Citation Nr: 21014131 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 14-13 711 DATE: March 11, 2021 ORDER Entitlement to a rating greater than 10 percent for right inguinal herniorrhaphy residual scars is denied. REMANDED Entitlement to service connection for a gastrointestinal disability, to include gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for bilateral foot fungus, athlete's feet is remanded. Entitlement to service connection for a blood pressure condition (previously addressed as hypertension) is remanded. Entitlement to service connection for a disability characterized by short-term memory loss is remanded. FINDING OF FACT Although there is evidence of five scars associated with the right inguinal herniorrhaphy, the Veteran only has one scar that is painful. CONCLUSION OF LAW The criteria for entitlement to a rating greater than 10 percent for right inguinal herniorrhaphy residual scars have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7804. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from June 1966 to February 1969. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2016 rating decision issued by the Department of Veterans Affairs (VA). In his March 2014 substantive appeal, the Veteran requested a hearing before the Board; however, he cancelled his request in a February 2018 letter. Thus, the hearing request is considered withdrawn. The Board previously remanded the issues above in July 2018 and October 2019 for further development. 1. Entitlement to a rating greater than 10 percent for right inguinal herniorrhaphy residual scars The Veteran has asserted that his service-connected scar, status post right inguinal herniorrhaphy warrants a compensable disability rating, and that his painful scar, status post right inguinal herniorrhaphy warrants a rating in excess of 10 percent. The Board notes that the Veteran filed a claim for increase in August 2016. Thus, the appellate period is from August 2015, one year prior to the date of claim. In a November 2016 rating decision, the RO increased the Veteran’s evaluation of painful scar, status post right inguinal herniorrhaphy to 10 percent. The Veteran’s is currently evaluated for scar status post right inguinal herniorrhaphy as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7805, and 10 percent for painful scar, status post right inguinal herniorrhaphy under 38 C.F.R. § 4.118, Diagnostic Code 7804. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Diagnostic Code 7800 was not changed by the August 13, 2018, amendments. However, Diagnostic Code 7800 pertains to scars or other disfigurement of the head, face and neck and is not applicable in this case. Prior to August 13, 2018, Diagnostic Code 7801 was for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear. Under these criteria, a scar with an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrants a 10 percent rating. A scar with an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.) warrants a 20 percent rating. A scar with an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.) warrants a 30 percent rating. A scar with an area or areas of 144 square inches (929 sq. cm.) or greater warrants a 40 percent rating. 38 C.F.R. § 4.118. Prior to August 13, 2018, Note 1 to Diagnostic Code 7801 instructed that a deep scar is one associated with underlying soft tissue damage. Id. Since August 13, 2018, Diagnostic Code 7801 is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Diagnostic Code 7801 was otherwise unchanged by the August 13, 2018 amendments. Prior to August 13, 2018, Diagnostic Code 7802 was for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that were superficial and nonlinear. Under these criteria, a scar with an area or areas of 144 square inches (929 sq. cm.) or greater warrants a 10 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7802 instructed that a superficial scar was one not associated with underlying soft tissue damage. Id. Since August 13, 2018, Diagnostic Code 7802 is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Diagnostic Code 7802 was otherwise unchanged by the August 13, 2018 amendments. Diagnostic Code 7804 was not changed by the August 13, 2018 amendments. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent rating. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. Diagnostic Code 7805 was not changed by the August 13, 2018 amendments. Diagnostic Code 7805 instructs that any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 are to be evaluated under an appropriate diagnostic code. The Veteran was afforded a VA examination in October 2016. The Veteran reported that he had a right inguinal hernia repair in 1968 and that he has occasional pain in the scar. The examiner noted that there was 1 scar of the trunk or extremities that is painful. The Veteran indicated that he has pain soreness of the right groin with bending and lifting. No scar of the trunk or extremities were unstable with frequent loss of covering of skin over the scar. There were no scars due to burns. The examiner stated that the anterior trunk was affected with 1 linear scar that was measured at 9 x 0.3 centimeters. The Veteran did not have any superficial non-linear scars or deep non-linear scars. The examiner noted that the Veteran did not have any scars that result in limitation of function. The Veteran was afforded a VA examination in May 2019. The examiner noted that there were no scars of the trunk or extremities that were painful or unstable with frequent loss of covering of skin over the scar. There were no scars due to burns. The examiner noted that the anterior trunk was affected with 1 scar that was measured at 10 x 0.5 centimeters. The Veteran did not have any superficial non-linear scars or deep non-linear scars. The examiner noted that the Veteran did not have any scars that result in limitation of function. In its October 2019 Board remand, the Board found that the May 2019 VA examiner failed to address the Veteran’s other, previously identified scars, from the laparoscopic surgery on the right inguinal hernia. See March 2014 VA examination. Thus, the Board remanded for another VA examination. The Veteran was afforded a VA examination in January 2020. The examiner noted that the Veteran had 5 scars of the trunk or extremities. The examiner indicated that the Veteran did not have any scars of the trunk or extremities that were painful or unstable with frequent loss of covering of skin over the scar. There were no scars due to burns. The examiner noted that the anterior trunk was affected with scar 1 measured at 10 x 0.1 centimeters; scar 2 measured at 1.5 x 0.1 centimeters; scar 3 measured at 1.5 x 0.1 centimeters; scar 4 measured at 1.5 x 0.1 centimeters; and scar 5 measured at 1.5 x 0.1 centimeters. No scars were tender to palpation. No scars were noted to have underlying soft tissue damage. The approximate total area was noted to be 7.5 centimeters squared. The examiner indicated that there were no scars that resulted in limitation of function to include limitation of motion. The examiner noted that on the day of examination, none of the Veteran’s scars were painful to palpation. The examiner noted that review of the claims file reveals that the Veteran has consistently reported no complaints of hernia scar pain. For the entire period on appeal, the Board finds that a rating in excess of 10 percent for right inguinal herniorrhaphy residual scars is not warranted under Diagnostic Code 7804. The evidence does not show that the Veteran had 3 or 4 scars that are unstable or painful. Although there is evidence of pain associated with 1 scar, the remaining 4 scars have no evidence of any associated symptoms such as pain. In addition, none of the scars were noted to be unstable. The Board considered whether any other relevant diagnostic codes may afford the Veteran a higher 20 percent evaluation for his right inguinal herniorrhaphy residual scars. However, the Veteran’s scars are not deep and nonlinear, nor do not exhibit any underlying soft tissue damage (Diagnostic Code 7801) and do not cover an area or areas of 144 square inches or greater (Diagnostic 7802). Further, the evidence of record shows that there are no other disabling effects not considered in a rating provided under Diagnostic Code 7800-7804 as contemplated under both pre- and post-August 13, 2018. See 38 C.F.R. § 4.118, Diagnostic Code 7805. Accordingly, throughout the appeal period, the Veteran’s right inguinal herniorrhaphy residual scars are no more than 10 percent disabling. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the appeal is denied. REASONS FOR REMAND 1. Entitlement to service connection for a gastrointestinal disability, to include GERD is remanded. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. A remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the remand. Stegall v. West, 11 Vet. App. 268 (1998). In its October 2019 Board remand, the Board noted that the Veteran was afforded a VA examination in May 2019 in which the examiner expressed that the Veteran takes NSAIDs for pain which can aggravate his GERD. The Board also noted that the Veteran reported experiencing reflux since service, with burning and tasting stomach acid when he ate. Thus, the Board requested an additional VA opinion. The Board requested an opinion that addressed whether it is at least as likely as not that any currently present gastrointestinal disability is etiologically related to the Veteran’s active service. The Board expressed that the examiner MUST consider the Veteran’s lay statements regarding the onset and continuity of his symptoms. The examiner was also requested to opine as to whether it is at least as likely as not that any currently present gastrointestinal disability was caused by OR worsened by a service-connected disability, to include any medication for treatment of such. The Veteran was afforded a VA examination in January 2020. The examiner opined that the Veteran’s GERD is caused by a mechanical dysfunction of his lower esophageal sphincter, not by any of his other disabilities. The examiner stated that the Veteran’s service-connected disabilities have been reviewed and none of these are known to cause or aggravate his GERD. The examiner stated that there is no evidence that the Veteran’s gastrointestinal disability or GERD is related to or has been worsened by a service-connected disability, to include any medication for treatment as such. The examiner noted that the Veteran had no issues related to GERD prior to military service and no documentation that he had GERD in the military. The examiner stated that after separation, the Veteran was diagnosed with GERD and there were many reasons that he had flares of GERD, but it was not because of NSAID use. The Veteran reported that in November 2004, the Veteran was told not to use NSAIDs because of an allergic reaction to them, not because it was aggravating his GERD. The examiner expressed that on the current examination, the Veteran stated that he did not have any GERD symptoms as long as he took his medication for GERD. Thus, the examiner opined that it is less likely than not that the Veterans GERD was caused secondary to NSAID use for service-connected disabilities during service. Although instructed by the October 2019 remand, the January 2020 VA examiner did not address the Veteran’s lay statements regarding the onset of his gastrointestinal disability and continuity of his symptoms. Thus, the January 2020 VA examination report is inadequate to make an informed decision on the Veteran’s claim and does not constitute substantial compliance with the Board’s prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Thus, a remand for an addendum opinion is necessary. 2. Entitlement to service connection for bilateral foot fungus, athlete's feet is remanded. In its October 2019 remand, the Board expressed that the previous July 2018 Board remand specifically directed that an examiner should opine whether the Veteran’s athlete’s foot clearly and unmistakably existed prior to service, and if so, whether it was clearly and unmistakably not aggravated by service. The Board noted that the Veteran was afforded a May 2019 VA examination; however, the opinion provided was inadequate. Specifically, the examiner, skipped over the questions regarding whether athlete’s foot existed prior to service, and opined that the Veteran was noted to have tinea pedis during service, and that this is a common infection which typically resolves, and that an Agent Orange examination in 1988 was normal. The Board found that this opinion was not adequately responsive to the former Board remand directives, and as such, another remand for compliance with the remand directives was necessary. The October 2019 remand requested a VA opinion that addresses whether any currently present athlete’s foot clearly and unmistakably existed prior to the Veteran’s active service and if so, was any such pre-existing athlete’s foot clearly and unmistakability NOT aggravated by active service. The Board noted that the Veteran’s lay statements alone are not sufficient to support a finding that athlete’s foot clearly and unmistakably existed prior to active service. The Board stated that if athlete’s foot is NOT found to clearly and unmistakably exist prior to the Veteran’s active service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present athlete’s foot had its onset during the Veteran’s active service, or is otherwise etiologically related to such service. The Veteran was afforded a VA examination in January 2020. The examiner reported that the correct Disability Benefits Questionnaire (DBQ) for Skin was not given. The examiner noted that the Veteran stated that he had tinea pedis during service, but the claims file does not state it and the exit examination did not show it as a chronic diagnosis. Thus, the examiner opined that it is less likely than not a condition caused by an in-service diagnosis and treatment. The examiner also opined that the Veteran’s athletes’ foot, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness. For rationale, the examiner once again stated that athlete’s foot is a skin condition and is not addressed appropriately in this DBQ. The Veteran was afforded another VA examination in August 2020 by a different examiner. The VA examiner was asked whether the Veteran’s athlete’s foot (which clearly and unmistakably existed prior to service) aggravated beyond its natural progression and if so, was any such pre-existing athlete’s foot clearly and unmistakability NOT aggravated by active service? The examiner stated that the claimed condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury or illness. The examiner expressed that she was unable to find records of any evidence of specific treatment for tinea pedis. The examiner noted that the Veteran contends that he used the recommendations by medics to keep feet dry as much as possible, such as putting talcum powder daily, but the war conditions and the monsoon seasons understandably precluded adhesion to these recommendations. The examiner opined that there was no aggravation of this condition noted during service. The examiner expressed that it was mentioned at entrance and mentioned at separation, with no interim treatment documented. The examiner also answered the question of whether the Veteran’s athlete’s foot had its onset during the Veteran’s service or is otherwise related to service. The examiner opined that it was less likely than not that the Veteran’s athletes foot incurred in or was caused by service. The examiner noted that the Veteran has a mention of athlete’s foot by the medical officer on his entrance physical dated in June 1966 and on his exit physical in February 1969. The examiner stated that there was evidence of tinea corporis/cruris in service, but no mention of the feet. The examiner reported that a review of the medical literature support the fact that often times, tinea cruris is due to a primary infection of the feet, transmitted to the groin areas, and from a medical standpoint, it is likely that tinea pedis, present on entrance physical examination, continued to exist during service. The examiner further stated that although the Veteran had it during service, his subsequent medical records did not show continued symptoms/ medical care over the years following separation and there are several notes of normal foot skin examinations in 2010, 2011, 2013. Thus, the examiner opined that the current infection is likely a new infection and there is no nexus with the tinea pedis in service. After review, the Board finds inconstancies with the VA examiner’s opinions. Here, the January 2020 VA examiner opined that Veteran’s athletes’ foot, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness. However, the Veteran was afforded another VA examination due to the fact that the wrong DBQ was provided. A different VA examiner in August 2020 examiner was not asked whether the Veteran’s athlete’s foot clearly and unmistakably existed prior to service, rather, the VA examiner was asked whether the Veteran’s athletes’ foot, which “clearly and unmistakably existed prior to service,” was aggravated beyond its natural progression and if so, was any such pre-existing athlete’s foot clearly and unmistakability NOT aggravated by active service. In providing the examiner with this question, the August 2020 VA examiner failed to form an opinion as to whether the Veteran’s athlete’s foot clearly and unmistakably existed prior to service. In addition, the examiner stated that the Veteran’s athlete’s foot, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury or illness because there was no aggravation noted during service. The examiner did not use the correct legal standard when she addressed aggravation. The Board instructed that if the examiner found that the Veteran’s athlete’s foot clearly and unmistakably existed prior to service, the examiner was asked to opine whether such pre-existing athlete’s foot clearly and unmistakability was NOT aggravated by active service. The Board notes that if a disability clearly and unmistakably existed prior to service, aggravation is presumed unless there is a finding that the disability was clearly and unmistakably NOT aggravated by service. The August 2020 VA examiner also provided an opinion with regards to whether the Veteran’s athlete’s foot had its onset during the Veteran’s service or is otherwise related to service. The examiner reported that a review of the medical literature supports the fact that often times, tinea cruris is due to a primary infection of the feet, transmitted to the groin areas, and from a medical standpoint, it is likely that tinea pedis, present on entrance physical examination, continued to exist during service. The examiner also opined that although the Veteran had tinea cruris during service, the subsequent infection is likely a new infection. As such, in her second opinion, the VA examiner conceded that that the Veteran had tinea cruris during service and therefore, it is inconsistent with the Veteran’s opinion that there was no aggravation in service because there was no mention of treatment documented in the Veteran’s service treatment records. Thus, a remand is necessary in order to provide the Veteran an adequate VA examination. 3. Entitlement to service connection for a blood pressure condition (previously addressed as hypertension) is remanded. In its October 2019 Board remand, the Board noted that the Veteran was afforded a VA examination in May 2019, however, the VA examiner failed to address the aggravation prong of secondary service connection. The Board requested an opinion that addresses whether it is at least as likely as not that any currently present hypertension is etiologically related to service, to include any elevated blood pressure readings in service, and the Veteran’s presumed herbicide agent exposure (notwithstanding the fact that it may not be a presumed association). The Board requested the examiner to opine on what the likelihood is that this Veteran’s hypertension is related to his herbicide exposure given his medical history, family history, other risk factors, etc. In rendering the opinion, the examiner was asked to consider the National Academy of Sciences excerpt indicating a limited or suggestive association between herbicide exposure and hypertension. The examiner was also instructed to opine whether it is at least as likely as not the Veteran’s hypertension is caused or worsened by his service-connected disabilities, to include medications (NSAIDs, etc) he takes to treat his service-connected disabilities. Pursuant to the Board remand, the Veteran was afforded a VA examination in January 2020. The examiner opined that the Veteran’s hypertension was less likely than not incurred in or caused by service. The examiner stated that the Veteran was not diagnosed with hypertension in active duty in the military and that there is no evidence in the claims file that he was diagnosed with hypertension in active duty. The examiner opined that the Veteran’s hypertension is less likely than not incurred in or caused by the claimed elevated blood pressure readings in service or by herbicide exposure in the service. The examiner noted that the Veteran’s blood pressure is labile and that shows that he most likely has essential hypertension. The examiner stated that the Veteran has a family history of hypertension and this is the biggest risk factor in getting hypertension. The examiner reported that the Veteran’s age and obesity are other risk factors for hypertension. The examiner noted that the Veteran had an Agent Orange exam in 1988, 20 years after being out of the military, and his blood pressure was 110/80, which is not at the level of hypertension. The examiner stated that there is no evidence in the claims file that an exposure to Agent Orange had any effect on his blood pressure. The examiner opined that it is less likely than not that the Veteran’s hypertension is proximately due to or the result of Veteran’s service-connected condition. The examiner stated that she is unable to confirm NSAID use in the military with current available records and thus it is less likely than not that the Veteran’s hypertension was worsened by Veteran’s use of NSAIDs taken in the military, and more likely related to his family history of hypertension, and his other risk factors of age and obesity. The Board finds the January 2020 VA examiner’s opinion is inadequate. With regards to whether the Veteran’s hypertension is caused or worsened by his service-connected disabilities, to include medications he takes to treat his service-connected disabilities, the VA examiner based her negative opinion only on NSAID used in the military service. The examiner did not address whether the Veteran’s current hypertension was caused by or aggravated by the Veteran’s service-connected disabilities to include current use of medication, such as NSAID, for his service-connected disabilities. In addition, the Veteran’s representative indicated that hypertension has a known relationship with diabetes. See February 2021 IHP. The examiner did not address whether the Veteran’s hypertension is related to his service-connected diabetes. Thus, remand is necessary in order to provide an adequate examination. 4. Entitlement to service connection for a disability characterized by short-term memory loss is remanded. In its October 2019 Board remand, the Board noted that the Board’s previous remand directives in July 2018 instructed the VA examiner to discuss if memory impairment is separate and distinct from service-connected PTSD. The Board stated that although there is no memory disorder according to the DSM-5, the April 2019 examiner indicated that the testing showed below average basic attention and reported memory. As such, the Board found that it appears that there is either a disability characterized by memory and attention impairment, or these symptoms are part and parcel of the already service-connected PTSD. The Board found that another VA opinion was necessary to comply with the previous remand directives and clarify the etiology of the Veteran’s symptomatology. The Board instructed the examiner to provide an opinion as to whether it is at least as likely as not that the Veteran has a short-term memory impairment that is separate and distinct from his other service-connected disabilities, to specifically include his service-connected PTSD. Pursuant to the October 2019 Board remand, the Veteran was afforded a VA examination in January 2020. The examiner opined that the Veteran’s claimed condition was less likely than not related to service. The examiner stated that the Veteran does not meet diagnostic criteria for a memory related condition. Although instructed by previous remands, the January 2020 opinion does not state whether the Veteran has a short-term memory impairment that is separate and distinct from his other service-connected disabilities, to specifically include his service-connected PTSD. Thus, the January 2020 VA examination report is inadequate and does not constitute substantial compliance with the Board’s prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). On remand, an addendum opinion must be provided. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s gastrointestinal disability to include GERD. The claims file and a copy of this REMAND must be made available to the examiner for review. Based on the examination results and review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present gastrointestinal disability is etiologically related to the Veteran’s active service. The examiner must consider the Veteran’s lay statements regarding the onset and continuity of his symptoms. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present gastrointestinal disability was caused or aggravated by a service-connected disability, to include any medication for treatment of such. The examiner should reconcile prior conflicting evidence indicating that NSAIDs can aggravate GERD. The examiner should note that this question requires two separate opinions: one for proximate causation and a second for aggravation. The term “aggravation” means a permanent worsening of the Veteran’s disability beyond its natural progression. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, then a reason for doing so must be provided. A complete rationale must be provided for the opinion proffered. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s bilateral foot fungus (athlete’s feet). The claims file and a copy of this REMAND must be made available to the examiner for review. The VA examiner must provide an opinion as to whether there is clear and unmistakable evidence that any bilateral foot fungus (athlete’s feet) preexisted the Veteran’s period of active duty service. If a bilateral foot fungus (athlete’s feet) is found to have clearly and unmistakably preexisted the Veteran’s military service, then the examiner must state the specific clear and unmistakable evidence upon which the finding was made. Rationale must be provided for the opinion proffered. If the VA examiner finds that there is clear and  unmistakable evidence that bilateral foot fungus (athlete’s feet) preexisted his entry into active duty service, then the examiner must also provide an opinion as to whether there is clear and unmistakable evidence that the preexisting bilateral foot fungus (athlete’s feet) was NOT aggravated beyond the normal progression of the disease during service, and if so, the VA examiner must state the specific clear and unmistakable evidence upon which the finding is based. Rationale must be provided for the opinion proffered. If, and only if, the VA examiner finds that there is not clear and unmistakable evidence that bilateral foot fungus (athlete’s feet) preexisted service and was not aggravated beyond the normal progression of the disease, then the examiner must opine as to whether it is at least as likely as not (a 50 percent probability or greater) that bilateral foot fungus (athlete’s feet) began in service, was caused by service, or is otherwise etiologically related to his military service. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, then a reason for doing so must be provided. A complete rationale must be provided for the opinion proffered. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s hypertension. The claims file and a copy of this REMAND must be made available to the examiner for review. Based on the examination results and review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran’s hypertension is etiologically related to service, to include any elevated blood pressure readings in service, and the Veteran’s presumed herbicide agent exposure (notwithstanding the fact that it may not be a presumed association). The examiner should address what the likelihood that this Veteran’s hypertension is related to his herbicide exposure given his medical history, family history, other risk factors, etc. In rendering the opinion, the examiner should consider the National Academy of Sciences excerpt indicating a limited or suggestive association between herbicide exposure and hypertension. The examiner must also opine whether it is at least as likely as not the Veteran’s hypertension is caused or aggravated by his service-connected disabilities, to include his service-connected diabetes mellitus, and/or medications (NSAIDs, etc) he takes to treat the Veteran’s service-connected disabilities. The examiner should note that this question requires two separate opinions: one for proximate causation and a second for aggravation. The term “aggravation” means a permanent worsening of the Veteran’s disability beyond its natural progression. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, then a reason for doing so must be provided. A complete rationale must be provided for the opinion proffered. 5. Obtain an addendum opinion from a VA examiner in order to determine the nature and etiology of any currently present memory impairment. The claims file, including a copy of this REMAND must be made available to, and reviewed by the examiner. Based on a complete review of the record, the examiner should provide an opinion as to whether it is at least as likely as not that the Veteran has a short-term memory impairment that is separate and distinct from his other service-connected disabilities, to specifically include his service-connected PTSD. If so, the examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any short-term memory impairment is etiologically related to the Veteran’s active service. A complete rationale must be provided for the opinion proffered. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.D. 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.