, arrange for the Veteran to undergo a VA examination to address the claimed hearing loss and tinnitus. The relevant information in the claims file must be made available to the examiner for review. The examiner is asked to review the pertinent evidence, including the Veteran's lay assertions regarding the history of his symptomatology, and undertake any indicated studies. Based on the examination results, the examiner is asked to provide an expert medical opinion on each of the following questions: (a) For each diagnosed disorder, is it at least as likely as not (i.e., at least equally probable) that the disorder had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service? If the examiner determines that the Veteran's hearing loss and/or tinnitus is due to civilian noise exposure, the examiner is asked to explain why the military noise exposure, which would be of the same type and intensity (if not worse) did not contribute to the onset of the condition. In answering these questions, please articulate the reasons underpinning each conclusion. That is, (1) identify what facts and information, whether found in the record or outside the record, support the conclusion, and (2) explain how that evidence justifies the conclusion. 6. Also, arrange for the Veteran to undergo a VA examination to address the claimed low back disorder. The relevant information in the claims file must be made available to the examiner for review. Accordingly, the examiner is asked to review the pertinent evidence, including the Veteran's lay assertions regarding the history of his symptomatology, and undertake any indicated studies. Based on the examination results, the examiner is asked to provide an expert medical opinion on each of the following questions: (a) Provide a current diagnosis for any and all low back disorders found extant. If the Veteran previously had any such medical condition, but it is no longer extant, when did that condition resolve? (b) For each diagnosed disorder, is it at least as likely as not (i.e., at least equally probable) that the disorder had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service? In answering these questions, the examiner is asked to consider the statements from the Veteran indicating that low back pain started during service. For instance, his contemporaneous letters written home during the Persian Gulf War show complaints of low back pain. The examiner is asked to explain why this evidence makes it more or less likely that a low back condition started during service. If indicated, it should be explained whether there is a **medical** reason to believe that the Veteran's recollection of his symptoms during and after service may be inaccurate or not medically supported. The examiner should only rely on silence in the medical records if it can be explained either (a) why the silence in the record can be taken as proof that the symptom did not occur, or (b) why the fact would have normally been recorded if present. In answering these questions, please articulate the reasons underpinning each conclusion. That is, (1) identify what facts and information, whether found in the record or outside the record, support the conclusion, and (2) explain how that evidence justifies the conclusion. 7. Also, arrange for the Veteran to undergo a VA examination to address the claimed left foot disorder. The relevant information in the claims file must be made available to the examiner for review. Accordingly, the examiner is asked to review the pertinent evidence, including the Veteran's lay assertions regarding the history of his symptomatology, and undertake any indicated studies. Based on the examination results, the examiner is asked to provide an expert medical opinion on each of the following questions: (a) Provide a current diagnosis for any and all left foot disorders found extant. If the Veteran previously had any such medical condition, but it is no longer extant, when did that condition resolve? (b) For each diagnosed disorder, is it at least as likely as not (i.e., at least equally probable) that the disorder had its onset directly during the Veteran's service or is otherwise causally related to any event or circumstance of his service? In answering these questions, the examiner is asked to consider the statements from the Veteran indicating that his symptoms started during service after a bad parachute jump landing in 2003. The examiner is asked to explain why this evidence makes it more or less likely that a left foot condition started during service. If indicated, it should be explained whether there is a **medical** reason to believe that the Veteran's recollection of his symptoms during and after service may be inaccurate or not medically supported. The examiner should only rely on silence in the medical records if it can be explained either (a) why the silence in the record can be taken as proof that the symptom did not occur, or (b) why the fact would have normally been recorded if present. In answering these questions, please articulate the reasons underpinning each conclusion. That is, (1) identify what facts and information, whether found in the record or outside the record, support the conclusion, and (2) explain how that evidence justifies the conclusion. 8. Also, arrange for the Veteran's information to be forwarded for an opinion regarding the claimed hypertension. The examiner is asked to provide an expert medical opinion on each of the following questions: (a) Is it at least as likely as not (i.e., at least equally probable) that hypertension is proximately due to, the result of, or caused by any other medical condition(s)? If so, please identify the primary medical condition(s). (b) If not caused by another medical condition, has hypertension been aggravated (made worse or increased in severity) by any other medical condition(s)? If so, please identify the primary medical condition(s). Also, please identify whether any increase in severity was due to the natural progress of the disease. In answering these questions, please articulate the reasons underpinning each conclusion. That is, (1) identify what facts and information, whether found in the record or outside the record, support the conclusion, and (2) explain how that evidence justifies the conclusion. 9. Schedule the Veteran for a VA examination to assess the severity of the service-connected intestinal bowel disorder. 10. After completing all actions set forth in paragraphs 1-9, undertake further action needed as a consequence of the development completed in those paragraphs, to include arranging for VA examinations to address the claimed kidney cancer, urethral condition, and stomach scar, as indicated herein above. Finally, readjudicate the remanded claims. If any benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate supplemental statement of the case (SSOC). The Veteran and his representative should be afforded the appropriate time period to respond. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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. §§ 5109B, 7112. ______________________________________________ RYAN T. KESSEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs