Citation Nr: 1313992 Decision Date: 04/26/13 Archive Date: 05/03/13 DOCKET NO. 98-10 928 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for fatigue and drowsiness, to include as due to an undiagnosed illness. 3. Entitlement to service connection for fevers or sweats, to include as due to an undiagnosed illness. 4. Entitlement to service connection for a chronic disability of the joints, to include as due to an undiagnosed illness. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD L. Jeng, Counsel INTRODUCTION The Veteran served on active duty for training from January to May 1977, with active service from May 1979 to January 1985, and from September 1990 to June 1991. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 1996 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. Jurisdiction of the case has since been transferred to the RO in Atlanta, Georgia. In July 2009, the Veteran testified at a hearing before the undersigned Acting Veterans Law Judge at the RO. The Veteran also testified before a Decision Review Officer (DRO) at the RO in September 1998. Transcripts of the hearings are of record. The Board remanded the claims for further development in June 2004, April 2009, December 2009, and December 2011. The case has now returned to the Board for further appellate action. The Veteran's appeal originally included service connection for skin symptoms, posttraumatic stress disorder (PTSD), stomach symptoms, and dizziness. In addition, the December 2009 Board remand referred the issue of a total disability rating due to individual employability resulting from service-connected disability (TDIU) to the RO for appropriate action. A November 2008 rating decision granted service connection for chronic urticaria and bilateral dishydrotic eczema, a June 2011 rating decision granted service connection for PTSD and awarded TDIU, and an August 2011 rating decision granted service connection for irritable bowel syndrome (claimed as a stomach symptoms). Most recently, in a September 2012 rating decision, the RO granted service connection for hypertension (claimed as dizziness). As these decisions represent a full grant of the benefits sought, and the Veteran has not disagreed with the disability evaluations or effective dates assigned for these claims, the matters of service connection for skin symptoms, PTSD, stomach symptoms, and dizziness are no longer in appellate status. Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (noting that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). With regard to the claim for service connection for a chronic disability of the joints, the Board notes that in a February 1985 rating decision, the RO denied service connection for a back disorder. The Veteran did not appeal that decision and would typically be required to submit new and material evidence to reopen his claim for service connection. See 38 C.F.R. § 3.156(a) (2012). However, since the February 1985 rating decision, the Veteran had additional active service and additional service records were associated with the claims folder. In such an instance, where VA receives additional service department records, VA will reconsider the claim, notwithstanding the requirement of new and material evidence. See 38 C.F.R. § 3.156(c) (2012). In essence, the finality of any previous decision is vitiated by the association of additional, pertinent service department records, and the claim must be reconsidered. In other words, the submission of new and material evidence is not required in this case for VA to consider the claim on the merits. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claims. The Board has reviewed the documents in both the paper claims file and the electronic claims file in rendering this decision. The issue of service connection for a chronic disability of the joints is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia theater of operations from November 1990 to May 1991. 2. The Veteran's does not have chronic fatigue syndrome; his fatigue and drowsiness are etiologically related to his service-connected and non-service connected disabilities. 3. The Veteran's fevers or sweats cannot be attributed to any known clinical diagnosis. CONCLUSIONS OF LAW 1. The criteria for service connection for fatigue and drowsiness, to include as due to an undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2012). 2. The criteria for service connection for fever or sweats due to an undiagnosed illness have been met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Stegall Considerations As noted above, the Board remanded this matter on several occasions. In June 2004, the Board instructed the RO/Appeals Management Center (AMC) to obtain written verification of the Veteran's pre-1979 period of active duty with the National Personnel Records Center (NPRC), send an updated notification letter in compliance with the Veterans Claims Assistance Act of 2000 (VCAA) and laws pertaining to Persian Gulf War veterans, provide examinations for the claimed disabilities, and readjudicate the claims. Pursuant to the Board's remand, the Veteran was sent a letter in June 2004 in compliance with the Board's remand directives, in July 2004 NPRC confirmed his active duty service from May 1979 to January 1985, he was provided VA examinations in January 2007 and February 2007, and his claims were readjudicated in a December 2008 Supplemental Statement of the Case (SSOC). In April 2009, the Board remanded the case to provide the Veteran with a Travel Board hearing. He provided testimony before the undersigned in a July 2009 hearing. Then in December 2009, the Board remanded the matter to obtain records from the Social Security Administration (SSA), afford the Veteran with additional examinations for his claimed disabilities, and readjudicate the claims. Subsequently, SSA records were obtained, the Veteran was afforded examinations in February 2010 and March 2010, a supplemental examination report was obtained in August 2011, and his claims were re adjudicated in an August 2011 SSOC. However, in December 2011, the Board determined the examination reports of record were inadequate as the VA examiners failed to provide rationales for the opinions provided and instructed the RO/Appeals Management Center (AMC) to obtain addendum reports and readjudicate the claims. Subsequently, addendum reports to the earlier VA examination reports were obtained in January 2012, May 2012, and December 2012. His claims were then readjudicated in a December 2012 SSOC. Thus, there is compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Duties to Notify and Assist On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. § 5100 et seq; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). This law eliminated the concept of a well-grounded claim, redefined the obligations of VA with respect to the duty to assist, and imposed on VA certain notification requirements. Without deciding whether the notice and development requirements of VCAA have been satisfied in the claim for service connection for fever or sweats, it is the Board's conclusion that the VCAA does not preclude the Board from adjudicating this clam. This is so because the Board is taking action favorable to the Veteran on this issue and a decision at this point poses no risk of prejudice to the Veteran. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). As to the claim for service connection for fatigue and drowsiness, in correspondence dated in December 2003 and June 2004, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. The claim was subsequently readjudicated in various SSOC's, most recently in December 2012. See Prickett v. Nicholson, 20 Vet. App. 370, 377-78 (2006) (noting that VA cured its failure to afford statutory notice to the claimant prior to an initial rating decision by issuing a notification letter after the decision, readjudicating the claim, and notifying the claimant of such readjudication in the statement of the case). The Board notes that the letters did not notify the Veteran of the process by which initial disability ratings and effective dates are established as set forth in Dingess v. Nicholson, 19 Vet. App. 473 (2006). However, because the claim is being denied, any question as to the appropriate disability rating or effective date is moot, and there can be no failure-to-notify prejudice to the Veteran. See id. at 484. VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). All identified and available treatment records have been secured. The Veteran's service treatment records and post-service medical records are in the claims folder. Furthermore, the Veteran was provided multiple VA examinations during the appeal. Although the Board previously determined that earlier examination reports were inadequate, he was most recently provided addendum reports to the previous examination reports. Cumulatively, these examination reports reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate evaluations of the Veteran, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that these examination reports are adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran and his representative have not contended otherwise. Additionally, the Veteran presented testimony in support of his claims before the undersigned, and the hearing addressed the elements of the claims and the evidence needed to support the claims. See Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010). Thus, the duties to notify and assist have been met. Analysis In general, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In order to show a chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2012). A recent decision of the U. S. Court of Appeals for the Federal Circuit (Federal Circuit), however, clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board observes that the record reflects that the Veteran served in Southwest Asia from November 1990 to May 1991. Accordingly, he is a Persian Gulf War Veteran within the meaning of the applicable statute and regulation, and service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2016. See 76 Fed. Reg. 81834 (Dec. 29, 2011) (codified at 38 C.F.R. § 3.317(a)(1) (2012)). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5) (2012); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A "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) (2012). Functional gastrointestinal disorders are a group of conditions characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease and may be related to any part of the gastrointestinal tract. Specific functional gastrointestinal disorders include, but are not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia. These disorders are commonly characterized by symptoms including abdominal pain, substernal burning or pain, nausea, vomiting, altered bowel habits (including diarrhea, constipation), indigestion, bloating, postprandial fullness, and painful or difficult swallowing. Diagnosis of specific functional gastrointestinal disorders is made in accordance with established medical principles, which generally require symptom onset at least six months prior to diagnosis and the presence of symptoms sufficient to diagnose the specific disorder at least three months prior to diagnosis. 38 C.F.R. § 3.317(a)(2)(i)(B)(3) (2012). Presumptive service connection is warranted for certain infectious diseases: (i) Brucellosis; ii) Campylobacter jejuni; (iii) Coxiella burnetii (Q fever); (iv) Malaria; (v) Mycobacterium tuberculosis; (vi) Nontyphoid Salmonella; (vii) Shigella; (viii) Visceral leishmaniasis; and (ix) West Nile virus. 38 C.F.R. § 3.317(c)(1-2) (2012). The diseases listed in paragraph 38 C.F.R. § 3.317(c)(2) will be considered to have been incurred in or aggravated by service under the circumstances outlined in paragraphs (c)(3)(i) and (ii) of this section even though there is no evidence of such disease during the period of service. With three exceptions, the diseases listed in 38 C.F.R. § 3.317(c)(2) must have become manifest to a degree of 10 percent or more within one year from the date of separation from a qualifying period of service as specified in paragraph (c)(3)(ii) of this section. Malaria must have become manifest to a degree of 10 percent or more within one year from the date of separation from a qualifying period of service or at a time when standard or accepted treatises indicate that the incubation period commenced during a qualifying period of service. There is no time limit for visceral leishmaniasis or tuberculosis to have become manifest to a degree of 10 percent or more. Further, if a Veteran who has or had an infectious disease identified in column A of 38 C.F.R. § 3.317(d)(2) also has a condition identified in column B of that section as potentially related to that infectious disease, VA must determine, based on the evidence in each case, whether the column B condition was caused by the infectious disease for purposes of paying disability compensation. This does not preclude a finding that other manifestations of disability or secondary conditions were caused by an infectious disease. If a Veteran presumed service connected for one of the diseases listed in paragraph (c)(2) of this section is diagnosed with one of the diseases listed in column "B" in the table within the time period specified for the disease in the same table, if a time period is specified or, otherwise, at any time, VA will request a medical opinion as to whether it is at least as likely as not that the condition was caused by the veteran having had the associated disease in column "A" in that same table. "Objective indications of 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. 38 C.F.R. § 3.317(a)(3) (2012). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b) (2012). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-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. 38 C.F.R. § 3.317(a)(4) (2012). Fatigue and Drowsiness The Veteran essentially contends that he has fatigue and drowsiness due to service, specifically due to his service in the Gulf War. At an October 1994 VA examination, the Veteran complained of constant fatigue among other maladies. He was diagnosed as having multiple somatic complaints which he related to his Persian Gulf experience. Following a December 1998 VA examination, the examiner stated that he believed a lot of the Veteran's symptoms (including chronic fatigue and daytime somnolence) might be related to his mental condition. Further psychiatric evaluation was recommended, and the examiner concluded that the neurologic examination was entirely normal and that he did not suspect any organic etiology of the Veteran's symptoms. As noted in the Board's June 2004 remand, based on the evidence at that time, it was unclear whether the Veteran's reported fatigue and drowsiness were symptoms of a undiagnosed illness or a "medically unexplained chronic multisymptom illness" such as chronic fatigue syndrome arising from his active duty in the Southwest Asia theater of operations, or are in fact symptoms of a known diagnostic illness which nevertheless began in service. Accordingly, the Board remanded for further examination. On VA examination in January 2007, the examiner indicated that the Veteran did not meet the diagnostic criteria for chronic fatigue syndrome. Rather his symptoms were attributed to his psychiatric diagnoses. The examiner concluded that there was no objective evidence of an unexplained illness as a cause of the Veteran's multiple complaints. Pursuant to the Board's December 2009 remand, the Veteran was afforded another VA examination for his claims of fatigue and drowsiness in February 2010. The assessment was that there was no specific diagnosis for fatigue and drowsiness, and the criteria for chronic fatigue syndrome were not met. The examiner further noted that fatigue and drowsiness were "as likely as not, a symptom related to sleep apnea, sedentary lifestyle, possible TBI (traumatic brain injury) and non-medical (mental health) issues." In addition, drowsiness was also attributed to the Veteran's obesity. In an August 2011 addendum in connection with the issue of fatigue, the examiner opined that "fatigue, as likely as not, is a symptom related to sleep apnea, obesity, sedentary lifestyle which are non-service related conditions insofar as such a relationship can be discerned at this time." Determining that the August 2011 addendum report was inadequate as the examiner provided no rationale for his opinion, the Board remanded the matter again in December 2011. Subsequently, an addendum report was rendered in May 2012. The examiner indicated that there was no residual from the Veteran's September 1980 motor vehicle accident, and that fatigue and drowsiness were not caused by the mild TBI. Based on the evidence, the Board finds that service connection for fatigue and drowsiness is not warranted. As an initial matter, the Board notes that all of the medical evidence is clear that the Veteran does not meet the criteria for a diagnosis of chronic fatigue syndrome to warrant a grant of presumptive service connection as a qualifying chronic disability. See 38 C.F.R. § 3.317 (a)(2)(i) (2012). Additionally, the VA examiners have determined the Veteran's fatigue and drowsiness are not manifestation of undiagnosed illness or a medically unexplained multi-symptom illness. The symptoms have been attributed to various conditions (psychiatric, sleep apnea, obesity, etc.). Accordingly, there is no presumed link between these symptoms and the Veteran's military service. Gutierrez, 19 Vet. App. at 8-9. The Board also finds that service connection for fatigue and drowsiness is not warranted on a direct theory of entitlement. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). As demonstrated above, the most probative medical evidence of record indicates that the Veteran's fatigue and drowsiness do not, in and of themselves, constitute a disability. Rather, they are symptoms associated with diagnosed disorders. Accordingly, the most probative medical and other evidence of record reflects that the Veteran's fatigue and drowsiness are not of an independent pathology but are symptoms of either a psychiatric condition, sleep apnea, or various other non-medical issues. Therefore, the condition does not in and of itself constitute a disability for VA compensation purposes. See, e.g., Sanchez-Benitez v. Principi, 259 F.3d 1359, 1361-62 (Fed. Cir. 2001). In light of the foregoing, the Board finds that the preponderance of the evidence is against the claim for service connection for symptoms of fatigue and drowsiness as a qualifying chronic disability under 38 C.F.R. § 3.317, and the claim is denied. The Board finds that the VA examination reports are competent, credible, and highly probative as a whole they were based on a thorough review of the Veteran's medical records, evaluation of the Veteran, and cite to relevant medical principles. These opinions are also consistent with the other evidence of record and are supported by a detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (noting that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. The Board finds these opinions to highly probative. See Guerrieri v. Brown, 4 Vet. App. 467 (1993) (observing that the evaluation of medical evidence involves inquiry into, inter alia, the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches). The Veteran has submitted no competent medical evidence contrary to the VA opinions. The Veteran has been accorded ample opportunity to furnish medical and other evidence in support of his claim; he has not done so. See 38 U.S.C.A. § 5107(a) (2012) (noting it is a claimant's responsibility to support a claim for VA benefits). Indeed, there is no medical evidence of record showing that the Veteran's current symptoms are due to service. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Duenas v. Principi, 18 Vet. App. 512, 520 (2004). Lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, in this case, assertions as to whether the Veteran's symptoms were due to service, to include as due to an undiagnosed illness, concern medical concepts rather than direct observation. But see Barr v. Nicholson, 21 Vet. App. 308-09 (2007) (finding that lay testimony is competent to establish the presence of varicose veins). There is nothing in the record to suggest that the Veteran, his wife, or his representative have the appropriate training, experience, or expertise to render a complex medical opinion on this matter. See 38 C.F.R. § 3.159 (a)(1) (2012) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). As the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Fevers or Sweats The Veteran essentially contends that he has fevers or sweats due to service, specifically due to his service in the Gulf War. At an October 1994 VA examination, the Veteran complained of a feverish-type sensation. He also stated that he would sometimes awaken in a sweat; and he was diagnosed as having multiple somatic complaints which he related to his Persian Gulf experience. Following the December 1998 VA examination, the examiner stated that he believed a lot of the Veteran's symptoms (including night sweats) might be related to his mental condition. Further psychiatric evaluation was recommended, and the examiner concluded that the neurologic examination was entirely normal and that he did not suspect any organic etiology of the Veteran's symptoms. As noted in the Board's June 2004 remand, based on the evidence at that time, it was unclear whether the Veteran's reported fever and sweats were symptoms of a undiagnosed illness or "medically unexplained chronic multisymptom illness" arising from his active duty in the Southwest Asia theater of operations, or are in fact symptoms of a known diagnostic illness which nevertheless began in service. Accordingly, the Board remanded for further examination. On VA examination in January 2007, the examiner indicated that the Veteran's symptoms were attributed to his psychiatric diagnoses. The examiner concluded that there was no objective evidence of an unexplained illness as a cause of the Veteran's multiple complaints. Pursuant to the Board's December 2009 remand, the Veteran was afforded another VA examination for fevers and sweats in February 2010. The assessment was that there was no specific diagnosis for sweats. The examiner found that sweats were as likely as not a symptom related to body size (surface area relative to body mass) and activity (nocturnal restless muscular activity) resulting in need for perspiratory cooling which has medical (sleep apnea, obesity) and non-medical (mental health (e.g., anxiety)) underpinnings. The assessment included a diagnosis of fevers which were related to acute post-service medical issues. Determining that the August 2011 addendum report was inadequate as the examiner provided no rationale for his opinion, the Board remanded the matter again in December 2011. The Veteran was provided another examination in December 2012 for his claim for sweats and fever, for which the examiner reviewed the claims folder in conjunction with evaluation of the Veteran. During the evaluation, the Veteran reported that there had been no change to the pattern of fever and sweats. He denied chills, respiratory, or urinary problems. He had no other specific symptoms that might cause the fever/sweats, which came on two to three times a week without a pattern. He experienced them at times while asleep and other times during the day. The Veteran indicated that he had not experienced a change in the pattern of his symptoms since his release from service in 1991. The examiner noted that previous evaluation of the Veteran showed no documentation of fever and only presented his story of sweats; all evaluations, including laboratory and imaging films, had been negative. The assessment included no documentation of fever or sweats, normal evaluation, fever and sweats by themselves did not interfere with gainful employment, and there was no need for further evaluation. In citing to the Veteran's statement that there has been no change in the condition after 21 years, the examiner found that this was unusual for any known medical condition. He pointed out that evaluation by several clinicians showed no positive tests, imagining, or indication; and no noted unexplained fever in the medical record that was not caused by a known intercurent process. It was noted that several of the clinicians and at least two medical health specialists concluded that the Veteran's mental health issues may be the cause of the sweats, but that was based on their best clinical judgment and did not include any unknown causes related to Southwest Asia exposure. The examiner indicated that this was truly an undiagnosable condition (or no-condition as there was no documentation of the Veteran's complaints). The examiner determined that because the term "undiagnosable" meant just that, and the Veteran was in Southwest Asia and the science of medicine will lead no further, this must be an undiagnosable disorder related to Southwest Asia exposure. In this case, the Board notes that the Veteran has not been diagnosed with a specific disorder to account for his claimed fevers and sweats. Significantly, the December 2012 VA examiner indicated that the symptoms were undiagnosable. Additionally, the Veteran has indicated that his symptoms manifested during active duty. See 38 C.F.R. § 3.317(a)(1) (2012). Accordingly, resolving all doubt in the Veteran's favor, service connection for fever or sweats due to an undiagnosed illness, must be granted. ORDER Service connection for fatigue and drowsiness, to include as due to an undiagnosed illness, is denied. Service connection for fevers or sweats, to include as due to an undiagnosed illness, is granted. REMAND The Board finds that additional development is warranted with regard to the claim for service connection for a chronic disability of the joints before a decision may be rendered. As an initial matter, the Board notes that the Veteran is already service-connected for bilateral arthritis of the knees and therefore the current claim will focus on joints other than the knee. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion only when it is deemed necessary to make a decision on the claim. 38 U.S.C.A. § 5103A (d) (West 2002); 38 C.F.R. § 3.159(c) (4) (2012). See also Robinette v. Brown, 8 Vet. App. 69, 76 (1995). The Board notes that there are several relevant reports of record. The Veteran was afforded a VA joints examination in March 2010. The examiner evaluated the Veteran concerning his cervical and lumbar spine as the Veteran indicated that was what was bothering him the most and he was already service connected for his knees. The examiner opined that it was less likely as not that the Veteran's lower back and cervical spine conditions were related to his period of active duty service. In January 2012, the March 2010 VA examiner provided an addendum to his earlier report. Upon review of the claims folder, the examiner indicated that as to the upper and lower extremities, other than the knees, he could not find any significant entries in the record to demonstrate any type of vague joint condition which began during active service. As to the cervical and thoracolumbar spine, the examiner found some entries related to low back pain but a September 1984 lumbar x-ray report was negative. It was noted that there was no indication of any significant injury to the neck or thoracolumbar spine and no indication of any ongoing problems in these areas. Although he acknowledged that the Veteran had visits for spinal complaints, these were not during his period of service. The examiner concluded that the Veteran was over 50 years old, and most likely developed arthritis changes in the various joints as part of the aging process. The Board finds that the VA examination reports of record are inadequate. A significant basis for the examiner's conclusion that the Veteran's spine disability was not related to service was that the Veteran did not have visits for spine complaints in service. However, review of the service treatment records are replete for entries showing multiple visits for complaints for recurrent back pain. See e.g. service treatment records dated in May 1982, March 1983, October 1983, January 1984, April 1984, September 1984, November 1984, October 1990. Additionally, in September 1982, the Veteran was seen for complaints of right shoulder pain. Accordingly, the factual basis for the VA examiner's opinion is inaccurate. Furthermore, the examiner did not take into account any assertions that the Veteran may have made as to continuity of symptoms since service. See Walker, supra. In this regard, the Board notes that the Veteran filed his initial claim for service connection for his spine in January 1985 after his first period of active service and before his second period of active service. The Board notes that a Veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. See 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b) (2012). Therefore, on remand, the Veteran should be afforded another VA examination to determine the nature and etiology of any chronic joint disability, to specifically include any spinal disability and whether there is clear and unmistakable error that such disability preexisted the Veteran's second period of active military service and was aggravated therein and whether any right shoulder disability is related to service . See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that when VA undertakes to provide a VA examination, it must ensure that the examination is adequate). Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for an examination to ascertain the nature and etiology of any current chronic disability of the joints, including specifically an assessment as to whether any current spine or right shoulder disability is etiologically related to service. The claims file and a copy of this Remand must be made available to and be reviewed by the examiner in conjunction with the examination. The examination report must indicate that the claims file was reviewed in conjunction with the examination. The examiner should: a. Elicit a detailed history from the Veteran about the manifestations of the claimed disability. b. Determine the diagnoses of any currently manifested current joint disability, to include the cervical and lumbar spine or right shoulder. c. For each disability identified, determine whether the disability clearly and unmistakably existed prior to the Veteran's second period entry into active duty. The examiner should be advised that "clear and unmistakable evidence" means with a much higher certainty than "as likely as not" or "very likely." See Vanerson v. West, 12 Vet. App. 254, 258 (1999). It is an "onerous" evidentiary standard, requiring that the preexistence of a condition and the non-aggravation result be "undebatable." Cotant v. Principi, 17 Vet. App. 116, 131 (2003), citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993). d. For each disorder that clearly and unmistakably existed prior to service, the examiner should proffer an opinion as to whether the disorder clearly and unmistakably DID NOT increase in severity beyond the natural progression of the disorder during active duty. e. For any disability that did not clearly and unmistakably exist prior to the second period of active duty and was not aggravated by active duty, the examiner should provide an opinion as to whether there is a 50 percent or better probability that the disorder is related to his military service. f. Determine whether any of the Veteran's joint complaints are chronic but cannot be attributed to any known medical causation or clinical diagnosis. g. Comment on the approximate date of onset and etiology of any diagnosed disability as shown by the evidence of record. The examiner should provide a rationale for any opinion rendered and should attempt to reconcile any contradictory evidence of record. 2. Readjudicate the Veteran's claim, to include consideration of any additional evidence obtained as a result of this Remand. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case. The Veteran has the right to submit additional evidence and argument on the matter 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. 2012). ______________________________________________ A. C. MACKENZIE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs