Citation Nr: 21041545 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 16-35 282A DATE: July 9, 2021 ORDER Entitlement to service connection for a sebaceous cyst is granted. Entitlement to service connection for cardiomegaly, to include chest pain, is denied. REMANDED Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for right foot plantar fasciitis is remanded. Entitlement to service connection for a right foot disability, to include metatarsalgia with Morton's neuroma and paresthesia, is remanded. Entitlement to service connection for a left foot disability, to include metatarsalgia with Morton's neuroma, is remanded. Entitlement to service connection for onychomycosis is remanded. Entitlement to service connection for gout of the right foot, right ankle, and right toes is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right thumb disability is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for anemia is remanded. Entitlement to service connection for splenomegaly is remanded. Entitlement to service connection for major depression is remanded. FINDINGS OF FACT 1. The Veteran has a sebaceous cyst that manifested during service and continued during the pendency of the claim. 2. The Veteran has not had a heart condition other than hypertension, to include cardiomegaly, during the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for service connection for sebaceous cyst are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for cardiomegaly to include chest pain are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1978 to September 1983, July 2005 to July 2008, and October 2010 to January 2012. These matters come to the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded these matters in October 2018 for additional development, which as discussed below, has not been substantially completed for all issues on appeal. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 1. Entitlement to service connection for a sebaceous cyst is granted. The Veteran seeks service connection for a sebaceous cyst on his back. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran has had a current disability during the pendency of the claim that began during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The Veteran filed a claim for service connection for a cyst on his back on September 20, 2011, which was during his final period of active service. That same day, in preparation for retirement from service, he completed a report of medical history (RMH) form. The Veteran reported the cyst on his back and the clinician confirmed the presence of the cyst on the RMH form. The Veteran separated from service in January 2012 and in October 2012, the Veteran had a VA examination. The VA examiner also observed a cyst on the Veteran's back. Another VA examination was conducted in April 2019. The examiner found no nexus between the cyst and service; however, the opinion is not adequate for rating purposes since the examiner did not address the September 2011 RMH form. Since the evidence shows the Veteran had a cyst on his back at the time the retirement RMH was completed, which was also the date VA received his claim, and since the Veteran continued to have a cyst on his back in October 2012, the Board finds that the Veteran had a cyst on his back that manifested during service and continued thereafter. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a sebaceous cyst on the back is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The appeal is granted. 2. Entitlement to service connection for cardiomegaly to include chest pain is denied. The Veteran seeks service connection for cardiomegaly, to include chest pain. The question for the Board is whether the Veteran has a current heart disability, other than hypertension, that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of cardiomegaly, or a heart condition other than hypertension, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Service treatment records dated in April 2007 include a computerized tomography (CT) scan showing cardiomegaly. While the Veteran had a diagnosis of cardiomegaly during service, treatment records dated since September 2011 have not shown a continued diagnosis. Notably, the September 2011 RMH form completed at the Veteran's retirement from service indicates a history of cardiomegaly. A current diagnosis was not indicated. Further, other than hypertension, which is discussed below, no other chronic heart condition has been identified during the pendency of the claim. Briefly, the October 2012 examiner stated that the Veteran had mild right ventricular enlargement, with the etiology unclear. However, no other treatment records document the enlargement, and in April 2019, the Veteran's right ventricle was of normal size. The April 2019 examiner stated that the Veteran did not have a current diagnosis of cardiomegaly or any current medical evidence or sequelae of prior reported cardiomegaly. He did not have any cardiac symptoms. While the Veteran believes he has a current diagnosis of cardiomegaly, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires the ability to interpret complicated diagnostic medical testing, which has shown no cardiomegaly or heart condition other than hypertension at any time during the pendency of the claim or recent to the filing of the claim. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Based on a review of the evidence, the Board finds that the Veteran has not had cardiomegaly or a heart condition other than hypertension, addressed below, during the pendency of the claim or recent to the filing of the claim. Without a current disability, service connection for cardiomegaly with chest pain cannot be granted. The appeal is denied. REASONS FOR REMAND The Veteran seeks service connection for several disabilities, which he claims are due to or were aggravated by a period of active service. As noted above, the Veteran had three periods of active service; however, the RO was unable to obtain service treatment records for his periods of service from July 2005 to July 2008 and October 2010 to January 2012. See Correspondence, July 11, 2013. While the Veteran appears to have submitted some service treatment records, the entrance examinations for his periods of service from July 2005 to July 2008 and October 2010 to January 2012 are not available. Absent evidence to the contrary, it is presumed that an entrance examination was provided to a veteran, prior to all periods of active duty service. It follows that the presumption of soundness applies in the present case, even when the record of the Veteran's entrance examination has been lost or destroyed. See, e.g., Quirin v. Shinseki, 22 Vet. App. 390, 397 n.5 (2009) ("[T]his Court has held that the presumption applies even when the record of a veteran's entrance examination has been lost or destroyed while in VA custody."); see also Lee v. Brown, 10 Vet. App. 336, 339 (1997) (directing the Board to consider the presumption of soundness on remand in a case in which the veteran's service medical records were presumed destroyed in a fire). 1. Entitlement to service connection for a left shoulder disability is remanded. The Veteran seeks service connection for a left shoulder disability, which he claims was aggravated during a period of active service. In October 2018, the Board found that the VA opinions dated in October 2012 and April 2016 were inadequate for rating purposes and remanded this matter to obtain an adequate opinion addressing the etiology of the Veteran's left shoulder disability. The Board specifically asked the examiner to opine whether the Veteran has a left shoulder disability that clearly and unmistakably existed prior to his active service and if so, whether the disability was clearly and unmistakably not aggravated by service. An opinion was obtained in April 2019; however, the opinion is inadequate for rating purposes. Specifically, the examiner did not address whether the in-service injury in late 2005 aggravated the left shoulder disability. January 2006 service treatment records indicate that the Veteran had left shoulder pain following a fall two months prior. The diagnosis was shoulder sprain. The Veteran continued to report painful left shoulder throughout 2006, and in September 2006, the medical provider noted that the Veteran's pain was worse and that he possibly had a rotator cuff tear. The Veteran was put on a profile, which became permanent in March 2007. In March 2007, the provider stated that the Veteran had likely aggravated the left acromioclavicular (AC) joint, thus accelerating the arthrosis of the AC joint. The Veteran continued to report painful left shoulder in September 2011 at retirement from his final period of active service. The April 2019 VA examiner did not address any of this in-service medical treatment or findings; therefore, a remand is necessary to obtain an etiology opinion that considers this evidence. 2. Entitlement to service connection for right foot plantar fasciitis is remanded. The Veteran seeks service connection for plantar fasciitis of the right foot. The Board remanded this matter in October 2018 for an examination to determine the etiology of his disability. In April 2019, the Veteran attended a VA examination and the examiner provided an etiology opinion; however, the opinion is inadequate for rating purposes. The April 2019 examiner stated that the Veteran had plantar fasciitis in 2006 but that it was acute and since resolved. However, at retirement from his last period of active service, the Veteran indicated on the September 2011 RMH form that he had, or had a history of, right foot plantar fasciitis. The clinician indicated that the Veteran had right foot pain, possibly plantar fasciitis. Further, a March 2012 VA treatment record notes plantar fasciitis. The April 2019 VA examiner did not address these records. Therefore, an addendum opinion must be obtained that addresses whether the Veteran's right foot plantar fasciitis is ether related to service or whether it clearly and unmistakably pre-existed a period of active service and was clearly and unmistakably not aggravated during a period of active service. 3. Entitlement to service connection for a right foot disability, to include metatarsalgia with Morton's neuroma and paresthesia, is remanded. 4. Entitlement to service connection for a left foot disability, to include metatarsalgia with Morton's neuroma, is remanded. The Veteran seeks service connection for bilateral foot metatarsalgia with Morton's neuroma and right foot paresthesia. The Board remanded this matter in October 2018 for an examination to determine the etiology of his disabilities. In April 2019, the Veteran attended a VA examination and the examiner provided an etiology opinion; however, regarding the right foot, the opinion is inadequate for rating purposes. The April 2019 examiner stated that there was no objective evidence in the medical records to support the diagnosis of right metatarsalgia with Morton's neuroma or treatment for either of these conditions during service. However, the Veteran was treated for Morton's neuroma in the months prior to his last period of active service, and in fact, was placed on a profile in March 2010 for right foot Morton's neuroma. The Veteran indicated that he had or previously had Morton's neuroma on his September 2011 RMH form, and the clinician documented right foot pain, possibly plantar fasciitis. Notably, the clinician referred the Veteran for follow-up care. The examiner did not address these records or provide an opinion indicating whether the Veteran's right foot condition clearly and unmistakably pre-existed his last period of active service and was clearly and unmistakably not aggravated during his last period of active service. The Board points out that at the time the Veteran filed his claim, he filed for multiple foot disabilities. As a layperson, he is not expected to know the underlying pathology for all his symptoms. Significantly, the September 2011 RMH form shows the clinician documented right foot pain and during the October 2011 retirement examination, the examiner documented symptomatic feet, pes cavus. At the October 2012 VA examination, the Veteran was diagnosed with hammer toes of all toes, bilaterally; hallux valgus, bilaterally; and osteoarthritis, bilaterally. In January 2015, he had a continued diagnosis of hammer toes with foot pain. Since the Veteran was diagnosed with additional conditions within a year following separation from his last period of service and during the pendency of the claim, the Board finds that the Veteran's claims should be expanded to consider whether these bilateral foot conditions are related to service. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). On remand, an opinion should be obtained addressing the relationship, if any, between pes cavus, hammer toes, hallux valgus, and osteoarthritis of the feet, and active service. 5. Entitlement to service connection for onychomycosis is remanded. The Veteran seeks service connection for onychomycosis of the toenails. The Board remanded this matter in October 2018 for an examination to determine the etiology of his disability. In April 2019, the Veteran attended a VA examination and the examiner provided an etiology opinion; however, the opinion is inadequate for rating purposes. The April 2019 examiner stated that there is no objective evidence of a diagnosis of onychomycosis during the Veteran's periods of active service. She stated that per the Veteran's statement, the onset of his disability was in 2009. While the evidence shows the Veteran was treated for his fungal infection in 2009, to include removal of his nails in June 2009, he had a subsequent period of service from October 2010 to January 2012. Significantly, the Veteran reported continued nail problems in September 2011 and the October 2012 VA examination showed fungal infection of the toenails. The examiner did not address these records or provide an opinion indicating whether the Veteran's condition clearly and unmistakably pre-existed his last period of active service and was clearly and unmistakably not aggravated during his last period of active service. Accordingly, a remand is necessary to obtain an opinion addressing this matter. 6. Entitlement to service connection for gout of the right foot, right ankle, and right toes is remanded. The Veteran seeks service connection for gout. The Board remanded this matter in October 2018 for an examination to determine the etiology of his disability. In April 2019, a VA examiner provided an etiology opinion; however, the opinion is inadequate for rating purposes. Specifically, the examiner provided a negative opinion based, in part, on the finding that the Veteran was not treated for gout during active service. However, treatment records show the Veteran was prescribed medication and had an active diagnosis of gout throughout his period of active service in 2005. The examiner did not address this treatment. Further, the examiner indicated that the Veteran reported that his gout started in 1992. The examiner did not provide an opinion indicating whether the Veteran's condition clearly and unmistakably pre-existed his final two periods of active service and was clearly and unmistakably not aggravated during his last two periods of active service. Accordingly, a remand is necessary to obtain an opinion addressing this matter. 7. Entitlement to service connection for a left knee disability is remanded. The Veteran seeks service connection for a left knee disability. The Board remanded this matter in October 2018 for an examination to determine the etiology of his disability. In April 2019, the Veteran had a VA examination and the examiner provided a negative nexus opinion finding that the Veteran did not have a chronic left knee condition during service. However, the examiner did not address the September 2011 RMH, showing he marked "knee trouble" and indicated he had a left knee disability, to include arthritis. In October 2012, the Veteran was diagnosed with osteoarthritis of the left knee based on x-ray findings. He reported that his left knee symptoms started in 2005. Notably, the left knee was asymptomatic on examination. Given the indication of left knee pain at separation from his last period of active service, and the diagnosis of arthritis in October 2012, an addendum opinion must be obtained to determine whether the left knee arthritis is related to service or whether it clearly and unmistakably pre-existed his last period of active service and was clearly and unmistakably not aggravated during his last period of active service. 8. Entitlement to service connection for a right thumb disability is remanded. The Veteran seeks service connection for a right thumb disability, which he contends started during his first period of active service, in 1980 or 1981. See VA examination, October 2012. The Board remanded this matter in October 2018 for an examination to determine the etiology of his disability. In April 2019, the Veteran had a VA examination and reported that he injured his thumb in the 1980's while playing baseball. The examiner provided a negative nexus opinion based on a finding that there was no objective evidence of a history of a right hand or thumb injury or trauma during service. Service treatment records do not show injury to the thumb; however, on the September 2011 RMH, he noted a right thumb joint disability to include arthritis diagnosed by x-ray. The clinician noted osteoarthritis and degenerative joint disease of the right first metacarpal joint. On the October 2011 Report of Medical Assessment (RMA), the Veteran stated that he injured his thumb in 1980 playing softball. The October 2011 retirement examination report shows osteoarthritis of the right thumb. The April 2019 examiner did not address the September 2011 RMH or October 2011 RMA. As such, the opinion is inadequate for rating purposes and a remand is necessary to obtain an opinion addressing whether the right thumb disability is related to service or whether it clearly and unmistakably pre-existed any period of active service and was clearly and unmistakably not aggravated during active service. 9. Entitlement to service connection for hypertension is remanded. The Veteran seeks service connection for hypertension. The Board remanded this matter in October 2018 for an examination to determine the etiology of his disability. In April 2019, the Veteran attended a VA examination and the examiner provided an etiology opinion; however, the opinion is inadequate for rating purposes. Specifically, the examiner provided a negative opinion based, in part, on the finding that the Veteran was not treated for hypertension during active service. However, service treatment records show the Veteran was treated throughout his second period of service for hypertension. At retirement from his third period of service, the clinician documented on the September 2011 RMH that the Veteran was taking medication for hypertension. The examiner did not address these treatment records. Further, the examiner indicated that the Veteran reported that his hypertension started in the mid-1980s. The examiner did not provide an opinion indicating whether his subsequent periods of service aggravated his hypertension. Accordingly, a remand is necessary to obtain adequate opinions addressing whether the Veteran's hypertension is related to service or whether it clearly and unmistakably pre-existed a period of active service and was clearly and unmistakably not aggravated during a period of active service. 10. Entitlement to service connection for anemia is remanded. 11. Entitlement to service connection for splenomegaly is remanded. The Veteran seeks service connection for anemia and splenomegaly, which he contends were aggravated during service, to include as due to vaccines received in July 2005 in preparation for deployment. The Board remanded these matters in October 2018 for examinations to determine the etiology of his disabilities. In April 2019, the Veteran had a VA examination and the examiner provided negative etiology opinions, finding no nexus between his conditions and service because he was diagnosed in the early 1990s and not during active service. The examiner did not provide an opinion addressing whether either of his conditions were aggravated during his subsequent periods of active service; therefore, the opinions are inadequate for rating purposes. Accordingly, a remand is necessary to obtain adequate opinions addressing whether the Veteran's anemia and splenomegaly are related to service or whether the disabilities clearly and unmistakably pre-existed a period of active service and were clearly and unmistakably not aggravated during a period of active service. The Board points out that the Veteran's anemia and splenomegaly appear to have been symptoms of, or possibly progressed to, a diagnosis of myelofibrosis. VA treatment records show myelofibrosis was diagnosed in April 2014. On remand, the examiner should clarify the relationship between anemia, splenomegaly, and myelofibrosis, and indicate whether any of the diagnoses are related to service or have been aggravated during service. 12. Entitlement to service connection for major depression is remanded. The Veteran seeks service connection for major depression. The Board remanded this matter in October 2018 for an examination to determine the etiology of his disability. VA treatment records show the Veteran reported symptoms of depression to medical providers in 2009 and 2010. The Veteran reported continued symptoms during his period of service from October 2010 to January 2012. On the September 2011 RMH, the Veteran noted trouble sleeping and depression or excessive worry. The clinician documented symptoms of posttraumatic stress disorder (PTSD) with some evidence of depression and referred the Veteran for further evaluation. The October 2011 retirement examination report shows the examiner also noted symptoms of PTSD and referred the Veteran for further evaluation. The Veteran separated from service in January 2012 and in a February 2012 statement, he indicated that he had mild depression. In October 2012, the Veteran had a VA examination. The examiner diagnosed major depressive disorder, recurrent, episode in full remission, and indicated that the Veteran had a formally diagnosed condition but that his symptoms were not severe enough to either interfere with occupational and social functioning or to require continuous medication. In April 2019, the Veteran had a VA examination. The examiner stated that the Veteran did not have a current mental disorder diagnosis that met the DSM criteria. In a separate opinion, the examiner noted that the Veteran's depression was in full remission per the October 2012 examination. The examiner did not provide an etiology opinion. Notably, the October 2012 examiner specifically stated that the Veteran had a formally diagnosed condition but that his symptoms were not severe enough to either interfere with occupational and social functioning or to require continuous medication. As such, the Board finds that the Veteran did have a diagnosed disability during the pendency of the claim. On remand, the examiner must address the October 2012 diagnosis and indicate whether the Veteran's depression was either due to service or whether it clearly and unmistakably pre-existed a period of active service and was clearly and unmistakably not aggravated during a period of active service. The matters are REMANDED for the following actions: 1. Associate with the electronic claims file VA treatment records dated since October 2019. 2. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's left shoulder disability. After reviewing the claims file, the examiner should address the following: Does the Veteran have a left shoulder disability that clearly and unmistakably existed prior to his active service? The examiner is notified that the Veteran had active service from March 1978 to September 1983, July 2005 to July 2008, and October 2010 to January 2012. For any disability found to clearly and unmistakably exist prior to the Veteran's active service, was that disability clearly and unmistakably NOT aggravated by service? In forming the opinion, the examiner must note that the Veteran's lay statements alone are not a sufficient basis with which to support a finding that a disability clearly and unmistakably existed prior to service. With regard to any left shoulder disability determined to NOT clearly and unmistakably exist prior to the Veteran's active service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that such disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service. The rationale for all opinions expressed must be provided. In providing the opinions, the examiner must address the in-service treatment of a left shoulder injury in 2005 and 2006, and the clinician's finding that the Veteran had likely aggravated the left acromioclavicular (AC) joint, thus accelerating the arthrosis of the AC joint. A complete rationale must be provided for any opinion rendered. 3. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's right foot plantar fasciitis. After reviewing the claims file, the examiner should address the following: Does the Veteran have a right foot plantar fasciitis that clearly and unmistakably existed prior to any period of active service? The examiner is notified that the Veteran had active service from March 1978 to September 1983, July 2005 to July 2008, and October 2010 to January 2012. For any disability found to clearly and unmistakably exist prior to a period of active service, was that disability clearly and unmistakably NOT aggravated by service? In forming the opinion, the examiner must note that the Veteran's lay statements alone are not a sufficient basis with which to support a finding that a disability clearly and unmistakably existed prior to service. With regard to any right foot plantar fasciitis determined to NOT clearly and unmistakably exist prior to the Veteran's active service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that such disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service. The rationale for all opinions expressed must be provided. In providing the opinion, the examiner must address the September 2011 RMH form, showing right foot pain, possibly plantar fasciitis, and March 2012 VA treatment record diagnosing plantar fasciitis. 4. Obtain addendum opinions from an appropriate clinician regarding the etiology of the Veteran's bilateral foot disabilities other than plantar fasciitis. The examiner should specifically address the diagnoses of right foot Morton's neuroma, metatarsalgia, and paresthesia, as well as bilateral hammer toes of all toes, bilateral hallux valgus, and bilateral osteoarthritis. After reviewing the claims file, the examiner should address the following: Does the Veteran have a right foot Morton's neuroma, metatarsalgia, and paresthesia that clearly and unmistakably existed prior to any period of active service? Does the Veteran have bilateral hammer toes of all toes, bilateral hallux valgus, and bilateral osteoarthritis that clearly and unmistakably existed prior to any period of active service? The examiner is notified that the Veteran had active service from March 1978 to September 1983, July 2005 to July 2008, and October 2010 to January 2012. For any disability found to clearly and unmistakably exist prior to a period of active service, was that disability clearly and unmistakably NOT aggravated by service? In forming the opinions, the examiner must note that the Veteran's lay statements alone are not a sufficient basis with which to support a finding that a disability clearly and unmistakably existed prior to service. With regard to any foot disability determined to NOT clearly and unmistakably exist prior to the Veteran's active service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that such disability had its onset during a period of active service, or is otherwise etiologically related to such service. The rationale for all opinions expressed must be provided. In providing the opinion, the examiner must address the September 2011 RMH form with the clinician's note of right foot pain, possibly plantar fasciitis and October 2011 retirement examination, the examiner documented symptomatic feet, pes cavus. The examiner should also address the October 2012 diagnoses of hammer toes of all toes, bilaterally; hallux valgus, bilaterally; and osteoarthritis, bilaterally, regardless of whether the disabilities are currently present. 5. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's onychomycosis of the toenails. After reviewing the claims file, the examiner should address the following: Does the Veteran have onychomycosis of the toenails that clearly and unmistakably existed prior to any period of active service? The examiner is notified that the Veteran had active service from March 1978 to September 1983, July 2005 to July 2008, and October 2010 to January 2012. For any disability found to clearly and unmistakably exist prior to a period of active service, was that disability clearly and unmistakably NOT aggravated by service? In forming the opinion, the examiner must note that the Veteran's lay statements alone are not a sufficient basis with which to support a finding that a disability clearly and unmistakably existed prior to service. With regard to any disability determined to NOT clearly and unmistakably exist prior to the Veteran's active service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that such disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service. The rationale for all opinions expressed must be provided. In providing the opinion, the examiner must address the September 2011 RMH form, showing continued nail problems and the October 2012 VA examination showed fungal infection of the toenails. 6. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's gout. After reviewing the claims file, the examiner should address the following: Does the Veteran have gout that clearly and unmistakably existed prior to any period of active service? The examiner is notified that the Veteran had active service from March 1978 to September 1983, July 2005 to July 2008, and October 2010 to January 2012. For any disability found to clearly and unmistakably exist prior to a period of active service, was that disability clearly and unmistakably NOT aggravated by service? In forming the opinion, the examiner must note that the Veteran's lay statements alone are not a sufficient basis with which to support a finding that a disability clearly and unmistakably existed prior to service. With regard to any disability determined to NOT clearly and unmistakably exist prior to the Veteran's active service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that such disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service. The rationale for all opinions expressed must be provided. In providing the opinion, the examiner must address treatment/medications documented in 2005. 7. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's left knee disability. After reviewing the claims file, the examiner should address the following: Does the Veteran have a left knee disability that clearly and unmistakably existed prior to any period of active service? The examiner is notified that the Veteran had active service from March 1978 to September 1983, July 2005 to July 2008, and October 2010 to January 2012. For any disability found to clearly and unmistakably exist prior to a period of active service, was that disability clearly and unmistakably NOT aggravated by service? In forming the opinion, the examiner must note that the Veteran's lay statements alone are not a sufficient basis with which to support a finding that a disability clearly and unmistakably existed prior to service. With regard to any disability determined to NOT clearly and unmistakably exist prior to the Veteran's active service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that such disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service. The rationale for all opinions expressed must be provided. In providing the opinion, the examiner must address the September 2011 RMH, showing he marked "knee trouble" and indicated he had a left knee disability, to include arthritis. In October 2012, the Veteran was diagnosed with osteoarthritis of the left knee based on x-ray findings. 8. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's right thumb disability. After reviewing the claims file, the examiner should address the following: Does the Veteran have a right thumb disability that clearly and unmistakably existed prior to any period of active service? The examiner is notified that the Veteran had active service from March 1978 to September 1983, July 2005 to July 2008, and October 2010 to January 2012. For any disability found to clearly and unmistakably exist prior to a period of active service, was that disability clearly and unmistakably NOT aggravated by service? In forming the opinion, the examiner must note that the Veteran's lay statements alone are not a sufficient basis with which to support a finding that a disability clearly and unmistakably existed prior to service. With regard to any disability determined to NOT clearly and unmistakably exist prior to the Veteran's active service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that such disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service. The rationale for all opinions expressed must be provided. In providing the opinion, the examiner must address the Veteran's lay statement that he injured his thumb playing softball during his first period of service; the September 2011 RMH noting a right thumb joint disability to include arthritis diagnosed by x-ray; the September 2011 RMH clinician's note of osteoarthritis and degenerative joint disease of the right first metacarpal joint; and the October 2011 retirement examination report showing osteoarthritis of the right thumb. 9. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's hypertension. After reviewing the claims file, the examiner should address the following: Does the Veteran have a disability that clearly and unmistakably existed prior to any period of active service? The examiner is notified that the Veteran had active service from March 1978 to September 1983, July 2005 to July 2008, and October 2010 to January 2012. For any disability found to clearly and unmistakably exist prior to a period of active service, was that disability clearly and unmistakably NOT aggravated by service? In forming the opinion, the examiner must note that the Veteran's lay statements alone are not a sufficient basis with which to support a finding that a disability clearly and unmistakably existed prior to service. With regard to any disability determined to NOT clearly and unmistakably exist prior to the Veteran's active service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that such disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service. The rationale for all opinions expressed must be provided. In providing the opinion, the examiner must address the service treatment records showing the Veteran was treated throughout his second period of service for hypertension and the September 2011 RMH indicating that the Veteran was taking medication for hypertension. 10. Obtain addendum opinions from an appropriate clinician regarding the etiology of the Veteran's anemia and splenomegaly. After reviewing the claims file, the examiner should address the following: Are the Veteran's diagnoses of anemia and splenomegaly related to, or symptoms of, myelofibrosis? If so, the etiology of myelofibrosis must also be addressed. Does the Veteran have a disability that clearly and unmistakably existed prior to any period of active service? The examiner is notified that the Veteran had active service from March 1978 to September 1983, July 2005 to July 2008, and October 2010 to January 2012. For any disability found to clearly and unmistakably exist prior to a period of active service, was that disability clearly and unmistakably NOT aggravated by service? In forming the opinions, the examiner must note that the Veteran's lay statements alone are not a sufficient basis with which to support a finding that a disability clearly and unmistakably existed prior to service. With regard to any disability determined to NOT clearly and unmistakably exist prior to the Veteran's active service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that such disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service. The rationale for all opinions expressed must be provided. The examiner should address the Veteran's assertion that vaccines received in July 2005 in preparation for deployment aggravated his conditions. 11. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's major depression. After reviewing the claims file, the examiner should address the following: Does the Veteran have an acquired psychiatric disability that clearly and unmistakably existed prior to his active service? The examiner is notified that the Veteran had active service from March 1978 to September 1983, July 2005 to July 2008, and October 2010 to January 2012. For any disability found to clearly and unmistakably exist prior to the Veteran's active service, was that disability clearly and unmistakably NOT aggravated by service? In forming the opinion, the examiner must note that the Veteran's lay statements alone are not a sufficient basis with which to support a finding that a disability clearly and unmistakably existed prior to service. With regard to any disability determined to NOT clearly and unmistakably exist prior to the Veteran's active service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that such disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service. The rationale for all opinions expressed must be provided. In providing the opinions, the examiner must address the October 2012 VA examination report, which indicated a formal diagnosis of major depressive disorder; the September 2011 RMH showing the Veteran noted trouble sleeping and depression or excessive worry and the clinician noted symptoms of PTSD; the October 2011 retirement examination indicating symptoms of PTSD; and February 2012 lay statement noting mild symptoms of depression. 12. Confirm that the medical opinions provided comport with this remand, and undertake any other development found to be warranted. 13. Then, readjudicate the Veteran's claims on appeal. If the benefits sought on appeal remain denied, provide the Veteran and his/her representative a supplemental statement of the case and allow an appropriate period for response. L. Chu Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. G. Alderman, 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.