Citation Nr: 1333448 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 10-12 974 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a low back disorder. 2. Entitlement to service connection for fatigue. 3. Entitlement to service connection for a digestive disorder. 4. Entitlement to service connection for a respiratory disorder. 5. Entitlement to service connection for memory loss. 6. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and/or generalized anxiety disorder (GAD). 7. Entitlement to an initial disability rating (evaluation) in excess of 10 percent for chronic right ankle sprain. 8. Entitlement to an initial compensable disability rating (evaluation) for allergic rhinitis. 9. Entitlement to an initial compensable disability rating (evaluation) for tinea pedis of the left foot. 10. Entitlement to an initial compensable disability rating (evaluation) for residual scars, status post excision multiple dysplastic nevi. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from May 1998 to June 2006, which included a tour of duty in Southwest Asia in support of Operation Iraqi Freedom from February 2003 to May 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board has reviewed the Veteran's physical claims file, as well as the electronic file on the "Virtual VA" system, to ensure a complete review of the evidence in this case. The Veteran initially requested a RO hearing on the Optional Appeals Hearings form received in January 2010; however, he later canceled the scheduled hearing and indicated that he did not desire a RO hearing. See October 2010 letters from the representative and the Veteran. Therefore, the request for a RO hearing has been withdrawn. The Veteran has not requested a Board hearing. The issues of: (1) service connection for a low back disorder, (2) service connection for fatigue, (3) service connection for a digestive disorder, and (4) service connection for a respiratory disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran did not engage in combat with the enemy during service. 2. The Veteran had service in Southwest Asia when hostilities were present. 3. The Veteran was exposed to hostile military activity while serving in Southwest Asia. 4. The Veteran's currently diagnosed PTSD has been linked to combat-related stressor events by a VA psychiatrist. 5. The Veteran does not have a diagnosed psychiatric disorder other than PTSD. 6. The Veteran's current memory loss is etiologically related to PTSD. 7. For the rating period, the right ankle disability has been manifested by intermittent symptoms of pain, stiffness, giving way, and effusion, loss of plantar flexion, and lateral laxity, and more closely approximates marked limitation of right ankle motion. 8. For the entire rating period, allergic rhinitis has been manifested by occasional difficulty breathing, with each of the Veteran's nasal passages having less than 50-percent obstruction (i.e., a 30-percent obstruction and 40-percent obstruction). 9. For the entire rating period, tinea pedis has been manifested by an intermittent red, pruritic rash that affects less than five percent of the entire body and none of the Veteran's exposed areas, is treated with topical ointment and does not require systemic therapy. 10. For the entire rating period, the evidence demonstrated a slightly elevated, oval residual scar at the base of the right neck and shoulder area measuring 1 centimeter (cm) by 0.5 cm. 11. For the entire rating period, there are no residual scars that are deep, cover an area exceeding 39 square (sq.) cm., unstable, painful on examination, or cause limitation of motion. CONCLUSIONS OF LAW 1. Giving the benefit of the doubt to the Veteran, PTSD was incurred during active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303(f)(3) (2013). 2. Giving the benefit of the doubt to the Veteran, memory loss was incurred as the result of PTSD. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310(a) (2013). 3. Giving the benefit of the doubt to the Veteran, the criteria for an initial 20 percent rating for chronic right ankle sprain are met for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5271 (2013). 4. The criteria for an initial compensable rating for allergic rhinitis are not met or approximated for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.31, 4.97, DC 6522 (2013). 5. The criteria for an initial compensable rating for tinea pedis of the left foot are not met or approximated for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.31, 4.118, DC 7813 (2013). 6. Giving the benefit of the doubt to the Veteran, the criteria for an initial 10 percent rating for residual scars, status post excision multiple dysplastic nevi, are met for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.21, 4.118, DC 7800 (prior to October 23, 2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service-connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. If complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent legally adequate VCAA notice, followed by readjudication of the claim, as in a Statement of the Case (SOC) or Supplemental SOC (SSOC). Moreover, where there is an uncured timing defect in the notice, subsequent action by the RO which provides the claimant a meaningful opportunity to participate in the processing of the claim can prevent any such defect from being prejudicial. Mayfield v. Nicholson, 499 F.3d 1317, 1323-24 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In November 2007 and January 2008 notice letters sent prior to the initial denial of the claims for service connection, the RO apprised the Veteran of the information and evidence necessary to substantiate the claims, which information and evidence that he was to provide, and which information and evidence that VA would attempt to obtain on his behalf. The RO also explained how VA determined the disability rating and the effective date once service connection has been established, which satisfied Dingess notice requirements. These notice letters fully satisfied VCAA notice requirements with respect to the service connection claims. Regarding the initial rating appeals, the Veteran is challenging the initial disability ratings assigned following the grant of service connection for chronic right ankle sprain, allergic rhinitis, tinea pedis of the left foot, and residual scars status post excision of multiple dysplastic nevi in the May 2008 rating decision. The Court has held that, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has in fact been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess v. Nicholson, 19 Vet. App. 473, 490-91; Dunlap v. Nicholson, 21 Vet. App. 112, 117 (2007). Furthermore, under 38 C.F.R. § 3.159(b)(3)(i), there was no duty to provide the Veteran with VCAA notice upon receipt of a Notice of Disagreement, such as in this case. For these reasons, the Board finds that no further notice, beyond that afforded in the context of the original claims for service connection, is needed under the VCAA. In view of the foregoing, the Board concludes that the requirements of the notice provisions of the VCAA have been met, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. Regarding VA's duty to assist in claims development, the RO afforded the Veteran with VA medical examinations in connection with the initial rating appeals in April 2008. Collectively, the medical examination reports include all relevant findings and medical opinions needed to evaluate fairly the initial rating appeals decided herein. The medical examiners took a thorough history of the disabilities from the Veteran, including history of onset, diagnosis, report of symptomatology, other limitations, and treatment. The medical examiners had adequate facts and data regarding the history and condition of the disabilities. See VAOPGCPREC 20-95 (interpreting that in some cases an accurate history by a veteran may be a valid basis for an examination report rather than claims file review); see also Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran). The medical examiners also considered the Veteran's subjective complaints as it related to current symptomatology and its effects on his daily life and performed a thorough physical evaluation of the Veteran, to include x-rays. In the August 2013 Appellant's Brief, the representative noted that the Veteran's last examination was in April 2008 and asked that another VA medical examination be provided if the Board was unable to grant the claims; however, the representative has not alleged, and the evidence does not show, that there has been any worsening of the Veteran's disabilities since the last VA medical examination. Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007) (mere passage of time is not basis for requiring new examination). For these reasons, the Board finds that the collective medical examination reports are adequate for deciding the Veteran's initial rating claims and service connection claims decided herein, and there is no need for further medical examination. The Veteran's complete service treatment records, as well as post-service treatment records adequately identified as relevant to the appeal, have been obtained and are associated with the record. There are no pertinent treatment records found in the Veteran's Virtual VA folder. The Veteran has not made the RO or the Board aware of any other evidence relevant to the appeal that needs to be obtained. Neither the Veteran nor the representative has made the RO or the Board aware of any other evidence relevant to the appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the appeal. In view of the foregoing, the Board will proceed with appellate review. It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C.A. § 7104(a). The Board has thoroughly reviewed all the evidence of record in this case. The analysis below focuses on the most relevant evidence and on what this evidence shows, or fails to show, on the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence); see also Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). Service Connection Legal Criteria Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The Veteran's current diagnosis of PTSD, to include the symptom of memory loss, is not listed under 38 C.F.R. § 3.309(a) as a "chronic disease," and is not shown to have been manifested by psychosis; therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are not applicable. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for disability which is proximately due to (caused by) or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). "When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation." Allen v. Brown, 7 Vet. App. 439 (1995). Service Connection for PTSD Analysis In this case, the Veteran contends that he currently suffers from PTSD due to several combat-related stressor events that occurred during service. He has reported that he was exposed to enemy fire (i.e., mortars, rockets, and small arms fire) while stationed in Southwest Asia in support of Operation Iraqi Freedom, and has experienced psychiatric symptoms since 2003. During the course of this appeal, VA amended 38 C.F.R. § 3.304(f), the regulatory provision pertaining to service connection for PTSD. Prior to the amendment, in order for service connection to be awarded for PTSD, the record had to show: (1) a current medical diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a); (2) combat status or credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a causal nexus between diagnosed PTSD and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (in effect prior to July 13, 2010). Effective July 13, 2010, VA amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. The amended 38 C.F.R. 3.304(f) adds the following: If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f)(3); 75 Fed. Reg. 39,843 -852 (July 13, 2010). The amendment to the regulation is effective, in pertinent part, for all claims pending at the Board on July 13, 2010. After a review of the lay and medical evidence of record, the Board finds that the Veteran did not engage in combat with the enemy during service. The Veteran's DD Form 214 reveals that he served as a postal clerk or postal chief throughout his period of active service, which are not military occupational specialties typically associated with combat service. On the May 2003 post-deployment questionnaire, the Veteran checked "No" when asked if, during the deployment, he had engaged in direct combat where he discharged a weapon. When the Veteran later underwent a VA psychological assessment in August 2007, he specifically stated that he had been exposed to enemy fire but had not fired a weapon during service. For these reasons, the Board finds that the Veteran did not engage in combat with the enemy during service, and does not have combat service as contemplated by 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d); therefore, those provisions are not applicable in this case. The Board next finds, however, that the amended PTSD regulation of 38 C.F.R. § 3.304(f)(3) is applicable in this case. The Veteran has alleged fear of hostile military activity and the claimed stressor events are related to such activity. Although the Veteran did not provide a stressor statement in connection with the claim, the VA treatment records include the Veteran's reported stressors of being exposed to enemy fire while serving in Southwest Asia in support of Operation Iraqi Freedom. When the Veteran underwent a VA psychological assessment approximately one year after service separation (i.e., in August 2007) and two months before filing the current service connection claim, he reported that he was exposed to mortars, rockets, and small arms fire during service. Also, at a March 2009 VA individual therapy session, the Veteran reported that, during service, he witnessed a missile blow up nearby in the middle of the night, had Kuwaitis point their weapons at him, and saw wounded and dead men evacuated. The Board finds the statements made to mental health care professionals to be credible and of significant probative value. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Although the Board notes that the Veteran's report of in-service stressors when seeking mental health treatment after service appears to contradict the answers he provided on the May 2003 service post-deployment questionnaire (i.e., he checked "No" when asked if, during the deployment, he ever felt that he was in danger of being killed and denied having any psychiatric symptoms), the Veteran may have been reluctant to admit to any symptoms that may be indicative of mental distress while he remained in the service; therefore, the post-deployment questionnaire is of lesser probative value than the statements made to mental health providers after service. Furthermore, the Veteran's reported stressor event of being subject to enemy fire is consistent with the places, types, and circumstances of his service in an area where hostilities were present; therefore, the Board finds that his lay account of the stressor events, alone, is sufficient to establish the occurrence of the claimed in-service stressor events. The Board further finds that the Veteran's claimed stressor events, which involve fear of hostile military activity (i.e., exposure to enemy fire), have been confirmed by a VA psychiatrist as adequate to support a diagnosis of PTSD. Although the Veteran was not provided with a VA medical examination in connection with the claim, the VA treatment records show that the treating VA psychiatrist has attributed the in-service hostile military activity stressor events to the diagnosis of PTSD. In this regard, the Board recognizes that, prior to August 2009, the Veteran's psychiatric disorder was variously diagnosed as post deployment adjustment issues with depressed mood, PTSD, adjustment disorder rule out PTSD, and GAD rule out PTSD on Axis I by different mental health providers, including a VA social worker, a VA nurse, and a VA psychologist. However, in August 2009, the Veteran's treating VA psychiatrist diagnosed PTSD on Axis I and specifically attributed the symptoms to in-service hostile military activity stressors. Therefore, in summary, the claimed stressor event of being subject to in-service hostile military activity is consistent with the places, types, and circumstances of the Veteran's service; thus, the Veteran's lay account is sufficient to establish the occurrence of the claimed in-service stressor event. Also, the Veteran's claimed stressor event of being subject to hostile fire is related to his fear of hostile military activity, and a VA psychiatrist has confirmed that the claimed stressor event is adequate to support a diagnosis of PTSD. Thus, resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for PTSD is warranted. In awarding service connection for PTSD for reasons stated above, the Board again notes that the psychiatric disability has been various diagnosed by different mental health providers during the course of the appeal; however, the only psychiatric disability diagnosed on Axis I by the VA psychiatrist was PTSD. The VA psychiatrist made no other Axis I psychiatric diagnosis. Because the VA psychiatrist considered the Veteran's prior psychiatric diagnoses and has expertise in the area of psychiatric disorders, the medical opinion that the Veteran is currently diagnosed with PTSD, but no other psychiatric disability, on Axis I is of great probative value. In consideration of the foregoing, the Board finds that the Veteran is not currently suffering from any diagnosed psychiatric disorder other than PTSD. Furthermore, the evidence shows that the psychiatric symptoms manifested by the Veteran during the course of this appeal were consistently attributed to the same psychiatric disability, despite the different diagnoses rendered. The treating VA psychiatrist diagnosed the psychiatric disability as PTSD. The Board finds that all psychiatric symptoms manifested by the Veteran during the course of this appeal, which were attributed to various Axis I psychiatric diagnoses, are attributable to the diagnosis of PTSD and are fully encompassed in the grant of service connection for PTSD. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (stating that the Board is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence that does so, although the Board may not ignore such distinctions where they appear in the medical record); see also 38 C.F.R. § 4.14 (2013) (both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation and the evaluation of the same manifestation under different diagnoses are to be avoided). Service Connection for Memory Loss Analysis The Veteran contends that he has memory loss of unknown etiology related to service. He seeks service-connected compensation benefits on such basis. After review of the lay and medical evidence of record, the Board finds that the evidence is in equipoise on the question of whether the Veteran's current memory loss is etiologically related to the diagnosed disability of PTSD. For reasons articulated above, the Board has granted service connection for PTSD. When the Veteran presented for an annual evaluation in February 2009, the treating VA medical provider considered the Veteran's psychiatric complaints, included an assessment of memory loss, and opined that it was related to the Veteran's psychiatric disorder. The VA medical provider had adequate facts and data on which to render an opinion on the cause of the Veteran's memory loss, and there is no competent medical opinion to the contrary of record. The Board also notes that memory impairment is a symptom specifically contemplated in the general rating formula for mental disorders. See 38 C.F.R. § 4.130. For these reasons, resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for memory loss, as secondary to PTSD, is warranted. 38 C.F.R. § 3.310(a). Disability Rating Legal Criteria Disability evaluations (also referred to as ratings) are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The factors involved in evaluating, and rating, disabilities of the joints include weakness; fatigability; incoordination; restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. Although pain may cause a functional loss, pain itself does not constitute functional loss. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1 and 4.2, which require the evaluation of the complete medical history of a veteran's condition. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In an appeal for a higher rating after an initial award of service connection, all the evidence submitted in support of a veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. Initial Rating for Chronic Right Ankle Sprain Analysis For the entire rating period, the right ankle disability was initially rated at 10 percent under the criteria found at 38 C.F.R § 4.71a, DC 5271, for limited motion of the ankle. See January 2010 decision. Under DC 5271, a 10 percent rating is warranted for moderate limitation of ankle motion. A 20 percent evaluation is prescribed for marked limitation of ankle motion. See 38 C.F.R. § 4.71a. Normal ankle dorsiflexion is from 0 to 20 degrees, and normal ankle plantar flexion is from 0 to 45 degrees. 38 C.F.R. § 4.71, Plate II (2013). After review of the lay and medical evidence of record, the Board finds that the evidence is in equipoise on the question of whether the manifestations of the Veteran's right ankle disability more closely approximate marked limitation of ankle motion. On the one hand, the April 2008 VA medical examination report weighs against finding that the right ankle disability more closely approximates the criteria for a 20 percent evaluation under DC 5271. At the April 2008 VA medical examination, the Veteran reported intermittent right ankle symptoms of giving way, pain, stiffness, and repeated effusion, with periods of remission. On range of motion testing, right ankle dorsiflexion was 20 degrees (out of 20 degrees), and right ankle plantar flexion was 40 degrees (out of 45 degrees). X-ray of the right ankle was normal. Thus, the April 2008 VA medical examination report shows that the right ankle is manifested by intermittent symptoms of giving way, pain, stiffness, and repeated effusion, normal dorsiflexion, a five-degree loss of motion on plantar flexion, and normal x-ray, which weighs against finding that the right ankle disability is manifested by marked limited motion of the ankle. On the other hand, the Veteran's VA treatment records show that the right ankle disability is also manifested by lateral laxity. At the June 2008 follow-up VA primary care visit, for example, the VA medical provider noted that current x-rays showed laxity in the right ankle lateral ligaments, and the right ankle demonstrated increased laxity in the lateral ankle mortis on physical examination. Similarly, during the February 2009 VA annual physical evaluation, the Veteran reported that he had right ankle laxity with mobility, in addition to pain and swelling, and the right ankle demonstrated lateral laxity on physical examination. The Board notes that the April 2008 VA examination report shows that the Veteran denied having the symptom of instability, and, on physical examination, demonstrated no ankle instability or tendon abnormality. However, treatment records both before and after the April 2008 VA medical examination show right ankle laxity. See, e.g., January 2005 service treatment record (noting that the right ankle was positive for laxity); February 2009 VA treatment record (noting right ankle laxity). In consideration thereof, the Board finds that the Veteran's right ankle disability has been manifested by lateral laxity with mobility throughout the rating period. The evidence relevant to the rating period shows that the right ankle disability is manifested by intermittent symptoms of pain, stiffness, giving way, and effusion, loss of plantar flexion, and lateral laxity with mobility. When viewing the disability picture as a whole, the Board finds that the evidence shows that the right ankle disability approximates marked limitation of right ankle motion. Resolving reasonable doubt in favor of the veteran, the Board finds that a higher initial rating of 20 percent under DC 5271 is warranted for the entire rating period. The 20 percent rating is the maximum allowable under DC 5271. 38 C.F.R. §§ 4.3, 4.7. The Board notes that no higher or separate schedular rating is warranted under any of the other codes pertaining to the ankle. The evidence shows that the Veteran's right ankle disability is not manifested by ankylosis; therefore, a higher rating is not warranted under either DC 5270 for ankle ankylosis or DC 5272 for subastragalar or tarsal joint ankylosis. Also, the evidence does not show that the Veteran's right ankle has undergone astragalectomy or is manifested by malunion of os calcis or astragalus; therefore, a higher rating under DC 5274 or DC 5273 is not warranted. 38 C.F.R. § 4.71a. Extraschedular Consideration The Board has further considered whether the initial rating appeal warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321. Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, it must be determined whether the disability picture is such that the schedular criteria are inadequate, i.e., whether there are manifestations or impairment that are not encompassed by the schedular criteria. If the rating criteria are not inadequate, the analysis does not need to proceed any further. In this case, the Board does not find any functional impairment or symptoms that are not already encompassed by the 20 percent schedular rating. The schedular rating criteria contemplate the impairments and symptoms associated with the ankle disability. The Veteran's right ankle disability has been manifested by intermittent symptoms of pain, stiffness, giving way, and effusion, loss of plantar flexion, and lateral laxity with mobility. The 20 percent schedular rating for marked limitation of motion was awarded in consideration of such symptomatology and the resultant functional impairment (e.g., reported limitations of difficulty standing for more than one hour but less than three hours). The functional effects of pain, stiffness, giving way, effusion, and laxity have been taken into account as limiting motion or function, and are incorporated into the schedular rating criteria, so are contemplated in the assigned ratings. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 205-06. Therefore, because the right ankle symptomatology and associated functional impairment are fully contemplated by the schedular rating criteria, the schedular criteria are not inadequate to rate the right ankle disability, and no referral for extraschedular consideration is required. 38 C.F.R. § 3.321. Initial Rating for Allergic Rhinitis Analysis For the entire rating period, allergic rhinitis is rated at 0 percent under the criteria found at 38 C.F.R § 4.97, DC 6522, for allergic or vasomotor rhinitis. 38 C.F.R. § 4.31 (providing for zero percent evaluations in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code and the requirements for a compensable evaluation are not met). Under DC 6522, a 10 percent rating is warranted for allergic or vasomotor rhinitis without polyps, but with greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side. A 20 percent evaluation is warranted for allergic or vasomotor rhinitis with polyps. See 38 C.F.R. § 4.97. After review of the lay and medical evidence of record, the Board finds that the evidence weighs against finding that manifestations of the Veteran's allergic rhinitis more closely approximate the criteria for a higher rating under DC 6522 for any period. At the April 2008 VA medical examination, the Veteran reported taking antihistamines approximately once per month with no side effects and occasional breathing difficulty. The Veteran reported no current rhinitis symptoms. On physical examination, the Veteran demonstrated 40-percent nasal obstruction on the left side, and 30-percent nasal obstruction on the right side, with no nasal polyps. X-ray of the paranasal sinuses showed a negative paranasal sinus study. Review of the treatment records relevant to the rating period contain no findings that contradict those noted in the April 2008 VA examination report. Thus, the Veteran's allergic rhinitis has been manifested by occasional difficulty breathing, and each of the Veteran's nasal passages with less than 50-percent obstruction (i.e., a 30-percent obstruction and 40-percent obstruction). Because the Veteran's allergic rhinitis is not manifested by greater than 50-percent obstruction of nasal passage on both sides or complete nasal passage obstruction on one side, a higher rating for allergic rhinitis under DC 6522 is not warranted for the entire rating period. The Board also notes that the lay and medical evidence weighs against finding that the disability picture associated with allergic rhinitis more closely approximates the criteria for a higher rating other potentially applicable diagnostic codes. For example, under DC 6523 for bacterial rhinitis, a 10 percent rating is assigned for bacterial rhinitis with permanent hypertrophy of turbinates and with greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side. A 50 percent rating is prescribed when there is evidence of rhinoscleroma. In this case, the evidence does not show that there is greater than 50-percent nasal passage obstruction (as discussed above), or permanent hypertrophy of turbinates; therefore, a higher rating is not warranted for allergic rhinitis under DC 6523. Also, under DC 6524 for granulomatous rhinitis, a 20 percent rating is assigned for types of granulomatous infection other than Wegener's granulomatosis, lethal midline granuloma. A 100 percent rating is assigned for Wegener's granulomatosis, lethal midline granuloma. In this case, the evidence does not show that the Veteran has granulomatous infection. The April 2008 VA medical examiner specifically noted that there was no evidence of Wegener's granulomatosis or granulomatous infection, and the treatment records relevant to the rating period contain no contrary findings. Therefore, a higher rating for allergic rhinitis is not warranted under DC 6524. Additionally, under the general rating formula for sinusitis, a 10 percent rating is warranted when there is evidence of one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non-capacitating episodes per year characterized by headaches, pain, purulent discharge, or crusting. Higher ratings are warranted for more severe and/or frequently occurring sinus symptomatology. 38 C.F.R. § 4.97, DCs 6510-6514. In this case, the Veteran does not contend, and the evidence does not show, that allergic rhinitis is manifested by the symptomatology required for a compensable rating under the general rating formula for sinusitis; therefore, a higher rating is not warranted under the rating criteria for sinusitis. The Board has further considered whether the initial rating appeal warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321; Thun, 22 Vet. App. at 111. In this case, the Board does not find any symptoms or functional impairment that is not already encompassed by the 0 percent schedular rating. The schedular rating criteria contemplate all symptoms and functional impairment associated with the Veteran's allergic rhinitis, and provide for a 0 percent rating when the Veteran does not meet the criteria for a compensable rating. 38 C.F.R. § 4.31. The Veteran's allergic rhinitis is manifested by occasional difficulty breathing, with each of the Veteran's nasal passages having less than 50-percent obstruction (i.e., a 30-percent obstruction and 40-percent obstruction). The schedular rating criteria specifically provide ratings based on obstruction of the nasal passages, which impliedly includes consideration of difficulty breathing through the nasal passages. Comparing the Veteran's disability level and symptomatology of allergic rhinitis to the rating schedule, the degree of disability throughout the entire period under consideration is fully contemplated by the rating schedule; therefore, the schedular criteria is not inadequate to rate the disability, and no referral for extraschedular consideration is required. Initial Rating for Tinea Pedis Analysis For the entire initial rating period, the Veteran's tinea pedis has been rated at 0 percent under the criteria found at 38 C.F.R. § 4.118, DC 7813. DC 7813 provides that dermatophytosis, including tinea pedis, is to be rated as disfigurement of the head, face and neck (DC 7800), scars (DC's 7801, 7802, 7803, 7804 or 7805), or dermatitis (DC 7806), depending on the predominant disability. In this case, the predominant disability of tinea pedis more closely approximates dermatitis or eczema. DC 7806 provides that a 0 percent rating is assignable for dermatitis or eczema when less than 5 percent of the entire body or less than 5 percent of exposed areas are affected and no more than topical therapy required in the past 12-month period. A 10 percent rating is assignable when at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected; or when intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a duration of less than six weeks during the past 12-month period. A 30 percent rating is assignable when 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected or where systemic therapy such as corticosteroids or other immunosuppressive drugs are required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is assignable where more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs are required during the past 12-month period. 38 C.F.R. § 4.118. After review of the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that manifestations of the tinea pedis more closely approximate the criteria for a higher (i.e., compensable) rating under DC 7806. The evidence for the entire rating period shows that tinea pedis affects less than five percent of the entire body and none of the Veteran's exposed areas, and does not require systemic therapy, which is a disability picture commensurate with the current 0 percent rating. At the April 2008 VA medical examination, the Veteran reported that he had flare-ups of a red, pruritic rash when he wore combat boots, last broke out in a rash four months ago, and had intermittently self-treated the tinea pedis with a topical ointment (i.e., Desitin) for a duration of one to six weeks during the past 12 months. The VA medical examiner noted that the percentage of exposed area affected by tinea pedis was "none," and the percentage of total body area affected by tinea pedis was less than five percent. The VA medical examiner also noted that the topical treatment used by the Veteran was neither a corticosteroid nor an immunosuppressive drug. The treatment records relevant to the rating period include no contrary findings. In consideration of the foregoing, the Board finds that a compensable rating for tinea pedis is not warranted under DC 7806 for the entire rating period. Extraschedular Consideration The Board has further considered whether the initial rating appeal warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321; Thun at 111. In this case, the schedular rating criteria contemplate all symptoms and functional impairment associated with the Veteran's tinea pedis. The Veteran's tinea pedis is manifested by a red, pruritic rash that affects less than five percent of the entire body and none of the Veteran's exposed areas, is treated with topical ointment, and does not require systemic therapy. The schedular criteria specifically contemplate the percentage of total body and exposed area affected by tinea pedis, as well as the treatment required for the skin disease. The noncompensable (i.e., 0 percent) rating fully encompasses the symptoms and functional impairment associated with tinea pedis. For these reasons, the schedular rating criteria are adequate to rate tinea pedis, and no referral for extraschedular consideration is required. 38 C.F.R. § 3.321(b)(1) . Initial Rating for Residual Scars Analysis During the pendency of the appeal, the rating criteria for evaluating skin disorders, to include scars, were revised. See 73 Fed. Reg. 54,708 -12 (Sept. 23, 2008). The effective date of the revisions is October 23, 2008, and the revised criteria apply to all applications for benefits received by VA on or after that date. In this case, the Veteran filed the service connection claim before October 23, 2008; therefore, the revised criteria do not apply. Although the amendment allows for a veteran to request a review of a scar disability under the revised criteria irrespective of whether such veteran's disability has increased since the last review, no such request has been made in this case. For the entire initial rating period, the residual scars have been rated at 0 percent under the criteria found at 38 C.F.R § 4.118, DC 7801, for scarring other than on the head, face, or neck, that is deep or that causes limited motion. Under DC 7801, a 10 percent evaluation is warranted where a scar, that is not on the head, face, or neck, is deep or causes limitation of motion, and is at least 6 square inches in size. A 20 percent rating is warranted under DC 7801 for scars that are deep or cause limitation of motion and exceed 12 square inches in size. 38 C.F.R. § 4.118 (prior to October 23, 2008). After review of the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that manifestations of any scar disability more closely approximate the schedular criteria for a compensable rating under DC 7801. None of the Veteran's residual scars are deep or cause limitation of motion. The April 2008 VA medical examination report reveals that none of the residual scars adhere to underlying tissue or show underlying soft tissue damage or tissue loss; therefore, the scars are not deep. The April 2008 VA medical examiner specifically wrote "No" when asked, for each of the scars, whether the scar resulted in limitation of motion or loss of function. The treatment records relevant to the rating period do not contain contrary findings. For these reasons, the Board finds that a higher (i.e., compensable) rating under DC 7801 is not warranted for the entire rating period. The Board will next consider whether the Veteran is entitled to a compensable rating under other potentially applicable diagnostic codes for rating scar disabilities. Under Diagnostic Code 7800, disfigurement of the head, face, or neck, a 10 percent rating is warranted when a veteran experiences one characteristic of disfigurement. A 30 percent rating is warranted with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips; or two or three of the aforementioned characteristics of disfigurement. The 8 characteristics of disfigurement for the purposes of evaluation under § 4.118 are: scar of 5 in. or more (13 or more cm) in length; scar at least 1/4 in. (0.6 cm) wide at its widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo- or hyper-pigmented in an area exceeding 6 sq. in. (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding 6 sq. in. (39 sq. cm.); underlying soft tissue missing in an area exceeding 6 sq. in. (39 sq. cm.); and skin indurated and inflexible in an area exceeding 6 sq. in. (39 sq. cm.). 38 C.F.R. § 4.118. After review of the lay and medical evidence, the Board finds that the evidence is in equipoise on the question of whether the scar located in the area of the Veteran's right neck/shoulder area approximates the schedular criteria for a 10 percent rating under DC 7800. The April 2008 VA medical examiner noted that the Veteran demonstrated a slightly elevated oval scar at the base of the right neck and shoulder area measuring 1 cm. by 0.5 cm. Although the April 2008 VA medical examiner wrote that the scar was not disfiguring, the rating criteria provide for a 10 percent rating when one of eight characteristics of disfigurement are shown. The Veteran demonstrated an elevated scar in the area of the neck at the April 2008 VA medical examination, and an elevated scar is considered a disfiguring characteristic under the rating criteria. Therefore, resolving reasonable doubt in favor of the Veteran, the Board finds that the criteria for a 10 percent rating under DC 7800 are met for the entire rating period. 38 C.F.R. §§ 4.3, 4.7. Because the Veteran does not demonstrate any more of the characteristics of disfigurement, or show visible or palpable tissue loss and gross distortion or asymmetry of one feature or paired set of features, the criteria for an even higher 30 percent evaluation under DC 7800 are not met or more nearly approximated. The Board notes that the Veteran's remaining residual scars are not located on the head, face, or neck. Under DC 7802, a maximum 10 percent evaluation is warranted where a scar that is not on the head, face, or neck is superficial, does not cause limitation of motion, and is at least 144 square inches in size. Diagnostic Code 7803 provides a maximum 10 percent rating for scars that are superficial and unstable. Under DC 7804, a maximum 10 percent rating is warranted for scars that are superficial and painful on examination. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. A superficial scar is one not associated with underlying soft tissue damage. Finally, under DC 7805, other scars are to be rated based on limitation of function of the part affected. 38 C.F.R. § 4.118. In this case, there are no residual scars that are deep, unstable, or painful on examination, cover an area exceeding 39 sq. cm., or cause limitation of motion; therefore, a separate, higher (i.e., compensable) rating for any of the remaining scars under DCs 7802-7805 is not warranted. Extraschedular Consideration The Board has further considered whether the initial rating appeal warrants referral for consideration of an extraschedular rating under 38 C.F.R. § 3.321; Thun at 111. In this case, the Board does not find any symptoms or functional impairment that is not already encompassed by the current 10 rating, which is based on the elevated residual neck scar with no disfiguring characteristics. None of the scars causes limitation of motion, is deep, is painful on examination, is unstable, or is of the size required for a compensable rating. The schedular criteria for rating scar disabilities contemplates resulting disfigurement, scars that are deep and cause limited motion, the size of the scars, scars that are unstable, and scars are painful on examination. The 10 percent schedular rating fully contemplates all of the symptoms and functional impairment related to the scar disabilities; therefore, the Board finds that the schedular criteria are adequate to rate the scar disabilities, and referral for consideration of extraschedular rating is not required. TDIU Consideration Moreover, the Board finds that the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) has not been raised by the Veteran or the record in this case. Rice v. Shinseki, 22 Vet. App. 447 (2009). Neither the Veteran nor the evidence suggests unemployability due to service-connected disability. The Veteran is shown to have been employed full time throughout the period at issue in this case. At the April 2008 VA medical examination, the Veteran reported that he was employed full time. See VA joints examination report, page 14. Therefore, the issue of TDIU is not raised, and is not part of the initial rating appeal. ORDER Service connection for PTSD is granted. Service connection for memory loss is granted. An initial 20 percent rating for the right ankle disability, for the entire rating period, is granted. An initial compensable rating for allergic rhinitis is denied. An initial compensable rating for tinea pedis is denied. An initial 10 percent rating for the residual scars, status post excision multiple dysplastic nevi, for the entire rating period, is granted. REMAND Review of the record reveals that the issues of service connection for a low back disorder, fatigue, a digestive disorder, and a respiratory disorder should be remanded for further evidentiary development before proceeding with appellate review. Service Connection for a Low Back Disorder The evidence shows that, during service, the Veteran complained of and was treated for low back pain. In December 2004, the Veteran reported low back pain secondary to favoring the left leg due to the right ankle disability. In January 2005, the Veteran reported that the low back was feeling better. The evidence also shows a current low back disorder. At the April 2008 VA medical examination provided in connection with the claim, the Veteran reported low back pain during service after his in-service ankle injury with intermittent low back pain since that time. The VA medical examiner diagnosed the Veteran with a chronic strain/lumbago. See VA medical examination report, page 15; and 38 C.F.R. § 4.71a, Diagnostic Code 5237 (for rating lumbosacral strain). However, the medical opinion provided by the April 2008 VA medical examiner is not adequate. Although the April 2008 VA medical examiner opined that the Veteran's low back disorder was less likely as not caused by or a result of the right ankle disability, the VA medical examiner did not address the secondary theory of aggravation. The April 2008 VA medical opinion is also inadequate because the VA medical examiner did not provide a medical opinion on the likelihood that the current low back disorder had its onset during service or is otherwise causally related to the complaints of low back pain documented during service. When VA undertakes to provide a veteran with an examination, that examination must be adequate for VA purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). For these reasons, the Board finds that a remand for a VA addendum medical opinion addressing secondary aggravation is necessary. Service Connection for Fatigue A VA medical examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). In this case, the Veteran served in Kuwait from February 2003 to May 2003 and participated in Operation Iraqi Freedom; therefore, he has qualifying Persian Gulf service. See 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317 (2013); see also DD Form 214 and May 2003 post-deployment questionnaire. On the January 2010 VA Form 21-4138, the Veteran wrote that, ever since returning from Operation Iraqi Freedom, he has had prolonged and severe tiredness that is not relieved by rest and is not related to any other conditions. He has further asserted that he suffers from chronic fatigue syndrome. Elsewhere, the Veteran expressed concern that he suffered from Gulf War Syndrome. See August 2009 VA psychological consult record. Signs or symptoms of a medically unexplained chronic multisymptom illness include fatigue. 38 C.F.R. § 3.317(b). The Veteran has not yet been provided with a VA medical examination in connection with the claim, and the evidence of record is insufficient to decide the claim. Thus, because the Veteran has qualifying Persian Gulf service, and has competently reported chronic fatigue since service and manifested during the presumptive period under 38 C.F.R. § 3.317, a remand to provide the Veteran with a VA medical examination is warranted. Service Connection for a Digestive Disorder The Veteran has also competently reported that he currently experiences gastrointestinal problems. See generally October 2007 VA Form 21-526. The service treatment records show that the Veteran was treated for gastrointestinal complaints assessed as gastroenteritis in March 1999 and treated for gastroenteritis/viral syndrome in November 2001. Furthermore, signs or symptoms of a medically unexplained chronic multisymptom illness include gastrointestinal signs or symptoms. 38 C.F.R. § 3.317(b). The Veteran has not yet been provided with a VA medical examination in connection with the claim, and the evidence of record is insufficient to decide the claim. Thus, because the Veteran has qualifying Persian Gulf service, has current gastrointestinal complaints manifested during the presumptive period under 38 C.F.R. § 3.317, and was treated for gastrointestinal problems during service, a remand to provide the Veteran with a VA medical examination is warranted. Service Connection for a Respiratory Disorder The Veteran has further competently reported that he currently experiences respiratory problems. At the August 2009 VA psychological evaluation, the Veteran reported breathing difficulties, among other symptoms. Also, during service, the Veteran complained of, and was treated for, respiratory illness, other than allergic rhinitis, on several occasions. The service treatment records show that the Veteran was treated for pharyngitis in July 1998, upper respiratory complaints with the noted impression of viral upper respiratory infection (URI) versus dry air irritation in December 1998, an upper respiratory infection in April 1999, and bronchitis and costochondritis in January 2004. On the May 2003 post-deployment questionnaire, the Veteran reported that, during the deployment, he had a chronic cough that was resolved. Signs or symptoms of a medically unexplained chronic multisymptom illness include signs or symptoms involving the respiratory system. 38 C.F.R. § 3.317(b). The Veteran has not yet been provided with a VA medical examination or medical opinion in connection with the claim, and the evidence currently of record is insufficient to decide the claim. Therefore, because the Veteran has complained of current respiratory problems that manifested during the presumptive period under 38 C.F.R. § 3.317, has qualifying Persian Gulf service, and was treated for respiratory illness during service, a remand for a VA medical examination is warranted. Accordingly, the issues of service connection for a low back disorder, fatigue, a digestive disorder, and a respiratory disorder are REMANDED for the following actions: 1. Obtain a supplemental medical opinion from the April 2008 VA medical examiner who evaluated the Veteran's low back disability (or another appropriate medical professional, if the examiner is unavailable). Another medical examination is not necessary unless needed to provide the requested opinion. The relevant documents in the record should be made available to the VA examiner for review. In the addendum report, the examiner should confirm that the record was reviewed. a. Based on review of the appropriate records, the examiner should provide an opinion on whether it is "at least as likely as not" (i.e., to at least a 50-50 degree of probability) that the current chronic lumbago/strain had its onset during service or is otherwise causally or etiologically related to service. In rendering the medical opinion, please address the December 2004 report of low back pain secondary to favoring the left leg due to the right ankle disability. b. Based on review of the appropriate records, the examiner should provide an opinion on whether it is "at least as likely as not" (i.e., to at least a 50-50 degree of probability) that the current chronic lumbago/strain was permanently worsened beyond the normal progression (i.e., aggravated) by the right ankle disability, to include consideration of an abnormal gait due to favoring the left leg. If aggravation is found, the examiner should attempt to identify the baseline level of severity of the low back disability before the onset of aggravation. A rationale should be provided for all opinions given, and the factors upon which each medical opinion is based should be set forth in the report. 2. Schedule the Veteran for appropriate VA medical examination for the claimed fatigue, digestive disorder, and respiratory disorder. All relevant documents should be made available to and reviewed by the examiner. In the addendum report, the examiner should confirm that the record was reviewed.. a. Based on review of the appropriate records, the examiner should provide an opinion on whether the Veteran has a chronic disability manifested by fatigue, gastrointestinal symptoms, and/or respiratory symptoms and, if so, whether the disability is consistent with a clinically known diagnosis or is due to an undiagnosed illness or medically unexplained chronic multisymptom illness. b. Based on review of the appropriate records, the examiner should state, for each diagnosis, whether it is "at least as likely as not" (i.e., to at least a 50 percent degree of probability) that any current (1) disorder manifested by fatigue; (2) gastrointestinal disorder; and/or (3) respiratory disorder had its onset during, or is otherwise causally or etiologically related to, active military service. A rationale should be provided for all opinions given, and the factors upon which each medical opinion is based should be set forth in the report. 3. After any additional notification and/or development deemed necessary is undertaken, the remanded issues should be readjudicated. If any benefit sought on appeal remains denied, the Veteran and the representative should be provided with a Supplemental Statement of the Case that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issues. An appropriate period of time should be allowed for response by the Veteran and the representative. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. The Veteran has the right to submit additional evidence and argument on the 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). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs