Citation Nr: 21068303 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 18-31 712 DATE: November 9, 2021 ORDER New and material evidence has been received to reopen the claim of entitlement to service connection for an acquired psychiatric disability, claimed as posttraumatic stress disorder (PTSD), and the request to reopen is granted. Entitlement to service connection for diabetes mellitus, type II, is denied. Entitlement to service connection for left foot numbness is denied. Entitlement to service connection for right foot numbness is denied. Entitlement to service connection for chronic fatigue is denied. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for an acquired psychiatric disability, claimed as PTSD, is remanded. Entitlement to service connection for a respiratory disorder is remanded. Entitlement to service connection for a neck disability, claimed as numbness, is remanded. Entitlement to service connection for left hand numbness is remanded. Entitlement to service connection for right hand numbness is remanded. Entitlement to service connection for a back disability, to include numbness, is remanded. Entitlement to service connection for rheumatoid arthritis, to include arthritis of the right foot/ankle, is remanded. Entitlement to service connection for skin lesions is remanded. FINDINGS OF FACT 1. The appellant has submitted evidence that was not previously submitted, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim of entitlement to service connection for an acquired psychiatric disability, claimed as PTSD. 2. The Veteran did not have diabetes mellitus during service or within one year after separation from active duty service; his diabetes mellitus is not due to a service-connected disability, nor is it secondary to a disability for which service connection is on appeal; diabetes mellitus was not incurred in the line of duty during active duty for training; and diabetes mellitus is a known diagnosis. 3. The Veteran's left foot numbness has been attributed to diabetes mellitus, which is not a service-connected disability. 4. The Veteran's right foot numbness has been attributed to diabetes mellitus, which is not a service-connected disability. 5. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of a disease that is manifested by chronic fatigue that was incurred in or is otherwise related to service, and the Veteran's chronic fatigue is not a manifestation of an undiagnosed illness or a medically unexplained chronic multisymptom illness. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen the claim of entitlement to service connection for an acquired psychiatric disability, claimed as PTSD. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.1103. 2. The criteria for entitlement to service connection for diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 101, 106, 1110, 1112, 1117, 1131, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317. 3. The criteria for entitlement to service connection for left foot numbness have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 4. The criteria for entitlement to service connection for right foot numbness have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 5. The criteria for entitlement to service connection for chronic fatigue have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. §§ 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1987 to October 1991. The record indicates additional service, including active duty for training and inactive duty training, that ended in March 2004. The record also contains a period of service from July 2001 to December 2001 for which the status has not yet been determined. This matter comes before the Board on appeal from an August 2016 Regional Office (RO) rating decision. The issues of entitlement to service connection for a back disability (as hernia of the spine) and a respiratory disability (as a respiratory/breathing condition) were previously denied in an August 2008 rating decision. Since these rating decisions, additional relevant records from the Department of Defense were added to the claims file. Despite the prior rating decisions denying service connection for these issues, reconsideration of these claims is required, as relevant service department records (which include Department of Defense records) were received that had existed and had not been associated with the claims file when VA first decided the claims. 38 C.F.R. § 3.156(c); Blubaugh v. McDonald, 773 F.3d 1310, 1313 (Fed. Cir. 2014); Emerson v. McDonald, 28 Vet. App. 200, 208 (2016). Thus, the Veteran does not need to submit new and material evidence in connection with these claims, and the issues have been recharacterized as service connection claims. In addition, the Board notes that, despite extensive efforts by VA to locate them, the service treatment records from the period of service spanning from July 2001 to December 2001 are unavailable. In such circumstances, VA has a heightened duty to assist a veteran in developing his or her claim. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). VA has met this duty and has obtained the Veteran's available outstanding medical records. It has also given heightened consideration to the Veteran's lay testimony regarding the disabilities that are at issue. Service Connection Rating actions from which an appeal is not perfected become final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing and, after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. A final decision cannot be reopened unless new and material evidence is presented or secured with respect to that claim. See 38 U.S.C. § 5108; see also Knightly v. Brown, 6 Vet. App. 200 (1994). New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The question of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court has held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Id. A final denial on one theory is a final denial on all theories. Thus, a new theory in support of a claim for a particular benefit is not equivalent to a separate claim. See Ashford v. Brown, 10 Vet. App. 120 (1997). As such, new and material evidence is necessary to reopen a claim for the same benefit asserted under a different theory. See Boggs v. Peake, 520 F.3d 1330, 1336-37 (Fed. Cir. 2008). Service connection is warranted where the evidence of record establishes that an injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for listed chronic diseases, such as diabetes mellitus, if such were shown as chronic in service; manifested to a compensable degree within a presumptive period (usually one year) after separation from service; or were noted in service with continuity of symptomatology since service. 38 U.S.C. §§ 1112, 1113; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). A disability that is proximately due to, or results from, a service-connected disease or injury shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection on the basis of aggravation is permitted. 38 C.F.R. § 3.310(b). Compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability and not due to the natural progress of the nonservice-connected disease. Allen v. Brown, 7 Vet. App. 439 (1995). Under 38 C.F.R. § 3.317, service connection may be granted on a presumptive basis if there is evidence (1) that the claimant is a Persian Gulf Veteran; (2) who exhibits objective indications of chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Active military, naval, or air service includes any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of inactive duty training during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. 38 U.S.C. § 101(21-24); 38 C.F.R. § 3.6. Service connection may thus be granted for disability resulting from disease or injury incurred or aggravated while performing active duty for training, or from injury incurred or aggravated while performing inactive duty training. 38 U.S.C. §§ 101, 106, 1110, 1131. The advantages of certain evidentiary presumptions that assist veterans in establishing service connection for a disability do not extend to those who claim service connection based only on a period of active duty for training or inactive duty training. Paulson v. Brown, 7 Vet. App. at 470-71; see also Smith v. Shinseki, 24 Vet. App. 40, 48 note 7. Therefore, the presumptions of sound condition at entrance (38 U.S.C. §§ 1111, 1132), of aggravation where evidence shows an increase in severity of a pre-existing disease (38 C.F.R. § 3.306), and service incurrence for certain chronic diseases that manifest themselves to a degree of 10 percent or more disabling within a year from the date of separation from service (38 C.F.R. §§ 3.307, 3.309) are not available with respect to periods of active duty for training or inactive duty training. The term "Persian Gulf veteran" refers to a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The Persian Gulf War period begins on August 2, 1990, and is ongoing as of the date of this decision. 38 C.F.R. § 3.2(i). The "Southwest Asia theater of operations" refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). 1. New and material evidence has been received to reopen the claim of entitlement to service connection for an acquired psychiatric disability, claimed as PTSD, and the request to reopen is granted. The claim of entitlement to service connection for PTSD was previously denied in an August 2008 rating decision. The Veteran was notified of this decision in August 2008, and he neither initiated an appeal nor submitted new and material evidence within one year of the rating decision notice. In addition, unlike with the back and respiratory disabilities claims, service department records that are relevant to the psychiatric disability claim have not been added to the record. Therefore, new and material evidence is required to reopen the claim of entitlement to service connection for an acquired psychiatric disability, claimed as PTSD. The August 2008 rating decision denied this claim based, in part, on a finding that the Veteran did not have a diagnosis of PTSD. The record now contains a June 2018 VA medical record that contains an assessment that includes PTSD. The Board finds that this evidence is new in that it was not of record at the time of the August 2008 rating decision. It is material in that it presents a medical indication of PTSD. Therefore, new and material evidence having been received, the claim is reopened. To this extent, the claim is granted. It will be considered on the merits below. 2. Entitlement to service connection for diabetes mellitus, type II, is denied. The Veteran contends that his diabetes mellitus, type II, is due to his Gulf War service. Alternatively, he contends that his diabetes was diagnosed in 2005 and was caused by his PTSD. (See February 2013 personal statement.) As will be discussed in more detail below, it is unclear whether the Veteran qualifies as a "Persian Gulf veteran" for purposes of entitlement to presumptions that are available to Persian Gulf veterans. The Board finds, however, that the question of whether the Veteran qualifies as a Persian Gulf veteran within the meaning of the applicable law is not relevant to this particular issue. The Veteran's service treatment records reflect that he was not diagnosed with diabetes mellitus during service. An April 2002 record reflects that the Veteran did not have diabetes. Post-service medical records dated in April 2002, July 2005, March 2006, and November 2006 reflect that the Veteran did not have diabetes mellitus. The earliest diagnosis of diabetes of record is contained in an August 2009 post-service medical record from Fort Stewart. The earliest indication of diabetes appears in a March 2007 medical record that notes that the Veteran "points out that there is diabetes in his family. His father had diabetes in late years and he had weight control problems. He also notes that his own weight has been gradually coming up, as well as his blood pressure." No diagnosis of diabetes was made at that time, however, as the March 2007 record lists a past medical history of "[a]llergies, hypertension, back pain along the spinal cord," but does not list diabetes. Thus, the record does not contain evidence of diabetes mellitus in service or within one year after his separation from active duty service. Nor does the record contain competent medical evidence linking the Veteran's diabetes mellitus directly to his military service. As indicated above, the Veteran has had periods of military service, including active duty for training and inactive duty training, ending in March 2004. As indicated above, the competent medical evidence of record reflects that the Veteran did not have diabetes mellitus during that period. Therefore, to the extent that the Veteran may have been on active duty for training as recently as March 2004, the record does not reflect that he was found to have diabetes mellitus in the line of duty during that period. As noted above, the Veteran contends that either his chemical exposures in the Persian Gulf or his PTSD has caused his diabetes mellitus. The Board notes that, regardless of whether the Veteran is classified as a Gulf War veteran for disability compensation purposes, diabetes mellitus is a diagnosis. Therefore, diabetes mellitus cannot qualify as an undiagnosed illness for purposes of service connection based on Persian Gulf War service. In addition, the Veteran has not submitted any medical opinion or medical literature to support his contention of a relationship between any potential chemical exposures and his diabetes mellitus. Therefore, the Board must find that further consideration of entitlement service connection for diabetes mellitus based on the Gulf War service is not warranted. The Board also finds that remand is not required to further develop the Veteran's claim that his diabetes mellitus was either caused or aggravated by an acquired psychiatric disability. The Board notes that the record does not contain medical evidence of a link, either a causal link or a link based on aggravation, between the Veteran's diabetes mellitus and an acquired psychiatric disability. The only assertion of such a link comes from the Veteran himself. This does not meet the low threshold of an indication that the claimed disability is due to a psychiatric disorder. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (distinguishing cases where only a conclusory generalized statement is provided by the veteran and rejecting the theory that medical examinations are to be routinely and virtually automatically provided to all veterans in disability cases involving nexus issues). Consequently, VA is under no duty to afford the Veteran a VA examination. 38 U.S.C. § 5103A(d) (2012); 38 C.F.R. § 3.159(c)(4) (2018); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the question of whether there is a medical link between an acquired psychiatric disability and diabetes mellitus is of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. Therefore, even if service connection were eventually to be granted for an acquired psychiatric disability, service connection for diabetes mellitus on a secondary basis would not be warranted. In short, the Board finds that entitlement to service connection for diabetes mellitus on a direct basis (to include based on Persian Gulf exposures), on a presumptive basis based on chronic disability, and on a secondary basis, is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 3. Entitlement to service connection for left foot numbness is denied. 4. Entitlement to service connection for right foot numbness is denied. The Board notes that the Veteran reported in a September 2013 statement that his "feet go numb while walking, sitting & standing. The pain runs from my spine to my feet daily & is very severe." He also noted that numbness started in 1998 and continues to the present day. The Board notes that the only foot disability diagnoses of record are for diabetic neuropathy. To the extent that this claim is requesting service connection for radiculopathy of the lower extremities, those issues are part and parcel of the claim of entitlement to service connection for a back disability, to include numbness. At this time, the Board will focus on the Veteran's diagnosed disabilities of the left and right feet. Review of the record reflects that the Veteran's numbness of the feet has been attributed exclusively to diabetic neuropathy. (See, e.g., VA medical records dated in April 2014, July 2016, October 2018, December 2018, and June 2021.) No other diagnosis of a foot disability appears of record. As discussed above, service connection for diabetes mellitus is not in effect. Thus, entitlement to service connection for left and right foot numbness on a secondary basis to his nonservice-connected diabetes mellitus must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). 5. Entitlement to service connection for chronic fatigue is denied. The Veteran's service treatment records reflect that he did not complain of or seek treatment for fatigue during service. Post-service medical records reflect regular denial of fatigue. (See, e.g., medical records dated in February 2010, November 2010, June 2011, December 2011, February 2014, July 2015, and July 2016.) The Veteran underwent a sleep study in July 2018. At that time, he was diagnosed with sleep apnea and given a CPAP machine. A June 2019 pain management record notes that one of the medications the Veteran takes causes tiredness. The Veteran underwent a VA examination in connection with his claim of entitlement to service connection for chronic fatigue in July 2013. In relevant part, the examination report lists the criteria that are required for a diagnosis of chronic fatigue syndrome. At the time of the examination, he reported that "he is tired all the time, he feels restless. He states that this has been going on for 10 years...." He reported daytime sleepiness and that "His wife states he snores loudly and stops breathing at times." It was noted that the Veteran "has not been evaluated for the fatigue. He denies any associated illness with the fatigue." Based on review of the record and interview and examination of the Veteran, the VA examiner determined that the Veteran does not currently have and has never been diagnosed with chronic fatigue syndrome. The examiner noted that the Veteran's reported "symptoms do not meet the criteria for chronic fatigue syndrome; Veteran has not sought treatment for illness related to chronic fatigue." The examiner found that the Veteran does not have any findings, signs, and symptoms attributable to chronic fatigue syndrome: debilitating fatigue, low grade fever, nonexudative pharyngitis, palpable or tender cervical or axillary lymph nodes, generalized muscle aches or weakness, fatigue lasting 24 hours or longer after exercise, headaches (of a type, severity, or pattern that is different from headaches in the pre-morbid state), migratory joint pains, neuropsychological symptoms, sleep disturbance, or other symptoms. He does not have any cognitive impairment related to chronic fatigue syndrome. The Board finds that entitlement to service connection for chronic fatigue is not warranted. The Board notes that, regardless of whether the Veteran is eventually found to satisfy the criteria to be a Persian Gulf veteran for purposes of 38 C.F.R. § 3.317, a competent medical professional has reviewed the record and interviewed and examined the Veteran and has found that the Veteran does not satisfy the diagnostic criteria to be diagnosed with chronic fatigue syndrome. The examiner also determined that the Veteran has not been treated for illness related to chronic fatigue. This finding is consistent with the Veteran's VA medical records, which reflect that the Veteran has consistently denied experiencing fatigue. The only suggestions of fatigue have been attributed to pain medication, not to service, and to sleep apnea, which was diagnosed in 2018. The fatigue that has been attributed to a pain medication, even if the medication were taken for a disability for which service connection is subsequently granted, is a symptom rather than its own diagnosis and is therefore not eligible for service connection as its own distinct disability. The Veteran's sleep apnea did not manifest in service or for many years thereafter, and he has not otherwise submitted evidence that suggests a link between his sleep apnea and service. The Board acknowledges the Veteran's July 2013 assertion that he has had fatigue for approximately 10 years. At the time of the examination, he reported that "he is tired all the time, he feels restless. He states that this has been going on for 10 years...." The Board finds, however, that the Veteran's numerous express denials of fatigue during that period (as noted above in medical records dated in February 2010, November 2010, June 2011, and December 2011) and an absence of complaints of fatigue during that period are more probative and credible. Therefore, the Board finds that the Veteran has not had continuous episodes of fatigue since service. In short, the Board must find that entitlement to service connection for chronic fatigue is not warranted, either on a direct basis or as due to Persian Gulf exposures. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. REASONS FOR REMAND 1. Entitlement to service connection for hypertension is remanded. The Veteran's service personnel records contain a DD Form 214, Certificate of Release or Discharge from Active Duty, noting that the Veteran had entered active duty on July 26, 2001, and ending on December 21, 2001. It notes a "TYPE OF SEPARATION" of "RELEASE FROM ACTIVE DUTY." However, it also notes "NARRATIVE REASONS FOR SEPARATION" of "COMPLETION OF REQUIRED ACTIVE DUTY TRNG." On remand, the RO should take all appropriate measures to verify whether this period of service was active duty or active duty for training. 2. Entitlement to service connection for an acquired psychiatric disability, claimed as PTSD, is remanded. 3. Entitlement to service connection for a respiratory disorder is remanded. 4. Entitlement to service connection for a neck disability, claimed as numbness, is remanded. 5. Entitlement to service connection for left hand numbness is remanded. 6. Entitlement to service connection for right hand numbness is remanded. Generally, the evidence necessary to establish the occurrence of a stressor during service to support a claim of entitlement to service connection for PTSD will vary depending on whether a veteran engaged in combat with the enemy. See Gaines v. West, 11 Vet. App. 353, 358 (1998); Hayes v. Brown, 5 Vet. App. 60, 66 (1993). Service department evidence that the veteran engaged in combat or that a veteran was awarded the Purple Heart, Combat Infantryman Badge, or similar combat citation will be accepted, in the absence of evidence to the contrary, as conclusive evidence of the claimed in-service stressor. 3 8 C.F.R. § 3.304(f). If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor, provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service. 38 C.F.R. § 3.304(f). For a veteran who is not determined to have "engaged in combat with the enemy," if the claimed stressor is related to a veteran's fear of hostile military or terrorist activity, in the absence of clear and convincing evidence to the contrary, a veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor, provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service. In such cases, service connection may be granted if (1) a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD; and (2) the veteran's symptoms have been medically related to the claimed stressor. See 38 C.F.R. § 3.304(f)(3). Such determinations must be made by mental health professionals who are qualified to perform initial Compensation and Pension (C&P) examinations. Stressor Determinations for Posttraumatic Stress Disorder, 75 Fed. Reg. 39843, 39846-47 (July 13, 2010). As noted above, the term "Persian Gulf veteran" refers to a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The Persian Gulf War period begins on August 2, 1990, and is ongoing as of the date of this decision. 38 C.F.R. § 3.2(i). The "Southwest Asia theater of operations" refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). In the case at hand, the Veteran contends that he suffers from a current acquired psychiatric disability that is due to his Persian Gulf service. He has submitted several statements in which he describes seeing blown-up bodies and body parts, including of people he knew, floating in the water while he was stationed aboard the USS Reeves and USS Constellation. (See personal statements dated in October 2007, July 2008, January 2013, and February 2013.) However, it is unclear whether the period that the Veteran is describing occurred during the Persian Gulf War period. The Veteran reported in a July 2008 statement that this stressor occurred when he was stationed aboard the USS Reeves. He estimated that this stressor occurred in 1987, and he noted that he was assigned to the Reeves from June 1987 to October 1989. He reported in a January 2013 statement that this stressor occurred when he was stationed aboard the USS Reeves and the USS Constellation and that these events occurred between August 1987 and October 1991. He noted in a February 2013 statement that the Reeves was in the Persian Gulf from August 1987 to 1988, with the month being unclear. Review of the Veteran's service personnel records indicates that his assignment aboard the USS Reeves ended prior to the Persian Gulf War period. However, the Veteran's service aboard the USS Constellation does not appear to have ended until October 1991. It is unclear to the Board when the USS Constellation was in the Persian Gulf. If the Constellation were to have been in the Persian Gulf during the period of war (from August 2, 1990), the RO would need to make a determination as to whether his reported stressor is related to his fear of hostile military or terrorist activity. Thereafter, the Veteran should be scheduled for an examination and an etiology opinion should be obtained. 7. Entitlement to service connection for a back disability, to include numbness, is remanded. The Veteran contends that he has a current back disability that is related to duties he performed during service. He contends that he injured his spine and suffered a herniated disc while performing his duties aboard the USS Reeves and USS Constellation. (See personal statements dated in February 2013 and September 2013.) He stated that his spinal condition, specifically a herniated spine, "is due to being on deck scrub[bing] & painting the ship in 1987-1988 & dry dock in 1990-1991- painting and cleaning & chipping painting bending & stooping back and forth, up & down." He noted that he was on the Reeves from 1987 to 1989 and on the Constellation from 1989 to 1991. The claims file contains medical records provided by the Department of Defense reflecting that the Veteran received treatment for low back pain in June 1998, July 1998, September 1998, May 2000, June 2000, and March 2003. An undated medical record from when the Veteran was 34 years old (given his birthdate, this record is likely from 1998) reflects that the Veteran missed three weeks of work with back problems. It notes that he strained his back when he stopped a crate from falling on him at work. The Veteran sought treatment for musculoskeletal low back pain multiple times in June 1998. A June 1998 lumbar spine series radiology report, which was ordered because of "recurrent hematuria," notes an impression of vague lucency within the left L5 pars which likely represents confluence of shadows; however, if concerned for a spondylolysis defect, further evaluation with oblique images of the lumbar spine is recommended. Otherwise unremarkable lumbar spine series. A July 1998 lumbar spine obliques only radiology report notes an impression of normal oblique views of the lumbar spine without evidence of spondylosis or spondylolisthesis. A May 2000 CT of the lumbar spine showed (1) evidence of very subtle early degenerative change of the lumbar spine without evidence of degenerative disc disease, and (2) very mild spinal canal stenosis just above the L5-S1 level primarily due to ligamentum flavum hypertrophy. The Veteran had a follow-up appointment for his back in June 2000. A March 2003 record notes that the Veteran sought treatment for back pain with numbness radiating down the back of the legs. Given the above, the Board finds it necessary to remand the low back claim so that the Veteran may undergo a back examination and an etiology opinion may be obtained. 8. Entitlement to service connection for rheumatoid arthritis, to include arthritis of the right foot/ankle, is remanded. The Veteran also contends that he has arthritis that is related to duties he performed aboard the USS Reeves and USS Constellation during service. (See personal statements dated in February 2013 and September 2013.) He has described "being on deck scrub[bing] & painting the ship in 1987-1988 & dry dock in 1990-1991- painting and cleaning & chipping painting bending & stooping back and forth, up & down." He noted that he was on the Reeves from 1987 to 1989 and on the Constellation from 1989 to 1991. An August 2015 VA podiatrist's record notes that the Veteran has osteoarthritis in the right foot/ankle and states that he and the Veteran "discussed possible correlation to arthritis in foot/ankle and prior military activity while [on] active duty on board ship." Given the above, the Board finds it necessary to remand this claim for an examination and etiology opinion. 9. Entitlement to service connection for skin lesions is remanded. The Veteran underwent a VA skin diseases examination in July 2013. At that time, the examiner diagnosed folliculitis. With respect to pertinent medical history, the examiner noted that the "Veteran states that he started having skin problems about 15 years ago. He states he will get skin nodules that will appear on back, and posterior neck. He has never had condition evaluated." It was noted that "He states he has bumps that are constant in these areas. He denies itching or pustules. He states he was treated for acne of his face. While in service, but this is no longer a problem, this skin condition is different." The VA examiner did not provide an etiology opinion for the folliculitis. The Veteran's service treatment records reflect that he was treated for tinea pedis and "intertriginous abscess, left fourth and fifth toes, rule out osteomyelitis" in November 1987 and December 1987. The Veteran was treated for acne in July 1989. Post-service medical records include treatment for skin symptoms. For example, a March 2006 medical record notes that the Veteran has "multiple small vesicular lesions on left posterior head." An undated record from approximately that time notes that the Veteran has a history of folliculitis. Given the in-service skin treatment and the current diagnosis of folliculitis, the Board finds it necessary to remand this claim for a new examination and etiology opinion. The Board notes that the first element of a service connection claim, the presence of a current disability, is satisfied if a disability is diagnosed at any point since the filing of the claim or prior but proximate to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In the case at hand, even if the examiner were to find that the Veteran does not currently have a diagnosis of folliculitis, the examiner should provide an opinion with respect to the folliculitis that manifested in July 2013. The matters are REMANDED for the following action: 1. Obtain all relevant VA and private treatment records not currently associated with the claims file, to include any VA medical records that were created since the Veteran's records were last obtained. 2. Take all appropriate steps to determine whether the Veteran's period of service beginning on July 26, 2001, and ending on December 21, 2001, was active duty service or active duty for training. The Veteran's DD Form 214 from that period notes a "TYPE OF SEPARATION" of "RELEASE FROM ACTIVE DUTY," but it also notes "NARRATIVE REASONS FOR SEPARATION" of "COMPLETION OF REQUIRED ACTIVE DUTY TRNG." 3. Take all appropriate steps to determine the dates on which dates the USS Constellation was located in the Persian Gulf. 4. Make a factual determination as to whether the Veteran's reported stressor (having witnessed blown-up bodies and body parts, including of people he knew, floating in the water while he was stationed aboard the USS Reeves and USS Constellation while in the Persian Gulf) is related to a fear of hostile military or terrorist activity. 5. Arrange for the Veteran to undergo an examination to determine the nature and etiology of any current acquired psychiatric disability. The claims file must be reviewed by the examiner in connection with the examination, and review of the record should be noted in the examination report. A complete history should be elicited directly from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. After reviewing the record and examining the Veteran, the examiner should diagnose all current acquired psychiatric disabilities, specifically diagnosing or ruling out PTSD. The examiner should specifically discuss the diagnostic criteria in relation to the Veteran's psychiatric symptoms. For any such disability that is diagnosed, the examiner should express an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any such disability is as a result of his military service. The examiner should expressly discuss whether the Veteran's reported stressor event (his witnessing blown up bodies and body parts floating in the Persian Gulf) is related to a fear of hostile military or terrorist activity. Any opinion expressed by the VA examiner should be accompanied by a complete rationale that includes a discussion of the facts of the Veteran's case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 6. Arrange for the Veteran to undergo an examination to determine the nature and etiology of any current back disability. The claims folders must be reviewed by the examiner in connection with the examination, and review of the record should be noted in the examination report. A complete history should be elicited directly from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. After reviewing the record and examining the Veteran, the examiner should diagnose all current back disabilities. For any such disability that is diagnosed, the examiner should express an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any such disability was caused or aggravated by his military service (either the period from April 1987 to October 1991 or from July 2001 to December 2001). The examiner should discuss the following evidence: (a) The Veteran's lay description of his in-service duties aboard the USS Reeves and USS Constellation. (See personal statements dated in February 2013 and September 2013.) He stated that his spinal condition, specifically a herniated spine, "is due to being on deck scrub[bing] & painting the ship in 1987-1988 & dry dock in 1990-1991- painting and cleaning & chipping painting bending & stooping back and forth, up & down." He noted that he was on the Reeves from 1987 to 1989 and on the Constellation from 1989 to 1991. (b) An undated medical record from when the Veteran was 34 years old (given his birthdate, this record is likely from 1998) reflecting that the Veteran missed three weeks of work with back problems. It notes that he strained his back when he stopped a crate from falling on him at work. (c) The fact that the Veteran sought treatment for musculoskeletal low back pain multiple times in June 1998. (d) A June 1998 lumbar spine series radiology report, which was ordered because of "recurrent hematuria," noting an impression of vague lucency within the left L5 pars which likely represents confluence of shadows; however, if concerned for a spondylolysis defect, further evaluation with oblique images of the lumbar spine is recommended. Otherwise unremarkable lumbar spine series. (e) A July 1998 lumbar spine obliques only radiology report noting an impression of normal oblique views of the lumbar spine without evidence of spondylosis or spondylolisthesis. (f) A May 2000 CT of the lumbar spine showing (1) evidence of very subtle early degenerative change of the lumbar spine without evidence of degenerative disc disease, and (2) very mild spinal canal stenosis just above the L5-S1 level primarily due to ligamentum flavum hypertrophy. The Veteran had a follow-up appointment for his back in June 2000. (g) A March 2003 record noting that the Veteran sought treatment for back pain with numbness radiating down the back of the legs. Is there any medical reason to accept or reject the proposition that the claimed mechanism of injury caused the current back conditions? Any opinion expressed by the VA examiner should be accompanied by a complete rationale that includes a discussion of the facts of the Veteran's case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 7. Arrange for the Veteran to undergo an examination to determine the nature and etiology of any current right foot/ankle disability. The claims folders must be reviewed by the examiner in connection with the examination, and review of the record should be noted in the examination report. A complete history should be elicited directly from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. After reviewing the record and examining the Veteran, the examiner should diagnose all current disabilities of the right foot/ankle. For any such disability that is diagnosed, the examiner should express an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any such disability was caused or aggravated by his military service (either the period from April 1987 to October 1991 or from July 2001 to December 2001). In providing this opinion, the examiner should discuss the Veteran's reported mechanism of injury: Specifically, the Veteran contends that he has arthritis that is related to duties he performed aboard the USS Reeves and USS Constellation during service. (See personal statements dated in February 2013 and September 2013.) He has described "being on deck scrub[bing] & painting the ship in 1987-1988 & dry dock in 1990-1991- painting and cleaning & chipping painting bending & stooping back and forth, up & down." He noted that he was on the Reeves from 1987 to 1989 and on the Constellation from 1989 to 1991. Is there any medical reason to accept or reject the proposition that the claimed mechanism of injury caused the current right foot/ankle conditions? The examiner should also discuss the August 2015 VA podiatrist's record noting that the Veteran has osteoarthritis and states that he and the Veteran "discussed possible correlation to arthritis in foot/ankle and prior military activity while [on] active duty on board ship." Any opinion expressed by the VA examiner should be accompanied by a complete rationale that includes a discussion of the facts of the Veteran's case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 8. Arrange for the Veteran to undergo an examination to determine the nature and etiology of any current acquired skin disability. The claims folders must be reviewed by the examiner in connection with the examination, and review of the record should be noted in the examination report. A complete history should be elicited directly from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. After reviewing the record and examining the Veteran, the examiner should diagnose all current skin disabilities. For any such disability that is diagnosed, the examiner should express an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that any such disability is related to his military service. Because the Veteran was diagnosed with folliculitis in his July 2013 VA examination report, an etiology opinion must specifically be provided with respect to his folliculitis. Any opinion expressed by the VA examiner should be accompanied by a complete rationale that includes a discussion of the facts of the Veteran's case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 9. Following completion of the above, readjudicate the issues on appeal, to include the issues of entitlement to service connection for a respiratory disorder, a neck disability, left hand numbness, and right hand numbness. If any requested benefit remains denied, furnish the Veteran and his representative with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Elizabeth Jalley, 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.