Citation Nr: 20042011 Decision Date: 06/19/20 Archive Date: 06/19/20 DOCKET NO. 16-42 876 DATE: June 19, 2020 ORDER Entitlement to service connection for eczema (claimed as chronic fungal infection) of the hands is granted. Entitlement to a disability rating of 50 percent for posttraumatic stress disorder (PTSD) is granted. Entitlement to a disability rating higher than 10 percent for tinnitus is denied. Entitlement to a disability rating higher than 0 percent for bilateral hearing loss is denied. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for left knee disability is remanded. Entitlement to service connection for right knee disability is remanded. Entitlement to service connection for lumbar strain with degenerative arthritis is remanded. Entitlement to service connection for thoracic spine disability is remanded. Entitlement to service connection for cervicothoracic spine disability is remanded. Entitlement to service connection for right shoulder disability is remanded. Entitlement to service connection for respiratory disorders is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for chronic fungal infection of the feet is remanded. FINDINGS OF FACT 1. Eczema of the skin of both of the Veteran’s hands during his first active service period continued through and after his first and second active service periods. 2. The Veteran’s PTSD has produced occupational and social impairment with reduced reliability and productivity. 3. The Veteran’s tinnitus has been assigned a 10 percent rating. 4. The Veteran’s hearing has been measured at Level I in the right ear and Level I in the left ear. CONCLUSIONS OF LAW 1. Eczema of the skin of both hands was incurred in service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 2. The criteria for disability rating of 50 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2019). 3. The current 10 percent rating is the maximum schedular rating for tinnitus; a higher schedular rating may not be assigned. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.87, Diagnostic Code 6260 (2019). 4. The criteria for disability rating higher than 0 percent for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.85, Diagnostic Code 6100 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1989 to October 1993, and from February 2003 to May 2004. His later active duty period included a tour in Iraq. He also had National Guard and Reserve service. Service Connection Service connection may be established on a direct basis for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, may be established based upon a legal presumption by showing that the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of discharge from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2019). Aggravation of a non-service-connected disease or injury by a service-connected disability may also be service-connected. 38 C.F.R. § 3.310(b). Service connection may be established on a presumptive basis under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 for a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active service in the Southwest Asia Theater of Operations during the Persian Gulf War, or became manifest to a degree of 10 percent or more not later than December 31, 2021. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a), (b). A “qualifying chronic disability” includes: (A) an undiagnosed illness; (B) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms; or (C) any diagnosed illness that the Secretary of the Department of Veterans Affairs (VA) determines, in regulations, warrants a presumption of service connection. 38 C.F.R. § 3.317(a). The signs or symptoms of an undiagnosed illness or a medically unexplained chronic multi-symptom illness include, but are not limited to, (1) fatigue, (2) signs or symptoms involving skin, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs or symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the respiratory system (upper or lower), (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, and (13) menstrual disorders. 38 C.F.R. § 3.317(b). The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War. See 38 C.F.R. § 3.2(i). He is a Persian Gulf War veteran. The United States Court of Appeals for Veterans Claims (Court) has indicated that the Board of Veterans’ Appeals (Board) must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The types of evidence that indicate that a current disability may be associated with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon, 20 Vet. App. at 83. For purposes of determining whether an examination or opinion is warranted, the threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. 1. Skin disorder (claimed as chronic fungal infection) of the hands In June 2013 the Veteran submitted a claim for service connection for multiple disorders, including chronic fungal infection of both hands. On examination in October 1989, for entrance into service, the Veteran marked no for history of skin diseases. The examiner noted that the Veteran had mild acne. The examiner marked normal for the condition of his upper extremities. On the Veteran’s July 1993 separation examination, he reported a 2½ year history of hand eczema. The examiner noted dyshidrotic hand eczema. In the Veteran’s April 2004 post-deployment assessment, he reported having skin diseases or rashes during the deployment and presently. In VA treatment in September 2005, the Veteran reported that both of his hands were dry and scaly, and had been so since 1990. Subsequent VA treatment records contain notations of eczema and dry skin, including affecting the palms of his hands. Medical records from the Veteran’s first active service period reflect eczema on his hands from approximately 1991 through the end of that service period. During his second active service period he reported skin diseases or rashes. In 2005 he reported problems affecting the skin of his hands since 1990. The evidence that hand eczema in the first service period continued through and after both service periods is consistent and reasonably clear. Giving the Veteran the benefit of the doubt, the Board grants service connection for eczema affecting both hands. Increased Ratings VA assigns disability ratings by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.10. In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2. If two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Court has held that, at the time of the assignment of an initial rating for a disability following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as staged ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Court also has held that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim for an increased rating was filed until a final decision is made. See Hart. v. Mansfield, 21 Vet. App. 505 (2007). PTSD The Veteran contends that the effects of his PTSD warrant a disability rating higher than 30 percent. In a September 2007 rating decision, a VA Regional Office (RO) granted service connection for his PTSD and assigned a 30 percent rating. In June 2013 the Veteran sought an increased rating. In an August 2014 rating decision, the RO continued the 30 percent rating. The Veteran appealed that decision. The rating schedule provides for evaluating mental disorders including PTSD under a General Rating for Mental Disorders, at 38 C.F.R. § 4.130, which follows: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 100 percent Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, 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 the 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 worklike setting); inability to establish and maintain effective relationships. 70 percent 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; difficulty in establishing and maintaining effective work and social relationships. 50 percent Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 30 percent Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 10 percent A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. 0 percent Treatment and examination records provide information about the effects of the Veteran’s PTSD around and since his 2013 claim for an increased rating. In VA mental health treatment in January 2012, treatment for his PTSD included antidepressant medication. He reported that he thought somebody was out to get him. He indicated that two months earlier he was involved in a brawl, and he worried about retaliation. He reported increased anxiety, and disrupted sleep over the past two months. The clinician observed psychomotor agitation, in the form of bouncing his lower extremities. The clinician noted that he had a tense affect and anxious mood, with normal speech, fair insight, and adequate attention and concentration. The clinician found no psychotic thought or suicidal or homicidal ideation. In April 2012, the Veteran continued on antidepressant medication. He stated that he remained somewhat hypervigilant, but was functioning adequately. He reported improved relationships with family members. He said that he was working full time as a truck driver. In VA treatment in October 2012, the Veteran reported that he stopped taking the antidepressant medication. He related having an argument with his teenage daughter and striking her in the face while trying to take an object away from her. He related that he was arrested and had a no contact order. He stated that he was upset and remorseful. He related that he wanted to resume taking the antidepressant medication and get help for his temper. The clinician noted that he was depressed and anxious, with restless motor activity. He had normal speech, attention, concentration, and memory. In VA treatment in November 2012, the Veteran stated that he had resumed living at home, but that there were ongoing tensions with family members. In December 2012 he reported no new altercations. In June 2013 private psychologist W. J. A., Psy.D., evaluated the Veteran, through interview and testing. The Veteran reported that he disliked working for others and strongly preferred being self-employed. Dr. A. observed that the Veteran had a labile and intense affect. Dr. A found that the Veteran had reexperiencing, avoidance, and hyperarousal symptoms. Dr. A. also noted significant depressive symptoms, including anhedonia, and emotional lability. Dr. A. noted that events the Veteran described indicated impaired impulse control and intermittent, impulsive homicidal ideation. Dr. A. found that the Veteran had social and occupational impairment and significant cognitive difficulties. Dr. A. stated that his irritability and angry outbursts were likely to substantially negatively impact his employability. In VA treatment in January 2014, the Veteran reported having been off of antidepressant medication for several months. He indicated that presently he was coping adequately. He did not report any significant symptoms of PTSD. The clinician found that he did not need ongoing mental health treatment. On VA examination in August 2014, the Veteran reported. He stated that he worked driving a truck locally. He indicated that he was seeking better paying truck driving work. He indicated that while driving his truck he frequently experienced road rage at other drivers. The examiner found that the Veteran had a calm and euthymic mood and affect, and normal thought and speech. The examiner expressed the opinion that the Veteran’s present PTSD symptoms were not severe enough to interfere with occupational and social functioning. Treatment and examination records present somewhat differing pictures of the effects of the Veteran’s PTSD. Dr. A. found greater occupational and social impairment than treating clinicians. Notably, the 2014 VA examiner determined that PTSD symptoms were not severe enough to interfere with occupational and social functioning. Giving the Veteran the benefit of the doubt, particularly in light of Dr. A’s opinion, the Board finds that from 2012 forward the Veteran’s occupational and social impairment has approached reduced reliability and productivity. The effects of his PTSD have met or closely approached the criteria for a disability rating of 50 percent. The Board grants a higher rating. Assignment of a 70 percent rating is not warranted as the Veteran does not have deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. He does not have symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; or inability to establish and maintain effective relationships. Tinnitus The Veteran appealed the initial 10 percent disability rating that the RO assigned for his tinnitus. He reports having tinnitus with flare-ups that are very annoying and interrupt his concentration. The rating schedule provides for a 10 percent rating for recurrent tinnitus. A single in rating is assigned for recurrent tinnitus, whether the sound is perceived in one ear, in both ears, or in the head. A 10 percent rating is the maximum rating provided under the rating schedule. 38 C.F.R. § 4.87, Diagnostic Code 6260. There is no legal basis to award a higher rating for tinnitus, as the maximum rating for tinnitus has already been assigned. The Board denies a rating higher than 10 percent. Bilateral hearing loss The Veteran appealed the initial 0 percent rating that the RO assigned for his bilateral hearing loss. Under the VA rating schedule, hearing impairment is evaluated based on audiological testing, including a puretone audiometry test and the Maryland CNC controlled speech discrimination test. 38 C.F.R. § 4.85. The puretone threshold average is the average of the puretone thresholds, in decibels, at 1000, 2000, 3000, and 4000 Hertz, shown on a puretone audiometry test. 38 C.F.R. § 4.85. To find the appropriate disability rating based on test results, the puretone threshold average for each ear is considered in combination with the percentage of speech discrimination to establish a hearing impairment level, labeled from I to XI. See 38 C.F.R. § 4.85, Table VI. The hearing impairment levels of both ears are then considered together to establish a disability rating for the hearing loss. See 38 C.F.R. § 4.85, Table VII. Tables VI and VII are reproduced below. Continued on next page   TABLE VI NUMERIC DESIGNATION OF HEARING IMPAIRMENT BASED ON PURETONE THRESHOLD AVERAGE AND SPEECH DISCRIMINATION Puretone Threshold Average % of discrim-ination 0-41 42-49 50-57 58-65 66-73 74-81 82-89 90-97 98+ 92-100 I I I II II II III III IV 84-90 II II II III III III IV IV IV 76-82 III III IV IV IV V V V V 68-74 IV IV V V VI VI VII VII VII 60-66 V V VI VI VII VII VIII VIII VIII 52-58 VI VI VII VII VIII VIII VIII VIII IX 44-50 VII VII VIII VIII VIII IX IX IX X 36-42 VIII VIII VIII IX IX IX X X X 0-34 IX X XI XI XI XI XI XI XI Continued on next page   TABLE VII PERCENTAGE EVALUATION FOR HEARING IMPAIRMENT (DIAGNOSTIC CODE 6100) Better ear XI 100* X 90 80 IX 80 70 60 VIII 70 60 50 50 VII 60 60 50 40 40 VI 50 50 40 40 30 30 V 40 40 40 30 30 20 20 IV 30 30 30 20 20 20 10 10 III 20 20 20 20 20 10 10 10 0 II 10 10 10 10 10 10 10 0 0 0 1 10 10 0 0 0 0 0 0 0 0 0 XI X IX VIII VII VI V IV III II I Poorer Ear * Review for entitlement to special monthly compensation under § 3.350 of this chapter. In May 2013, private chiropractor Dr. Y. reported having tested the Veteran’s hearing in a very quiet room, then again in a room to normal noise levels. Dr. Y. found that under normal conditions the Veteran had hearing loss of 30 percent in the right ear and 30 percent in the left ear. In a VA audiological evaluation in June 2014, it was reported that the Veteran speaks loudly, misses what others said, and often had to ask others to repeat what they said. On testing, puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 30 25 30 30 LEFT 30 30 35 30 The puretone threshold averages were 29 decibels in the right ear and 31 decibels in the left ear. The speech recognition scores were 96 percent in the right ear and 96 percent in the left ear. Under Table VI, the hearing impairment levels were I in the right ear and I in the left ear. Under Table VII, the test results were consistent with a 0 percent rating for the bilateral hearing loss. Dr. Y. did not report test results in the form of auditory thresholds and speech recognition percentages. His report does not relate the Veteran’s hearing levels in the manner that VA uses to evaluate hearing loss. The only testing reported in that manner, the 2014 VA testing, shows hearing levels consistent with a 0 percent rating. The Board denies a rating higher than 0 percent. REASONS FOR REMAND Service connection for hypertension The Veteran’s claims file contains the report of a post-deployment health assessment in April 2004, but does not contain any other service treatment records (STRs) from his February 2003 to May 2004 active service period. The Board is remanding the issue for the RO to request the Veteran’s complete STRs for that service period. In May 2013, private chiropractor P. J. Y., D.C., interviewed and examined the Veteran. Dr. Y stated that the Veteran was diagnosed with hypertension within one year after his separation from service. A rationale was not provided. In August 2016, a VA physician reviewed the Veteran’s claims file. The physician found that the Veteran’s hypertension is a medically diagnosed and explained condition. The physician stated that his hypertension arose after service and was not service connected. Given the conflicting opinions and outstanding treatment records, a new opinion should be obtained regarding the etiology of hypertension. Service connection for left knee disability The Board is remanding this issue to obtain service treatment records and additional VA medical opinion. The Veteran contends that during service in Iraq he fell and sustained left knee injury. His claims file contains the report of a post-deployment health assessment in April 2004, but does not contain any other service treatment records (STRs) from his February 2003 to May 2004 active service period. The Board is remanding the issue for the RO to request the Veteran’s complete STRs for that service period. In service in April 2004, the Veteran reported swollen, stiff, or painful joints. After service, he reported muscle and joint pain in September 2005. From 2009 he reported left knee pain, and he had left knee surgery in 2012. He has not had a VA medical examination or opinion that specifically addressed his claim that left knee problems are related to injury in service. After medical records from his second service period are obtained, the RO should obtain a VA medical opinion addressing the likely etiology of his left knee disability. Service connection for right knee disability The Board is remanding this issue for additional VA medical opinion. The Veteran contends that his left knee disability, for which he is seeking service connection, affected his body mechanics and caused right knee problems. In addition, his post-service treatment records reflect at least one report that a fall during service in Iraq caused injury to his left and right knees. The complete STRs for his 2003 to 2004 service period being sought in this remand are relevant to his right knee claim. The Board is remanding this issue for the RO to obtain a VA medical opinion addressing the nature and likely etiology of any current right knee disability. Service connection for lumbar strain with degenerative arthritis The Board is remanding this issue for additional medical opinion. The Veteran contends that his low back disability, which has been diagnosed as lumbar strain with degenerative arthritis, was caused by a fall during service in Iraq. He also has contended that his low back is caused or aggravated by his left and right knee disabilities, for which he is seeking service connection. In a medical history the Veteran completed in July 1993, near separation from his first active service period, he marked yes for history of recurrent back pain. During his second active service period, in the April 2004 post-deployment assessment, he reported having back pain during the deployment and presently. After service, in VA treatment in September 2005, the Veteran reported muscle and joint pains. From 2010 forward he reported back pain. On VA examination in June 2014, the examiner diagnosed lumbosacral strain, and degenerative arthritis of the thoracolumbar spine. The examiner opined against a likely connection between the current disorders and the Veteran’s first active service period. However, the 2004 post-deployment assessment was added to the claims file after the 2014 VA examination. The complete STRs for his 2003 to 2004 service period being sought in this remand are relevant to his lumbar strain and arthritis claim. The Board is remanding this issue for the RO to obtain a VA medical opinion addressing the likely etiology of his lumbar strain with degenerative arthritis. Service connection for thoracic spine disability The Board is remanding this issue for additional VA medical opinion. In June 2013, the Veteran submitted claims for service connection for disability affecting three separate areas of his spine, which he described as the lumbar, thoracic, and cervicothoracic areas. VA generally evaluates spine disorders as disorders of the cervical area and the thoracolumbar area. In the June 2014 VA examination, the examiner addressed the thoracolumbar and lumbosacral areas. The information relevant to the Veteran’s claim regarding the thoracic area, then, overlaps with the information relevant to the thoracolumbar area. His contention that he sustained back injury in service, without specifying which area, potentially applies to the lumbar and thoracic areas. The complete STRs for his 2003 to 2004 service period being sought in this remand are relevant to his right knee claim. The Board is remanding this issue for the RO to obtain a VA medical opinion addressing the likely etiology of his thoracic spine disability. Service connection for cervicothoracic spine disability The Board is remanding this issue for additional VA medical opinion. As noted above, there is overlapping evidence regarding the Veteran’s claims for disability of the cervicothoracic, thoracic and lumbar areas of his back. The VA medical opinion addressing the other areas of his back should also address the cervicothoracic area. Service connection for right shoulder disability The Board is remanding this issue for a VA medical opinion. The Veteran contends that a right shoulder disability began during service or was caused by injuries in service from recoil from fired weapons. Before separation from his first period of active service, the Veteran reported a history of arthritis or bursitis. After his 2003 and 2004 deployment, he reported swollen, stiff, or painful joints. The complete STRs for his 2003 to 2004 service period being sought in this remand are relevant to his right shoulder disability claim. After service, in VA treatment in September 2005, the Veteran reported chronic muscle and joint pains. From 2009 forward he reported right shoulder pain. In May 2013 private chiropractor Dr. Y. wrote that the Veteran reported that in service he frequently fired an M-16 weapon, and was struck in his right shoulder by the recoil. Dr. Y. expressed the opinion that it is more likely than not that those forces against his shoulder caused chronic right shoulder pain and presently diagnosed right shoulder bursitis and arthritis. However, Dr. Y. did not indicate that he had reviewed the Veteran’s service treatment records. The Veteran has not had a VA medical examination or opinion that specifically addressed his right shoulder disability claim. The Board is remanding this issue to obtain a VA medical opinion addressing the likely etiology of his right shoulder disability. Service connection for respiratory disorders The Board is remanding this issue for additional VA medical examination and opinion. The Veteran contends that he has asthma, chronic obstructive pulmonary disease (COPD), bronchitis, and pulmonary nodules, and that each began during one of his service periods or is attributable to events in Iraq, including exposure to burn pit smoke. The assembled evidence leaves questions as to which respiratory disorders the Veteran has and as to the etiology of current disorders. Toward the end of the Veteran’s first service period he reported a history of asthma and shortness of breath. Toward the end of his second service period he reported experiencing chronic cough, runny nose, fever, chest pain or pressure, and difficulty breathing. Pulmonary nodules were noted in VA treatment after both service periods. Private chiropractor Dr. Y. found that the Veteran has asthma and COPD, and opined that those conditions began during or were caused by exposures in the Veteran’s second service period. A VA physician who examined the Veteran in June 2014 found no objective evidence of present asthma, COPD, or bronchitis. That physician did not have access, however, to any medical records from the Veteran’s second service period. A VA physician who reviewed the claims file in August 2016 opined that pulmonary nodules are not service-connected. The complete STRs for the Veteran’s second service period sought on remand are relevant to his respiratory disorders claim. The Board is remanding the issue for a new VA medical examination, with file review, to clarify the diagnoses of current respiratory disorders and provide opinions, based on more complete information, as to the likely etiology of current disorders. Service connection for sleep apnea The Board is remanding this issue for additional VA medical opinion. The Veteran contends that his sleep apnea began during service, and that it is related to his asthma and COPD, for which he is seeking service connection. In a post-deployment health assessment in April 2004, the Veteran reported that during the deployment he had difficulty breathing and he felt tired after sleeping. In VA treatment in May 2009, the Veteran reported symptoms of sleep apnea. From 2010 forward VA treatment records contained notations of obstructive sleep apnea. In 2013 Dr. Y. opined that the Veteran’s sleep apnea was related to his asthma and COPD. A VA physician who reviewed the Veteran’s claims file in August 2016 concluded that the Veteran’s sleep apnea began after service, but did not comment on the respiratory symptoms the Veteran reported in service in 2004. The complete STRs for his 2003 to 2004 service period being sought in this remand are relevant to his sleep apnea claim. The Board is remanding this issue for the RO to obtain a VA medical opinion addressing the likely etiology of his sleep apnea. Service connection for chronic fungal infection of the feet The Board is remanding this issue for a VA medical examination. In 2013 the Veteran told private chiropractor contends that a chronic fungal infection on both feet was treated during his active service. He effectively contends that the disorder began or was aggravated in service. Service treatment records from his first service period do not reflect any issues affecting the skin of his feet. In an April 2004 post-deployment assessment, he reported having skin diseases or rashes during the deployment and presently. Post-service VA treatment records from 2009 forward reflect skin disorders, without specific reference to the skin on his feet. The complete STRs for his 2003 to 2004 service period being sought in this remand are relevant to this claim. The Board is remanding the issue for a VA medical examination, with file review, to address the nature and likely etiology of any chronic skin or nail disorder affecting his feet.   The matters are REMANDED for the following action: 1. Request from the appropriate military and archival sources the Veteran’s complete service treatment records from his period of service from February 2003 to May 2004. Associate those records with his electronic claims file. Document requests for the records and responses. 2. Then provide the Veteran’s expanded claims filed to an appropriate VA clinician for review. Ask the examiner to provide an opinion as to the date of onset of hypertension; whether it is at least as likely as not that hypertension began during service or became manifest to a compensable level within one year of service separation. Ask the examiner to consider and address the positive May 2013 opinion of the private chiropractor. 3. Then provide the Veteran’s expanded claims file to an appropriate VA clinician for review. Inform the reviewer that the Veteran had active service from November 1989 to October 1993, and from February 2003 to May 2004, and that the later period included service in Iraq. Ask the reviewer to note what post-service disorders of the left knee and right knee are indicated by the record. Ask the provide an opinion, for each post-service disorder of each of the Veteran’s knees, as to whether it is at least as likely as not that the disorder is related to injury, symptoms, or other events during service. Ask the reviewer to also provide an opinion, for each post-service disorder of the Veteran’s right knee as to whether it is at least as likely as not that the disorder is caused or aggravated by his left knee disability. Ask the reviewer to explain the conclusions and opinions. 4. Then provide the Veteran’s expanded claims file to an appropriate VA clinician for review. Inform the reviewer that the Veteran had active service from November 1989 to October 1993, and from February 2003 to May 2004, and that the later period included service in Iraq. Ask the reviewer to provide an opinion, for each of the disorders of the cervical, thoracic, lumbar, and/or sacral areas of the Veteran’s back, including lumbosacral strain and thoracolumbar spine arthritis, as to whether it is at least as likely as not that the disorder is (a) related to injury or other events in service, or (b) caused or aggravated by disability of either or both knees. Ask the reviewer to explain the conclusions and opinions. 5. Then provide the Veteran’s expanded claims file to an appropriate VA clinician for review. Inform the reviewer that the Veteran had active service from November 1989 to October 1993, and from February 2003 to May 2004, and that the later period included service in Iraq. Ask the reviewer to provide an opinion as to whether it is at least as likely as not that bursitis, arthritis, and/or any other current disorder of the Veteran’s right shoulder is related to injury, duties including weapons firing, or other events during his service. Ask the reviewer to explain the conclusions and opinions. 6. Then schedule the Veteran for a VA respiratory disorders examination with an appropriate VA physician, preferably a specialist in respiratory disorders. Provide the expanded claims file to the examiner for review. Inform the examiner that the Veteran had active service from November 1989 to October 1993, and from February 2003 to May 2004, and that the later period included service in Iraq. Ask the examiner to review the claims file, examine the Veteran, and perform any necessary testing or imaging. Ask the examiner to provide diagnoses for all current respiratory disorders. Ask the examiner to specifically state whether the Veteran has each of the following: asthma, chronic obstructive pulmonary disease, bronchitis, and pulmonary nodules. Ask the examiner to provide an opinion, for each current respiratory disorder, as to whether it is at least as likely as not that the disorder began or was aggravated during either of the Veteran’s service periods, or is causally related to burn pit smoke or other exposures in service in Iraq. Ask the examiner to explain the conclusions and opinions. (Continued on the next page)   7. Then provide the Veteran’s expanded claims file to an appropriate VA clinician for review. Inform the reviewer that the Veteran had active service from November 1989 to October 1993, and from February 2003 to May 2004, and that the later period included service in Iraq. Ask the reviewer to provide an opinion as to whether it is at least as likely as not that the Veteran’s sleep apnea began during his 2003 to 2004 service period, or is causally related to or aggravated any other current respiratory disorder, including any asthma, COPD, or bronchitis. Ask the reviewer to explain the conclusions and opinions. 8. Then schedule the Veteran for a VA skin disorders examination with an appropriate VA clinician. Provide the expanded claims file to the examiner for review. Ask the examiner to provide diagnoses for all current disorders affecting the skin or nails of either or both of the Veteran’s feet. Ask the examiner to provide an opinion, for each current foot skin or nail disorder, as to whether it is at least as likely as not that the disorder began or was aggravated during the Veteran’s service. Ask the examiner to explain the conclusions and opinions. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. J. Kunz, 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.