Citation Nr: 20009952 Decision Date: 02/06/20 Archive Date: 02/05/20 DOCKET NO. 17-51 292 DATE: February 6, 2020 ORDER The request to reopen the claim of entitlement to service connection for hypertension is granted. The request to reopen the claim of entitlement to service connection for neck pain is granted. The request to reopen the claim of entitlement to service connection for a back condition is granted. The request to reopen the claim of entitlement to service connection for foot pain is granted. Entitlement to an effective date prior to October 23, 2009 for the grant of service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to an effective date prior to October 23, 2009 for the grant of service connection for left knee strain is denied. Entitlement to an effective date prior to October 23, 2009 for the grant of service connection for left thumb strain is denied. REMANDED The request to reopen the claim of entitlement to service connection for shin splints is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a thoracolumbar spine disability is remanded. Entitlement to service connection for a bilateral foot disability is remanded. Entitlement to service connection for a heart disability is remanded. Entitlement to service connection for a disability manifesting in tremors is remanded. Entitlement to service connection for a disability manifesting in fatigue is remanded. Entitlement to service connection for a stomach disability is remanded. Entitlement to service connection for residuals of traumatic brain injury (TBI) is remanded. Entitlement to service connection for bladder disability is remanded. Entitlement to service connection for a disability manifesting in a compromised immune system is remanded. Entitlement to service connection for a right ring fingernail disability is remanded. Entitlement to service connection for a disability manifesting in skin lesions is remanded. FINDINGS OF FACT 1. In a July 2006 rating decision, the Veteran was denied service connection for hypertension, neck pain, a back condition, and foot pain on the basis that the evidence did not show each disability was incurred in or caused by service. The Veteran was notified of the decision in correspondence issued the same month. He did not appeal the decision. While new evidence discussing Enduring Freedom casualties was submitted within a year after the decision, see December 2006 documents, such evidence is not material because information regarding other servicemembers’ deaths is irrelevant to whether the Veteran’s hypertension, neck pain, a back condition, and foot pain is related to service. Therefore, the decision became final. 2. In correspondence received in October 2014, the Veteran submitted an undated letter from Dr. M. Irvin, DO, who discussed the Veteran’s foot pain and damage in the neck and lower back, and opined that these health problems could have resulted from the Veteran’s exposure to toxins in Afghanistan. This evidence is relevant and probative, and it helps cure a prior evidentiary defect; namely, the lack of a relation to the Veteran’s service. 3. In December 2013, Dr. V. Khetpal, MD, noted that the Veteran’s hypertension could have resulted from the Veteran’s exposure to toxins in Afghanistan. This evidence is relevant and probative, and it helps cure a prior evidentiary defect; namely, the lack of a relation to the Veteran’s service. 4. In a January 2007 rating decision, the Veteran was denied service connection for PTSD. The Veteran was notified of the decision in correspondence issued the same month. He did not appeal the decision and new evidence was not submitted within a year after the decision. Therefore, the decision became final. 5. After the January 2007 rating decision became final, the first correspondence that can be interpreted as a claim of service connection for any acquired psychological disorder was received by VA on October 23, 2009. 6. The first correspondence that can be interpreted as a claim of service connection for a left knee disability or a left thumb disability was received by VA on October 23, 2009. CONCLUSIONS OF LAW 1. The July 2006 rating decision, which denied service connection for hypertension, neck pain, a back condition, and foot pain, is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. § 20.302 (2018). 2. The evidence received since the July 2006 rating decision, which denied service connection for hypertension, is new and material, and the claim is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (2018). 3. The evidence received since the July 2006 rating decision, which denied service connection for neck pain, is new and material, and the claim is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (2018). 4. The evidence received since the July 2006 rating decision, which denied service connection for a back condition, is new and material, and the claim is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (2018). 5. The evidence received since the July 2006 rating decision, which denied service connection for foot pain, is new and material, and the claim is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (2018). 6. The January 2007 rating decision, which denied entitlement to service connection for PTSD, is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. § 20.302 (2018). 7. The criteria for entitlement to an effective date prior to October 23, 2009 for the grant of service connection for PTSD have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.1, 3.155 (2014, 2018), 3.156, 3.400 (2018). 8. The criteria for entitlement to an effective date prior to October 23, 2009 for the grant of service connection for left knee strain have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.1, 3.155 (2014, 2018), 3.400 (2018). 9. The criteria for entitlement to an effective date prior to October 23, 2009 for the grant of service connection for left thumb strain have not been met. 38 U.S.C. §§ 5101, 5110 (2012); 38 C.F.R. §§ 3.1, 3.155 (2014, 2018), 3.400 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 2003 to November 2004 with additional periods of active duty for training (ACDUTRA) from January 1981 to May 1981, June 1985 to September 1985, and January 1991 to May 1991. He served in Afghanistan from January 2004 to October 2004. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from May 2010 and June 2010 rating decisions by the Department of Veterans Affairs (VA). These issues were previously remanded by the Board in May 2017 pursuant to Manlincon v. West, 12 Vet. App. 238 (1999). Although the Agency of Original Jurisdiction (AOJ) adjudicated two separate issues of entitlement to service connection for a weakened immune system and lymphangitis, both of which were appealed to the Board, in light of Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Board has recharacterized the issues into one issue encompassing any disability manifesting in a weakened immune system, to include lymphangitis. Although the AOJ reopened the Veteran’s claims of service connection for hypertension, neck pain, a back condition, shin splints, and foot pain by adjudicating the issues on the merits in an August 2017 statement of the case, the question of whether new and material evidence has been received to reopen such claims must be addressed in the first instance by the Board because the issue goes to the Board’s jurisdiction to reach the underlying claim and adjudicate it on a de novo basis. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no such evidence has been offered, that is where the analysis must end; hence, what the AOJ may have determined in this regard is irrelevant. Barnett, 83 F.3d at 1383. The Board has characterized the issues accordingly. For the reasons stated above, the requests to reopen a claim of service connection for hypertension, neck pain, a back condition, and foot pain are granted. During the course of the appeal, service connection for dry eyes and sinusitis was granted in an August 2017 rating decision. Because that decision represents a full grant of the benefits sought for the issues of entitlement to service connection for dry eyes and allergies, those issues are no longer on appeal. Effective date Except as otherwise provided, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. Prior to March 24, 2015, a claim is a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1(p) (2014). The essential elements for any claim, whether formal or informal, are: (1) intent to apply for benefits; (2) identification of the benefits sought; and (3) communication in writing. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). A veteran must file a Notice of Disagreement (NOD) with a determination by the AOJ within one year from the date that the AOJ mails notice of the determination to him or her. Otherwise, that determination will become final. 38 C.F.R. § 20.302. However, if new and material evidence is received prior to the expiration of the appeal period, then the evidence will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Although there are outstanding VA treatment records that need to be obtained, see infra, the issues related to earlier effective date may be adjudicated now because these issues are predicated on evidence that was already of record prior to when the effective date at issue was assigned. As a result, any evidence received thereafter is irrelevant to the determination of whether an earlier effective date is warranted and the Board may proceed with adjudication. 1. Entitlement to an effective date prior to October 23, 2009 for the grant of service connection for PTSD. The Veteran asserted that he is entitled to an effective date in 2005. He stated that he missed his VA examination during his initial claim of service connection because he was incapacitated by his mental and physical problems. See, e.g., August 2010 correspondence. He also stated that has continued to send documents to VA and that his claim has been ongoing. See August 2016 statement. In a January 2007 rating decision, the Veteran was denied service connection for PTSD. He was notified of the decision in correspondence issued the same month. He did not appeal the decision and new evidence was not submitted within a year after the decision. Therefore, the decision became final. The next correspondence received by the Veteran that can be interpreted as a claim of service connection for an acquired psychological disorder was received by VA on October 23, 2009. See October 2009 statement. Indeed, the October 23, 2009 claim is the first correspondence from the Veteran of any kind after the January 2007 rating decision. To establish an effective date earlier than October 23, 2009 for the grant of service connection for PTSD, the Veteran would need to show at least that he had a prior claim of service connection for an acquired psychological disorder that remained pending, such that an earlier date of claim would be preserved. See 38 C.F.R. § 3.400. Consequently, regardless of when the Veteran’s PTSD first manifested and that his PTSD may have affected his ability to pursue benefits, there is no legal basis for awarding an earlier effective date because the January 2007 rating decision became final. Thus, the issue must be denied. 2. Entitlement to an effective date prior to October 23, 2009 for the grant of service connection for left knee strain. On June 28, 2005, the Veteran submitted an application for benefits, which did not discuss the Veteran’s knee. See June 2005 VA Form 21-526. Attached to that application was a statement from the Veteran that included a statement that “Joint pain was a constant, especially in the hips, knees, and ankles.” See June 2005 statement. The Board finds that this statement is not considered an informal claim of service connection for a left knee disability because it does not indicate an intent to apply for benefits related to his left knee. Instead, it merely is a statement regarding knee pain in service, which is insufficient to be considered an intent to apply for benefits related to that knee pain, to include when considered together with the June 2005 VA Form 21-526 and when considered individually. The first correspondence that can be interpreted as a claim of service connection for a left knee disability was received on October 23, 2009. See October 2009 statement. Thus, the Veteran did not have a claim that remained pending prior to that date, he is not entitled to an effective date prior to October 23, 2009, and the matter must be denied. 3. Entitlement to an effective date prior to October 23, 2009 for the grant of service connection for left thumb strain. To establish an effective date earlier than October 23, 2009 for the grant of service connection for left thumb strain, the Veteran would need to show at least that he had a prior claim of service connection for a left thumb disability that remained pending, such that an earlier date of claim would be preserved. See 38 C.F.R. § 3.400. There is no evidence the Veteran intended to file a disability compensation claim for his left thumb or even discussed his left thumb prior to October 23, 2009. Consequently, regardless of when the Veteran’s left thumb strain first manifested, there is simply no basis for awarding an effective date prior to October 23, 2009 for the grant of service connection for left thumb strain, and the issue must be denied. REASONS FOR REMAND As an initial matter, the Board notes that the Veteran’s service does not qualify for service in the Southwest Asia theater of operations for purposes of the Gulf War presumption, because he served only in Afghanistan. See 38 C.F.R. § 3.317(e). While his service would qualify for presumptive service connection for infectious diseases, see 38 C.F.R. § 3.317(c), none of those disabilities are at issue in the current matter. It appears that there are outstanding VA treatment records. See November 2010 VA treatment records (referencing treatment in Oklahoma VA Medical Center (VAMC)). As a result, all issues must be remanded. 1. Entitlement to service connection for hypertension is remanded. Records from immediately after service reflect a diagnosis of labile uncontrolled hypertension. See November 2004 treatment records. In April 2005, the Veteran noted that his blood pressure was variable, and he was working with his family doctor to get it stable. See April 2005 VA treatment records. A VA examiner opined that the Veteran did not have hypertension in May 2006. See May 2006 VA examination. Finally, the Veteran was diagnosed with hypertension in an April 2010 VA examination. Certain chronic diseases (including hypertension) will be presumed to have been incurred in service if manifested to a compensable degree of at least 10 percent disabling within one year after service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The record is unclear whether the Veteran had hypertension within one year after service or whether his hypertension was incurred in service. Thus, remand for a VA examination is necessary. 2. Entitlement to service connection for a cervical spine disability, thoracolumbar spine disability, and a bilateral foot disability is remanded. The Veteran asserted that his neck and back problems are due to constantly carrying a load, sleeping conditions, and bouncing over rough, dangerous roads during service. See, e.g., June 2005 correspondence. His service treatment records (STRs) reflect multiple complaints of neck, back, and foot pain during this deployment, but he did not report trauma or injury. He was assessed to have multiple musculoskeletal strain secondary to the mission, and osteoarthritis needed to be ruled out. See July 2004 STRs. The Veteran reported that his physician told him his structural foot problems were congenital but exacerbated by years in service. See September 2017 substantive appeal (VA Form 9). In an undated letter received in October 2014, Dr. M. Irvin noted the Veteran’s foot pain and damage in the neck and lower back and opined that these health problems could have resulted from the Veteran’s exposure to toxins in Afghanistan. This opinion is inadequate because it is not supported by a rationale and it is speculative. See Bostain v. West, 11 Vet. App. 124, 127-28 (1998); Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor’s statement framed in terms such as “could have been” is not probative). If the Veteran wishes to obtain an addendum opinion, he is welcome to do so. A July 2017 VA examiner diagnosed degenerative arthritis of the cervical spine and opined that it was less likely than not related to service because there was no objective medical evidence in service. See July 2017 VA cervical spine examination. Similarly, the VA examiner diagnosed bilateral flat foot and plantar fasciitis, and opined they were less likely than not related to service because there was no objective medical evidence in service. See July 2017 VA foot examination. These opinions are inadequate because they rely on the absence of medical evidence and do not take the Veteran’s lay statements into consideration. Because there are medical questions outstanding regarding the nature and cause of the Veteran’s neck, back, and foot disabilities and adequate opinions have not been obtained, remand for new VA examinations is necessary. 3. Entitlement to service connection for a heart disability is remanded. STRs reflect that the Veteran had complaints of noncardiac chest pain while in service and a questionable abnormal chest x-ray. See October 2004 STRs. There is an undated STR reflecting bradycardia secondary to physical conditioning. The Veteran’s private physician, Dr. Khetpal, diagnosed supraventricular tachycardia, pacemaker syndrome, and tachycardia-bradycardia syndrome and opined that his symptoms “seem to have been caused by exposure” to toxins in Afghanistan and his “health problems could have resulted” from any combination of such toxins. The Veteran’s onset of symptoms is not identified. See December 2013 correspondence. Dr. Khetpal’s opinion is inadequate because it is speculative. See Bostain, 11 Vet. App. at 127-28; Warren, 6 Vet. App. at 6. If the Veteran wishes to obtain a new opinion from Dr. Khetpal, he is welcome to do so. Because there are medical questions outstanding, remand for a VA examination is necessary. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 4. Entitlement to service connection for a disability manifesting in tremors is remanded. The Veteran and his family reported that he has had tremors since coming home from Afghanistan. See, e.g., December 2010 family statement. Dr. Khetpal diagnosed Parkinsonism, but his opinion is inadequate for the same reasons as discussed for a heart disability, supra. VA treating physicians have opined that the Veteran does not have Parkinson’s disease. See May 2014 VA treatment records; November 2011 VA treatment records (noting that the Veteran has risk factors for conversion disorder and/or malingering). The Veteran also once reported that he was told his neuropathy is causing complaints of tremors. See August 2013 VA treatment records. Given the contradicting evidence of record, remand for a VA examination is necessary. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 5. Entitlement to service connection for a disability manifesting in fatigue is remanded. The Veteran reported significant fatigue, see, e.g., March 2010 correspondence, and has submitted articles detailing the effects of exposure to burn pits and effects of the anthrax vaccine, along with other chemicals. See, e.g., October 2014 correspondence. Because there are medical questions outstanding, remand for a VA examination is necessary. See McLendon, 20 Vet. App. at 81. 6. Entitlement to service connection for residuals of TBI is remanded. The Veteran reported that he was on a convoy Humvee vehicle and a road side bomb exploded on a bridge. He did not hit his head. He also had multiple accidents when his camp was attacked by mortar and rocket fire. Additionally, in 1983 while not on active duty, the Veteran was knocked down by pyrotechnics explosion and lost vision and hearing for few minutes. The treating physician opined that the history and physical was not supportive of TBI, and that the Veteran’s symptoms were attributable to PTSD and post-concussion syndrome sustained in 1983. See August 2009 VA treatment records. The opinion by the treating physician is conclusory, and remand for a VA examination is necessary to obtain an adequate opinion. See McLendon, 20 Vet. App. at 81. 7. Entitlement to service connection for a disability manifesting in a compromised immune system, to include lymphangitis, is remanded. The Veteran is diagnosed with “other and unspecified nonspecific immunological findings,” see July 2012 private treatment records, and he reported he has been having immune problems since service. See December 2010 statement. He also indicated, and submitted articles in support of, that drugs taken, such as for anthrax and those containing Lariam, may be the cause of his symptoms. See, e.g., August 2011 correspondence. Because there are medical questions outstanding, remand for a VA examination is necessary. See McLendon, 20 Vet. App. at 81. 8. Entitlement to service connection for a right ring fingernail disability is remanded. The Veteran reported a problem under his right ring fingernail that resulted in occasional inflammation and pain while in service. See June 2005 correspondence. STRs reflect a growth under his right fourth finger nailbed. See October 2004 STRs. He was diagnosed with nail dystrophy. See August 2016 VA treatment records. Because there are outstanding medical questions, remand for a VA examination is necessary. See McLendon, 20 Vet. App. at 81. 9. Entitlement to service connection for a disability manifesting in skin lesions is remanded. The Veteran reported being treated for skin cancers and that his doctors told him they were most likely caused by a combination of exposures to the sun during deployment. See September 2017 VA Form 9. VA treatment records reflect a diagnosis of actinic keratoses. See August 2014 VA treatment records. Because there are outstanding medical questions, remand for a VA examination is necessary. See McLendon, 20 Vet. App. at 81. The matters are REMANDED for the following action: 1. The AOJ should obtain copies of VA treatment records for the Veteran’s disabilities from August 2017 to the present, and all other outstanding VA treatment records, to include from the Oklahoma VAMC. 2. The AOJ should obtain, if possible, records of all private evaluations and treatment the Veteran has received. The Veteran must assist in the matter by identifying his private healthcare providers and by submitting releases for VA to obtain any private records identified. If any private records identified are not received pursuant to the AOJ’s request, the Veteran should be so notified and advised that it is ultimately his responsibility to ensure that any available private records are received. 3. After the development in the first two instructions is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of his hypertension. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Did the Veteran’s hypertension manifest within one year of his discharge from service in November 2004? If so, was diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; was there a history of diastolic pressure predominantly 100 or more who requires continuous medication for control? Please explain why. The examiner must discuss the November 2004 diagnosis of labile uncontrolled hypertension. (b.) Was the Veteran’s hypertension at least as likely as not (50% or greater probability) either incurred in or otherwise related to his active duty or ACDUTRA service? Please explain why. The examiner must discuss the November 2004 diagnosis of labile uncontrolled hypertension. 4. After the development in the first two instructions is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any cervical spine disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all cervical spine disabilities present during the appeal period (from October 2009). (b.) For each cervical spine disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran’s active duty or ACDUTRA service, to include exposure to toxins in Afghanistan? Please explain why. The examiner must discuss the Veteran’s report of neck pain in service, corroborated by STRs, and Dr. Irvin’s report of health problems due to exposure to toxins in Afghanistan. The examiner may not rely solely on the absence of medical evidence during and immediately after service. 5. After the development in the first two instructions is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any thoracolumbar spine disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all thoracolumbar spine disabilities present during the appeal period (from October 2009). (b.) For each thoracolumbar spine disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran’s active duty or ACDUTRA service, to include exposure to toxins in Afghanistan? Please explain why. The examiner must discuss the Veteran’s report of back pain in service, corroborated by STRs, and Dr. Irvin’s report of health problems due to exposure to toxins in Afghanistan. The examiner may not rely solely on the absence of medical evidence during and immediately after service. 6. After the development in the first two instructions is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any foot disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all foot disabilities present during the appeal period (from October 2009). (b.) For each foot disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran’s active duty or ACDUTRA service, to include exposure to toxins in Afghanistan? Please explain why. The examiner must discuss the Veteran’s report of foot and arch pain in service, corroborated by STRs, and Dr. Irvin’s report of health problems due to exposure to toxins in Afghanistan. The examiner may not rely solely on the absence of medical evidence during and immediately after service. (c.) Is any foot disability a congenital defect, a congenital disease? (A defect is a condition that can neither improve nor worsen. A congenital disease, for VA adjudication purposes, is a congenital condition that is subject to improvement and/or worsening.) (i) If any disability is found to be a congenital defect, the examiner must opine whether any other non-congenital defects of the feet represent superimposed diseases or disorders of that congenital defect. If so, the examiner should discuss whether such superimposed disease or disorder began during military service, or if present prior to service, was aggravated (i.e., permanently worsened beyond the normal progression of that disease) by service. (ii) If any disability is found to be a congenital disease, the examiner must opine whether it first became evident during active duty service or was aggravated (i.e., worsened beyond the normal progression of that disease) during the Veteran’s active service. 7. After the development in the first two instructions is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any heart disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all heart disabilities present during the appeal period (from March 2010). (b.) For each heart disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran’s service, to include exposure to toxins in Afghanistan? Please explain why. The examiner must discuss the Veteran’s report of chest pain in STRs and Dr. Khetpal’s report of health problems due to exposure to toxins in Afghanistan. The examiner may not rely solely on the absence of medical evidence during and immediately after service. 8. After the development in the first two instructions is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any disability manifesting in tremors, to include Parkinson’s disease. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all disabilities manifesting in tremors present during the appeal period (from March 2010). The examiner should discuss Parkinson’s disease and neuropathy. (b.) For each disability manifesting in tremors diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran’s military service, to include exposure to toxins in Afghanistan? Please explain why. 9. After the development in the first two instructions is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any disability manifesting in fatigue. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all disabilities manifesting in fatigue present during the appeal period (from March 2010). (b.) For each disability manifesting in fatigue diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran’s military service, to include exposure to toxins in Afghanistan and as a result of vaccines or drugs administered prior to deployment? Please explain why. The examiner must articles concerning the anthrax vaccine and Lariam. 10. After the development in the first two instructions is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of any residuals of TBI. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: Is it at least as likely as not (50% or greater probability) that the Veteran has residuals of a TBI in service? Please explain why. The examiner must discuss the Veteran’s report of a road side bomb exploding while he was in a Humvee vehicle and his proximity to mortar and rocket fire attacks. A conclusory opinion will not be deemed adequate. 11. After the development in the first two instructions is completed, the AOJ should arrange for a VA examination of the Veteran to determine the nature and likely cause of disability manifesting in a compromised immune system, to include lymphangitis. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all disabilities manifesting in a compromised immune system present during the appeal period (from October 2009). (b.) For each disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran’s military service, to include exposure to toxins in Afghanistan and as a result of vaccines or drugs administered prior to deployment? Please explain why. The examiner must discuss lay statements that the Veteran has been sick since his return from Afghanistan and articles concerning the anthrax vaccine and Lariam. 12. After the development in the first two instructions is completed, the AOJ should arrange for a VA skin examination of the Veteran to determine the nature and likely cause of any skin disability and right ring fingernail disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record and examination of the Veteran, the examiner should provide an opinion with detailed rationale that responds to the following: (a.) Please identify, by diagnosis, all skin and right ring fingernail disabilities present during the appeal period (from October 2009). (b.) For each disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran’s military service, to include sun exposure in Afghanistan? Please explain why. STRs reflecting right ring fingernail symptoms must be discussed. 13. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Sandler, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.