Citation Nr: 1825152 Decision Date: 04/30/18 Archive Date: 05/07/18 DOCKET NO. 14-10 272 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for fibromyalgia. 2. Entitlement to service connection for sleep apnea. 3. Entitlement to service connection a heart condition, to include ischemic heart disease. 4. Entitlement to service connection for bilateral upper extremity neuropathy. 5. Entitlement to service connection for bilateral lower extremity neuropathy. 6. Entitlement to an initial evaluation in excess of 50 percent for a post-traumatic stress disability (PTSD). 7. Entitlement to service connection for hypertension. 8. Entitlement to service connection for erectile dysfunction. 9. Entitlement to service connection for GERD. REPRESENTATION Veteran represented by: J. Michael Woods, attorney ATTORNEY FOR THE BOARD R. Brunot, Associate Counsel INTRODUCTION The Veteran served in the United States Army from August 1966 to August 1968. These mattes come to the Board of Veterans Appeals (Board) on appeal from March 2011, June 2011, May 2014, and June 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona, and a July 2013 rating decision of the RO in Fargo, North Dakota. The March 2011 rating decision granted service connection for PTSD and assigned an initial 10 percent rating and denied service connection for ischemic heart disease, erectile dysfunction, and hypertension. The June 2011 rating decision denied service connection for peripheral neuropathy of the upper and lower extremities. The July 2013 rating decision denied service connection for GERD. In a February 2014 Decision Review Officer (DRO) decision, the RO increased the Veteran's initial PTSD rating to 50 percent. The May 2014 rating decision denied service connection for fibromyalgia. The June 2015 rating decision denied service connection for sleep apnea. In a March 2014 VA Form 9 filed in conjunction with his PTSD claim, the Veteran stated that he wanted a hearing before a member of the Board. However, his attorney subsequently withdrew the hearing request. The Board has rephrased the Veteran's claim of entitlement to service connection for ischemic heart disease to one of service connection for a heart condition, to include ischemic heart disease. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The issues of entitlement to service connection for hypertension, erectile dysfunction, a heart condition, and GERD are addressed in the Remand portion of the decision below and are remanded to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The preponderance of evidence reflects that the Veteran's fibromyalgia was caused by or aggravated by a service-connected disability. 2. The preponderance of evidence reflects that the Veteran's sleep apnea was caused by or aggravated by a service-connected disability. 3. The preponderance of evidence reflects that the Veteran's bilateral upper extremity neuropathy disability was caused by or aggravated by a service-connected disability. 4. The preponderance of evidence reflects that the Veteran's bilateral lower extremity neuropathy disability was caused by or aggravated by a service-connected disability. 5. The Veteran's PTSD manifests as occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The Veteran's fibromyalgia is proximately due to, the result of, or chronically aggravated by a service-connected disability. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 2. The Veteran's sleep apnea is proximately due to, the result of, or chronically aggravated by a service-connected disability. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 3. The Veteran's bilateral upper extremity neuropathy is proximately due to, the result of, or chronically aggravated by a service-connected disability. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 4. The Veteran's bilateral lower extremity neuropathy is proximately due to, the result of, or chronically aggravated by a service-connected disability. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 5. The criteria for an initial disability rating of 70 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his attorney have raised any other 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). I. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). To establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303 (2017); see also Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110 (2012); see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997). In the absence of evidence of a current disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disability or injury. 38 C.F.R. § 3.310(a) (2017). 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(a) (2017); Allen v. Brown, 7 Vet. App. 439, 448 (1995). 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 nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Second, the Board must determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Third, the Board must weigh the probative value of the evidence in light of the entirety of the record. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102 (2017). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 4 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Fibromyalgia The evidence includes a March 2014 opinion from the Veteran's private doctor. The Veteran's doctor opined that the Veteran had fibromyalgia. Further, the doctor concluded the Veteran's pain symptoms continued to get worse and prevented him from being able to work. The Veteran received a VA examination in April 2014. The VA examiner noted the Veteran experienced generalized pain in shoulders, neck, chest, hips, and buttocks. The examiner considered the evidence of record and determined that the Veteran did not have fibromyalgia nor signs or symptoms attributed to fibromyalgia. The examiner noted the Veteran had osteoarthritis with radiating pain which could be responsible for the majority of his pain symptoms. The examiner stated that if the Veteran did not have osteoarthritis, then a diagnosis of fibromyalgia may be more likely. Nevertheless, due to a variety of contributing factors with positive etiologies of pain source, including the Veteran's multiple joint surgeries, fibromyalgia was less likely. Moreover, the VA examiner noted that PTSD itself is not known to cause fibromyalgia, but associated symptoms can be responsible for aggravating underlying pain, physical injuries, emotional trauma, or viral infections which may trigger the disorder, but no one trigger has been proven to cause primary fibromyalgia. Despite the VA examiner's conclusion that the Veteran did not have a diagnosis of fibromyalgia, the records from the Veteran's private doctor presented a different diagnosis. In a March 2015 record, the Veteran's doctor noted that the Veteran has been his patient since August 2013, and he initially presented with symptoms of widespread body pain, poor sleep, and history of PTSD. The doctor concluded the Veteran's examination and lab work was consistent with a diagnosis of fibromyalgia. Further, the doctor noted that PTSD could be a trigger for his fibromyalgia and was least as likely as not a cause or contributing factor of his PTSD. The Veteran's private doctor also provided a similar opinion in August 2015. The Veteran's doctor noted the Veteran continued to have fibromyalgia and that it developed as a result of his severe PTSD symptoms. The doctor opined that the Veteran's PTSD symptoms have depleted the Veteran's body's defenses against pain and thus led to his fibromyalgia. Accordingly, the Veteran's fibromyalgia was more likely than not caused by or aggravated by his PTSD. This opinion was echoed in the Veteran's private records from May 2016. The Veteran's most recent VA examination was in April 2017. The VA examiner considered the conflicting opinions of the previous VA examinations and the Veteran's private doctors. The VA examiner concluded there was still no conclusive evidence that the Veteran had fibromyalgia. The examiner noted that until the Veteran's records were reviewed by a rheumatologist who concluded there was a diagnosis of fibromyalgia the examiner found there was no conclusive evidence. Moreover, the examiner noted that psychiatric disorders mimic a number of features of fibromyalgia such as low mood, reduced energy, and sleep disturbances. Further, the Veteran likely had psychological problems and generalized muscle/joint pain prior to his fibromyalgia diagnosis in 2013. Therefore, if the Veteran's fibromyalgia was related to his PTSD symptoms, would have been seen closer to service. Last the Board considers the lay statements of record. The Veteran's wife and the Veteran's friend submitted statements noting the Veteran's continued struggle with constant pain and fatigue. In addition, the Veteran submitted several statements describing how he is unable to exercise because of the muscle and joint paint and stated that he is in constant pain. In considering all the evidence, the Board finds there is an equal balance of positive and negative evidence. The Board finds the Veteran's private doctor and the VA examiners both provided competent, probative opinions of the Veteran's condition. The Board also considers the lay statements of record which described the Veteran's ongoing pain issues that occurred prior to his diagnosis in 2013. The opinions of the VA examiners and the Veteran's private doctor are of equal probative weight. Consequently, as the evidence is in relative equipoise, the Board finds service connection secondary to service-connected PTSD is warranted. See Gilbert v. Derwinski, 1 Vet. App. 4 (1990). Sleep Apnea The Veteran underwent a sleep study and was diagnosed with moderate obstructive sleep apnea in March 2015. The Veteran then submitted multiple articles showing a positive relationship between sleep apnea and PTSD. In June 2015, the Veteran underwent a VA examination. The VA examiner noted there was no evidence of PTSD as a risk factor for either obstructive or central sleep apnea. The examiner stated there was an association between psychiatric disorders and sleep disorders but not a causal relationship. The risk factors for the Veteran instead included obstructive lung disease and his remote alcohol abuse. The examiner was unable to provide a baseline of severity for the Veteran's sleep apnea in relation to his PTSD as his PTSD existed prior to his sleep apnea. Therefore, the VA examiner opined his sleep apnea was not aggravated by his PTSD. Conversely, in an August 2015 opinion and a May 2016 medical record, the Veteran's private doctor opined the Veteran's sleep apnea developed as a result of his PTSD. The doctor noted the Veteran's PTSD, which was associated with nightmares, caused a long-term impact on the Veteran's sleep cycle. Therefore, the doctor concluded the Veteran's sleep apnea was more likely than not caused by and aggravated by the Veteran's PTSD. Similar to the fibromyalgia opinions, the Board finds there is an equal balance of positive and negative evidence. The medical opinions of record provided competent, credible, probative evidence and the Board assigns equal value to both opinions. Therefore, as the evidence is in relative equipoise the Board concludes service connection for sleep apnea is warranted as secondary to service-connected PTSD. See Gilbert v. Derwinski, 1 Vet. App. 4 (1990). Bilateral Upper Extremity and Lower Extremity Neuropathy The Veteran received a VA examination in December 2008 and sensory loss was noted in his upper and lower extremities on his right and left sides. However, subsequent treatment records noted the Veteran's neuropathy did not fit the typical diabetic neuropathy picture. In March 2010, the Veteran received another VA examination. The examiner noted there was no conclusive evidence of diabetic neuropathy. Furthermore, the Veteran's test results were similar to the results noted at his December 2008 VA examination. The Veteran's blood sugar was well controlled despite his diagnosis of diabetes thus it was less likely that his peripheral neuropathy was caused or aggravated by his diabetes. The August 2010 VA examiner reached a similar opinion. There were no significant changes since the Veteran's December 2008 VA examination. The VA examiner noted the required electrodiagnostic (EDX) testing had still not been done to determine any potential aggravation of his neuropathy due to his diabetes. Thus, without conclusive evidence of diabetic neuropathy it was less likely than not that his diabetes had aggravated his condition. In March 2011, the VA examiner concluded there was no evidence of peripheral neuropathy based on the Veteran's normal EDX test results and findings on the examination when the Veteran did not have diabetes. The Veteran showed peripheral neuropathy on his December 2008 examination when he did not have a diabetes diagnosis. However, his current EDX studies showed no evidence of neuropathy. Conversely, in a September 2011 private record it was noted that the Veteran's neuropathy was secondary to his diabetes and seemed to be worsening. In January 2014, the Veteran received a VA examination and the examiner considered the conflicting medical evidence. The examiner noted the Veteran's neurological exanimations for his bilateral upper and lower extremities were normal. The VA examiner noted the Veteran's neuropathy complaints preceded his diagnosis of diabetes mellitus by about 4 years. The VA examiner concluded the Veteran was erroneously diagnosed with diabetes in June 2008, as his blood sugar numbers did not show he had diabetes; the Veteran did not meet the criteria until 2013. The examiner noted that extensive review of the Veteran's subjective complaints showed that his complaints predated his actual diagnosis of diabetes. There was no medical evidence to support the Veteran's claims only his subjective complaints. Furthermore, the examiner noted the Veteran had a history of obesity and alcoholism which could be the cause of his subjective complaints reported. However, in an April 2015 private record, the Veteran's doctor stated the Veteran's peripheral neuropathy was more likely than not related to his diabetes. The Board finds the private medical records and VA opinions both provide competent, credible evidence and the Board assigns high probative value to both opinions. Thus, the Board finds the probative evidence is in relative equipoise. Therefore, the Board concludes service connection for bilateral upper and lower extremity neuropathy is warranted. See Gilbert v. Derwinski, 1 Vet. App. 4 (1990). II. Increased Rating PTSD Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.20 (2017). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Given the nature of the present claim for a higher initial evaluation, the Board has considered all evidence of severity since the effective date for the award of service connection in July 2010. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's PTSD is evaluated under Diagnostic Code 9411. 38 C.F.R. § 4.130 (2017). PTSD is evaluated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130 (2017). Under this Rating Formula, a 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130 (2017). Symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). A veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Additionally, while symptomatology should be the primary focus when deciding entitlement to a given disability rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused the requisite occupational and social impairment. Id. Prior to the Veteran's first VA examination his symptoms were noted in his VA treatment records. The Veteran had recurring nightmares that caused panic and agitation upon waking. The Veteran had panic attacks during loud thunderstorms that triggered his memories. The Veteran was withdrawn and shy in public. He had mood swings, extreme anger, and compulsive behaviors. The Veteran had no history of suicidal acts or self-harm. The Veteran's first VA examination was in September 2010. The Veteran still suffered from sleep impairments and had distressing dreams. The Veteran engaged in obsessive ritualistic behaviors. He had panic attacks and persistent re-experiencing of traumatic events. The Veteran had problems with anger, high anxiety, and was verbally aggressive. The examiner opined the Veteran did not have total social and occupational impairment, but due to his PTSD had deficiencies in judgement, thinking, family relations, and mood, which is directly contemplated by the 70 percent criteria. The Veteran's next VA examination was in April 2013. The VA examiner opined the Veteran had occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. Nevertheless, the Veteran generally functioned satisfactorily with normal routine behavior, self-care, and conversation. The VA examiner noted the Veteran would wake up, go to the gym, do chores around the house, and attend to his horses. However, the Veteran still did not like to socialize with others and avoided most social interactions. The Veteran continued to have recurrent and distressing recollections, depression, weekly panic attacks, and chronic sleep impairment. The Veteran also engaged in obsessive behaviors. The VA examiner stated that while the Veteran continued to have distressing PTSD symptoms his condition showed slight improvement. In addition to the VA examinations the evidence of record contained private opinions. The Veteran submitted private opinions from December 2013 and March 2014. The private examiners noted the Veteran had irritability, sleep disturbances, hyper alertness, anger, and mood swings. The Veteran had a low tolerance for others behaviors and shut down emotionally due to grief. The Veteran's private treatment records and VA treatment records are consistent with the evidence presented in the VA examinations and private opinions. Last the evidence of record contains several lay statements. The lay statements from the Veteran, his wife, and his friend provide a similar description of the Veteran's symptoms as described in the aforementioned opinions. They all described his irritability and anger issues. In weighing the VA examinations, private records, and lay statements, the Board finds the preponderance of evidence is for the Veteran's claim that an increase is warranted. The preponderance of the evidence shows the Veteran is withdrawn from his relationships and becomes irritable and verbally abusive with family members. In addition, the evidence documents the Veteran's chronic sleep impairment and irritability. The evidence also shows the Veteran continually engages in obsessive behaviors such as checking the door and cleaning. The Veteran also has panic attacks, hypervigilance, and depression. Significantly, the September 2010 VA examiner found that the Veteran's PTSD resulted in social and occupational impairment with deficiencies in most areas, which is directly contemplated by the 70 percent criteria. Therefore, the Board concludes when considering all of the evidence a 70 percent rating is warranted. However, the overall disability picture for the Veteran's PTSD does not more closely approximate the criteria for a 100 percent rating under the applicable Diagnostic Code because the evidence does not show the Veteran has total occupational and social impairment. See 38 C.F.R. § 4.7. He and his wife have been married for over 40 years albeit with some strain on the relationship. Although his relationship with his adult son is poor, his relationship with his adult daughter was described as "good" at his September 2010 VA examination. The September 2010 VA examiner specifically found that there was not total occupational and social impairment. At his April 2013 VA examination he described his marital relationship as "excellent." He noted that his relationship with his son was strained due to his son's engagement in criminal activity. He reported a good relationship with his daughter. His descriptions of his relationship with his family members support a finding that total social impairment is not present. He went to the gym to exercise, which also supports a finding that total social impairment is not present. The probative evidence of record does not show that the Veteran is a persistent danger to himself or others. A 100 percent rating for PTSD is not warranted. ORDER Service connection for fibromyalgia is granted. Service connection for sleep apnea is granted. Service connection for bilateral upper extremity neuropathy is granted. Service connection for bilateral lower extremity neuropathy is granted. An initial rating of 70 percent for PTSD is granted. REMAND The Board acknowledges the Veteran had a VA examination for his hypertension in December 2008. However, the VA examiner only discussed whether the Veteran's hypertension was related to his service-connected diabetes mellitus. The examiner stated that hypertension pre-existed the onset of diabetes by 10 years and that there was no diabetic renal condition contributing to aggravation of hypertension. The examiner's opinion regarding whether the Veteran's hypertension was caused or aggravated by his service-connected diabetes mellitus is adequate. However, the examiner did not opine as to whether the Veteran's hypertension was caused by his herbicide agent exposure in Vietnam. The National Academy of Sciences (NAS) has placed hypertension in the category of "limited or suggestive evidence of an association" with exposure to herbicides. See e.g., Health Effects Not Associated with Exposure to Certain Herbicide Agents, 75 Fed. Reg. 32,540, 32,549 (June 8, 2010) ("In Update 2006, NAS concluded that there was 'limited or suggestive evidence of an association between exposure to the compounds of interest and hypertension.'"); Health Outcomes Not Associated With Exposure to Certain Herbicide Agents; Veterans and Agent Orange: Update 2008, 75 Fed. Reg. 81,332, 81,333 (December 27, 2010) (NAS, in 2008, categorized certain health outcomes, including hypertension, to have "'limited or suggestive evidence of an association.' This category is defined to mean that evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence."). This was reiterated again in Update 2010. See Determinations Concerning Illnesses Discussed in National Academy of Sciences Report: Veterans and Agent Orange: Update 2010, 77 Fed. Reg. 47,924, 47,926 (Aug. 10, 2012). Because hypertension may be associated with herbicide agent exposure an addendum opinion is needed to determine a nexus between the Veteran's disability and in-service exposure. Furthermore, the Board finds an addendum opinion is also necessary for the Veteran's erectile dysfunction. Like the Veteran's hypertension, the Veteran's erectile dysfunction, was only evaluated in terms of its relationship to his diabetes. The examiner's opinion regarding the causation prong of a secondary service connection with regard to diabetes is adequate. However, the opinion regarding whether the Veteran's service-connected diabetes aggravated his ED is inadequate. The examiner stated that ED was not aggravated by diabetes, but then provided a rationale regarding peripheral neuropathy. An opinion regarding aggravation is needed. If the Veteran's claim for service connection for hypertension is granted, then a VA examination is necessary to determine if his erectile dysfunction is secondarily related to his hypertension, as the March 2011 VA examiner indicated medication use for hypertension as a potential cause of his ED. With regard to the Veteran's heart condition, multiple VA examinations have established that he does not have ischemic heart disease for the purposes of presumptive service connection. The February 2014 VA examination is particularly probative against a finding that the Veteran has ischemic heart disease. However, the VA examinations also noted that the Veteran has coronary arteriosclerosis. As the Veteran could not be expected to identify the specific heart condition that he has, the Board finds that an opinion regarding his heart condition that is not ischemic heart disease is needed. With regard to the Veteran's GERD, every Veteran is assumed to be in sound condition when examined, accepted, and enrolled for service except as to when there are conditions noted on the entrance examination. See 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304(b) (2017). The Veteran's pre-service spastic colitis was noted on his entrance examination because the examining physician found that the Veteran was hospitalized for spastic colitis prior to service. The Board acknowledges that spastic colitis is a condition that impacts a different part of the body than GERD. However, the presumption of soundness with regard to GERD is called into question because at his VA examination for GERD, the examiner stated that the Veteran had chronic anxiety prior to service that caused indigestion and that his abusive child hood may have contributed to his pre-service symptoms. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran's claims file to a qualified clinician to provide an opinion regarding the Veteran's hypertension. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the clinician. The examiner must provide an opinion as to whether it is at least as likely as not that the Veteran's hypertension is directly related to his herbicide agent exposure. It is insufficient for the examiner to provide a negative opinion merely because hypertension is not a condition on the presumption list for herbicide agents. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Provide the Veteran's claims file to a suitable clinician to provide an opinion with regard to the Veteran's erectile dysfunction (ED). The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must opine as to the following: a. Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's ED was proximately due to or the result of his service-connected diabetes mellitus. b. Whether it is at least as likely as not that ED was aggravated beyond its natural progression by his service-connected diabetes mellitus. In the event that the clinician rendering the hypertension opinion provides a positive opinion, the ED examiner must also opine as to the following: a. Whether it is at least as likely as not that the Veteran's ED was proximately due to or the result of his hypertension medication. b. Whether it is at least as likely as not that ED was aggravated beyond its natural progression by his hypertension medication. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Return the Veteran's claims file to the examiner who conducted the February 2014 ischemic heart disease examination so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran's claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must provide diagnoses for the Veteran's heart conditions. Then, for each heart condition diagnosed, the examiner must provide opinions as to whether it is at least as likely as not that the heart condition is directly related to the Veteran's herbicide agent exposure. It is insufficient for the examiner to provide a negative opinion merely because the heart condition is not on the list of conditions and diseases presumptively associated with exposure to herbicide agents. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Provide the Veteran's claims file to a suitable clinician to provide an opinion regarding his GERD. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. Although an independent review of the claims file is required, the Board calls the examiner's attention to the following: a. The Veteran's entrance examination noting a pre-service hospitalization for spastic colitis. b. The report of the Veteran's July 2013 VA examination for GERD. The examiner must provide opinions for each of the following: a. Whether the Veteran's GERD clearly and unmistakably existed prior to his entry into active military service. b. If GERD is found to have clearly and unmistakably existed prior to service, whether it is also clear and unmistakable that it was not aggravated to a permanent degree in service beyond that which would be due to the natural progression of the disease. If GERD is not found to have preexisted a period of active service the examiner must provide opinions as to the following: a. Whether it is as least as likely as not (50 percent or greater probability) that it began in or is related to active military service. b. Whether it is at least as likely as not that the Veteran's GERD was proximately due to or the result of his service-connected PTSD. c. Whether it is at least as likely as not that GERD was aggravated beyond its natural progression by his service-connected PTSD. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 5. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ D. Martz Ames Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs