Citation Nr: 1323331 Decision Date: 07/22/13 Archive Date: 08/01/13 DOCKET NO. 05-22 409 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for a nose and throat disability, including as due to an undiagnosed illness. 2. Entitlement to service connection for tinnitus, including as due to an undiagnosed illness. 3. Entitlement to service connection for fibromyalgia/intermittent migratory arthralgia, including as due to an undiagnosed illness. 4. Entitlement to service connection for benign prostatic hypertrophy, including as due to an undiagnosed illness. 5. Entitlement to service connection for gastroesophageal reflux disease, including as due to an undiagnosed illness. 6. Entitlement to service connection for chronic fatigue syndrome, including as due to an undiagnosed illness. 7. Entitlement to service connection for dermatophytosis of the inguinal areas and keratolysis of the feet, including as due to an undiagnosed illness. 8. Entitlement to service connection for an acquired psychiatric disorder, including as due to an undiagnosed illness. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Siobhan Brogdon, Counsel INTRODUCTION The Veteran served on active duty from September 1989 to September 1992. He served in the Southwest Asia Theater of Operations during the Persian Gulf War. This appeal initially came before the Department of Veterans Appeals Board of Veterans Appeals (Board) from a rating decision of the VA Regional Office in Pittsburgh, Pennsylvania that denied all of the issues as recited on the title page of this decision. By Board decision in March 2013, service connection for bilateral hearing loss and a lung disability were denied. These matters that were previously on appeal are no longer for appellate consideration. Following review of the record, the issue of entitlement to service connection for an acquired psychiatric disorder 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 had active military service in the Southwest Asia Theater of operations during the Persian Gulf War. 2. Nose and throat disability, including sinusitis, was first clinically manifested years after discharge from service and is not attributed to an undiagnosed illness, or a medically unexplained multisymptom illness. 3. Benign prostatic hypertrophy was first clinically manifested years after discharge from service and is not attributed to an undiagnosed illness, or a medically unexplained multisymptom illness. 4. Gastroesophageal reflux disease was first clinically manifested years after discharge from service and is not attributed to an undiagnosed illness or to a medically unexplained multisymptom illness. 5. Dermatophytosis was first clinically manifested years after discharge from service and is not attributed to an undiagnosed illness, or to a medically unexplained multisymptom illness. 6. The Veteran does not have tinnitus attributable to service or in-service noise exposure; tinnitus was first clinically manifested years after discharge from service and is not attributed to an undiagnosed illness, or a medically unexplained multisymptom illness. 7. There is competent evidence of record that fibromyalgia/intermittent migratory arthralgia is attributable to an undiagnosed illness. 8. There is competent evidence of record that chronic fatigue syndrome is attributable to an undiagnosed illness. CONCLUSIONS OF LAW 1. Nose and throat disability, including sinusitis, is a diagnosed illness and was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2012). 2. Benign prostatic hypertrophy is a diagnosed illness and was not incurred in or aggravated by service. §§ 1110, 1117, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2012). 3. Gastroesophageal reflux disease is a diagnosed illness and was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2012). 4. Dermatophytosis/pitted keratolysis is a diagnosed disorder and was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2012). 5. Tinnitus is a diagnosed disability and was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2012). 6. With resolution of reasonable doubt in the appellant's favor, fibromyalgia/intermittent migratory arthralgia is presumed to be an undiagnosed illness of Persian Gulf War origin. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2012). 7. With resolution of reasonable doubt in the appellant's favor, chronic fatigue syndrome is presumed to be an undiagnosed illness of Persian Gulf War origin. 38 U.S.C.A. §§ 1110, 1117, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met in this instance. There is no issue as to providing an appropriate application form or the completeness of the application. VA notified the Veteran in March 2004 and December 2008 of the information and evidence needed to substantiate and complete the claims, to include notice of what evidence the claimant could provide in support of the claims, the evidence VA would attempt to obtain, and how disability ratings and effective dates are determined. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate the claims, and affording VA examinations. These examinations are adequate to render a determination as to the issues on appeal. The Board finds that there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). As such, the claims are ready to be considered on the merits. Pertinent Law and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). For the showing of 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." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may legitimately be questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303. For Persian Gulf War veterans, service connection may be granted for objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms, to include, but not limited to, fatigue; muscle or joint pain; neurologic signs or symptoms; neuropsychologic signs or symptoms; signs or symptoms involving the respiratory system; or sleep disturbances. The chronic disability must have become manifest either during active military, naval, or air 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, and must not be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317(a)(b) (2012). A Persian Gulf veteran is a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 U.S.C.A. § 1117(e) (West 2002); 38 C.F.R. § 3.317(d) (2012). For purposes of § 3.317, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) An undiagnosed illness; (B) The following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) Chronic fatigue syndrome; (2) Fibromyalgia; (3) Irritable bowel syndrome; or (4) Any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptoms illness; or (C) Any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). For purposes of this section, 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.§ 317(a)(2)(ii). "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) For purposes of § 3.317, disabilities that have existed for 6 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. 38 C.F.R. § 3.317(a)(4). 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 defined as doubt that exists because of an approximate balance of positive and negative evidence, which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102 (2012). Factual Background The Veteran's service treatment records reflect that he was seen for complaints associated with a cold in October 1989. In February 1990, he sought treatment for back pain of a month's duration. From July 1990, he was treated for a painful right upper thigh and low back pain with symptoms that included with paravertebral muscle spasm and tenderness. It was noted that the onset of such was after moving boxes. Right adductor/groin strain was diagnosed. A lumbosacral spine X-ray in August 1990 was within normal limits. In January 1992, the appellant reported continuing on and off back pain of different degrees. An assessment of low back pain was recorded. On physical examination in June 1992 for Chapter 16 purposes, the Veteran indicated that he had had swollen or painful joints, tumor, growth or cyst, recurrent back pain and trick or locked knee on the Report of Medical History. He denied nose and throat trouble, chronic and frequent colds, sinusitis, hay fever, skin diseases, chronic cough, cramps in legs, frequent indigestion, stomach trouble, frequent or painful urination, arthritis or bursitis, foot trouble, hearing impairment, etc. The examining official noted that the appellant had episodic back and knee pain that did not require profile. The nose, throat and sinuses, mouth and throat, ear drums, genitourinary, feet, musculoskeletal system, skin and neurologic status were evaluated as normal. In March 2004, the appellant filed claims of entitlement to service connection for nose and throat disability, tinnitus, musculoskeletal aches and pan, skin disease, a genitourinary disorder, an upper digestive system disorder, chronic fatigue and body aches, etc. A private physical examination was conducted in May 2003 for a complaint not pertinent to this appeal where it was noted that the Veteran smoked two to three packs of cigarettes per week and drank 12 beers a week. He denied recurrent epistaxis or significant sinusitis. It was noted that he had a large prostate. He reported that he took Prilosec for acid reflux and hiatus hernia. The Veteran denied hearing loss and did not reference a problem with tinnitus. He denied arthritis, arthralgias and myalgias. The Veteran subsequently underwent extensive diagnostic follow-up and treatment for sleep apnea. While being treated for such in January 2004, it was recorded that he appeared tired and had some nasal congestion. The Veteran's wife wrote in June 2004 that she witnessed the beginning of chronic fatigue eight to nine years before. She related that his joints and muscles ached after only minor activity, and occasionally "locked up". It was related that within the past 5-6 years, the appellant had had a problem with frequent urination and inability to control his bladder at times. She stated that he almost always had a cough and dry throat, a stuffy nose and sores inside his nose. The affiant reported that the most recent symptoms she had observed were out-of-character mood swings, slurred speech and stuttering, difficulty remembering, and difficulty during conversations. She indicated that in the 10 years she had known him, she had observed stomach acid issues with occasional vomiting. Subsequently received were private clinical records showing that in August 1998, the Veteran was seen for complaints that included sweating feet and peeling skin with a foul odor. It was noted that he had heartburn a lot, more with spicy food. He complained of feeling tired a lot and that his legs fell asleep on him. He reported using over-the-counter agents, including Tinactin, and said that this helped as long as he used the medication. The appellant indicated that his symptoms began in Saudi Arabia. On examination, the left nostril was mildly injected and mucous membranes were moist. The bottom of his feet exhibited skin thickness, scaling, and erythema, bilaterally. He was prescribed Lamisel for his feet in October 1998. In November 1998 it was noted that he was taking medication for heartburn with improvement in symptoms. The Veteran underwent upper gastrointestinal endoscopy in June 1999 for a history of recurrent heartburn of a few years duration. The final diagnosis was gastroesophageal reflux disease and hiatal hernia. In August 1999, the appellant presented to the emergency room after falling off his bike the prior evening. He stated that he struck his right shoulder. It was reported that he denied neck pain and/or any other injuries or complaints at that time. It was noted that medical history was significant for tobacco and alcohol use and that he took Prilosec. The skin was warm pink and dry. The findings were otherwise negative on general physical examination. The appellant was seen for a check-up in October 2000 and complained of no energy and tiredness all the time. Another clinical entry in October 2000 reflected diagnoses that included fatigue and urinary frequency for which he continued to be treated. The Veteran was afforded a general medical examination in July 2004. History was reported that he had had benign prostatic hypertrophy since 2003. It was noted that he had a problem with arthralgia and myalgia in multiple joint areas, fatigue since about 1993 or 1994, gastroesophageal reflux disease since "1964" as well as progressive hearing loss with occasional tinnitus. He indicated that he had recently gone to the dermatologist because of a rash on the feet and that a diagnosis of pitted keratolysis had been made for which he had been placed on Clindamycin with improvement. He stated that he had a rash in the groin area, bilaterally. The appellant related that he had migratory muscle aches and a dry hacking cough with occasional chest discomfort. He said that his skin was dry and itchy and that he had felt chronic fatigue for the last few years at least. It was noted that he worked as a parts manager and had not missed any particular work because of the problems because he had a family to support. A comprehensive physical examination was performed. Following examination, the impressions included benign prostatic hypertrophy, does not meet the criteria for chronic fatigue, occasional tinnitus, gastroesophageal reflux disease, pitted keratolysis of the feet, dermatophytosis both inguinal areas, and intermittent migratory arthralgias involving the anterior chest. An audiology examination was conducted in July 2004. The Veteran indicated that he had some difficulty hearing and also claimed a mild, bilateral, periodic ringing-type tinnitus. He reported noise exposure from gunfire and engines while on active duty. It was noted that there was a history of recreational noise exposure with sporadic use of personal hearing protection. Following evaluation, the diagnostic and clinical tests disclosed mild-moderate sensorineural hearing loss at 6000-8000 Hertz with excellent word recognition. The examiner noted that there was a complaint of tinnitus, bilaterally. The Veteran was referred to the VA War Related Illness and Study Center by his VA primary care provider for evaluation of reported "medically unexplained symptoms related to deployment." In a November 2004 report, it was noted he reported that his symptoms began in the Gulf with 'acne of the feet' heartburn, and urination/dribbling/large prostate in 1992 or 1993. The appellant stated that he had had a dry mouth and metallic taste in his mouth for several years, and that fatigue had gotten worse, culminating in his seeking medical attention in 1998. He related that muscle and joint pain and stiffness had gotten gradually worse over the years and dated back to the early 1990s. The appellant indicated that he first sought treatment for such in 1998. Comprehensive screening and analysis were performed. The recommendations included that the Veteran met the criteria for the medically unexplained syndrome of fibromyalgia and chronic fatigue syndrome, among other things. VA outpatient clinical records dating from 2005 reflect that the Veteran continued to receive treatment and carry diagnoses that included gastroesophageal reflux disease, benign hypertrophy of the prostate, and fibromyalgia, etc. In April 2007, he was seen for nasal congestion where it was noted that he had some mild allergic complaints. Examination disclosed that the turbinates were moderately hypertrophied and that the septum was slightly deviated to the right. Nasal endoscopy did not demonstrate any other abnormalities or obstruction. The impressions were turbinate hypertrophy, slightly deviated septum and rhinitis. The appellant continued to seek treatment for nasal congestion that was diagnosed as allergic rhinitis in February 2008. Pursuant to Board remand, the appellant was afforded VA examinations in April 2013. The examiner indicated that the claims folder was reviewed. Pertinent history as reported above was recited. Multiple physical examinations were performed. Gastroesophageal reflux disease was diagnosed. Following examination, the examiner opined that gastroesophageal reflux disease was less likely than not incurred in or caused by service. The rationale provided was that the Veteran was diagnosed with this disorder in 1998. It was noted that although he reported symptoms for several years prior to this, in reviewing his service treatment records, there were no notations or entries related to or discussing gastroesophageal reflux disease or similar conditions. It was added that this was a medically diagnosable condition with a specific etiology. The Veteran underwent evaluation for chronic fatigue syndrome in April 2013. Pertinent history was recited in detail. A physical examination was performed. Following examination, chronic fatigue syndrome was diagnosed. The examiner opined that chronic fatigue syndrome was at least as likely as not (50 percent or greater probability) incurred in or caused by service. In this regard, it was noted that the appellant served in the Gulf War Zone in 1991 and chronic fatigue syndrome was a chronic multisystem illness without a specific and known etiology that was considered a presumptive condition related to service in the Gulf War. The Veteran was provided VA examination with respect to the upper respiratory tract in April 2013. A physical examination was performed and he was found to have chronic sinusitis with rhinitis. Following examination, the examiner opined that claimed upper respiratory disability was less likely than not incurred in or caused by service. The rationale provided was that this would be classified as medically diagnosable condition with an etiology. The examiner noted that in reviewing the service treatment records, there was no mention or any evaluation of sinusitis or similar complaints of sinus congestion. It was added that there was no medical evidence that substantiated a diagnosis of such during the immediate period after discharge from service. A physical examination was performed pertaining to the claim of entitlement to service connection for migratory arthralgia/fibromyalgia. Detailed pertinent history was recited. Following examination, the examiner determined it was at least as likely as not (50 percent or greater probability) that it was incurred in or caused by service. It was noted that the appellant served in the Gulf War Zone in 1991 and that fibromyalgia was a chronic multisystem illness of unknown etiology that was presumptively connected to service in the Gulf War. A skin examination was conducted in April 2013. Pertinent history was recited and the Veteran's statements in this regard were reported. An examination was performed. Pitted keratolysis was diagnosed. It was noted that on current examination, the appellant did not complain of dermatophytosis of the inguinal areas and he had no skin symptoms in the groin area. The examiner stated that the groin was normal. The feet were observed to have dryness of the soles and toes and sides but no current areas of weeping or infection. Pertinent history was reported with respect to the prostate and an examination was conducted. Benign prostatic hypertrophy was diagnosed. The Veteran related that after leaving service, he began to have some increased urinary frequency in about 1994 that slowly progressed until he was evaluated in the late 1990s. The examiner stated that review of service treatment records did not reflect any complaints or urinary difficulty. Following examination, the examiner opined that the claimed skin disability and benign prostatic hypertrophy were less likely than not incurred in or caused by service. The rationale provided was that neither pitted keratolysis nor prostatic hypertrophy was noted in service, that there was no medical evidence of a diagnosis of such in service or in proximity thereto. It was added that neither of these conditions was presumed to be related to service in the Gulf War Zone. The Veteran was afforded a VA audiology evaluation in April 2013. The examiner indicated that the claims folder was carefully reviewed. The appellant reported noise from gunfire and engines during active duty. He reiterated that he had difficulty hearing with periodic tinnitus in the evenings. The examiner related that the history of onset of tinnitus was unclear. Following evaluation, it was noted that at the time of the appellant's last audiometric examination in service, there was no note concerning hearing loss or tinnitus in the service treatment records. The examiner opined that it was therefore not at least as likely as not that the claimed tinnitus was associated with noise exposure or acoustic trauma while the Veteran was on active duty. Legal Analysis 1. Service connection for gastroesophageal reflux disease, benign prostatic hypertrophy, nose and throat disability and a skin disorder, claimed as dermatophytosis of the inguinal areas and keratolysis of the feet. The Veteran asserts that he has gastroesophageal disease, a prostate disorder, nose and throat disability and a skin condition of the groin and feet that are of service onset, or are attributable to an undiagnosed illness caused by environmental conditions while serving in the Persian Gulf War. The Veteran's service treatment records do not reflect that he was seen for any symptoms pertaining to the esophageal tract, prostate, or skin. He sought treatment on a single occasion for a common cold but it is not shown that he had any continuing complaints or residuals in this regard. The evidence reflects that prior to service discharge, among other things, he denied nose and throat trouble, chronic and frequent colds, sinusitis, hay fever, skin diseases, chronic cough, frequent indigestion, stomach trouble, and frequent or painful urination, etc and systems were evaluated as normal. The post service record does not refer to any problems relating to the skin or the feet until 1998 and the appellant was prescribed medication at that time. He complained of heartburn in 1998 and gastroesophageal reflux disease was diagnosed in 1999. In a clinical record dated in October 2000 it was noted that he had urinary frequency, and he admitted on VA examination in 2004 that benign prostatic hypertrophy had been diagnosed in 2003. On VA examination in 2004, he related that he had a rash of the groin, and had recently gone to a dermatologist who had diagnosed pitted keratolysis. Following that examination, dermatophytosis of the inguinal areas were diagnosed. The record does not indicate that he was treated for any nose/throat complaints until 2007, whereupon the assessments included rhinitis, slightly deviated septum and turbinate hypertrophy. A assessment of sinusitis with rhinitis was noted on VA examination in 2012. Prior to those dates, the VA outpatient and private records reflect no complaints or treatment of the claimed disorders. As such, the Board must find that current diagnoses of gastroesophageal reflux disease, benign prostatic hypertrophy, nose/throat disability variously diagnosed as rhinitis, slightly deviated septum, turbinate hypertrophy and sinusitis with rhinitis and keratolysis of the feet were first clinically indicated years after discharge from service in 1992. As such, they are not found to be directly related to service. See 38 U.S.C.A. §§ 1110, 1131. The Board observes that while the record indicated that the appellant was found to have dermatophytosis of the inguinal areas on VA examination on VA examination in 2004, no disability of this nature was observed on most recent VA examination in 2013. Therefore, the Veteran has no current disability diagnosed as dermatophytosis of the inguinal area for which service connection may be granted and there can be no valid claim. See Brammer v. Derwinski, 3 Vet.App. 223, 225. The Board recognizes that lay assertions may serve to establish a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d. 1372 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). A layman is competent to report what he experiences through the senses and lay evidence must be considered when a Veteran seeks disability benefits. See Layno v. Brown, 6 Vet.App. 465, 470 (1994). In this case, however, there is no reliable evidence of symptoms related to gastroesophageal disease, a prostate disorder, nose and throat disability and a skin condition of the groin and feet in service, nor is there any showing of continuity of symptomatology from service as the Veteran reports. As indicated previously, evidence of such was first clinically demonstrated years after discharge from active duty. In this regard, the Board finds that the Veteran has not been a reliable historian, and that his account of gastroesophageal, nose and throat, skin and prostate symptoms deriving from service is not credible. Additionally, no physician in the record has provided a nexus between these claimed conditions and service, to include on VA examination in April 2013. At that time, after review of the record, the VA examiner provided reasoned rationale as why gastroesophageal reflux disease, benign prostatic hypertrophy, sinusitis with rhinitis and pitted keratolysis were not related to service. In view of the above, service connection must be denied. In the alternative the Veteran argues that he has gastroesophageal disease, a prostate disorder, nose and throat disability and a skin condition of the groin and feet that are attributable to an undiagnosed illness caused by environmental conditions while serving in the Persian Gulf War Theater of Operations. The Board points out, however, that the appellant has been determined to have gastroesophageal reflux disease, benign prostatic hypertrophy, nose and throat disorders variously diagnosed as allergic rhinitis, sinusitis, deviated septum and turbinate hypertrophy, as well as a skin disorder diagnosed as pitted keratolysis, as most recently shown on VA examinations in April 2013. These are known clinical diagnoses and are not chronic undiagnosed or medically unexplained chronic multisymptom illnesses pursuant to 38 C.F.R. § 3.317(a)(2)(i) for Persian Gulf War disability purposes. As such, this theory of entitlement is unavailing as a basis to establish service connection and a discussion of such is unnecessary. See VAOPGCPREC 8-98. Accordingly, the Board must conclude that the weight of the evidence is against the claims of service connection for nose and throat disability, gastroesophageal reflux disease, benign prostatic hypertrophy and skin disease as undiagnosed illnesses under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317; Gutierrez v. Principi, 19 Vet.App. 1, 7 (2004). The Board would also point out that neither the Veteran nor his representative is competent to opine that the claimed disorders are due to an undiagnosed or multisymptoms illnesses. This is because this question involves a medically complex question that goes beyond their lay assertions. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In summary, the Board concludes that there is no reliable and/or probative evidence indicating that the Veteran's gastroesophageal reflux disease, benign prostatic hypertrophy, nose and throat disability and pitted keratolysis are related to service or to any incident therein. For the foregoing reasons, the Board finds that the preponderance of the evidence is against the claims and service connection is denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49, 54-56 (1990). 2 Service connection for tinnitus In this case, exposure to noise is found to be consistent with the circumstances of the Veteran's service. See 38 U.S.C.A. § 1154(a) (West 2002 & Supp. 2012). Accordingly, in-service exposure to noise is conceded. However, this does not by itself provide for grant of service connection. Rather, the evidence must demonstrate that tinnitus is related to such service. After reviewing the evidence in its entirety, the Board concludes that service connection for tinnitus is not warranted. The Board finds that despite a military duty in which it may be conceded that the Veteran was exposed to noise, his service treatment records are not indicative of any complaints or references to ringing of the ears, to include on examination prior to discharge in 1992. He specifically denied any ear trouble at that time. The Veteran has provided no records in proximity to service showing complaints, treatment, or a diagnosis of tinnitus. The first reference to tinnitus does not appear in the record until the prosecution of the claim in 2004. This is more than a decade after discharge from active duty. No medically sound basis has been presented attributing tinnitus to service. Significantly, a VA examiner in April 2004 found that tinnitus was less likely than not related to service given that there was no indication or either hearing loss or tinnitus on his last audiometric examination in service. The Board has carefully considered the appellant's lay statement as to the onset of tinnitus in service and does not dispute his account of noise exposure during active duty. However, to the extent that there may be a vague assertion of chronicity and/or continuity of symptomatology since service, his assertions are less reliable than the normal separation examination, the denial of any ear problems at separation, no documentation of tinnitus for so many years after discharge from service, and the opinion of the skilled clinical professional. In this instance, the Board concludes that the Veteran's assertions of causation are less probative than the contemporaneous records and the VA opinion. See Buchanan v. Nicholson, 451, F.3d 1331 (2006). Additionally, tinnitus is not a chronic undiagnosed or medically unexplained chronic multisymptom illness pursuant to 38 C.F.R. § 3.317(a)(2)(i) for Persian Gulf War disability purposes. Under the circumstances, the Board concludes that there is no reliable and probative evidence indicating that the Veteran has tinnitus related to service. The Board thus finds that the preponderance of the evidence is against the claim and service connection is denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App, 49, 54-56 (1990). 3. Service connection for chronic fatigue syndrome and intermittent migratory arthralgias. The evidence establishes that the appellant has longstanding chronic fatigue syndrome and intermittent migratory arthralgias. Review of the overall clinical evidence of record discloses these disabilities are not due to a known clinical diagnosis. For Persian Gulf War veterans, service connection may be established for objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms, to include fatigue and/or muscle or joint pain, etc. Chronic qualifying disabilities include chronic fatigue syndrome and fibromyalgia. See 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317. The appellant's symptoms were manifest prior to December 31, 2006. Moreover, on VA examinations in April 2013, the examiner clearly found that both arthralgia/fibromyalgia were chronic multisystem illness without a specific and known etiology that were considered presumptive conditions related to service in the Gulf War. This assessment corroborates the findings by the VA War Related Illness and Study Center in November 2004. As such, the Board resolves any benefit of the doubt by finding that chronic fatigue syndrome and arthralgia/fibromyalgia are of service onset and that service connection is warranted. ORDER Service connection for nose and throat disability, to include sinusitis with rhinitis, deviated nasal septum, turbinate hypertrophy and allergic rhinitis, etc, is denied. Service connection for benign prostatic hypertrophy is denied. Service connection for gastroesophageal reflux disease is denied. Service connection for a skin disorder to include dermatophytosis and pitted keratolysis, is denied. Service connection for tinnitus is denied. Service connection for intermittent migratory arthralgias/fibromyalgia as due to an undiagnosed illness is granted. Service connection for chronic fatigue syndrome as due to an undiagnosed illness is granted. REMAND The Veteran asserts that he has an acquired psychiatric disorder that is of service onset, or is due to an undiagnosed illness from service in the Persian Gulf War Zone. The record reflects that he was afforded a VA mental health examination in July 2004 and was determined to have no psychiatric diagnosis. However, a VA War Related Illness and Study Center in November 2004 diagnosed Adjustment disorder and related this to physical symptoms impacting on his employment leading to mild depressive/anxiety symptoms. VA outpatient clinic notes dating from 2005 reflect that Veteran was followed for depression and/or a depressive disorder and appeared to indicate that his symptoms derived from ongoing job stresses. When he was afforded a VA examination in April 2013, the VA psychologist diagnosed depressive disorder and stated that this was consistent with diagnosis of adjustment disorder in 2004. On this occasion, it was found that the psychiatric disorder was at least as likely as not incurred in or caused by service. At the same time, however, the examiner also concluded that adjustment difficulties, notably depression, were secondary to his ongoing physical problems, related functional decline and related decline in quality of life. The examiner indicated that this was documented in the Veteran's records at Erie VA and in the psychological assessment prepared in conjunction with the VA War Related Illness and Study Center report in November 2004. He also opined that should the Veteran be service connected for chronic fatigue syndrome or fibromyalgia, his depression was secondary thereto. As noted above, however, the Board observes that ongoing VA outpatient clinical records clearly attribute adjustment disorder and/or depression to job-related stresses. In 2004, a VA examiner determined that he had no psychiatric disability. As such, the Board finds that there is a clear conflict in the evidence as to the etiology of claimed psychiatric disability such that a clarifying opinion is warranted. Accordingly, the case is REMANDED for the following actions: 1. Send the claims file to a VA psychiatrist (preferably board-certified and one who has not seen him previously) to obtain a medical opinion concerning the nature and etiology of the Veteran's psychiatric disorder(s). All pertinent symptomatology, findings and clinical manifestations should be reported in detail. All appropriate studies should be performed. A specific diagnosis should be provided. Following a review of the claims file, the examiner is requested to respond to the following: a) Whether it is at least as likely as not (a 50% probability or more) that any diagnosed acquired psychiatric disability (including, but not limited to depressive disorder and/or adjustment disorder) had its onset during the Veteran's active duty service? b) Whether it is at least as likely as not (a 50% probability or more) that any diagnosed acquired psychiatric disorder is caused by or aggravated by the service-connected chronic fatigue syndrome and/or fibromyalgia/migratory arthralgias? A complete rationale for all opinions expressed should be provided. It is requested that the examiner discuss all of the prior medical evidence in detail and reconcile any contradictory evidence. If the examiner determines that a full examination is required to render this opinion, the RO shall schedule an appointment. The RO is advised that the Veteran must be given adequate notice of the date and place of any requested examination and a copy of the notification must be associated with the claims file. 2. The RO should ensure that the medical report requested above complies with this remand and its instructions. If the report is insufficient, or if any requested action is not taken or is deficient, it should be returned for correction. 3. After taking any further development deemed appropriate, re-adjudicate the remaining issue on appeal. If the benefit is not granted, provide a supplemental statement of the case to the Veteran and his representative before the case is returned to the Board. 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. 2012). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs