Citation Nr: 1806431 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 13-14 642 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a compensable evaluation for high frequency sensorineural hearing loss of the left ear. 2. Entitlement to service connection for right ear hearing loss. 3. Entitlement to service connection for a back disability. 4. Entitlement to service connection for hemorrhoids. 5. Entitlement to service connection for bilateral flat feet. 6. Entitlement to service connection for ingrown toenails. 7. Entitlement to service connection for bone spurs of the bilateral heels, to include as secondary to bilateral flat feet. 8. Entitlement to service connection for a right knee disability, to include as secondary to bilateral flat feet. 9. Entitlement to service connection for varicose veins, to include as secondary to bilateral flat feet. 10. Entitlement to service connection for a skin disability, to include chloracne, and to include as due to herbicide exposure. 11. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 12. Entitlement to service connection for a heart disability, to include as due to herbicide exposure. 13. Entitlement to service connection for hypertension, to include as secondary to a heart disorder, and to include as due to herbicide exposure. 14. Entitlement to service connection for erectile dysfunction, to include as secondary to a heart disorder, and to include as due to herbicide exposure. REPRESENTATION Veteran represented by: Curtis New, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Journet Shaw, Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from February 1969 to November 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The Veteran testified before the undersigned Veterans Law Judge at an August 2017 videoconference hearing. A transcript of this hearing is of record. Following the December 2016 supplemental statement of the case, the Veteran submitted additional evidence in support of his appeal. The Veteran filed his substantive appeal in May 2013. Accordingly, under the Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, this evidence is subject to initial review by the Board, because the Veteran did not request in writing that the Agency of Original Jurisdiction (AOJ) initially review such evidence. See 38 U.S.C. § 7105(e)(1) (2012). The Board acknowledges that the appeal of the issue of entitlement to service connection for diverticulitis has been perfected, but not yet certified to the Board. The Board's review of the claims file reveals that the AOJ is still taking action on this issue. As such, the Board will not accept jurisdiction over it at this time, but it will be the subject of a subsequent Board decision, if otherwise in order. In August 2017, the Veteran executed a new power-of-attorney (VA Form 21-22), designating Curtis New as his representative. The Board recognizes the change in representation. The issues of entitlement to a compensable evaluation for high frequency sensorineural hearing loss of the left ear; and entitlement to service connection for right ear hearing loss, a back disability, a skin disability, a heart disability, hypertension, and erectile dysfunction are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The preponderance of the evidence demonstrates that the Veteran does not have a current diagnosis for hemorrhoids. 2. The evidence demonstrates that the Veteran's pes planus was noted on entry into active duty service. 3. The preponderance of the evidence demonstrates that there was no increase in the severity of the Veteran's pes planus beyond the natural progression of the condition during service. 4. The preponderance evidence does not demonstrate that the Veteran's current ingrown toenails are etiologically related to his active duty service. 5. The preponderance of the evidence does not demonstrate that the Veteran's bone spurs of the bilateral heels had their onset during active duty service, were not otherwise etiologically related to service, and were not proximately due to, the result of, or aggravated by, a service-connected disability. 6. The preponderance of the evidence does not demonstrate that the Veteran's currently diagnosed right knee degenerative joint disease had its onset during active duty service, manifested within one year of separation, or are otherwise etiologically related to service; nor, was it proximately due to, the result of, or aggravated by, a service-connected disability. 7. The preponderance of the evidence does not demonstrate that the Veteran's currently diagnosed varicose veins had their onset during active duty service, were not otherwise etiologically related to service, and were not proximately due, the result of, or aggravated by, a service-connected disability. 8. Resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that the Veteran's currently diagnosed PTSD is related to his reported in-service stressor. CONCLUSIONS OF LAW 1. The criteria to establish entitlement to service connection for hemorrhoids have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. The criteria to establish entitlement to service connection for bilateral flat feet have not been met. 38 U.S.C. §§ 1110, 1111, 1153, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2017). 3. The criteria to establish entitlement to service connection for ingrown toenails have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 4. The criteria to establish entitlement to service connection for bone spurs of the bilateral heels, to include as secondary to bilateral flat feet, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 5. The criteria to establish entitlement to service connection for a right knee disability, to include as secondary to bilateral flat feet, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 6. The criteria to establish entitlement to service connection for varicose veins, to include as secondary to bilateral flat feet, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 7. The criteria to establish entitlement to service connection for an acquired psychiatric disorder, to include PTSD, have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C. § 7104 (2012); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each piece of evidence. Id. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. It should not be assumed that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Id. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record, and every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Id. Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 (2017). Neither the Veteran nor his/her representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection requires: (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. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. That presumption is rebuttable by probative evidence to the contrary. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection when the requirements for application of the presumption are not met. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Continuity of symptomatology may establish service connection if a claimant can demonstrate (1) that a condition was "noted" during service; (2) there is post-service evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). Thus, in order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Hemorrhoids At his August 2017 Board hearing, the Veteran testified that his hemorrhoids developed from his in-service duties lifting heavy supplies and equipment, including 10-foot long solid steel pipe. He said that he still had hemorrhoids. Service treatment records (STRs) do not document any findings related to any complaints, treatment, or diagnosis for hemorrhoids. At his August 1971 separation examination, the Veteran's anus and rectum clinical evaluation results were normal. Post-service, a May 1997 private treatment record reflects that the Veteran sought treatment for rectal bleeding with a bowel movement occurring 24 hours earlier. The blood was surrounding the stool. At present, his bowel movement was normal. The private physician noted that the Veteran did not have a history of hemorrhoids, but had a history of recurrent boils in the buttocks. The assessment was rectal bleeding of an unknown etiology. According to a June 1997 private physician letter, the Veteran was sent for a colonoscopy after experiencing three episodes of hematochezia (defined as presence of blood in the feces, see Dorland Illustrated Medical Dictionary, 831, (32nd ed. 2012)). A July 1997 private operative report revealed no abnormalities during the digital rectal examination. The Veteran was diagnosed with polyps of the cecum and rectum, but his colonoscopy was otherwise normal. A July 2005 private endoscopy report noted no anal or rectal abnormalities. An April 2011 VA Gastroenterology Consult documents that the Veteran had a normal rectal examination. No complaints of hemorrhoids or related symptoms were made. Based on a careful review of the subjective and clinical evidence, the Board finds that the preponderance of the evidence weighs against finding service connection for hemorrhoids is warranted. The Veteran's STRs are negative for any symptoms related to hemorrhoids. The Federal Circuit has noted that in order for a veteran to qualify for entitlement to compensation, the Veteran must prove the existence of a disability, and one that has resulted from a disease or injury that occurred during active duty service. See Sanchez- Benitez v. Principi, 259 F.3d 1356 (2001). The requirement that a current disability be present is satisfied when a claimant has a disability during the appeal period or proximate thereto, even if the disability resolves prior to the adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). In this case, the Veteran filed his original claim for service connection in December 2010, and the competent and credible evidence does not indicate that he has a current diagnosis for hemorrhoids. The Veteran is competent to diagnose hemorrhoids as the disorder involves observable symptomatology. Layno v. Brown, 6 Vet. App. 465, 470 (1994); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, despite the Veteran's lay assertions that he had hemorrhoids during service and that they have continued since service, the overwhelming clinical evidence makes these assertions less credible. Notably, multiple private and VA treatment records, which specifically examined the Veteran's rectum, found no abnormalities present, even after he presented with symptoms of rectal bleeding. Indeed, at no time during those examinations did the Veteran report having hemorrhoids. Rather, at his May 1997 private clinic visit, the physician noted that the Veteran had no history of hemorrhoids. Therefore, the Board finds that the Veteran's self-diagnosis for hemorrhoids has little probative value. The Veteran has not presented any competent and credible evidence of a current diagnosis for hemorrhoids. The most probative evidence, in the form of his private and VA treatment records, does not support that the Veteran has any persistent symptomatology related to hemorrhoids that would suggest that he has an underlying chronic disability. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran's service connection for hemorrhoids. Accordingly, the benefit-of-the-doubt rule does not apply, and the service connection claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Bilateral Flat Feet The Veteran contends that his bilateral flat feet developed as a result of him being issued and wearing boots that were too small during his active duty service. He also said that he was told he had flat feet upon his induction into service, and that wearing the wrong size boots aggravated his condition. Every veteran is presumed to have been in sound condition at entry into service except as to defects, infirmities, or disorders noted at the time of such entry, or where clear and unmistakable evidence demonstrates that the injury or disease existed before entry and was not aggravated by such service. 38 U.S.C. § 1111. In this case, pes planus was noted on the Veteran's May 1968 pre-induction examination. When a defect, infirmity, or disorder is noted on the enlistment examination, the presumption of soundness never attaches, and the only benefits that can be awarded are for aggravation pursuant to 38 U.S.C. § 1153 and 38 C.F.R. § 3.306. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Thus, the dispositive issue in this regard is whether the Veteran's preexisting pes planus was aggravated by his service. An important distinction between section 1111's aggravation prong of the presumption of soundness and section 1153 presumption of aggravation is the burden of proof. Under section 1111, the burden is on the Government to show by clear and unmistakable evidence that there was no increase in disability in service or, that any increase was due to the natural progress of the disease. Wagner v. Principi, supra. Under section 1153, however, the Appellant bears the burden of showing that his preexisting condition worsened in service. Once the veteran establishes worsening, the burden shifts to the Secretary to show by clear and unmistakable evidence that the worsening of the condition was due to the natural progress of the disease. Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). In determining whether there has been aggravation, the statute and regulation indicate that the first question to be asked is whether there was an increase in disability. See 38 U.S.C. § 1153; 38 C.F.R. § 3.306 (a preexisting injury or disease will be considered to have been aggravated by service "where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease"). In other words, if there is an increase in disability during service, aggravation is presumed, and this presumption can only be rebutted with clear and unmistakable evidence that the increase was due to the natural progress of the disease. 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993). If VA determines that there has been an increase in disability, the presumption of aggravation applies regardless of whether the degree of worsening is enough to warrant compensation under the VA rating schedule. Browder v. Derwinski, 1 Vet. App 204, 207 (1991). STRs do not document any findings related to any complaints, treatment, or diagnosis of foot problems. At his August 1971 separation examination, the Veteran's feet clinical evaluation results were normal. No pes planus was noted. Post-service, a March 1998 private treatment record noted that the Veteran had no arches in his feet. A December 2015 VA Podiatry Consult reflects that the Veteran had a bilateral flat foot deformity. Based on a careful review of the subjective and clinical evidence, the Board finds that the preponderance of the evidence weighs against finding service connection for bilateral flat feet is warranted. The Board finds that the clinical evidence does not show that the Veteran's preexisting bilateral pes planus increased in severity during his active duty service. In fact, the evidence demonstrates that upon separation in August 1971, the Veteran's feet were evaluated to be normal. It was more than 25 years later when any symptoms of flat feet were documented. Despite the Veteran's lay assertions that his bilateral flat feet worsened during service, the objective findings during service dispute his contentions. Given the objective findings, the Board finds that the Veteran has not presented any competent and credible evidence of a worsening of his bilateral flat feet so as to warrant a presumption of aggravation as contemplated by 38 U.S.C. § 1153. In summary, the Board finds that the preponderance of the evidence shows that the Veteran's preexisting pes planus did not increase in severity during service, and thus, the presumption of aggravation is not for application. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for bilateral flat feet must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Ingrown Toenails The Veteran contends that his ingrown toenails began during his active duty service as a result of him wearing boots that were too small. He said that during service, he was taught by a medic how to excise his nails himself. Following service, the Veteran said that he continued to self-treat his condition until he sought VA treatment. STRs do not document any findings related to any complaints, treatment, of diagnosis for ingrown toenails. In August 1971, the Veteran's feet clinical evaluation results were normal. At a March 2011 VA clinic visit, the Veteran complained of having painful ingrown nails of the bilateral hallux. In April 2011, the Veteran returned for treatment of ingrown and/or infected toenails of the bilateral hallux. An objective evaluation revealed toenails that were hypertropic, elongated, ingrown, and painful due to deformity. As treatment, he underwent nail avulsion with matricectomy surgery of the bilateral hallux. Three weeks after his surgery, the Veteran reported that his left toe was doing well and had no complaints; however, his right hallux was still sore, and he had noticed some pus from the margin. No etiological opinion was provided. Subsequent VA and private treatment records did not show any further treatment for the Veteran's ingrown toenails. Based on a careful review of the subjective and clinical evidence, the Board finds that the preponderance of the evidence weighs against finding service connection for ingrown toenails is warranted. The Veteran's STRs are negative for any symptoms of ingrown toenails. Indeed, at his August 1971 separation examination, a clinical evaluation of the Veteran's feet were normal. Although the Veteran's post-service VA treatment records reflect treatment for ingrown toenails in 2011, none of his VA or private treatment records discuss that his ingrown toenails were related to his active duty service. Notably, the Veteran did not indicate during his VA clinic visits that he had been experiencing ongoing problems with his ingrown toenails since his active duty service, or that he had been excising the toenails to treat the problem himself. The Veteran is competent to report his history of ingrown toenails as they are an observable condition. Layno v. Brown, supra. However, the only evidence of record that the Veteran's current ingrown toenails were caused by his active duty service are his lay statements; those contentions are not supported by the available clinical evidence. Additionally, the Board finds that the Veteran's assertions that he has had continuous problems with ingrown toenails that began during service are not credible. Therefore, the Veteran's statements concerning the etiology of his ingrown toenails have little probative value. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran's service connection claim for ingrown toenails. Accordingly, the benefit-of-the-doubt rule does not apply, and the service connection claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Bone Spurs of the Bilateral Heels The Veteran contends that his bone spurs of the bilateral heels developed as a result of his wearing boots that were too small during his active duty service. Alternatively, the Veteran asserts that his bilateral flat feet caused his bone spurs of the bilateral heels. STRs do not document any findings related to any complaints, treatment, or diagnosis for any heel problems. At his August 1971 separation examination, the Veteran's feet clinical evaluation results were normal. A March 1998 private treatment record documents that x-rays taken of the Veteran's left lateral heel revealed an eight millimeter (mm.) spur on the calcaneus. Subsequent private and VA treatment records do not document any further findings related to the Veteran's left heel spur. At a August 2007 private clinic visit, the private physician noted that the Veteran had a right heel spur. March 2012 and June 2012 VA treatment records reflect that the Veteran sought treatment for a right heel spur. The Veteran indicated that he was receiving ultrasound treatments to his heel at his private chiropractor with some relief. A December 2015 VA Podiatry Consult noted that the Veteran had a history of heel spur syndrome to the right foot, which was currently being treated with foot orthotics. Neither the private nor VA treatment records provided any etiological opinions regarding the Veteran's bone spurs of the bilateral heels. Based on a careful review of the subjective and clinical evidence, the Board finds that the preponderance of the evidence weighs against finding service connection for bone spurs of the bilateral heels on a direct or secondary basis is warranted. As an initial matter, the Board finds that service connection for bone spurs of the bilateral heels on a secondary basis is not warranted, because service connection for bilateral flat feet has not been established. Nevertheless, the Board must consider whether the Veteran is entitled to service connection for bone spurs of the bilateral heels on a direct basis. In that regard, the Board finds that there is no competent evidence establishing a medical link between the Veteran's current bone spurs of the bilateral heels and his active duty service. His STRs were negative for any complaints, treatment, or diagnosis for any heel problems. Indeed, at separation, the Veteran's feet clinical evaluation results were normal. Post-service private and VA treatment records show an isolated treatment for a left heel spur and sporadic treatment for a right heel spur, but no medical opinion on etiology. The Veteran's lay assertions are the only evidence providing that his bone spurs of the bilateral heels are related to his active duty service, in particular his use of the wrong size footwear. However, the Board finds that as the Veteran has not been shown to have the requisite specialized training, he is not competent to provide such a medically complex etiological opinion. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). As the Veteran has not presented any medical evidence to support his contention, the Board must find that the Veteran is not entitled to service connection for bone spurs of the bilateral heels on a direct basis. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran's service connection claim for bone spurs of the bilateral heels on a direct or secondary basis. Accordingly, the benefit-of-the-doubt rule does not apply, and the service connection claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Right Knee Disability The Veteran contends that his current right knee disability developed as a result of his bilateral flat feet causing him to change his gait. He asserts that his right knee problems began after he was discharged. STRs do not document any findings related to any complaints, treatment, or diagnosis for any knee problems. At the Veteran's August 1971 separation examination, his lower extremities clinical evaluation results were normal. The first post-service documented report of right knee problems was in June 2006. A June 2006 private treatment record noted that the Veteran had right knee crepitus with range of motion. At a June 2010 private clinic visit, the Veteran reported having right knee pain for the past two months. After undergoing a right knee x-ray in July 2010, the private physician diagnosed the Veteran with osteoarthritis of the right knee. Subsequent VA treatment records, starting in 2011, document the Veteran's continued treatment for moderate right knee degenerative joint disease. An April 2011 VA treatment record reflects that the Veteran had been experiencing chronic right knee pain for years. However, neither the Veteran's private or VA treatment records provide an etiological opinion. Based on a careful review of the subjective and clinical evidence, the Board finds that the preponderance of the evidence weighs against finding in favor of service connection for a right knee disability on a direct, presumptive, or secondary basis. As an initial matter, the Veteran does not contend, and the evidence does show that the Veteran's right knee disability had its onset during active duty service, or was directly caused by his service. Accordingly, service connection for a right knee disability on a direct basis is not warranted. As arthritis is a chronic disease under 38 C.F.R. § 3.309(a), the Board has also considered whether the Veteran was entitled to presumptive service connection under 38 C.F.R. § 3.307(a)(3). However, the available clinical evidence demonstrates that the Veteran was diagnosed with right knee arthritis almost 40 years after his discharge from service. Furthermore, when the Veteran was discharged, his August 1971 separation examination showed normal lower extremities clinical evaluation results. Notably, the Veteran has not presented any evidence, lay or clinical, that he has had any continuous right knee symptoms since his active duty service. Indeed, the Veteran specifically asserted that his right knee symptoms began after service. Thus, the Board finds that the evidence does not show that the Veteran's current right knee arthritis manifested within one year of discharge; nor does it show that he had continuous symptoms of arthritis following service. Therefore, the Board finds that there is no basis upon which to award service connection for a right knee disability on a presumptive basis. Finally, the Board finds that the Veteran is not entitled to service connection for a right knee disability on a secondary basis, because service connection for bilateral flat feet has not been established. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran's service connection claim for a right knee disability on a direct, presumptive, or secondary basis. Accordingly, the benefit-of-the-doubt rule does not apply, and the service connection claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Varicose Veins The Veteran contends that his current varicose veins began while he was serving in Vietnam during his active duty service and have continued since service. He said that his private chiropractor told him that his varicose veins could have been caused by his bilateral flat feet. STRs do not document any findings related to any complaints, treatment, or diagnosis for varicose veins. At his August 1971 separation examination, the Veteran's lower extremities clinical evaluation results were normal. Post-service, the first documented evidence of varicose veins was a September 1982 private treatment record, which documents that the Veteran had been hospitalized for three days in August 1982 following vein ligation and stripping of the left leg. In April 2002 during a private clinic visit, the Veteran's private physician noted that the Veteran had a skin lesion of his left lower lateral leg, which was worrisome for some venous insufficiency. An October 2011 VA treatment record noted that the Veteran complained of more swelling in the left calf with long standing varicosities. The Veteran was diagnosed with varicosities. A June 2012 VA Vascular Surgery Consult noted that the Veteran had undergone surgical absence of left great saphenous vein and that he had recurrent varicose veins of the left posterior calf. Subsequent VA treatment records document that the Veteran continued to experience symptoms of cramping and claudication of the left lower extremity and was treated with compression stockings. See January 2013, February 2013, May 2013, September 2013, April 2014, and July 2014 VA treatment records. In October 2014, the Veteran underwent laser venous ablation surgery. Neither the Veteran's VA or private treatment records provide an etiological opinion regarding his varicose veins. Based on a careful review of the subjective and clinical evidence, the Board finds that the preponderance of the evidence weighs against finding service connection for varicose veins on a direct or secondary basis is warranted. As an initial matter, the Board finds that service connection for varicose veins on a secondary basis is not warranted, because service connection for bilateral flat feet has not been established. Nevertheless, the Board must consider whether the Veteran is entitled to service connection for varicose veins on a direct basis. In that regard, the Board finds that there is no competent evidence linking the Veteran's current varicose veins to his active duty service. His STRs were negative for any complaints, treatment, or diagnosis for any varicose vein problems. Indeed, at separation, the Veteran's lower extremities clinical evaluation results were normal. The earliest record of varicose veins were in August 1982. There was no indication in the Veteran's treatment records that his varicose veins had begun during service. Notably, the Veteran did not report that he had been experiencing problems with varicose veins since service. Finally, despite the documented treatment for recurring varicose veins, no physician identified any potential cause for the condition. The Veteran is competent to report his history of varicose veins as they are an observable condition. Layno v. Brown, supra. However, the only evidence of record that the Veteran's current varicose veins were caused by his active duty service are his lay statements; those contentions are not supported by the available clinical evidence. Additionally, the Board finds that the Veteran's assertions that he has had continuous problems with varicose veins that began during service are not credible. Therefore, the Veteran's statements concerning the etiology of his varicose veins have little probative value. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran's service connection claim for varicose veins on a direct or secondary basis. Accordingly, the benefit-of-the-doubt rule does not apply, and the service connection claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Acquired Psychiatric Disorder The Veteran contends that his current mental health symptoms developed as a result of his traumatic in-service experiences. In particular, he described that while serving in Vietnam, he was performing guard duty in addition to his duties as a Petroleum Storage Specialist. During one incident, the Veteran said he was almost hit by enemy fire and engaged the enemy with return fire. He also described being bombarded by sniper fire on a weekly basis. During another incident, he was working with another serviceman to load pipe along the side of the road. The serviceman stepped on a land mine, and the Veteran had to pick up the body parts and place them into a body bag. In April 2012 lay statements submitted by the Veteran's current and two former wives, the wives summarized the Veteran's behavior upon returning from service as well as his current symptoms. His first wife explained that upon returning from Vietnam, the Veteran had become very moody and mean. After they divorced, they remained in contact because they shared three children. His first wife said that he remained moody. His second wife said that while he slept, the Veteran would have dreams and conversations that would become angry and loud. The next day, he would have no memory of them. The Veteran was distant with his family and his children and did not have any close friends. During their marriage, the Veteran consumed a 12-pack of beer on a daily basis, which increased during stressful situations. Any attempt to get him to discuss Vietnam was met with anger. The Veteran's current wife, who is now deceased, described the Veteran as having extreme mood swings and nightmares, which woke her up. Service connection for PTSD requires medical evidence diagnosing the condition; a link, established by medical evidence, between current symptoms and an in-service stressor; and 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), which provides that all psychiatric diagnoses must conform to the fourth edition of the American Psychiatric Association 's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). See 38 C.F.R. § 3.304(f). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 U.S.C. § 1154(b) (2012); 38 C.F.R. § 3.304(f)(2). 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. 38 C.F.R. § 3.304(f)(3). For purposes of 38 C.F.R. § 3.304(f)(3), "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders (DSM) and replace them with references to the recently updated Fifth Edition (DSM-V). The rulemaking also updated the nomenclature used to refer to certain mental disorders in accordance with DSM-V. Specifically, the rulemaking amends 38 C.F.R. §§ 3.384, 4.125, 4.126, 4.127, and 4.130. See 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that are pending before the Agency of Original Jurisdiction (AOJ) on or after August 4, 2014. The Secretary does not intend for the provisions of this interim final rule to apply to claims that have been certified for appeal to the Board of Veterans' Appeals or are pending before the Board, such as this one, the United States Court of Appeals for Veterans Claims, or the United States Court of Appeals for the Federal Circuit, even if such claims are subsequently remanded to the AOJ. VA adopted as final, without change, the interim final rule, effective March 19, 2015. 80 Fed. Reg. 53, 14308 (March 19, 2015). Based on a careful review of the subjective and clinical evidence, and resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for an acquired psychiatric disorder, to include PTSD, is warranted. As an initial matter, the Board finds that the Veteran's reported in-service stressor based on his combat experiences appear to be both competent and credible, as they are not disputed by any evidence to the contrary. His military occupational specialty (MOS) was Petroleum Storage Specialist, and he did not receive any combat medals. However, the evidence demonstrates that the Veteran did serve in Vietnam from July 1969 to July 1970. The Veteran's lay statements that in addition to his regular duties, he also performed guard duty, does not appear to be inconsistent with the circumstances of his service. In that regard, the Board finds that the Veteran's report of engaging with enemy fire during such guard duty to be credible, and sufficient to establish the occurrence of the claimed in-service stressor. See 38 U.S.C. § 1154(b) (2012); 38 C.F.R. § 3.304(f)(2). Now, the Board recognizes that the record includes conflicting medical opinions regarding whether the Veteran has a current diagnosis for PTSD, or any other mental health disorder, that meets DSM-IV criteria. With regard to the medical opinions obtained, as with all types of evidence, it is the Board's responsibility to weigh the conflicting medical evidence to reach a conclusion as to the ultimate grant of service connection. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board may favor the opinion of one competent medical expert over another if its statement of reasons and bases is adequate to support that decision. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Stated another way, the Board decides, in the first instance, which of the competing medical opinions or examination reports is more probative of the medical question at issue. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). According to a December 2010 VA Psychiatry Consult, the VA psychiatrist found that the Veteran did not meet the PTSD criteria. The VA psychiatrist found that the Veteran's reported symptomatology suggested that he may have had significant problems with PTSD after Vietnam, but had been able to cope with his symptoms over the years and reduced them to the point where he no longer met the PTSD criteria. However, the VA psychiatrist did opine that his physical symptoms (i.e., rashes and acne) from possible Agent Orange exposure had affected him and may be related to his current mental health problems. He received a provisional diagnosis for mood disorder due to physical condition (Agent Orange). The Board notes that the Veteran is not currently service-connected for a skin disability. At his May 2011 VA examination, the examiner found the Veteran did not have a mental health diagnosis under DSM-IV criteria based on the Veteran's reported symptomology during his examination. However, in an April 2012 statement, the Veteran expressed that the May 2011 examiner had mischaracterized his statements and wanted to be reevaluated. The Board notes that, at the time of the examination, the May 2011 VA examiner did not have the benefit of reviewing the Veteran's claims file. As the May 2011 VA examiner's assessment of the Veteran's lay statements are in dispute, and his claims file was unavailable for review, the Board finds that the May 2011 VA examination is inadequate, and therefore, has little probative value in establishing whether the Veteran has a current diagnosis for PTSD, or any other mental health disorder. In an October 2013 VA Psychology Note, the VA psychologist summarized the Veteran's reported in-service traumatic experiences and current mental health symptomatology. After performing objective testing, the VA psychologist opined that the Veteran did not have PTSD. Specifically, the VA psychologist found that the Veteran expressed subjective distress related to his mental health symptoms, but that he did not express guilt over acts of commission or omission, survivor guilt, a reduction in awareness of surroundings, de-realization and depersonalization. The VA psychologist diagnosed him with depressive disorder not otherwise specified. No etiological opinion was provided. Most recently, the Veteran submitted a September 2014 private Comprehensive Psychological Evaluation. After interviewing the Veteran, including a review of his current mental health symptomatology and his reported in-service traumatic experiences, and performing an objective evaluation, the private psychologist determined that the Veteran met the DSM-IV criteria for PTSD. The private psychologist noted that the Veteran was currently experiencing nightmares, flashbacks, depression and suicidal ideations. Moreover, the private psychologist found that the Veteran had experienced multiple incidents during service that had contributed to his overall PTSD symptoms and that there were specific incidents during his service in Vietnam that were bothering him emotionally at present. Even though the Veteran had reported having his current mental health symptoms since returning from Vietnam, the private psychologist surmised that he had only recently become aware of these symptoms, which prompted him to seek mental health treatment. Overall, finding no other events that would account for the Veteran's specific mental health symptoms experienced since his return from Vietnam and at present, the private psychologist opined that it was "within a reasonable degree of psychological probability that his current symptoms are a result of his tour of duty in Vietnam that included combat, or at least as likely as not a result of his tour of duty in Vietnam." In this case, the Board finds that the competing medical opinions (December 2010 VA Psychiatry Consult, October 2013 VA Psychology Note and September 2014 private Comprehensive Psychological Evaluation) are all based on an objective evaluation of the Veteran, an interview of the Veteran, and consideration of his lay statements and reported mental health symptomatology, and are supported by a complete rationale. Under these circumstances, the Board cannot find a basis for which competing medical opinion is more probative over the other. Therefore, the Board finds that the evidence is at least in equipoise that the Veteran has a current diagnosis for PTSD. As the diagnosis for PTSD has been established, the Board finds that the September 2014 private Comprehensive Psychological Evaluation is the most probative evidence as to its etiology. Stated above, the private psychologist concluded that the Veteran's PTSD was at least as likely as not caused by his tour in Vietnam that included combat. Accordingly, resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that his currently diagnosed PTSD is related to his reported in-service combat stressor. In summary, resolving all reasonable doubt in favor of the Veteran, his claim for service connection for an acquired psychiatric disorder, to include PTSD, is granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for hemorrhoids is denied. Entitlement to service connection for bilateral flat feet is denied. Entitlement to service connection for ingrown toenails is denied. Entitlement to service connection for bone spurs of the bilateral heels, to include as secondary to bilateral flat feet, is denied. Entitlement to service connection for a right knee disability, to include as secondary to bilateral flat feet, is denied. Entitlement to service connection for varicose veins, to include as secondary to bilateral flat feet, is denied. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is granted. REMAND Unfortunately, a remand is required in this case for the issues remaining on appeal. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the claims so that the Veteran is afforded every possible consideration. With regard to the higher initial evaluation claim for high frequency sensorineural hearing loss of the left ear, the Veteran's last VA examination was in January 2016. At his August 2017 Board hearing, the Veteran testified that his hearing was becoming steadily worse, and that he was going to be fitted for hearing aids. VA is required to afford the Veteran a contemporaneous VA examination to assess the current nature, extent, and severity of his service-connected disabilities. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also 38 C.F.R. § 3.326(a) (2017). As the evidence suggests that the Veteran's left ear hearing loss may have worsened since his last VA examination, a remand is required to determine the current severity of his service-connected disability. With regard to the service connection claim for right ear hearing loss, the Board finds that the June 2011 VA examiner's opinion is inadequate. The June 2011 VA examiner opined that the veteran's current right ear hearing loss was less likely than not the result of his military service and military noise exposure. That determination was based on the findings that a May 1972 VA audiological evaluation, conducted one year after military discharge, showed his right ear hearing was well within normal limits, and that a comparison of his May 1972 hearing test results to his May 1968 pre-induction audiogram showed no evidence of a significant threshold shift of hearing in the right ear. As a result, the VA examiner explained that had the Veteran's right ear hearing been permanently decreased due to military noise exposure then the loss of significant shift should have shown on his May 1972 VA hearing test, and would not have been delayed in onset. Overall, the June 2011 VA examiner concluded that it was more likely that the current right ear hearing loss was due to causes after military service, including possibly occupational noise working at a paper factory for 38 years and idiopathic (unknown) causes. Despite these conclusions, the Board finds that the June 2011 did not address the threshold shift that occurred from his May 1968 pre-induction examination to his August 1971 separation examination. Furthermore, in an April 2012 list of audiological testing conducted by the Veteran's employer from 1986 to 2010, use of hearing protection was noted. Nevertheless, over time, the test results showed that his right ear hearing had decreased. As the Board finds that the June 2011 VA examiner's opinion was based on incomplete or inaccurate findings, a new VA opinion is warranted to determine the etiology of the Veteran's current right ear hearing loss. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). With regard to the Veteran's service connection claim for a back disability, the Veteran has asserted that his current back problems developed as a result of his in-service duties performing heavy lifting of supplies and equipment, including 10-foot long solid steel pipe. He asserts that at the end of each day, his back would hurt. Furthermore, a November 2016 VA Team Letter reflects that a chest x-ray showed mild degenerative changes throughout the mid and lower thoracic spine. The record does not include an etiological opinion, and the Board finds that the available competent evidence is insufficient to decide the claim. As the evidence suggests that the Veteran's reported in-service back symptoms may be related to his currently diagnosed back disability, a remand is required to provide the Veteran with a VA examination to determine its etiology. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). With regard to the service connection claim for a skin disability, to include chloracne, the Veteran asserts that his skin problems developed during his active duty service and has persisted since his discharge. He contends that he first noticed his skin problems occurring on his back, arms, and face while serving in Vietnam; so, he believes that his exposure to herbicides caused his current skin condition. Private and VA treatment records reflect treatment for reoccurring skin problems since 1997. The earliest diagnosis for chloracne was made in September 2010. See September 2010 VA Physician Note. VA regulations provide that to establish service connection on a presumptive basis for chloracne, it must have manifested to a degree of at least 10 percent within one year of his in-service exposure to an herbicide agent. See 38 C.F.R. §§ 3.307(a)(6)(ii) and 3.309(e) (2017). Although the VA physician determined that the Veteran's chloracne was probably related to his Agent Orange exposure, no rationale for that opinion was provided. The record also includes multiple other skin diagnoses (seborrheic keratoses, hidradenitis, acne, rash, and actinic keratosis), but no definitive etiology. By virtue of the Veteran's service in Vietnam during the relevant period, his exposure to herbicide agents is presumed. See 38 C.F.R. § 3.307(a)(6)(iii). As the evidence suggests that the Veteran's current skin problems may be related to his active duty service, to include herbicide exposure, a remand is required to provide the Veteran with a VA examination to determine the etiology of his skin disability. See McLendon v. Nicholson, supra. With regard to the Veteran's claim for a heart disability, the Veteran claims that his current heart problems are directly related to his active duty service, specifically his exposure herbicides. The record currently includes conflicting medical evidence as to whether the Veteran has a current diagnosis for coronary artery disease (CAD), which is a disease for establishing presumptive service connection for exposure to herbicides. See March 2011 and May 2011 VA examinations. In addition, the record includes multiple complaints and treatment for chest pain with shortness of breath and heart palpitations. More recent VA treatment records document diagnoses for paroxysmal atrial fibrillation. No etiological opinion has been provided that specifically addresses whether the Veteran's paroxysmal atrial fibrillation is etiologically related to his active duty service, to include his exposure to herbicides. Accordingly, the Board finds that a new VA examination is required for the Veteran's heart disability that resolves the conflicting determination as to whether or not the Veteran has CAD, confirms the Veteran's current heart diagnosis, and provides an opinion which addresses whether the Veteran's current heart disability is etiologically related to service. In December 2010 and April 2012 statements, the Veteran has asserted that his hypertension and erectile dysfunction were caused by his heart disability. It would be premature to adjudicate the service connection claims for hypertension and erectile dysfunction before the Veteran's service connection claim for a heart disability has been considered. Therefore, these claims are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the issues of entitlement to service connection for hypertension and entitlement to service connection for erectile dysfunction must also be remanded. Accordingly, the case is REMANDED for the following actions: 1. Obtain all of the Veteran's outstanding treatment records for his bilateral hearing loss, back disability, skin disability, heart disability, hypertension, and erectile dysfunction that are not currently of record. 2. After completing the above, to the extent possible, schedule the Veteran for a VA audiological examination to determine the current severity of his service-connected left ear hearing loss by an appropriately qualified examiner. Provide the claims file, including a copy of this REMAND, to the examiner for review. The examiner should provide current findings regarding all symptoms associated with the service-connected left ear hearing loss and should opine as to its severity. The examiner should comment on the extent of any functional impairment caused by the Veteran's service-connected left ear hearing loss, to include in an occupational setting and in performing ordinary, daily activities. All findings should be fully documented in the examination report. 3. Obtain a supplemental VA opinion from the June 2011 VA examiner, or, if not available, another appropriately qualified examiner. Provide the claims file, including a copy of this REMAND, to the examiner for review. After reviewing the claims file, the examiner should respond to the following: Is it at least as likely as not (50 percent probability or greater) that the Veteran's currently diagnosed right ear hearing loss had its onset during active duty service, or was otherwise etiologically related to service, to include military noise exposure? In providing the above opinion, the examiner should address the threshold shift in the right ear from the Veteran's May 1968 pre-induction examination to his August 1971 separation examination. The examiner should also address the April 2012 employer audio listing showing use of hearing protection and a decrease in right ear hearing. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 4. Schedule the Veteran for a VA orthopedic examination for his back disability by an appropriately qualified examiner. Provide the examiner with the claims file, including a copy of this REMAND, for review. After a review of the claims file, the examiner should respond to the following: Is it at least as likely as not (50 percent probability or greater) that the Veteran's current back disability had its onset during active duty service, manifested within one year of separation from service, or was otherwise etiologically related to service? A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 5. Schedule the Veteran for a VA skin examination for his skin disability by an appropriately qualified examiner. Provide the examiner with the claims file, including a copy of this REMAND, for review. After a review of the claims file, the examiner should respond to the following: Is it at least as likely as not (50 percent probability or greater) that the Veteran's current skin disability had its onset during active duty service, or was otherwise etiologically related to service, to include as due to herbicide exposure? In providing the above opinion, the examiner should consider and address the previous diagnoses for skin disabilities, including chloracne, seborrheic keratoses, hidradenitis, acne, rash, and actinic keratosis, as reflected in the Veteran's VA and private treatment records. The examiner should also presume that the Veteran was exposed to herbicide agents during active duty service. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 6. Schedule the Veteran for a VA examination for his heart disorder by an appropriately qualified examiner. Provide the examiner with the claims file, including a copy of this REMAND, for review. After reviewing the claims file, the examiner should respond to the following: Is it at least as likely as not (50 percent probability or greater) that the Veteran's heart disability had its onset during active duty service, manifested within one year of separation, or is otherwise etiologically related to service, to include exposure to herbicides? In providing the above opinion, the examiner should resolve the conflicting medical opinions provided by the March 2011 and May 2011 VA examiners concerning whether the Veteran has coronary artery disease. The examiner should also note that during the pendency of his appeal, the Veteran has been diagnosed with paroxysmal atrial fibrillation, which should also be addressed when providing the above opinion. The examiner should also presume that the Veteran was exposed to herbicide agents during active duty service. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 7. Then, if no additional development is in order, to include an opinion to address the etiology of the Veteran's hypertension and erectile dysfunction, then readjudicate the increased rating claim for left ear hearing loss and the service connection claims for right ear hearing loss, a back disability, a skin disability, a heart disability, hypertension, and erectile dysfunction. If the benefits sought on appeal remain denied, in whole or in part, the Veteran and his representative should be provided a supplemental statement of the case. Then, the case should be returned to the Board. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ LESLEY A. REIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs