Citation Nr: 21025312 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 18-06 582 DATE: April 27, 2021 ORDER 1. The appeal to reopen a claim of service connection for left ear hearing loss is granted. 2. Entitlement to a compensable rating for a right little finger disability is denied. REMANDED 3. Entitlement to service connection for type 2 diabetes mellitus (diabetes) is remanded. 4. Entitlement to service connection for left lower extremity peripheral neuropathy is remanded. 5. Entitlement to service connection for a disability manifested by left arm numbness is remanded. 6. Entitlement to service connection for right lower extremity peripheral neuropathy (affecting the toes) is remanded. 7. Entitlement to service connection for a psychiatric disability, to include anxiety, depression, and posttraumatic stress disorder (PTSD), is remanded. 8. Entitlement to service connection for a right nostril disorder is remanded. 9. Entitlement to service connection for lumbar spine degenerative joint disease (DJD) is remanded. 10. Entitlement to service connection for right knee arthritis is remanded. 11. Entitlement to service connection for left knee arthritis is remanded. 12. Entitlement to service connection for a right hip disability is remanded. 13. Entitlement to service connection for a left hip disability is remanded. 14. Entitlement to service connection for a respiratory disability to include emphysema and chronic obstructive pulmonary disease (COPD) is remanded. 15. Entitlement to service connection for left ear hearing loss (on de novo review) is remanded. 16. Whether new and material evidence has been received to reopen a claim of service connection for a right eye disability (as the result of an in-service injury) is remanded. FINDINGS OF FACT 1. The (most recent) unappealed October 2008 rating decision denied the Veteran service connection for bilateral hearing loss based essentially on a finding that a left ear hearing loss disability was not shown. 2. Evidence received since the October 2008 rating decision includes the Veteran's December 2020 hearing testimony that his left ear hearing acuity has declined considerably; relates to an unestablished fact necessary to substantiate the claim of service connection for left ear hearing loss; and raises a reasonable possibility of substantiating such claim. 2. The Veteran’s residuals of a right little finger disability are not shown to be manifested by amputation of the finger or to have resulted in limitations of function in other fingers. CONCLUSIONS OF LAW 1. New and material evidence has been received and the claim of service connection for left ear hearing loss may be reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 2. A compensable rating for a right little finger disability is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.21, 4.40, 4.59, 4.71a, Codes 5227, 5230, 5155. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from July 1974 to July 1977. These matters are before the Board of Veterans’ Appeals (Board) on appeal from an April 2017 rating decision. In December 2020, a virtual hearing was held before the undersigned; a transcript is in the record. The Veteran has psychiatric diagnoses other than depression and anxiety, to include an asserted diagnosis of PTSD, and under Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009) his claim seeking service connection for anxiety and depression is interpreted as encompassing all psychiatric diagnoses. The issue is characterized accordingly. 1. The appeal to reopen a claim of service connection for left ear hearing loss is granted. Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105. However, a claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 U.S.C. § 5108. New and material evidence is defined by regulation. New evidence means evidence not previously submitted to agency decision-makers. Material evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of establishing the claim. See 38 C.F.R. § 3.156(a). The Court has held that the phrase ‘raises a reasonable possibility of establishing the claim’ must be viewed as enabling rather than precluding reopening. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). An October 2008 (most recent last) rating decision denied service connection for left ear hearing loss on the basis that a left ear hearing loss disability was not shown. He was informed of, and did not appeal, that decision, or submit new and material evidence within a year following, and it is final. 38 U.S.C. § 7105. Evidence received since the October 2008 rating decision includes the Veteran’s December 2020 videoconference hearing testimony that his hearing acuity had declined significantly in the interim. He related that he could barely hear out of his left ear. As hearing acuity is perceived through one of the special senses, he is competent to report a decline in hearing acuity; and his report is competent evidence he may now have a hearing loss disability. As service connection for left ear hearing loss was previously denied (in part) on the basis that the Veteran was not shown to have a left ear hearing loss disability, for evidence to be new and material in the matter, it would have to be evidence not previously of record that tends to show that he now has a left ear hearing loss disability. As noted above, he testified that his hearing acuity had declined, and he is competent to make that observation. The testimony bears directly on an unestablished fact necessary to substantiate the claim, and given that his duties in service exposed him to noise (a known cause of hearing loss) raises a reasonable possibility of substantiating the claim. Accordingly, the evidence is new and material and the claim of service connection for a left ear hearing loss disability may be reopened. De novo consideration of the claim is discussed in the remand below. 2. Entitlement to a compensable rating for a right little finger disability is denied. Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule). The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate Codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Under 38 C.F.R. § 4.40, consideration must be given to functional loss due to pain and weakness causing additional disability beyond that reflected by range of motion measurements. Under 38 C.F.R. § 4.45, consideration must be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are related considerations. Painful, unstable, or misaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Where entitlement to compensation has already been established and an increase in the disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In a claim for an increased rating, “staged” ratings may be warranted where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Ankylosis of the little finger, unfavorable or favorable, is rated 0 percent. 38 C.F.R. § 4.71A, Code 5227. A note following each of those Codes advises; consider whether rating as amputation, or for resulting limitation of motion of other digits, or for interference with overall function of the hand may be warranted. Under Code 5230, any little finger limitation of motion is rated 0 percent. 38 C.F.R. § 4.71A. An index or little finger disability may be rated compensable under Codes 5153, 5156 if there is functional loss equivalent to, at least, amputation, without metacarpal resection, at proximal interphalangeal joint, or proximal thereto. 38 C.F.R. § 4.71A. Where the rating schedule does not provide a 0 percent evaluation for a diagnostic code, a 0 percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The instant claim for increase was received on November 18, 2016. Accordingly, the period for consideration begins one year prior, November 18, 2015. On February 2017 VA hand and finger examination, post avulsion fracture of the distal interphalangeal (DIP) joint of the right little finger was diagnosed. The Veteran reported that his right little finger was painful and that he was unable to bend it. He related that he had not sought treatment for his right little finger disability. The Veteran’s right hand is his dominant one and although he did not report flare-ups of his right little finger joint, he did report functional loss that consisted of worsening pain and/or range of motion (ROM) with hand use. ROM of the right little finger was abnormal with maximum extension of the DIP joint to 10 degrees, and maximum flexion of the DIP joint to 20 degrees. There was no gap between the little finger and proximal transverse crease of the hand. Pain was noted on examination, but did not contribute to functional loss. He was able to perform repetitive use testing with no additional functional loss or ROM after three repetitions. Right hand grip strength was 5/5, and there was no muscle atrophy or ankylosis. Regarding impact on employment, the examiner noted that the Veteran reported that his right hand pain and/or ROM worsened with use. At the December 2020 virtual hearing, the Veteran testified that his right little finger pain had increased, he had difficulty holding objects in his right hand, and the right little finger motion was severely limited. He stated that he was not currently receiving treatment for his right little finger. The Veteran’s service-connected right little finger disability is rated under Code 5230 based on limitation of motion, and provides that any limitation of motion is rated 0 percent. Alternatively, it may be rated under Code 5227 (for ankylosis of a ring or little finger), which provides that (favorable or unfavorable) ankylosis of either finger is rated 0 percent. To warrant a compensable rating for a little finger disability (under Code 5155) there would have to be amputation of the finger [which is not shown]. 38 C.F.R. § 4.71a. Symptoms or impairment equivalent to amputation are also not shown. A compensable rating would also be warranted if there is limitation of movement/function of other digits of the right hand due to the service-connected right little finger disability. Here, such limitation is not shown at any time. Consequently, the Veteran’s right little finger disability cannot be considered for rating as a disability resulting in limitation of motion of multiple digits, or for overall impairment of the hand. See Notes following Code 5227. The Board notes that swelling, pain, and stiffness have consistently been noted throughout the pendency of this appeal. However, the record does not show or suggest that the disability picture presented/functional limitations shown due solely to the service-connected right little finger disability meet, or approximate, any criteria for a compensable rating of such disability. The functional limitations (of motion due to pain) found on examination, and described by the Veteran at the December 2020 virtual hearing pertaining to the little finger (such as right little finger pain and difficulty holding objects) fall far short of the level of impairment that would warrant a compensable rating. See also 38 C.F.R. § 4.31. In summary, no schedular criteria for a 10 percent schedular rating for a right little finger disability are met, factors warranting referral of the matter for an extraschedular compensable rating are not shown or alleged, and a compensable rating for the service-connected right little finger disability is not warranted. REASONS FOR REMAND 3., 4., 5., 6. Entitlement to service connection for diabetes, left and right lower extremity peripheral neuropathy, and a disability manifested by left arm numbness. The Veteran contends that he developed diabetes mellitus from exposure to herbicide agents when he was stationed at Fort Chaffee, Arkansas, for five to 6 months between 1975-1976. He claims that his left and right lower extremity peripheral neuropathy and left arm numbness are secondary to his diabetes mellitus. If a Veteran was exposed to an “herbicide agent,” such as Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam from January 9, 1962, to May 7, 1975, then, absent affirmative evidence to the contrary, certain diseases, including diabetes mellitus, will be presumptively service connected even if there is no record of the disease in service. 38 U.S.C. §§ 1110, 1116, 1131; 38 C.F.R. §§ 3.307(a)(6), (d), 3.309(e). Under VA law, type 2 diabetes mellitus is a disease presumed to be associated with herbicide agent exposure. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a)(6)(iii), 3.309(e). If exposure to herbicide agents is shown, but based other than on service in Vietnam, the presumptions under this law and regulation (as defined by 38 C.F.R. § 3.307(a)(6)) still apply. Moreover, although at least 90 days of service are required for presumptive service connection for chronic diseases generally, “[a]ny period of service is sufficient to establish presumptive service connection of a specified disease under the conditions listed in § 3.309[](e).” 38 C.F.R. § 3.307(a)(1). The Veteran’s medical treatment records show diagnoses of type 2 diabetes mellitus, neuropathy of both lower extremities, and suggest that he has a diagnosis of left upper extremity neuropathy. At the December 2020 Board hearing, the Veteran first raised an alternate theory of entitlement, i.e., that he was exposed to herbicide agents at Fort Chaffee, Arkansas. The Regional Office (RO) has not yet attempted to verify the dates and locations of his service at Fort Chaffee. Although he testified that he was there for 5-6 months, the specific period was not identified. Therefore, further development to verify the dates of the Veteran’s service at Fort Chaffee is needed. Once service at Fort Chaffe is confirmed, the next question before the Board is whether the Veteran was exposed to herbicide agents during his service there. In his December 2020 hearing testimony, the Veteran related that he was sent to Fort Chafee because in 1975 and 1976 large numbers of Vietnam refugees were sent there to be processed and that he drank water from the base water supply system. Subsequent to the hearing, in December 2020, he submitted additional evidence regarding his alleged herbicide exposure, including a copy of a November 2018 Report to Congressional Addressees from the Government Accountability Office (GAO) regarding Agent Orange and Actions Needed to Improve Accuracy and Communication of Information on Testing and Storage Locations. This document indicates that Agent Orange (and other herbicide agents) were sprayed on Fort Chaffee, between December 1966 and October 1967, approximately 8 years prior to the Veteran’s asserted service at Fort Chaffee. Even if the Veteran is not entitled to presumptive service connection for a disease claimed as due to herbicide exposure, VA must also consider the claim on a direct service connection basis. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); 38 U.S.C. § 1113(b); 38 C.F.R. § 3.304(d). If the Veteran alleges exposure to herbicides in a location other than Thailand, he should be asked for the approximate dates, location, and nature of the alleged exposure. If this information is received, VA should provide the Veteran’s detailed description to the Compensation and Pension Service (C&P Service) via email with a request for review of the Department of Defense (DoD) inventory of herbicide operations to determine whether herbicides were used as he has alleged. If the Compensation Service’s review does not confirm that herbicides were used as alleged, and if sufficient information to permit a search by the Joint Services Records Research Center (JSRRC) has been provided, a request for verification of exposure to herbicides should be sent to that entity. Therefore, the Board finds that an attempt to verify the dates of the Veteran’s service at Fort Chaffee should be made, and if such service is verified, it should be followed by a further attempt to verify the Veteran’s alleged herbicide exposure during his service at Fort Chaffee by making the necessary requests to the C&P Service and JSRRC. 7. Entitlement to service connection for a psychiatric disability, to include anxiety, depression, and PTSD. Service connection for anxiety and depression has been denied because the Veteran’s STRs are silent regarding psychiatric disorders and VA and private treatment records did not relate a current psychiatric disability to his service. At the December 2020 Board hearing, he raised an alternate theory of entitlement, i.e., that he has anxiety and/or depression secondary to diabetes. He also testified that he has received a diagnosis of PTSD, and when asked about stressors, he reported that he had been in a couple of helicopters that “went down,” (presumably meaning they sustained hard or crash landings). These reported stressors in service have not been verified. As the stressor events reported by the Veteran (hard helicopter landings) have not been corroborated, proper development of his service connection for PTSD (or other psychiatric disability) claim requires first a finding of whether or not there is credible corroborating evidence of a stressor event in service. Additionally, the claim for anxiety and depression has now been expanded to include any psychiatric disability (to include PTSD) and an examination to obtain an adequate medical advisory opinion is necessary. 8. Entitlement to service connection for a right nostril disorder. At the outset, the Board notes that an October 2008 rating decision denied service connection for left nostril nose bleed because the RO found that there was no evidence of a disabling condition, nose bleeds are considered a symptom of an underlying condition and alone do not constitute a disability for which service connection can be granted, the Veteran’s STRs show no evidence of or treatment for a condition causing nose bleeds while on active duty, and treatment records show no evidence of a current disability causing nose bleeds. He did not appeal the decision, and it became final. In November 2016, he filed a claim of service connection for a right nostril nosebleed, and the claim was denied essentially for the same reasons as the left nostril. However, a January 1977 STR notes that he reported coughing up blood from his mouth and nose, and bleeding from his nose (particular nostril not identified) when he blew his nose, and a March 2009 VA treatment record notes that reported his right nostril was cauterized (during service) in 1975, and that it still bled occasionally. At the December 2020 Board hearing, he testified that his right nostril is related to service because his nose began to bleed during training in the desert near El Paso (possibly at Fort Bliss), and he was flown to Fort Bliss to have a vein in his (albeit left) nostril cauterized. He reported that he continued to have nose bleeds (supposedly from either nostril) and had recently sought treatment for nose bleeds at the Jamaica Plain VAMC, (records of which do not appear to have been associated with the claims file). Development to obtain hospital records from Fort Bliss and updated treatment records from Jamaica Plain VAMC is necessary. If records obtained from such development confirm treatment for a right nostril bleed in service and that the Veteran sought postservice VA treatment for a right nostril bleed, an examination to secure an adequate medical opinion regarding the etiology of any current right nostril disability may be necessary. 9., 10., 11., 12., 13. Entitlement to service connection for lumbar spine DJD, right and left knee arthritis, and right and left hip disabilities. The Veteran contends that his lumbar spine DJD, right and left knee disabilities, and right and left hip disabilities were incurred in service. A July 1974 STR notes that he reported knee pain after marches. The assessment was normal knees, and ace wraps were provided. A May 1977 STR notes that the Veteran reported pain in both lower extremities from a long run over the weekend. The impression was strained muscles, and he was provided analgesic balm and ace wrap. A May 1977 STR report of medical history notes that he reported, in part, swollen joints, a bone deformity, and foot trouble. A July 2005 private treatment record notes that a previous lumbar spine X-ray showed arthritic changes. February 2008 X-rays showed right and left knee degenerative arthritis, and a March 2016 VA treatment record notes that the Veteran reported chronic bilateral hip pain. At the December 2020 hearing, the Veteran testified that his lumbar spine, bilateral knee, and bilateral hips disabilities were due to wear and tear from running and backpacking (ruck-marching) activities during service. He related that he recently sought orthopedic treatment at the Jamaica Plain VAMC. He has not been afforded a VA examination to determine the nature and etiology of his lumbar spine and right and left knee and hip disabilities, and considering his contentions and the state of the medical evidence, an examination to secure a medical opinion regarding the nature and etiology of his lumbar spine, and right and left knee and hip disabilities is necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board further notes that pain may, in the absence of a diagnosis or underlying pathology, of itself be considered a current disability under 38 U.S.C. § 1110 if it results in functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). 14. Entitlement to service connection for a respiratory disability to include emphysema and COPD. The Veteran asserts that he has emphysema and/or COPD due to his exposure to JP-4 fuel fumes. A January 1977 STR notes that the Veteran reported coughing up blood from his mouth and nose, and a May 1977 STR report of medical history notes that the Veteran reported that he coughed up blood. At the December 2020 Board hearing, the Veteran testified that breathing JP-4 fuel fumes during service damaged his respiratory system. The current record does not include an adequate medical opinion addressing whether the Veteran’s COPD (or any other respiratory disability) is related to his service, to include as due to exposure to jet fuel fumes. An examination to secure an adequate medical opinion regarding the etiology of any respiratory disability, to include COPD and emphysema, is necessary. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 15. Entitlement to service connection for left ear hearing loss. Considering the Veteran’s testimony that his hearing acuity has declined significantly since October 2008 (when a hearing loss disability was not found), a contemporaneous examination to determine whether he now has a left ear hearing loss disability, and if so, its etiology, is necessary. 16. Whether new and material evidence has been received to reopen a claim of service connection for a right eye disability. An October 2008 rating decision denied the Veteran service connection for a right eye disability because there was no evidence of a right eye disorder diagnosis in service and private treatment records showed no evidence of a right eye disorder that was considered to be a residual of an in-service right eye injury. At the December 2020 Board hearing the Veteran testified that he had not submitted any treatment records that showed a link between a current right eye disorder and a right eye injury in service. However, the record suggests that he has sought treatment for various right eye disorders since the 2006 rating decision, and development is being undertaken for VA, SSA, and prison treatment records. [Such development is necessary prior to consideration of whether the claim of service connection for a right eye disability may be reopened. If the claim is reopened, the duty to assist by arranging for a VA examination or medical opinion would attach.] A July 2017 VA treatment record notes that the Veteran reported he receives Social Security Administration (SSA) disability benefits for diabetes and back pain; copies of the award and medical records considered are not in the record. VA has a duty to obtain SSA records, provided they are relevant. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). The Board is unable to find SSA records would not be relevant. As the record reflects that the Veteran continues to receive ongoing treatment for his left ear hearing loss, lumbar spine DJD, right and left knee arthritis, right and left hip disabilities, diabetes, left and right lower extremity peripheral neuropathy, left arm numbness, a right nostril disorder, a psychiatric disability, and a right eye disability, outstanding records of the treatment must be obtained and considered; notably, VA records are constructively of record. The most recent records of such treatment in the file are from January 2018. A March 2016 VA treatment record notes that the Veteran reported that he was incarcerated at the Columbia Correction Prison in Lake City, Florida for 7 years from approximately January 2009 to January 2016. Prior to his incarceration, he had sought VA treatment for chronic low back pain, pain his lower extremities, diabetes with neurological manifestations, and other chronic pain. Since it is plausible that the Veteran would have continued to seek treatment for such medical conditions during his incarceration, any treatment records from his period of incarceration should be sought. The matters are REMANDED for the following: 1. Secure for association with the record all outstanding, up to date, records of VA treatment the Veteran has received for left ear hearing loss, lumbar spine DJD, right and left knee arthritis, right and left hip disabilities, diabetes, left and right lower extremity peripheral neuropathy, left arm numbness, a right nostril disorder, a psychiatric disability, and a right eye disability, specifically the Boston VA system which includes the Jamaica Plain VAMC. If any such records are unavailable, the reason for their unavailability must be explained for the record, and the Veteran should be so advised. 2. Ask the Veteran to identify all private providers of evaluations or treatment he has received for the claimed disabilities (records of which are not already in the record) and to submit authorizations for VA to secure for the record complete clinical records from the providers identified, including specifically, all treatment records from his period of incarceration by the Florida Department of Corrections, to include his incarceration in the Columbia Correction Prison, Lake City, Florida, from January 2009 to January 2016. Obtain those records. 3. Obtain for the record from SSA their determination awarding the Veteran SSA disability benefits, and the medical records considered in that determination. If the records are unavailable, it should be so noted in the record (with explanation), and the Veteran should be so advised. 4. Ask the Veteran to identify the specific locations of his alleged exposure to herbicides/Agent Orange on Fort Chaffee, Arkansas, and the approximate dates when such exposures occurred as well as the units to which he was assigned at such times. Then forward the information the Veteran provides to the National Personnel Records Center (NPRC) for verification of his service at Fort Chaffee, Arkansas. (a) If the Veteran’s service on Fort Chaffee is confirmed, request the C&P Service to conduct a review of the inventory of herbicide operations maintained by the Department of Defense to determine whether herbicide agents were used, stored, transported, or otherwise may have come in contact with the Veteran at Fort Chaffee, Arkansas, when he was stationed there in the manner alleged. Specifically, ask the C&P Service to consider the November 2018 Report to Congressional Addressees from the GAO regarding Agent Orange and Actions Needed to Improve Accuracy and Communication of Information on Testing and Storage Locations. (b) If the C&P Service cannot verify exposure, forward the Veteran’s files, specifically noting the Veteran’s dates of service on Fort Chaffee, to the JSRRC and request verification of his alleged exposure to herbicide agents at Fort Chaffee, when he was stationed there on the verified dates. All steps taken and the ultimate findings must be documented in a memorandum for the record. 5. Thereafter, only if exposure to herbicide agents is confirmed, arrange for a neurological examination of the Veteran to confirm the existence, and ascertain the likely etiology of any bilateral lower extremity and left upper extremity peripheral neuropathy. The Veteran’s record must be reviewed by the examiner in conjunction with any such examination. Upon review of the record and interview and examination of the Veteran, the examiner should respond to the following: (a) Does the Veteran have peripheral neuropathy of either (or both) lower extremity(ies) and his left upper extremity? (b) Identify the likely etiology for any peripheral neuropathy found. Specifically, is it at least as likely as not (a 50% or better probability) that it is etiologically related to his service (to include as due to exposure to Agent Orange/herbicide agents) or was caused or aggravated (the opinion must specifically address aggravation) by his diabetes mellitus? (c) If any peripheral neuropathy of the lower extremities or left upper extremity is determined to not have been incurred in service or caused or aggravated by diabetes, identify the etiology for the disability that is considered to be more likely. The examiner must include rationale with all opinions. 6. Ask the Veteran to provide detailed information regarding his all of his alleged stressor events in service (i.e., date, place and unit information); arrange for all indicated development to verify his alleged stressor event (to specifically include the reported hard landings in helicopters) based on the information provided; and then make a finding for the record indicating what, if any, stressor event in service is corroborated by credible supporting evidence. (a) Then arrange for a psychiatric examination of the Veteran to ascertain the nature and likely etiology of his psychiatric disability. The Veteran’s record must be reviewed by the examiner in conjunction with the examination, and the provider should be advised of what stressor events in service, if any, are recognized as corroborated. Following examination and interview of the Veteran and review of his medical history, the examiner should offer an opinion that responds to the following: (b) Identify (by diagnosis) each psychiatric disability entity found (or shown by the record). Specifically, does the Veteran have a diagnosis of PTSD based on a corroborated stressor event in service? If so, identify the corroborated stressor and symptoms supporting the diagnosis. If not, identify the factors necessary for such diagnosis found lacking. (c) Also identify the likely etiology of any other psychiatric disability entity diagnosed. Specifically, is it at least as likely as not that the disability is related directly to the Veteran’s service/events therein? [If service connection is established for diabetes, further opine if the diabetes caused or aggravated (the opinion must address aggravation) a diagnosed psychiatric disability.] (d) If a psychiatric disability is found to be unrelated to his service, and not caused or aggravated by diabetes (if it is service-connected) identify the more likely etiology. The examiner must explain the rationale for all opinions, citing to supporting factual data and medical literature, as appropriate. 7. Ask the Veteran to identify the approximate date of his right nosebleed during training in El Paso/at Fort Bliss. If, and only if, he provides the date of the treatment for such nosebleed, arrange for an exhaustive search of alleged treatment for a right nosebleed at William Beaumont Army Medical Center, Fort Bliss (to include contacting that facility and any storage facility where records from that facility may have been retired). If the records cannot be located, the Veteran should be so notified, and the scope of the search should be noted in the record. If and only if, treatment for a right nostril bleed in service is confirmed and the above development confirms post service treatment for a right nostril bleed, arrange for an appropriate VA examination to determine whether the Veteran has current a current disability manifested by a right nostril nosebleed, that is, at least as likely as not, related to service. The Veteran’s claims file must be reviewed by the examiner in conjunction with the examination. Based on review of the record, including service medical records, the above development, and examination of the Veteran, the examiner should opine whether the Veteran has a disability manifested by a right nostril bleed, and, if so, whether it is related to his active service, to include the episode of a bloody nose in service or treatment at Fort Bliss therein. The examiner must explain the rationale for any opinion given. 8. Arrange for an orthopedic examination of the Veteran to confirm whether he has right and left hip disabilities (to include by virtue of pain in the hips causing functional impairment), and if so, determine their likely etiology and the likely etiology of his lumbar spine and right and left knee disabilities. The Veteran’s claims file must be reviewed by the examiner in conjunction with the examination. Any tests or studies indicated should be completed, and all pertinent findings should be described in detail. On examination of the Veteran and review of his record, the examiner should: (a) Identify (by diagnosis) any lumbar spine and right and left knee disability found and any right and/or left hip disability (to include one due to pain causing functional impairment) found. (b) If a left or right hip disability (with underlying pathology) is not found, note each hip joint in which the Veteran reports pain, and if so indicate whether the pain results in functional impairment. (c) Identify the likely etiology for each lumbar spine, right and left knee and right and left hip disability (including due to pain with related functional joint) found and indicate (regarding any hip disability due to pain) whether there is underlying functional impairment. Opine specifically, if it at least as likely as not (a 50% or better probability) is etiologically related to the Veteran’s service, to include as due to running or ruck-marching therein? If a lumbar spine, knee and/or hip disability is found to not be related to the Veteran’s service, identify the more likely etiology for each. The examiner must include rationale with all opinions. 9. Also arrange for a respiratory diseases examination of the Veteran to determine the existence and (if found) likely etiology of his claimed COPD and emphysema. The Veteran’s entire record must be reviewed by the examiner. On examination/interview of the Veteran and review of his record, the examiner should: (a) Identify (by diagnosis) each respiratory disability entity found. (b) Identify the likely etiology of each respiratory disability entity diagnosed. Specifically, is it at least as likely as not (a 50% or greater probability) that any diagnosed respiratory disability is related to the Veteran’s military service/events therein, in particular as due to his exposure to chemicals in his MOS (and specifically, JP-4 fuel fumes)? (c) If an identified respiratory disability is found to not be etiologically related to service, identify the etiology for such disability considered more likely (and explain why that is so). The examiner must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. 10. Then arrange for an audiological examination of the Veteran (with audiometric studies) to ascertain whether or not he now has a left ear hearing loss disability (as defined in 38 C.F.R. § 3.385), and if so, the likely etiology of the hearing loss. The entire record must be reviewed by the examiner in conjunction with the examination. Based on a review of the record, and examination of the Veteran, the examiner should provide opinions that respond to the following: (a) Does the Veteran have a left ear hearing loss disability (as defined in 38 C.F.R. § 3.385)? (b) If a left ear hearing loss disability is found, identify the likely etiology of such disability. Specifically, is it at least as likely as not (i.e., a 50% or better probability) that it is related to the Veteran’s service (to include as due to his acknowledged exposure to noise therein)? If the hearing loss is determined to be unrelated to service, identify the etiology for the hearing loss that is considered to be more likely (and explain why that is so). The examiner must include rationale with all opinions (acknowledging that by virtue of his duties in service the Veteran was likely exposed to loud noise in service). 11. If, and only if, the above development suggests that a current right eye disability is a residual of an in-service right eye injury, arrange for an ophthalmologic examination of the Veteran to determine the nature and likely etiology of his right eye disability. (a) The examiner should identify each right eye disability found by diagnosis. (b) Regarding each right eye disability diagnosed, the examiner should opine whether it at least as likely as not (a 50 percent or greater probability) is etiologically related to the Veteran’s military service. (c) If a diagnosed right eye disability is found to not be related directly to service, identify the etiology considered more likely (and explain why that is so). The examiner must include rationale with all opinions, citing to relevant evidence and to supporting factual data and medical literature. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Bayles, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.