Citation Nr: A25035238 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 240319-426739 DATE: April 16, 2025 ORDER Entitlement to service connection for right wrist disability is denied. Entitlement to service connection for right elbow disability is denied. Entitlement to service connection for left elbow disability is denied. REMANDED Entitlement to service connection for bilateral foot disability, to include plantar fasciitis, is remanded. Entitlement to service connection for pseudofolliculitis barbae is remanded. Entitlement to service connection for dry skin disability is remanded. Entitlement to service connection for psychiatric disability, to include depression, is remanded. Entitlement to service connection for sinus disability is remanded. Entitlement to service connection for respiratory disability (claimed as dry cough) is remanded. Entitlement to service connection for toenail fungus disability is remanded. FINDINGS OF FACT 1. The evidence of record persuasively weighs against finding that the Veteran's right wrist disability began during active service or is otherwise related to an in-service injury or disease. 2. The evidence of record persuasively weighs against finding that the Veteran's right elbow disability began during active service, manifested to a compensable degree within a year of service, or is otherwise related to an in-service injury or disease. 3. The evidence of record persuasively weighs against finding that the Veteran's left elbow disability began during active service, manifested to a compensable degree within a year of service, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for right wrist disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for right elbow disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for left elbow disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1969 to December 1971. In May 2023, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of a January 2023 decision denying service connection for depression, bilateral plantar fasciitis, bilateral toenail fungus, elbows, dry cough, dry skin, pseudofolliculitis of face, right wrist, and sinusitis. In August 2023, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal (for the issues of service connection for dry cough, dry skin, depression, plantar fasciitis, pseudofolliculitis barbae, and sinusitis), which considered the evidence of record at the time of the prior January 2023 decision. In the March 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, for the issues of service connection for dry cough, dry skin, depression, plantar fasciitis, pseudofolliculitis barbae, and sinusitis, the Board may only consider the evidence of record at the time of the January 2023 AOJ decision, which was subsequently subject to higher-level review. 38 C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the decision, which was subsequently subject to higher-level review the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801. Upon receipt of the May 2023 HLR request, the AOJ identified duty to assist errors as to the issues of service connection for toenail fungus, right wrist disability, and right and left elbow disability. After developing the claims, the AOJ issued a decision in January 2024, considering the evidence of record at the time of the January 2024 rating decision. Therefore, for the issues of service connection for toenail fungus, right wrist disability, and right and left elbow disability, the Board may only consider the evidence of record at the time of the January 2024 rating decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. However, for remanded claims, any evidence the Board could not consider will be considered by the AOJ in the adjudication of the claims. 38 C.F.R. § 3.103(c)(2)(ii). The Board has expanded the Veteran's claims as reflected above, in light of the evidence in the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service Connection Generally, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases, such as arthritis, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable 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. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). If a veteran was exposed to an herbicide agent during active military, naval, or air service, during the period beginning on January 9, 1962, and ending on May 7, 1975, in the Republic of Vietnam (Vietnam), including the waters offshore, and other identified locations, certain diseases may be service connected if the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service. 38 C.F.R. §§ 3.307(d), 3.309(e). Here, the Veteran has conceded service in Vietnam during the Vietnam War and is presumptively exposed to herbicide agents. In addition, on August 10, 2022, a statute known as "the PACT Act" was signed into law expanding the scope of presumed in-service toxic exposures. See Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), Pub. L. 117-168 (August 10, 2022). The legislation established standards for Veterans exposed to toxic exposure risk activities (TERAs). Although VA has an obligation to obtain medical opinions for any service connection claim which cannot be granted where there is evidence of a TERA and of a disability, VA has identified several exceptions to this general obligation where there is no indication of an association between the disability and the TERA. See 38 U.S.C. § 1168(b). Specifically, a TERA opinion is not required for disabilities resulting from physical trauma; mental disorders; disabilities that have not been shown to have any positive association with herbicide exposure; and disabilities that manifested during service or with a clear etiology that is not associated with toxic exposure. See VBA Letter 20-22-10 at 10-13, Processing Claims Involving the PACT Act, 87 Fed. Reg. 78,543 (Dec. 22, 2022). In this case, while the Veteran has presumed in-service TERAs, including conceded herbicide agent exposure, no opinion is needed regarding whether the Veteran's right wrist and bilateral elbow disabilities are related to such exposures. Rather, an exception to the requirement for a TERA examination under the PACT Act applies as the Veteran's wrist and elbow claims are based on physical trauma - from heavy lifting as a rifleman during service. See 38 U.S.C. § 1168(b); VBA Letter 20-22-10 at 11-12. In cases where a veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C. § 1154(b) and its implementing regulation, 38 C.F.R. § 3.304(d), are applicable. This statute and regulation ease the evidentiary burden of a combat veteran by permitting the use, under certain circumstances, of lay evidence. If the veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that in the case of a combat veteran not only is the combat injury presumed, but so is the disability due to the in-service combat injury. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). To establish service connection, however, there must be evidence of a current disability and a causal relationship between the current disability and the combat injury. Id. (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). In Reeves v. Shinseki, 682 F.3d 988, 998 (Fed. Cir. 2012), the Federal Circuit further expanded on the 3-step sequential test of 38 U.S.C. § 1154(b) as follows: (1) The Veteran must offer credible evidence of in-service incurrence or aggravation of an injury or disease (during said combat events); then (2) The Board must determine that the evidence is consistent with the circumstances, condition, or hardships of such service; (3) If (1) and (2) are met, then the Board must presume the Veteran's injury or disease was incurred or aggravated in service unless rebutted by "clear and convincing evidence to the contrary" considering all potentially applicable laws and presumptions. See Reeves v. Shinseki, 682 F.3d 988, 998 (Fed. Cir. 2012). In Reeves, the Court further explained that the Board not only presumes the Veteran's injury was incurred in service (in that case, acoustic trauma), but also the claimed resulting disability (i.e., the permanent hearing loss) unless there is clear and convincing evidence to the contrary. Id. The Veteran in this case has established combat service. In rendering this decision, the Board has reviewed all evidence of record whether discussed in detail. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (holding the Board must only discuss the evidence which is relevant to the issues on appeal). To the extent the evidence is found in "approximate balance," the Board will afford the benefit of the doubt in favor of the Veteran. Lynch v. McDonough, 21 F. 4th 776 (Fed, Cir. 2021) (holding that exact equipoise is not required for the benefit of the doubt to be applied, but rather the Veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal"). 1. Entitlement to service connection for right wrist disability is denied. 2. Entitlement to service connection for right elbow disability is denied. 3. Entitlement to service connection for left elbow disability is denied. The Veteran seeks service connection for right wrist and bilateral elbow disability, asserting that such disability is related to his job and heavy lifting during service. The January 2024 rating decision on appeal included favorable findings that the Veteran has current disability of right and left elbow degenerative arthritis, current disability of right wrist strain, and in-service TERAs. Therefore, the question left for the Board to decide is whether the Veteran's current elbow and wrist disabilities had an onset in service or are otherwise related to service. Turning to the evidence, the Veteran's service treatment records are silent for wrist or elbow complaints. The Veteran's December 1971 examination upon separation from service notes normal upper extremities. Beginning in 2013, the Veteran's VA treatment records show complaints of elbow pain reportedly beginning approximately a year prior. The records note no history of surgery, shots, or therapy. The records note the Veteran works as a truck driver. The Veteran's VA treatment records show complaints of left wrist issues beginning in 2019, and the right wrist beginning in 2022. In October 2023, the Veteran underwent VA examination. The examiner noted in-person examination of the Veteran and review of the records. The Veteran was diagnosed with bilateral elbow degenerative arthritis and right wrist strain. The Veteran reported that he was unable to remember the date of onset for his elbow pain but was fairly sure it had been over 10 years. The Veteran believed his right wrist pain was within the last 10 years. The October 2023 examiner opined that the Veteran's elbow and right wrist conditions are less likely than not incurred in or caused by service. The examiner explained that there were no complaints of elbow or right wrist conditions during service and that the Veteran's separation examination from 1971 was silent for any such conditions. The examiner noted that the Veteran's military occupational specialty as rifleman would have caused him to lift heavy weapons and ammunition repeatedly. However, the examiner also noted the lack of complaints during service and for more than 40 years after service. The examiner noted that the Veteran had been a truck driver for more than 30 years and that truck drivers are known to be prone to shoulder, elbow, and wrist dysfunction due to prolonged steering, vibration/shock, poor posture, and repetitive motions. Given the combination of facts in this case, the examiner found it less likely than not that the Veteran's current elbow and wrist conditions are related to service or consistent with the hardship, conditions, and circumstances of his service, including his heavy lifting as a rifleman during service. The Board finds that based on the nature of the Veteran's military occupational specialty of rifleman and being a combat veteran, heavy lifting during service is conceded. As noted above, a combat veteran is entitled to a relaxed evidentiary standard and if he contends he incurred an injury during combat service, the Board will presume such service connection unless there is clear and convincing evidence to the contrary. Cf. Reeves, 682 F. 3d. at 998. In this case, however, the Veteran has not contended that he incurred an elbow or wrist injury during combat service. Instead, he asserts that his current elbow and wrist disabilities, which reportedly began more or less than 10 years prior to the 2023 VA examination, and which he cannot remember the date or details of onset, are attributable to his job-related tasks including heavy lifting during service. The Veteran has not specifically contended his current disabilities are related to his combat service, let alone reported that they stem from a particular elbow or wrist injury during combat service. Instead, the Veteran generally asserts that his current disabilities are related to his in-service job tasks during his two years of active service. In that regard, the Board finds the persuasive weight of the evidence is against the claim. Viewing the evidence as a whole, the Board finds the evidence persuasively weighs against a finding that the Veteran's current elbow and wrist disabilities had an onset in service or are otherwise related to service or that the Veteran's elbow arthritis manifested to a compensable degree within a year of service. The Veteran's service treatment records and 1971 separation examination do not mention right wrist or elbow complaints. The evidence shows complaints in the record beginning in 2013, more than 40 years after service. The October 2023 examiner opined that the Veteran's elbow and right wrist conditions are less likely than not incurred in or caused by service. The examiner acknowledged the Veteran's in-service combat duties as a rifleman and the repeated heavy lifting involved. However, in light of the lack of complaints during service or at separation, or for more than forty years after service, combined with the Veteran's more than 30 years of truck driving (which generally leads to elbow and wrist dysfunction due to prolonged steering, vibration/shock, poor posture, and repetitive motions), the examiner concluded the Veteran's current wrist and elbow disabilities are less likely related to service, including the heavy lifting conditions of such service. The Board finds the October 2023 medical opinion highly probative, as it provided clear conclusions with supporting data based on the Veteran's particular circumstances and addressed the evidence in the record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no contrary medical opinion in the claims file. To the extent the Veteran asserts that his current wrist and elbow disabilities are related to service, the Board finds that he is not competent to determine the etiology of such disabilities as it requires specialized medical knowledge and training and the Veteran has not been shown to have such medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Thus, the Board relies upon the competent and probative medical evidence of record, especially the October 2023 VA opinion. As the evidence persuasively weighs against finding that the Veteran's current right wrist and bilateral elbow disabilities are related to service, service connection for such disabilities is not warranted. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for bilateral foot disability, to include plantar fasciitis, is remanded. 2. Entitlement to service connection for pseudofolliculitis barbae is remanded. The Veteran's claims for service connection for bilateral foot disability and pseudofolliculitis barbae must be remanded to correct a duty to assist error that occurred prior to the January 2023 rating decision, in not obtaining outstanding VA treatment records. The Veteran seeks service connection for bilateral foot disability, claimed as bilateral plantar fasciitis, and for pseudofolliculitis barbae, asserting that such disabilities had an onset during service and that his foot disability is related to wearing boots during service. Although the evidence at the time of the January 2023 rating decision did not show a current foot or pseudofolliculitis barbae disability, the evidence in the claims file at that time did show that there were outstanding VA treatment records which should have been obtained prior to adjudication. The claims file at that time included VA treatment records, including those prior to August 2013 and those from January 2021 to January 2023. However, VA treatment records from August 2013 to January 2021 were generally not in the claims file despite indications in the later treatment records that the Veteran had received VA treatment (including laboratory testing and diagnoses) during that August 2013 to January 2021 time frame. Accordingly, remand is warranted to obtain the outstanding VA treatment records and correct this pre-decisional duty to assist error. 3. Entitlement to service connection for dry skin disability is remanded. The Veteran's claim for service connection for dry skin disability must be remanded to correct duty to assist errors that occurred prior to the January 2023 rating decision, in not obtaining outstanding VA treatment records and adequate VA medical opinion. The Veteran seeks service connection for dry skin disability, asserting that such disability had an onset in service or is related to in-service exposures. First, as noted above, 2021 and 2022 VA treatment records in the claims file at the time of the January 2023 rating decision show that the Veteran had earlier VA treatment (from August 2013 to January 2021) yet the earlier records were not in the claims file. Accordingly, remand is warranted to obtain the outstanding VA treatment records and correct this pre-decisional duty to assist error. Second, remand is warranted to obtain additional VA medical opinion. Although a VA skin diseases examination was obtained in November 2022, the examination appeared limited to the Veteran's pseudofolliculitis barbae disability claim. The claimed condition in the examination report was listed as pseudofolliculitis, and the history obtained and opinion provided were for pseudofolliculitis. The examiner indicated that the Veteran did not have a current skin condition and there was no treatment in the prior 12 months for a skin condition. However, the examiner did not address the Veteran's reports of painful dry skin and his treatment within the prior 12 months for dry skin and rash on his hands. See, e.g., December 2021 VA Treatment Record (prescribing hydrocerin ointment for hands/ dry skin and triamcinolone ointment for rash on hands); March 2022 VA Treatment Record (noting prescriptions still active for dry skin and rash on hands). The Board also notes that the Veteran submitted pictures of his skin in October 2022, including cracked and peeling skin on his hands. In light of the above, remand is warranted to obtain additional VA medical opinion regarding whether the Veteran has had a current skin disability during the claims period, even if resolved, and whether any such disability is related to his service, to correct the pre-decisional duty to assist error. 4. Entitlement to service connection for psychiatric disability, to include depression, is remanded. The Veteran's claim for service connection for psychiatric disability must be remanded to correct duty to assist errors that occurred prior to the January 2023 rating decision, in not obtaining outstanding VA treatment records and adequate VA medical opinion. The Veteran seeks service connection for psychiatric disability, asserting that such disability began during service or is secondary to his service-connected hearing loss disability. First, as noted above, 2021 and 2022 VA treatment records in the claims file at the time of the January 2023 rating decision show that the Veteran had earlier VA treatment (from August 2013 to January 2021) yet the earlier records were not in the claims file. Accordingly, remand is warranted to obtain the outstanding VA treatment records and correct this pre-decisional duty to assist error. Second, remand is warranted to obtain additional VA medical opinion. The November 2022 VA psychiatric examiner found that the Veteran did not now have any diagnosed mental disorder and had never been diagnosed with a mental disorder. The examiner noted that the Veteran had never had mental health care from any sort of provider. However, the VA examiner did not address the Veteran's recent VA treatment records (in 2021 and 2022) noting depression (at times mild, moderate, or moderately severe), nor the Veteran's reports that certain smells take him back to Vietnam. The Veteran's VA treatment records in the claims file at the time of the January 2023 rating decision show a mental health treatment plan to address the Veteran's symptoms and a diagnosis of adjustment disorder. See, e.g., December 2021, June 2022, December 2022 VA Treatment Records. In light of this inconsistency between the examination and the records, remand is warranted to obtain adequate VA psychiatric opinion and correct this pre-decisional duty to assist error. 5. Entitlement to service connection for sinus disability is remanded. 6. Entitlement to service connection for respiratory disability (claimed as dry cough) is remanded. The Veteran's claims for service connection for sinus and respiratory disability must be remanded to correct duty to assist errors that occurred prior to the January 2023 rating decision, in not obtaining outstanding VA treatment records and VA medical opinion. The Veteran seeks service connection for sinus and respiratory disability, asserting that such disability began during service or is related to in-service environmental exposures. First, as noted above, 2021 and 2022 VA treatment records in the claims file at the time of the January 2023 rating decision show that the Veteran had earlier VA treatment (from August 2013 to January 2021) yet the earlier records were not in the claims file. Accordingly, remand is warranted to obtain the outstanding VA treatment records and correct this pre-decisional duty to assist error. Second, remand is warranted to obtain VA medical opinion. The evidence in the claims file at the time of the January 2023 rating decision includes sinus and cough complaints in the Veteran's VA treatment records. See, e.g., May 2022 VA Treatment Record (noting sinus pain/pressure); June 2022, July 2022 VA Treatment Records (noting cough complaints, with assessments of subacute cough and chronic bronchitis). The Veteran has conceded herbicide agent exposure from his service in Vietnam during the Vietnam War. No VA examiner has addressed whether the Veteran has a current sinus or respiratory disability which had an onset in service or is related to service, to include from his conceded in-service exposures to include consideration under the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act). Accordingly, remand is warranted to obtain VA medical opinion and correct this pre-decisional duty to assist error. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 U.S.C. § 1168(a). 7. Entitlement to service connection for toenail fungus is remanded. The Veteran's claim for service connection for toenail fungus must be remanded to correct a duty to assist error that occurred prior to the January 2024 rating decision, in not obtaining adequate VA medical opinion. The Veteran seeks service connection for toenail fungus, asserting that such disability had an onset during service or is related to wearing boots during service. Prior to the January 2024 rating decision, an October 2023 VA examiner opined that the Veteran's claimed toenail fungus was less likely than not incurred in or caused by service. The examiner noted that the Veteran is currently diagnosed with tinea unguium and tinea pedis. The examiner explained that medical records are silent for references to tinea unguium and tinea pedis (Athlete's foot). The examiner explained that a nexus was unable to be established as the Veteran was not diagnosed with either condition during service nor has he had any care for such condition since service. However, the Veteran's service treatment records show complaints during service and his VA treatment records show treatment for tinea pedis and tinea unguium. See March 1971 STR (noting complaints of sore, swollen, cracked, and itching feet with notation of athletic foot); March 2017 VA Treatment Records (podiatry consult noting Veteran's complaints of fungal nails with tinea pedis to bilateral lower extremities; examination showed flaking of skin and thickened and dystrophic nails; assessment of tinea pedis and onychomycosis was provided). The October 2023 VA medical opinion therefore appears based on inaccurate facts. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Accordingly, remand is warranted to obtain additional VA medical opinion and correct this pre-decisional duty to assist error. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records, to include VA treatment records from August 2013 to January 2021. Associate with the claims file all potentially relevant documents scanned into Vista Imaging or CPRS but not associated with the Veteran's claims file. 2. Ask an appropriate examiner to review the Veteran's file. The necessity of an in-person examination is left to the discretion of the examiner. The examiner should identify any and all skin disability the Veteran has presented at any time during the claims period, even if resolved. NOTE: For VA purposes, "pain" without a specific diagnosis can be a disability if such pain causes functional impairment of earning capacity. For each such disability, the examiner should opine whether the disability at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher): (a) had an onset in service; or (b) is related to service, to include the Veteran's in-service exposures. NOTE: The examiner shall consider the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner should consider all relevant medical and lay evidence of record, including the Veteran's treatment for dry skin and rash on his hands and the photographs submitted in October 2022. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). The examiner is asked to explain the reasons behind any opinions expressed. 3. Ask an appropriate examiner to review the Veteran's file. The necessity of an in-person examination is left to the discretion of the examiner. The examiner should identify any and all psychiatric disability the Veteran has presented at any time during the claims period, even if resolved. For each such disability, the examiner should opine whether the disability at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher): (a) had an onset in service; (b) is related to service, to include the Veteran's combat service; (c) was caused by his service-connected hearing loss disability; or (d) was aggravated beyond its natural progression by his service-connected hearing loss disability (specifically, would the disability have been less severe "but-for" the service-connected disability, either because there is an etiological link or because the service-connected disability resulted in the inability to treat the disability); NOTE: If the examiner opines that there is aggravation, the examiner should provide an opinion about the baseline severity before aggravation. The examiner should consider all relevant medical and lay evidence of record, including the 2021 and 2022 VA treatment records noting depression (at times mild, moderate, or moderately severe), the Veteran's reports that certain smells take him back to Vietnam, and the diagnosis of adjustment disorder. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). The examiner is asked to explain the reasons behind any opinions expressed. 4. Ask an appropriate examiner to review the Veteran's file. The necessity of an in-person examination is left to the discretion of the examiner. The examiner should identify any and all sinus and respiratory disability the Veteran has presented at any time during the claims period, even if resolved. For each such disability, the examiner should opine whether the disability at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher): (a) had an onset in service; or (b) is related to service, to include the Veteran's in-service exposures. NOTE: The examiner shall consider the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner should consider all relevant medical and lay evidence of record, including the Veteran's sinus and cough complaints in his May 2022, June 2022, and July 2022 VA treatment records. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). The examiner is asked to explain the reasons behind any opinions expressed. 5. Ask an appropriate examiner to review the Veteran's file. The necessity of an in-person examination is left to the discretion of the examiner. The examiner should opine whether the Veteran's tinea unguium and tinea pedis disability at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher): (a) had an onset in service; or (b) is related to service, to include the Veteran's in-service complaints and exposures. NOTE: The examiner shall consider the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner should consider all relevant medical and lay evidence of record, including the March 1971 service treatment record and the Veteran's reports. If the Veteran's reports are discounted, the examiner should provide a rationale for doing so (e.g., whether there is any medical reason to accept or reject his contentions). The examiner is asked to explain the reasons behind any opinions expressed. 6. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Purcell, 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.