Citation Nr: 21025577 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 17-27 402 DATE: April 28, 2021 ORDER The petition to reopen the previously denied claim of entitlement to service connection for a panic disorder is granted. The petition to reopen the previously denied claim of entitlement to service connection for a sinus condition is granted. Entitlement to service connection for an acquired psychiatric disorder, diagnosed as unspecified trauma and stressor related disorder and a panic disorder, is granted. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for allergic rhinitis is remanded. Entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disorder is remanded. Entitlement to service connection for a skin condition, to include dermatitis is remanded. Entitlement to service connection for a sinus condition is remanded. Entitlement to service connection for muscle spasms of the head and/or neck is remanded. Entitlement to service connection for a bilateral eye condition is remanded. Entitlement to service connection for a left shoulder condition is remanded. FINDINGS OF FACT 1. In an unappealed October 1997 rating decision, the RO denied claims for entitlement to service connection for a panic disorder and a sinus condition. 2. Evidence received since the October 1997 rating decision was not previously considered by agency decision makers; is not cumulative and redundant of evidence already of record; relates to an unestablished fact; and raises a reasonable possibility of substantiating the Veteran’s claims for a panic disorder and sinus condition. 3. The Veteran’s current psychiatric disorder, diagnosed as unspecified trauma and stressor related disorder and a panic disorder, is etiologically related to his active military service. CONCLUSIONS OF LAW 1. The October 1997 rating decision, which denied claims for entitlement to service connection for a panic disorder and sinus condition, is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. 2. The criteria to reopen the claims of entitlement to service connection for a panic disorder and sinus condition have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for service connection for an acquired psychiatric disorder, diagnosed as unspecified trauma and stressor related disorder and a panic disorder, have been met. 38 U.S.C. §§ 1110, 1131, 5103; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from July 1980 to November 1980 and from September 1990 to July 1991, with additional service with the U.S. Army Reserves. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ); a transcript is of record. The Board notes that there may be outstanding, relevant private treatment records related to the Veteran’s claim for a psychiatric disorder. However, in light of the favorable decision below, the Board finds no prejudice to the Veteran in proceeding with a decision at this time. Moreover, since the issuance of the statement of the case in March 2017, the Veteran has submitted additional evidence. Waiver of RO consideration of the additional evidence is presumed given the date of the Veteran’s substantive appeal. See 38 U.S.C. § 7105(e). 1. The petition to reopen the previously denied claims of entitlement to service connection for a panic disorder and a sinus condition. The Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New evidence means existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. The evidence need only relate to one unestablished fact necessary to substantiate the claim to be material. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). 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. 38 C.F.R. § 3.156(a). When determining whether the submitted evidence meets the definition of new and material, VA must consider whether the new evidence, when considered with the evidence of record, at least triggers VA’s duty to assist by providing a medical opinion, which might raise a reasonable possibility of substantiating the claim. Shade, 24 Vet. App. at 118. For the purpose of determining whether a case should be reopened, the credibility of the evidence added to the record is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Service connection for a panic disorder and sinus condition was denied in an October 1997 rating decision on the basis that there was no evidence of a current disability or in-service incurrence. The Veteran did not initiate an appeal of that decision and thus, it became final. 38 U.S.C. § 7105; 38 U.S.C. §§ 20.302, 20.1103. No evidence was constructively or physically of record within one year of the October 1997 determination. 38 C.F.R. § 3.156(b); see also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011). At the time of the October 1997 rating decision, the pertinent evidence of record included service treatment records (STRs), private treatment records, and VA examination reports. Since the most recent final denial in October 1997, VA treatment records, private treatment records, and December 2014 VA examination reports and opinions were added to the record. As this evidence was not before VA or considered in the prior denial, it is new. The December 2014 VA psychiatric examination shows current diagnoses of unspecified trauma and stressor related disorder and panic disorder. The December 2014 VA sinus examination addresses whether the Veteran has a current sinus condition. As this evidence relates to whether the Veteran has current psychiatric and sinus disabilities, unestablished facts necessary to substantiate the claims, it is material. Accordingly, new and material evidence has been received. The request to reopen the prior denials is granted. 38 C.F.R. § 3.156. To this limited extent only, the appeal is granted. 2. Entitlement to service connection for an acquired psychiatric disorder. The Veteran contends that his current psychiatric condition is related to his active military service. Specifically, he contends that it is due to his service in a transportation unit during Desert Shield/Storm. For the reasons that follow, the Board finds that service connection is warranted. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, to establish service connection, there must be competent, credible evidence of 1) a current disability, 2) in-service incurrence or aggravation of an injury or disease, and 3) a nexus, or link, between the current disability and the in-service disease or injury. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of Operations (Southwest Asia) during the Persian Gulf War, or that became manifest to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1). The Veteran’s DD Form 214 shows that he served in Southwest Asia from September 1990 to June 1991. As such, the Veteran is considered a Persian Gulf War veteran. The Veteran’s current condition has been attributed to a known clinical diagnosis of conclusive pathophysiology and etiology. Thus, the law and regulations providing for presumptive service connection for Persian Gulf veterans with qualifying chronic diseases are not applicable. 38 C.F.R. § 3.317. Turning to the first element of service connection, as noted above, the Veteran underwent a VA psychiatric examination in December 2014 at which time the examiner diagnosed unspecified trauma and stressor related disorder and a panic disorder. Accordingly, the Veteran has a current psychiatric disability, and the first element of service connection is established. The Veteran contends that his psychiatric condition is related to his service with transportation duties during Desert Shield/Storm. Specifically, he has reported that he was a truck driver that delivered supplies in war zones and that during his deliveries he feared for his life and was in a hostile environment. See December 2014 VA examination; May 2019 substantive appeal (VA Form 9); October 2020 hearing transcript. At the October 2020 hearing, the Veteran reported that while delivering supplies, he saw dead bodies along the road, went into oil well factories that were burning, and encountered scuds going off over his head as well as friendly fire. The Veteran’s military personnel records confirm that he served as a transport operator/heavy vehicle driver. See DD Form 214; Record of Assignments. In light of the Veteran’s military occupational specialty as a transport operator and confirmed service in Southwest Asia during Desert Shield/Storm, the Board finds the Veteran’s reports of delivering supplies to war zones and fearing for his life/being in a hostile environment to be credible and consistent with the circumstances, conditions, and hardships of his service. Accordingly, the second element of service connection also has been established. Turning to the third element of service connection, a causal nexus, the Board finds that element also has been met. The Veteran contends that his psychiatric condition began in service shortly after he returned from Southwest Asia. Specifically, he reported that he experienced his first panic attack in 1991, the day he returned from Southwest Asia. See January 1994 VA examination; May 1996 Statement in Support of Claim; December 2014 VA examination report; October 2020 hearing transcript. Since then, he reports that his panic attacks have continued and have become more severe. See May 1996 Statement in Support of Claim. He has described experiencing chest pain/tightness as well as other symptomatology during these episodes. May 1996 Statement in Support of Claim; January 1997 VA examination; December 2014 VA examination; October 2020 hearing transcript. The Veteran is competent to report observable symptomatology. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran initially underwent a VA psychiatric examination in January 1997. However, no etiology opinion was provided. As noted above, the Veteran underwent another VA psychiatric examination in December 2014. The examiner opined that it is at least as likely as not that the Veteran’s current psychiatric disorders are related to his active military service. She explained that her opinion was based on the clinical interview, analyses of symptoms endorsed, reported events/stressors, and information regarding chest pains, dizziness, and neurosis during episodes. In a January 2015 addendum opinion, the December 2014 examiner further opined that the chest pains the Veteran experienced in service were one of the first anxiety symptoms of his current psychiatric disorders. She explained that psychological distress following traumatic or stressful events can vary in context from person to person, including anxiety and/or fear based, but sometimes the primary symptoms are loss of interest and dysphoric symptoms, externalizing anger and aggression, and dissociative symptoms. Although the only documented reports of chest pain were noted during the Veteran’s period of reserve service, he has credibly and competently reported experiencing chest pain/tightness during his panic attacks, which first occurred during his active duty service. The Board finds these opinions, supported by a rationale based on an accurate medical history with clear conclusions and supporting data, are highly probative. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board acknowledges that in her December 2014 opinion, the examiner opined that the Veteran’s psychiatric condition was at least as likely as not incurred in or caused by the Veteran’s direct service of being in combat. The Board notes that there is no evidence of record that shows the Veteran engaged in combat with the enemy, and the Veteran has not contended such. See January 1997 VA examination. However, reading the examiner’s opinion and rationale as a whole indicates that in using the phrase “being in combat” the examiner was referring to being deployed in a hostile environment and fearing for his life, which has been conceded, rather than being in actual combat with the enemy. In light of the foregoing, the Board finds that service connection for an acquired psychiatric disorder, to include unspecified trauma and stressor related disorder and a panic disorder, is warranted. Accordingly, the claim is granted. REASONS FOR REMAND 1. Entitlement to service connection for bilateral hearing loss. The Veteran contends that his current bilateral hearing loss is related to his active service, specifically his second period of active duty service. For the reasons that follow, the Board finds that additional development is necessary prior to adjudication. The Veteran underwent a VA audiological examination in December 2014. At that time, the examiner opined that the Veteran’s right ear hearing loss was less likely than not directly related his active military service. However, the evidence of record indicates that his right ear hearing loss may have preexisted his second period of active military service. A veteran is presumed to have been sound upon entry into active service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Where there is no official entrance examination, the presumption of soundness does not attach. See Smith v. Shinseki, 24 Vet. App. 40, 45 (2010) (citing Crowe v. Brown, 7 Vet. App. 238, 245 (1994)) (holding that the presumption of sound condition “attaches only where there has been an induction examination in which the later-complained-of disability was not detected” (citing Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991)). However, when an examination was conducted but is unavailable, the Veteran will be presumed sound. Quirin v. Shinseki, 22 Vet. App. 390 (2009). In this case, no official entrance examination for the Veteran’s second period of active duty is of record. While the Veteran underwent a Report of Medical Examination in May 1989, more than one year prior to his entrance onto active duty, a review of that examination shows that it was completed for purposes of enlistment in the U.S. Army Reserves. However, at the October 2020 hearing, the Veteran reported that he did undergo an examination when he entered active duty. As examinations are typically completed prior to entering active duty, and the Board has no reason to doubt the Veteran’s credibility, the Board finds that the presumption of soundness attaches. Id. Nonetheless, the May 1989 Report of Medical Examination indicates that the Veteran’s right ear hearing loss may have preexisted his second period of active duty service. Specifically, audiometric testing conducted at that time shows that the Veteran had a puretone threshold of 40 decibels at 4000 hertz in the right ear, which is considered a hearing loss disability for VA purposes. 38 C.F.R. § 3.385. As the record indicates that the Veteran might have had a right ear hearing loss disability prior to his second period of active duty service, and no VA examiner has provided an opinion as to whether clear and unmistakable evidence demonstrates that such disability existed before entry and was not aggravated by such service, the Board finds that such opinion should be obtained on remand. With regards to the Veteran’s left ear hearing loss, there is no evidence that it preexisted his active military service. The December 2014 examiner opined that the Veteran’s left ear hearing loss was less likely than not related to his active military service because there was no decrease in hearing acuity between his May 1989 audiological evaluation and March 1991 audiological evaluation. However, a review of these evaluations shows that there was in fact a decrease in hearing acuity between the two. Specifically, the Veteran had a puretone threshold of 15 decibels at 4000 hertz at his 1989 evaluation and a puretone threshold of 30 decibels at 4000 hertz at his 1991 evaluation. Thus, as the examiner’s opinion is based on an inaccurate factual premise, a new opinion should be obtained on remand. The Board also notes that it does not appear that any STRs from the Veteran’s first period of active duty were requested. See August 1997 Request for Information. Accordingly, the RO should request any outstanding STRs on remand. 2. Entitlement to service connection for allergic rhinitis. The Veteran contends that his rhinitis is related to his second period of active duty service, specifically environmental exposures in Southwest Asia. See October 2020 hearing transcript. As an initial matter, as explained above, the Board finds that the presumption of soundness attaches to the Veteran’s second period of active duty service. However, at the December 2014 examination for the Veteran’s rhinitis, the examiner opined that the Veteran’s rhinitis was a pre-existing condition based on the May 1989 Report of History completed at the time of the Veteran’s enlistment into the Reserves. Specifically, the Veteran reported “yes” to “sinusitis,” and it was noted that the Veteran took over the counter sinus pills. However, because the presumption of soundness applies, there must be clear and unmistakable evidence that the condition preexisted service and was not aggravated by service. It is unclear from the examiner’s opinion what standard was used in rendering the opinion (i.e. at least as likely as not or clear and unmistakable). Accordingly, the Board finds that a new opinion should be obtained on remand. Moreover, to the extent that the Veteran’s rhinitis could be granted service connection on a direct basis, the Board finds that an opinion addressing whether the condition is a diagnosed medically unexplained chronic multi-symptom illness (MUCMI) also should be obtained on remand. In this regard, the Veteran underwent a VA Gulf War General Medical Examination in December 2014. At that time, the examiner indicated that there were no diagnosed illnesses, including the Veteran’s rhinitis, for which no etiology was established. However, the examiner who provided the nexus opinion for the Veteran’s rhinitis indicated that the exact etiology of the condition is unknown. Given the foregoing, the Board finds it is unclear whether the Veteran’s rhinitis is considered a MUCMI. An illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. See Stewart v. Wilkie, 30 Vet. App. 383, 389-90 (2018). Accordingly, an opinion addressing such should also be obtained on remand. 3. Entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disorder. The Veteran contends that his hypertension is secondary to his now service-connected psychiatric disability, diagnosed as unspecified trauma and stressor related disorder and a panic disorder. While the Veteran underwent a VA examination for his hypertension in December 2014, no etiology opinion was provided. As the Veteran is now service-connected for a psychiatric disability, on remand, an opinion should be obtained that addresses secondary service connection. 4. Entitlement to service connection for a skin condition, to include dermatitis. The Veteran contends that his skin condition is related to his active military service. The Veteran underwent a VA examination for his skin condition in December 2014. At that time, the Veteran contended that his skin condition was due to sand exposure while serving in Southwest Asia. The examiner provided a negative nexus opinion. However, in rendering the opinion, it appears that the examiner solely relied on the absence of medical evidence of a skin condition in service and for nine years following service. Additionally, at the October 2020 hearing, the Veteran also contended that his skin condition was related to exposure to salt water while cleaning and decontaminating trucks. In light of the foregoing, the Board finds that a new etiology opinion should be obtained on remand. Additionally, as with the Veteran’s rhinitis, the Board finds that an opinion addressing whether the Veteran’s dermatitis is a MUCMI also should be obtained. Despite the December 2014 VA Gulf War General Medical Examination indicating that there were no diagnosed illnesses, including the Veteran’s dermatitis, for which no etiology was established, the examiner who provided the nexus opinion for the Veteran’s skin condition noted that the exact etiology of the condition is unknown. Accordingly, the Board finds it is unclear whether the Veteran’s dermatitis is a MUCMI and an opinion addressing such should be obtained on remand. 5. Entitlement to service connection for a sinus condition and a left shoulder condition. The Veteran contends that he has a sinus condition and left shoulder condition that is related to his active military service. There may be outstanding, relevant private treatment records. At the October 2020 hearing, the Veteran reported that he currently receives treatment for his sinus condition from Jefferson County Comprehensive Health Center as well as Family Medicine of Madison, Missippi. He also testified that he receives treatment for his left shoulder at Natchez Health Center as well as Jefferson County Comprehensive Health Center. While some records from Jefferson County Comprehensive Health Center are of record, the most recent records are from July 2009. Additionally, no records from the other aforementioned facilities are of record. Accordingly, a remand is required to allow VA to obtain authorization and request any outstanding records. Moreover, the Board also notes that it is unclear from the current evidence of record whether the Veteran has a left shoulder condition. While the Veteran has reported experiencing left shoulder pain, at his December 2014 VA examination for his neck, he also reported that his neck pain radiates to his left shoulder and that he does not have a left shoulder condition. At the October 2020 hearing, the Veteran contended that his left shoulder pain began in service and was due to sleeping incorrectly on a helmet in service. The Veteran has not yet been afforded a VA examination for his left shoulder. In light of the foregoing, the Board finds that a VA examination should be obtained on remand. McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). 6. Entitlement to service connection for a bilateral eye condition. The Veteran contends that he has a bilateral eye condition that is related to his second period of active military service, specifically exposure to dust storms and other environmental exposures while serving in Southwest Asia. See October 2020 hearing transcript. The Veteran underwent a VA eye examination in December 2014. The examiner did not find that the Veteran had a current diagnosis related to the eyes. However, it does not appear that this examination was conducted by an optometrist or ophthalmologist. The examination was conducted by Dr. W.M., and the only title provided was “physician.” Accordingly, the Board finds that a new VA examination should be obtained on remand. There also may be outstanding, relevant private treatment records. At the October 2020 hearing, the Veteran testified that he received treatment at Doherty’s Vision. However, no records from this private facility are of record. Accordingly, a remand is required to allow VA to obtain authorization and request any outstanding records. 7. Entitlement to service connection for muscle spasms of the head and/or neck. The Veteran contends that his neck/head muscle spasms are directly related to his second period of active military service, specifically sleeping incorrectly in service. See October 2020 hearing transcript. The Veteran underwent a VA examination for his muscle spasms in December 2014. While the examiner diagnosed muscle spasms of the head/neck, no etiology opinion was provided. Thus, a remand is warranted in order to obtain an opinion that addresses whether the Veteran’s muscle spasms are related to his active military service. Moreover, there may be outstanding, relevant private treatment records. At the October 2020 hearing, the Veteran testified that he receives treatment for his muscle spasms at Natchez Health Center and Jefferson County Comprehensive Health Center. As noted above, there may be oustanding records from these facilities. Accordingly, a remand is required to allow VA to obtain authorization and request any outstanding records. The matters are REMANDED for the following action: 1. Take the proper steps to obtain the Veteran’s STRs related to his first period of active duty service (July 1980 to November 1980). All facilities where such records may be stored should be searched. If such records have been destroyed or are irretrievably lost, it must be so documented for the record, and the Veteran should be so notified. The scope of the search must be noted in the record. 2. Ask the Veteran to complete a VA Form 21-4142 for Jefferson County Comprehensive Health Clinic, Natchez Health Center, Doherty’s Vision, and Family Medicine of Madison, Mississippi. Make two requests for the authorized records from the aforementioned providers, unless it is clear after the first request that a second request would be futile. 3. Obtain a VA medical opinion regarding the etiology of the Veteran’s bilateral hearing loss from a qualified medical professional. The need for a physical examination is left to the discretion of the VA examiner. The examiner must review the entire claims file and a copy of this Remand. The examiner is asked to opine: a) Whether the Veteran’s right ear hearing loss clearly and unmistakably existed prior to service entrance and, if so, b) Whether the right ear hearing loss was clearly and unmistakably not aggravated (i.e., not permanently worsened beyond the natural progression) during or as a result of service. c) If the Veteran’s right ear hearing loss did not clearly and unmistakably exist prior to service entrance, whether it is at least as likely as not (a 50 percent or greater probability) that the right ear hearing loss had its onset in, or is otherwise related to, his active duty service, including his reported noise exposure. d) Whether it is at least as likely as not (a 50 percent or greater probability) that the left ear hearing loss had its onset in, or is otherwise related to, his active duty service, including his reported noise exposure. In so opining, the examiner is advised that VA recognizes threshold levels greater than 20 decibels as indicative of some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The examiner also is advised that the May 1989 Report of Medical Examination is not the entrance examination for the Veteran’s active duty service but rather his Reserve service. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran’s lay statements. 4. Obtain a VA medical opinion regarding the etiology of the Veteran’s allergic rhinitis from a qualified medical professional. The need for a physical examination is left to the discretion of the VA examiner. The examiner must review the entire claims file and a copy of this Remand. The examiner is asked to opine: a) Whether the Veteran’s allergic rhinitis clearly and unmistakably existed prior to service entrance and, if so, b) Whether the allergic rhinitis was clearly and unmistakably not aggravated (i.e., not permanently worsened beyond the natural progression) during or as a result of service. c) If the Veteran’s allergic rhinitis did not clearly and unmistakably exist prior to service entrance, whether it is at least as likely as not (a 50 percent or greater probability) that the condition had its onset in, or is otherwise related to, his active duty service, to include exposure to dust storms and other environmental exposures in Southwest Asia or the notations of sinusitis in the Veteran’s STRs. d) If the Veteran’s allergic rhinitis is not directly related to service, is it at least as likely as not a medically unexplained multi-symptom illness? The examiner is advised that an illness is considered medically unexplained whether either the etiology or pathophysiology is inconclusive. e) If necessary, for any other sinus condition identified, whether it is at least as likely as not (a 50 percent or greater probability) that the condition had its onset in, or is otherwise related to, his active duty service, to include exposure to dust storms and other environmental exposures in Southwest Asia or the notations of sinusitis in the Veteran’s STRs; or whether it is at least as likely as not a medically unexplained multi-symptom illness. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran’s lay statements. 5. Obtain a VA medical opinion regarding the etiology of the Veteran’s hypertension from a qualified medical professional. The need for a physical examination is left to the discretion of the VA examiner. The examiner must review the entire claims file and a copy of this Remand. The examiner is asked to opine whether it is at least as likely as not that the Veteran’s hypertension is caused or aggravated by his service-connected psychiatric disability. The term “aggravation” means any incremental increase in disability—any additional impairment of earning capacity—in non-service-connected disabilities resulting from service-connected conditions…regardless of its permanence. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran’s lay statements. 6. Obtain a VA medical opinion regarding the etiology of the Veteran’s dermatitis from a qualified medical professional. The need for a physical examination is left to the discretion of the VA examiner. The examiner must review the entire claims file and a copy of this Remand. The examiner must opine: a) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s dermatitis had its onset in, or is otherwise related to, active service, to include exposure to sand and/or salt water. b) If the Veteran’s dermatitis is not directly related to his active service, is it at least as likely as not a medically unexplained multi-symptom illness? The examiner is advised that an illness is considered medically unexplained whether either the etiology or pathophysiology is inconclusive. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran’s lay statements. 7. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his claimed left shoulder condition. The examiner must review the claims file and a copy of this Remand. The examiner is asked to: a) State whether the Veteran has a clinical diagnosis related to the left shoulder. If no clinical diagnosis is appropriate, the examiner should offer an opinion as to whether the Veteran’s pain related to the left shoulder would result in functional impairment of earning capacity. b) Opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s left shoulder condition had its onset in, or is otherwise related to, active service, to include his report of sleeping incorrectly on a helmet in service. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran’s lay statements. 8. Schedule the Veteran for an examination by an optometrist or ophthalmologist to determine the nature and etiology of her eye disability. The examiner must review the claims file and a copy of this Remand. The examiner is asked to opine: a) Whether the Veteran has a current bilateral eye condition, to include early onset glaucoma. b) If the Veteran has a current bilateral eye condition, whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s eye condition had its onset in, or is otherwise related to, active service, to include exposure to dust storms and other environmental exposures in Southwest Asia. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran’s lay statements. 9. Obtain a VA medical opinion regarding the etiology of the Veteran’s head/neck muscle spasms from a qualified medical professional. The need for a physical examination is left to the discretion of the VA examiner. The examiner must review the entire claims file and a copy of this Remand. The examiner must opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s head/neck muscle spasms had their onset in, or are otherwise related to, active service, to include the Veteran’s report of sleeping incorrectly on a helmet in service. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran’s lay statements. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Mortimer, Associate 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.