Citation Nr: 22005201 Decision Date: 02/01/22 Archive Date: 02/01/22 DOCKET NO. 20-25 958 DATE: February 1, 2022 ORDER Entitlement to service connection for diabetes mellitus is denied. Entitlement to service connection for residuals of heat stroke is denied. Entitlement to service connection for nerve damage is denied. REMANDED Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) and/or depressive disorder, is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for migraines/headaches is remanded. Entitlement to service connection for a skin disability, to include acne, is remanded. Entitlement to service connection for left knee disability is remanded. FINDING OF FACT The most probative (meaning most competent and credible) evidence of record is against finding that the Veteran has diabetes mellitus, residuals of heat stroke, and/or nerve damage that was caused or aggravated by his active military service or that manifested to a compensable degree within a year of his separation from a qualifying period of service. CONCLUSION OF LAW The criteria are not met for entitlement to service connection for diabetes mellitus, residuals of heat stroke, and/or nerve damage. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from May 1983 to July 1987, from June 1988 to April 1989, from May 1991 to March 1992, and from December 1993 to August 1994. He also had additional periods of National Guard and/or Reserve service. The Veteran testified in support of these claims during an October 2021 "virtual" teleconference hearing before the undersigned Veterans Law Judge of the Board. A transcript of the proceeding is of record. In May 2021 correspondence to the Veteran, so before and in anticipation of his hearing, VA acknowledged that he was no longer being represented in this appeal because his representative had withdrawn. And this was confirmed during the hearing, and he elected to have it without any representative present and acting on his behalf, so he is proceeding with this appeal pro se. The Veteran was in the Coast Guard from June 1988 to April 1989. Service treatment records (STRs) from this period of service are not associated with his claims file, and he pointed this out during his hearing. Where possible, the Board is going ahead and adjudicating the claims that do not concern that service. That said, where STRs are missing, the Board has a heightened obligation to explain its findings and conclusions, a heightened duty to search for records and explain the efforts to that effect, and a requirement to carefully consider the benefit-of-the-doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The case law, however, does not lower the legal standard for proving a claim for service connection in this circumstance, instead, increases VA's obligation to evaluate and discuss in its decision all evidence that may be favorable to the Veteran. See Russo v. Brown, 9 Vet. App. 46 (1996). There is no presumption, either in favor of the claimant or against VA, arising from missing records. Service Connection In general, establishing service connection requires medical evidence or, in certain circumstances, lay evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a correlation ("nexus") between the disease or injury in service and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). See also 38 C.F.R. §§ 1110, 1131; 38 C.F.R. § 3.303. In addition, certain "chronic" diseases including diabetes mellitus, cardiovascular -renal disease (including hypertension) and organic diseases of the nervous system will be presumed to have been incurred in service, absent an intervening ("intercurrent") cause, if they were shown as chronic in service or if they manifested to a compensable degree within a year following separation from service, or if they were noted in service (or within the presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). "Active military, naval, or air service" includes active duty (AD) and any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or an injury incurred or aggravated in the line of duty, or any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury, though not also disease, incurred or aggravated in the line of duty or from an acute myocardial infarction, cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C. §§ 101(21), (24), 106; 38 C.F.R. § 3.6(a), (d). Reserve and National Guard service generally means ACDUTRA and INACDUTRA. ACDUTRA is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c). Basically, this refers to the two weeks of annual training that each Reservist or National Guardsman must perform each year. It can also refer to the Reservist's or Guardsman's initial period of training. INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d). Basically, this refers to the twelve weekend drills (each of which is usually divided into four, four-hour periods drills) that each Reservist or National Guardsman must perform each month. These drills are deemed to be part-time training. 1. Entitlement to service connection for diabetes The Veteran testified during his October 2021 hearing before this Board that he was diagnosed with diabetes during a period of service in the Reserves, but before he went back on AD. He further stated that Dr. Clark, who made this diagnosis, is no longer practicing (now out of business) but nonetheless told him that it was the type of diet he had had in service that made him diabetic, so he now has a vegetarian diet without red meat and salt, etc. But the Board finds that this contention of diabetes initially manifesting during AD or other qualifying service or manifesting to compensable degree within a year of separation from qualifying service lacks credibility. The first point worth noting in this regard is that this contention that Dr. Clark "told" the Veteran that his diabetes is related to his service or originated in service lacks probative value. As the U. S. Court of Appeals for Veterans Claims (Veterans Court/CAVC) has explained, the "connection between what a physician said and the layman's account of what he purportedly said, filtered as it was through a layman's sensibilities, is simply too attenuated and inherently unreliable to constitute 'medical evidence''' supporting a claim for service connection. See Robinette v. Brown, 8 Vet. App. 69, 77 (1995). Also, since the Veteran conceded that Dr. Clark is no longer practicing medicine, and has not for quite a while, there is no reasonable possibility of obtaining this doctor's records concerning his evaluation and treatment of the Veteran. 38 C.F.R. § 3.159(c)(1). It further deserves mentioning that reports of Medical History dated in April 1990, April 1994, and October 1996 all reflect that the Veteran contrarily denied sugar or albumin in his urine. Moreover, the corresponding Reports of Medical Examination likewise are unremarkable for suggestion of diabetes and/or specifically note that his urine was negative for sugar or albumin. Aside from that, a more recent May 2001 Report of Medical Examination again reflects that his endocrine system was normal and his urine, when tested, was negative for glucose. Still further, his Report of Medical History contains his personal acknowledgement that he was in "great health condition". He denied sugar or albumin in his urine. He again denied sugar in his urine even more recently in December 2004. The Veteran had no active service (i.e., AD or ACDUTRA) after May 16, 2006, also remembering that diabetes is a disease, not injury, therefore eliminating any INACDUTRA service from consideration. Perhaps most significant is a September 2008 letter from Dr. Clark (Northern Virginia Internal Medicine Associates) indicating the Veteran "was diagnosed with Type 2 Diabetes one year ago." This would mean an initial diagnosis of this disease in 2007, more than a decade after his separation from AD or more than a year after his last ACDUTRA in the Reserves/National Guard. Consider also that presumptive periods (allowing for initial manifestation of a "chronic" condition such as diabetes to a compensable degree within a year of separation from qualifying service) do not apply to periods of ACDUTRA or INACDUTRA, only instead to AD. See Biggins v. Derwinski, 1. Vet. App. 474, 477-78 (1991). As well, the lapse of time between service separation and the earliest documentation of the now claimed disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). See also Horn v. Shinseki, 25 Vet. App. 231, 239 (2012). Regarding this determinative issue of the etiology of his diabetes, the Veteran has not been shown to have the experience, training, or education necessary to give a probative opinion concerning the origins of it, including in terms of whether related or attributable to anything that occurred during his time in the military. This determination is beyond his lay competence, especially given this disease onset several, if not many, years after qualifying service, and records show he has a family history of this disease in his mother, father, and a sister. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011) (explaining that whether medical versus lay evidence is needed to support of a claim is fact specific, so dependent on the type of condition being claim in terms of whether complex or just simple; see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (indicating lay evidence must demonstrate some competence and affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). Since the most probative and therefore most persuasive, evidence is against this claim, not instead in approximate balance, the benefit of the doubt rule is not applicable. See Lynch v. McDonough, 999 F.3d 1391 (2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Thus, this claim is denied. 2. Entitlement to service connection for residuals of heat stroke AND 3. Entitlement to service connection for nerve damage The Veteran testified during his October 2021 Board hearing that, in 1985 or 1986, he passed out and was given an IV because of heat stroke or heat exhaustion. He said he was working in a temperature of 120 degrees, or higher, in a ship's hot engine room or quarters, and that he was unconscious for two days and woke up in sick bay. He also contends that, ever since, he has had migraines, intermittently slow or slurred speech, memory problems, and that doctors think he has consequent nerve damage due to a deficiency of oxygen. He says there was indication of white matter on a brain scan, which he suspects may be from not getting oxygen to his brain for some time. He added that he takes pills for his migraines every day, and that his doctors told him "most likely" or "yes" related to his service since there is no other possible source or cause. But those contentions notwithstanding, there are no STRs documenting the Veteran had a significant deficiency of oxygen. Rather, a September 1, 1985 STR explains that he had worked more than 11 hours in the past 24 hours with little intake except for soup and water. He reported feeling tired and nauseated but had no vomiting, chill, or sweat. He complained of a severe headache. He had no difficulty breathing. He reported that he had not been sweating much and had dark urine. It was noted that he felt fine, until that morning, and had stood four hours watch and then felt nauseous and weakness. It initially was suspected that he was a heat casualty, but he was given an IV and kept on the ward until he was afebrile. The next day, a September 2, 1985 STR clarifies his symptoms were not consistent with heat stress. It was noted that he now felt better and that he is well hydrated and rested. His symptoms were noted to probably be secondary to flu syndrome. Thus, his assertion that he was unconscious for two days lacks credibility because the STRs contemporaneous to that incident clarify that, on the day of that incident, he was able to inform a clinician of his symptoms and of the events preceding seeking treatment, and the next day he was released after feeling better, sleeping well, and eating breakfast. In establishing entitlement to service connection for a claimed condition, not only must there be probative evidence of relevant injury in service such as owing to the incident mentioned here, but there also must be "chronic" (i.e., permanent) disability resulting from that injury. And here, there is no probative evidence that, during the pendency of these claims, the Veteran has had residuals from that September 1985 incident during his service, however unfortunate. Notably, in Reports of Medical History subsequently dated in April 1990, August 1994, October 1996, May 2001, and December 2004, he denied epilepsy, fits, seizures, or convulsions, also denied fainting spells or passing out, denied frequent or severe headaches, denied heart problems, denied double vision, denied kidney problem, denied memory loss, and in the May 2001 report, when asked about nerve injury, he specifically denied it. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) ("[R]ecourse to the [Federal] Rules [of Evidence] is appropriate where they will assist in the articulation of the Board's reasons.")). Courts have recognized how medical history recounted during medical evaluation and treatment is especially probative (trustworthy) because the declarant has inherent incentive to give the most accurate history to, in turn, receive the best or most appropriate medical care. See Rucker, 10 Vet. App. at 73. See also AZ v. Shinseki, 731 F.3d 1303, 1318 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). A post-service March 2018 VA clinical record notes the Veteran had complaints of low back pain radiating into his left lower extremity. His clinical presentation was consistent with possible disc herniation with compression of his left L5 nerve root. Other records dated that same year, so also in 2018, indicate medication (Gabapentin) was prescribed. He has not established entitlement to service connection for any low back disability. The Veteran has not been shown to have the experience, training, or education necessary to diagnose a disability involving nerve damage or to assess residuals of heat stroke/stress or to provide a competent opinion regarding the cause or origins of any such disabilities in relation to his military service. When recognizing this, there is no probative evidence of record indicating that it is as likely as not the Veteran has a disability, to include nerve damage, memory loss, slurred or slow speech, or migraines, which was caused or aggravated by any qualifying period of service. Rather, the evidence contrarily indicates he does not have residuals of the September 1985 incident in service (which may have been the flu and not a heat stroke) or that his nerve damage alternatively is related or attributable to a service-connected disability, so even if caused or aggravated by the spine issue (disc herniation with compression of his left L5 nerve root) suspected in the years since conclusion of his service to establish secondary service connection. 38 C.F.R. § 3.310(a) and (b); Allen v. Brown, 7 Vet. App. 439 (1995). For these reasons and bases, the most probative and therefore most persuasive, evidence is against these claims, not instead in approximate balance, so the benefit of the doubt rule is not applicable, and these claims must be denied. REASONS FOR REMAND 4. Entitlement to service connection for an acquired psychiatric disability, including PTSD and/or depression, is remanded. Further development is required to obtain additional records relevant to this claim. The Veteran contends that he has depression (with some sort of aggressive disorder) and/or PTSD due to his service. He contends that he was diagnosed with depression while in the Coast Guard from June 1988 to April 1989 and discharged because of it. Official records, including a Department of Transportation Board for Correction of Military Records memorandum, indicate he was discharged for failure to meet minimal swimming requirements. As already mentioned, however, STRs and all other records, including personnel, concerning the Veteran's service the Coast Guard are not associated with his VA claims file. Moreover, he alleged during his hearing before this Board that military officials and authorities in service made it seem that his premature discharge was because of failing a swim test when, in actuality, it was owing to his mental impairment now being claimed. He added that he contested that initial characterization of his discharge, which in turn resulted in it being changed to "for the convenience of the government". In January 2018 correspondence, VA requested that the Veteran provide the unit of his Coast Guard service so that it may obtain relevant records. In February 2018, he replied that he had been stationed at Curtis Bay, Maryland, as a buoy tender. His DD Form 214 reflects that his last duty station was USCGC Red Birch, Baltimore, Maryland. VA therefore should attempt to obtain all his Coast Guard records. Reports of Medical History show the Veteran denied having depression or excessive worry or nervous trouble of any sort. See, e.g., April 1990, August 1994, October 1996, and May 2001 reports. In other testimony during his hearing before this Board, the Veteran said that he has been seen at the Bethesda Medical Center and that he has the required diagnosis, also that he is currently receiving treatment for his mental illness at the VA Medical Center (VAMC) in Martinsburg, West Virginia. He added that he also has received a diagnosis from a private clinician and even elsewhere (so he says 4 different sources confirm the diagnosis), that he has been dealing with this issue (in fact, hiding it) for many years now, and that it has affected his personal life (divorced 3 times, previously homeless, and cannot work). He also maintains the required "nexus" is established if VA adjudicators "put 2 & 2 together" when comparing his current diagnoses to what happened during his service, even if the records, themselves, do not necessarily provide the required link because his doctors were more concerned with treating his mental health rather than etiology. A November 2002 National Institute of Health (NIH) record explains the Veteran experienced trauma at age 18 when he was held at gunpoint and saw a friend shot in Jamaica. The consequent diagnoses were PTSD and major depressive disorder. He had not yet been in service at age 18; he did not join the military until he was over 20. Moreover, the incident occurred in Jamaica, where he was born and raised. Thus, the evidence indicates the incident forming the basis of his PTSD and major depressive disorder (MDD) diagnoses occurred prior to his service, not during, therefore outside the confines or parameters of it. That notwithstanding, a May 2005 private record (Dr. Patel) shows that a screening revealed severe depression; the Veteran consequently was started on Cymbalta. In March 2017, VA requested that the Veteran provide specific details of the alleged trauma that resulted in PTSD; however, he failed to provide details or return the provided VA Form 21-0781, despite being notified that it may result in a denial of his claim if he did not respond. A September 2019 VA record reflects that the Veteran does not have a PTSD diagnosis, despite seeking treatment. An October 2019 VA record reflects that he was interested in getting treatment for PTSD, but not necessarily because of his military service. It was noted that he had been seen at the Vet Center for 9 months. Another October 2019 VA mental health record for PTSD assessment shows he provided several examples of traumatic events that he had endured in his life, some of which meet the requirements of PTSD while some did not, and the events that did meet the requirement were from both his time in service and from when he was a child and from after he had separated from the military. The examiner found that it was clear that no one Criterion A event was responsible for the Veteran's symptom presentation. Service connection for PTSD requires medical evidence establishing a diagnosis of this condition in accordance with 38 C.F.R. § 4.125(a) (meaning in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM)), credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). Here, though, the Veteran has failed to provide VA with sufficient information or details regarding his alleged stressors to permit them to be corroborated. However, so nonetheless, VA has a duty to attempt to obtain his Vet Center records. If these records, or updated VA clinical records, tend to substantiate an alleged stressor, VA should attempt to verify it. Thereafter, if there is a verified stressor, the Veteran should be scheduled for an examination to determine whether he has an acquired psychiatric disability that is as likely as not related or attributable to his service, rather than to anything that occurred before or since his service or during a time that may not be considered qualifying service. To this end, the examiner should consider the pertinent evidence of record that has been discussed and, if also relevant, that the Veteran has a family history of depression (father and sister) and that he reported working in a civilian capacity in Afghanistan. 5. Entitlement to service connection for sleep apnea is remanded. The Veteran received a diagnosis of sleep apnea in 2005. He contends that his sleep apnea began during his time in the Coast Guard (June 1988 to April 1989), when he was shaken at times to be woken up from his sleep since he reportedly had stopped breathing (apnea). He also contends that it is due to his alleged PTSD and other mental impairment. Thus, his Coast Guard records should be obtained. Also, this claim is "inextricably intertwined" with his claim of entitlement to service connection for an acquired psychiatric disability. Thus, for that reason alone, the Board must temporarily defer deciding this claim until completion of the additional development being directed concerning that other claim. The Veteran's Reports of Medical History and NIH Self-Report of Medical History show he denied frequent trouble sleeping. See, e.g., April 1990, August 1994, October 1996, May 2001, November 2002, and December 2004 reports. The May 2001 report also notes that he denied easy fatigability. An April 2005 private record (Dr. Patel) relates the Veteran was seen for an initial visit. Among other complaints, he said he had some snoring at nighttime, fatigue during the daytime for a long time, and that his family had noticed that he stopped breathing off and on during the nighttime. He therefore was referred for a sleep study and advised to exercise, modify his diet, and lose weight. A May 2005 record confirms sleep apnea was diagnosed based on the results of that sleep study. Obstructive sleep apnea in adults is seen primarily in middle-aged obese individuals, with male predominance. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY. Records show the Veteran weighed 229 lbs. and was 71 inches tall with a body mass index (BMI) of 32 in May 2005, which is heavier than his weight when he was on AD. Moreover, his contention that his sleep apnea began between June 1988 and April 1989 would have been when he was only 23 or 24 years old (i.e., not middle age). The Veteran contends that he was diagnosed with sleep apnea prior to his 2005 AD service. He had no AD or ACDUTRA between May 2004 and May 2005, also keeping in mind that obstructive sleep apnea (OSA) is a disease, not injury, therefore is excluded from any INACDUTRA service. As a body of lay adjudicators, the Board cannot assess symptoms of sleep apnea; however, a clinician with this qualification should opine on whether the Veteran's Reports of Medical History in service, and his denials of various complaints (e.g., headaches, sleep problems), are probative of whether he had sleep apnea during his service. Other relevant factors may include his weight and age upon diagnosis. In addition, if there is an indication that his sleep apnea is related to a service-connected disability, either by way of causation or aggravation, an opinion on this should be obtained as well. Finally, the dates of the Veteran's AD, ACDUTRA, and INACDUTRA service between May 17, 2005 and May 16, 2006, should be ascertained and documented in his VA claims file. 6. Entitlement to service connection for hypertension is remanded. The Veteran contends that he has hypertension related to his sleep apnea which, in turn, is related to his PTSD. Thus, this claim also is "inextricably intertwined" with those other claims meaning that it, too, cannot be decided until completion of the additional development being directed concerning those other claims. Reports of Medical History show the Veteran denied high blood pressure, much less persistently elevated blood pressure suggestive of hypertension. See, e.g., reports dated in April 1990, August 1994, October 1996, May 2001, and December 2004. Moreover, the corresponding Reports of Medical Examination do not reflect hypertension either by complaint or diagnosis. The Veteran testified that he was diagnosed with hypertension by Dr. Patel before a period of AD in 2005. Clinical records do not support this assertion. 2005 private records from Dr. Patel show blood pressure readings of 128/94 (April 2005), 118/82 (May 2005), and 120/78 (June 2005). Only that initial reading of diastolic pressure (the bottom number) was marginally elevated. It was noted that he had sleep apnea, depression, and hyperlipidemia (elevated cholesterol). He resultantly was advised to lose weight. It also was noted that his father has hypertension. The records are unremarkable for a diagnosis of hypertension as relating to the Veteran, personally. The Board acknowledges that an earlier September 1985 STR notes a blood pressure of 140/100 when he was obtaining treatment for several symptoms, but subsequent readings that same day reflect that it was 128/96, 112/74, and 122/72 when again measured. Thus, only the diastolic pressure during that re-take was marginally elevated. A September 2005 STR indicates that, while being seen for sinusitis and allergic rhinitis, the Veteran had a blood pressure reading of 157/103; however, the record also notes that, when taking manually, his blood pressure was only 122/88; the record is unremarkable for a diagnosis of hypertension. Thus, the evidence currently in the file does not tend to support finding entitlement to service connection on a direct incurrence basis. However, if probative evidence obtained on remand tends to indicate the Veteran's hypertension may be due to, or aggravated by, a service-connected disability, a clinical opinion should be obtained to assist in determining whether there is this correlation. 7. Entitlement to service connection for a skin disability is remanded. The Veteran informed a 2017 DBQ examiner that his skin rash began in approximately 1989, and that it comes and goes, with each episode lasting a month, and then returning in approximately one month. He testified during his October 2021 hearing before this Board that it is due to exposure to metals and oils while in the Navy from 1983-1987. His STRs shows he was treated for acne/urticaria (January, March, and June 1984), had chicken pox/varicella (June 1991), was concerned about herpes (June 1994), and received a diagnosis of intradermal nevi (June 1994). A January 1998 private record from Kaiser Permanente reflects explains the Veteran had breakouts on his face; a July 1999 record notes continuous treatment for acne; and a May 2000 record notes that he reported having acne "for years" and had pigmented areas on his back. A July 2016 VA clinical record relates the Veteran complained of a rash on both arms for three months. It was observed to be near his elbow and forearm. This onset would be more than a decade after his separation from service. A September 2016 VA clinical record shows he reported that his rash, which was itchy and over his body for the last several days, had gotten worse after taking HCTZ. November 2016 records list a diagnosis of lichen simplex chronicus/prurigo nodularis, which is the end-result of scratching; it also was noted that the problem had begun in July 2016, so long after conclusion of his service. Thus, the evidence currently of record does not tend to support the notion that the Veteran's conditions began during the 1980s and 1990s caused itching and scratching more than a decade later or that they caused continuity of itching and scratching since his service. Reports of Medical History after the 1994 skin complaints indicate that, in August 1994, October 1996, and May 2001, he denied having a chronic skin disorder. In addition, the May 2001 record notes there were no sequalae (meaning residuals) of chicken pox. In a December 2004 Report of Medical History, he specifically denied having eczema, psoriasis, and atopic dermatitis. Moreover, corresponding Reports of Medical Examination note normal skin (except for tattoos) upon evaluation. Nevertheless, Coast Guard STRs, if any are obtained, may be probative. A September 2017 DBQ contains the opinion of the examiner that it is less likely than not the Veteran has a current skin disability owing to his military service. The examiner's opinion considered the Veteran's contentions but found that there was no evidence of lichen simplex chronicus during his active service upon which to support an etiology. The examiner did not discuss the Veteran's acne or any residuals of it; thus, an addendum opinion is needed. 8. Entitlement to service connection for migraines is remanded. The Veteran contends that, since his alleged heat stroke in 1986, he has had recurring migraines. But for the reasons and bases already discussed, the Board has denied his claim of entitlement to service connection for residuals of heat stroke, so he cannot relate or attribute his migraines to his service on that premise of secondary service connection. The Board, however, is considering whether service connection is warranted alternatively on another basis for his alleged migraines. STRs note headaches in service, but they are usually associated with other complaints such as gastroenteritis (July 1983), possible flu syndrome (March 1985), fever (January 1986) and sore throat and chills (January 1987). In comparison, an October 1986 STR notes a complaint of headache only. The Veteran's Reports of Medical history show he denied frequent or severe headaches. See, e.g., April 1990, August 1994, October 1996, May 2001, and December 2004 reports. The same is true for a November 2002 NIH Self-Report of Medical History. Thus, based on the evidence currently of record, his contention of continuity of symptoms since 1986 lacks credibility. The earliest post-service complaint of headaches is not until in 2016. A May 2016 VA clinical record relates the Veteran reported "high blood pressure with headache"; it was noted that he had run out of his blood pressure medication 10 days earlier. A September 2016 record notes a headache, and that he had taken his blood pressure medication three days earlier. Another September 2016 record reflects that he reported running out of his blood pressure medication approximately a month earlier and since noticing more frequent headaches, also that he is much better when he takes his medication. A November 2017 VA clinical record indicates the Veteran reported intermittent headaches. He gave a history of an abnormal brain MRI 10 years earlier at Emory University with noted "white spots". Despite being made aware of what is necessary to substantiate his claim, he has not provided evidence of "white spots" on his brain from approximately 2007 that are indicative of having begun during his service or are otherwise related or attributable to his service. See 38 C.F.R. § 3.303(d). An October 2018 VA record shows the Veteran reported headaches, right hand clumsiness, and then recent Lyme's disease. On CT scan, there was no evidence of intracranial hemorrhage, mass effect or acute cortical stroke. A May 2018 VA clinical record notes the Veteran reported "chronic left sided headaches with photophobia and phonophobia. Has had them for many years on beta blocker for migraine prevention and [blood pressure]. Has had mri in the past with "white spots"'. A May/June 2019 DBQ explains the Veteran reported having right-sided headaches. A June 2019 MRI indicates "there is no acute intracranial abnormality. Several nonspecific small, scattered areas of T2/FLAIR signal hyperintensity in the subcortical and periventricular white matter are likely sequela of chronic mild microangiopathic ischemic white matter disease." The examiner opined that it is less likely than not the Veteran has a headache disability because of his service. The examiner considered the extensive STRs, private records, and medical literature and found no evidence of a chronic headache condition in service or symptoms that can be attributed to chronic headaches. The examiner also reasoned that, although there is mention of episodic headaches in service, these symptoms were related to minor illness or without evidence of chronicity. In addition, the examiner surmised the Veteran's headache condition started well after he separated from service. That opinion notwithstanding, if the RO finds that service connection is warranted for hypertension, a clinical opinion then will be needed regarding whether it is as likely as not that any headache disability is caused or aggravated by it. 9. Entitlement to service connection for a left knee disability is remanded. A December 1985 STR indicates the Veteran had multiple complaints that included left knee pain. It was noted that he was on a soccer team, and that his complaints were due to his last leave. Upon examination, his left knee did not have effusion and had full range of motion. McMurray and anterior drawer tests were negative for meniscus damage. His medical collateral ligament (MCL) and anterior cruciate ligament (ACL) were stable. The assessment was "stable knee [with] chronic pain. No evidence of serious pathology. [Probably a] strain." After AD service, a July 1998 Kaiser record shows the Veteran was seen for evaluation of left knee injury. He reported injuring his right knee in May 1998 and, approximately two weeks later, he was refereeing a soccer match, stepped in a pothole and twisted his left knee. He heard a loud pop and was unable to bear weight and had significant immediate swelling. It was noted that, in May 1998, an X-ray was negative and revealed normal knees. The diagnosis was sprain. An April 2000 Kaiser Permanente record shows the Veteran reported left knee pain for many years, noting he had injured it playing soccer in 1987 and again in 1998. X-rays showed marginal osteophytes. It was suspected that he had early degenerative joint disease (DJD), i.e., arthritis. Reports of Medical History and medical prescreening show the Veteran denied a trick or locked knee, denied arthritis, denied bone, joint, or other deformity, denied a knee problem, denied giving way of the knee, and/or denied limitation of motion of the knee. See, e.g., April 1990, August 1994, October 1996, May 2001, November 2002, and December 2004 reports. A May 2019 DBQ examiner found it less likely as not the Veteran had a left knee disability because of his service. The rationale cited a lack of complaints in service after 1985, or diagnosis of a left knee disability in service, and the two decades after separation from service until diagnosis. However, records show the Veteran received an intervening diagnosis of left knee marginal osteophytes in 2000. Thus, an addendum opinion is needed. Accordingly, these claims are REMANDED for the following action: 1. Ascertain the exact dates when the Veteran was on AD, ACDUTRA, and INACDUTRA while in the National Guard and Reserves between May 17, 2005 and May 16, 2006 including, if necessary, by obtaining his Master Military Pay Account (MMPA) History report for that time period. 2. Also obtain the Veteran's Coast Guard service personnel records (SPRs) and STRs from June 1988 to April 1989 (regarding his claimed service at Curtis Bay, Maryland, and/or at USCGC Red Birch, Baltimore, Maryland). 3. Ask the Veteran to complete an authorization form (VA Form 21-4142) so that VA may obtain the records of his mental health care at the Vet Center he has cited. If he provides this necessary authorization, obtain these additional records. 4. Obtain the Veteran's VA treatment records from March 2020 to the present. 5. If the Veteran's alleged PTSD stressors are not noted in Vet Center or VA clinical records, again request that he provide VA with details regarding his alleged stressors. 6. Thereafter, if the Veteran has verified or credible stressors, schedule him for an examination to ascertain whether it is as likely as not (50 percent or greater probability) that he has an acquired psychiatric disability (PTSD, MDD, or whatever other diagnosis) because of his military service. To this end, the examiner should consider the pertinent evidence of record, to include: a) the Veteran's Reports of Medical History showing he denied depression or excessive worry or nervous trouble of any sort (April 1990, August 1994, October 1996, May 2001); b) the November 2002 NIH record explaining he had experienced trauma at age 18 (so before his service) when he was held at gunpoint and saw a friend shot in Jamaica; the resultant diagnoses of PTSD and MDD; c) May 2005 private records (Dr. Patel) explaining that a screening revealed severe depression; the Veteran consequently was started on Cymbalta; d) October 2019 VA treatment records; and e) his civilian employment (e.g., work in Afghanistan), if it is relevant. If the examiner determines the Veteran meets the criteria for a DSM-5 diagnosis, whatever that may be, the examiner must discuss the etiology and time of onset in relation to the Veteran's service. 7. If clinical records indicate the Veteran's sleep apnea may be due to or aggravated by his service or a service-connected disability (including by an acquired psychiatric disability if it first is determined to be related or attributable to his service), obtain a clinical opinion concerning whether it is as likely as not (50 percent or greater probability) his sleep apnea is caused or aggravated by his service or a service-connected disability. In making this important determination, the examiner should consider the pertinent evidence to include: a) the Veteran's Reports of Medical History and NIH Self-Report of Medical History showing he denied frequent trouble sleeping (April 1990, August 1994, October 1996, May 2001, November 2002, and December 2004 reports), and the May 2001 report also noting he denied easy fatigability; b) his risk factors for sleep apnea; c) the diagnosis in May 2005; and d) whether his STRs are suggestive of symptoms of sleep apnea. If the examiner finds that it is as likely as not (50 percent or greater probability) the Veteran's sleep apnea is aggravated by a service-connected disability, the examiner should, if possible, determine the degree of aggravation (i.e., the baseline of disability before aggravation in comparison to the degree after it). 8. If clinical records indicate the Veteran's hypertension may be due to, or aggravated by, a service-connected disability (including an acquired psychiatric disability or sleep apnea if they are first determined to be attributable to his service), a clinical opinion should be obtained concerning whether it is as likely as not (50 percent or greater probability) the Veteran has a service-connected disability that aggravates his hypertension. In confirmed, the examiner should, if possible, also specify the degree of aggravation (i.e., the baseline of disability before aggravation in comparison to the degree after it). 9. Schedule the Veteran for an examination to determine whether he has acne and, if so, whether it is as likely as not (50 percent or greater probability) causally related to his service, including to his complaints in service (January, March, and June 1984, April 1990, January 1992, January and June 1994). The examiner also should consider the Veteran's post-service complaints (January 1998, July 1999, and May 2000 Kaiser Permanente records). 10. If the RO finds that service connection is warranted for hypertension, obtain a clinical opinion concerning whether it is as likely as not (50 percent or greater probability) the Veteran has headaches including especially migraines, that are caused OR aggravated by his hypertension. The examiner should consider the pertinent evidence of record to include: a) a May 2016 VA clinical record showing the Veteran reported "high blood pressure with headache"; it was noted that he had run out of his blood pressure medication 10 days earlier; b) September 2016 records noting he reported more frequent headaches since running out of his medication, and that he is much better when he takes his medication; c) an October 2018 VA record showing he reported headaches, right hand clumsiness and then recent Lyme's disease; on CT scan, there was no evidence of intracranial hemorrhage, mass effect or acute cortical stroke; d) a June 2019 MRI indicating "there is no acute intracranial abnormality. Several nonspecific small, scattered areas of T2/FLAIR signal hyperintensity in the subcortical and periventricular white matter are likely sequela of chronic mild microangiopathic ischemic white matter disease." 11. Obtain a supplemental opinion to the May 2019 DBQ concerning whether it is as likely as not (50 percent or greater probability) the Veteran has a left knee disability because of his service, with consideration of records not noted to have been reviewed in the May 2019 DBQ, including a post-service July 1998 Kaiser Permanente record indicating the Veteran reported injuring his left knee in approximately May or June 1998, a report that a May 1998 X-ray was normal, and an April 2000 Kaiser Permanente record noting an X-ray showed marginal osteophytes. KEITH W. ALLEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Wishard 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.