Citation Nr: 0814606 Decision Date: 05/02/08 Archive Date: 05/12/08 DOCKET NO. 05-28 541A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for chronic fatigue claimed due to undiagnosed illness and/or due to pyridostigmine vaccination. 2. Entitlement to service connection for chronic fatigue. 3. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a sleep disorder claimed due to undiagnosed illness and/or due to pyridostigmine vaccination. 4. Entitlement to service connection for a sleep disorder. 5. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for joint pains claimed due to undiagnosed illness and/or due to degenerative joint disease and/or due to pyridostigmine vaccination. 6. Entitlement to service connection for joint pains. 7. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for cervical spondylitis, C5-6, also claimed due to pyridostigmine vaccination. 8. Entitlement to service connection for cervical spondylitis. 9. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for memory loss, claimed due to undiagnosed illness and/or due to pyridostigmine vaccination. 10. Entitlement to service connection for memory loss. 11. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for post- traumatic stress disorder (PTSD). 12. Entitlement to service connection for PTSD. 13. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for tuberculosis. 14. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for hyporeflexia and clonus, claimed due to undiagnosed illness and/or due to brain damage and/or pyridostigmine vaccination. 15. Entitlement to service connection for fibromyalgia, claimed due to undiagnosed illness and/or due to brain damage and/or pyridostigmine vaccination. 16. Entitlement to service connection for a cognitive disorder, claimed due to undiagnosed illness and/or due to brain damage and/or pyridostigmine vaccination. 17. Entitlement to service connection for immune system disorder, claimed due to undiagnosed illness and/or pyridostigmine vaccination. 18. Entitlement to service connection for acquired scoliosis, claimed due to undiagnosed illness and/or pyridostigmine vaccination. 19. Entitlement to service connection for bilateral carpal tunnel syndrome, claimed due to undiagnosed illness and/or pyridostigmine vaccination. 20. Entitlement to service connection for hiatal hernia, esophagitis, and/or gastric reflux, claimed due to undiagnosed illness and/or pyridostigmine vaccination. 21. Entitlement to service connection for right elbow joint arthritis, claimed due to undiagnosed illness and/or pyridostigmine vaccination. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Fetty, Counsel INTRODUCTION The veteran had active military service from April 1970 to January 1972 and from January 18, 1991, to April 1, 1991. He also had active duty for training and inactive duty training prior to and after his second period of active military service. He served in Southwest Asia during February and March 1991. This appeal comes to the Board of Veterans' Appeals (Board) from a July 2003-issued rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana, that denied service connection for the disabilities listed on pages 1 and 2. In a June 2000-issued rating decision, the RO denied several original service connection claims and denied reopening previously denied claims. The veteran was notified of that decision in June 2000. He timely filed a notice of disagreement (NOD), but he did not file a VA Form 9, Substantive Appeal, after the RO issued a statement of the case (SOC). Thus, that decision became final. Where previous final decisions denying a service connection claim are of record, the Board must first address the issue of new and material evidence. If new and material evidence has been submitted, the Board will grant the application to reopen the claims and may then consider them on the merits. In June 1994, the RO denied service connection for tuberculosis. The veteran submitted a timely NOD and the RO issued an SOC; however, the veteran did not submit a substantive appeal and the RO closed the case. In his June 1999 claim for service connection for PTSD, the veteran also requested service connection for depression. This issue has not been developed and it is referred for appropriate action. In September 1999, the veteran reported that he was no longer working due to service-related disabilities. This is referred as an informal claim for a total disability rating for compensation purposes based on individual unemployability (TDIU). In November 2007, the veteran submitted additional evidence without waiving his right to initial RO consideration of that evidence. Because new evidence has been submitted, where appropriate, the Board has remanded the claims for initial RO consideration of that evidence. Whether new and material evidence has been submitted to reopen claims of entitlement to service connection for tuberculosis, hyporeflexia, and clonus is addressed in the REMAND portion of the decision. Service connection for cognitive disorder, memory loss, fibromyalgia, immune system disorder, scoliosis, bilateral carpal tunnel syndrome, and right elbow arthritis is also addressed in the REMAND portion of the decision below. These issues are REMANDED to the agency of original jurisdiction (AOJ) via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. By rating decision of June 2000, the RO denied service connection for chronic fatigue, a sleep disorder, joint pains, memory loss, and PTSD, and properly notified the veteran of that decision. 2. The veteran did not appeal the June 2000 decision and it became final. 3. Evidence received at the RO since the June 2000 rating decision raises a reasonable possibility of substantiating the claims for service connection for an undiagnosed illness manifested by chronic fatigue, for service connection for a sleep disorder, for service connection for joint pains, for service connection for memory loss, and for service connection for PTSD. 4. Chronic fatigue due to undiagnosed illness has been manifested to a degree of 10 percent since the veteran returned from Southwest Asia. 5. The veteran is presumed sound at the time of entry into active military service in January 1991. 6. Competent medical evidence relates insomnia to active military service. 7. Chronic pains of the shoulder, left elbow, knees, and ankles, due to undiagnosed illness, has been manifested to a degree of 10 percent since the veteran returned from Southwest Asia. 8. Competent medical evidence relates cervical spondylosis to active military service. 9. The veteran is not a combat veteran. 10. A diagnosis of PTSD related to independently verified non-combat stressors has been offered. 11. A diagnosis of GERD and hiatal hernia related to active service has been offered. 12. Esophagitis is not shown by the evidence of record. CONCLUSIONS OF LAW 1. The June 2000 rating decision, which denied service connection for chronic fatigue, a chronic sleep disorder, joint pains, cervical spondylosis, memory loss, and PTSD, is final. 38 U.S.C.A. § 7105(c) (West 2002 & Supp. 2007); 38 C.F.R. §§ 20.302, 20.1103 (2007). 2. New and material evidence has been received to warrant reopening the previously and finally denied claims of entitlement to service connection for an undiagnosed illness manifested by chronic fatigue and multiple joint pains, service connection for a sleep disorder, cervical spondylosis, memory loss, and PTSD and those claims are reopened. 38 U.S.C.A. § 5108 (West 2002 & Supp. 2007); 38 C.F.R. § 3.156(a) (2007). 3. The regulatory requirements for presumptive service connection for an undiagnosed illness manifested by chronic fatigue and pains of the shoulders, left elbow, knees, and ankles have been met. 38 U.S.C.A. §§ 1110, 1113, 1117, 1118, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2007). 4. Insomnia, cervical spondylosis, PTSD, GERD, and hiatal hernia were incurred in active military service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has a duty to notify and assist claimants in substantiating claims for benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). In this case, the Board is either granting the benefits sought on appeal or remanding the claims for further development consistent with the above-cited authorities. Accordingly, the duty to notify and the duty to assist need not be discussed. New and Material Evidence When a claim has been disallowed by the RO, the claim may not thereafter be reopened and allowed and a claim based upon the same factual basis may not be considered unless new and material evidence has been presented. 38 C.F.R. §§ 3.156(a), 20.1103 (2007). Pursuant to 38 C.F.R. § 3.156(a), a claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can neither be cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. This version of 38 C.F.R. § 3.156(a) applies to any claim to reopen a finally decided claim received on or after August 29, 2001. The veteran's application to reopen his service connection claims was received at the RO in January 2003, subsequent to the effective date of the revision. Therefore, this version of § 3.156(a) applies. In Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998), the United States Court of Appeals for the Federal Circuit stressed that newly submitted evidence could be material if it resulted in a more complete record for evaluating the disability. With respect to reopening a finally decided claim, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). If new and material evidence is presented or secured with respect to a claim that has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C.A. § 5108; Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). Chronic Fatigue In a June 2000 rating decision, the RO determined that new and material evidence had not been submitted to reopen a claim for service connection for fatigue. The veteran and his representative were notified of the decision in a letter from the RO, but did not appeal. Thus, the rating decision became final. 38 U.S.C.A. § 7105(b), (c) (West 2002). The relevant evidence of record at the time of the June 2000 RO rating decision consists of service medical records (SMRs), VA examination reports, VA treatment records, private medical reports, and claims and statements of the veteran. Fatigue is not mentioned in the SMRs. VA clinical records reflect that the veteran underwent a VA general medical examination in December 1993, but did not mention fatigue. Neither a May 1994 VA Persian Gulf War Registry examination report nor a September 1994 VA general medical examination report mentions any fatigue, but a September 1994 VA mental disorders examination report does note chronic fatigue. In August 1997, a VA clinical psychologist noted complaints of chronic fatigue. A diagnosis of anxiety disorder NOS was offered; however, this diagnosis appears related to other reported stressors, rather than to complaints of fatigue. In January 1998, the RO denied service connection for fatigue. The veteran submitted an NOD in February 1998. The RO did not issue a SOC discussing fatigue until May 2001. The veteran did not file a substantive appeal, however. In April 2000, the veteran submitted an article by the American Gulf War Veterans Association that suggests a relationship between anthrax vaccine given to 2.4 million service persons and undiagnosed illnesses. In September 1996, the veteran's supervisor reported that the veteran had missed work because of symptoms that included chronic fatigue. In June 2000, the RO denied service connection for fatigue due to undiagnosed illness based on the absence of evidence of a chronic disability. The veteran did not file a substantive appeal following the issuance of an SOC and the June 2000 rating decision became final. Below, the Board will review evidence submitted since the June 2000 RO decision to determine whether new and material evidence has been submitted. The evidence submitted since the June 2000 RO decision includes a June 2001 VA general medical examination report. The examiner noted that there was no known endocrine disorder such as diabetes or thyroid disorder, or hemic disorder such as anemia, or respiratory or cardiac disorder, which might explain the veteran's fatigue. The relevant diagnosis was chronic fatigue syndrome from 1992. The examiner reiterated the veteran's complaints of fatigue, and remarked, "As best as can be determined from the patient's prior records, all of these complaints and/or morbidities were incurred during his active duty service." The June 2001 VA examination report is new and material evidence to reopen the claim. The physician identified chronic fatigue and has related it to active service in the Persian Gulf. Given the benefit of the doubt doctrine set forth at 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102, this opinion could place the evidence for service connection in relative equipoise. Thus, it is neither cumulative nor redundant and it raises a reasonable possibility of substantiating the claim. Because the RO's previously stated basis for denial was that a chronic disability had not been shown, this medical evidence is certainly new and material. Because the evidence submitted is sufficiently new and material to reopen the claim, the application to reopen the service connection claim must be granted. Sleep Disorder In a June 2000 rating decision, the RO determined that new and material evidence had not been submitted and denied an application to reopen a claim for service connection for a sleep disorder. The veteran and his representative were notified of the decision in a letter from the RO, but did not appeal. Thus, the rating decision became final. The SMRs include a March 1987 retention examination report and medical history questionnaire on which the veteran checked "yes" to frequent trouble sleeping. The next military examination report, dated September 1987, does not note a sleep disorder, however. The SMRs do not contain an entry examination report at the time of entry into active service for deployment to the Persian Gulf. A redeployment examination report of March 10, 1991, however, reflects that the veteran checked "yes" to frequent trouble sleeping. The examiner noted a history of terminal insomnia for many years and offered a diagnosis of possible sleep disorder. A VA general medical examination report of December 1993 does not mention a sleep disorder. Neither a May 1994 VA Persian Gulf War Registry examination report nor a September 1994 VA general medical examination report, nor a September 1994 VA mental disorders examination report mentions a sleep disorder. An April 1999 VA sleep disorders clinic report reflects that after a clinical sleep study four sleep-related diagnoses were offered. Those diagnoses are: environmental sleep disorder; psychophysiological insomnia, dyssomnia secondary to psychiatric conditions; and, dyssomnia secondary to medical conditions. The medical condition noted was "pain". An April 1999 VA psychiatry consultation notes a complaint of broken sleep for which Prozac(r) had helped. The psychiatrist offered a diagnosis of depression, NOS, but did not relate sleep disorders to that diagnosis. In April 2000, the veteran submitted an article by the American Gulf War Veterans Association that suggests a relationship between anthrax vaccine given to 2.4 million service persons and undiagnosed illnesses. In June 2000, the RO denied service connection for a sleep disorder on the basis it pre-existed active service. The veteran did not file a substantive appeal to the June 2000 rating decision and it became final. Evidence submitted since that time is discussed next. In April 2001, the veteran submitted several news articles that discuss side effects of various vaccines that had been administered to Persian Gulf War service members. Because these do not link a sleep disorder to active service, this evidence is not material. A June 2001 VA general medical examination report notes a history of insomnia dating back to 1993. The relevant diagnosis was simply insomnia. The examiner reiterated a list of complaints, including insomnia, and remarked, "As best as can be determined from the patient's prior records, all of these complaints and/or morbidities were incurred during his active duty service." The June 2001 VA examination report is new and material evidence to reopen the claim. The examiner offered a diagnosis of insomnia and a direct link to active service. Given the benefit of the doubt doctrine set forth at 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102, this opinion could place the evidence for service connection in relative equipoise. Thus, it is neither cumulative nor redundant and it raises a reasonable possibility of substantiating the claim. Because the RO's previously stated basis for denial was that it pre-existed active service, this medical evidence is certainly new and material. Because the evidence submitted is sufficiently new and material to reopen the claim, the application to reopen the service connection claim for a sleep disorder must be granted. Joint Pains In a June 2000 rating decision, the RO determined that new and material evidence had not been submitted and denied an application to reopen a claim for service connection for joints pains, specifically naming the ankles, knees, shoulders, and elbows. The veteran and his representative were notified of the decision and submitted a timely NOD, but did not file a substantive appeal. Thus, the rating decision became final. 38 U.S.C.A. § 7105(b), (c) (West 2002). The veteran's SMRs reflect that myofacial neck pains began in Saudi Arabia, but do not mention any other joint pain. A March 1994 VA Persian Gulf War examination note mentions 1- 2+ clonus of the ankles with questionable exposure to chemicals. A September 1994 VA general medical examination report mentions joint pains. According to a September 1994 VA joints compensation examination report, elbow and knee pains began six months after returning from Saudi Arabia. X-rays showed normal joints. The diagnosis was normal knees and elbows. A July 1997 VA joints compensation examination report reflects that the veteran complained of neck and lumbar pains, sore knees, shoulders, elbows, and ankles. The diagnosis was normal joints, but the examiner then offered diagnoses of old healed bursitis of the right shoulder, minimal degenerative changes at L5-S1 and at C5-6, and minimal degenerative changes and scoliosis at T6 and T7. In January 1998, the RO denied service connection for joint pains. The veteran did not file a substantive appeal and that decision became final. A May 1998 Willis-Knighton hospital report notes a history of joint pains for eight years. A January 1999 report notes arthritis. April 1999 VA X-rays of the knees and left elbow were normal, but a right elbow X-ray showed an olecrannon spur. An April 1999 VA rehabilitation clinic note reflects worsening knee and elbow pains since returning from the Persian Gulf War. The impression was joint pains, possibly due to mild osteoarthritis. In August 1999, a Fitness World employee reported that the veteran received therapy there for joint pain and arthritis. In April 2000, the veteran submitted an article by the American Gulf War Veterans Association that suggests a relationship between anthrax vaccine given to 2.4 million service persons and undiagnosed illnesses. In June 2000, the RO determined that new and material evidence for service connection for joint pain due to undiagnosed illness had not been submitted. The RO based the denial on the absence of evidence of a chronic condition manifested by joint pains. The veteran did not file a substantive appeal and the June 2000 rating decision became final. The evidence submitted since the June 2000 RO decision includes a June 2001 VA general medical examination report. That report notes a history of polyarthralgia dating back to 1992. The examiner noted that there was no lyme disease, autoimmune process, or swelling to explain the joint pains. The relevant diagnosis was chronic polyarthralgia from 1992. The examiner related this to active service, stating, "As best as can be determined from the patient's prior records, all of these complaints and/or morbidities were incurred during his active duty service." The June 2001 VA examination report is new and material evidence to reopen the claim. The VA physician has offered a diagnosis, albeit a symptom-based diagnosis, and has related it to active service in the Persian Gulf. Given the benefit of the doubt doctrine set forth at 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102, this opinion could place the evidence for service connection in relative equipoise. Thus, it is neither cumulative nor redundant and it raises a reasonable possibility of substantiating the claim. Because the RO's previously stated basis for denial was that a chronic disability had not been shown, this medical evidence is certainly new and material. Because the evidence submitted is sufficiently new and material to reopen the claim, the application to reopen the service connection claim must be granted. Cervical Spondylitis In a June 2000 rating decision, the RO determined that new and material evidence had not been submitted and denied an application to reopen a claim for service connection for spondylosis of C5-6. The veteran and his representative were notified of the decision and submitted a timely NOD, but did not file a substantive appeal after receiving the SOC. Thus, the rating decision became final. 38 U.S.C.A. § 7105(b), (c) (West 2002). The SMRs reflect that neck pains began in Saudi Arabia. In March 1991, the veteran was evaluated for a "wry neck." Myofascial neck pain was assessed and X-rays showed degenerative changes at C5-6. According to a September 1994 VA joints compensation examination report, a stiff neck developed while in Saudi Arabia, but cleared up with physical therapy. X-rays showed spondylosis and disc space narrowing at C5-6. The diagnosis was abnormal cervical spine. A July 1997 VA joints compensation examination report reflects minor neck pains. The veteran noted a history of four motor vehicle accidents in the 1970s. The examiner noted that the SMRs included January 1991 X-rays that showed cervical spondylosis and narrowed disc space at C5-6. The veteran complained of neck pains. The examiner offered a diagnosis of minimal degenerative changes at C5-6. The examiner felt that degenerative disc disease of C5-6 preceded active duty, as this was present in a January 1991 X-ray. In January 1998, the RO denied service connection for C5-6 spondylosis. The veteran did not file a substantive appeal and that decision became final. April 1999 VA X-rays showed scoliosis and spurring of the lumbar spine. An April 1999 VA magnetic resonance imaging (MRI) report of the neck showed disc bulging at C3-6. An April 1999 VA rehabilitation clinic note reflects that the veteran denied any history of a neck injury. The impression was joint pains possibly due to mild osteoarthritis. In June 2000, the RO determined that new and material evidence for service connection for C5-6 spondylosis had not been submitted. The RO based the denial on the evidence that spondylosis pre-existed active service. The veteran did not file a substantive appeal to the June 2000 rating decision and it became final. The evidence submitted since the June 2000 RO decision includes a June 2001 VA general medical examination report. That report notes a history of polyarthralgia, which included neck pain, dating back to 1992. The relevant diagnosis was chronic polyarthralgia from 1992. The examiner stated, "As best as can be determined from the patient's prior records, all of these complaints and/or morbidities were incurred during his active duty service." The June 2001 VA examination report is new and material evidence to reopen the claim. The VA physician has offered a diagnosis and has related it to active service. Given the benefit of the doubt doctrine set forth at 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102, this opinion could place the evidence for service connection in relative equipoise. Thus, it is neither cumulative nor redundant and it raises a reasonable possibility of substantiating the claim. Because the RO's previously stated basis for denial was that a chronic disability had not been shown, this medical evidence is certainly new and material. Because the evidence submitted is sufficiently new and material to reopen the claim, the application to reopen the service connection claim must be granted. Memory Loss In a June 2000 rating decision, the RO determined that new and material evidence had not been submitted and denied an application to reopen a claim for service connection for memory loss and forgetfulness. The veteran and his representative were notified of the decision in a letter from the RO, but did not appeal. Thus, the rating decision became final. The SMRs reflect no amnestic disorder, such as memory loss or forgetfulness. VA clinical records reflect that the veteran underwent a VA general medical examination in December 1993, but did not mention memory loss. The examiner found the veteran to be neurologically and psychiatrically normal. A September 1994 VA general medical examination report mentions a complaint of episodes of forgetfulness. No diagnosis was offered. A September 1994 VA mental disorders examination report notes that the veteran displayed good memory. In August 1997, a VA clinical psychologist noted that chronic fatigue and memory loss were the primary problem. No objective evidence of any memory loss was found, however. In January 1998, the RO denied service connection for memory loss due to an undiagnosed illness. The veteran submitted an NOD in February 1998. The RO did not issue a SOC until May 2001. The veteran did not file a substantive appeal, however. An April 1999 VA clinical report notes a possible cerebrovascular accident and recommended a magnetic resonance imaging (MRI). An April 1999 VA Persian Gulf War assessment notes that neurotoxins may cause psychiatric and cognitive problems that impair short-term memory. The impression after interviewing the veteran was cognitive disorder, NOS. The cognitive disorder shown includes impairment of visual memory. In April 2000, the veteran submitted an article by the American Gulf War Veterans Association that suggests a relationship between anthrax vaccine given to 2.4 million service persons and undiagnosed illnesses. An April 2000 VA psychological evaluation report reflects that no evidence of a memory problem was found, although the veteran maintained that he did have a memory problem. In June 2000, the RO found no new and material evidence for service connection for memory loss due to undiagnosed illness. The RO based the denial on the absence of evidence of a link between active service and any current memory loss. The veteran did not file a substantive appeal to the June 2000 rating decision and it became final. The Board will review the evidence submitted since the June 2000 RO decision to determine whether any of it is new and material evidence. In April 2005, the veteran submitted internet articles, one of which links Gulf war syndrome with neuropsychological signs or symptoms, including memory loss. This is new and material evidence. In April 2005, the veteran also submitted Social Security Administration (SSA) records. One report specifically notes that the veteran's depression had apparently caused memory impairment. This is new and material evidence as it contains medical evidence of memory loss, an element necessary for service connection. Because new and material evidence of memory loss and evidence that tend to suggest that memory loss could be related to active service in the Persian Gulf War has been submitted, the application to reopen the service connection claim must be granted. Service connection for memory loss will be addressed in the REMAND portion of the decision. PTSD In June 2000, the RO denied service connection for PTSD. Because the veteran failed to file a substantive appeal, that decision became final. The Board will review the record to determine whether new and material evidence has been submitted to reopen the claim. Although the veteran entered active military service in January 1991, there is no entry examination report of record. Shortly before discharge, however, on a March 1991 report of medical history questionnaire, the veteran checked "no" to depression or excessive worry and "no" to nervous trouble of any sort. The March 10, 1991, examination report itself reflects that the examiner failed to annotate whether the veteran was psychiatrically normal or abnormal. An August 1997 VA psychological evaluation (not for PTSD) reflects that mildly depressed mood and anxiety were shown. In June 1999, the veteran requested service connection for depression and PTSD. He submitted a Willis-Knighton Hospital treatment report dated in August 1998 that contains an assessment of PTSD. He submitted VA outpatient treatment reports that reflect that depression and mild PTSD were found in October 1998. In April 1999, VA found depression and anxiety and offered a diagnosis of depression NOS. Also in April 1999, the veteran's VA treating psychiatrist noted that depression and other mental problems might be related to service in the Persian Gulf due to exposure to oil smoke, or due to eating and drinking from local sources, vaccination prior to going to the desert, and/or taking pyrostigmine bromide. An April 1999 VA psychological assessment yields several impressions, including rule-out PTSD. An April 2000 VA psychological evaluation report contains an Axis I diagnosis of anxiety disorder, NOS. The clinical psychologist felt that the full criteria for PTSD were not met. The only stressor or service-related problem mentioned in the report was anxiety that was caused by or related to gas attack alerts in the Persian Gulf. In June 2000, the RO denied service connection for PTSD on the basis that the PTSD diagnoses are based only on the veteran's reported history. Because the veteran did not file a substantive appeal, that decision became final. The veteran again requested service connection for PTSD in January 2003. The new evidence submitted includes the June 2001 VA general medical examination report. The examiner noted multiple symptoms, including depression and anxiety, and stated, "As best as can be determined from the patient's prior records, all of these complaints and/or morbidities were incurred during his active duty service." This medical opinion is new and material evidence to reopen a claim for service connection for PTSD, as PTSD is an anxiety disorder that the examiner has linked to active service. Service Connection In order to establish service connection for a disability, the evidence must demonstrate the presence of it and that it resulted from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). VA compensation shall be paid for certain disabilities due to undiagnosed illnesses to veterans who exhibit objective indications of chronic disability [explained below] resulting from an illness or combination of illnesses manifested by one or more signs or symptoms listed in this regulation provided that such disability became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2006. Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: (1) fatigue (2) signs or symptoms involving skin (3) headache (4) muscle pain (5) joint pain (6) neurologic signs or symptoms (7) neuro-psychological signs or symptoms (8) signs or symptoms involving the respiratory system (upper and lower) (9) sleep disturbances (10) gastrointestinal signs or symptoms (11) cardiovascular signs or symptoms (12) abnormal weight loss (13) menstrual disorders. Supervening conditions, willful misconduct or affirmative evidence that the condition was not incurred during active military service in Southwest Asia will preclude payment of compensation under this section. 38 U.S.C.A. §§ 1113, 1117, 1118 (West 2002); 38 C.F.R. § 3.317 (2007). In materials published in the Federal Register when 38 C.F.R. § 3.317 was issued, VA explained objective indications of chronic disability: Ordinarily, an objective indication is established through medical findings, i.e., "signs" in the medical sense of evidence perceptible to an examining physician. However, we also will consider non-medical indications which can be independently observed or verified, such as time lost from work, evidence that a veteran has sought medical treatment for his or her symptoms, evidence affirming changes in the veteran's appearance, physical abilities, and mental and emotional attitude, etc. 60 Fed. Reg. 6660, 6663 (1995). Chronic Fatigue The veteran maintains that he has an undiagnosed illness manifested by chronic fatigue. Fatigue complaints have continued throughout the appeal period and have not been attributed to a known diagnosis, except a diagnosis of "chronic fatigue syndrome." 38 C.F.R. § 3.317(a)(2)(i) specifically includes "chronic fatigue syndrome" as an undiagnosed illness. Under the circumstances, the provisions of 38 C.F.R. § 3.317 will be applied. The veteran first noticed fatigue following service in Southwest Asia and complaints of fatigue have continued for several years. No evidence has been presented that tends to establish that the veteran does not suffer from fatigue. Thus, there is objective evidence that the veteran' fatigue is chronic, that is, it has existed for more than six months. It has not been attributed to any known diagnosis (chronic fatigue syndrome is a cluster of symptoms, rather than a diagnosed disease). It appears to be at least 10 percent disabling. Under Diagnostic Code 6354, a 10 percent rating is warranted for chronic fatigue syndrome where there is debilitation due to such symptoms as inability to concentrate, forgetfulness, confusion, or a combination of other signs and symptoms. Considering these provisions, the Board finds that the veteran's fatigue has been shown to be manifested to a degree of 10 percent. Evidence of a supervening condition, willful misconduct or evidence tending to show that the condition was not incurred during active military service in Southwest Asia has not been presented. The regulation envisages service connection for symptoms reported by the veteran where independently observed or verified. In this case, the veteran has asserted fatigue and his medical examiners have not voiced any disagreement. The regulatory requirements for presumptive service connection for chronic fatigue have therefore been met. Service connection is therefore granted for undiagnosed illness manifested by chronic fatigue. Sleep Disorder The first issue for resolution is whether a sleep disorder existed prior to entry in January 1991. There is no entrance examination report of record for the period of active service that began in January 1991. In a similar situation, where a veteran's enlistment examination report was missing, the Court held that the presumption of soundness at entry attaches. Doran v. Brown, 6 Vet. App. 283, 286 (1994) (where a portion of the veteran's service medical records including his service entrance examination report were unavailable and were presumed to have been lost in a fire, the presumption of soundness attached). A veteran who served during a period of war or during peacetime service after December 31, 1946, is presumed in sound condition except for defects noted when examined and accepted for service. Clear and unmistakable evidence that the disability manifested in service existed before service will rebut the presumption. 38 U.S.C.A. §§ 1111, 1137; 38 C.F.R. § 3.304(b). To rebut the presumption of sound condition under 38 U.S.C.A. § 1111, a claimant must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 3-2003. A March 1987 medical history form simply notes that the veteran reported frequent trouble sleeping. It does not contain a medical diagnosis of insomnia. Therefore, it is not clear and unmistakable evidence to rebut the presumption of soundness. A March 1991 SMR notation of a "history of" terminal insomnia for many years is not a condition noted at entry. According to 38 C.F.R. § 3.304 (b) (1), "History of" preservice existence of conditions noted at entry does not constitute notation of such conditions at entry. Moreover, the March 1991 medical examination report itself reflects that the examiner failed to check either the normal or the abnormal box relevant to the veteran's psychiatric status at that time. Because the presumption of soundness at entry is not successfully rebutted, the veteran is presumed sound at entry. His insomnia, therefore, did not pre-exist active service. The April 1999 VA sleep study that offers four sleep-related diagnoses does much to describe the sleep disorder or disorders, but does not tend to dissociate insomnia from active service. Because insomnia was first noted during active service and because a VA medical professional has offered a diagnosis of insomnia related to active service, the Board finds that evidence favors service connection for insomnia. Joint Pains A June 2001 VA general medical examination report reflects a diagnosis of chronic polyarthralgia since 1992. The examiner noted point tenderness in the olecrannon processes and the knees with no swelling, redness, edema, effusion, or limitation of motion. The examiner related this to active service, stating, "As best as can be determined from the patient's prior records, all of these complaints and/or morbidities were incurred during his active duty service." A July 2003 VA treatment report reflects chronic joint pains. The impression was osteoarthritis. With respect to the shoulders, elbows, knees, and ankles, only the right elbow pains can be attributed to a known diagnosis, that of olecrannon spurring, according to an April 1999 VA rehabilitation clinic report. The right elbow is addressed further in the remand portion of the decision. Although a more recent treatment report notes osteoarthritis in response to the complaint of diffuse joint pains, no VA compensation examiner has made such a diagnosis to explain pains of the shoulders, left elbow, knees, and ankles. With respect to service connection for the shoulder, left elbow, knees, and ankles, there has been no diagnosis and all X-rays have consistently been normal. The pains have existed for more than six months. This is unequivocal objective evidence of a chronic condition. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, a painful joint warrants at least a 10 percent rating. Therefore, the Board may presume that an undiagnosed illness has caused chronic diffuse joint pains that have been manifested to a degree of 10 percent. There has been no evidence presented that suggests that these symptoms are the result of a supervening condition, willful misconduct, or that the condition was not incurred during active military service in Southwest Asia. The regulatory requirements for presumptive service connection for joint pains of the shoulders, left elbow, the knees, and the ankles are met. Service connection is therefore granted for an undiagnosed illness manifested by chronic joint pains of the shoulders, left elbow, the knees, and the ankles. Cervical Spondylitis The SMRs do not reflect that this disorder pre-existed either period of active service, but do reflect that neck pains began during the second period of active service. Moreover, a March 1991 Army X-ray notes the earliest degenerative changes of the cervical spine. The June 2001 VA examiner has linked neck complaints to active service. No medical evidence contradicts this opinion except for the July 1997 VA examiner, who felt that the neck disability pre-existed active service. The June 2001 VA opinion is more persuasive than the July 1997 opinion as it appears to be based on correct facts, that is, that the neck complaints and spondylosis did begin during active service, and not earlier. After considering all the evidence of record, including the testimony, the Board finds that the evidence favors the claim. Service connection for cervical spondylitis must therefore be granted. PTSD Service connection for PTSD requires (in addition to other service connection requirements set forth above) medical evidence diagnosing the condition in accordance with 38 C.F.R. § Sec. 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy, and the claimed stressor is related to that combat, his lay testimony-alone-may establish the occurrence of the claimed in-service stressor in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of his service. 38 C.F.R. § 3.304(f) (2007); see also Cohen v. Brown, 10 Vet. App. 128 (1997). The evidence that is favorable to service connection for PTSD includes a Willis-Knighton Hospital treatment report dated in August 1998 that contains an assessment of PTSD. An October 1998 VA outpatient treatment reports that reflect that depression and PTSD were found. In April 1999, depression and anxiety were found and a diagnosis of depression NOS was offered. Also in April 1999, the veteran's VA treating psychiatrist noted that depression and other mental problems might be related to service in the Persian Gulf due to exposure to oil smoke, or due to eating and drinking from local sources, vaccination prior to going to the desert, and/or taking pyrostigmine bromide. An April 1999 neuropsychological assessment yielded several impressions, including rule-out PTSD. An April 2000 VA psychological evaluation report contains an Axis I diagnosis of anxiety disorder, NOS. The clinical psychologist felt that the full criteria for PTSD were not met. The only stressor, or service-related problem mentioned in the report was anxiety related to gas attack alerts during the Persian Gulf War. Thus, regardless of the lack of a PTSD diagnosis, this report tends to relate anxiety disorder to active service. As noted above, a June 2001 VA general medical examiner noted multiple symptoms, including depression and anxiety and stated, "As best as can be determined from the patient's prior records, all of these complaints and/or morbidities were incurred during his active duty service." An August 2002 private assessment for SSA reflects that the veteran's short-term memory was impaired and was probably related to an attention problem. The examiner also noted that concentration was poor. The Axis I diagnosis was major depressive disorder and anxiety disorder, NOS. The veteran requested that his claim for service connection for PTSD be reopened in January 2003. An October 2003 VA outpatient treatment report contains assessments of major depressive disorder and PTSD. In a letter dated in December 2003, the Department of the Army notified the veteran that depression and PTSD could disqualify him from further military service. An August 2004 VA mental health clinic report notes that the veteran's memory was intact. A January 2006 VA mental health clinic report notes that the veteran complained of adverse side effects of sertraline, which he could not remember. He changed medication. In February 2005, the Center for Unit Records Research (CURR) reported that from January 20 to February 26, 1991, enemy ballistic missile (SCUD) attacks were launched against U.S. ground forces stationed in Saudi Arabia, Bahrain, and Qatar. These attacks triggered chemical alarms at our bases. At Bahrain, after an attack on February 22, 1991, SCUD debris was found. On February 25, a SCUD killed 28 US service personnel and injured over 100 at one U.S. base. In April 2005, the veteran reported that his PTSD stressors included SCUD attacks, chemical warfare alerts, and the bombing of Khobar Towers, Saudi Arabia (occurred June 25, 1996). He reported that the fear of dying gripped him 24 hours a day. He reported that he served in Dhahran and Bahrain. According to January 2006 and later-dated VA psychiatric treatment reports, the impression was anxiety disorder, NOS; history of affective disorder; and, history of PTSD per patient report. A March 2006 VA psychiatric treatment report contains a different primary diagnosis. In that report, the primary Axis I diagnosis was PTSD. Next listed on Axis I is history of affective disorder, and third listed is depression. In April 2006, the psychiatrist changed the diagnoses and their order to: history of affective disorder; then, PTSD; and then anxiety disorder. In February 2008, the veteran testified at a videoconference hearing before the undersigned Veterans Law Judge that he served in Dhahran and then in Bahrain. From the first night in Saudi Arabia, there were attacks and sirens. He could see flashes from missile launches. He donned all his chemical gear and the fear of dying took over. These attacks and alerts continued for days. The evidence that favors service connection for PTSD includes medical evidence that the veteran has PTSD. A diagnosis of PTSD has been offered by VA and private examiners at various times. While combat is not shown, the claimed stressors are corroborated by independent evidence obtained by CURR. After considering all the evidence of record, including the testimony, the Board finds that the evidence favors service connection for PTSD. The claim for service connection for PTSD is therefore granted. Hiatal Hernia, Esophagitis, Gastric Reflux The SMRs do not reflect any relevant complaint; however, a December 1993 VA general medical examination report clearly notes a history of upper gastrointestinal pains present since Persian Gulf War service. The diagnosis was history of gastrointestinal pains of undetermined cause. A March 1994 VA Persian Gulf Registry examination noted continued reflux, cramps, and bowel problems. A September 1994 VA general medical examination report notes continued abdominal pains with vomiting. In July 1995, the RO denied service connection for abdominal pain due to undiagnosed illness on the basis of no disabling symptom shown. The veteran submitted a notice of disagreement (NOD) and the RO issued an SOC, but the veteran's VA Form 9, Substantive Appeal, was untimely and the RO closed the case. In a January 1998 rating decision, the RO denied service connection for irritable bowel syndrome claimed as diarrhea, vomiting, nausea, upper abdominal pain, due to undiagnosed illness. The veteran submitted a timely NOD, but the RO did not issue a SOC on the issue. VA clinical records of 1997 and 1998 reflect continued abdominal complaints. April 1999 endoscopy confirmed lower esophageal hiatal hernia. Gastroesophageal reflux disease (GERD) was found in October 1998. Esophagitis was not found. In June 2000, the RO denied service connection for irritable bowel syndrome, but did not address GERD or hiatal hernia. In June 2001, a VA general medical examiner reviewed the medical history and determined that GERD with hiatal hernia had existed from 1993. Moreover, the physician then offered an opinion that his gastrointestinal-related complaints were incurred in active service. In February 2008, the veteran testified at a videoconference before the undersigned that his hiatal hernia and reflux began after Desert Storm. It is significant that in June 2001 a VA physician related the current hiatal hernia and GERD to active service. No medical evidence contradicts this opinion. Although the veteran included esophagitis in his service connection claim, the medical evidence does not show this to be a disability or symptom separate from GERD. After considering all the evidence of record, including the testimony, the Board finds that the evidence favors the claim. Service connection for GERD and hiatal hernia must therefore be granted. ORDER Service connection for an undiagnosed illness manifested by chronic fatigue is granted. Service connection for insomnia is granted. Service connection for an undiagnosed illness manifested by chronic joint pains of the shoulders, left elbow, the knees, and the ankles is granted. Service connection for cervical spondylosis is granted. Service connection for PTSD is granted. Service connection for GERD and hiatal hernia is granted. REMAND Tuberculosis, Hyporeflexia, Clonus Since the most recent SSOC was issued, the veteran submitted additional evidence, possibly relevant to the claims, without a waiver of his right to initial RO consideration of that evidence. Thus, a remand is necessary so that the AOJ can consider this evidence prior to Board consideration. Memory Loss and Cognitive Disorder New and material evidence has been submitted to reopen claims of entitlement to service connection for cognitive disorder and for memory loss. Because the RO has not adjudicated these reopened claims on the merits, they are remanded for this procedural safeguard. An April 1999 VA hospital discharge summary contains a diagnosis of cognitive disorder, NOS. The etiology of this cognitive disorder is not clear. Nor is it clear whether cognitive disorder encompasses the veteran's claimed memory loss. The duty to assist includes obtaining a medical opinion on the matter. 38 U.S.C.A. § 5103A; McLendon v. Nicholson, 20 Vet. App. 79 (2006). The veteran should therefore be offered an examination by an appropriate specialist to determine the nature and etiology of his claimed memory loss and cognitive disorder. Fibromyalgia The veteran claims that taking pyridostigmine bromide as a nerve agent antidote or other exposure to toxic substance in the Persian Gulf War has caused fibromyalgia. He submitted medical treatises that reflect that fibromyalgia involves widespread pain of the muscles, ligaments, and tendons. Although the veteran possesses medical competence as an operating room technician, he is not shown to be versed in the etiology of fibromyalgia. Therefore, according to the tenets of McClendon, supra, VA must offer an examination to determine the nature and etiology of his claimed fibromyalgia. Immune System Disorder In April 1999, a VA physician noted that multiple problems might have been due to taking pyridostigmine bromide or other exposures in the Persian Gulf War. In June 2003, the veteran claimed that pyridostigmine bromide antidote had caused an immune system disorder. He did not state what disabling symptom or symptoms might have resulted, but he did submit supporting documentation in the form of a news article that notes that this substance might be a major factor in Persian Gulf War-related illness. In 2005, the veteran submitted an internet article that reflects that Gulf War Syndrome might be an immune system imbalance syndrome triggered by war-related exposures. In February 2008, the veteran testified that he and other Persian Gulf War service members were given pyridostigmine bromide as a precaution. Although the veteran possesses medical competence, he is not shown to be versed in the diagnosis, symptomatology, or etiology of autoimmune disorders. According to McClendon, supra, VA must offer the veteran an examination to determine the nature and etiology of any immune system-related impairment. Scoliosis A July 1997 VA joints compensation examination report reflects scoliosis at T6-T7 and notes S-shaped scoliosis of the thoracic and lumbar spine with slight wedging at the 7th vertebral body. April 1999 VA X-rays showed scoliosis of the lumbar spine and the examiner noted history of scoliosis with right rib hump and right convexity in mid-thoracic spine. An August 2002 private X-ray showed mild scoliosis at the thoracolumbar junction, but nowhere else. Thus, the extent of the veteran's scoliosis is unclear. Because the extent of the veteran's scoliosis is unclear and because no VA medical professional has addressed the etiology of the veteran's scoliosis, VA should examine the veteran to determine the nature and etiology of his scoliosis. McClendon, supra. Bilateral Carpal Tunnel Syndrome An October 2001 private electromyograph (EMG) report confirmed bilateral carpal tunnel syndrome. The veteran claims that carpal tunnel syndrome was caused by pyridostigmine bromide. Although the veteran possesses medical training, he is not shown to be versed in the diagnosis, symptomatology, or etiology of carpal tunnel syndrome. Therefore, according to the tenets of McClendon, supra, VA must offer the veteran an examination to determine the etiology of his bilateral carpal tunnel syndrome. Right Elbow Arthritis Olecrannon spurring of the right elbow is shown on X-rays. This essentially precludes consideration of right elbow pain due to undiagnosed illness; however, other avenues for service connection must be addressed. The veteran should be afforded an appropriate examination to determine the nature and etiology of any current right elbow disorder. McClendon, supra. Accordingly, the case is REMANDED for the following action: 1. The AOJ should review the entire file and ensure that all notification and development necessary to comply with 38 U.S.C.A. §§ 5103(a) and 5103A (West 2002 & Supp. 2007) and 38 C.F.R. § 3.159 (2007)) is fully satisfied. In particular, VA must send the veteran a notice that includes: (1) an explanation as to the information or evidence needed to establish a disability rating and an effective date, as outlined by the Court in Dingess v. Nicholson, 19 Vet. App. 473 (2006) and (2) requests or tells the veteran to provide any evidence in his possession that pertains to his claims. The claims file must include documentation that there has been compliance with the VA's duties to notify and assist a claimant as specifically affecting the issues on appeal. VA's duty to notify the claimant must include information specific to reopening a previously denied claim based on the submission of new and material evidence. Kent v. Nicholson, 20 Vet. App. 1, 10 (2006). 2. After the development requested above has been completed, VA should make arrangements with the appropriate VA medical facility for the veteran to be afforded an examination by an appropriate specialist to determine the nature and etiology of his cognitive disorder and memory loss. The claims files should be made available to the physician for review of the pertinent evidence. The physician should elicit a complete history of relevant symptoms and of any exposure to toxic substances from the veteran, and answer the following: I. What is the current diagnosis or diagnoses relative to cognitive disorder and/or memory loss? II. For each diagnosis offered, is it at least as likely as not (50 percent or greater probability) that this disability had its onset in service? III. If the answer to question II above is "no," then is it at least as likely as not that this disability is related to exposure to chemicals in the Persian Gulf, including pyridostigmine bromide or anthrax vaccination? IV. If the answer to question III above is "no," then is it at least as likely as not that this disability is related to a service- connected disability? At the time of this writing, service-connected is in effect for chronic fatigue, sleep disorder, joint pains, cervical spondylitis, and PTSD. V. The physician should offer a rationale for any conclusion in a legible report. If any question cannot be answered, the physician should state the reason. VA should make arrangements with the appropriate VA medical facility for the veteran to be afforded an examination by an appropriate specialist to determine the nature and etiology of his claimed fibromyalgia. The claims files should be made available to the physician for review of the pertinent evidence. The physician should elicit a complete history of any exposure to toxic substances from the veteran, and answer the following: I. What is the current diagnosis or diagnoses relative to fibromyalgia? II. Is it at least as likely as not (50 percent or greater probability) that this disability had its onset in service? III. If the answer to question II above is "no," then is it at least as likely as not that this disability is related to exposure to chemicals in the Persian Gulf, including pyridostigmine bromide or anthrax vaccination? IV. If the answer to question III above is "no," then is it at least as likely as not that this disability is related to a service- connected disability? At the time of this writing, service-connected is in effect for chronic fatigue, sleep disorder, joint pains, cervical spondylitis, and PTSD. V. The physician should offer a rationale for any conclusion in a legible report. If any question cannot be answered, the physician should state the reason. VA should make arrangements with the appropriate VA medical facility for the veteran to be afforded an examination by an appropriate specialist to determine the nature and etiology of his claimed immune system disorder. The claims files should be made available to the physician for review of the pertinent evidence. The physician should elicit a complete history of any exposure to toxic substances from the veteran and answer the following: I. What is the current diagnosis or diagnoses relative to a claimed immune system disorder? II. Does this diagnosis represent a disability? III. If the answer to question II above is "yes" then is it at least as likely as not (50 percent or greater probability) that this disability had its onset in service? IV. If the answer to question II above is "yes," but the answer to question III above is "no" then is it at least as likely as not that this disability is related to exposure to chemicals in the Persian Gulf, including pyridostigmine bromide or anthrax vaccination? V. If the answer to question IV above is "no," then is it at least as likely as not that this disability is related to a service- connected disability? At the time of this writing, service connection is in effect for chronic fatigue, sleep disorder, joint pains, cervical spondylitis, and PTSD. VI. The physician should offer a rationale for any conclusion in a legible report. If any question cannot be answered, the physician should state the reason. VA should make arrangements with the appropriate VA medical facility for the veteran to be afforded an examination by an appropriate specialist to determine the nature and etiology of his scoliosis. The claims files should be made available to the physician for review of the pertinent evidence. The physician should elicit a complete history of any exposure to toxic substances from the veteran, and answer the following: I. What is the current diagnosis or diagnoses relative to scoliosis? II. Is it at least as likely as not (50 percent or greater probability) that this disability had its onset in service? III. If the answer to question II above is "no," then is it at least as likely as not that this disability is related to exposure to chemicals in the Persian Gulf, including pyridostigmine bromide or anthrax vaccination? IV. If the answer to question III above is "no," then is it at least as likely as not that this disability is related to a service connected disability? At the time of this writing, service connection is in effect for chronic fatigue, sleep disorder, joint pains, cervical spondylitis, and PTSD. V. The physician should offer a rationale for any conclusion in a legible report. If any question cannot be answered, the physician should state the reason. VA should make arrangements with the appropriate VA medical facility for the veteran to be afforded an examination by an appropriate specialist to determine the nature and etiology of bilateral carpal tunnel syndrome. The claims files should be made available to the physician for review of the pertinent evidence. The physician should elicit a complete history of any exposure to toxic substances from the veteran, and answer the following: I. Is it at least as likely as not (50 percent or greater probability) that carpal tunnel syndrome had its onset in service? III. If the answer to question I above is "no," then is it at least as likely as not that this disability is related to exposure to chemicals in the Persian Gulf, including pyridostigmine bromide or anthrax vaccination? III. If the answer to question II above is "no," then is it at least as likely as not that this disability is related to a service connected disability? At the time of this writing, service connection is in effect for chronic fatigue, sleep disorder, joint pains, cervical spondylitis, and PTSD. IV. The physician should offer a rationale for any conclusion in a legible report. If any question cannot be answered, the physician should state the reason. VA should make arrangements with the appropriate VA medical facility for the veteran to be afforded an examination by an appropriate specialist to determine the nature and etiology of right elbow arthritis manifested by olecrannon spurring. The claims files should be made available to the physician for review of the pertinent evidence. The physician should elicit a complete history of right elbow trauma and of any exposure to toxic substances from the veteran and answer the following: I. Is it at least as likely as not (50 percent or greater probability) that right elbow arthritis had its onset in service? II. If the answer to question I above is "no," then is it at least as likely as not that right elbow arthritis is related to exposure to chemicals in the Persian Gulf, including pyridostigmine bromide or anthrax vaccination? III. If the answer to question II above is "no," then is it at least as likely as not that this disability is related to a service- connected disability? At the time of this writing, service connection is in effect for chronic fatigue, sleep disorder, joint pains, cervical spondylitis, and PTSD. IV. If the answer to question III above is "no," then is it at least as likely as not any right elbow arthritis began within one year of discharge from active service? V. The physician should offer a rationale for any conclusion in a legible report. If any question cannot be answered, the physician should state the reason. 3. After the development requested above has been completed to the extent possible, the AOJ should re-adjudicate the applications to reopen claims for service connection for tuberculosis, hyporeflexia, and clonus, and then re- adjudicate all remaining service connection claims. If the benefits sought remain denied, the veteran and his representative should be furnished a supplemental statement of the case (SSOC) and given an opportunity to respond. The SSOC should reflect consideration of all evidence submitted since the July 2007 SSOC. Thereafter, the case should be returned to the Board, if otherwise in order. The purposes of this remand are to comply with due process of law and to further develop the veteran's claims. No action by the veteran is required until he receives further notice; however, the veteran is advised that failure to cooperate by reporting for examination may result in the denial of the claim. 38 C.F.R. § 3.655 (2007). The Board intimates no opinion, either legal or factual, as to the ultimate disposition warranted in this case, pending completion of the above. 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). 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. 2007). ______________________________________________ A. BRYANT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs