Citation Nr: 1738540 Decision Date: 09/13/17 Archive Date: 09/22/17 DOCKET NO. 11-04 252 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Whether new and material evidence has been received in order to reopen a claim for service connection for a bladder disorder. 2. Whether new and material evidence has been received in order to reopen a claim for service connection for arthritis of the shoulders, hands, and knees. 3. Whether new and material evidence has been received in order to reopen a claim for service connection for type II diabetes mellitus. 4. Whether new and material evidence has been received in order to reopen a claim for service connection for shingles. 5. Whether new and material evidence has been received in order to reopen a claim for service connection for loss of vision. 6. Whether new and material evidence has been received in order to reopen a claim for service connection for a left ankle disorder. 7. Entitlement to service connection for a bladder disorder, to include as due to herbicide exposure and chemical exposure. 8. Entitlement to service connection for arthritis of the shoulders, hands, and knees. 9. Entitlement to service connection for type II diabetes mellitus, to include as due to herbicide and chemical exposure. 10. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as due to type II diabetes mellitus. 11. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as due to type II diabetes mellitus. 12. Entitlement to service connection for coronary artery disease, to include as due to type II diabetes mellitus, herbicide, and chemical exposure. 13. Entitlement to service connection for a stroke, to include as due to coronary artery disease. 14. Entitlement to service connection for loss of vision, to include as due to a stroke. 15. Entitlement to service connection for sleep apnea/hypopnea, to include as due to herbicide and chemical exposure. 16. Entitlement to service connection for shingles. 17. Entitlement to service connection for psoriasis. 18. Entitlement to service connection for arthritis of the bilateral elbows. 19. Entitlement to service connection for arthritis of the bilateral ankles. 20. Entitlement to service connection for head trauma, claimed as unconsciousness and headaches. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Krunic, Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from June 1963 to May 1967 and had additional service in the Unites States Naval Reserve. This case comes before the Board of Veterans' Appeals (Board) on appeal from June 2010 and October 2010 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran's appeal initially included the issues of entitlement to service connection for neck tumors and a prostate disorder as well as whether new and material evidence was received to reopen the previously denied claims of service connection for hypertension and tinnitus. However, in a February 2012 statement, the Veteran withdrew his appeals regarding neck tumors, a prostate disorder, and hypertension; thus, no further consideration is necessary. Moreover, in a June 2012 rating decision, the RO granted service connection for tinnitus and assigned a 10 percent evaluation, effective July 23, 2009. The record indicates that the Veteran did not initiate an appeal with the evaluation or effective date assigned. Thus, the issue is not in appellate status. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). In February 2012, a hearing with a Decision Review Officer (DRO) was held at the RO. A transcript of the hearing is of record. A Travel Board hearing was held before the undersigned Veterans Law Judge in March 2017. A transcript of the hearing is of record. The undersigned Veterans Law Judge held the record open for a 30-day period following the hearing to allow for the submission of additional evidence; thereafter, along with a waiver of RO consideration of the evidence, the Veteran submitted articles regarding the use of herbicides at Eglin Air Force Base and a medical opinion that was duplicative of an opinion previously associated with the claims file. During his March 2017 Board hearing, the Veteran and his representative clarified the issues on appeal as well as the theories of entitlement to service connection for these issues. Therefore, the Board notes that the issues, as framed on the cover page of this decision, reflect such clarification. The Board further notes that in the June 2010 rating decision, the RO considered the issue of a reopened claim for service connection for a left ankle disorder to encompass the Veteran's claim for arthritis of the bilateral ankles. Subsequently, the RO adjudicated whether new and material evidence had been received to reopen the "left ankle condition (now claimed as arthritis, bilateral ankles)" and entitlement to service connection for arthritis of the bilateral ankles. However, the Board finds that the issue of reopening the previously denied claim for a left ankle disorder does not also include the issue of entitlement to service connection for a right ankle disorder because the RO had not previously adjudicated the issue in a final rating decision. Hence, the Board will only consider whether new and material evidence was received regarding the left ankle and then address the merits of the claim for service connection for bilateral ankle arthritis as a separate issue. The Board notes that during the Board hearing, the Veteran expressed confusion as to whether a claim for service connection for a back disorder was also on appeal. However, a review of the record indicates that the Veteran did not submit a claim to reopen the issue of service connection for a back disorder at any point during the appeal period. The RO initially denied entitlement to service connection for a back disorder in an unappealed September 2004 rating decision. In this regard, the Veteran and his representative are advised that a claim for benefits, to include reopening a previously denied claim for service connection, must be submitted on the application form prescribed by the Secretary. 38 C.F.R. §§ 3.1 (p), 3.155, 3.160 (2016). In a September 2004 rating decision, the RO denied the Veteran's claims for entitlement to service connection for a bladder disorder, diabetes mellitus, left ankle disorder, arthritis of the shoulders, hands, and knees, shingles, and loss of vision. The Board finds that the evidence received since the September 2004 rating decision is new and material. During his Board hearing, the Veteran testified that he has been diagnosed as having shingles and asserted new theories of entitlement to service connection for a left ankle disorder, bladder disorder, arthritis, and loss of vision. In addition, the Veteran has provided new allegations of herbicide and chemical exposure during service. See Board hearing transcript. This evidence is presumed to be credible for the purposes of reopening the claims. Justus v Principi, 3 Vet. App. 510 (1992). Therefore, the claims are reopened and will be considered on the merits. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing system. The Board notes that the RO has not reviewed the additional VA and private treatment records that have been associated with Virtual VA and VBMS following the December 2015 Supplemental Statement of the Case (SSOC). However, on remand, the RO will have the opportunity to do so. Any future consideration of this Veteran's case should take into account the existence of this electronic record. The issues of entitlement to service connection for type II diabetes mellitus, a bladder disorder, shingles, loss of vision, stroke, residuals of a head trauma to include headaches, arthritis of the bilateral elbows, peripheral neuropathy of the bilateral lower extremities, psoriasis, sleep apnea, arthritis of the bilateral ankles, coronary artery disease, and service connection for arthritis of the shoulders, knees, and hands, are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. In a September 2004 rating decision, the AOJ denied service connection for a left ankle disorder, loss of vision, bladder disorder, shingles, diabetes mellitus, and arthritis of the bilateral hands, shoulders, and knees. The Veteran was informed of the decision and of his appellate rights, but he did not appeal that determination. There was also no new and material evidence received within one year of that determination. 2. The evidence received since the September 2004 rating decision, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the underlying claims. CONCLUSIONS OF LAW 1. The September 2004 rating decision denying service connection for a left ankle disorder, loss of vision, bladder disorder, shingles, diabetes mellitus, and arthritis of the bilateral hands, shoulders, and knees is final. 38 U.S.C.A. § 7105 (c) (West 2014); 38 C.F.R. §§ 3.104, 3.156, 20.200, 20.201, 20.302, 20.1103 (2016). 2. New and material evidence has been received sufficient to reopen the claims for service connection for a left ankle disorder, loss of vision, bladder disorder, shingles, diabetes mellitus, and arthritis of the bilateral hands, shoulders, and knees. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (a) (2016). ORDER New and material evidence having been submitted, the petition to reopen the claim of entitlement to service connection for a left ankle disorder is granted. New and material evidence having been submitted, the petition to reopen the claim of entitlement to service connection for a bladder disorder is granted. New and material evidence having been submitted, the petition to reopen the claim of entitlement to service connection for diabetes mellitus is granted. New and material evidence having been submitted, the petition to reopen the claim of entitlement to service connection for loss of vision is granted. New and material evidence having been submitted, the petition to reopen the claim of entitlement to service connection for shingles is granted. New and material evidence having been submitted, the petition to reopen the claim of entitlement to service connection for arthritis of the shoulders, knees, and hands is granted. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claims. With regard to his claims for service connection for diabetes mellitus, sleep apnea, coronary artery disease, and a bladder disorder, the Veteran has asserted that his current disorders may be related to herbicide exposure and/or chemical exposure during service. As a preliminary matter, the Board notes that the AOJ issued a June 2010 Memorandum finding that the Veteran failed to specify a 60 day time period for exposure to Agent Orange. Subsequently, the Veteran's allegation of service in the Republic of Vietnam and Agent Orange exposure during military service could not be verified. VA treatment records and private treatment records document that during the appeal period, the Veteran has been diagnosed as having type II diabetes mellitus, coronary artery disease, and obstructive sleep apnea. The Veteran's private medical records document that in April 2009, he underwent a bladder diverticulectomy; a November 2014 VA treatment record noted that the Veteran had bladder incontinence. During his Board hearing, the Veteran summarized the various in-service events that may have exposed him to herbicides and chemicals. In this regard, he has asserted herbicide exposure while working in a helicopter training squadron (HT-8) in Pensacola, Florida between 1963 and 1964. Specifically, the Veteran stated that as a captain and crewmember of an H-34 helicopter, he would fly to Eglin Air Force Base where herbicides were being sprayed on the training site. In addition, the Veteran testified that he was a member of a work crew that had to clean out several old Spanish forts around Naval Air Station Pensacola that had been sprayed with Agent Orange to kill the surrounding overgrowth. See Board hearing transcript at 5-8. Furthermore, the Veteran testified that he was transferred to China Lake Naval Air Weapons Station for a training course in crash firefighting and salvage. He stated that during firefighting simulations, he was exposed to large amounts of smoke and fumes caused by burning benzene, old tires, waste, oil, grease, and any other liquid that would burn; the Veteran testified that he did not have the benefit of wearing a protective mask or breathing apparatus. Moreover, he reported that he witnessed 55 gallon drums that had orange rings around them and stated that he was told at the time the barrels contained Agent Orange. See Board hearing transcript at 9-11; Veteran and buddy April 2010 statements. Moreover, the Veteran stated he was exposed to chemicals while stationed at US Naval Auxiliary Air Station, Ream Field, Imperial Beach, California. Specifically, he reported that he washed aircraft on the flight line with a mix of bruline and water, without wearing protective gloves. See Veteran's April 2010 statement. Finally, the Veteran has alleged that he spent one day and night in DaNang while he was on active duty for training (ACDUTRA) in the Naval Reserve. The Veteran testified that on a flight to Hawaii for ACDUTRA, a pilot who was sitting next to him, convinced him to go to the Philippines. However, the Veteran ended up in DaNang and stayed overnight because the pilot said he needed to get his ticket punched. See Board hearing transcript at 16-19. The Board notes that in his April 2004 original claim for disability compensation, the Veteran stated that he had been in Vietnam during the month of September 1973, which is during his period of Navy Reserve service. The Board finds that additional development is warranted to verify the Veteran's allegations of herbicide exposure. Moreover, the Board finds that a medical opinion rendered by a toxicology specialist would be helpful in ascertaining whether there is a nexus between the claimed disorders and any in-service chemical exposure. The Board is mindful that although sleep apnea and bladder disorders are not on the list of diseases that VA has associated with Agent Orange exposure, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange). The Veteran has alternatively claimed that his coronary artery disease first manifested during active service. The Veteran was afforded a VA examination in January 2015 at which time he was diagnosed as having coronary artery disease and a history of myocardial infarction; the examiner remarked that these diagnoses did not qualify within the generally accepted medical definition of ischemic heart disease. In addition, the examiner stated that the Veteran did not have congestive heart failure but then noted that he had one episode of acute congestive heart failure in the past year. The examiner opined that although the Veteran has evidence of continual care of a heart condition, it would be sheer speculation that the in-service instance of shortness of breath and chest pain caused his current condition since no testing was done at the time of the incident. The examiner further stated that shortness of breath and chest pain are multi-factorial. In support of his coronary artery disease claim, the Veteran submitted a January 2014 private medical opinion from Dr. C.M. (initials used to protect privacy). She reported that she had reviewed the Veteran's service treatment records and noted an October 1965 record documenting symptoms of dull pain in the sternum with deep breathing, soreness of the chest and in the cervical area, and shortness of breath after walking a short way up a hill. The physician opined that she could not exclude the possibility of coronary artery disease present at the time of the 1965 complaints. She also noted that no cardiac testing had been performed during active service. The Board finds that the examiners' opinions are inadequate insofar as medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. See e.g. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (doctor's opinion that "it is possible" and "it is within the realm of medical possibility" too speculative to establish medical nexus); Goss v. Brown, 9 Vet. App. 109, 114 (1996) (using the word "could not rule out" was too speculative to establish medical nexus). Finally, the Veteran's private treatment records from S&W MH indicate that he is also diagnosed as having diastolic heart failure. See August 2015 treatment record; November 2015 echocardiogram. Based on the foregoing, the Board finds that an additional VA examination and medical opinion are necessary to ascertain the nature and etiology of any of the Veteran's heart disorders that may be present. When VA undertakes to provide VA examinations or obtain VA opinions, it must ensure that the examinations are adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran has also asserted that he has arthritis in his shoulders, hands, elbows, knees, and ankles which manifested during military service. Specifically, he testified that he believes that the arthritis began in his hands during service and then spread to his other joints. He stated that he had complained of hand pain and also experienced aches and pains in the aforementioned joints during service. See Board hearing transcript at 37-41. The Veteran also testified that during a rescue mission, he injured his right knee and left ankle as a result of slipping and falling on foam that had blanketed the jet from which he pulled out the pilot. However, the Veteran stated that he did not seek treatment for these injuries and just had the joints wrapped in ACE bandages. See Board hearing transcript at 45-48. In support of his claim, the Veteran submitted an April 2010 buddy statement from R.N. who had served with the Veteran, and indicated that the Veteran had injured his knee and ankle after slipping on foam while trying to remove a pilot from an aircraft. Moreover, the Veteran's service treatment records show that in September 1966, he sustained an injury to the distal tip of his right second finger while starting a machine. Furthermore, private treatment records from K.P. indicate that in May 1972, the Veteran was assessed as having a right ankle strain following a twisting injury. The Veteran's VA treatment records reflect that in an April 2016 history and physical, the Veteran was noted to have arthritis in his shoulders and all of his fingers. The Veteran also stated that he had chronic right knee and left ankle pain stemming from an in-service injury. Regarding the claims for psoriasis and shingles, the Veteran testified that his current psoriasis and shingles first manifested during service. Specifically, the Veteran reported that he currently has a patch of psoriasis that intermittently presents on his back as well as shingles that occur every year and a half to two years. See Board hearing transcript at 49-52. The Veteran stated that he believes that the in-service diagnosis and treatment for tinea cruris was actually shingles. The Veteran's service treatment records reflect that the May 1967 report of medical examination at separation noted that the Veteran was diagnosed as having tinea cruris which was under treatment. With respect to the Veteran's claim for service connection for residuals of a head injury, to include unconsciousness and headaches, the Veteran has alleged that he was knocked unconscious from an explosion while working around jet aircraft. An April 2010 buddy statement from R.N. attests to the Veteran having lost consciousness after an aircraft wheel blew out and knocked him out for a few minutes. The record shows that in conjunction with the Veteran's posttraumatic stress disorder (PTSD) claim, the AOJ requested verification of the alleged explosion; however, in a July 2016 response, the Joint Services Records Research Center (JSRRC), determined that the incident reported by the Veteran was not recorded in the 1965 command history for the Naval Air Weapons Station, China Lake or the Naval Auxiliary Landing Field, San Clemente Island. Notwithstanding the JSRRC finding, the Board notes that the Veteran's service treatment records reveal that he was treated for complaints of headaches and dizziness in March 1967. In addition, an August 1966 treatment record indicated that the Veteran should not work on heights because of dizziness. A November 2014 VA treatment record shows that the Veteran was treated for migraines. The Veteran also testified that he believed that symptoms of obstructive sleep apnea, such as snoring, began during service because his fellow ship mates would complain about how loudly he snored. See Board hearing transcript at 33. To date, with the exception of coronary artery disease, the Veteran has not been afforded VA examinations to determine the nature and likely etiology of any of his claimed disorders. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, the Board finds that VA examinations and medical opinions should be obtained. The Veteran has contended that his stroke with subsequent loss of vision was caused by his coronary artery disease. See Board hearing transcript at 26-27. He also stated that his peripheral neuropathy of the bilateral lower extremities is due to his type II diabetes mellitus. See Board hearing transcript at 21-22. Thus, the Board finds that these issues are inextricably intertwined with the claims remanded herein. See Henderson v. West, 12 Vet.App. 11, 20 (1998) (matters are "inextricably intertwined" where action on one matter could have a "significant impact" on the other). Actions on those issues are therefore deferred. Finally, the Board notes that the Veteran's period of service in the Naval Reserve remains unverified. In a June 2004 response to the AOJ request for verification of all of the Veteran's periods of active duty service, the National Personnel Records Center (NPRC) indicated that subsequent to active service, the Veteran served in the Naval Reserve and the only additional active duty would have been active duty for training. The Board finds that it is necessary to determine whether the Veteran was serving on ACDUTRA or INACDUTRA at the time of his claimed herbicide exposure in DaNang. As the Board cannot make this determination based on the evidence currently in the claims file, a remand is warranted. Accordingly, the case is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his type II diabetes mellitus, peripheral neuropathy, coronary artery disease, stroke, loss of vision, shingles, psoriasis, bladder disorder, sleep apnea, residuals of head injury to include headaches, and arthritis affecting the shoulders, knees, elbow, hands, and ankles. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA treatment records. 2. The AOJ should request that the National Personnel Records Center (NPRC) or the Defense Finance and Accounting Service (DFAS) verify all periods of the Veteran's reserve service, including when reserve service began and ended, and clearly delineating the periods of active reserve service, active duty for training (ACDUTRA), and inactive duty for training (INACDUTRA). Reports of retirement points do not provide sufficient information to satisfy the requirements of this remand order. A listing of dates of service and whether within those dates the service can be characterized as active, ACDUTRA, or INACDUTRA, is required. 3. The AOJ should send a request to the JSRRC for verification of the Veteran's claimed exposure to herbicides during his service in light of his assertions, in particular those proffered during the March 2017 Board hearing, regarding exposure at Eglin Air Force Base training grounds and around any forts located in close proximity to Naval Air Station Pensacola between 1963 and 1964; Naval Air Weapons Station, China Lake and the Naval Auxiliary Landing Field, San Clemente Island in 1965; and DaNang in September 1973 (only if the Veteran has been confirmed to have been on ACDUTRA at the time based on the response to the above request). 4. The AOJ should obtain an opinion, report, or other appropriate evidence from a VA environmental toxicologist to address the question of whether it is at least as likely as not (50 percent or greater probability) that the Veteran was exposed to large amounts of smoke and fumes caused by burning benzene, old tires, waste, oil, grease, and any other liquids that would burn while attending crash firefighting and salvage training in 1965 at China Lake Naval Air Weapons Station and whether it is at least as likely as not (50 percent or greater probability) that the Veteran was exposed to chemicals such as bruline to wash aircraft on the flight line while serving at US Naval Auxiliary Air Station, Ream Field, Imperial Beach, California. The Veteran's service personnel records show that he was assigned to a helicopter training squadron (HT-8) at Naval Air Station Pensacola between November 1963 and November 1964. The Veteran was then stationed at USNAF China Lake at ALW San Clemente between May 1965 and December 1965. Finally, the Veteran was assigned to US Naval Auxiliary Air Station, Ream Field, Imperial Beach, California from December 1966 to May 1967. The Veteran's military occupational specialty (MOS) was Aviation Boatswain's Mate (aircraft handling). A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any type II diabetes mellitus that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay statements. The examiner is asked to review the toxicologist's report regarding the Veteran's alleged chemical exposure. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's type II diabetes mellitus is causally or etiologically related to his military service, to include any chemical exposure therein and any verified herbicide exposure. In addition, the examiner should identify and describe all complications of the Veteran's type II diabetes mellitus. In this regard, the Veteran has asserted that his peripheral neuropathy of the bilateral lower extremities and coronary artery disease are due to his type II diabetes mellitus. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. The Veteran should be afforded a VA examination to determine the nature and etiology of any bladder disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay statements. The examiner is asked to review the toxicologist's report regarding the Veteran's alleged chemical exposure. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify all current bladder disorders. For each bladder disorder identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the disorder is causally or etiologically related to his military service, to include any chemical exposure therein and any verified herbicide exposure. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 7. The Veteran should be afforded a VA examination to determine the nature and etiology of any obstructive sleep apnea that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay statements. The examiner is asked to review the toxicologist's report regarding the Veteran's alleged chemical exposure. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's obstructive sleep apnea manifested during service or is otherwise causally or etiologically related to his military service, to include any chemical exposure therein and any verified herbicide exposure. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 8. The Veteran should be afforded a VA examination to determine the nature and etiology of any heart disorder, including coronary artery disease, that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, the January 2015 VA examination report, and lay statements. The examiner is asked to review the toxicologist's report regarding the Veteran's alleged chemical exposure. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify all current heart disorders. For each heart disorder identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the disorder manifested during service or is otherwise causally or etiologically related to his military service, to include any chemical exposure therein and any verified herbicide exposure. In rendering the opinion, the examiner should address the October 1965 service treatment record documenting the Veteran's symptoms of dull pain in the sternum with deep breathing, soreness of the chest and in the cervical area, and shortness of breath after walking a short way up a hill. In addition, the examiner should address the January 2014 private medical opinion from Dr. C.M. wherein she opined that she could not exclude the possibility of coronary artery disease being present at the time of the 1965 complaints. Furthermore, the examiner should identify and describe all complications of the Veteran's coronary artery disease. In this regard, the Veteran has asserted that his stroke and loss of vision are due to his coronary artery disease. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 9. The Veteran should be afforded a VA examination to determine the nature and etiology of any skin disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay statements. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The Veteran has asserted that he is currently diagnosed with psoriasis and shingles which he claims first manifested during service. The examiner should identify all current skin disorders. For each skin disorder identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the disorder manifested during service or is otherwise causally or etiologically related to his military service, to include any symptoms therein. In rendering the opinion, the examiner should address the Veteran's service treatment records which contain a May 1967 report of medical examination at separation showing that he was diagnosed as having tinea cruris which was under treatment. The examiner should discuss whether the Veteran's diagnosis of tinea cruris was in fact shingles as the Veteran has contended. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 10. The Veteran should be afforded a VA examination to determine the nature and etiology of any bilateral shoulder, bilateral elbow, bilateral hand, bilateral knee, and bilateral ankle disorders, including arthritis, that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay statements and assertions, including his assertion that he injured his right knee and left ankle after slipping and falling on foam surrounding an aircraft while extricating the pilot. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all current bilateral shoulder, bilateral elbow, bilateral hand, bilateral knee, and bilateral ankle disorders that are present. For each disorder, the examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder manifested during service or is otherwise causally or etiologically related to the Veteran's military service, to include any symptomatology or injury therein related to his MOS as an Aviation Boatswain's Mate (aircraft handling). If arthritis if found, the examiner should also opine as to whether it is at least as likely as not that arthritis manifested within one year of separation from service The examiner should also address whether arthritis in the Veteran's bilateral hands led to arthritis in his other joints, including his elbows, shoulders, knees, and ankles. In rendering these opinions, the examiner should consider the Veteran's September 1966 service treatment record showing that he sustained an injury to the distal tip of his right second finger while starting a machine. The examiner should discuss medically known or theoretical causes of degenerative joint disease and describe how arthritis generally presents or develops in most cases, in determining the likelihood that any arthritis affecting the joints is related to in-service events as opposed to some other cause. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear and complete rationale for any opinions or conclusions expressed should be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 11. The Veteran should be afforded a VA examination to determine the nature and etiology of any residuals of a head injury, including headaches, that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay statements. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The Veteran asserted that he sustained a period of unconsciousness and residual headaches after an aircraft wheel exploded near him. See Board hearing transcript; April 2010 buddy statement. The Veteran's MOS was Aviation Boatswain's Mate (aircraft handling). The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any residuals of a traumatic brain injury manifested during service or are otherwise causally or etiologically related to his military service, to include any symptoms therein. In rendering the opinion, the examiner should consider the Veteran's service treatment records which note that he was treated for complaints of headaches and dizziness in March 1967 and the August 1966 treatment record which indicated that the Veteran should not work on heights because of dizziness. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 12. After completing the above actions, the AOJ should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. 13. When the development requested has been completed, the case should be reviewed by the AOJ on the basis of additional evidence. If any benefit sought is not granted, the Veteran should be furnished a Supplemental Statement of the Case (SSOC) and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ ANTHONY C. SCIRÉ, JR. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs