Citation Nr: 1307163 Decision Date: 03/04/13 Archive Date: 03/11/13 DOCKET NO. 07-20 800 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for conjunctivitis. 2. Entitlement to service connection for hypertension, including as due to a chronic qualifying disability. 3. Entitlement to service connection for chronic fatigue syndrome, including as due to a chronic qualifying disability. 4. Entitlement to service connection for sleep problems, including as due to a chronic qualifying disability. 5. Entitlement to service connection for fibromyalgia and/or joint and muscle pain, including as due to a chronic qualifying disability. 6. Entitlement to service connection for digestive system disorders, including as due to a chronic qualifying disability. 7. Entitlement to service connection for a respiratory disorder manifested by chest pain, including as due to a chronic qualifying disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. J. Kunz, Counsel INTRODUCTION The Veteran served on active duty from December 1989 to October 1992. He served in Southwest Asia, stationed in Saudi Arabia, from October 1990 to April 1991. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions by the Waco, Texas Regional Office (RO) of the United States Department of Veterans Affairs (VA). In a September 2006 rating decision, the RO denied service connection for conjunctivitis. In a November 2009 rating decision, the RO denied service connection for hypertension, chronic fatigue syndrome, sleep problems, fibromyalgia, joint and muscle pain, irritable bowel syndrome (IBS), gastrointestinal problems, and a respiratory disorder manifested by chest pain. As the issues of service connection for IBS and for gastrointestinal problems involve the same or overlapping symptoms, the Board is addressing them together as an issue of service connection for digestive system disorders. Similarly, the issues of service connection for fibromyalgia and joint and muscle pain involve the same or overlapping symptoms. The Board is addressing them together as an issue of service connection for fibromyalgia and/or joint and muscle pain. The Veteran has sought service connection for a mental disorder or disorders, including post-traumatic stress disorder (PTSD). He also has sought service connection for sleep apnea. In a May 2012 rating decision, the RO denied service connection for PTSD, anxiety disorder, and depressive disorder, and denied service connection for sleep apnea. There is no indication that the Veteran has initiated an appeal of that decision. The Board has not only reviewed the Veteran's physical claims file, but also the Veteran's file on the Virtual VA electronic file system, to ensure a total review of the evidence. The issues of service connection for conjunctivitis, hypertension, and fibromyalgia and/or joint and muscle pain, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran service on active duty in the Southwest Asia theater of operations during the Persian Gulf War. 2. In recent years the Veteran has experienced fatigue, but not to the extent of warranting a diagnosis of chronic fatigue syndrome. 3. The fatigue the Veteran has experienced is attributable to diagnosed depression and diagnosed obstructive sleep apnea. 4. The Veteran did not experience frequent sleep problems during service. 5. Post service sleep problems result from nightmares, which are a symptom of diagnosed mental disorders, and from diagnosed obstructive sleep apnea. 6. The Veteran had recurrent diarrhea and constipation during service. 7. The Veteran experiences chronic diarrhea and constipation and intermittent heartburn; by 2010 clinicians diagnosed IBS and gastroesophageal reflux disease (GERD). 8. The Veteran did not report chronic or recurrent chest pain nor chronic or recurrent lung or lower respiratory symptoms during service. 9. Chest pain that manifested many years after service has not been medically related to the lungs or lower respiratory system, but has been medically related to the Veteran's diagnosed GERD. CONCLUSIONS OF LAW 1. No chronic fatigue syndrome was incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 4.88(a) (2012). 2. The Veteran's fatigue is attributable to clinically diagnosed disorders. 38 U.S.C.A. §§ 1117, 5107 (West 2002); 38 C.F.R. § 3.317 (2012). 3. The Veteran's sleep problems were not incurred or aggravated in service, and they are attributable to clinically diagnosed disorders. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.303, 3.317. 4. Functional gastrointestinal disorders including IBS and GERD were incurred in service or result from a medically unexplained chronic multisymptom illness. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.303, 3.317. 5. No respiratory disorder manifested by chest pain was incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 6. The Veteran's post-service chest pain is attributable to a clinically diagnosed disorder. 38 U.S.C.A. §§ 1117, 5107; 38 C.F.R. § 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Chronic Fatigue Syndrome The Veteran contends that the disorders for which he seeks service connection developed as a result of his Persian Gulf War service. One of the claimed disorders is chronic fatigue syndrome. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. The United States Court of Appeals for Veterans Claims (Court) has explained that, in general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). In addition, any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the non-service-connected disability, will be service connected. 38 C.F.R. § 3.310(b) (2012). Service connection may also be established for a Persian Gulf veteran who has a qualifying chronic disability that became manifest during service or to a degree of 10 percent or more not later than December 31, 2016. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. A "Persian Gulf veteran" is one who served in the Southwest Asia theater of operations during the Persian Gulf War. See 38 C.F.R. § 3.317. A "qualifying chronic disability" includes: (A) an undiagnosed illness, or (B) a medically unexplained chronic multisymptom illness, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal disease). 38 U.S.C.A. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). For purposes of considering service connection for such disabilities, the term "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six month period will be considered chronic. 38 C.F.R. § 3.317(a)(4). A qualifying chronic disability shall be considered service connected. 38 C.F.R. § 3.317(a)(6). Compensation shall not be paid for a qualifying chronic disability is there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between the Veteran's most recent Southwest Asia duty and the onset of the disability. 38 C.F.R. § 3.317(a)(7)(ii). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) fatigue, (2) signs or symptoms involving skin, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs or symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, or (13) menstrual disorders. 38 C.F.R. § 3.317(b). For VA purposes, the diagnosis of chronic fatigue syndrome (CFS) requires: (1) new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months; and (2) the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and (3) six or more of the following: (i) acute onset of the condition, (ii) low grade fever, (iii) nonexudative pharyngitis, (iv) palpable or tender cervical or axillary lymph nodes, (v) generalized muscle aches or weakness, (vi) fatigue lasting 24 hours or longer after exercise, (vii) headaches (of a type, severity, or pattern that is different from headaches in the pre-morbid state), (viii) migratory joint pains, (ix) neuropsychologic symptoms, and (x) sleep disturbance. 38 C.F.R. § 4.88(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. The Veteran's service medical records do not show any complaints of fatigue. The claims file contains records of VA medical treatment of the Veteran from 1999 forward. Records from 1999 to 2007 are silent regarding fatigue. In July 2008, the Veteran requested service connection for chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. He attributed those disorders to his service in the Persian Gulf War. He stated that he had continuous problems with those disorders. In August 2008, the Veteran had a VA Persian Gulf registry examination. At that time, he presented with multiple somatic complaints of fatigue, muscle aches, fibromyalgia, irritable bowel disease, hypertension, and nerves. He also reported having depression, anxiety, nightmares, and flashbacks. He expressed the belief that he had PTSD. He indicated that he had experienced fatigue and other issues since 1991. The examiner observed that the Veteran was alert and oriented. She indicated that the Veteran's account of symptoms was vague, and that he was unable to provide details of his complaints. She observed that he appeared tired, and was slumped in his chair. The examiner's impressions included chronic fatigue. In VA primary care later in August 2008, the Veteran underwent a depression screening. The score was positive for depression. The Veteran expressed that he believed that he had chronic fatigue. The treating physician expressed that treatment of the Veteran's depression would likely lead the Veteran to feel better. The physician's assessments were obesity, hypertension, depression, and arthralgias. The physician initiated trial of an antidepressant medication. In a December 2008 statement, the Veteran requested service connection for multiple conditions he believed had resulted from his Persian Gulf War service. He included fatigue, stating that ever since the Gulf War he had not had the same energy he previously had. In January 2009, the Veteran had another VA Persian Gulf registry examination. He reported having chronic fatigue, as well as muscle aches, fibromyalgia, irritable bowel syndrome, hypertension, depression, anxiety, and PTSD. He indicated that his fatigue and other problems had occurred since 1991. The examiner found that the Veteran was alert and oriented, and that his account of symptoms was vague and without details. The examiner's impressions included malaise, chronic fatigue, and depression/anxiety. In a VA psychiatric consultation in January 2009, the Veteran reported spells of depression lasting up to a week. He stated that during those episodes his mood and appetite were low, and his energy levels and motivation were reduced. The psychiatrist listed diagnoses of anxiety disorder not otherwise specified (mild subthreshold PTSD) and depressive disorder not otherwise specified. In June 2009, the Veteran had a VA chronic fatigue syndrome examination. The Veteran reported having experienced fatigue since January 2009. He indicated that he had not sought any treatment for fatigue. He reported having frequent generalized muscle aches and frequent migratory joint pains. He did not indicate that fatigue lasted 24 hours or longer after exercise. He stated that he was employed full time as a bus driver, and had not lost any time from work over the preceding year. Examination did not reveal any weight change or other significant abnormal physical findings. The examiner found that the Veteran did not have debilitating fatigue, providing highly probative evidence against this claim. The examiner found that the Veteran had no restriction of daily activities. The examiner noted that the Veteran had a history of depression, and that depression could present with the same symptoms as chronic fatigue. The examiner stated that the Veteran did not appear to meet the criteria for chronic fatigue syndrome. The examiner indicated that the Veteran's depression could produce the symptoms that the Veteran attributed to fatigue. In VA primary care in August 2009, the Veteran complained of fatigue. He indicated that presently he was not in mental health treatment. In a list of active problems, the examiner included anxiety disorder, but did not include chronic fatigue syndrome. In VA primary care in April 2010, a depression screen was positive. On several occasions in VA treatment in 2010, the Veteran reported drinking energy drinks. In VA treatment in December 2010, the Veteran reported a year to year and a half history of waking suddenly at night, needing air. He stated that his snoring disturbed his wife's sleep. He related that on awakening in the morning he was still tired. He reported that he got sleepy at work, and used energy drinks to try to get energy. A diagnostic sleep study was performed in December 2010, and the reviewing clinician diagnosed obstructive sleep apnea. In January 2011, VA provided the Veteran a continuous positive air pressure machine (CPAP) to address his sleep apnea. Treatment notes from 2011 reflect the Veteran's reports that the CPAP machine helped when he used it. The Veteran had a VA mental health examination in January 2011. The Veteran recounted some of his experiences before service and during service. The examining psychologist concluded that the Veteran did not have PTSD, but had anxiety disorder and depressive disorder. In a December 2011 addendum, the examiner provided the opinion that the Veteran's anxiety and depressive disorders developed as a result of events before the Veteran's service and not events during the Veteran's service. The VA physician who examined the Veteran in June 2009 found that the Veteran did not have chronic fatigue syndrome, providing highly probative evidence against the Veteran's claim, outweighing the Veteran's lay statements regarding this issue. That examiner explained that the Veteran did not have symptoms or effects that met the criteria for a diagnosis of CFS. The preponderance of the evidence is against finding that the Veteran has CFS. In recent years, the Veteran has reported experiencing fatigue. There is no record that the Veteran reported fatigue during service, and he has not made any clear contention that he began during service to experience fatigue. The preponderance of the evidence thus is against finding that fatigue first reported long after service began during service. The June 2009 examiner related the Veteran's fatigue symptoms to his depression. The Veteran also sought treatment for difficulty sleeping, which he stated was followed by fatigue. Medical inquiries led to a diagnosis of obstructive sleep apnea, and treatment was prescribed. The best evidence in this case clearly indicates, for reasons cited above, the Veteran does not have this disability. In any event, even the Board assumes the Veteran has "fatigue", sound medical evidence indicates that the Veteran's fatigue, assuming the Veteran has this disability, is related to his diagnosed depression and diagnosed sleep apnea, and that his fatigue is medically explained and is not a sign of an undiagnosed illness. Thus, the preponderance of the evidence is against service connection of fatigue symptoms as due to a chronic qualifying disability based on Persian Gulf War service. Service connection has been denied for mental disorders and for sleep apnea, so those conditions cannot form a basis for secondary service connection. Sleep Problems The Veteran essentially contends that he has sleep problems resulting from his Persian Gulf War service. His service medical records do not show any complaints regarding sleep. In July 1991, following his April 1991 return from Southwest Asia service, the Veteran completed a questionnaire. He checked no as to whether he had experienced any nightmares or trouble sleeping. On a medical history completed in August 1992 in preparation for separation from service, the Veteran checked no for any history of frequent trouble sleeping. No psychiatric disorder nor respiratory disorder was noted on the report of the August 1992 service separation examination. The earliest post-service evidence in the file is records of VA medical treatment of the Veteran in 1999 and 2000. At that time, he did not report any issues involving sleep. Statements from the Veteran and medical records from 2008 forward reflect the Veteran's reports of fatigue, nightmares, and sleep problems. In the August 2008 VA Persian Gulf registry examination, he reported having had fatigue and nightmares since 1991. His account of his symptoms was vague and without details. The examiner observed that the Veteran appeared tired, and was slumped in his chair. In December 2008, the Veteran requested service connection for sleeping problems. He stated that he continued to have nightmares and that he did not get much sleep anymore since the war. In the January 2009 VA Persian Gulf registry examination, he reported that since 1991 he had experienced nightmares and sleep problems. In the June 2009 VA chronic fatigue syndrome examination, he reported that he awakened having trouble breathing. He stated that he had been told that it was due to gastroesophageal reflux disorder (GERD). In December 2010 the Veteran told a VA clinician that for a year to year and a half he had experienced waking suddenly at night, needing air. He stated that his snoring disturbed his wife's sleep. He related that on awakening in the morning he was still tired. He reported that he got sleepy at work, and used energy drinks to try to get energy. A diagnostic sleep study was performed in December 2010, and the reviewing clinician diagnosed obstructive sleep apnea. In January 2011, VA provided the Veteran a continuous positive air pressure machine (CPAP) to address his sleep apnea. Treatment notes from 2011 reflect the Veteran's reports that the CPAP machine helped when he used it. In April 2011, the Veteran's wife wrote that for several years the Veteran had snored loudly and had paused in his breathing while he was asleep. She stated that the Veteran also had nightmares from which he woke up screaming, sweating heavily, and talking about driving his tank through mine fields in Iraq. In a December 2011 VA PTSD examination, the Veteran reported that he slept poorly, sometimes had night sweats, and had nightmares two to three times a month. The examiner noted the records of a diagnosis of sleep apnea. During service, the Veteran reported that he had not had frequent trouble sleeping. Many years later, in 2009, he indicated that since 1991 he had experienced sleeping problems. The Veteran's account during of his experiences during service is more likely to be accurate than his recollection of those times made between ten and twenty years later. The Board finds the contemporaneous account more reliable. The more persuasive evidence, then, indicates that the Veteran did not have sleep problems while he was in service. The Veteran has related his current sleep problems to nightmares and to difficulty breathing. The Veteran's nightmares are symptoms of disorders that are diagnosed, an anxiety disorder and a depressive disorder. The VA psychologist who examined the Veteran in January 2011 concluded that the Veteran's current mental health symptoms are not related to his service, and the RO denied service connection for mental disorders. VA clinicians investigated the Veteran's difficulty breathing while sleeping, and diagnosed obstructive sleep apnea. The RO denied service connection for the Veteran's sleep apnea. The Veteran's current sleep problems are symptoms of mental disorders and sleep apnea which are diagnosed conditions. His sleep problems therefore do not represent an undiagnosed illness such as could warrant service connection under 38 C.F.R. § 3.317 or a separate disability related to service. His sleep problems stem from disorders that are not service connected and which thus cannot form a basis for secondary service connection. Digestive System Disorders The Veteran is seeking service connection for digestive system disorders manifested by diarrhea, constipation, and chest pain. He has been diagnosed with IBS and GERD. He attributes these disorders to his service, including his Persian Gulf War service. For purposes of considering service-connection of gastrointestinal disorders as a qualifying chronic disability in Persian Gulf War veterans, functional gastrointestinal disorders are a group of conditions characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease and may be related to any part of the gastrointestinal tract. Specific functional gastrointestinal disorders include, but are not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia. These disorders are commonly characterized by symptoms including abdominal pain, substernal burning or pain, nausea, vomiting, altered bowel habits (including diarrhea, constipation), indigestion, bloating, postprandial fullness, and painful or difficult swallowing. Diagnosis of specific functional gastrointestinal disorders is made in accordance with established medical principles, which generally require symptom onset at least 6 months prior to diagnosis and the presence of symptoms sufficient to diagnose the specific disorder at least 3 months prior to diagnosis. 38 C.F.R. § 3.317(a)(2)(i)(B)(3), Note. No digestive system disorders were noted when the Veteran was examined in September 1989 for entrance into service. However, important for this case, in June 1991, the Veteran sought treatment, reporting a one day history of stomach cramps, diarrhea, and vomiting. He did not have a fever. The treating clinician's assessment was viral syndrome. Treatment included fluids provided intravenously, followed by bedrest and forced fluids. On follow up three days later, the Veteran reported feeling much better. The clinician reported that the Veteran's viral gastroenteritis was improving. Later in June, about two weeks after the initial treatment, the Veteran completed a questionnaire regarding his condition following his April 1991 return from Southwest Asia service. The Veteran checked no as to whether he had stomach or belly pain, nausea, diarrhea, or bloody bowel movements. On July 14, 1992, the Veteran went to sick call for constipation, with daily bowel movements with hard stool and straining. The treating clinician prescribed a stool softener medication. On July 27, 1992, the Veteran came to sick call with a one day history of vomiting and diarrhea, accompanied by weakness, dizziness, and headaches. He did not have a fever. The clinician indicated that examination was normal, and called for pushing fluids. On August 11, 1992, the Veteran had his medical examination for separation from service. On a medical history, he checked no for history of stomach, liver, or intestinal trouble or pain or pressure in the chest. On the examination report, the examiner checked normal for the conditions of the abdomen, throat, and chest. On August 12, 1992, the Veteran went to sick call with an eighteen hour history of headache, dizziness, stomach pain, and nausea. His temperature was 100.2 degrees Fahrenheit. The clinician's assessment was viral syndrome. From August 13, 1992, through October 8, 1992, the date of the Veteran's separation from service, the Veteran was seen in sick call on four occasions, each for conditions without digestive system symptoms. The Veteran has not reported receiving treatment for digestive system symptoms during the years immediately following his service. In July 2008, the Veteran requested service connection for IBS, claimed as related to Persian Gulf War service. In the August 2008 VA Persian Gulf registry examination, the Veteran reported having IBS, sharp chest pains, and vague stomach pains. He stated that he had twice daily diarrhea occurred two days per week, that constipation occurred up to five days per week, and that he had blood in his stool after a hard stool. He reported that he had some chest pain at night. On examination, there was no evidence of abdominal tenderness. The impressions the examiner listed included constipation and diarrhea. In VA treatment in August 2008, the Veteran reported having chest pain on and off. He stated that he had heartburn. The treating clinician found that the Veteran's cardiovascular sounds were normal. The clinician stated that the Veteran's chest pain was atypical, but that he had risk factors in the form of high cholesterol and family history. Later in August 2008, the Veteran reported that he had IBS. He stated that he sometimes had diarrhea and sometimes had constipation. On cardiology stress testing in August 2008, the Veteran had a hypertensive response to exercise. In November 2008, the Veteran reported a two day history of chest tightness. He had no shortness of breath. An EKG was normal. He also reported having rectal bleeding and intermittent diarrhea and constipation. A clinician indicated that it was likely that the Veteran had hemorrhoids and possible that he had IBS. In December 2008, the Veteran requested service connection for gastrointestinal problems manifested by chest pain. In the January 2009 Persian Gulf registry examination, the Veteran reported alternating constipation and loose stools. He stated that three to four days per week he had loose stools occurring at least three times per day. He stated that when he had constipation it lasted up to five days, and he occasionally had blood in his stools. He reported having a sore throat, and denied having dysphagia. He related having some chest pain at night. On examination, the Veteran's abdomen was not tender. The examiner's impressions included constipation and diarrhea. The Veteran had a VA gastroenterology consultation in January 2009. He reported intermittent rectal bleeding, diarrhea, intermittent lower abdominal pain, and intermittent severe heartburn. He indicated that he was on medication for heartburn. The clinician's impressions were diarrhea with rectal bleeding, GERD, and intermittent lower abdominal pain. Colonoscopy performed in January 2009 showed a small polyp, a small isolated diverticulum, and small internal hemorrhoids. In VA primary care in January 2009, the Veteran reported that he missed one to two days of work per month because of diarrhea from his IBS. In VA primary care in August 2009, the treating physician noted that the Veteran had IBS and mild GERD. Those diagnoses also were also noted in VA treatment records from 2010 and 2011. In a March 2010 statement, the Veteran asserted that his IBS and other gastrointestinal problems were attributable to his Gulf War service. In a November 2011 VA examination, the Veteran reported a seven to eight year history of diarrhea alternating with constipation. The examiner indicated that after a February 2009 colonoscopy IBS was diagnosed. The examiner found that the Veteran had IBS. The Veteran reported a seven to eight year history of occasional heartburn and an acid feeling in the back of his throat, occurring about two times per month. The examiner stated that upper gastrointestinal radiographic studies performed in February 2009 showed minimal intermittent gastroesophageal reflux. The examining physician found that the Veteran had GERD. Later in November 2011, after the examination, the examiner received and reviewed the Veteran's claims file. In an addendum to the examination report, the examiner noted the digestive system findings in the service medical records and the post-service evidence of IBS and GERD. Noting the passage of more than ten years between the Veteran's service and post-service symptoms of IBS and GERD, the examiner expressed the opinions that it less likely than not that the post-service IBS was incurred in or caused by service and that it is less likely than not that the GERD was incurred in or caused by service. The examiner also stated that the Veteran's IBS and GERD were common clinical entities and did not represent an undiagnosed illness. He opined that the Veteran's IBS and GERD, which manifested long after his Gulf Service, also did not represent diagnosable but medically unexplained chronic multisymptom illness related to exposure to environmental hazards in the Gulf. The Veteran received treatment during service for diarrhea and constipation, occurring soon after his Southwest Asia duty, and recurring shortly before his separation from service. After service, from 2008 forward, he has reported frequent diarrhea and constipation, and intermittent heartburn. After many months of the Veteran's reports of such gastrointestinal symptoms, clinicians diagnosed IBS and GERD. While the physician who examined the Veteran in 2011 opined that the Veteran's gastrointestinal disorders do not constitute a medically unexplained chronic multisymptom illness, he explained that his opinion was based on the passage of several years between the Veteran's Gulf service and manifestation of the current symptoms. The Veteran's functional gastrointestinal disorders, including IBS and GERD, became manifest, however, before the date provided in 38 C.F.R. § 3.317 regarding an association between Gulf War service and functional gastrointestinal disorders. The Board finds that the evidence supporting service connection for the Veteran's digestive system disorders is at least balanced with the evidence against service connection. Resolving reasonable doubt in favor of the claimant, the Board grants service connection. The nature and extent of the disability is not at issue before the Board at this time. Respiratory Disorder with Chest Pain Recent medical records reflect the Veteran's reports of chest pain. The Veteran is seeking service connection for a respiratory disorder he believes may be the cause of the chest pain. During service, the Veteran received treatment for allergies manifested by nose, sinus, and throat symptoms. He was seen on several occasions, and his allergic rhinitis symptoms were treated with medication. On one occasion, in April 1992, the Veteran reported that he felt like his breathing was heavy and like he was wheezing. The treating clinician's assessment was seasonal rhinitis. On an August 1992 medical history, the Veteran checked no for history of asthma, shortness of breath, pain or pressure in chest, and chronic cough. On the report of the Veteran's August 1992 service separation examination, the examiner checked normal for the condition of the Veteran's lungs and chest. Between the August separation examination and actual separation in October 1992, the Veteran was seen two more times for nasal congestion attributed to allergic rhinitis. The notes from that treatment are silent for complaints affecting the lungs or chest. The Veteran has not stated that he has a long history of chest pain that began during or soon after service. Some post-service records from 2008 forward contain references to chest pain. In the August 2008 VA Persian Gulf registry examination, the symptoms the Veteran reported included sharp chest pains. He reported that he had some chest pain at night. He denied dyspnea, cough, hemoptysis, asthma, bronchitis, or pneumonia. The examiner found that the Veteran's lungs were clear to auscultation. The impressions the examiner listed did not include any respiratory disorders. In VA treatment in August 2008, the Veteran reported having chest pain on and off. He stated that he had heartburn. The treating clinician found that the Veteran's cardiovascular sounds were normal. The clinician stated that the Veteran's chest pain was atypical, but that he had risk factors in the form of high cholesterol and family history. On cardiology stress testing in August 2008, the Veteran had a hypertensive response to exercise. In November 2008, the Veteran reported a two day history of chest tightness. He had no shortness of breath. An EKG was normal. In December 2008, the Veteran requested service connection for a respiratory condition manifested by unexplained chest pain, and for gastrointestinal problems manifested by chest pain. In the January 2009 Persian Gulf registry examination, the Veteran reported having shortness of breath and sharp chest pain. The examiner reported that the Veteran denied dyspnea, cough, hemoptysis, asthma, bronchitis, or pneumonia. On examination the Veteran's lungs were clear to auscultation. The impressions the examiner listed did not include any respiratory disorders. On VA examination in June 2009, it was reported that the Veteran experienced chest pain was attributed to GERD. The Veteran sought treatment in 2010 for breathing problems while sleeping. Those problems were diagnosed as obstructive sleep apnea. The Veteran's service medical records do not reflect chronic chest pain symptoms, and he does not report that he had recurrent chest pain in service that continued after service. The preponderance of the evidence is against any respiratory disorder manifested by chest pain having first manifested during service or soon thereafter. In 2008, the Veteran sought treatment for unexplained chest pain. The clinician who saw him did not find any lung or other respiratory disorder related to the chest pain. Subsequent treatment and examinations have not shown any lung or other lower respiratory disorder. Treating clinicians have attributed the Veteran's chest pain to his diagnosed GERD. GERD is a disorder of the digestive system, not the respiratory system. The Veteran has diagnosed sleep apnea. The symptoms he has described associated with his sleep apnea, however are snoring and sudden awakening during sleep, and not chest pain. The preponderance of the evidence indicates that the Veteran does not have any chronic lung or lower respiratory disorder. The preponderance of the evidence indicates that Veteran's chest pain is related to his diagnosed GERD, and not to any respiratory disorder. Thus, the preponderance of the evidence is against service connection for a claimed respiratory disorder manifested by chest pain either as incurred or aggravated in service or as a qualifying chronic disability such as an undiagnosed illness or a medically unexplained chronic multisymptom illness. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2011)) redefined VA's duty to assist a claimant in the development of a claim for VA benefits. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b). The Court has stated that the requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insufficiency in the timing or content of VCAA notice is harmless, however, if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). The RO provided the Veteran with VCAA notice in letters issued in April 2006, July 2006, March 2007, July 2008, February 2009, August 2009, March 2010, and September 2010. Those letters addressed the information and evidence necessary to substantiate claims for service connection. Some of the letters informed the Veteran how VA assigns disability ratings and effective dates, and some addressed the statutes and regulations that apply to certain service connection claims based on Gulf War service. The letters also addressed who was to provide the evidence. The claims file contains the Veteran's service medical records, post-service medical records, statements from the Veteran, and the reports of VA medical examinations. The Veteran has had VA medical examinations that provided adequate information to address his claims for service connection for chronic fatigue syndrome, sleep problems, digestive system disorders, and a respiratory disorder manifested by chest pain. With respect to the claims that the Board is deciding at this time, the Veteran has not identified potentially relevant evidence that is not associated with the claims file. With respect to the claims that the Board is deciding at this time, the Veteran was notified and aware of the evidence needed to substantiate the claims, as well as the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran has actively participated in the claims process by providing evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process, and he has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication nor to have caused injury to the Veteran's interests. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless, and does not prohibit consideration on the merits of the claims that the Board is deciding at this time. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). ORDER Entitlement to service connection for chronic fatigue syndrome is denied. Entitlement to service connection for sleep problems is denied. Entitlement to service connection for a digestive system disorder is granted. Entitlement to service connection for a respiratory disorder manifested by chest pain is denied. REMAND The Veteran reports that during service he had conjunctivitis that recurred intermittently. He states that since service he has continued to have recurrences of conjunctivitis. He is seeking service connection for conjunctivitis. The Veteran had a VA eye examination in September 2006. The examiner observed no symptoms of conjunctivitis. In statements in support of his claim, the Veteran stated that he did not have symptomatic conjunctivitis on the day of the VA examination, but that he continues to have intermittent periods of symptomatic conjunctivitis. The Board will remand the case for a new VA examination with review of the file and an opinion regarding the likely etiology of post-service outbreaks of conjunctivitis (regardless as to whether there is an outbreak on the day of the new examination). The Veteran reports having had some elevated blood pressure during service, and having been diagnosed with hypertension after service. He is seeking service connection for hypertension. Hypertension is among the chronic diseases for which service connection may be established based upon a legal presumption by showing that the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1112, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). In addition, cardiovascular signs or symptoms are among the signs and symptoms which may be manifestations of a qualifying chronic disability in a Persian Gulf War veteran. 38 C.F.R. § 3.317(b). The Veteran's service medical records show blood pressure within normal limits on many occasions and elevated on a small number of occasions. Post service medical records reflect the Veteran's reports of having been on medication for hypertension. In recent years, clinicians have treated the Veteran for hypertension. The claims file does not contain any medical records from the year following the Veteran's separation from service. The Board will remand the claim to provide the Veteran an opportunity to identify potential evidence that his hypertension became manifest during the year following his service. The Veteran is seeking service connection for fibromyalgia and for joint and muscle pain. As a VA examiner provided a diagnosis of fibromyalgia, and fibromyalgia is manifested by joint and muscle pain, the evidence relevant to the fibromyalgia claim is also relevant to the joint and muscle pain claim. The Veteran states that since his Persian Gulf War service he has unexplained joint pain and frequent muscle spasms. In a June 2009 VA examination, the Veteran reported that he had daily pain in both arms and both legs, and that he treated the pain with nonprescription pain medication. The examiner provided a diagnosis of fibromyalgia manifested by myalgias and arthralgias. The Veteran's reports sufficiently establish that the symptoms diagnosed as fibromyalgia have existed for more than six months. His fibromyalgia manifested before the end of 2016. Service connection is warranted if it became manifest to a degree of 10 percent disabling or more. See 38 C.F.R. § 3.317 (a)(i). Under the rating schedule, to be 10 percent disabling or more fibromyalgia must require continuous medication for control, or be symptomatic more than one third of the time. See 38 C.F.R. § 4.71a, Diagnostic Code 5025 (2012). The report of the 2009 examination does not indicate whether continuous medication is required for control of the Veteran's fibromyalgia symptoms, nor how much of the time his symptoms are present. VA treatment records reflect that the Veteran takes nonprescription pain medication three times daily as needed, but that information also fails to answer the relevant questions. The Board therefore will remand the issues for a new VA examination, with review of the claims file, to obtain evidence and an opinion as to whether the Veteran's fibromyalgia is 10 percent disabling or more. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. The RO should provide the examiners who will review the file in conjunction with this remand all evidence that is in the Virtual VA electronic claims file and not in the paper claims file and that is relevant to the remanded claims. Beyond the above, it is important for the Veteran to understand that his credibility with the VA is a clear factor in this case. Any indication that the Veteran is exaggerating his complaints for VA compensation purposes will have severe impact on the VA determination regarding all claims. Accordingly, the case is REMANDED for the following action: 1. In addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claims. The AMC or RO is to review the electronic file. With all documents contained therein deemed to be relevant to the remanded claims and not duplicative of the documents already found in the paper claims file, take action to ensure that the records in the electronic file are made available (whether by electronic means or by printing) to the clinicians who are asked to review the claims file and provide medical findings in conjunction with the development requested herein. 2. Inform the Veteran that evidence that he had hypertension during the year following separation from service would support service connection for hypertension. Ask the Veteran to identify sources of medical treatment he received during the year following his separation from service. Obtain records of the treatment that the Veteran identifies. 3. Schedule the Veteran for a VA eye examination to address the likely etiology of intermittent or recurrent conjunctivitis (if any). Provide the examiner with the Veteran's claims file for review. The Veteran had conjunctivitis on multiple occasions during service. He reports that since separation from service he has had symptomatic conjunctivitis repeatedly, although not continuously. Ask the examiner to indicate whether the Veteran has symptomatic conjunctivitis at the time of the examination. Ask the examiner, regardless of whether there is symptomatic conjunctivitis on the day of the examination, to provide an opinion as to whether it is at least as likely as not (at least a 50 percent likelihood) that the Veteran's post-service intermittent conjunctivitis is a continuation of or otherwise related to conjunctivitis treated on several occasions during service. Ask the examiner to provide a clear explanation of the reasoning leading to the opinion. 4. Schedule the Veteran for a VA examination to determine the manifestations of the Veteran's fibromyalgia (if any). Provide the examiner with the Veteran's claims file for review. Ask the examiner to interview the Veteran and obtain a history with answers to the following questions: A) Is it at least as likely as not that the Veteran has fibromyalgia? B) If so, how intermittently or continuously is medication needed to control the symptoms of the Veteran's fibromyalgia? C) If so, what proportion of the time are fibromyalgia symptoms present, in particular, are the symptoms present more than one third of the time? 5. Thereafter, perform any other development deemed necessary, and review the expanded record and reconsider the remanded claims. Consideration of the hypertension service connection claim should include consideration as to whether the Veteran has hypertension due to a chronic qualifying disability. Thereafter, if any of the remanded claims remains denied, issue a supplemental statement of the case and afford the Veteran an opportunity to respond. Thereafter, return the case to the Board for appellate review if otherwise in order. The Board intimates no opinion as to the ultimate outcome of the remanded issues. The Veteran has the right to submit additional evidence and argument on those issues. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals 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 Supp. 2012). ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs