Citation Nr: 21032791 Decision Date: 05/28/21 Archive Date: 05/28/21 DOCKET NO. 17-62 955 DATE: May 28, 2021 ORDER The petition to reopen the previously-denied claim to establish service connection for gout of the right shoulder is granted. The petition to reopen the previously-denied claim to establish service connection for gout of the left shoulder is granted. The petition to reopen the previously-denied claim to establish service connection for gout of the right hand is granted. The petition to reopen the previously-denied claim to establish service connection for gout of the left hand is granted. The petition to reopen the previously-denied claim to establish service connection for gout of the right knee is granted. The petition to reopen the previously-denied claim to establish service connection for gout of the left knee is granted. The petition to reopen the previously-denied claim to establish service connection for gout of the right ankle is granted. The petition to reopen the previously-denied claim to establish service connection for gout of the left ankle is granted. The petition to reopen the previously-denied claim to establish service connection for gout of the feet is granted. The petition to reopen the previously-denied claim to establish service connection for gout of the toes is granted. Entitlement to service connection for gout of the right ankle is granted. REMANDED Entitlement to service connection for gout of the right shoulder is remanded. Entitlement to service connection for gout of the left shoulder is remanded. Entitlement to service connection for gout of the right hand is remanded. Entitlement to service connection for gout of the left hand is remanded. Entitlement to service connection for gout of the right knee is remanded. Entitlement to service connection for gout of the left knee is remanded. Entitlement to service connection for gout of the left ankle is remanded. Entitlement to service connection for gout of the feet is remanded. Entitlement to service connection for gout of the toes is remanded. Entitlement to service connection for an acquired psychiatric disability, claimed as posttraumatic stress disorder (PTSD) and depression, is remanded. Entitlement to service connection for left ear hearing loss is remanded. Entitlement to service connection for diabetes mellitus, type II, is remanded. Entitlement to service connection for residuals of a stroke, to include as secondary to a service-connected disability, is remanded. FINDINGS OF FACT 1. A July 2009 rating decision denied the Veteran's claims to establish service connection for gout of the shoulders, hands, knees, ankles, feet, and toes; the Veteran did not appeal that decision, nor was any new and material evidence submitted within the appeal period. 2. A June 2011 rating decision denied the Veteran's petitions to reopen the previously-denied claims to establish service connection for gout of the shoulders, hands, knees, ankles, and toes, and the Veteran requested reconsideration of these determinations in August 2011. 3. A December 2011 rating decision denied the Veteran's petitions to reopen the previously-denied claims to establish service connection for gout of the hands and left shoulder; the Veteran did not appeal that decision, nor was any new and material evidence submitted within the appeal period. 4. Evidence received since the final July 2009 rating decision raises a reasonable possibility of substantiating the claims to establish service connection for gout of the feet, toes, ankles, knees, right shoulder. 5. Evidence received since the final December 2011 rating decision raises a reasonable possibility of substantiating the claims to establish service connection for gout of the hands and left shoulder. 6. The most probative evidence reflects that the Veteran experienced in-service symptoms of gout of the right ankle, a chronic disability which was diagnosed and manifested to a degree of 10 percent within the initial post-service year. CONCLUSIONS OF LAW 1. The July 2009 rating decision is final with respect to the Veteran's claims to establish service connection for gout of the feet, toes, ankles, knees, right shoulder. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103. 2. The December 2011 rating decision is final with respect to the Veteran's claims to establish service connection for gout of the hands and left shoulder. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103. 3. Since the July 2009 rating decision, evidence has been received which is new and material and raises a reasonable possibility of substantiating the claims to establish service connection for gout of the feet, toes, ankles, knees, right shoulder, and the claims are reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156(a). 4. Since the December 2011 rating decision, evidence has been received which is new and material and raises a reasonable possibility of substantiating the claims to establish service connection for gout of the hands and left shoulder, and the claims are reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156(a). 5. The criteria to establish service connection for gout of the right ankle are met. 38 C.F.R. §§ 3.303 (b), 3.307, 3.309, 4.71a Diagnostic Codes 5002 and 5017; see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Burton v. Shinseki, 25 Vet. App. 1 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1980 to July 2004. This matter comes to the Board of Veterans' Appeals (Board) from May 2013 and March 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) of the Veterans Benefits Administration (VBA), which is the Agency of Original Jurisdiction (AOJ). The Veteran expressed timely disagreement with this determination, and the present appeal ensued. In February 2021, the Veteran and his spouse presented oral testimony in support of his appeal at a Board hearing that was conducted by the undersigned Veterans Law Judge (VLJ) via videoconferencing equipment. A transcript of this hearing is of record. At the February 2021 hearing, the VLJ agreed to hold the record open for 30 days for the submission of additional evidence. The Veteran submitted such evidence within this period, and thus, original consideration of this evidence by the AOJ is waived. Characterization of issues on appeal As will be fully detailed below, the evidence reflects that he participated in many parachute jumps and demonstrated elevated uric acid levels upon laboratory testing during active duty. The former has resulted in orthopedic disabilities of the spine, right shoulder, right knee, right ankle, and feet, for which service connection has been established; however, the Veteran asserts that the latter was an early manifestation of gouty arthritis, a disease which subsequently affected many of his joints, to include some already associated with a service-connected disability. Noting the overlapping nature of the Veteran's gout-related appeal and his service-connected disabilities, his filings throughout the appeal period and testimony at the February 2021 Board hearing make clear his intent to establish service connection for gout affecting his various joints. As such, petitions to reopen these previously-denied claims and underlying appealed issues on the merits have been recharacterized to more accurately reflect the benefits sought by the Veteran. As all of these petitions and underlying appealed issues are being either granted in full or remanded for additional development, the Veteran is not prejudiced by the Board's actions in this regard. Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). 1. The petition to reopen the previously-denied claim to establish service connection for gout of the right shoulder is granted. 2. The petition to reopen the previously-denied claim to establish service connection for gout of the left shoulder is granted. 3. The petition to reopen the previously-denied claim to establish service connection for gout of the right hand is granted. 4. The petition to reopen the previously-denied claim to establish service connection for gout of the left hand is granted. 5. The petition to reopen the previously-denied claim to establish service connection for gout of the right knee is granted. 6. The petition to reopen the previously-denied claim to establish service connection for gout of the left knee is granted. 7. The petition to reopen the previously-denied claim to establish service connection for gout of the right ankle is granted. 8. The petition to reopen the previously-denied claim to establish service connection for gout of the left ankle is granted. 9. The petition to reopen the previously-denied claim to establish service connection for gout of the feet is granted. 10. The petition to reopen the previously-denied claim to establish service connection for gout of the toes is granted. Pertinent procedural regulations provide that "[n]othing in [38 U.S.C. § 5103A] shall be construed to require [VA] to reopen a claim that has been disallowed except when new and material evidence is presented or secured, as described in [38 U.S.C. § 5108]." 38 U.S.C. § 5103A (f). Reopening a claim for service connection which has been previously and finally disallowed requires that new and material evidence be presented or secured since the last final disallowance of the claim. 38 U.S.C. § 5108; Evans v. Brown, 9 Vet. App. 273, 285 (1996). Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). If a chronic disease, such as gout (a form of arthritis) is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309 (a). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the theory of continuity of symptomatology under 38 C.F.R. § 3.303 (b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303 (b). Service connection may also be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). New evidence means existing evidence not previously submitted to VA. 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. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). In Elkins v. West, 12 Vet. App. 209 (1999), the United States Court of Appeals for Veterans Claims (the Court) held the Board must first determine whether the appellant has presented new and material evidence under 38 C.F.R. § 3.156(a) in order to have a finally denied claim reopened under 38 U.S.C. § 5108. Then, if new and material evidence has been submitted, the Board may proceed to evaluate the merits of the claim, but only after ensuring that VA's duty to assist has been fulfilled. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The Court has also held that the law should be interpreted to enable reopening of a claim, rather than to preclude it. See Shade v. Shinseki, 24 Vet. App. 110 (2012). Even if no appeal is filed, a rating decision is not final if new and material evidence is submitted within the appeal period and has not yet been considered by VA. 38 C.F.R. § 3.156(b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). Petitions to reopen The Board concludes that, since the AOJ's prior final denials of the Veteran's claims in the July 2009, June 2011, and December 2011, rating decisions, VA has received evidence which is new and material and raises a reasonable possibility of substantiating the claims. As such, the appeal to reopen these previously-denied claims is granted. Pertinently, the Veteran initially filed a claim to establish service connection for gout affecting the shoulders, hands, knees, ankles, feet, and toes, in January 2009. In a July 2009 rating decision, the AOJ denied these claims because the evidence at the time did not reflect an in-service event congruent with a diagnosis of gout. The Veteran did not submit a timely expression of disagreement with the AOJ's July 2009 rating decision, nor did he submit pertinent new and material evidence within the appeal period of such. Accordingly, the July 2009 rating decision became final regarding the AOJ's denial of these claims. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156 (a), (b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). In September 2010, the Veteran filed a petition to reopen the previously-denied claims to establish service connection for gout; however, the specific body parts allegedly affected by this disease were not recounted. In a June 2011 rating decision, the AOJ denied the Veteran's petitions to reopen the previously-denied claims to establish service connection for gout of each body part addressed in the July 2009 rating decision except for the feet, determining that new and material evidence sufficient to reopen the claims had not been received by VA. In August 2011, the Veteran requested that the AOJ reconsider the denial of the petitions to reopen the previously-denied claims to establish gout for his various joints. For reasons unclear to the Board, the AOJ accepted this motion to reconsider for gout affecting the Veteran's hands and left shoulder only, and the petitions continued to be denied in a December 2011 rating decision. The Veteran was notified of such later that month, and he did not express disagreement with this determination or submit new and material evidence within the appeal period. Accordingly, the December 2011 rating decision became final regarding the AOJ's denial of the petitions to reopen the Veteran's previously-denied claims to establish service connection for gout affecting the hands and left shoulder. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156 (a), (b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). However, the Board notes that the Veteran's August 2011 motion for reconsideration of the June 2011 denial of the petitions to reopen the previously-denied claims to establish service connection for the right shoulder, knees, toes, and ankles, remained pending until readjudication by the AOJ in the March 2014, from which the appeal stems. In sum, the July 2009 rating decision represents the prior final denial of the Veteran's claim to establish service connection for gout of the feet, toes, ankles, knees, right shoulder, and the appeal stems from the Veteran's petition to reopen received by VA on September 7, 2010; the June 2011 rating decision did not become final regarding any of the Veteran's claims or petitions to reopen such; and the December 2011 rating decision represents the prior final denial of the Veteran's petitions to reopen the previously-denied claims to establish service connection for gout affecting the hands and left shoulder and the appeal stems from the Veteran's petition to reopen received by VA on September 19, 2013. In order for this previously-denied claims to be reopened, evidence must have been added to the record since the prior final denials that addresses this basis. The AOJ's determinations during the pendency of the present appeal concerning whether or not new and material evidence has been received by VA since the prior final denials is not binding on the Board. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Evidence received by VA since the prior final denials in the July 2009 and December 2011 rating decisions includes the Veteran's assertions at the February 2021 Board hearing in-service laboratory testing showing elevated uric acid levels were an early manifestation of gout, which was diagnosed as affecting the Veteran's right ankle during his initial post-service year. The above evidence is "new," as it was not before VA at the time of the July 2009 and December 2011 rating decisions, and "material" as it raises the reasonable possibility of substantiating the previously-denied claims. The Board thus finds that new and material evidence has been submitted to reopen the issues to establish service connection for gout affecting the shoulders, hands, knees, ankle, feet, and toes, since the final denials in July 2009 and December 2011. On that basis, the claims are reopened. The merits of the underlying claims will be addressed separately below. 11. Entitlement to service connection for gout of the right ankle is granted. The Veteran contends that gout of the right ankle had its initial onset during active duty and manifested to a degree of 10 percent within his initial post-service year. For the reasons set forth below, the Board concludes that the most probative evidence bolsters his contention, and thus, service connection for gout affecting the right ankle is warranted. The Veteran's service records reflect in-service complaints of right ankle pain and laboratory testing showing elevated uric acid levels. After the Veteran's July 2004 service retirement, he continued receiving treatment at Martin Army Community Hospital in Fort Benning, Georgia, and records from this facility reflect his continued reports of right ankle pain and demonstration of elevated uric acid levels on urinalysis. After further examination and testing, gout of the right ankle was diagnosed in June 2005 within the Veteran's initial post-service year. The Board observes that gout is a form of arthritis, which is a disability listed among the those that VA has denoted as "chronic." 38 C.F.R. § 3.307; Dorland's Illustrated Medical Dictionary, 799 (32nd ed. 2012). Further, VA's rating schedule provides that a 10 percent evaluation is warranted for painful motion of a major joint, such as the ankle, due to a chronic disability, such as gouty arthritis. 38 C.F.R. §§ 3.303 (b), 3.307, 3.309, 4.71a Diagnostic Codes 5002 and 5017; see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Burton v. Shinseki, 25 Vet. App. 1 (2011). In light of above, the most probative evidence of record reflects a diagnosis of a chronic disability (gout of the right ankle) which was manifested by symptoms meeting the criteria for at least a 10 percent evaluation during the same. In such cases, the Board finds that governing laws provide that service connection for gout of the right ankle is warranted. In implementing the Board' allowance, the AOJ is on notice of the Board's determination that this matter originates from a petition to reopen received by the AOJ on September 7, 2010, as the Veteran's August 2011 motion for reconsideration of the June 2011 denial of the petition to reopen such remained open until promulgation of the March 2014 rating decision from which this appeal stems. REASONS FOR REMAND 1. Entitlement to service connection for gout of the right shoulder is remanded. 2. Entitlement to service connection for gout of the left shoulder is remanded. 3. Entitlement to service connection for gout of the right hand is remanded. 4. Entitlement to service connection for gout of the left hand is remanded. 5. Entitlement to service connection for gout of the right knee is remanded. 6. Entitlement to service connection for gout of the left knee is remanded. 7. Entitlement to service connection for gout of the left ankle is remanded. 8. Entitlement to service connection for gout of the feet is remanded. 9. Entitlement to service connection for gout of the toes is remanded. The Veteran asserts that gouty arthritis, for which the Board has already established service connection, has affected his shoulders, hands, knees, left ankle, feet, and toes. As noted above, gout is a systemic disorder, characterized by migratory, flare-ups in various joints (possibly leaving residual pathology). Since service connection for the underlying disease (gouty arthritis) has been established, the primary question to be resolved with regard to the appealed issues enumerated above is whether the most probative evidence reflects that gout affected the claimed joints during the appeal period. The Veteran's post-service treatment records from Martin Army Community Hospital in Fort Benning Georgia, reflect that the Veteran was prescribed medication for treatment and prevention of further progression of this disease within his initial post-service year. These records also show that the Veteran reported gout with flare-ups affecting all of the joints subject to the Veteran's appealed issues; however, except for the Veteran's right ankle, these reports did not occur during the Veteran's initial post-service year or within the appeal period for consideration regarding the current appealed issues. The Veteran's VA and private treatment records reflect his continued use of medication for gout and allusions to a history of the disease affecting various joints; however, there is no evidence that the Veteran has been diagnosed with gout affecting his feet, toes, left ankle, knees, or right shoulder, since September 7, 2010, or hands and left shoulder since September 19, 2013. To the above point, the Board observes that the record for review is currently incomplete. Specifically, while the Veteran notified the AOJ in April 2012 that he had been granted disability benefits from the Social Security Administration (SSA) by a March 2011 decision, no efforts have been made to obtain the evidence upon which this decision was made. Under 38 U.S.C. § 5107(a), VA's duty to assist specifically includes requesting information from other Federal departments or agencies. As these records are pertinent to the issues on appeal, efforts to obtain and associate them with the record must be undertaken. Murincsak v. Derwinski, 2 Vet. App. 363 (1992); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Further, the Veteran has not been provided a VA examination to determine whether gout has affected his feet, toes, left ankle, knees, or right shoulder, since September 7, 2010, or hands and left shoulder since September 19, 2013. In light of the Board's allowance of service connection for this disability and the ample evidence that such affected these body parts since the Veteran's service, the Board concludes that VA's duty to assist the Veteran by providing him a VA examination has been triggered. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 10. Entitlement to service connection for an acquired psychiatric disability, claimed as PTSD and depression, is remanded. At the February 2021 Board hearing, the Veteran asserted that he began experiencing psychiatric symptoms during active duty due to several in-service stressors, to include while stationed in Grenada, at the Demilitarized Zone (DMZ) in Korea from 1992 to 1993, and at Fort Hood, where he witnessed the accidental mortal wounding of a fellow soldier by M60 machine gun fire during a live firing exercise. The Veteran's VA treatment records reflect positive PTSD and depression screens; however, no formal diagnoses are of record. Notwithstanding this, the March 2011 favorable SSA decision references that the Veteran's PTSD and depression have negative impacted his employability since his service separation. Obviously, associating the Veteran's SSA records is critical to this appealed issue. Further, the Board concludes that the low threshold to provide the Veteran with a VA psychiatric examination to determine the nature, date of initial onset, and etiology of any acquired psychiatric disability, has been met. 11. Entitlement to service connection for left ear hearing loss is remanded. The Board observes that the Veteran initially filed a claim to establish service connection for bilateral hearing loss. In-service exposure to excessive noise has been conceded based on the Veteran's Military Occupational Specialty (MOS) as an infantryman, and VA audiometric testing completed in November 2012 and May 2013 reflected hearing loss for VA purposes in the right ear (for which service connection has been established), but not the left ear. At the February 2021 Board hearing, the Veteran asserted that his hearing acuity has decreased since the completion of the most recent audiometric testing in May 2013. Accordingly, it is possible that the Veteran may have demonstrated decibel losses which meet the criteria for a left ea hearing loss disability for VA purposes under 38 C.F.R. § 3.385. As such, the Board concludes that remand is necessary to provide the Veteran a VA audiometric examination to determine the nature and etiology of any left ear hearing loss present during the pendency of the appeal. 12. Entitlement to service connection for diabetes mellitus, type II, is remanded. At the February 2021 Board hearing the Veteran asserted that diabetes mellitus, type II, had initially manifested during his active duty. The Veteran's service treatment records are devoid of any notation confirming a diagnosis of this disability; however, the Veteran's July 2004 retirement physical unambiguously reflects elevated glucose readings upon laboratory testing, and he was advised to follow-up with his primary care provider after service separation. The Veteran's post-service medical records reflect that his glucose levels have been monitored closely since his service separation. Medications associated with diabetic treatment regimens have been prescribed, and his records make allusions diabetes; however, the evidence of a current diagnosis of this disability is tenuous based on the record for review. To this point, the records upon which the March 2011 favorable SSA decision are critical to this appealed issue, and the Board concludes that the Veteran must be provided a VA examination to determine the nature, date of initial onset, and etiology of this claimed disability. 13. Entitlement to service connection for residuals of a stroke, to include as secondary to a service-connected disability, is remanded. At the February 2021 Board hearing, the Veteran testified that he experienced a stroke in 2011 that he believes was caused by a long-standing diagnosis of hypertension. The record reflects that the Veteran presented to St. Francis Hospital in Columbus, Georgia, in July 2011 for treatment of a disability diagnosed as "[trans ischemic attack] vs. stroke;" however, further clarity regarding the nature of this disability and associated symptoms is not of record. The Board observes that the Veteran was first prescribed medication for hypertension in 1986, and service connection has been established for this disability since August 1, 2004 the day after the Veteran's separation from active duty. In light of the above evidence and the Veteran's assertions Board concludes that the low threshold to provide the Veteran with a VA examination to determine the nature and etiology of this claimed disability has been met. The matters are REMANDED for the following actions: 1. The AOJ must obtain and associate with the file all updated records of VA and private treatment pertaining to the Veteran, with his assistance regarding the latter. 2. The AOJ must contain the Social Security Administration (SSA) and request a copy of the Veteran's complete SSA file, to include the transcript of the March 2011 SSA hearing and all evidence (medical or otherwise) upon which the favorable March 2011 decision was based. If the search for such records has negative results, the claims file must be properly documented as to the unavailability of these records. 3. Thereafter, the AOJ must request that the Veteran be scheduled for a VA audiological examination for the purpose of determining the nature and etiology of any left ear hearing loss identified. The examiner must review the complete record and complete an examination of, and interview with, the Veteran. The examiner must perform an evaluation for hearing impairment that is required by 38 C.F.R. § 4.85, which shall include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. Any and all efforts should be made to obtain reliable results that are adequate for rating purposes, and the Veteran should be encouraged to fully cooperate with this process. Thereafter, the examiner must provide an opinion concerning whether the Veteran demonstrated hearing loss for VA purposes under 38 C.F.R. § 3.385, and if so, whether such is at least as likely as not proximately due to or the result of any incident of his service, to include his confirmed exposure to in-service acoustic trauma. If the examiner cannot provide the requested opinion without resorting to mere speculation, this should be so stated along with supporting rationale. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question. 4. Thereafter, the AOJ must request that the Veteran be scheduled for a VA psychiatric examination to determine the nature and etiology of any acquired psychiatric disability present during the appeal period. The complete record, to include a complete copy of this remand, should be made available to, and reviewed by, the designated examiner. Any and all appropriate tests and studies should also be performed, and all clinical findings should be reported in detail. Based on a review of the evidence of record and an interview and examination of the Veteran, the examiner should address the following: a. Identify all acquired psychiatric disabilities present during the appeal period (since December 15, 2011). *If diagnoses of PTSD and/or Major Depressive Disorder are ruled out, such a finding must be reconciled with the evidence within the appeal period providing such. b. For each diagnosed acquired psychiatric disability in part (a), provide an opinion concerning whether such is at least as likely as not proximately due to or the result of the Veteran's service, to include any in-service events outlined within the file, to include the Veteran's April 2012 stressor statement and the transcript of the Veteran's February 2021 Board hearing. In providing the requested opinions, the examiner should cite to specific evidence supporting the conclusions reached. If the examiner cannot provide an opinion without resorting to mere speculation, this should be so stated along with supporting rationale. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question. 5. Thereafter, the AOJ must request that the Veteran be scheduled for appropriate VA examinations to determine the nature, dates of initial onset, and etiology of the Veteran's claimed diabetes mellitus, type II, residuals of a stroke, and gout affecting the shoulders, hands, knees, left ankle, feet, and/or toes, during the appeal period. The complete record, to include a complete copy of this remand, should be made available to, and reviewed by, the designated examiner. Any and all appropriate tests and studies should also be performed, and all clinical findings should be reported in detail. Based on a review of the evidence of record and an interview and examination of the Veteran, the examiner should address the following: a. Identify or rule out a diagnosis of diabetes mellitus, type, II, during the appeal period (since December 15, 2011). b. If a diagnosis of diabetes mellitus, type II, is identified during the appeal period, provide an approximate date of initial onset (month and year). c. If a diagnosis of diabetes mellitus, type II, is identified during the appeal period, provide an opinion concerning whether such is at least as likely as not proximately due to or the result of any incident of the Veteran's active duty. *In addressing the above, the examiner is asked to discuss whether the Veteran's elevated glucose readings at his July 2004 retirement examination were initial manifestations of this disability. d. Identify or rule out a diagnosis of a stroke, trans ischemic attack, and any residuals of such during the appeal period (since December 15, 2011). e. For any disability identified in part (d), provide an opinion concerning whether such is at least as likely as not caused or aggravated by a service-connected disability. *In addressing the above, the examiner is asked to discuss whether any identified disability was caused or aggravated his long-standing service-connected hypertension, as he asserted at the February 2021 Board hearing. f. Identify whether gout affected any of the joints/body parts enumerated below within the provided time period: i. Either foot since September 7, 2010; ii. Any toe since September 7, 2010; iii. Left ankle since September 7, 2010; iv. Either knee since September 7, 2010; v. Right shoulder since September 7, 2010; vi. Either hand since September 19, 2013; vii. Left shoulder since September 19, 2013. g. If the response to any subpart of (f) is affirmative, please provide opinions concerning whether the gout affecting the joint/body part is associated with the same disease process that initially manifested during active duty via elevated uric acid level upon testing and initially affected the Veteran's right ankle during the initial post-service year. In providing the requested opinions, the examiner should cite to specific evidence supporting the conclusions reached. If the examiner cannot provide an opinion without resorting to mere speculation, this should be so stated along with supporting rationale. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question. 6. Thereafter, the AOJ must readjudicate the issues remaining on appeal. If any benefit is not granted to the fullest extent requested, the Veteran and his representative must be furnished with a copy of the readjudication and afforded the applicable opportunity to respond. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Scott W. Dale, 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.