Citation Nr: 18139915 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 10-41 921 DATE: October 1, 2018 ORDER New and material evidence having been received, the previously denied claim of entitlement to service connection for a left elbow disability, now captioned as a claim of entitlement to service connection for a bilateral elbow disability, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is reopened. New and material evidence having been received, the previously denied claim of entitlement to service connection for a right elbow disability, now captioned as a claim of entitlement to service connection for a bilateral elbow disability, to include as secondary to service-connected PTSD, is reopened. New and material evidence having been received, the previously denied claim of entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, is reopened. New and material evidence having been received, the previously denied claim of entitlement to service connection for a testicular disability (other than erectile dysfunction) is reopened. REMANDED Entitlement to service connection for a bilateral elbow disability, to include as secondary to service-connected PTSD, is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, is remanded. Entitlement to service connection for a testicular disability (other than erectile dysfunction), claimed as testicular pain and swelling, is remanded. Entitlement to service connection for diabetes mellitus, type II, to include as due to herbicide exposure, is remanded. Entitlement to service connection for a bilateral knee disability, to include as secondary to service-connected PTSD, is remanded. Entitlement to service connection for a pulmonary or respiratory disability, claimed as asthma and bronchitis, is remanded. Entitlement to an initial rating in excess of 50 percent, outside of the periods dated from July 28, 2014, to August 31, 2014, and October 4, 2016, to December 31, 2016, during which temporary total ratings are in place, for service-connected PTSD, is remanded. Entitlement to a compensable rating for service-connected bilateral hearing loss is remanded. Entitlement to a compensable rating for service-connected hemorrhoids is remanded. Entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran did not appeal a June 2003 Department of Veterans Affairs (VA) Regional Office (RO) decision that denied service connection for a left elbow disability. 2. The Veteran did not appeal an August 1985 RO decision that denied service connection for a right elbow disability. 3. The Veteran did not appeal an April 2005 RO decision that denied service connection for hypertension. 4. The Veteran did not appeal an August 1985 RO decision that denied service connection for a testicular disability. CONCLUSIONS OF LAW 1. The June 2003 RO decision that denied service connection for a left elbow disability is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.201, 20.302. 2. The August 1985 RO decision that denied service connection for a right elbow disability is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.201, 20.302. 3. The April 2005 RO decision that denied service connection for hypertension is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.201, 20.302. 4. The August 1985 RO decision that denied service connection for a testicular disability is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.201, 20.302. 5. The evidence received after the June 2003 RO decision is new and material; the claim of entitlement to service connection for a left elbow disability, now captioned as a claim of entitlement to service connection for a bilateral elbow disability, is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 6. The evidence received after the August 1985 RO decision is new and material; the claim of entitlement to service connection for a right elbow disability, now captioned as a claim of entitlement to service connection for a bilateral elbow disability, is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 7. The evidence received after the April 2005 RO decision is new and material; the claim of entitlement to service connection for hypertension is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 8. The evidence received after the August 1985 RO decision is new and material; the claim of entitlement to service connection for a testicular disability is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1977 to October 1984. In November 2016, the Veteran and his spouse testified at a video conference hearing before the undersigned Veterans Law Judge (VLJ). A copy of the transcript of that hearing is of record. The Veteran is pursuing a claim for service connection for erectile dysfunction, for which he elected to participate in the Rapid Appeals Modernization Program (RAMP). As such, his claim for service connection for a testicular disability that is currently on appeal will not address his claimed erectile dysfunction. New and material evidence having been received, the previously denied claims of entitlement to service connection for left and right elbow disabilities, now captioned as a claim of entitlement to service connection for a bilateral elbow disability, to include as secondary to service-connected PTSD; hypertension; and a testicular disability are reopened. In general, VA rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.302. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. New evidence is defined as evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156 (a). The Veteran’s claim for service connection for a left elbow disability was last denied in a June 2003 rating decision, his claim for service connection for a right elbow disability was last denied in an August 1985 rating decision, his claim for service connection for hypertension was last denied in an April 2005 rating decision, and his claim for service connection for a testicular disability claimed as testicular pain and swelling, was last denied in an August 1985 rating decision. No party filed a Notice of Disagreement (NOD) to the rating decisions, nor was there any relevant new and material evidence, medical or lay, physically or constructively received by VA prior to the expiration of the appellate periods. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156 (b); 20.201. As such, the June 2003, August 1985, and April 2005 rating decisions are final. Relevant evidence added to the record since the prior decisions includes additional statements of the Veteran as to the etiology of his disabilities, VA treatment records, and reports of VA examinations. In May 2010, the Veteran underwent VA examination of his elbows, in February 2013, he underwent VA examination of his hypertension and the examiner offered an opinion in May 2013, and in March 2012, he underwent VA examination of his testes. However, no examiner submitted adequate etiological opinions as to the Veteran’s disabilities and additional examinations and/or opinions are warranted. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010) (in determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim with VA’s assistance). Accordingly, the evidence is new, as it was not previously before decision makers, and the evidence is material, as it could serve as bases to substantiate the claims, with VA’s assistance; and the claims of entitlement to left and right elbow disabilities, now captioned as a claim of entitlement to service connection for a bilateral elbow disability, to include as secondary to service-connected PTSD, hypertension, and a testicular disability, have been reopened. REASONS FOR REMAND Entitlement to service connection for a bilateral elbow disability, to include as secondary to service-connected PTSD, is remanded. The Veteran asserts that his elbow disabilities are related to service. During his November 2016 Board hearing, the Veteran asserted that he injured his elbows when he fell while playing basketball. He reported this his left elbow, having developed an abrasion, developed cellulitis and he was treated, as an inpatient, for such. His service treatment records dated in September 1979 indicate that he injured his left elbow playing basketball when he fell. He was admitted in February 1980 for left elbow cellulitis. In February 1985, the Veteran filed a claim of entitlement to service connection for a bilateral elbow disability. On VA examination in May 1985, the Veteran reported that his elbows “kept fluid in them” and he was treated for such in service, and complained that his elbows were still bothersome. He reported an injury to both of his elbows when he hit them during service in 1982 or 1983 on a truck while putting a camouflage net over it. He had no current complaints and the examiner determined that there was no residual of disease or injury. During VA treatment in December 2002, the Veteran complained of elbow pain, and in July 2009, he complained of right elbow pain, off and on, for years. On VA examination in May 2010, the Veteran reported that he fell on his left elbow during service while playing basketball and developed abrasions that became cellulitis, with inpatient treatment. It appears that the examiner reported that there were no more left elbow complaints until 15 years ago when the Veteran complained of aching and stiff elbows, especially in the morning. There was no swelling on examination, but there was puffiness in the bursae, bilaterally. The examiner diagnosed the Veteran with bilateral degenerative joint disease (DJD) and bursitis, however, the diagnosis of DJD appears to be based on report of a September 2009 VA X-ray examination report demonstrating degenerative changes in the right elbow. The examiner opined that such was not related to the Veteran’s in-service cellulitis, as there were no complaints after service until 15 years ago, that cellulitis is not a cause for DJD, because cellulitis is a superficial skin infection, and that the Veteran’s bilateral elbow DJD and bursitis is more likely related to multiple body joint DJD, obesity, and his previous occupation a truck driver. During his November 2016 Board hearing, the Veteran asserted that the examiner did not discuss whether his in-service infection has resulted in a systemic vulnerability, to which his current disability may be attributed. The Veteran also asserted that it did not appear that the examiner considered the many instances of complaint and treatment for left elbow cellulitis. As will be discussed below, a VA examiner has attributed the Veteran’s hypertension to a number of factors, including obesity, and in turn, the Veteran has asserted that such is due to his service-connected PTSD. While the Veteran has not specifically asserted that his bilateral elbow disability is secondary to his service-connected PTSD, he has asserted that his obesity is related to such, and considering the examiner’s opinion here as to the Veteran’s DJD of the bilateral elbows and bursitis and obesity, the record raises this theory of entitlement. On remand, the RO should send the Veteran sufficient Veterans Claims Assistance Act of 2000 (VCAA) notice as to claim on a secondary basis Also, it remains unclear if the Veteran has DJD in the left elbow, as noted above, the VA examiner’s diagnosis of such appears to be based on a September 2009 VA X-ray examination report demonstrating degenerative changes in the right elbow. It does not appear that the examiner considered the Veteran’s lay statements as to an in-service injury to both of his elbows, both the injury when he fell during a basketball game and the injury when he hit his elbows on a truck while covering it with a camouflage net. The RO should afford the Veteran a new VA examination to determine the precise nature and etiology of his bilateral elbow disability. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD, is remanded. The Veteran asserts that his hypertension is secondary to his service-connected PTSD. His service treatment records are silent for complaint or treatment of hypertension. He underwent VA examination of his hypertension in February 2013, and in May 2013, the examiner opined that the Veteran’s hypertension was not related to his PTSD, as the current medical literature failed to show a direct connection between PTSD and hypertension, that the exact causes of hypertension are not known and several factors play a role, including history of obesity, age, alcohol abuse, and lack of activity. The examiner did not provide an opinion as to whether the Veteran’s hypertension is aggravated by is PTSD. During the Veteran’s November 2016 Board hearing, he asserted that problems with his temper, from his PTSD, effect his hypertension, and that the examiner did not appear to consider that the Veteran’s obesity may be due to his PTSD. On remand, the RO should afford the Veteran a new VA examination to determine whether the Veteran’s hypertension is proximately caused or aggravated by his PTSD, considering whether any obesity, alcohol abuse, or lack of activity, is related to PTSD. Entitlement to service connection for a testicular disability (other than erectile dysfunction), claimed as testicular pain and swelling, is remanded. The Veteran asserts that he has a current testicular disability, characterized by pain and swelling, related to his in-service treatment for the same. His service treatment records beginning in April 1980 indicate that he complained of swollen testicles. He was treated for left epididymitis in May 1980 and June 1980. In June 1980, he had a physical profile for a left scrotal infection, and in May 1981, he had a physical profile for groin pain. In February 1985, the Veteran filed a claim of entitlement to service connection for a testicular disability, however on VA examination in May 1985, the examiner reported that the Veteran’s in-service epididymitis, treated with antibiotics, resolved, and there were no current complaints or findings on physical examination. In connection with his current claim, the Veteran, in a November 2009 statement, asserts that he had a “hernia on his testicles.” On VA examination in March 2012, the Veteran complained of pain and swelling in his testicles, and physical examination revealed normal testicles and normal epididymis. The Veteran was diagnosed with erectile dysfunction, a disability for which he has filed a separate claim of entitlement to service connection; however, such is not before the Board. The examiner opined that it is unlikely that the Veteran’s current symptoms of intermittent pain and swelling are related to the Veteran’s in-service epididymitis, as such is caused by infection, not related to pulled muscles. There is no indication that the Veteran has asserted that his testicular disability is related to any in-service pulled muscle; he continues to assert that his disability is related to his in-service treatment for swollen testicles. During his November 2016 Board hearing, the Veteran asserted that the examiner did not discuss whether his in-service infection has resulted in a systemic vulnerability, to which his current disability may be attributed. The Veteran also asserted that it did not appear that the examiner considered the many instances of complaint and treatment for swollen testicles during service. On remand, the RO should afford the Veteran a new examination to determine the precise nature of any current testicular disability, and the etiology thereof, considering that medical comment is required as to whether the testicular pain of which he has complained results in functional impairment such that the testicular pain may be considered a disability for VA compensation purposes. Saunders v. Wilkie, No. 2017-1466, 2018 U.S. App. LEXIS 8467 (Fed. Cir. Apr. 3, 2018).   Entitlement to service connection for diabetes mellitus, type II, to include as due to herbicide exposure, is remanded. The Veteran has been diagnosed with diabetes mellitus, type II, and underwent VA examination of the same in February 2013. The Veteran asserts that his diabetes mellitus, type II, is related to in-service exposure to herbicides. In a June 2012 statement, the Veteran reported that he was completing a field training exercise, for two or three weeks in July 1980, at Fort Polk in Louisiana, and was told that the United States (U.S.) Army was using Fort Polk as a dumping ground for herbicides. During his November 2016 Board hearing, the Veteran asserted that he noticed a foul odor at Fort Polk, and that other service members complained about it, and that the vegetation was brown, and that he found out years later that herbicides were dumped there. The Veteran’s service records appear to be silent for any service at Fort Polk; his service records, showing his chronological listing of duty stations, include report of service at Fort Stewart, Fort Hood, and Fort Gordon, and service in Korea. However, the RO sought information from the Department of Defense as to any herbicides used at Fort Polk. Of record is a May 2013 Formal Finding as to the lack of information required to verify exposure to herbicides during service; indicating that the Department of Defense information does not list storage of herbicides in Louisiana, and lists the last date of use or storage of herbicides was at sea, by incineration, in the summer of 1977, by the U.S. Air Force. However, while the RO requested review of the Veteran’s claim against the Department of Defense’s inventory of herbicide operations to determine whether herbicides were used or tested as alleged, there is no indication that the RO requested verification of exposure from the U.S. Army and Joint Services Records Research Center (JSRRC). Thus, on remand, the RO should seek verification from the JSRRC as to any duty at Fort Polk during the Veteran’s active service, and any use, testing, storing, or dumping of herbicides at Fort Polk during the Veteran’s active service. Entitlement to service connection for a bilateral knee disability, to include as secondary to service-connected PTSD, is remanded. The Veteran asserts that his bilateral knee disability is related to service. His service treatment records dated in February 1979 indicate that he injured a joint on the right side, however, the joint is illegible, and in December 1979, he complained of pain in the right knee and was diagnosed with a bruised knee. Post-service, in April 1988, the Veteran sought VA treatment for left knee pain, and reported a contusion incurred during work; X-ray examination was normal. VA treatment records dated in August 2001 indicate that he complained of knee pain, without trauma, and the physician reported that he likely had a musculoskeletal injury to the left knee, exacerbated by weight. In February 2003, during VA treatment, the Veteran reported knee pain and a history of arthroscopic surgery in 1999. During VA treatment in September 2009, the Veteran complained of knee pain, intermittent, for the past year, and reported an injury to both knees when he fell from the back of a truck in 1999. He reported that he had arthroscopic surgery related to such. In July 2010, during VA treatment, the Veteran reported that he had been in a motor vehicle accident and had a flare of left knee pain; he was diagnosed with degenerative joint disease of the left knee. On VA examination in March 2012, the Veteran complained of pain in both of his knees and reported that during service, he fell, landing on both knees, but felt pain primarily in the left knee. He also reported that in 1995, post-service, he fell and bumped his knees, and in 1999, he had surgery on his left knee. The Veteran was diagnosed with DJD of the bilateral knees, and the examiner opined that such was not related to service, as his service treatment records showed only treatment for a bruised right knee, and that excessive weight puts a great deal of stress on the knees; and that it was more likely that his arthritis of the knees is due to his obesity and post-service injuries than his bruise during service. As noted, a VA examiner has attributed the Veteran’s hypertension to a number of factors, including obesity, and in turn, the Veteran has asserted that such is due to his PTSD. While the Veteran has not specifically asserted that his bilateral knee disability is secondary to his service-connected PTSD, he has asserted that his obesity is related to such, and considering the examiner’s opinion here as to the Veteran’s DJD of the bilateral knees and obesity, the record raises this theory of entitlement. On remand, the RO should send the Veteran sufficient VCAA notice as to claim on a secondary basis. On remand, the RO should afford the Veteran a new VA examination to determine the etiology of his bilateral knee disability. Entitlement to service connection for a pulmonary or respiratory disability, claimed as asthma and bronchitis, is remanded. The Veteran asserts, during his November 2016 Board hearing, that his pulmonary or respiratory disability, claimed as asthma and bronchitis, is related to his in-service exposure to gas and fuel used in generators and in motor pool equipment. He reported that he noticed a foul odor during work around such equipment, and that he first noticed symptoms of his claimed disabilities after service. The Veteran’s service treatment records indicate that the Veteran was treated on a number of occasions for pulmonary or respiratory complaints. In November 1977, he was treated for an upper respiratory infection (URI), in February 1978, he had a cough, in April 1979 and July 1979, he had a cold, in October 1979, he had a sore throat, in February 1982, he was treated for a viral infection, in April 1982, he was treated for a URI, and in March 1984, he was treated for a cold, with normal X-ray examination. The Veteran’s VA treatment records indicate that he has been treated for bronchitis in January 2011, and asthma and chronic obstructive pulmonary disease (COPD) in July 2011. On remand, the RO should afford the Veteran a VA examination to determine the precise nature of any current pulmonary or respiratory disability, claimed as asthma and bronchitis, and the etiology thereof.   Entitlement to an initial rating in excess of 50 percent, outside of the periods dated from July 28, 2014, to August 31, 2014, and October 4, 2016, to December 31, 2016, during which temporary total ratings are in place, for service-connected PTSD, is remanded. The Veteran last underwent examination of his service-connected PTSD in February 2017, in a Disability Benefits Questionnaire (DBQ). While the Veteran’s substantive appeal was filed on or after February 2, 2013, such that there is an automatic waiver of RO review of newly submitted evidence unless there is a specific, written request for RO review, the DBQ appears to be VA-generated evidence that warrants RO consideration. See 38 U.S.C. § 7105 (e)(1), (2). The most recent Supplemental Statement of the Case (SSOC) on this issue is dated in June 2016; there is no indication that the RO readjudicated the Veteran’s increased rating claim considering the February 2017 DBQ. On remand, the RO must issue a SSOC as to this issue. Entitlement to a compensable rating for service-connected bilateral hearing loss is remanded. The Veteran last underwent examination of his service-connected bilateral hearing loss in January 2017, in a DBQ. Prior to January 2017, the Veteran’s disability was last evaluated by VA in May 2012, and during his November 2016 Board hearing, he asserted that such had worsened since that time. While the Veteran’s substantive appeal was filed on or after February 2, 2013, such that there is an automatic waiver of RO review of newly submitted evidence unless there is a specific, written request for RO review, the DBQ appears to be VA-generated evidence that warrants RO consideration. See 38 U.S.C. § 7105 (e)(1), (2). The most recent SSOC on this issue is dated in June 2016; there is no indication that the RO readjudicated the Veteran’s increased rating claim considering the January 2017 DBQ. On remand, the RO must issue a SSOC as to this issue.   Entitlement to a compensable rating for service-connected hemorrhoids is remanded. The Veteran last underwent examination of his service-connected hemorrhoids in April 2011. During his November 2016 Board hearing, he asserted that his disability had worsened. On remand, the RO should afford the Veteran a new VA examination to determine the current severity of his service-connected hemorrhoids. Entitlement to a TDIU due to service-connected disabilities is remanded. Given that final adjudication of the service connection and increased rating claims on remand could result in eligibility for a TDIU on a schedular basis, or result in additional evidence speaking to the Veteran’s employability; the claim of entitlement to a TDIU is inextricably intertwined with the service connection and increased rating claims being remanded herein, and the claims should be considered together. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 2 Vet. App. 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a Veteran’s claim for the second issue). The most recent VA treatment records available for Board review are dated in March 2018, on remand, the RO should obtain and associate with the claims file the Veteran’s updated VA treatment records. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from March 2018 to the present. 2. Request verification from the JSRRC as to the Veteran’s assertion that he was exposed to herbicides in July 1980 at Fort Polk in Louisiana, and that he noticed a foul odor and brown vegetation, and was later told that the US Army was dumping herbicides at Fort Polk. Request that the JSRRC verify: (a) if the Veteran had any duty at Fort Polk in July 1980, or at any time during his active service from December 1977 to October 1984; and (b) if there was any use, testing, storing, or dumping of herbicides at Fort Polk in 1980, or at any time during his active service from December 1977 to October 1984. 3. Send the Veteran sufficient VCAA notice as to his claims of entitlement to service connection for bilateral knee and elbow disabilities, each to include as secondary to service-connected PTSD. See 38 C.F.R. § 3.310. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected hemorrhoids. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. To the extent possible, the examiner should identify any symptoms and functional impairments due to service-connected hemorrhoids alone and discuss the effect of such on any occupational functioning and activities of daily living. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral hearing loss. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. To the extent possible, the examiner should identify any symptoms and functional impairments due to service-connected hearing loss alone and discuss the effect of such on any occupational functioning and activities of daily living. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. To the extent possible, the examiner should identify any symptoms and functional impairments due to service-connected PTSD alone and discuss the effect of such on any occupational functioning and activities of daily living. • Further, the examiner should describe the relationship, if any, between the Veteran’s PTSD and his obesity, alcohol consumption and lack of physical activity. The examiner must provide a complete explanation for all opinions and conclusions reached. 7. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any testicular disability (other than erectile dysfunction). Specifically, the examiner should elicit information from the Veteran as to any claimed functional impairment related to his testicular pain such that any testicular pain may be considered a disability for VA compensation purposes. The examiner should diagnose any testicular disability found present. All indicated tests and studies should be conducted. The examiner must opine whether it is at least as likely as not that any testicular disability is related to an in-service injury, event, or disease, specifically, his in-service complaints and treatment for painful and swollen testicles, left scrotal infection, and left epididymitis, as well as his lay statements of post-service pain and swelling, and his assertion that his in-service infection resulted in a systemic vulnerability that caused a current testicular disability. The examiner should specifically acknowledge and address the service treatment record (Urology Clinic) dated June 26, 1980 wherein on follow-up for epididymitis the examiner noted that it may take much longer for the epididymis to return to normal and that it may never be completely normal. The examiner must provide a complete explanation for all opinions and conclusions reached. 8. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any pulmonary or respiratory disability. The examiner should diagnose any such disability found present, and if no disability presently exists, the examiner must respond to the inquiry below considering the asthma, bronchitis, and COPD diagnoses of record. All indicated tests and studies should be conducted. The examiner must opine whether it is at least as likely as not that any pulmonary or respiratory disability, including asthma, bronchitis, and COPD, is related to an in-service injury, event, or disease, specifically, the Veteran’s significant in-service complaints and treatment for URIs, coughs, colds, sore throat, and viral syndrome, as well as his lay statements of in-service exposure to gas and fuel used in generators and in the motor pool equipment, when he noticed a foul odor during work around such equipment. The examiner must provide a complete explanation for all opinions and conclusions reached. 9. Schedule the Veteran for an examination by an appropriate clinician as to his bilateral knee disability. All indicated tests and studies should be conducted. (a) The examiner must opine whether it is at least as likely as not that any right and/or left knee disability is related to an in-service injury, event, or disease, specifically, the Veteran’s in-service right knee bruise, as well as his lay statements of an in-service bilateral knee injury, when he fell, and his lay statements describing post-service knee symptoms. (b) The examiner must opine whether it is at least as likely as not that the Veteran’s right and/or left knee disability is: (i) proximately due to service-connected PTSD, or (ii) aggravated beyond its natural progression by service-connected PTSD, specifically considering his assertion that his obesity (to which the prior VA examiner attributed his bilateral knee disability) is due to his PTSD. The examiner must provide a complete explanation for all opinions and conclusions reached. 9. Schedule the Veteran for an examination by an appropriate clinician as to his hypertension. All indicated tests and studies should be conducted. The examiner must opine whether it is at least as likely as not that the Veteran’s hypertension is: (i) proximately due to service-connected PTSD, or (ii) aggravated beyond its natural progression by service-connected PTSD, specifically considering the medication used to treat his PTSD, his assertion as to his temper from PTSD effecting his hypertension, and his assertion that his obesity, alcohol abuse, and lack of activity (to which the prior VA examiner attributed his hypertension) are due to his PTSD. The examiner must provide a complete explanation for all opinions and conclusions reached. 10. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any bilateral elbow disability. All indicated tests and studies should be conducted. (a) The examiner should diagnose any bilateral elbow disability found present, and specifically comment on the September 2009 VA X-ray examination report demonstrating degenerative changes in the right elbow and the May 2010 VA examiner’s diagnosis of bilateral elbow DJD. (b) The examiner must opine whether it is at least as likely as not that any right and/or left elbow disability is related to an in-service injury, event, or disease, specifically, his significant in-service complaints and treatment for left elbow cellulitis, as well as his assertions of in-service injuries to the bilateral elbows, when he injured his elbows falling during a basketball game and when he injured his elbows hitting such on a truck while covering it in a camouflage net, his post-service symptoms, and his assertion that his in-service cellulitis infection resulted in a systemic vulnerability that caused a current bilateral elbow disability. The examiner must opine whether it is at least as likely as not that any right and/or left elbow disability is: (i) proximately due to service-connected PTSD, or (ii) aggravated beyond its natural progression by service-connected PTSD, specifically considering his assertion that his obesity (to which the prior VA examiner attributed his bilateral elbow disability) is due to his PTSD. The examiner must provide a complete explanation for all opinions and conclusions reached. (Continued on the next page)   11. Finally, after completing any other development that may be warranted, readjudicate the claims on appeal. If the benefits sought are not granted, the Veteran and his attorney must be given a supplemental statement of the case (SSOC) and a reasonable opportunity to respond before the record is returned to the Board. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Purdum