Citation Nr: 23020122 Decision Date: 03/31/23 Archive Date: 03/31/23 DOCKET NO. 18-23 086A DATE: March 31, 2023 ORDER Entitlement to an effective date prior to September 19, 2010, for the grant of service connection for bipolar disorder with posttraumatic stress disorder (PTSD) features is denied. Entitlement to an initial evaluation of 100 percent, from September 19, 2010, for bipolar disorder with PTSD features is granted. The application to reopen the previously denied claim of service connection for chronic anal fissure is granted. The application to reopen the previously denied claim of service connection for right eye disability is granted. The application to reopen the previously denied claim of service connection for a low back disability is granted. REMANDED Entitlement to compensation under 38 U.S.C. § 1151 for additional disability as a result of a repair surgery for ventral hernia at VA medical center (VAMC), claimed as unspecified intestinal obstruction with hypothermia, anemia, lactose intolerance, nausea, nutrition deficient, malabsorption, vitamin deficient, wound infection/sores, immune disorder, is remanded. Entitlement to service connection for GERD, claimed as signs of symptoms involving digestive system, gastrointestinal problems, digestive disorder, non-specific digestive complaints, as secondary to surgical residuals, status post ventral hernia repair, and/or service-connected bipolar disorder, is remanded. Entitlement to service connection for aortic valve stenosis, claimed as atherosclerotic heart disease, signs or symptoms involving cardiovascular system, as secondary to bipolar disorder, and/or surgical residuals, status post ventral hernia repair, is remanded. Entitlement to service connection for nerve damages, claimed with peripheral neuropathy, signs or symptoms involving nervous system as secondary to surgical residual, status post ventral hernia repair, is remanded. Entitlement to service connection for chronic anal fissure, to include as secondary to service-connected bipolar disorder is remanded. Entitlement to service connection for right eye disability, to include as secondary to bipolar disorder, and/or status post ventral hernia repair, is remanded. Entitlement to service connection for disability involving prostate gland and/or bladder disability, to include as secondary to bipolar disorder and/or surgical residuals, and/or status post ventral hernia repair, is remanded. Entitlement to service connection for joint pains, claimed with muscle pains, non-specific nervous complaints, sleep disturbance) Entitlement to service connection for lumbar spine disability is remanded. Entitlement to service connection for erectile disorder, to include as secondary to bipolar disorder and/or surgical residuals, status post ventral hernia repair, is remanded. Entitlement to service connection for chronic fatigue syndrome, claimed as non-specific nervous complaints, as secondary to surgical residuals, status post ventral hernia repair, is remanded. Entitlement to service connection for chest pains, claimed as shortness of breath, as secondary to aortic valve stenosis and/or bipolar disorder, is remanded. Entitlement to service connection for dizziness, claimed as non-specific ear condition, as secondary to surgical residuals, status post ventral hernia repair, and/or bipolar disorder, is remanded. Entitlement to service connection for eczema, claims as signs or symptoms involving skin, as secondary to surgical residuals, status post ventral hernia repair, is remanded. Entitlement to service connection for diabetes, as secondary to medication side effects of aortic valve stenosis, is remanded. Entitlement to service connection for hypertension, to include as secondary to surgical residuals, status post ventral hernia repair, is remanded. Entitlement to service connection for feet, claimed as unspecified condition of extremity, to include as secondary to surgery residuals, status post ventral hernia repair, is remanded. Entitlement to service connection for chronic abdominal pain, to include as secondary to bipolar disorder, and/or surgical residuals, status post ventral hernia repair, is remanded. Entitlement to service connection for bilateral leg disability, to include as secondary to surgical residuals, status post ventral hernia repair, and/or bipolar disorder, is remanded. Entitlement to service connection for sleep apnea, to include as secondary to bipolar disorder, is remanded. Entitlement to service connection for Bell's palsy, to include as secondary to surgical residuals, status post ventral hernia repair, is remanded. Entitlement to service connection for syncope, as secondary to bipolar disorder, and/or aortic valve stenosis, is remanded. Entitlement to SMC FINDINGS OF FACT 1. The Veteran's claim of service connection for bipolar and PTSD was denied in a December 17, 2004, rating decision. The Veteran was notified of this decision in a December 21, 2004, notification letter. No additional evidence or notice of disagreement was received within one year from the date of notification letter. 2. A claim to reopen the previously denied claim of service connection for a psychiatric disability was received on September 19, 2010; no documents that could be construed as an informal claim prior to that date were associated with the claims file. 3. With resolution of reasonable doubt in the Veteran's favor, the evidence of record indicates that after the April 2004 initial episode of paranoia, the Veteran's psychiatric symptoms have been productive, in severity, frequency, and duration, of total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place. 4. . In a December 2004 rating decision, the RO denied service connection for chronic anal fissure, right eye implant, and low back disability. The Veteran neither timely appealed nor submitted new and material evidence within the one-year appeal period. 5. Evidence received since this rating decision relates to unestablished facts necessary to substantiate the Veteran's claims for service connection for chronic anal fissure, right eye disability, and low back disability. CONCLUSIONS OF LAW 1. The December 2004 rating decision became final with respect to the claim of service connection for an acquired psychiatric disability. 38 U.S.C. § 7105 (c) (2000); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2004). 2. The criteria for entitlement to an effective date earlier than September 19, 2010, for the grant of entitlement to service connection for an acquired psychiatric disability are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.1 (p), 3.155, 3.156(b), 3.400. 3. With reasonable doubt resolved in favor of the Veteran, from September 19, 2010, the criteria for an initial rating of 100 percent for service-connected bipolar disorder with PTSD features are met. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. § 4.130, Diagnostic Code (DC) 9432. 4. The December 2004 rating decision that denied service connection for chronic anal fissure, right eye disability, and low back disability is final. 38 U.S.C. § 7105(c) (2000); 38 C.F.R. §§ 3.104(a), 3.160(d), 3.156(b), 20.302, 20.1103 (2004). 5. Evidence received since the rating decision is new and material, and the Veteran's claims for entitlement to service connection for chronic anal fissure, right eye disability, and low back disability are reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1976 to August 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from Department of Veterans Affairs (VA) Regional Office (RO)'s rating decision issued in August 2015. Earlier Effective Date 1. Effective date prior to September 19, 2010, for the grant of service connection for bipolar disorder with PTSD features Generally, when granting entitlement to service connection for a disability in response to an application to reopen a claim that had previously been denied, VA cannot assign an effective date earlier than the date of receipt of the application to reopen. 38 U.S.C. § 5110 (a); see also 38 C.F.R. § 3.400 (r) (effective date of reopened claim is date of receipt of claim or date entitlement arose, whichever is later); Comer v. Peake, 552 F.3d 1362, 1370 (Fed. Cir. 2009) ("The earliest effective date for an award based on a veteran's request to reopen a final decision based on new and material evidence is generally the date that the application to reopen was filed"). When determining the effective date of an award of compensation benefits, the Board is required to review all the communications in the file that could be interpreted to be a formal or informal claim for benefits. Lalonde v. West, 12 Vet. App. 377, 380-381 (1999). A claim is defined as a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. §§ 3.1 (p); 3.155. Any communication or action from a claimant indicating an intent to apply for one or more benefits under the laws administered by VA and which identifies the benefit sought, may be considered an informal claim. 38 C.F.R. § 3.155 (a). Thus, the essential elements for any claim, whether formal or informal, are "(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing." Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009); see also MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed. Cir. 2006) (holding that the plain language of the regulations requires a claimant to have an intent to file a claim for VA benefits). Based on a review of the evidence of record, the Board finds that an effective date prior to September 19, 2010, for the grant of service connection for acquired psychiatric disability is not warranted for the following reasons. The Veteran's claim of service connection for bipolar and PTSD was denied in a December 17, 2004, rating decision. The Veteran was notified of this decision in a December 21, 2004, notification letter. No additional evidence or notice of disagreement was received within one year from the date of notification letter. As such, the December 2004 rating decision became final. 38 U.S.C. § 7105 (c) (2000); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2004). No document that could be construed as an informal claim was submitted subsequent to the December 2004 rating decision and prior to the September 2010 submission of a VA Form 21-526 claiming service connection for PTSD. Accordingly, entitlement to an effective date prior to September 19, 2010, for the award of service connection for acquired psychiatric disability must be denied. For the above reasons, the evidence is neither evenly balanced nor approximately so regarding whether an earlier effective date is warranted for the award of service connection for a psychiatric disability. Rather, the evidence persuasively weighs against such a claim. The benefit of the doubt doctrine, see 38U.S.C. §5107 (b), 38 C.F.R. § 4.3, is therefore not for application in this regard. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). Increased Rating 1. Initial evaluation for bipolar disorder with PTSD features Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38U.S.C. §1155; 38C.F.R. §4.1. If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38C.F.R. §4.7. Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in VA's Rating Schedule. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). As this is an initial rating claim, the appeal period begins September 19, 2010, the effective date of the grant of service connection. Ratings are assigned according to the manifestation of symptoms and the extent to which they cause occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F. 3d 112, 115 (Fed. Cir. 2013). In this case, the Veteran's bipolar disorder with PTSD features is currently rated as 50 percent under the DC 9432. Under 38 C.F.R. § 4.130 and DC 9432 of the General Rating Formula, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such an unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. A total rating of 100 percent, which is currently assigned to the Veteran's schizoaffective disorder, is warranted for total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9432. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the veteran's symptoms, but it must also make findings as to how those symptoms impact the veteran's occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F. 3d 112, 114-18 (Fed. Cir. 2013). The Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Pursuant to Bankhead, "VA must engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment." For the following reasons, with resolution of reasonable doubt in the Veteran's favor, the evidence warrants an initial 100 percent rating for the entirety of the appeal. The evidence of record reflects that the Veteran was assessed with adjustment disorder with depressive mood at VA in July 1996. He reported having depression in his May1997 application for Social Security Benefits. Further, as a May 1999 private treatment record reflects, the Veteran reported being diagnosed with PTSD and he was depressed about declining health. An April 2001 VA treatment record indicates that he was treated for depression. An April 17, 2004, VA treatment record indicates that the Veteran presented to the Emergency Room (ER) with paranoid thoughts that his family was trying to kill him. The Veteran was offered inpatient psychiatric hospitalization, but he refused admission, stating he did not see how it would help him. Assessment was history of depression now presenting with paranoid ideation and rule out depression with psychotic features, rule out bipolar II. About 10 days later, he voluntarily came back to the ER with his wife. He had another episode of paranoia in May 2004. He was diagnosed with bipolar I disorder in May 2004. The Veteran was provided with prescription medications to treat his psychiatric disability. An August 2012 VA treatment record reflects that he reported having panic attacks both at night and during the day and he recognized that at times, his fears were out of touch with reality. A January 2014 VA treatment record indicates that the Veteran was admitted for psychiatric episode. A February 2014 VA treatment record indicates that the Veteran's psychiatric symptoms flared up lately because he reduced his medication on his own. It further indicates that the Veteran's paranoia episode led to some assault incidents involving the police. A May 2015 VA treatment record indicates that he reported having suicidal ideation with plants to shoot himself with a rifle. Viewed in its entirety, with resolution of reasonable doubt in the Veteran's favor, the evidence of record indicates that after the April 2004 initial episode of paranoia, the Veteran's psychiatric symptoms have been productive, in severity, frequency, and duration, of total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place. Since the initial episode in 2004, the Veteran's psychiatric symptoms have been managed with medications, and without strict compliance with the medications, he experiences flareups of his psychiatric symptoms with gross impairment in through process or communication, persistent delusions or hallucinations, grossly inappropriate behavior, and persistent danger of hurting self or others, for which he has been admitted to the hospital multiple times over the years, to include the appeal period pertinent to his claim. Accordingly, an initial evaluation of 100 percent since September 19, 2010, for service-connected acquired psychiatric disability is granted. NEW AND MATERIAL EVIDENCE 1. The application to reopen the previously denied claim of service connection for chronic anal fissure 2. The application to reopen the previously denied claim of service connection for right eye disability 3. The application to reopen the previously denied claim of service connection for a low back disability Generally, a claim that has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105 (c). The exception to this general rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim that has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means 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 previously of record and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). There is a low threshold for determining whether evidence raises a reasonable possibility of substantiating a claim. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For the purposes of establishing whether new and material evidence has been submitted, the credibility of the evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). In this case, the RO denied service connection for anal fissure, right eye implant, and a low back disability in a December 17, 2004, rating decision. It found for all the disabilities that the evidence did not show nexus with service. The Veteran was provided notice of the decision in a December 21, 2004, letter sent to his address of record which included notice of his procedural and appellate rights. The Veteran did not file a Notice of Disagreement challenging this determination, nor was additional evidence received within one year of the December 2004 notice letter. Thus, the December 2004 rating decision became final. 38 U.S.C. § 7105(c) (2000); 38 C.F.R. §§ 3.104(a), 3.160(d), 3.156(b), 20.302, 20.1103 (2004). Since the December 2004 rating decision, the Veteran has provided additional information about those disabilities. In an April 2013 statement, the Veteran reported that he has issues with anal fissure when he is severely constipated, and an August 2012 VA treatment record indicates that he was treated for constipation secondary to anticholinergic activity caused by psychiatric medications. He is currently service connected for bipolar disorder. As for the right eye disability, a September 2012 VA treatment record indicates that he complained that he was not able to open the right eye after the abdominal lipoma surgery in May, and he claims he has a right eye disability as a result of the surgery. Lastly, in a March 2014 VA Form 26-4555, the Veteran claims that he has low back pain due to the second abdominal surgery to remove a section of small intestines. In sum, in the additionally received evidence, the Veteran indicates that he has chronic anal fissure as secondary to service-connected psychiatric disability and a right eye disability and low back disability as a result of the hernia repair surgery at VA, and he raises a new basis for which those disabilities could be service connected. Thus, the additional evidence relates to the basis of the prior denial and raises a reasonable possibility of substantiating the claims. The Board thus considers it to be new and material. Reopening of the service connection claims for chronic anal fissure, right eye disability, and low back disability is therefore warranted. REASONS FOR REMAND 1. Entitlement to compensation under 38 U.S.C. § 1151 for additional disability as a result of a repair surgery for ventral hernia at VAMC, claimed as unspecified intestinal obstruction with hypothermia, anemia, lactose intolerance, nausea, nutrition deficient, malabsorption, vitamin deficient, wound infection/sores, immune disorder 2. Entitlement to service connection for GERD, claimed as signs of symptoms involving digestive system, gastrointestinal problems, digestive disorder, non-specific digestive complaints, as secondary to surgical residuals, status post ventral hernia repair, and/or service-connected bipolar disorder 3. Entitlement to service connection for aortic valve stenosis, claimed as atherosclerotic heart disease, signs or symptoms involving cardiovascular system, as secondary to bipolar disorder, and/or surgical residuals, status post ventral hernia repair 4. Entitlement to service connection for nerve damages, claimed with peripheral neuropathy, signs or symptoms involving nervous system as secondary to surgical residual, status post ventral hernia repair 5. Entitlement to service connection for chronic anal fissure, to include as secondary to service-connected bipolar disorder 6. Entitlement to service connection for right eye disability, to include as secondary to bipolar disorder, and/or status post ventral hernia repair 7. Entitlement to service connection for disability involving prostate gland and bladder, to include as secondary to bipolar disorder, and/or status post ventral hernia repair 8. Entitlement to service connection for joint pains, claimed with muscle pains, non-specific nervous complaints, sleep disturbance 9. Entitlement to service connection for lumbar spine disability 10. Entitlement to service connection for erectile disorder, to include as secondary to bipolar disorder and/or surgical residuals, status post ventral hernia repair 11. Entitlement to service connection for prostate gland and/or bladder disability, to include as secondary to bipolar disorder and/or surgical residuals, status post ventral hernia repair 12. Entitlement to service connection for chronic fatigue syndrome, claimed as non-specific nervous complaints, as secondary to surgical residuals, status post ventral hernia repair 13. Entitlement to service connection for chest pains, claimed as shortness of breath, as secondary to aortic valve stenosis and/or bipolar disorder 14. Entitlement to service connection for dizziness, claimed as non-specific ear condition, as secondary to surgical residuals, status post ventral hernia repair, and/or bipolar disorder 15. Entitlement to service connection for eczema, claims as signs or symptoms involving skin, as secondary to surgical residuals, status post ventral hernia repair 16. Entitlement to service connection for diabetes, as secondary to medication side effects of aortic valve stenosis 17. Entitlement to service connection for hypertension, to include as secondary to surgical residuals, status post ventral hernia repair 18. Entitlement to service connection for feet, claimed as unspecified condition of extremity, to include as secondary to surgery residuals, status post ventral hernia repair 19. Entitlement to service connection for chronic abdominal pain, to include as secondary to bipolar disorder, and/or surgical residuals, status post ventral hernia repair 20. Entitlement to service connection for bilateral leg disability, to include as secondary to surgical residuals, status post ventral hernia repair, and/or bipolar disorder 21. Entitlement to service connection for sleep apnea, to include as secondary to bipolar disorder 22. Entitlement to service connection for Bell's palsy, to include as secondary to surgical residuals, status post ventral hernia repair 23. Entitlement to service connection for syncope, as secondary to bipolar disorder, and/or aortic valve stenosis 24. Entitlement to SMC A remand is required to ascertain diagnoses or functional impairment and etiology of the disabilities claimed for service connection. A review of the evidence of record appears to raise a possibility that his psychiatric disability has been productive of or otherwise aggravating some of somatic symptoms. The evidence of record reflects that the Veteran underwent an exploratory laparotomy with a diagnosis of small vowel lipomatous mass in January 2012. And then, in May 2012, he underwent another exploratory laparotomy with extensive lysis of adhesions, small bowel resection, and hand-sewn enteroenterostomy. It appears that almost 80 centimeters of small bowel was resected during this procedure. Both procedures were conducted at VA. In a September 2014 VA Form 21-526, the Veteran stated that during the recovery from the bowel resection in May 2012, it was discovered by attending doctor that a nutrition supply IV was pinched and that he became cold and lost consciousness afterwards. Subsequent to the May 2012 procedure, various symptoms manifested, such as numbness and pain in the right side of his body, syncope, gastrointestinal issues, sensory decrease in bilateral legs and arms. An August 2012 treatment record from Conroe Regional Medical Center indicates that he was admitted with diagnoses of dysphagia, secondary to psychogenic causes; Bell's palsy; diabetes; hypertension; depression; sleep apnea; hyperlipidemia; PTSD with bipolar disorder. In the hospital course section, the treating physician noted that "[w]e feel that some of the symptomatology may be linked to his recent surgery, which may have been quite traumatic for him and causes exacerbation of his PTSD [with] various somatic complaints." A December 2012 VA treatment record documents the Veteran's complaint that he had progressively gotten worse since his surgery in January and May 2012 and that his partially clogged aorta valve could cause dizziness and loss of balance. Moreover, he also reported that his right side of the face was affected after the surgery and the affected side was becoming painful around the right eye socket. Additionally, the evidence also indicates that some of his claimed disabilities are proximately related to his psychiatric disability. For instance, an August 2012 VA treatment records reflects a note that constipation was secondary to anticholinergic activity caused by psychiatric disorder. A May 2007 VA treatment record indicates that shaking in the leg was more likely akithisia from Aripiprazole, antipsychotic medication. A March 2014 VA treatment record indicates that he had bladder issues while at sleep during which he often had nightmares due to his psychiatric disability. Lastly, some of the claimed disabilities could be a symptom of other claimed disabilities, such as chronic fatigue syndrome, neurological symptoms, joint pains, syncope, and chest pains. Accordingly, the Veteran must be afforded a VA examination to ascertain diagnoses and/or functional impairment of the claimed disabilities, and etiology opinions must be obtained. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The Board notes that the issue of entitlement to SMC is inextricably intertwined with the remanded service-connected disabilities. As such, it is remanded as well. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Obtain a copy of the informed consent document in its entirety, signed by the Veteran, for the January and May 2012 procedures related to his hernia. 2. Schedule the Veteran for a VA examination for ventral hernia, GERD, aortic valve stenosis, nerve damage, chronic anal fissure, right eye disability, disability involving prostate gland and bladder, lumbar spine, erectile disorder, chronic fatigue syndrome, dizziness, eczema, diabetes, hypertension, feet, chronic abdominal pain, bilateral leg disability, sleep apnea, Bell's palsy, and syncope. The examiner must review the claims file, to include this remand text, and conduct a thorough interview with the Veteran concerning symptomatology and etiology of the claimed disabilities. The examiner must also consider any relationship between his service-connected psychiatric disability and other disabilities, to include impact of the psychiatric medications. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. Or if the examiner can ascertain better diagnoses to characterize the Veteran's various disabilities, the examiner must report such diagnoses with explanation for the diagnoses. For the claim of the residuals of hernia repair surgeries in January and May 2012 pursuant to 38 U.S.C. § 1151, the examiner must provide the following opinions, after reviewing the entire claims file, to include relevant treatment records, operation reports, and signed informed consent: (a) Whether the Veteran has additional disability as a result of the January and May 2012 hernia repair surgeries. If the Veteran has additional disability, the examiner must further provide opinions on the following: (b) whether it is at least as likely as not (i.e., a 50 percent or more probability) that the Veteran's additional disability was caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part or VA's failure to exercise the degree of care that would be expected of a reasonable health care provider; and (c) whether it is at least as likely as not that any additional disability was due to an event not reasonably foreseeable. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not find to be an ordinary risk of the treatment or lack of treatment. For each claimed disability with a diagnosis or ascertainable functional impairment, to include ventral hernia for which the Veteran underwent repair surgeries, the examiner must provide following opinions: (a) whether it is at least as likely as not (approximately 50 percent or better probability) that the claimed disability is proximately due to or aggravated beyond its natural progression by a service-connected disability, to include bipolar disorder with PTSD features and/or medications for the disability; and (b) whether it is at least as likely as not (approximately 50 percent or better probability) that the claimed disability had its onset during service or is otherwise etiologically related to service. All opinions expressed must accompany sufficient explanation. 3. Review the claims folder and ensure that all the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. 4. Readjudicate the claims, to include the claim of entitlement to SMC. Emily Tamlyn Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Y. Taylor, 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.