Citation Nr: 18123715 Decision Date: 08/02/18 Archive Date: 08/02/18 DOCKET NO. 14-32 005A DATE: August 2, 2018 ORDER The severance of service connection for posttraumatic stress disorder (PTSD) being improper, the appeal is granted. Service connection for a skin condition claimed as skin cancer of the face, itching and excessive skin growth, caused by exposure to Agent Orange, jet and diesel fuel, or other herbicides, is denied. Entitlement to compensation for residuals of a pulmonary embolism under the provisions of 38 U.S.C. 1151 is denied. Service connection for diabetes mellitus type II associated with herbicide exposure is denied. Service connection for high cholesterol is denied. REMANDED Entitlement to service connection for an upper back disability claimed as upper back severe pain is remanded. Service connection for a condition affecting the left upper extremity to include hand, wrist, forearm, elbow and shoulder with tingling, weakness, numbness, burning and loss of use, is remanded. Service connection for a condition affecting the right upper extremity to include hand, wrist, forearm, elbow and shoulder with tingling, weakness, numbness, burning and loss of use, is remanded. Service connection for a low back condition, claimed as severe degenerative disc disease lower back, is remanded. Service connection for sciatic nerve condition in the buttocks, left lower extremity, is remanded. Service connection for a sciatic nerve condition in the buttocks, right lower extremity, is remanded. Service connection for irritable bowel syndrome is remanded. Service connection for any lower leg disability, to include of the foot, ankle, calf, knee and thigh which manifests with tingling, weakness, numbness, burning and loss of use, left lower extremity, is remanded. Service connection for any lower leg disability, to include of the foot, ankle, calf, knee and thigh which manifests with tingling, weakness, numbness, burning and loss of use, including your knee giving out, right lower extremity, is remanded. Service connection for myocardial infarction is remanded. Service connection for hypertension is remanded. Service connection for any acquired psychiatric condition other than PTSD, to include agoraphobia, also claimed as depression, anxiety, GAD, stress, and nerves, is remanded. Service connection for hemorrhoids is remanded. The issue of entitlement to an initial compensable disability rating for bilateral hearing loss is remanded. The issue of entitlement to an initial disability rating in excess of 50 percent for PTSD is remanded. The issue of entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. Service connection for the purpose of establishing eligibility for treatment under 38 U.S.C. 1702 is remanded. REFERRED The issue of service connection for a pulmonary embolism was raised in a January 2013 statement and is referred to the Agency of Original Jurisdiction (AOJ) for adjudication.   FINDINGS OF FACT 1. There is not clear and unmistakable evidence establishing that the Veteran did not witness an Axe Murder incident in the Korean Demilitarized Zone in August 1976. 2. The preponderance of the evidence is against finding that the Veteran has a skin condition, including skin cancer, due to a disease or injury in service, to include exposure to Agent Orange, jet and diesel fuel, or other environmental conditions. 3. The preponderance of the evidence is against finding that the Veteran was exposed to Agent Orange during service or that diabetes is due to an in-service, including exposure to jet and diesel fuel, or other environmental conditions. 4. The Veteran has high cholesterol, which is not a disease for VA purposes. 5. The Veteran does not have additional disability resulting from the diagnosis and treatment of his pulmonary embolisms, and even if there were additional disability, it was not the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part in furnishing the surgery, and any additional disability was not the result of an event not reasonably foreseeable. CONCLUSIONS OF LAW 1. The severance of service connection for PTSD was improper. 38 U.S.C. § 5112; 38 C.F.R. § 3.105. 2. The criteria for service connection for a skin condition claimed as skin cancer of the face, itching and excessive skin growth, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.313. 3. The criteria for service connection for diabetes mellitus type II are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.313. 4. The criteria for service connection for high cholesterol are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 5. The criteria for compensation under 38 U.S.C. 1151 for pulmonary embolism are not met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. §§ 3.102, 3.361. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1974 to October 1977. This matter is on appeal from a November 2012 decision. In May 2018, the Veteran withdrew his prior request for a Board hearing. Misfiled documents were discovered by the Board in this Veteran’s claims file. The documents consisted of two entries in the electronic file containing VA medical record pertaining to a different Veteran. These misfiled documents appear to have been mistakenly included in this Veteran’s file, but do not appear to have had any impact in the instant appeal. Accordingly, the Board removed those records for association with the correct Veteran’s claims file. Severance 1. Whether the severance of service connection for PTSD was proper Due Process The RO granted service connection for PTSD in a March 2012 rating decision. The RO found that service connection was established as directly related to service. The RO cited the Veteran’s service in Korea, with a VA examination in February 2012 diagnosing PTSD related to fear of hostile military action. The RO also cited an article on an “Axe Murder Incident,” which the Veteran reported as having witnessed. In a November 2012 rating decision, the RO proposed to sever service connection for the disability. The RO explained that the original award for service connection was in error because the previous adjudicator failed to consider February 2012 VA examiner’s statement that the current diagnosis was based solely on his subjective statements, whereby the Veteran’s reports of “having experienced or witnessed events leading to trauma” were not, and could not, be verified. In fact, according to the RO, the stressor “can never be verified and as such, service connection was not and is not in order based on this fact.” The RO determined that neither the Veteran’s military specialty (supply), nor his service records disclosed the nature of his duties as exposing him “to more than an ordinary stressful environment” and that “[t]here is no independent evidence confirming that you were exposed to more than ordinary stress inherent in service as a supply specialist other than your unsubstantiated statements to the VA examiner as well as those of record in your VA claims folder.” The Veteran was notified in November 2012 at his latest address of record of this contemplated action and furnished detailed reasons therefor and was given 60 days for the presentation of additional evidence to show that service connection should be maintained. The November 2012 notice letter also informed the Veteran that he had the opportunity for a predetermination hearing if such a request for a hearing was received by VA within 30 days from the date of the notice. See 38 C.F.R. § 3.105(i). The Veteran did not then file a notice of disagreement (NOD), submit additional evidence, or request a predetermination hearing. Thereafter, the RO severed service connection in a July 2013 rating decision. In support, the RO reiterated the same reasons set forth in the November 2012 proposed rating decision. The severance was made effective from October 1, 2013. This date was greater than the last day of the month in which a 60-day period from the date of the July 2013 notice to the beneficiary of the final rating action expired. Notice of this rating decision, plus his appeal rights, was sent to the Veteran under a July 2013 cover letter. All due process requirements were met in severing service connection. See 38 C.F.R. § 3.105(d). A. Applicable Law Service connection will be severed only where evidence establishes that it is clearly and unmistakably erroneous (CUE) (the burden of proof being on the Government). 38 C.F.R. § 3.105(d). To establish that a grant of service connection was the product of CUE, VA must show that (1) either the correct facts as they were known at the time were not before the adjudicator, the adjudicator made an erroneous factual finding, or the statutory or regulatory provisions were incorrectly applied; (2) the alleged error was undebatable, not merely a disagreement as to how the facts were weighed or evaluated; and (3) the error manifestly changed the outcome of the prior decision. See Allen v. Nicholson, 21 Vet. App. 54, 58-59 (2007); Stallworth v. Nicholson, 20 Vet. App. 482, 487-88 (2006); cf. Bustos v. West, 179 F.3d 1378, 1380-81 (Fed. Cir. 1999); Damrel v. Brown, 6 Vet. App. 242, 245 (1994); Russell v. Principi, 3 Vet. App. 310, 313-14, 319 (1992) (en banc). A clear and unmistakable error is one about which reasonable minds could not differ. See, e.g., 38 C.F.R. § 20.1403(a). B. Discussion The question before the Board in this case is whether the grant of service connection for PTSD was clearly and unmistakably erroneous. The Board concludes that the severance of service connection was improper because there is conflicting, but not clear and unmistakable evidence that the Veteran’s in-service PTSD stressors actually occurred. A February 2012 VA examiner gave a diagnosis of PTSD, and related the diagnosis to the Veteran’s service. The VA examiner twice stated that the diagnosis was “entirely based on” the Veteran’s subject reports of his in-service stressors. Thus, the central question of fact was whether the Veteran’s in-service stressors actually occurred. The Veteran submitted several statements describing an incident during his service where two United States Army officers were killed by North Korean soldiers in the Demilitarized Zone (DMZ) in August 1976. He submitted Internet articles, which tend to confirm the occurrence of this event, and his service records confirm that he was in Korea at the time. He has given conflicting statements as to whether he witnessed the event first-hand. In several witness statements, such as in September 2014, and at the February 2012 VA examination, the Veteran directly stated that he was present and witnessed the event. He indicated that he took photographs of the incident. In a November 2011 PTSD statement, by comparison, he wrote that he only saw pictures of the incident, which were circulated afterwards. Thus, there is conflicting evidence regarding whether the Veteran witnessed the event, which rests solely on the credibility of his account. The Board finds that the evidence is not clear and unmistakable in establishing that he did not witness the event. Rather, this conflicting evidence presents a reasonable disagreement as to such, and reasonable minds could disagree as to the ultimate determination. However, this determination, at this point, amounts to no more than a disagreement as to how to weigh the facts. In context of a severance case, a disagreement as to how to weigh the facts is legally insufficient to establish that the award of service connection was clearly erroneous. Accordingly, the severance of service connection was improper, service connection is restored, and the appeal is granted. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. “To establish a right to compensation for a present disability, a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service”—the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). 2. Service connection for a skin condition claimed as skin cancer of the face, itching and excessive skin growth cause by exposure to Agent Orange, jet and diesel fuel, or other herbicides As set forth in his April 2012 claim, the Veteran contends that he has skin cancer, itching, and excessive skin growth caused by exposure to herbicides, chemicals, diesel and jet fuel, and burning diesel fuel in a tent stove. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Private treatment records show that the Veteran was diagnosed with basal cell carcinoma of the bridge of the nose in May 2003. Then, he was diagnosed at VA in July 2012 with seborrheic keratoses and an uncertain neoplasm on the tip of his nose, which was found in August 2012 to be basal cell carcinoma. There is no indication that a current diagnosis is related to any event of the Veteran’s service. As explained herein below, the Veteran was not exposed to Agent Orange. Furthermore, although it is plausible that he was exposed to other substances as described, the Veteran is not competent to determine that these diagnoses are related to those exposures. The issue is medically complex, and it is not within the common knowledge or experience of a lay person. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran has not undergone a VA examination, but he is not entitled to a VA examination based solely on his own conclusory statements indicating that there is a relationship between an in-service event and a present disability. See Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010). Accordingly, the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine is not applicable, and service connection is not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 3. Service connection for diabetes mellitus type II associated with herbicide exposure The Veteran maintains that he has a diagnosis of diabetes mellitus type II (diabetes) related to Agent Orange exposure in the Korean DMZ or other environmental exposures during service. The threshold question for the Board is whether the Veteran was exposed to Agent Orange during service. The Board concludes that, while the Veteran has a diagnosis of diabetes, the preponderance of the evidence is against finding that he was exposed to Agent Orange. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). With regard to herbicide exposure, VA laws and regulations provide that a veteran who, during active military, naval, or air service, served between April 1, 1968, and August 31, 1971, in a unit that, as determined by the Department of Defense, operated in or near the Korean DMZ in an area in which herbicides are known to have been applied during that period, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307(a)(6)(iv). Here, the Veteran served in Korea from June 1976 to June 1977. This was after the qualifying time period for establishing presumptive exposure to herbicides in the Korean DMZ. Therefore, it cannot be presumed that he was exposed to herbicides. He has not indicated any factual basis for how he might otherwise have been exposed to herbicides during service. Accordingly, the evidence weighs against finding that he was exposed to Agent Orange during service. In April 2012 and October 2015 statements, the Veteran indicated that he was exposed to jet fuel, diesel fuel, and fumes from a pot belly stove. While it is likely that he was exposed to these environmental conditions to some extent, there is no indication that diabetes is related to any such exposure. The Veteran is not competent to relate diabetes to these exposures as this is a medically complex question not within the common knowledge or experience of a lay person. Jandreau, 492 F.3d at 1377 n.4. To this extent, the Veteran has not undergone a VA examination for this question, but he is not entitled to a VA examination based solely on his own conclusory statements indicating that there is a relationship between such in-service exposures and diabetes. See Waters, 601 F.3d at 1278. Accordingly, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and service connection is not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 4. Service connection for high cholesterol The Veteran contends that he has high cholesterol related to service or secondary to hypertension. The Board concludes that, although the Veteran has a current diagnosis of high cholesterol, such diagnosis is not a condition for which service connection can be granted. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). An August 2013 VA Cardiology report reflects the diagnosis of hyperlipidemia. However, hyperlipidemia, elevated triglycerides, and elevated cholesterol are laboratory test results, and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities for the rating schedule to address. See 61 Fed. Reg. 20440 (May 7, 1996); VBA Manual M21-1, IV.ii.2.A.2.h., Abnormal Laboratory Findings. Because service connection for high cholesterol readings alone cannot be granted, this claim is denied. For this reason, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and service connection is not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 1151 5. Entitlement to compensation for residuals of a pulmonary embolism under the provisions of 38 U.S.C. 1151 As set forth in his April 2012 claim, the Veteran contends compensation is warranted under § 1151 due to a lack of proper care during treatment at a VA emergency department in March 2012. He explained that he went to seek treatment for respiratory symptoms, but was diagnosed with pneumonia and released. He went back the following day after spitting up blood, which resulted in a diagnosis of two blood clots in his lungs. He then waited for months to have follow-up treatment. The Veteran has also raised a secondary service connection theory of entitlement for this same disability. Although raised, it has not been adjudicated or appealed to the Board. Therefore, the secondary service connection theory of entitlement is not within the scope of this appeal. See, e.g., Wood v. McDonald, No. 14-4345, 2016 U.S. App. Vet. Claims LEXIS 596, at *21-23 (Vet. App. Apr. 27, 2016) (J. Pietsch) (nonprecedential) (explaining the legal and jurisdictional distinctions between 1151 and secondary service connection claims). Under 38 U.S.C. § 1151, compensation is awarded for a qualifying additional disability or death in the same manner as if such additional disability or death were service-connected. For purposes of this section, a disability or death is a qualifying additional disability if (1) the disability or death was not the result of the veteran’s willful misconduct, (2) the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under the law administered by the Secretary, and (3) the proximate cause of the disability or death was (A) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination, or (B) an event not reasonably foreseeable. 38 U.S.C. § 1151; 38 C.F.R. § 3.361; Viegas v. Shinseki, 705 F.3d 1374, 1377-78 (Fed. Cir. 2013). The question for the Board is whether it is at least as likely as not that the Veteran sustained additional disability that was not the result of the his/her willful misconduct; and the disability or death was caused by hospital care, medical or surgical treatment, or examination furnished under the law administered by VA; and the proximate cause of the disability or death was either (a) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination, or (b) an event not reasonably foreseeable. Additional Disability Element VA treatment records on March 31, 2012, show that the Veteran was diagnosed with a pulmonary embolism at the emergency department after presenting with complaints of blood tinged sputum starting that day. The prior day, March 30, 2012, the Veteran presented for treatment at the same emergency department with symptoms diagnosed and treated as pneumonia. The Veteran’s essential contention is that there was a negligent failure to timely diagnosis and treat the pulmonary embolism when he initially presented for treatment the day prior. Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA’s failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). Here, a VA examiner in December 2015 reviewed this matter and concluded that the pulmonary embolism was less likely caused by or became worse as a result of the VA treatment at issue. The VA examiner observed that the Veteran had initially presented with fevers and had infiltrate on X-rays at time of presentation, so the diagnosis of pneumonia was justified at that time. The examiner noted that the Veteran felt improved with treatment rendered in emergency room, and he did not have any evidence of oxygen desaturations, so the differential diagnosis of pulmonary embolisms was less likely at that time. Further, according to the examiner, the Veteran was clearly instructed to return if the symptoms got worse, and he and his wife both understood the instructions at that time. The VA examiner further concluded that it is less likely that there was failure on the part of VA to timely diagnose and/or properly treat the claimed disease or disability that allowed the disease or disability to continue. The VA examiner found that the Veteran had completed treatment with coumadin, and there had been no recurrence of pulmonary embolism or DVT since then, and no heart strain on echocardiogram resulted from the pulmonary embolism. The VA examiner further noted that the Veteran was presently not on any treatment for a lung disorder and there was no evidence of any residuals or progression of disease. The VA examiner finally observed that the Veteran had normal a pulmonary function test (PFT) done. The VA examiner ultimately concluded that the Veteran had no residuals related to the pulmonary embolism. This examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data as relevant to the § 1151 issue. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In light of the VA examiner’s opinion, the Board finds that the Veteran does not have additional disability caused by the March 30, 2012 treatment. Thus, the additional disability element of the claim has not been met. See 38 U.S.C. § 1151(a)(1); 38 C.F.R. § 3.361(b)-(d). While the Veteran believes he has additional disability related to the diagnosis and treatment for pulmonary embolism, he is not competent to provide a diagnosis. This question is medically complex as it concerns interpreting the medical data to rule in or out a diagnosis. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA examiner’s opinion. Fault Element Even if there were additional disability, the Board finds that it was not due to the carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault by VA when it provided treatment to the Veteran. The December 2015 VA examiner concluded that it is less likely that there was additional disability resulting from carelessness, negligence, lack of skill, or similar incidence of fault on the part of the attending VA personnel. The VA examiner found that, after the Veteran came back, he had an immediate study done to show the pulmonary embolism, and there was no delay in diagnostic study. The VA examiner explained that the pulmonary embolism was small, and did not result in any cardiac involvement as per normal echocardiogram done afterwards. Plus, according to the VA examiner, the Veteran completed coumadin therapy, and there had been no recurrence. Again, the examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data as relevant to the § 1151 issue. Nieves-Rodriguez, 22 Vet. App. at 304. The Board therefore finds that the additional disability was not the result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA’s part in diagnosing and treating the pulmonary embolism. As such the fault element of the claim has not been met. See 38 U.S.C. § 1151(a)(1)(A); 38 C.F.R. § 3.361(d)(1). Although the Veteran may feel that there was negligence, this question is medically complex, as it requires knowledge of the presenting symptoms of pulmonary embolisms, the standards of care for diagnosing and treating the condition, and how those factors fit with his case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA examiner’s opinion. Foreseeability Element Finally, there is no indication of additional disability that was not reasonably foreseeable. The December 2015 VA examiner concluded that it is less likely there was additional disability resulting from an event that could not have reasonably been foreseen by a reasonable healthcare provider. The VA examiner reasoned that, based on the Veteran’s clinical presentation with fevers, normal oxygen saturations, infiltrate on X-ray, the initial diagnosis was justified. Furthermore, according to the VA examiner, after the Veteran returned with new complaint of hemoptysis, he had diagnostic studies study done immediately with no delay in diagnostic studies. The examiner’s opinion on this question is probative, because provides an explanation that contains clear conclusions and supporting data as relevant to the § 1151 issue. Nieves-Rodriguez, 22 Vet. App. at 304. The Board therefore finds that the additional disability was not the result of an event not reasonably foreseeable. As such, the foreseeability element of the claim has not been met. See 38 U.S.C. § 1151(a)(1)(B); 38 C.F.R. § 3.361(d)(2). Conclusion In sum, although the Veteran believes that he has additional disability as a result of the diagnosis and treatment for pulmonary embolism, none of the elements that would allow for compensation under 38 U.S.C. § 1151 have been met. The Board considered the benefit-of-the-doubt rule. However, because the preponderance of the evidence is against the Veteran’s claim for compensation under 38 U.S.C. § 1151, the benefit-of-the-doubt rule is not applicable, and thus, such compensation is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for an upper back disability claimed as upper back severe pain is remanded. 2. Service connection for condition affecting left upper extremity to include hand, wrist, forearm, elbow and shoulder with tingling, weakness, numbness, burning and loss of use, is remanded. 3. Service connection for condition affecting right upper extremity to include hand, wrist, forearm, elbow and shoulder with tingling, weakness, numbness, burning and loss of use, is remanded. 4. Service connection for a lower back condition claimed as severe degenerative disc disease lower back, is remanded. 5. Service connection for sciatic nerve condition in the buttocks, left lower extremity, is remanded. 6. Service connection for sciatic nerve condition in the buttocks, right lower extremity, is remanded. 7. Service connection for hemorrhoids is remanded. 8. Service connection for irritable bowel syndrome is remanded. 9. Service connection for any lower leg disability, to include of the foot, ankle, calf, knee and thigh which manifests with tingling, weakness, numbness, burning and loss of use, left lower extremity, is remanded. 10. Service connection for any lower leg disability, to include of the foot, ankle, calf, knee and thigh which manifests with tingling, weakness, numbness, burning and loss of use, including your knee giving out, right lower extremity, is remanded. 11. Service connection for myocardial infarction is remanded. 12. Service connection for hypertension is remanded. Issues 1-12 are remanded for a VA examination. The Veteran contends that the spine and hemorrhoid disabilities were caused by the strain from carrying and lifting boxes and gear on 5 mile trainings every day. His service records confirm a specialty in storage and supply. Thus, the carrying and lifting of boxes is consistent with the circumstances of such service. Training while wearing gear is also consistent with the circumstances of his service. To this extent, it is common knowledge and within the ordinary experience of a lay person to understand that back conditions and hemorrhoids may be associated with straining. Furthermore, although the medical records do not reflect a clinical diagnosis of hemorrhoids, the Veteran was given medication for such on different occasions, including in November 2012, on the basis of his subjective complaints alone. To this extent, hemorrhoids are directly observable and within the competence of lay person to identify. At present, the Board cannot make a fully-informed decision on the issues because no VA examiner has opined whether the Veteran’s back and hemorrhoid conditions may be associated with the circumstances of his service. Also, in October 2012, the Veteran submitted several medical articles and a VA treatment guide for PTSD. This information indicates that a diverse number of medical conditions may be associated with or aggravated by PTSD, including low back pain, fibromyalgia, depression, neuropathic pain, and digestive diseases. The Board herein above restores service connection for PTSD. Thus, it is a service-connected disability for which service connection on a secondary basis may be established for the remaining conditions. At present, a VA examination has not been conducted and the medical evidence currently of record, including the articles and treatment guide, are insufficient to establish a nexus in this particular case. Nonetheless, it is sufficient to indicate the possibility of a secondary nexus to PTSD. Accordingly, a VA examination is needed. (To the extent the Veteran also contends that such disabilities may have resulted from environmental exposures during service, to include Agent Orange, the Board herein above finds that he was not exposed to Agent Orange during service. Nor is there any indication that any such diagnoses may be associated with the other environmental exposed alleged. As such, a VA examination is not needed to address a direct theory of entitlement.) 13. Service connection for any acquired psychiatric condition other than PTSD, to include agoraphobia, also claimed as depression, anxiety, GAD, stress, and nerves is remanded. The claim of service connection for a psychiatric condition other than PTSD is remanded for a new VA examination. First, a secondary nexus is indicated. The medical articles and VA treatment guide cited herein above indicate that other psychiatric symptoms may be associated with or aggravated by PTSD and chronic pain. Additionally, various VA medical records, such as in January 2013, document the Veteran’s complaints of worries associated with his medical conditions. A November 2012 VA medical record likewise documents symptoms of depression and anxiety worsened due to his medical problems. Second, a direct theory of entitlement is raised by the Veteran complaints of symptoms since service. At VA in September 2011, the Veteran reported “all of his symptoms started when he left the service.” A May 2012 VA medical record indicates symptoms of auditory hallucinations, “present on and off since return from deployment.” A December 2011 VA medical record also reflects complaints of auditory hallucinations ongoing “for the last 30 something odd years.” Of further note, the Veteran’s enlistment examination shows that he endorsed a history of depression or excessive worry at that time. The examiner’s associated comment indicates “No [unreadable] NP positive.” This indicates that symptoms of a psychiatric condition may have preexisted service. The Veteran previously underwent a VA examination in February 2012. The VA examiner stated his opinion that the Veteran’s diagnosed anxiety disorder “is not believed by this examiner to be related to his military service.” However, the VA examiner did not address the notation on the enlistment examination. Nor did the examiner give a rationale for this opinion. For these reasons, a new VA examination is needed. 14. The issue of entitlement to an initial compensable disability rating for bilateral hearing loss is remanded. Evidence indicates that there may be outstanding relevant VA treatment records. A January 2013 VA Audiology note reflects that an audiogram was conducted at that appointment. It states that the audiogram could be viewed by utilizing a toolbar that is not accessible to the Board. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issue. A remand is required to allow VA to obtain the results of this audiogram. Furthermore, a new VA examination is needed. The January 2013 VA Audiology note indicates complaints of vertigo. An earlier VA Primary Care note from November 2012 indicated complaints of ear pain. It is not clear whether these complaints are associated with the service-connected bilateral hearing loss disability. As such, a new VA examination is needed to ascertain the current severity and manifestations of the bilateral hearing loss disability. 15. The issue of entitlement to an initial disability rating in excess of 50 percent for PTSD is remanded. Regarding the claim of entitlement to an increased initial disability rating for PTSD, the Veteran submitted a timely notice of disagreement in May 2012 disagreeing with the initial rating assigned in the March 2012 rating decision granting service connection for PTSD. As service connection was subsequently severed for the disability, a statement of the case was not issued. The Board herein above, however, restores service connection for the condition. As such, the Veteran’s disagreement with the initial disability rating assigned remains in effect. A remand is required for the AOJ to issue a statement of the case. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). 16. The issue of entitlement to a TDIU is remanded. 17. Service connection for the purpose of establishing eligibility for treatment under 38 U.S.C. 1702 Because a decision on the other remanded issues will significantly impact a decision on the TDIU and eligibility for treatment issues, these issues are inextricably intertwined. A remand of the claims is therefore required. The matters are REMANDED for the following action: 1. Obtain the Veteran’s outstanding VA treatment records to include a copy of an audiogram conducted in January 2013 by VA’s Audiology department. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology (1) upper back, (2) left and right upper extremity, (3) lower back, (5) left and right sciatic nerve conditions, (6) lower extremity, and (7) hemorrhoids. (a.) The examiner must opine whether any diagnosis is at least as likely as not are related to an in-service injury, event, or disease, including the strain from carrying and lifting boxes and gear on 5 mile trainings. (b.) The examiner must opine whether it is at least as likely as not that any diagnosis is (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by a service-connected disability. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the claimed (1) irritable bowel syndrome, (2) myocardial infarction, and (3) hypertension. The examiner must opine whether it is at least as likely as not that any diagnosis is (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by a service-connected disability, particularly PTSD. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any psychiatric condition other than PTSD. The examiner must opine on the following: (a.) Whether any diagnosis other than PTSD clearly and unmistakably (undebatable) preexisted the Veteran’s service in light of the April 1974 endorsement at service entrance of a history of depression or excessive worry. If the examiner finds it did clearly and unmistakably preexist service, the examiner must opine whether it was clearly and unmistakably not aggravated by service. (b.) Whether any diagnosis other than PTSD, including a psychosis, if indicated, at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. (c.) Whether any diagnosis other than PTSD is at least as likely as not (1) proximately due to a service-connected disability, or (2) aggravated beyond its natural progression by a service-connected disability. 5. Schedule the Veteran for a VA examination to assess the severity of the service-connected bilateral hearing loss. In doing so, the examiner should identify whether any other symptoms, such as ear pain and/or vertigo, are associated with the bilateral hearing loss disability. If so, the examiner should also assess the severity of those symptoms. 6. Send the Veteran and his representative a statement of the case that addresses the issue of entitlement to an increased initial rating for PTSD. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Bosely, Counsel