Citation Nr: 21007217 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 17-02 081 DATE: February 9, 2021 ORDER As new and material evidence has been received, the petition to reopen previously denied claim for service connection for residuals of bilateral hammertoes, is granted. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for a sinus disorder is denied. Entitlement to service connection for a bilateral eye disorder, to include cataracts and glaucoma is denied. Entitlement to service connection for severe arthritis is denied. Entitlement to service connection for a left knee disorder is denied. Entitlement to service connection for a right knee disorder is denied. Entitlement to service connection for a right arm disorder is denied. Entitlement to service connection for a left arm disorder is denied. Entitlement to service connection for a right hand disorder is denied. Entitlement to service connection for a left hand disorder is denied. Entitlement to service connection for a stomach scar is denied. Entitlement to service connection for a head injury is denied. Entitlement to service connection for residual scar on left side is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for fibromyalgia is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for residual scar, status post left fifth hammertoe, is remanded. Entitlement to service connection for residual scar, status post right fifth hammertoe, is remanded. Entitlement to service connection for a left little toe with corn is remanded. Entitlement to service connection for a right little toe with corn is remanded. Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for a left leg disorder is remanded. Entitlement to service connection for a right leg disorder is remanded. Entitlement to service connection for hypertension, to include as due exposure to herbicide agents, is remanded. Entitlement to service connection for a heart disorder is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and depression, is remanded. Entitlement to service connection for gastroesophageal reflux disorder (GERD) is remanded. Entitlement to service connection for a colon disorder is remanded. Entitlement to service connection for a headache disorder is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. In a September 1971 rating decision, the RO denied the Veteran’s claim for service connection for residuals of bilateral hammertoes; the Veteran did not appeal the decision and documentation constituting new and material evidence was not actually or constructively received within the one-year appeal period. 2. Additional evidence received since the September 1971 rating decision is not cumulative or redundant of the evidence of record at the time of that decision, relates to an unestablished fact necessary to substantiate the claim for service connection for residuals of bilateral hammertoes, and raises a reasonable possibility of substantiating the claim. 3. The Veteran’s bilateral hearing loss did not manifest in active duty service or within one year of separation from service, and the preponderance of the evidence is against a finding that it is otherwise related to service. 4. The Veteran’s current eye disorder, to include cataracts and pre-glaucoma, were not incurred during service, and the preponderance of the evidence is against finding that they are otherwise related to an in-service injury or disease, to include exposure to herbicide agents. 5. The preponderance of the evidence is against a finding that the Veteran has a current sinus disorder as a result of his period of service. 6. The Veteran’s severe arthritis did not manifest in active duty service or within one year of separation from service, and the preponderance of the evidence is against a finding that it is otherwise related to service. 7. The Veteran’s current left knee disorder, to include arthritis, did not manifest in active duty service or within one year of separation from service, and the preponderance of the evidence is against a finding that it is otherwise related to service. 8. The Veteran’s current right knee disorder, to include arthritis, did not manifest in active duty service or within one year of separation from service, and the preponderance of the evidence is against a finding that it is otherwise related to service. 9. The Veteran’s right arm disorder did not manifest in active duty service or within one year of separation from service, and the preponderance of the evidence is against a finding that it is otherwise related to service. 10. The Veteran’s left arm disorder did not manifest in active duty service or within one year of separation from service, and the preponderance of the evidence is against a finding that it is otherwise related to service. 11. The Veteran’s right hand disorder did not manifest in active duty service or within one year of separation from service, and the preponderance of the evidence is against a finding that it is otherwise related to service. 12. The Veteran’s left hand disorder did not manifest in active duty service or within one year of separation from service, and the preponderance of the evidence is against a finding that it is otherwise related to service. 13. The evidence of record does not demonstrate that the Veteran’s stomach scar was incurred in or aggravated by his military service. 14. The evidence of record does not demonstrate that the Veteran has a head injury that was incurred in or aggravated by his military service. 15. The evidence of record does not demonstrate that the Veteran’s residual scar on the left side was incurred in or aggravated by his military service. 16. The preponderance of the evidence is against a finding that the Veteran has sleep apnea that is etiologically related to his period of service. 17. The preponderance of the evidence of record is against finding that the Veteran has a diagnosis of fibromyalgia. 18. The competent evidence of record does not demonstrate that the Veteran has a current diagnosis of PTSD. CONCLUSIONS OF LAW 1. The September 1971 rating decision denying service connection residual of bilateral hammertoes is final; as new and material evidence has been received, the claim to reopen the previously denied claim for service connection for residuals bilateral hammertoes have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.1103. 2. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.385. 3. The criteria for entitlement to service connection for a sinus disorder have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. § 3.303. 4. The criteria for entitlement to service connection for a bilateral eye disorder, to include cataracts and glaucoma have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.303, 3.307, 3.309. 5. The criteria for entitlement to service connection for severe arthritis have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. §§ 3.303, 3.307, 3.309. 6. The criteria for entitlement to service connection for a right knee disorder have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. §§ 3.303, 3.307, 3.309. 7. The criteria for entitlement to service connection for a left knee disorder have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. §§ 3.303, 3.307, 3.309. 8. The criteria for entitlement to service connection for a right arm disorder have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. §§ 3.303, 3.307, 3.309. 9. The criteria for entitlement to service connection for a left arm disorder have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. §§ 3.303, 3.307, 3.309. 10. The criteria for entitlement to service connection for right hand disorder have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. §§ 3.303, 3.307, 3.309. 11. The criteria for entitlement to service connection for left hand disorder have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. §§ 3.303, 3.307, 3.309. 12. The criteria for entitlement to service connection for a stomach scar have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. § 3.303. 13. The criteria for entitlement to service connection for a head injury have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. § 3.303. 14. The criteria for entitlement to service connection for residual scar on left side have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. § 3.303. 15. The criteria for entitlement to service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. § 3.303. 16. The criteria for entitlement to service connection for fibromyalgia have not been met. 38 U.S.C. §§ 1110, 1131, 1117; 38 C.F.R. § 3.303. 17. The criteria for entitlement to service connection for posttraumatic stress disorder (PTSD) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125 (a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Army from January 1966 to March 1968. He had additional service in the Army Reserves. New and Material Evidence 1. The claim to reopen the previously denied claim for service connection for residuals of bilateral hammertoes In September 1971, the RO denied the Veteran’s claim of service connection for residuals of bilateral hammertoes because the evidence failed to demonstrate his pre-existing condition was aggravated by his period of service. The Veteran did not appeal the decision, nor was any new and material evidence actually or constructively received within a year following the decision. Therefore, the September 1971 rating decision became final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156, 19.20, 19.21, 19.52, 20.1103. Generally, a claim which has been denied may not thereafter be reopened and allowed based on the same record. 38 U.S.C. §§ 7104, 7105. However, pursuant to 38 U.S.C. § 5108, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the VA Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). 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. Id. Since the September 1971 rating decision, the record contains the Veteran’s lay assertions that his bilateral hammertoes were worsened by his period of service, and shortly after his period of service, he underwent surgical correction of his bilateral hammertoes. See April 2019 informal hearing presentation. The Board must presume that the Veteran’s statements are true for the purpose of determining whether to reopen the Veteran’s claim. See Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003); Justus v. Principi, 3 Vet. App. 510, 513 (1992). This evidence raises a reasonable possibility of substantiating the claim that the Veteran’s pre-existing bilateral hammertoes were aggravated by his period of service. The Board therefore finds that this evidence is new and material, and the Veteran’s claim is reopened. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may also be granted for certain diseases based on presumed exposure to certain herbicide agents, even though there is no record of such disease during service. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). As the record shows that the Veteran had active service in the Republic of Vietnam during the Vietnam era, he is presumed to have been exposed to herbicides during that service. 38 U.S.C. § 1116; 38 C.F.R. § 3.307. The presumptive provisions of 38 C.F.R. § 3.307 are specifically limited to enumerated chronic diseases listed in 38 C.F.R. § 3.309 (e). Even if a Veteran is not entitled to presumptive service connection for a disease claimed as secondary to herbicide exposure, VA must also consider whether there is actual exposure to herbicides. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 2. Entitlement to service connection for bilateral hearing loss The Veteran seeks entitlement to service connection for bilateral hearing loss. He contends that he has bilateral hearing loss as a result of his period of service, to include his exposure to herbicide agents while stationed in the Republic of Vietnam. For the purpose of applying the laws administered by VA, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels (dB) or greater; or when the auditory threshold for at least three of the frequencies 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. When audiometric test results at separation from service do not meet the regulatory requirements for establishing a “disability” at that time, a veteran may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155, 160 (1993). The threshold for normal hearing is from 0 to 20 decibels. Id. at 157. It is initially noted that bilateral hearing loss is not one of those diseases for which service connection may be presumed as a result of Vietnam Era service and consequent exposure to herbicides such as Agent Orange. See 38 C.F.R. §§ 3.307, 3.309(e). The Board concludes that, while the Veteran has a current diagnosis of bilateral hearing loss for VA purposes based on 38 C.F.R. § 3.385, the preponderance of the evidence weighs against finding that the Veteran’s hearing loss began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d). With regard to the 1965 and 1968 i-service audiological testing, because it is unclear whether such thresholds were recorded in using American Standards Association (ASA) units or International Standards Organization-American National Standards Institute (ISO-ANSI) units, the Board will consider the recorded metrics under both standards, relying on the unit measurements most favorable to the Veteran’s appeal. As it relates to VA examinations and VA records, audiological reports were routinely converted from ISO-ANSI results to ASA units until the end of 1975 because the regulatory standard for evaluating hearing loss was not changed to require ISO-ANSI units until September 9, 1975. In light of the above, and where necessary to facilitate data comparison for VA purposes in the decision below, including under 38 C.F.R. § 3.385, audiometric data originally recorded using ASA standards will be converted to ISO-ANSI standard by adding between 5 and 15 decibels to the recorded data as follows: Hertz 250 500 1000 2000 3000 4000 6000 8000 add 15 15 10 10 10 5 10 10 In-service audiological examination dated in November 1965 showed readings in decibels at 500, 1000, 2000, 3000, 4000 and 6000 hertz respectively, converted to ISO standard in parenthesis on the right of 0 (15), 0 (10), 0(10), 5 (15), 0 (5); and on the left of 5 (20), 15 (25), 0(10), 10 (20), 0 (5). The January 1968 separation examination shows readings in decibels at 500, 1000, 2000, 3000, 4000 and 6000 hertz respectively, converted to ISO standard in parenthesis on the right of 10 (25), 5 (15), 0(10), 10 (20), 0 (5); and on the left of 5 (20), 10 (20), 5(15), 5 (15), 5 (10). The inservice audiometric testing on the June 1965 and January 1968 examinations does include several reading above 25 decibels when converter to ISO standard, indicates some hearing loss but there is no clinical finding of hearing loss noted on examination. The Veteran’s remaining service treatment records do not show he complained of any hearing loss problems during his period of service. Rather, on his January 1968 report of medical history, the Veteran denied any history of “ear, nose, or throat trouble” during his period of service. If hearing loss was present during service, the Board would expect the Veteran would have responded “yes” when asked if he had such complaints at the time of his separation because a reasonable person would have interpreted the question to include hearing difficulties as hearing is perceived in the ears. Moreover, the Veteran responded affirmatively when asked whether he had other conditions at separation and the Board would thus expect the Veteran to have also responded affirmatively as to any hearing concerns. The Veteran’s Army Reserve service audiological examinations dated from January 1976 to January 1989 do not reflect any bilateral hearing disability for VA purposes. He specifically denied any history of hearing loss each associated report of medical history dated at those times. Post-service medical records are silent as to any complaints, treatment, or diagnosis of hearing loss after service until a November 2005 VA treatment record reflects complaints of hearing problems. However, there is no audiometric results that reveal bilateral hearing loss for VA purposes until the December 2014 VA audiology examination report. As sensorineural hearing loss is not shown to have been present during service or in the first year after separation of service, and continuity of symptomatology leading to a diagnosis of sensorineural hearing loss is not shown, in-service incurrence cannot be presumed. See 38 C.F.R. §§ 3.307, 3.309(a). The Veteran has not asserted, and the evidence does not demonstrate, that he first complained of hearing loss during service. In addition, to the extent that the Veteran would make such assertions, these statements would be in direct conflict with his service treatment records that are negative for any indication of hearing problems. These service records, including physical examinations and reports of medical history, are more reliable than more recent assertions as they were contemporaneous to service and for the purpose of identifying a disability at that time. The Board finds that the preponderance of the competent evidence is against a finding of continuity of bilateral hearing loss since service to support an award on a presumptive service connection basis. See 38 C.F.R. § 3.309; Walker, supra. The record also does not contain any competent medical evidence linking the Veteran’s current bilateral hearing loss disability to his period of service. In the December 2014 VA audiology examination report, the VA examiner concluded that it was less likely as not that his hearing loss was related to his military noise exposure. In support of this conclusion, the examiner noted that the Veteran’s separation examination was within normal limits with no threshold shifts compared to his enlistment examination, and cited studies by the Institute of Medicine (IOM) which found that the evidence from laboratory studies in humans and animals is not sufficient to determine whether permanent noise-induced hearing loss can occur much later in one’s lifetime and long after the cessation of that noise exposure (as was the case for this Veteran based on the medical evidence of record). Although the definitive studies to address this issue have not been performed, based on the anatomical and physical data available, the VA examiner noted that the IOM study found this unlikely. Finally, the VA examiner stated that while reports of specific military related noise exposure and/or reports of continuity of hearing problems since service are considered, there is a lack of objective evidence of permanent clinically significant increase in threshold over time in service based on frequency specific audiological test results. Given these factors, the VA examiner concluded that the Veteran’s current hearing loss is less likely than not due to military service. There is no other medical evidence in significant conflict with the above findings during the relevant evidentiary window. As noted, the record is absent complaints of hearing loss until 2004, with the Veteran specifically denying hearing loss on his service medical history reports dated through January 1989. The Board has considered the Veteran’s statements, to include his assertions that his hearing loss is related service, to include his exposure to chemicals, including herbicide agents. While the Veteran is competent to report observable symptoms such as hearing loss, the record does not reflect that he had the requisite training or expertise to offer a medical opinion linking a current disability to service decades earlier and he is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinion rendered by a trained medical professional based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim for service connection for bilateral hearing loss, that doctrine is not applicable in this case. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for a sinus disorder The Veteran seeks entitlement to service connection for a sinus disorder. The Veteran has only provided general assertions that service connection is warranted because of his exposure to chemical from contaminated equipment and environment, including herbicide agents, while participating in missions and training during his service. He has not raised any specific argument or assertion regarding his claim for a sinus disorder. The Board finds that the preponderance of the evidence is against the finding of that the Veteran has a current disability that is a result of in-service disease or injury to support an award of service connection. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303 (d). The Veteran’s service treatment records are silent for complaints, treatment, or diagnosis for sinus-related problems. Post-service VA treatment records reflect that a January 2000 head CT scan revealed normal sinuses, and the Veteran was assessed with acute sinusitis. Subsequent VA treatment records do not show complaints or treatment for chronic sinus-related problems. The Board acknowledges that lay persons are competent to observations of some medical issues, including symptoms of sinus pain and congestion. However, the Veteran has not provided any statement of a sinus disorder beyond the general assertion for entitlement to service connection as result of exposure to chemicals, to include herbicide agents. The Veteran has not provided specific evidence or assertions explaining why he believes that he has a current sinus disorder that is causally related to his service. There is no competent evidence linking the Veteran’s current sinus disorder to his period of service, to include any exposure to chemicals and herbicide agents. To the extent that, as the Veteran has filed a claim for service connection, he may believe that he has a current sinus disorder that was a result of his period of service. However, that is a medically complex inquiry outside the scope of a non-expert. The evidence does not otherwise show he has the requisite medical training or expertise needed to render a competent opinion as to medical causation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). His statements in that regard are afforded no probative value. The VA has not afforded the Veteran a comprehensive medical examination relating to his sinus claim. Under McLendon v. Nicholson, in disability compensation claims, VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. See Id., 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). A VA examination under the standards of McLendon is not warranted in this case because there is no competent evidence indicating that the Veteran has a current sinus disorder that may be related to any in-service incident or event. The Board finds the Veteran’s lay assertions, without some other actual basis, to be the type of speculative and conclusory inference that is insufficient to indicate a nexus to service. See Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010); cf Colantonio v. Shinseki, 606 F.3d 1378, 1381-82 (Fed. Cir. 2010). Notably, the Veteran has not identified what “evidence indicates that there may be a nexus” between a sinus disorder and chemical/herbicide exposure in service, and conclusory or generalized lay allegation of a nexus alone are not sufficient in this regard. See Euzebio v. Wilkie, 31 Vet. App. 394, 406 (2019). Indeed, when the issue was first raised by the Veteran in a November 2015 statement in support of the case, there was no specific assertion of a link between his claimed sinus disorder and exposure to chemicals, including herbicides. As such, the Board finds that his lay statements, alone, are not sufficient to trigger VA’s duty to assist him in substantiating his claim by providing a medical examination or opinion. Thus, the Board finds that such an examination is unnecessary to render a decision under the circumstances of this case, and service connection for a sinus disorder denied. See McLendon, 20 Vet. App. at 81; see also 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). Finally, the Veteran has not argued that he has a sinus disorder that is one of those disease for which service connection may be presumed as a result of Vietnam Era service and consequent exposure to herbicides such as Agent Orange. See 38 C.F.R. §§ 3.307, 3.309(e). In sum, the preponderance of the evidence does not demonstrate that the Veteran has a current sinus disorder that was incurred in service or is otherwise related to service, to include exposure to herbicide agents. There is no doubt to be resolved; the claim for service connection for a sinus disorder is denied. 4. Entitlement to service connection for a bilateral eye disorder, to include cataracts and glaucoma The Veteran contends that his current bilateral eye disorders are the result of exposure to chemicals, to include his presumed exposure to herbicide agents. In the alternative, he contends that his vision problems first manifested in service. See November 2015 statement in support of the case. VA medical records show that the Veteran has current bilateral eye diagnoses of refractive error (presbyopia), cataracts, and pre-glaucoma. Initially, the Board notes that “refractive error of the eye” are not eligible for service connection under VA regulations, absent evidence of aggravation by a superimposed, service-related condition. See 38 C.F.R. § 3.303 (d). Here, there is no evidence of refractive error in service or superimposed injury, and the Veteran has not asserted otherwise. Also, the Board observes that the herbicide presumption is not for application as none of the eye diagnoses is acknowledged as a presumptive condition in 38 C.F.R. § 3.309 (e). The Board concludes that, while the Veteran has current bilateral eye disorders, the preponderance of the evidence is against finding that it began during active service, and there is no competent evidence indicating a relationship to his period of service. The Veteran’s service treatment records are silent for complaints, treatment, or diagnosis for eye-related problems. The Veteran’s January 1968 examination prior to separation shows that his eyes were evaluated as normal and on distance vision his eyes were 20/20 bilaterally. The Veteran specifically denied a history of eye trouble on the associated report of medical history. The first evidence of any eye-related problems comes in April 1997, when the Veteran presented with subjective complaints and he was assessed with refractive error (ametropia) and prescribed glasses. Based on a review of the evidence, the Board finds that the preponderance of the evidence of records does not demonstrate that his current eye disorders were incurred in service or is otherwise related to his period of service. See 38 C.F.R. § 3.303. The Board acknowledges the Veteran’s contention that his current vision impairment had an onset during his period of service. The Veteran is competent to describe such readily observable symptoms and there is nothing obvious of record to diminish his credibility. Nonetheless, the Board recognizes that on the January 1968 Report of Medical History completed in conjunction with his separation examination, the Veteran specifically marked “no” to all potentially relevant eye symptomology. The Board finds that evidence is more probative than his recent statements regarding experiencing symptoms during service due to its contemporaneous nature. The veracity of those statements is also buttressed by the fact that the Veteran did identify other medical problems at the time; thus, he did not simply mark “no” to everything on the form, which suggests that if such symptoms did exist at the time he would have identified them. Accordingly, the Board concludes that the Veteran’s statements regarding experiencing vision during service are outweighed by the contemporaneous statements he made in conjunction with his separation examination. The Board acknowledges the Veteran’s sincere belief that his current eye disabilities were incurred during service, to include as a result of exposure to chemicals from contaminated equipment and environment, to include his presumed exposure to herbicide agents during his service in Vietnam. However, that is a medically complex inquiry outside the scope of a non-expert. See Jandreau, 492 F.3d at 1372. Moreover, the Board finds that his general conclusory assertions regarding his exposure to chemicals including herbicide agents, alone, are not sufficient evidence to trigger VA’s duty to assist him in substantiating his claim by providing a medical examination or opinion medical examination or opinion. See McLendon, 20 Vet. App. at 81; Waters, 601 F.3d at 1278-79; see also 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). In sum, although the Board finds evidence of current eye disabilities, the preponderance of the evidence does not establish evidence that an eye disorder was incurred in service or is otherwise related to service, to include exposure to herbicide agents. There is no doubt to be resolved; the claim for service connection for bilateral eye disorder, to include cataracts and pre-glaucoma, is not warranted. 5. Entitlement to service connection for severe arthritis 6. Entitlement to service connection for a left knee disorder 7. Entitlement to service connection for a right knee disorder 8. Entitlement to service connection for a right arm disorder 9. Entitlement to service connection for a left arm disorder 10. Entitlement to service connection for a right hand disorder 11. Entitlement to service connection for a left hand disorder The Veteran seeks entitlement to service connection for severe arthritis. He has asserted that he has severe arthritis of the whole body, including his knees, hands, arms, and back. See August 2015 VA 21-526EZ, Fully Developed Claim. The Board notes that his claim involves multiple issues, and the issues of arthritis in all joints other than the back will be decided herein. The issue of service connection for back disorder will be discussed further in the REMAND section below. The Veteran contends that he has degenerative arthritis in multiple joints, to include the knees, hands, and arms, related to exposure chemical from contaminated equipment and environment, to include herbicide agents, while participating in missions and training during his service. See August 2014 VA 21-526 Veterans Application for Compensation or Pension, and November 2015 statement in support of the case. Based on a review of the claims folder, the Board finds that the preponderance of the evidence weighs against finding that the Veteran’s claim for arthritis of multiple joints other than back and his claims for knees, hands, and arms are a result of his period of service. The medical evidence shows the Veteran has a current diagnosis of degenerative arthritis in the cervical spine and knees based on x-ray evidence. See VA treatment records. These records also reflect the Veteran complaints of various joint pain, including arms and hands. The Board notes that the Veteran has also asserted that he has carpal tunnel syndrome affect each hand; however, VA treatment records do not reflect treatment or diagnosis for carpal tunnel syndrome and service connection is not warranted for carpal tunnel syndrome. Although medical records do not reflect specific diagnoses of the hands and arms, VA treatment records do reflect the Veteran’s complaints of pain, numbness, and tingling in his arms and hands which is sufficient to demonstrate current disability. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Initially, the Board notes that that arthritis is not one of those disease for which service connection may be presumed as a result of Vietnam Era service and consequent exposure to herbicides such as Agent Orange. See 38 C.F.R. §§ 3.307, 3.309(e). Although acute and subacute peripheral neuropathy are eligible for presumptive service connection due to herbicide agent exposure, there is no current diagnosis of peripheral neuropathy, let alone evidence of peripheral neuropathy within one year of his Vietnam service. Therefore, there is no presumption of service connection. 38 C.F.R. §§ 3.307, 3.309(e). The Veteran’s January 1965 induction examination showed normal clinical evaluation of the musculoskeletal system, except for feet and spine. The Veteran marked “yes” to swollen or painful joints on the Report of Medical History completed in conjunction with that examination; however, the attending physician annotated that this referred to muscle strain in the back and bilateral hammertoes. There was no indication this related to any other joint. On a January 1968 separation examination, the Veteran’s musculoskeletal system was evaluated as normal and the Veteran marked “no” to swollen or painful joints; cramps in legs; history of broken bones; arthritis or rheumatism; bone, joint, or other deformity; painful or “trick” shoulder or elbow, “trick” or locked knee; neuritis; and paralysis. He only complained of foot trouble and noted “small toes.” The report did not contain notations indicating any other joint impairment. The Veteran has not asserted, and the evidence of record does not show, an injury or disease incurred or aggravated during a period of active duty for training or injury incurred or aggravated during period of inactive duty for training in his Army Reserve service. His Army Reserve service do not show treatment or complaints involving the musculoskeletal system, except for hammertoes. His January 1989 examination prior to separation from Army Reserve service shows he received normal evaluations of musculoskeletal system, and he only complained of foot troubles associated with history of hammertoes on the associated report of medical history. The evidence shows current degenerative arthritis in cervical spine and knees, and the Veteran’s statements suggest that he has arthritis in other joints as well. However, the evidence of records does not demonstrate that his current disorders were incurred in service, and there is no competent medical evidence that relates his current disorders to his period of service. The Veteran has not asserted, and the evidence of record, does not demonstrate that his current joint problems, other than back, had an onset during his period of service. To the extent that the Veteran would make such assertions, the Board notes that the Veteran is competent to describe such readily observable symptoms, and there is nothing obvious of record to diminish his credibility. Nonetheless, the Board recognizes that on the January 1968 Report of Medical History completed in conjunction with his separation examination, the Veteran marked “no” to all potentially relevant symptomology. The Board finds that evidence more probative than his recent statements regarding experiencing symptoms during service due to its contemporaneous nature. The veracity of those statements is also buttressed by the fact that the Veteran did identify other medical problems at the time; thus, he did not simply mark “no” to everything on the form, which suggests that if such symptoms did exist at the time he would have identified them. Accordingly, the Board concludes that the Veteran’s statements regarding experiencing joint symptomology during service are outweighed by the contemporaneous statements he made in conjunction with his separation examination. The record only contains the Veteran’s general assertion that his joint symptomology was due to exposure to chemicals, including his presumed exposure to herbicide agents. However, the evidence does not otherwise show he has the requisite medical training or expertise needed to render a competent opinion as to medical causation. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). His statements in that regard are afforded no probative value. The Board acknowledges that arthritis is considered a chronic disease under § 3.309(a). Presumptive service connection for arthritis as a chronic disease is not warranted because the evidence does not show the disability manifested to a degree of 10 percent or more during active service or within a year of discharge. 38 C.F.R. § 3.307 (a)(3). Moreover, application of the continuity of symptomatology framework to aid in the establishing a nexus is not warranted as because the condition was not noted during service. 38 C.F.R. § 3.303 (b). The evidence shows the Veteran has a current diagnosis of degenerative arthritis as well as his complaints involving his other joints, and the evidence of in-service exposure to herbicide agents and potentially other chemicals. Apart from the Veteran’s own statements asserting a nexus between his current condition and such in-service exposure, there is no other evidence to support a nexus. As noted above, the Veteran is not competent to render such an etiological determination. His lay statements, alone, are not sufficient to trigger VA’s duty to assist him in substantiating his claim by providing a medical examination or opinion. See McLendon, 20 Vet. App. at 81; Waters, 601 F.3d at 1278-79; see also 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). In sum, although the Board finds evidence of current disabilities, the evidence does not establish a nexus between these conditions and active service, to include exposure to herbicide agents. The evidence also does not show that degenerative arthritis was noted during service or manifested to a degree of 10 percent or more during service or within a year of discharge from service. There is no doubt to be resolved; the claims for service connection for severe arthritis, bilateral knee, bilateral hand, and bilateral arm disorders are not warranted. 12. Entitlement to service connection for a stomach scar The Veteran seeks entitlement to service connection for a stomach scar. Other than his general assertion that service connection is warranted, the Veteran has not articulated a specific stomach-related injury or surgery during his period of service. Service treatment records are silent for any stomach injury or surgery during his period of service. VA treatment records show that on August 16, 1984, the Veteran sustained injury from being stabbed with a knife in his stomach. He underwent exploratory laparotomy to determine any internal damage from knife injury but there was no evidence of intra-abdominal or intra-thoracic injury. It was noted that the wound was considered well-healed at his discharge from the hospital. Subsequent Army Reserve and VA treatment records note a history of exploratory surgery at a VA medical center in 1984 and observations of residual scar on the midline of the abdomen. Although the Veteran has a current residual stomach scar, the evidence does not demonstrate that there is any injury or event during military service on which to predicate a claim of service connection. Rather, the evidence demonstrates that his stomach scar is due to an intervening post-service injury. The Veteran has not asserted, and there is no indication, that the stomach injury had occurred during or was aggravated by a period of active duty for training or inactive duty for training during his Army Reserve service. The Veteran has not provided basic evidence or assertions explaining why he has a residual stomach scar is causally related to his service, and as such, VA has no duty to provide a medical examination or opinion in this case. See McLendon, 20 Vet. App. at 81; see also 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). Accordingly, without evidence of in-service injury and causal relationship to his period of service, the claim for service connection for a stomach scar is not warranted. 38 C.F.R. § 3.303. 13. Entitlement to service connection for head injury 14. Entitlement to service connection for residual scar on left side The Veteran seeks entitlement to service connection for head injury and a residual scar on the left side. Other than his general assertion that service connection is warranted, the Veteran has not articulated a specific head injury or trauma during his period of service. On his November 1965 enlistment examination, the Veteran’s head and scalp were evaluated as normal, and he did not indicate any history of head injury on the associated report of medical history. Subsequent service treatment records are silent for any head injury or trauma during his period of service. On his January 1968 examination prior to separation, the Veteran’s head and scalp were evaluated as normal, and he specifically denied any “history of head injury” on the associated report of medical history. A May 30, 1981 VA treatment record notes that the Veteran was admitted after sustaining injuries from a motor vehicle accident, to include abrasion to the left side of his forehead. On June 1, 1981, the Veteran complained of dizzy spells following the accident, and a few days later, he was complained of episodes of dizzy spells, lightheadedness, and headaches. The Veteran has not asserted, and the record does not demonstrate that the May 1981 accident occurred during a period of active duty for training or inactive duty for training during Army reserve service. Subsequent VA and Army reserve treatment records do not reflect complaints or treatment related to head injury associated with the May 1981 accident. However, on a February 1982 Army Reserve medical history report, the Veteran reported that he had sustained injuries during a 1959 motor vehicle accident which had resulted in injuries that caused him to be unconscious for two days. Based on a review of the claims folder, the Board finds that the evidence does not establish an in-service injury or relevant event with regard to head injury and residual scar on the left side. In this regard, the Veteran’s service treatment records are silent for any head injury during his period of service, and do not indicate aggravation of any head injury that existed prior to his enlistment into service. Moreover, the Veteran, himself, has not alleged a specific in-service injury or aggravation of a pre-existing injury in conjunction with his claim for service connection. The Veteran has not provided basic evidence or assertions explaining why he has a head injury and residual scar that are causally related to his service, and as such, VA has no duty to provide a medical examination or opinion in this case. See McLendon, 20 Vet. App. at 81; see also 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). While the Veteran is competent to attest to current symptomatology, such as residual scar on left side of his forehead, from a head injury, there is no evidence of in-service injury or aggravation of a pre-existing injury. 38 C.F.R. § 3.303. Therefore, the claims may not be granted. 15. Entitlement to service connection for sleep apnea The Veteran seeks entitlement to service connection for sleep apnea. The Veteran has only provided general assertion that service connection is warranted because of his exposure to chemical from contaminated equipment and environment, including herbicide agents, while participating in missions and training during his service. He has not raised any specific argument or assertion regarding his claim for sleep apnea. The Board finds that the preponderance of the evidence is against the finding of that the Veteran has a current disability that is a result of in-service disease or injury to support an award of service connection. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303 (d). A review of the service treatment records is silent for evidence of reports of symptoms related to or a diagnosis or treatment of sleep apnea. While post-service VA treatment records reflect the Veteran’s reports of trouble sleep and his self-reported history of sleep apnea, these records are silent for a diagnosis of and treatment for sleep apnea by his treating medical professionals. Although lay persons are competent to provide opinions on some medical issues, the specific issues in this case, the presence and etiology of sleep apnea, fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Sleep apnea diagnoses are generally based upon sleep studies and/or medical expert opinions as to observed symptom manifestation. The lay evidence does not constitute competent medical evidence and lacks probative value. As such, the competent evidence of record does not demonstrate a current disability for which service connection may be granted. Moreover, there is no evidence of an in-service incurrence or causal relationship to the Veteran’s active service. Apart from the Veteran’s own statements asserting a nexus between a current sleep apnea condition and such in-service exposure, there is no other evidence to support a nexus. As noted above, the Veteran is not competent to render such an etiological determination. His lay statements, alone, are not sufficient to trigger VA’s duty to assist him in substantiating his claim by providing a medical examination or opinion. See McLendon, 20 Vet. App. at 81; Waters, 601 F.3d at 1278-79; see also 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). In conclusion, the Board finds that the preponderance of the evidence is against the finding of that the Veteran has a current disability that is related to his period of service. Accordingly, service connection for sleep apnea is not warranted. 16. Entitlement to service connection for fibromyalgia The Veteran seeks entitlement to service connection for fibromyalgia. Other than his general assertion that service connection is warranted, the Veteran has not provided any further argument or evidence in support of his claim. The Board concludes that the Veteran does not have a current diagnosis of fibromyalgia and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Other than the Veteran’s lay assertion, there is no competent medical evidence that reflects a diagnosis of fibromyalgia. Service and post-service VA treatment records are silent for diagnosis of fibromyalgia. While the Veteran may believe that he has a current diagnosis of fibromyalgia, he is not competent to provide a diagnosis in this case. In this regard, while the Veteran can competently report the onset and symptoms of joint pain, any actual diagnosis of fibromyalgia requires objective testing to diagnose and can have many causes. The issue is medically complex, as it specialized medical education/knowledge of the interaction between multiple organ systems in the body and the ability to interpret complicated diagnostic medical testing. Jandreau, 492 F.3d at 1377 n.4. There no evidence of a current diagnosis of fibromyalgia during the appeal period. Moreover, there is no evidence of an in-service incurrence or causal relationship to the Veteran’s active service. As discussed above, in absence of a competent evidence of a current disability and lack of any indication of a nexus to service, the Board finds that a VA examination is not warranted in this case. See McLendon, 20 Vet. App. at 79; see also 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). In the absence of a present disability, there can be no valid claim. Accordingly, because the Veteran does not have a current diagnosis of fibromyalgia, service connection must be denied. 17. Entitlement to service connection for posttraumatic stress disorder (PTSD) The Veteran asserts entitlement to service connection for PTSD as a result of his service in the Republic of Vietnam. To establish entitlement to service connection for PTSD, the record must contain the following: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125 (a), which mandates that, for VA purposes, all mental disorder diagnoses must conform to the American Psychiatric Association ’s Diagnostic and Statistical Manual for Mental Disorders. 38 C.F.R. § 3.304 (f). The Board recognizes that the Veterans Benefits Administration is now required to apply concepts and principles set forth in DSM-5. In this case, the Veteran’s military personnel records indicate that he was stationed in Vietnam from September 1966 to September 1967, and he participated in Vietnam Counter Offensive Campaign Phase II. He was awarded the Vietnam Service Medical, Republic of Vietnam NCM, and bronze service star. The Veteran’s service treatment records do not reflect any diagnosis of PTSD and this VA treatment records do not show a diagnosis of PTSD at any time. In December 2014, the Veteran was afforded a VA PTSD examination. The Veteran indicated that he was witnessed death and destruction while stationed in Vietnam. Based on the findings from clinical examination, the VA examiner stated that the Veteran’s symptoms did not meet the diagnostic criteria for PTSD under DSM-V criteria. In light of the above, the Board finds that the claim for service connection for PTSD is not warranted. The December 2014 VA examiner found that the Veteran does not meet the other criteria necessary for such a diagnosis, and no medical professional has stated otherwise. The Board has considered the Veteran’s lay contentions that he has PTSD as a result of his military service. However, with regard to the actual diagnosis of PTSD, lay persons are not categorically incompetent to speak on matters of medical diagnosis or etiology. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this regard, the United States Court of Appeals for the Federal Circuit has held that “PTSD is not the type of medical condition that lay evidence... is competent and sufficient to identify.” Young v. McDonald, 766 F.3d 1348, 1352-53 (Fed. Cir. 2014). Regardless, the Board acknowledges the Veteran is competent to report psychiatric symptoms both during and after service. See 38 C.F.R. § 3.159 (a) (2); Jandreau, 492 F.3d at 1377. That notwithstanding, in the instant case, the Board has found the Veteran’s lay statements are less probative or persuasive than the post-service medical evidence finding that the Veteran does not meet the DSM V criteria for PTSD. Moreover, although the Veteran is competent to describe his psychiatric symptoms, by regulation, PTSD is a condition that can only be diagnosed by a medical professional, according to 38 C.F.R. § 3.304 (f). In summary, the competent evidence of record establishes that there is no current diagnosis of PTSD. Accordingly, the preponderance of the evidence is against the Veteran’s claim for service connection for PTSD. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for residual scar, status post right fifth hammertoe is remanded. 2. Entitlement to service connection for residual scar, status post left fifth hammertoe is remanded. 3. Entitlement to service connection for a right little toe with corn is remanded. 4. Entitlement to service connection for a left little toe with corn is remanded. The Veteran seeks entitlement to service connection for bilateral little toe disorder and residual scars, status post bilateral fifth hammertoes. The Veteran’s service treatment records show that upon his November 1965 enlistment examination, his feet were evaluated as abnormal, and it was noted he had hammertoe, bilaterally, asymptomatic. He also reported a history of foot trouble on the associated report of medical history. Although his feet were evaluated as normal on his January 1968 examination prior to separation, the Veteran reported a history of foot trouble, and in particular, involving his “small toes” on his report of medical history at separation. The Veteran asserts that his pre-existing foot problems were aggravated by his period of service. Pertinently, a year after his separation from service, April 1969 VA medical records show he was diagnosed with bilateral cock-up toes and dorsal callosities on fifth toes and he underwent phalangectomy of the fifth toe, bilaterally. It was noted that Veteran reported a history of bilateral fifth toe pain for the last two years beginning while on active duty in military. The Board finds that a remand is needed to obtain a VA examination to determine nature of the Veteran’s bilateral fifth toe disorders, and whether his current disorders are etiologically related to his period of service, to include aggravation of his pre-existing bilateral hammertoe. 5. Entitlement to service connection for a back disorder is remanded. The Veteran seeks entitlement to service connection for a back disorder. The Veteran contends that his current back disorder is a result of his period of service. In particular, the Veteran contends that his back condition noted upon his enlistment was aggravated by his period of service and has resulted in his current back disorder. See April 2019 informal hearing presentation. The Veteran’s service treatment records show that upon his November 1965 enlistment examination, his back was evaluated as abnormal, and it was noted he had muscle sprain, asymptomatic. Although the Veteran’s service treatment records do not show further back complaints, the Veteran asserts that his pre-existing back disorder was aggravated by his period of service. Post-service VA treatment records show that the Veteran has degenerative arthritis and severe stenosis of the lumbar spine. The Board finds that a VA examination is necessary to determine the nature and etiology of any current back disorder. 6. Entitlement to service connection for a left leg disorder is remanded. 7. Entitlement to service connection for right leg disorder is remanded. The Veteran seeks entitlement to service connection for bilateral leg disorder. He has described his bilateral leg disorder as pain radiating down from his back. See August 2014 VA 21-526 Veterans Application for Compensation or Pension. Notably, the VA treatment records show complaints of tingling and numbness in the legs, and assessment of lumbar radiculopathy. Since a decision on the Veteran’s claim for service connection for a back disorder could significantly impact a decision on the issues of service connection for bilateral leg disorder, the issues are inextricably intertwined. A remand of the claims for bilateral leg disorder is required. 8. Entitlement to service connection for hypertension, to include as due exposure to herbicide agents is remanded. The Veteran seeks entitlement to service connection for hypertension. He contends that his hypertension is a result of his presumed exposure to herbicide agents during his Vietnam service. The Veteran’s representative asserts a remand is needed to obtain a medical opinion that addresses whether the Veteran’s hypertension is etiological related to his presumed exposure to Agent Orange. See April 2019 informal hearing presentation. In support of his contention, the Veteran’s representative noted that the National Academies of Science, Engineering and Medicine (NAS) Institute of Medicine’s (IOM) Agent Orange Update 11 (2018) raises a potential association between Agent Orange and hypertension. In this most recent report, IOM upgraded hypertension from its previous classification in the category of “limited or suggestive” evidence of an association with exposure to Agent Orange to the category of “sufficient” evidence of such an association. A remand is needed to obtain a VA medical opinion that addresses the Veteran’s contention. 9. Entitlement to service connection for a heart disorder is remanded. The Veteran seeks entitlement to service connection for a heart disorder. He contends that his current heart disorder is a result of his period of service. Although the Veteran’s November 1965 enlistment examination report shows the service examiner marked normal heart evaluation, a heart-related finding was recorded on that report. In addition, on the associated report of medical history, the Veteran reported a history of frequent heart palpitations. There are no other heart-related complaints or findings noted in the Veteran’s service treatment records. Post-service VA medical records show his complaints of frequent heart palpitations were assessed as premature ventricular contractions. See January 2010 VA cardio consultation report. The Board finds that a VA examination is necessary to determine the nature and etiology of any current back disorder. 10. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety and depression is remanded. The Veteran asserts that he has an acquired psychiatric disorder as result of in-service stressor events. He contends that his current acquired psychiatric disorder is a result his service in the Republic of Vietnam. Although the Veteran has reported that he was not involved in any direct conflict with the enemy, he observed deaths and destruction while stationed there. Service treatment records show that the Veteran reported a history of nervousness at the time of his enlistment, but he received a normal psychiatric evaluation on his November 1965 enlistment examination. The Veteran complained of mental health symptoms in May 1966, and requested a psychiatric evaluation, which revealed no evidence of depression, psychosis or organic mental disease. A March 1968 VA treatment record shows that the Veteran complained of anxiety related to venereal disease. Subsequent VA treatment records show diagnosis of major depression disorder. The Veteran was afforded with a December 2014 VA PTSD examination in which the examiner noted a diagnosis of dysthymic disorder; however, the VA examiner did not provide a medical opinion regarding whether the Veteran had a mental health disorder that was etiologically related to his period of service. A remand is needed to obtain a supplemental VA medical opinion. 11. Entitlement to service connection for gastroesophageal reflux disorder (GERD) is remanded. 12. Entitlement to service connection for a colon disorder is remanded. 13. Entitlement to service connection for headache disorder is remanded. The Veteran seeks entitlement to service connection for GERD, colon disorder, and a headache disorder. He has indicated that his gastrointestinal problems and headaches are associated with his acquired psychiatric disorder. See August 2014 VA 21-526 Veterans Application for Compensation or Pension, and August 2015 notice of disagreement. Since a decision on the Veteran’s claim for service connection for acquired psychiatric disorder could significantly impact a decision on the issues of service connection for GERD, colon disorder, and headache disorder, the issues are inextricably intertwined. A remand of the claims for GERD, colon disorder, and headache disorder are required. 14. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. The Veteran seeks entitlement to a TDIU. He reports that he is no longer able to work due to his acquired psychiatric disorder, back disorder, hypertension, and heart problems. Since decisions on the service connection claims could significantly impact a decision on the issues of entitlement to a TDIU, the issues are inextricably intertwined. A remand of the TDIU claim is required. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his bilateral fifth toe disorder, to include residual scars and corns. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: (a) Did the Veteran’s bilateral hammertoe, which existed prior to service, at least as likely as not increase in severity during service? (b) If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? (c) Does the Veteran have any other current bilateral toe disorder that is at least as likely as not incurred in or related to his period of service, to include his in-service complaints of foot trouble? 2. Schedule the Veteran for a VA examination for his back disorder. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a.) For each current back disorder, the examiner should state whether the disorder clearly and unmistakably preexisted the Veteran’s active duty service. If so, the examiner should state whether there was an increase in the severity of the disorder during the Veteran’s active duty service and whether any increase was due to the natural progression of the disorder. (b.) If the examiner determines that the back disorder did not clearly and unmistakably preexist the Veteran’s active duty service, he or she should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to active duty service. 3. Schedule the Veteran for a VA examination for his hypertension. The examiner must review the claims file. The examiner is asked to provide an opinion on whether the Veteran’s hypertension is at least as likely as not related to his period of service, to include his presumed exposure to herbicide agents. The examiner is asked to consider the National Academy of Sciences (NAS) Institute of Medicine’s (IOM) Veterans and Agent Orange Updates, to include in 2018, which stated that there was “sufficient” evidence of an association between hypertension and herbicide exposure. Provide a rationale to support the opinion. 4. Schedule the Veteran for a VA examination for his claimed heart disorder. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a) For each current heart disorder, the examiner should state whether the disorder clearly and unmistakably preexisted the Veteran’s active duty service. If so, the examiner should state whether there was an increase in the severity of the disorder during the Veteran’s active duty service and whether any increase was due to the natural progression of the disorder. (Continued on the next page)   (b) If the examiner determines that the heart disorder did not clearly and unmistakably preexist the Veteran’s active duty service, he or she should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to active duty service. 5. Schedule the Veteran for a VA examination for his acquired psychiatric disorder, to include major depressive disorder. The examiner must review the claims file. The examiner is asked to provide an opinion on whether it is at least as likely as not that the Veteran’s acquired psychiatric disorder, to include major depressive disorder, disorder manifested in or is otherwise related to active duty service. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Murray 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.