Citation Nr: 21074732 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 14-15 193 DATE: December 16, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for depression with psychotic features is granted. REMANDED Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a skin disorder is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for erectile dysfunction is remanded. FINDINGS OF FACT 1. A competent medical opinion of record establishes a link between the Veteran's currently diagnosed PTSD and the in-service stressor of locating a drowning victim at sea, and the in-service stressor is corroborated by competent and credible statements of fellow service members. 2. The Veteran's depressive disorder with psychotic features was incurred during active duty service. CONCLUSIONS OF LAW 1. The criteria for service connection for posttraumatic stress disorder are met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304 2. The criteria for service connection for depressive disorder with psychotic features are met. 38 U.S.C. §§ 1110; 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1971 to September 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of September 2012 and January 2013. The Veteran requested a Board hearing by filings of April 2014 and October 2015. The request was withdrawn in September 2018. The Board remanded this matter in June 2020. Service Connection Service connection will be granted for a current disability that resulted from an injury or disease incurred in, or aggravated by, active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, service connection requires: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The claimant will be given the benefit of the doubt as to any issue material to the determination of a matter when there is an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for PTSD. 2. Entitlement to service connection for an acquired psychiatric disorder other than PTSD, to include depression. In May 2012, the Veteran filed a service-connection claim for PTSD. The claim includes any acquired psychiatric disorder that may reasonably be encompassed by the description of the claim, reported symptoms, or other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). A rating decision of January 2013 denied service connection for "acquired psychological disorder (claimed as mental problems)." The Veteran filed a notice of disagreement (NOD) in August 2013 and VA Form 9 in April 2014. Service connection for PTSD generally requires medical evidence establishing a diagnosis of the condition pursuant to 38 C.F.R. § 4.125(a), credible supporting evidence that the claimed in-service stressor occurred, and a link, established by medical evidence, between the current symptoms and the claimed in-service stressor. 38 C.F.R. § 3.304(f)(1); see also Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection may be granted for more than one mental health disorder (PTSD or otherwise), but the disabilities cannot be separately rated unless they result in different symptom manifestations. 38 C.F.R. § 414; see also Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). A service treatment record (STR) of June 1973 notes the Veteran's report of visual and auditory hallucinations, anxiousness, and difficulty concentrating. He stated at the time that he might have unknowingly ingested a hallucinogen on a previous Friday night. An STR of July 1973 notes the Veteran's report of an inability to concentrate, having a short attention span, and being nervous. The STRs reference the Veteran's September 1973 discharge from service as being "honorable by reason of unsuitability." The nature of the unsuitability is not specified. For the separation examination of September 1973, the Veteran was found to be normal with respect to "psychiatric." In his Report of Medical History, he answered "yes" as to past or current depression or excessive worry and nervous trouble. He stated on the form that he had been treated for a mental condition approximately a month previously. The Veteran argues that his current psychiatric disorder had its onset during service and has recurred to the present as nightmares and other mental impairment. Supporting statements of the Veteran's sister and mother filed in August 2019 attest to their personal knowledge that the Veteran, while happy and outgoing prior to military service, returned as a changed person who was impatient, distant, anxious, and angry. In his NOD and elsewhere in the record, the Veteran cites the traumatic effect of a 1972 incident in which, in response to a "man overboard" alert at night in the open ocean, he saw a body floating face down in the water. He states that the body was not recovered and drifted away by the time that search boats moved from port to starboard in response to the sighting by the Veteran. He maintains that, very soon after the event, he began having nightmares relating to the floating Marine and has continued to have such nightmares, depression, and other psychiatric symptoms to the present. In December 2020, the Veteran submitted three service-member statements purportedly from the website www.Navybuddies.com. The statements of M. C., J. F., and J. W., including as to place, time, and location, tend to corroborate the Veteran's account of the incident relating to a Marine who jumped overboard and drowned, with his corpse being seen but not recovered. The Veteran cites an additional stressor that allegedly occurred aboard the vessel on which he was stationed in 1972. He relates that, when he was in a port gun turret with others, a shell that he had just loaded into the gun did not fire and was ejected at his feet, that he froze because he did not know what to do, and that he handed the shell to a fellow service-member, who threw it over the rail into the ocean. The Veteran reports that he shook for an hour after the incident, which was not reported, and that the event caused or contributed to his current psychiatric disorder. The Veteran has also stated that it is possible that the hallucinations that he experienced in service resulted from being given a hallucinogenic drug when drinking wine with friends. He has no specific knowledge that this happened, however, and denies ever having knowingly taken any drugs not prescribed by a doctor. A June 2019 record of Dr. K. G., a licensed psychologist, diagnosed major depressive disorder, recurrent with psychotic features as the Veteran's only mental disorder. In the doctor's opinion, based on her review of service treatment records, an interview, and lay statements of the Veteran's mother and sister, the Veteran's depression more likely than not began during service. The rationale was that he had no pre-service history of mental health issues, experienced stressors during service (specifically, the "man overboard" fatality and the incident involving exposure to lethal danger from the shell ejected from the gun in the onboard turret), and first had nightmares, nervousness, concentration problems, and sleep difficulty during service. Dr. K. G. noted that the Veteran's mental health symptoms that began during service negatively affected his ability to cope with numerous psychosocial stressors over the years, such as divorce, raising children as a single parent, back and shoulder pain, and weight gain that limited his mobility. Dr. K. G. noted the Veteran's report, made without any specific knowledge, that his in-service hospitalization for hallucinations may have been caused by having ingested a hallucinogenic while drinking wine with friends. The Veteran denied that he ever knowingly took hallucinogens during service and stated with respect to the evening with friends, "I'm still not sure what actually happened." The Veteran underwent a VA examination for PTSD in October 2020. He was diagnosed as having 1) PTSD with psychotic features and 2) persistent depressive disorder with mood congruent psychotic features. The examiner explained that it was possible to differentiate the symptoms attributable to each diagnosis despite overlapping and interacting symptoms. Each of the in-service stressors (the drowning incident and the live shell incident) was found to be adequate to support the PTSD diagnosis. The October 2020 VA examiner offered a positive nexus opinion with respect to both PTSD with psychotic features and persistent depressive disorder with mood congruent psychotic features. In the examiner's opinion, the Veteran has a history of depression that began while in the Navy and that "is at least as likely as not the result of his deployment to Vietnam and his PTSD." The examiner attributed the PTSD to the Veteran's in-service stressors involving the body of the deceased sailor in the water and the ejected shell landing at the Veteran's feet. The examiner noted that, while the service treatment records note that the Veteran thought that he may have ingested a psychedelic drug that caused visual and auditory hallucination, this was never confirmed. In the examiner's opinion, the Veteran's hallucinations were caused by his in-service stressors, especially discovering the body of the Marine. The examiner's rationale relating to PTSD relied on the absence of psychiatric symptoms prior to service, the Veteran's endorsement of depression or excessive worry and nervous trouble for the separation examination of September 1973, and medical studies relating to psychotic symptoms in patients suffering from PTSD. In January 2013, the Veteran underwent a VA examination for mental disorders other than PTSD. The diagnosis was "mood disorder due to back and shoulder issues." A negative nexus opinion was offered. The opinion, being imprecise and incomplete in its analysis and conclusions, is not more persuasive than the subsequent, positive medical opinions of record. The January 2013 examiner acknowledged in the rationale that the Veteran did not appear to have suffered from symptoms of depression or other psychiatric issues prior to entering the military and that he "may have had a mood disorder when he left active duty service." The qualitative language, suggesting that the Veteran's current psychiatric disorder may indeed have had an in-service onset, reduces the probative value of the opinion. See Obert v. Brown, 5 Vet. App. 30, 33 (1995). In addition, the examiner was unable to consider evidence received subsequent to the 2013 examination. This evidence concerns the Veteran's specific account of the traumatic effect of discovering the drowning victim, the corroborating statements relating to that stressor, and the medical opinions linking the Veteran's PTSD and depression to the in-service stressor. Upon the current record, the Board is not able to find that the Veteran's current depression or PTSD results from willful misconduct or abuse of alcohol or drugs, which would preclude a grant of service connection. 38 U.S.C. § 105; 38 C.F.R. § 3.301(a), (d). The Veteran has speculated, but he has no specific knowledge that he actually ingested a hallucinogen during service, and he competently and credibly denies ever having done so intentionally. As a layperson, the Veteran is competent to report his experienced symptoms but not to determine the etiology of his own psychiatric disorders. See Layno v. Brown, 6 Vet. App. 465, 470 (1994); Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Board finds him to be competent and credible in his report of the in-service stressor of seeing the drowning victim and the psychological upset that he experienced during service. Psychiatric symptoms were noted in the STRs and reported by the Veteran at the service separation examination. The June 2019 opinion of Dr. K. G. and the October 2020 VA medical opinion link the Veteran's current depression to the in-service stressor involving the drowned sailor. Special regulatory requirements relating to credible supporting evidence that a claimed in-service stressor occurred apply to PTSD claims and not to other psychiatric disabilities generally. 38 C.F.R. § 3.304(f). With the three elements of Shedden having been met, service connection for depressive disorder with psychotic features is warranted. The October 2020 VA examiner also linked the Veteran's diagnosed PTSD to the in-service stressor of the Veteran's discovery of the drowned Marine. That stressor has been sufficiently corroborated by statements of fellow service members. Evidence corroborating a PTSD stressor need not be found in service records and may stem from any source tending to show that the claimed in-service stressor actually occurred. See Cohen v. Brown, 10 Vet. App. 128, 147-148. Furthermore, for PTSD claims, corroboration of every detail of a claimed stressor is not required; rather, independent evidence of a stressful event may suffice to imply a veteran's personal exposure. See Pentecost v. Principi, 16 Vet. App. 124, 128 (2002) (quoting Suozzi v. Brown, 10 Vet. App. 307 (1997)). In this case, the Board determines that the competent statements of the fellow service members are credible supporting evidence that the claimed in-service stressor occurred. Because the most probative evidence of record, including the positive nexus opinion of the October 2020 VA examiner, supports finding that the Veteran's PTSD resulted from the corroborated in-service stressor, service connection for PTSD is warranted. Because service connection for depression is being granted based on adequate evidence of actual causation, it is not necessary to consider a theory of service connection based on presumed service connection for the listed chronic disease of "psychoses." 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.303 (b), 3.307, 3.309, 3.384. REASONS FOR REMAND 3. Entitlement to service connection for a back disorder. In January 2012, the Veteran filed a service-connection claim for "lower back condition," which was denied by a rating decision of September 2012. The issue was appealed with the filing of a NOD of September 2012 and VA Form 9 of April 2014. The claim includes any disorder that may reasonably be encompassed by the description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In September 2018, the Veteran again filed a service-connection claim for a low back condition. The AOJ denied the claim by a rating decision of September 2018 on the basis that no new and material evidence had been received. As noted previously by the Board in its June 2020 remand, the Veteran's appeal dating from the September 2012 NOD remains active. A March 2005 record of Dr. J. B. diagnoses "back; sciatica," radiculopathy of the bilateral lower extremities, and a history of back surgery in 1989. A VA treatment record of January 2012 lists chronic low back pain as an active problem. A VA treatment record of August 2018 notes osteoarthritis and cervical spondylosis as current problems. In his NOD and elsewhere in the record, the Veteran alleges that he has a current back disorder that was caused by an in-service injury in January or February of 1972 when on mooring detail. He alleges that he "pulled [his] back out while pulling too hard" on heavy ropes. He allegedly received medical treatment and was put on light duty for the next week as a result. Approximately a month later, he maintains, an injury to the back reoccurred in the same way. The Veteran alleges having had recurrent back symptoms from the time of the initial, in-service injury the present. As a layperson, he is competent to report observable symptoms that come to a person through the senses and require only personal knowledge, not medical expertise. See Layno v. Brown, 6 Vet. App. 465 (1994). No back symptoms are noted in the STRs. A record of January 1972 notes that an examination found the Veteran to be physically qualified for transfer. For the September 1973 separation examination report, the Veteran was found to have a normal spine and musculoskeletal system. For the Report of Medical History, he answered "no" as to recurrent back pain. He alleges in his NOD that the service treatment records currently of record are incomplete and do not fully reflect his documented, in-service medical history. To date, no VA medical opinion has been obtained as to the likelihood that the current back pain is caused by a disease or injury of service, to include the Veteran's competent report of back symptoms that began during service and have recurred to the present. The Board will remand for a VA medical examination and nexus opinion. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 4. Entitlement to service connection for a right knee disorder. 5. Entitlement to service connection for a left knee disorder. By a filing of January 2012, the Veteran seeks service connection for a bilateral knee disorder. A rating decision of September 2012 denied service connection for a right knee condition and for a left knee condition. The Veteran filed a NOD in September 2012 and VA Form 9 in April 2014. In September 2018, the Veteran again filed a service-connection claim for a bilateral knee condition. The agency of original jurisdiction (AOJ) denied the claims as to both knees by a rating decision of September 2018 on the basis that no new and material evidence had been received. As noted previously in the Board's June 2020 remand, the Veteran's appeal dating from the September 2012 NOD remains active. A VA treatment record of January 2013 made an assessment of "knee arthralgia/djd." An October 2013 record of Dr. A. T. notes an assessment of knee pain. A VA treatment record of August 2018 lists knee pain and osteoarthritis as current problems. In his NOD and elsewhere in the record, the Veteran alleges that he has a current bilateral knee disorder that was caused in January 1972, when he allegedly tripped over a door threshold aboard his vessel while carrying an 80-pound bag, and then fell very hard upon his knees. He states that he was allowed to go home for the weekend due to this Friday accident and that was given light duty for the following week. He alleges having had recurrent knee symptoms from the time of the in- service fall to the present. As a layperson, the Veteran is competent to report observable symptoms that come to a person through the senses and require only personal knowledge, not medical expertise. See Layno v. Brown, 6 Vet. App. 465 (1994). No knee symptoms are noted in the STRs. A record of January 1972 notes that an examination found the Veteran to be physically qualified for transfer. For the September 1973 separation examination report, he was found to have a normal musculoskeletal system. For the Report of Medical History, the Veteran answered "no" as to swollen or painful joints and a "trick" or locked knee. He alleges in his NOD that the service treatment records currently of record are incomplete and do not fully reflect his documented, in- service medical history. To date, no VA medical opinion has been obtained as to the likelihood that the Veteran's current disorders of the right knee and left knee are caused by a disease or injury of service, to include the Veteran's competent report of bilateral knee symptoms that began during service and have recurred to the present. The Board will remand for a VA medical examination and nexus opinion. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 6. Entitlement to service connection for sleep apnea. In September 2018, the Veteran filed a service-connection claim for sleep apnea, which was denied by a rating decision of September 2018. The Veteran filed a NOD in October 2018 and VA Form 9 in September 2019. A VA treatment record of November 2012 notes an assessment of possible sleep apnea. In a VA treatment record of October 2014, in a consent form relating to long-term opioid therapy for the Veteran's chronic lumbar pain, sleep apnea is listed as a known risk or side effect of the treatment. A VA treatment record of November 2014 notes that a sleep study was ordered and that the Veteran was "encouraged to schedule." A VA treatment record of May 2018 makes an assessment of "fatigue, suspect OSA" and indicates that the Veteran declined a sleep study, saying that he is unable to sleep at a test facility or at home and feels claustrophobic when wearing a mask. A VA treatment record of August 2018 notes "still refused sleep study." A VA treatment record of July 2020 notes the Veteran's report that he has sleep apnea, uses a CPAP, and generally sleeps between four and six hours per night. As a layperson, the Veteran is competent to report certain sleep symptoms and a contemporaneous medical diagnosis of sleep apnea. See Layno v. Brown, 6 Vet. App. 465 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). No sleep apnea symptoms are noted in the STRs. For the separation examination of September 1973, the Veteran answered "no" as to any past or current sleeping trouble. The record contains medical evidence that the Veteran's recurrent symptoms may be associated with a sleep apnea disorder and that sleep apnea is a known risk of opioids that the Veteran takes for his low back pain. Therefore, the Board will remand for a VA examination and medical opinion. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Furthermore, because the claimed sleep apnea disorder may be caused or aggravated by medication taken for the claimed back disorder, the sleep apnea claim will be remanded as being inextricably intertwined with the remanded low-back claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 7. Entitlement to service connection for a skin disorder. In September 2018, the Veteran filed a service-connection claim for "skin condition," which was denied by a rating decision of September 2018. The Veteran filed a NOD in October 2018 and VA Form 9 in September 2019. An STR of September 1971 notes an impression of contact dermatitis. The Veteran was noted to have been sprayed with "some unknown chemical" and to have broken out in a pruritic rash in the axilla and groin. On physical examination, there were numerous maculopapular lesions (papules) of 1-2 mm. located on the axilla and groin. On the separation examination report of September 1973, a skin abnormality was noted, but the clinician's cursive notation is illegible other than the words "1st finger." The Veteran answered "no" at that time as to any past or current skin diseases. A VA treatment record of November 2011 makes a dermatological finding of "dry skin, benign nevi, mild patch dry skin r forearm." A nevus is a congenital lesion of the skin. See Dorland's Illustrated Medical Dictionary 1273 (32d ed. 2012). A VA treatment record of May 2014 relating to the Veteran's complaint of chest pain notes that no rashes or lesions were found upon examination. In a VA treatment record of October 2014, in a consent form relating to long-term opioid therapy for the Veteran's chronic lumbar pain, itching is listed as a known risk or side effect of the treatment. In August 2019, the Veteran underwent a VA examination for skin diseases. In the Diagnosis section of the report, the examiner, a nurse practitioner, answered "yes" as to whether the Veteran has a current skin condition. The listed diagnosis was contact dermatitis, with September 9, 1971 given as the date of diagnosis. The examination report noted, as history, that the Veteran "served in Agent Orange, Vietnam Era;" that the date of onset was 1971; that the Veteran was seen at sick bay initially for a small rash on the right pelvic region, which became bigger during service, reached the size of a silver dollar, and oozed; and that the Veteran reports that he was given Tinactin. Despite the finding of a current disorder of contact dermatitis, the examiner also indicated that, upon examination, the Veteran's contact dermatitis is completely resolved and covers "none" of his body area. The examiner provided no summary as any report of current symptoms made by the Veteran upon examination. A VA examination report must be adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). An examination report should be factually accurate and contain sound reasoning for the conclusion. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Board will remand for a new VA examination because the August 2019 made the contradictory findings that the Veteran both has a current skin disorder and has no symptoms of a current skin disorder. 38 C.F.R. § 19.9(a). Furthermore, because the claimed skin disorder may be caused or aggravated by medication taken for the claimed back disorder, the skin claim will be remanded as being inextricably intertwined with the remanded low-back claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 8. Entitlement to service connection for hypertension. In September 2018, the Veteran filed a service-connection claim for high blood pressure, which was denied by a rating decision of September 2018. The Veteran filed a NOD in October 2018 and VA Form 9 in September 2019. A VA treatment record of August 2018 lists benign essential hypertension as an active problem. The Veteran served aboard the USS Manitowoc. In February 2018, he submitted a signed "Deck Log Remarks Sheet" for the USS Manitowoc that references the Veteran by name and appears to place him on the vessel in the Gulf of Tonkin off the coast of North Vietnam in June 1972. The log indicates that the Veteran was transported from the USS Manitowoc to the USS Okinawa for medical treatment, as he alleges in his February 2018 statement. Generally, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam between January 9, 1962 and May 7, 1975 is presumed to have been exposed to an herbicide agent if a listed chronic disease becomes manifest to a degree of 10 percent disabling or more, unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(a). If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases are presumed to be service connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of the disease during service. 38 U.S.C. § 1116(a); 38 C.F.R. § 3.309(e). Hypertension is not one of the diseases listed under 38 C.F.R. § 3.309(e) for which service connection may be presumed based on herbicide exposure. Nonetheless, a claimant may establish service connection for a disability due to herbicide exposure upon adequate evidence of actual causation. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). As indicated in Veterans and Agent Orange: Update 11 (2018), the Institute of Medicine (IOM) of the National Academy of Sciences (NAS) has updated its conclusion with respect to herbicide agents and hypertension, finding "sufficient" epidemiologic evidence to identify a positive association between hypertension and herbicide exposure. Hypertension is also a listed "chronic" disease for which service connection may be presumed if the disease is shown as such during service or within one year of discharge from service. 38 U.S.C. § 1112; 38 C.F.R. § 3.309. The phrase "service in the Republic of Vietnam" in 38 U.S.C. § 1116 includes the territorial seas of the Republic of Vietnam extending 12 nautical miles from the shores of that nation. See Procopio v. Wilkie, 913 F.3d 1371 (Fed. Cir. 2019). Upon the current record, it cannot be determined whether it is at least as likely as not that the Veteran crossed the 12-nautical-mile threshold of Vietnam. The Board will remand for additional factual development to determine the likelihood that the Veteran was on the Vietnam mainland or was on a ship within the 12 nautical mile territorial sea of Vietnam. 9. Entitlement to service connection for erectile dysfunction. In September 2018, the Veteran filed a service-connection claim for erectile dysfunction (ED), which was denied by a rating decision of September 2018. The Veteran filed a NOD in October 2018 and VA Form 9 in September 2019. Erectile function is not noted in the service treatment records, and the Veteran has not been diagnosed with the disorder. As a layperson, he is not competent to identify the cause of his erectile function, but he is competent to report the fact of erectile dysfunction and its history as an experienced symptom. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). In general, there is a medically established link between high blood pressure and erectile dysfunction. See www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-blood-pressure-and-sex/art-20044209. Thus, it is possible that the Veteran's hypertension causes or aggravates the erectile dysfunction that he competently reports. Furthermore, in a VA treatment record of October 2014, in a consent form relating to long-term opioid therapy for the Veteran's chronic lumbar pain, "decreased sex hormones" is listed as a known risk or side effect of the treatment. Accordingly, the ED claim will be remanded as being inextricably intertwined with the remanded claims relating to service connection for hypertension and for a back disorder. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. In remanding these issues, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Undertake appropriate development to associate with the record any outstanding VA treatment records and any outstanding and identified private medical records that are pertinent to the remanded issues. All efforts to obtain such records should be documented in the record. 3. Undertake appropriate development to establish whether or not the Veteran likely served on the mainland of Vietnam or was within the 12 nautical mile territorial sea of Vietnam during his Vietnam-era service. 4. Specifically notify the Veteran that he may submit digital photographs of his claimed skin disorder when it is symptomatic. 5. Schedule the Veteran for a medical examination with an appropriate clinician to determine the nature and etiology of any back disorder and any associated neuropathy at any time since the Veteran's claim was filed in January 2012, even if now resolved. The examiner must opine as to whether any such disorder at least as likely as not: a. Is caused by an in-service injury, disease, or event, to include the Veteran's account of an in-service onset of back pain, as reflected in statements in the claims folder and history reported upon current examination; b. Had its inception during service; c. Manifested during active service or within one year after discharge from service; or d. Was noted during service or within one year after discharge from service such that the condition was not shown to be chronic at that time or a diagnosis of chronicity could be legitimately questioned, and there was a continuity of the same symptomatology since service or the year following service. Notify the examiner that the Veteran, as a layperson, is competent to attest to matters based on personal knowledge, not medical expertise, as they come to a person through his or her senses, including observable or experienced symptoms. Notify the examiner that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. 6. Schedule the Veteran for a medical examination with an appropriate clinician to determine the nature and etiology of any disorder of the right knee and/or left knee at any time since the Veteran's claim was filed in January 2012, even if now resolved. The examiner must opine as to whether any such disorder(s) at least as likely as not: a. Is caused by an in-service injury, disease, or event, to include the Veteran's account of an in-service onset of bilateral knee pain, as reflected in statements in the claims folder and statements made upon current examination; b. Had its inception during service; c. Manifested during active service or within one year after discharge from service; or d. Was noted during service or within one year after discharge from service such that the condition was not shown to be chronic at that time or a diagnosis of chronicity could be legitimately questioned, and there was a continuity of the same symptomatology since service or the year following service. Notify the examiner that the Veteran, as a layperson, is competent to attest to matters based on personal knowledge, not medical expertise, as they come to a person through his or her senses, including observable or experienced symptoms. Notify the examiner that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any sleep apnea disorder. The examiner must opine as to whether such a disorder at least as likely as not: a. Is related to an in-service injury, disease, or event, to include the Veteran's report of any sleep apnea symptoms, as reflected in statements in the claims folder and statements made upon current examination; b. Had its inception during active duty service; or c. Is proximately due to, or aggravated beyond its natural progression by a service-connected disability, to include medication taken for a service-connected disability, or by any other disorder, to include medication taken for any other disorder. Notify the examiner that laypersons, such as the Veteran, are considered competent to attest to matters of first-hand knowledge gained through the senses, including observable symptomatology. Notify the examiner that term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. Notify the examiner that a link between a current sleep apnea disorder and service may be as likely as not, regardless of whether sleep symptoms were documented during service. A rationale is required for all opinions in the report. 7. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any skin disorder. Undertake appropriate steps, to the extent possible, to schedule the examination during a flare-up of the alleged dermatological condition. The examiner must opine as to whether such a disorder at least as likely as not: a. Is related to an in-service injury, disease, or event, to include the Veteran's report of any skin symptoms, as reflected in statements in the claims folder and statements made upon current examination; b. Had its inception during active duty service; or c. Is proximately due to, or aggravated beyond its natural progression by a service- connected disability, to include medication taken for a service-connected disability, or by any other disorder, to include medication taken for any other disorder. Notify the examiner that laypersons, such as the Veteran, are considered competent to attest to matters of first-hand knowledge gained through the senses, including observable symptomatology. Notify the examiner that term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. (Continued on the next page) Notify the examiner that a link between a current sleep apnea disorder and service may be as likely as not, regardless of whether sleep symptoms were documented during service. A rationale is required for all opinions in the report. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Steven D. Najarian, 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.