Citation Nr: 1804899 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 15-18 388 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for rheumatoid arthritis (RA). 2. Entitlement to service connection for a left forearm scar. 3. Entitlement to service connection for a right shoulder disorder. 4. Entitlement to service connection for a left shoulder disorder. 5. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 6. Entitlement to service connection for gout. 7. Entitlement to service connection for bilateral hearing loss. 8. Entitlement to service connection for tinnitus, to include as secondary to bilateral hearing loss. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Kate Sosna, Associate Counsel INTRODUCTION The Veteran had active duty service from March 1962 to March 1982, including service in the Republic of Vietnam. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in April 2013 by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2016, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A hearing transcript is associated with the record on appeal. The Board notes that, while the Veteran's January 2014 notice of disagreement did not include a disagreement with the April 2013 denial of service connection for a left forearm scar, new and material evidence was received prior to the expiration of the appeal period in the form of a January 2014 VA scars examination report. As such, the Board finds that the April 2013 denial of service connection for a left forearm scar is not final and the claim will be reviewed on a de novo basis. See 38 C.F.R. § 3.156(b) (2017). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of entitlement to service connection for gout, bilateral hearing loss, and tinnitus are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. At the April 2016 hearing, prior to the promulgation of a decision in the appeal, the Veteran withdrew the claim of entitlement to service connection for RA from appeal. 2. Resolving all doubt in the Veteran's favor, his currently diagnosed left forearm scar is related to his military service. 3. At no time during the pendency of the claim does the Veteran have a current diagnosis of a right shoulder disorder and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim. 4. At no time during the pendency of the claim does the Veteran have a current diagnosis of a left shoulder disorder and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim. 5. At no time during the pendency of the claim does the Veteran have a current diagnosis of an acquired psychiatric disorder, to include PTSD, and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim CONCLUSIONS OF LAW 1. The criteria for withdrawal of appeal as to the issue of entitlement to service connection for RA have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. The criteria for service connection for a left forearm scar have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. The criteria for service connection for a right shoulder disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. The criteria for service connection for a left shoulder disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 5. The criteria for service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions 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); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Board notes that, as the Veteran reported treatment for his gout at a VA medical center in 1982, the Board is remanding such claim in order to obtain such records; however, the Veteran has not contended, and the record does not suggest, that he was ever treated for a shoulder or psychiatric disorder in 1982. Furthermore, as the evidence fails to show a current diagnosis referable to a shoulder or psychiatric disorder at any time proximate to the Veteran's May 2012 claim, records dated in 1982 would have no bearing on the current matter and there is no reasonable possibility that obtaining such records would substantiate the claims. See Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). Therefore, there is no prejudice to the Veteran in proceeding with a decision on such issues at this time. Further, neither the Veteran nor his representative has alleged any deficiency with respect to VA's duties to notify or assist. See Scott, supra (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 duty to assist argument). II. Withdrawal of Claim 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. § 7105 (2012). 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 (2017). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. At the April 2016 hearing, prior to the promulgation of a decision in the appeal, the Veteran withdrew the claim of entitlement to service connection for RA from appeal. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal in regard to such issue and it is dismissed. III. Service Connection Claims 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 may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Pertinent to a claim for service connection, such a determination requires a finding of a current disability that is related to an injury or disease in service. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). The requirement of a current disability is satisfied if the veteran has a disability at the time she files her service connection claim or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However, when the record contains a recent diagnosis of disability prior to the veteran's filing of a claim for benefits based on that disability, the report of the diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, to include psychosis and arthritis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition to the general principles governing service connection, to establish entitlement to service connection for PTSD the evidence must satisfy three basic elements. There must be: 1) medical evidence diagnosing PTSD; 2) a link, established by medical evidence, between current symptoms of PTSD and an in-service stressor; and 3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a). In this regard, the Board notes that, for cases certified to the Board after August 4, 2014, as is the case here, the diagnosis of PTSD must be in accordance with the DSM-5. With regard to the second PTSD element as set forth in 38 C.F.R. § 3.304(f), evidence of an in-service stressor, the evidence necessary to establish that the claimed stressor actually varies depending on whether it can be determined that the veteran "engaged in combat with the enemy." See 38 U.S.C. § 1154(b); 38 C.F.R. 3.304(d). If it is determined through military citation or other supportive evidence that a veteran engaged in combat with the enemy, and the claimed stressors are related to combat, the veteran's lay testimony regarding the reported stressors must be accepted as conclusive evidence as to their actual occurrence and no further development or corroborative evidence will be necessary. See 38 C.F.R. § 3.304(f). When the claimed stressor is not related to combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record must contain service records or other corroborative evidence that substantiates the veteran's testimony or statements as to the occurrence of the claimed stressors. See West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). However, in July 2010, the evidentiary standard outlined in 38 C.F.R. § 3.304(f)(3) for establishing in-service stressors in claims for PTSD was relaxed. The new regulations provide that if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 75 Fed. Reg. 39,843, 39,852 (July 13, 2010); 38 C.F.R. § 3.304(f)(3). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Left Forearm Scar The Veteran contends that he has a left forearm scar that was caused by an April 1969 in-service fall from a truck that resulted in abrasions to both of his arms. The Veteran was afforded a VA examination in December 2012, at which time the examiner noted the presence of a resolved left forearm scar. In this regard, she noted it was impossible to determine the boarders or measure any previous scar of the left forearm as the scar had blended with the Veteran's skin. Nevertheless, the examiner opined that it was at least as likely as not that the Veteran's left forearm scar was related to his military service. In support thereof, the examiner noted the Veteran's multi-day left arm wound treatment in April and May 1969. She further noted that the fact the scar had, in her opinion, blended with the surrounding skin did not rule out the presence of the scar historically. Therefore, she opined that, to the extent the Veteran suffered from a left forearm scar, such was related to his military service. Thereafter, during a January 2014 VA examination, another examiner diagnosed the Veteran with two painful scars of the left upper extremity that were reportedly 7 centimeters (cm) x .3 cm and 2 cm x .2 cm, with an approximate total area of 2.5 cm squared. Based on the foregoing, the Board finds that the evidence as to whether the Veteran has had a diagnosed left forearm scar related to his military service during the pendency of his claim, or close in proximity thereto, is in relative equipoise. Therefore, the Board resolves all doubt in the Veteran's favor and finds that he has a currently diagnosed left forearm scar that is proximately due to his in-service April 1969 fall from a vehicle. Therefore, service connection for such disorder is warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303; Gilbert, supra. Right and Left Shoulder Disorders The element of service connection at issue regarding the Veteran's claims for right and left shoulder disorders is the presence of a current disability. In this regard, the Board acknowledges that service treatment records document the Veteran's April 1969 fall from a vehicle, and his proximity to a July 1969 explosion while serving in Vietnam is consistent with the circumstances of his military service. Nevertheless, the probative evidence of record fails to demonstrate that the Veteran has a current diagnosis of a right or left shoulder disorder, to include as a result of such in-service events, at any time proximate to his claim. As such, service connection for right and left shoulder disorders must be denied. Turning to the evidence of record, the Veteran was afforded a VA Non-degenerative Arthritis examination and a VA Shoulder and Arms examination in December 2012. In conjunction with the arthritis examination, the Veteran reported to the examiner that he had been diagnosed with right shoulder arthritis and RA at Porter Adventist Hospital (PAH) in April 2012. While the Veteran is competent to report what medical professionals have told him, the Board finds his statements regarding the diagnosis of right shoulder arthritis lack credibility. In this regard, in an October 2012 letter, PAH denied ever having treated the Veteran. Additionally, the record does not contain any diagnosis of right shoulder arthritis or RA aside from the December 2012 examination report which was based solely on the Veteran's reported medical history. In fact, x-ray imaging performed in conjunction with the examination report was negative for findings of arthritis. Thereafter, at the April 2016 Board hearing, the Veteran reported that his right shoulder did not bother him. Ultimately, the Board finds the Veteran's assertions regarding his alleged right shoulder arthritis and RA diagnoses lack credibility as there is no documentation of such diagnoses by a competent medical professional, medical testing did not reveal the presence of such disorder (as further discussed below), and the Veteran had an incentive to report a diagnosis, given his claim for service connection. Buchanan v. Nicholson, 451 F.3d 1331, 1336-1337 (2006) (the lack of contemporaneous medical records, the significant time delay between the affiants' observations and the date on which the statements were written, and conflicting statements of the veteran are factors that the Board can consider and weigh against a veteran's lay evidence); Caluza v. Brown, 7 Vet. App. 498, 506 (1995) (VA adjudicators may properly consider internal inconsistency, facial plausibility and consistency with other evidence submitted on behalf of the veteran in weighing evidence); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (lack of corroborating contemporaneous evidence may be a factor in determining credibility); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; pecuniary interest may, however, affect the credibility of the evidence). Notably, even if the Veteran believes his recollections to be accurate, the Board finds that the Veteran is simply not a reliable historian as to this aspect of the claim. See Seng v. Holder, 584 F.3d 13, 19 (1st Cir. 2009) (notwithstanding the declarant's intent to speak the truth, statement may lack credibility because of faulty memory). Thus, as the December 2012 examiner's notation of the presence of arthritis was based solely on the Veteran's non-credible reports, the Board affords it no probative value. During the concurrent shoulder examination, the examiner, a nurse practitioner, diagnosed the Veteran with bilateral shoulder RA based on the presence of a positive rheumatoid factor in the Veteran's blood work and the Veteran's reports that RA had been diagnosed by PAH. As noted above, the Veteran's reports regarding diagnoses made by PAH lack credibility. Based on the 2012 examiner's notation of the positive rheumatoid factor in the Veteran's blood, the RO sought an addendum opinion from a physician in February 2013 to determine whether the Veteran had a diagnosed disorder of the bilateral shoulders, to include RA. After reviewing the record the examiner noted that "it is well-known in the [medical] literature that a positive rheumatoid factor blood test...cannot be used to diagnose RA." He further noted that the positive test can be associated with a range of other disabilities and is even found in persons with normal health and 20 percent of persons with RA have not tested positive for the factor. Thus, he opined the Veteran did not suffer from RA. The Board affords greater probative weight to the February 2013 VA examiner's opinion than the December 2012 examiner's opinion regarding the presence of RA. In this regard, the 2013 VA examiner was a physician, who has greater training and skill in evaluating medical conditions and practices than the 2012 examiner, a nurse practitioner. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data). Moreover, the 2013 examiner's opinion is supported by the record, which fails to reveal any diagnosis of RA or any other shoulder diagnosis aside from that made by the 2012 examiner. Indeed, the 2013 examiner further stated that as the Veteran did not report any arthritis or shoulder condition upon his separation from service, did not seek treatment for shoulder pain for 30 years thereafter, and described his shoulder pain as "new" in 2012, the weight of the medical evidence suggested that the Veteran's current complaints are age-related. Notably, neither the 2012 examiner, the 2013 examiner, nor any clinician of record has ever diagnosed the Veteran with a right or left shoulder disorder aside from RA. Again, the Board finds the 2012 examiner's opinion regarding the presence of RA to be less probative than the 2013 examiner's opinion that the Veteran does not suffer from such disorder. Additionally, as noted above, the Veteran has withdrawn his claim for service connection for RA. Ultimately, the probative evidence of record fails to demonstrate a current diagnosis of right or left shoulder disorders at any time during the appeal period. McClain, supra. While the Board has also considered the United States Court of Appeals for Veterans Claims' (Court's) holding in Romanowsky, supra, there is also no probative evidence of recent diagnoses of the right or left shoulders prior to the filing of the Veteran's claim. In this regard, the Board notes that the Veteran is competent to report on his symptoms or matters within his personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan, supra. In addition, laypersons may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, supra. However, the matter of a medical diagnosis for a disability not capable of lay observation, such as that of right or left shoulder arthritis, is a matter within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). Specifically, the diagnosis of arthritis involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, and requires the administration and interpretation of imaging test results. In the instant case, there is no suggestion that the Veteran has developed an expertise in the diagnosis of musculoskeletal disabilities. Therefore, as he does not have the appropriate medical training and expertise to competently diagnose right or left shoulder disorders, his lay assertions in this regard have no probative value. Jandreau, supra at 1377 n.4 ("[s]ometimes 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"); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Furthermore, pain alone, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a "disability" for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), vacated in part and remanded on other grounds sub nom. Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). In conclusion, the Board finds the February 2013 VA examiner's opinions to be more probative than the Veteran and the 2012 nurse practitioner's assertions as to the presence of current shoulder disorders. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See Brammer, supra. Thus, where, as here, the probative evidence indicates that the Veteran does not have a current diagnosis of the right or left shoulder for the entire appeal period, there can be no valid claim for service connection. Id.; see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for right and left shoulder disorders. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Acquired Psychiatric Disorder Unfortunately, service connection for an acquired psychiatric disorder must also be denied based on the lack of a current diagnosis. In this regard, the Veteran has presented numerous alleged stressors in support of his claim; however, as noted above, a prerequisite to any claim for service connection is the presence of a current disability. In this case, the Veteran has never been diagnosed with an acquired psychiatric disorder during or prior to the period on appeal. In this regard, in December 2012, after interviewing the Veteran and conducting a psychological evaluation, a VA examiner noted the Veteran did not suffer from any psychological disorder. Indeed, the examiner stated, "[t]he mere presence of psychiatric symptoms does not warrant a diagnosis unless they are clinically significant and impair functioning. This is not the case for [the Veteran and,] [t]herefore, no diagnosis was offered." The Board notes the examiner apparently administered such testing under the DSM-IV, not the DSM-5, but nevertheless finds such opinion probative as to the presence of a current disability, especially in light of the Veteran's own report at the April 2016 hearing that he has never been diagnosed with a psychiatric disorder under any diagnostic criteria. Moreover, subsequent screenings performed by VA after the adoption of the DSM-5 failed to reveal symptomatology associated with a psychiatric disorder. See April 2016, April 2015, July 2014, and November 2013 negative depression screens and November 2013 negative PTSD screen. Ultimately, the probative evidence of record fails to demonstrate a current diagnoses of a psychiatric disability at any time during the appeal period or a recent diagnosis prior to his filing of a claim. McClain, supra; Romanowsky, supra. Again, while the Veteran is competent to report on his symptoms or matters within his personal knowledge, the medical diagnosis of a psychiatric disorder is not capable of lay observation. See Jandreau, supra; Davidson, supra; Jones, supra. Moreover, the Veteran himself denies ever having been diagnosed with a psychiatric disorder. As such, the Board finds the December 2012 VA examiner's opinion and the opinions provided by VA clinicians thereafter as to the absence of a current disability to be of great probative value as to the presence of current psychiatric disorder. Thus, as the probative evidence indicates that the Veteran does not have a current psychiatric diagnosis for the entire appeal period, there can be no valid claim for service connection. Brammer, supra; see also Gilpin, supra. The preponderance of the evidence is against the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, and the benefit of the doubt doctrine is therefore inapplicable to the instant claim, which must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER The appeal as to the issue of entitlement to service connection for RA is dismissed. Service connection for a left forearm scar is granted. Service connection for a right shoulder disorder is denied. Service connection for a left shoulder disorder is denied. Service connection for an acquired psychiatric disorder, to include PTSD, is denied. REMAND Regarding the Veteran's claim for service connection for gout, he reported at the April 2016 hearing that he began experiencing foot trouble in service that has continued to the present time. He further presented his belief that his gout is related to the strenuous nature of his 20 years of military service or to the rich foods consumed therein. VA treatment records reflect that the Veteran is currently diagnosed with gout. Accordingly, the Board finds that the low threshold of the McLendon standard has been met in this instance, and that the Veteran should be afforded a VA examination and opinion prior to adjudication of his claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Additionally, the Veteran reported at the April 2016 hearing that he was treated for gout at the VA medical center in Denver (Clermont) in 1982; however, the record does not contain treatment records from the 1980s. As such, attempts to obtain these records should be made on remand. Remand is also required for procurement of an opinion as to the etiology of the Veteran's diagnosed bilateral hearing loss. In this regard, a December 2012 examiner reported she could not provide an opinion as to the etiology of the Veteran's hearing loss without resorting to speculation. She noted the Veteran had fluctuating hearing during his military service, but, as she did not have access to his 1982 separation examination report, she could not opine as to the etiology of the Veteran's hearing loss. Thereafter, in March 2013, another VA examiner opined it was less likely than not that the Veteran's hearing loss was related to service as he had normal hearing tests throughout service, to include at separation, and there were no significant threshold shifts when comparing the Veteran's entrance and exit examinations. Unfortunately, the opinions are inadequate as the 2012 examiner noted the absence of evidence that might enable her to provide an opinion (the separation report) and the 2013 examiner based her opinion on an inaccurate factual premise. In this regard, the Veteran's hearing was not normal throughout his service as indicated by a November 1977 report of medical examination that noted the presence of mild bilateral hearing loss. Thus, the Board finds an addendum opinion is necessary to determine the etiology of the Veteran's hearing loss. Notably, on remand the examiner must consider whether the Veteran's in-service audiograms were recorded using American Standards Association (ASA) units or International Standards Organization-American National Standards Institute (ISO-ANSI) units.1 In this regard, for the Board's purposes, if it is not clear which unit was used for records prior to January 1, 1967, the Board must assume the ASA standards were used. If the standard used between January 1, 1967, to December 31, 1970, is unclear, the Board must consider the data under both ASA and ISO-ANSI standards. Finally, if it is unclear which standard was used after December 31, 1970, the Board must assume the ISO-ANSI standard was used. Importantly, in conjunction with the 2012 and 2013 VA hearing loss examinations, the examiners opined it was at least as likely as not that the Veteran's currently diagnosed tinnitus was caused by his hearing loss. Thus, the Board finds the two claims are inextricably intertwined and the tinnitus claim must also be remanded. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain VA treatment records from the Denver (Clermont) facility dated in 1982 referable to the Veteran's gout. 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. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. The Veteran should be afforded an appropriate VA examination to determine the nature and etiology of his gout. All indicated tests and studies should be undertaken. The claims file, including a complete copy of this remand, must be made available for review of the Veteran's pertinent medical history. Following a review of the record and examination of the Veteran, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran's gout is related to his military service, to include the strenuous nature of his 20 years of service or the rich foods he ate therein? In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements. The rationale for any opinion offered should be provided. 3. Return the record to the VA examiner who conducted the Veteran's March 2013 audiological examination. The record and a copy of this Remand must be made available to the examiner. The examiner shall note in the examination report that the record and the Remand have been reviewed. If the March 2013 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Upon a review of the record, the examiner should respond to the following: (a) Review the audiograms in the Veteran's service treatment records (March 1962, August 1966, April 1968, July 1968, December 1970, March 1973, November 1973, May 1976, June 1975, November 1977, and January 1982) and, to the extent possible, opine whether ASA or ISO-ANSI units were used in rendering the audiogram findings. (b) Is it at least as likely as not (i.e., 50 percent or greater probability), that the Veteran's bilateral hearing loss had its onset during his military service? Please specifically discuss the November 1977 notation of mild bilateral hearing loss. (c) Is it at least as likely as not that the Veteran's bilateral hearing loss is otherwise related to his military service, including as due to his acknowledged in-service exposure to noise and any resulting acoustic trauma, or other injury or disease having its onset in service? (d) Is it at least as likely as not that the Veteran's bilateral hearing loss manifested within one year of discharge from service? If so, please describe the manifestations. (e) Is it at least as likely as not that the progressively worsening hearing loss the Veteran has reported after his separation from service constituted an early manifestation of his subsequent hearing loss diagnosis? In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements. The rationale for any opinion offered should be provided. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. 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 (2012). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs