Citation Nr: 1127027 Decision Date: 07/20/11 Archive Date: 07/29/11 DOCKET NO. 09-13 067 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for systemic lupus erythematosus, to include as due to an undiagnosed illness. 2. Entitlement to service connection for Sjogren's syndrome, to include as due to an undiagnosed illness. 3. Entitlement to service connection for hypogonadism, to include as due to an undiagnosed illness. 4. Entitlement to service connection for tinnitus. 5. Entitlement to service connection for bilateral hearing loss. 6. Entitlement to service connection for posttraumatic stress disorder (PTSD). 7. Entitlement to service connection for bilateral pes planus. 8. Entitlement to service connection for a pituitary disorder, to include as due to an undiagnosed illness. 9. Entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness. 10. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from August 1988 to July 1992, including in the Persian Gulf War. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2008 and September 2009 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. A Travel Board hearing was held at the RO in July 2010 before the undersigned Veterans Law Judge and a copy of the hearing transcript has been added to the record. In July 2010, the Veteran notified VA that he had moved to the jurisdiction of the RO in Columbia, South Carolina. That facility retains jurisdiction over this appeal. The issues of entitlement to service connection for irritable bowel syndrome (IBS), for a dental condition, for purposes of outpatient treatment only, and for a disability manifested by abnormal red blood cells and hemoglobin levels have been raised by the record but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). The Veteran filed these claims in October 2008 but they have not yet been adjudicated. The Veteran also testified before the Board in July 2010 that he intended to file a claim of service connection for IBS. Therefore, the Board does not have jurisdiction over these issues and they are referred to the AOJ for appropriate action. The Board also finds that a claim of entitlement to a TDIU has been reasonably raised by the record. The issues of entitlement to service connection for tinnitus, bilateral hearing loss, PTSD, bilateral pes planus, and for hypgonadism, a pituitary disorder, and for CFS, each to include as due to an undiagnosed illness, and entitlement to a TDIU are all addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. The Veteran's service personnel records, to include his DD Form 214, show that his military occupational specialty (MOS) was as a hospitalman and he received training as a hospital corpsman and operating room technician during service. 2. The competent evidence shows that the Veteran's systemic lupus erythematosus (SLE) is related to active service. 3. The competent evidence shows that the Veteran's Sjogren's syndrome is related to active service. CONCLUSIONS OF LAW 1. Systemic lupus erythematosus (SLE) was incurred in active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.304 (2010). 2. Sjogren's syndrome was incurred in active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.303, 3.304 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board grants entitlement to service connection for systemic lupus erythematosus (SLE) and for Sjogren's syndrome, which constitutes a complete grant of the Veteran's claims. Therefore, no discussion of VA's duty to notify or assist is necessary. The Veteran contends that he incurred SLE and Sjogren's syndrome during active service. He specifically testified that he incurred SLE and Sjogren's syndrome as a result of an undiagnosed illness experienced while he was on active service in Saudi Arabia during the Persian Gulf War. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including SLE, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Service connection may be established for a Persian Gulf Veteran who exhibits objective indications of chronic disability which cannot be attributed to any known clinical diagnosis, but which instead results from an undiagnosed illness that 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, 2011. 38 C.F.R. § 3.317(a)(1). A "Persian Gulf Veteran" is one who served in the Southwest Asia theater of operations during the Persian Gulf War. Id. Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(2)-(5). Effective March 1, 2002, the law affecting compensation for disabilities occurring in Persian Gulf War Veterans was amended. 38 U.S.C.A. §§ 1117, 1118. Essentially, these changes revised the term "chronic disability" to "qualifying chronic disability," and involved an expanded definition of "qualifying chronic disability" to include: (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2)(B); 38 C.F.R. § 3.317. 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 will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). With claims based on undiagnosed illness, the Veteran is not required to provide competent evidence linking a current disability to an event during service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). Signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multi-symptom illness include: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C.A. § 1117(g); 38 C.F.R. § 3.317(b). Section 1117(a) of Title 38 of the United States Code authorizes service connection on a presumptive basis only for disability arising in Persian Gulf Veterans due to "undiagnosed illness" and may not be construed to authorize presumptive service connection for any diagnosed illness, regardless of whether the diagnosis may be characterized as poorly defined. VAOPGCPREC 8-98 (Aug. 3, 1998). Compensation may be paid under 38 C.F.R. § 3.317 for disability which cannot, based on the facts of the particular Veteran's case, be attributed to any known clinical diagnosis. The fact that the signs or symptoms exhibited by the Veteran could conceivably be attributed to a known clinical diagnosis under other circumstances not presented in the particular Veteran's case does not preclude compensation under § 3.317. Id. If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. The Board finds that the evidence supports granting the Veteran's claim of service connection for SLE, to include as due to an undiagnosed illness. The Veteran has contended that he incurred SLE during active service. He alternatively has contended that he incurred SLE as a result of an undiagnosed illness he experienced while on active service in Saudi Arabia during the Persian Gulf War. The Veteran's service personnel records, including his DD Form 214, confirm that he served in Saudi Arabia during the Persian Gulf War and was assigned to Fleet Hospital Five between September 1990 and March 1991. The Veteran's military occupational specialty (MOS) was hospitalman and he received training as a naval corpsman and operating room technician during service. He also was awarded the Kuwait Liberation Medal and Southwest Asia Service Medal. Given the foregoing, the Board finds that the Veteran is a "Persian Gulf Veteran." See 38 C.F.R. § 3.317(a)(1). The competent evidence shows that the Veteran's SLE is related to active service on a direct service connection basis. See 38 C.F.R. §§ 3.303, 3.304. The Board notes in this regard that the Veteran's service treatment records do not show that he was diagnosed as having or treated for SLE at any time during active service, to include as due to an undiagnosed illness experienced while he was in Saudi Arabia during the Persian Gulf War. The medical evidence shows that, on VA Gulf War Guidelines examination in November 2007, the Veteran's complaints included lupus. The VA examiner reviewed the Veteran's claims file, including his service treatment records and VA outpatient treatment records. The Veteran reported that he had been symptomatic for lupus since 1992 but only had been diagnosed as having lupus in October 2006. He also reported that lupus had been intermittent with remissions since its onset. The Veteran currently was taking 400 mg per day of hydroxycholoroquine for treatment of his lupus. He described his lupus symptoms as "mainly" episodic skin rashes which presented as hyperpigmented areas on his arms, chest, or the face usually once or twice a year. He also experienced episodic joint pain sometimes associated with swelling mainly involving the ankles, knees, elbows, and knuckles "a few joints at a time" and occurring "once a month or so." He reported experiencing "episodes where he feels very drained out, fatigued, flu-like aching in the muscles and joints like he is going to die" about once a month. He also reported problems with hair loss, sores in his mouth, and photosensitivity. Physical examination showed a rash or other lesions on the skin, mild black streaks in the nails of the hands and feet, and pupils equal, round, and reactive to light and accommodation. The VA examiner opined that the Veteran's lupus was as likely as not (50/50 probability) related to active service. The VA examiner's rationale was that "the unexplained illnesses reported by some Gulf War Veterans are remarkably similar to other recognized symptom-based conditions." The diagnoses included lupus. In a February 2008 letter, Debra L. Robinson, M.D., stated that the Veteran had been under her care since January 2007 and had been diagnosed as having systemic lupus erythematosus (SLE). She stated that the Veteran was "permanently medically restricted from working directly in any occupational area that will likely place him in direct exposure to any human blood, body fluids or medical/infectious waste or ethylene oxide (EtO)." Dr. Robinson also stated that the Veteran "has a chronically low white blood cell count. These are the cells that fight infection and thus he is more susceptible to getting sick when exposed to pathogens." In a March 2008 letter, Adam Barron, M.D., stated that the Veteran had been diagnosed as having SLE and was "permanently medically restricted from working in any occupation including [his] current occupation (including Operating Room Nursing Assistant) that will directly expose [him] to any human blood, body fluids, or medical/infectious waste or Ethylene oxide (EtO). These environmental factors may exacerbate [the Veteran's] existing lupus." Dr. Barron also stated that, although the Veteran had been prescribed medication to treat his SLE, it did not "fully control" the chronic lupus symptoms which he experienced. Dr. Barron noted that the Veteran's lupus manifestations included exhaustion, fatigue, and joint pain. He also noted that SLE "involves periods of illness (flares) alternating with remission." The Board acknowledges the Veteran's assertions and Board hearing testimony that his SLE is related to active service, to include as due to an undiagnosed illness. The competent evidence supports finding that the Veteran's SLE is related to active service on a direct service connection basis. See 38 C.F.R. §§ 3.303, 3.304. There is no competent opinion of record contrary to the positive nexus opinion provided by the VA examiner in November 2007 which related the Veteran's lupus (or SLE) to active service on a direct service connection basis. Id. (The Board notes parenthetically that, because it is granting service connection for SLE on a direct basis, it need not address the Veteran's contention that an undiagnosed illness experienced during his Persian Gulf War service caused his SLE). Accordingly, the Board finds that service connection for SLE is warranted. The Board also finds that the evidence supports granting the Veteran's claim of service connection for Sjogren's syndrome, to include as due to an undiagnosed illness. The Board again acknowledges that the Veteran is a "Persian Gulf Veteran" who served as a hospital corpsman and surgical technician at Fleet Hospital Five in Saudi Arabia during the Persian Gulf War. See 38 C.F.R. § 3.317(a)(1). The competent evidence shows that the Veteran's Sjogren's syndrome is related to active service on a direct service connection basis. See 38 C.F.R. §§ 3.303, 3.304. The Board notes in this regard that the Veteran's service treatment records do not show that he was diagnosed as having or treated for Sjogren's syndrome at any time during active service, to include as due to an undiagnosed illness experienced while he was in Saudi Arabia during the Persian Gulf War. The medical evidence shows that, on VA Gulf War Guidelines examination in November 2007, the Veteran's complaints included dry eyes and dry mouth which he attributed to his Sjogren's syndrome. He reported that he had been diagnosed as having Sjogren's syndrome by a private rheumatologist in April 2007 as secondary to lupus. The VA examiner reviewed the Veteran's claims file, including his service treatment records and VA outpatient treatment records. The Veteran stated that his Sjogren's syndrome had been intermittent with remissions since onset. He currently was taking etodolac as needed for pain. He also used artificial tears to treat dry eyes associated with Sjogren's syndrome. He stated that he experienced dry eyes with episodes of joint pain and daily dry mouth. Physical examination showed pupils equal, round, and reactive to light and accommodation, normal gross visual fields in both eyes, no other eye abnormalities, a normal mouth, tongue, gums, uvula, palate, and tonsils, and teeth in good repair. The VA examiner opined that the Veteran's Sjogren's syndrome was as likely as not (50/50 probability) related to active service. The VA examiner's rationale was that "the unexplained illnesses reported by some Gulf War Veterans are remarkably similar to other recognized symptom-based conditions." The diagnoses included Sjogren's syndrome. The Board acknowledges the Veteran's assertions and Board hearing testimony that his Sjogren's syndrome is related to active service, to include as due to an undiagnosed illness. The competent evidence supports finding that the Veteran's Sjogren's syndrome is related to active service on a direct service connection basis. See 38 C.F.R. §§ 3.303, 3.304. There is no competent opinion of record contrary to the positive nexus opinion provided by the VA examiner in November 2007 which related Sjogren's syndrome to the Veteran's active service on a direct service connection basis. Id. (The Board notes parenthetically that, because it is granting service connection for Sjogren's syndrome on a direct basis, it need not address the Veteran's contention that an undiagnosed illness experienced during his Persian Gulf War service caused his Sjogren's syndrome). Accordingly, the Board finds that service connection for Sjogren's syndrome is warranted. ORDER Entitlement to service connection for systemic lupus erythematosus (SLE) is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to service connection for Sjogren's syndrome is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND The Veteran has contended that he incurred tinnitus, bilateral hearing loss, PTSD, hypogonadism, bilateral pes planus, a pituitary disorder, and chronic fatigue syndrome (CFS) during active service. He specifically has contended that he was exposed to significant in-service acoustic trauma from diesel generators used to power the field hospital where he worked during the Persian Gulf War and from incoming Scud missile attacks and such exposure caused his tinnitus and bilateral hearing loss. He also has contended that in-service stressors experienced while he was on active service in Saudi Arabia during the Persian Gulf War and assigned to Fleet Hospital Five between September 1990 and March 1991 contributed to or caused his PTSD. He testified that his testicles shrank while he was on active service but he did not seek medical treatment for this problem when it initially occurred because, as a medical corpsman, he knew that there were more serious medical problems of other service members being attended to at the field hospital where he worked and he would not receive treatment there for shrinking testicles. He also has contended that he incurred hypogonadism, a pituitary disorder, and CFS as a result of an undiagnosed illness experienced while on active service in Saudi Arabia during the Persian Gulf War. The Board again acknowledges that the Veteran is a "Persian Gulf Veteran." See 38 C.F.R. § 3.317(a)(1). The Veteran's service personnel records, to include his DD Form 214, show that he served as a hospital corpsman and received training as a naval corpsman and operating room technician during active service. The Veteran testified credibly before the Board in July 2010 that he had served as a surgical technician during active service. With respect to the Veteran's service connection claim for PTSD, the Veteran's service representative noted at the July 2010 Board hearing that VA recently had amended its regulations for adjudicating these claims. See 75 Fed. Reg. 39843 (July 13, 2010) as amended by 75 Fed. Reg. 41092 (July 15, 2010) (providing the correct effective date of July 13, 2010 for the revised 38 C.F.R. § 3.304(f)). The revised § 3.304(f) applies to claims of service connection for PTSD that were appealed to the Board before July 13, 2010, but have not been decided by the Board as of July 13, 2010. Because the Veteran's appeal for service connection for PTSD was pending at the Board before July 13, 2010, the Board finds that the revised 38 C.F.R. § 3.304(f) is applicable to the Veteran's claim. See 38 C.F.R. § 3.304(f) (effective July 13, 2010). The Board also notes that, in a June 2009 memorandum to the file, RO personnel concluded that the Veteran had not responded to VA's request for information regarding his in-service stressors. A review of the claims file does not support this conclusion and shows instead that the Veteran provided detailed information regarding his claimed in-service stressors in statements on a VA Form 21-0781 date-stamped as received by the RO on December 15, 2008. The Board observes in this regard that the Veteran's December 2008 VA Form 21-0781 was not mentioned in the RO memorandum which concluded incorrectly that there was no information in the claims file concerning the Veteran's claimed in-service stressors. Thus, the Board finds that, on remand, consideration must be given to the revised 38 C.F.R. § 3.304(f) and to the information provided by the Veteran in December 2008 concerning his claimed in-service stressors. The Board notes further that VA's duty to assist under the VCAA includes obtaining an examination or medical opinion when necessary. Because the Veteran had some medical training during active service, and because he has not been provided with examinations which address the contended etiological relationships between his tinnitus, bilateral hearing loss, PTSD, hypogonadism, bilateral pes planus, pituitary disorder, CFS, and active service, on remand, he should be scheduled for appropriate examination(s). 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) ; McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board acknowledges in this regard that the Veteran was examined for hypogonadism in November 2007 and a diagnosis of a history of hypogonadism was provided by the VA examiner. Unfortunately, however, the VA examiner did not provide a nexus opinion concerning the contended etiological relationship between the Veteran's history of hypogonadism and active service. Finally, as noted in the Introduction, the Board has found that a claim of entitlement to a TDIU has been reasonably raised by the record. The Veteran has submitted competent evidence which indicates that he is medically prohibited from continuing in his current vocation as a surgical technician due to the likelihood of exposure to contaminated blood products and other materials which would impact his systemic lupus erythematosus (SLE) negatively. Both Dr. Robinson in February 2008 and Dr. Barron, the Veteran's private treating rheumatologist, in March 2008 concluded that the Veteran was "permanently medically restricted" from continuing to work as a surgical technician and recommended that he pursue another line of work which reduced his exposure to contaminated blood products and other materials that impacted his SLE. The Board has found that service connection for SLE is warranted. Given the foregoing, the Board finds that, on remand, the Veteran should be scheduled for VA examination to determine the impact of his service-connected disabilities on his employability. The RO/AMC also should attempt to obtain the Veteran's up-to-date VA and private treatment records. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and/or his service representative and ask them to identify all VA and non-VA clinicians who have treated him for tinnitus, bilateral hearing loss, PTSD, hypogonadism, bilateral pes planus, a pituitary disorder, and/or chronic fatigue syndrome (CFS) since his separation from active service. Obtain all VA treatment records which have not been obtained already. Once signed releases are received from the Veteran, obtain all private treatment records which have not been obtained already. A copy of any records obtained, to include a negative reply, should be included in the claims file. 2. Schedule the Veteran for an examination to determine the current nature and etiology of his tinnitus and bilateral hearing loss. The claims file and a copy of this remand must be made available to the examiner in conjunction with the examination. All appropriate tests and studies should be accomplished. Based on a review of the Veteran's claims file and the results of his physical examination, the examiner is asked to opine whether it is at least as likely or not (i.e., a 50 percent or greater probability) that any current tinnitus and/or bilateral hearing loss, if diagnosed, is related to active service or any incident of service. A complete rationale must be provided for any opinions expressed. 3. Schedule the Veteran for an examination to determine the current nature and etiology of his PTSD. The claims file and a copy of this remand must be made available to the examiner in conjunction with the examination. All appropriate tests and studies should be accomplished. The Veteran should be asked to describe his claimed in-service stressors, if possible. Based on a review of the Veteran's claims file and the results of his physical examination, the examiner is asked to opine whether it is at least as likely or not (i.e., a 50 percent or greater probability) that any current PTSD, if diagnosed, is related to active service or any incident of service. The examiner should state which of the Veteran's claimed in-service stressors, if any, resulted in a diagnosis of PTSD. A complete rationale must be provided for any opinions expressed. 4. Schedule the Veteran for an examination to determine the current nature and etiology of his hypogonadism. The claims file and a copy of this remand must be made available to the examiner in conjunction with the examination. All appropriate tests and studies should be accomplished. The Veteran should be asked to provide a complete medical history of his hypogonadism, if possible. Based on a review of the Veteran's claims file and the results of his physical examination, the examiner is asked to opine whether it is at least as likely or not (i.e., a 50 percent or greater probability) that any current hypogonadism, if diagnosed, is related to active service or any incident of service, to include as due to an undiagnosed illness. The examiner is advised that the Veteran is a "Persian Gulf Veteran" who served in Saudi Arabia during the Persian Gulf War. A complete rationale must be provided for any opinions expressed. 5. Schedule the Veteran for an examination to determine the current nature and etiology of his bilateral pes planus. The claims file and a copy of this remand must be made available to the examiner in conjunction with the examination. All appropriate tests and studies should be accomplished. Based on a review of the Veteran's claims file and the results of his physical examination, the examiner is asked to opine whether it is at least as likely or not (i.e., a 50 percent or greater probability) that any current bilateral pes planus, if diagnosed, is related to active service or any incident of service. A complete rationale must be provided for any opinions expressed. 6. Schedule the Veteran for an examination to determine the current nature and etiology of his pituitary disorder. The claims file and a copy of this remand must be made available to the examiner in conjunction with the examination. All appropriate tests and studies should be accomplished. Based on a review of the Veteran's claims file and the results of his physical examination, the examiner is asked to opine whether it is at least as likely or not (i.e., a 50 percent or greater probability) that any current pituitary disorder, if diagnosed, is related to active service or any incident of service, to include as due to an undiagnosed illness. The examiner is advised that the Veteran is a "Persian Gulf Veteran" who served in Saudi Arabia during the Persian Gulf War. A complete rationale must be provided for any opinions expressed. 7. Schedule the Veteran for an examination to determine the current nature and etiology of his chronic fatigue syndrome (CFS). The claims file and a copy of this remand must be made available to the examiner in conjunction with the examination. All appropriate tests and studies should be accomplished. Based on a review of the Veteran's claims file and the results of his physical examination, the examiner is asked to opine whether it is at least as likely or not (i.e., a 50 percent or greater probability) that any current CFS, if diagnosed, is related to active service or any incident of service, to include as due to an undiagnosed illness. The examiner is advised that the Veteran is a "Persian Gulf Veteran" who served in Saudi Arabia during the Persian Gulf War. A complete rationale must be provided for any opinions expressed. 8. Schedule the Veteran for an examination to determine the effects of his service-connected systemic lupus erythematosus (SLE), Sjogren's syndrome, tinea versicolor, fibromyalgia, neutropenia (claimed as immune system disorder), pseudofolliculitis barbae, allergic rhinitis, and any other service connected disability on his ability to obtain and maintain employment. The examiner is asked to obtain a complete occupational history from the Veteran, if possible, and to provide an opinion as to whether, following a review of the claims file and physical examination of the Veteran, the Veteran's service-connected disabilities render him unable to secure or follow a substantially gainful occupation (more than marginal employment). When offering this opinion the examiner is instructed to disregard the effects of any non-service connected disabilities and the effects of age. A complete rationale must be provided for any opinion expressed. 9. Thereafter, readjudicate the Veteran's claims of service connection for tinnitus, bilateral hearing loss, PTSD, bilateral pes planus, and for hypogonadism, a pituitary disorder, and for chronic fatigue syndrome (CFS), each to include as due to an undiagnosed illness, and his TDIU claim. If the benefits sought on appeal remain denied, the Veteran and his service representative should be provided a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant 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. 2010). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs