Citation Nr: 1532266 Decision Date: 07/29/15 Archive Date: 08/05/15 DOCKET NO. 14-04 070 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for an upper respiratory disorder. 2. Entitlement to an initial disability rating in excess of 10 percent for gastroesophageal reflux disease (GERD). 3. Entitlement to service connection for diabetes mellitus. 4. Entitlement to service connection for shortness of breath. 5. Entitlement to service connection for sleep apnea. 6. Entitlement to service connection for memory loss. 7. Entitlement to service connection for chronic fatigue syndrome. 8. Entitlement to service connection for fibromyalgia. 9. Entitlement to service connection for irritable bowel syndrome. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Hinton, Counsel INTRODUCTION The Veteran had active service from August 22, 1971 to December 19, 1971; from September 21, 2001 to August 18, 2002; and, from June 13, 2005 to August 23, 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a December 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In March 2013 the Veteran submitted a notice of disagreement as to a February 2013 rating decision denial of service connection for chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome. These issues have been added to the appeal. See Manlincon v. West, 12 Vet. App. 238 (1999). The issues of entitlement to service connection for diabetes mellitus, shortness of breath, sleep apnea, memory loss, chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome are addressed in the REMAND portion of the decision below and are REMANDED to the agency of original jurisdiction (AOJ). FINDINGS OF FACT 1. Resolving reasonable doubt in his favor, the Veteran has rhinitis related to active service. 2. From January 11, 2010, the Veteran's GERD has been manifested by nausea, diarrhea, indigestion, heartburn, and associated loose stools and diarrhea that is productive of considerable impairment of health but not severe impairment of health. CONCLUSIONS OF LAW 1. The criteria for service connection for rhinitis have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2014). 2. The criteria for an initial 30 percent disability rating for GERD, but not higher, have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.20, 4.113, 4.114 including Diagnostic Codes 7319, 7346 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to provide notice of the information and evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2014). Regarding the initial rating claim, standard letters sent to the Veteran between January and October 2010 satisfied the duty to notify provisions. VA also has a duty to provide assistance to substantiate a claim. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c). The Veteran's service treatment and personnel records have been obtained. Post-service VA and private treatment records have also been obtained. The Veteran was provided VA medical examination for his claimed GERD in April 2010. The examination is sufficient evidence for deciding the claim. The report is adequate as it is consistent with and based upon consideration of the Veteran's prior medical history, describes the claimed symptomatology in sufficient detail so that the Board's evaluation is a fully informed one, and contains reasoned explanations. Thus, VA's duty to assist has been met. II. Service Connection for Upper Respiratory Disorder Legal Criteria In general, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2014). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). 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 after discharge is required if the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). A necessary element to establish entitlement to service connection is the existence of a current disability. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). The requirements of a current disability may be met by evidence of symptomatology at the time of filing or at any point during the pendency of the claim, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321-323 (2007). Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than not later than December 31, 2016. See 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi- symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A 1117(d) warrants a presumption of service connection. A medically unexplained chronic multisymptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (including irritable bowel syndrome). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay evidence can be competent and sufficient evidence of a diagnosis or used to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event; or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Evidence and Analysis The Veteran claims entitlement to service connection for an upper respiratory disorder on the basis of injury or disease incurred during his period of active service from June to August 2005, while stationed at Joint Base Balad in Iraq. In the Veteran's January 2010 application for benefits he reported that he began having breathing problems in June 2005, which were treated ever since then. In this regard, he further stated that he started having nasal congestion along with other problems including shortness of breath, sore throat, burning eyes, headaches, and diarrhea almost immediately on arrival in Iraq in 2005. In his June 2011 notice of disagreement, the Veteran stated that before his 2005 deployment he only had normal colds, but that on arrival to Iraq he started having severe problems that the medical personnel and he felt was due to local burn pits. He stated that the problem continued through the deployment and that his breathing problems continued to the present and were becoming worse, with shortness of breath, gasping for air and sinus blockage at night. In his February 2014 Substantive Appeal the Veteran stated that it was his belief that his breathing problems were all connected to the "Gulf War Burn Pits" since all of his problems started while he was in Iraq. He stated that the symptoms continued, and were discovered on his return. He reported that he continues to have severe sleep apnea, shortness of breath, burning of eyes, sore throat and nasal congestion. Private and service treatment records in the 1990s through April 2000 show treatment for various periodic complaints including short-term complaints of having a cold, fever, chills, nasal congestion or sinus congestion. These records include current assessments of upper respiratory infection or nasal congestion, and on one occasion in June 1993 an assessment of upper respiratory infection/early sinusitis. Service treatment records include reports of medical examination, history, and assessments, dated between 2000 and 2003, which show no findings or complaints of problems referable to sinusitis or rhinitis. In the June 2003 report of medical assessment, the Veteran made no report of any problems with sinusitis or rhinitis related symptoms. During a May 2005 pre-deployment health assessment, the Veteran reported that his health in general was good, and that he did not have any medical problems. The examiner concluded that no referral for any special assessment was indicated and that the Veteran was deployable. Service personnel records show that in June 2005, the Veteran was to be deployed to Balad Air Base on June 15, 2005 for 50 days. Service treatment records show that the Veteran was seen at Balad Air Base on June 18, 2005 with complaints of congestion. On examination the provider noted symptoms of congestion but normal chest; and diagnosed allergic rhinitis not otherwise specified (NOS). The Veteran was seen again on June 28, 2005 for complaints of congestion for two weeks; congestion and sinus pressure since arriving. The report noted symptoms of congestion; nonproductive cough; sinus discomfort and fullness; and yellow sputum. The provider diagnosed acute sinusitis, and prescribed Ciprofloxacin. An associated medical record generally addressed environmental/occupational health workplace exposure data and risk assessment for the Balad Air Base, Iraq. The report noted such factors including that associated with trash burning at Balad Air Base and other sources of airborne dust and emissions from petroleum production/other nearby industrial/disposal activities. The record described expected exposures to personnel, including pollutant chemical hazards produced during the burning process, including dioxins. During a July 2005 post-deployment health assessment, the Veteran reported that he had been at the Balad Air Base in Iraq and his combat specialty was Airfield Management. The Veteran reported that he had had a runny nose. He reported also that he did not have chronic cough or difficulty breathing. He reported that during deployment he was exposed to smoke from burning trash, and to sand or dust. He reported he had concerns regarding environmental exposure. The Veteran reported that while at Balad, he had been treated for sinus problems, drainage, and coughing, and was given Benadryl and Sudafed, and then Z-pack and Cipro. The examiner noted there had been treatment for sinusitis with two antibiotic courses; and that the Veteran still had some evening cough due to dust and smoke in the air. During an August 2006 post-deployment health assessment the Veteran reported a runny nose that he felt was related to his deployment. He also reported that he had had persistent major concerns regarding the health effects of his exposure to smoke from burning trash while on deployment to Iraq. He reported that he had minor concerns regarding physical symptoms and exposures, for which he was receiving care. Since 2006, VA and private medical records include findings of sinus drainage and rhinitis symptoms and diagnoses of rhinitis, including a private treatment note in January 2008 containing a diagnosis of allergic rhinitis. During an April 2010 VA examination the Veteran reported complaints of nasal congestion since 2005 when he was exposed to smoke in Southwest Asia. The report contains a review of systems noting there had been two episodes of sinusitis during the past 12 month period. The report contains a report of imaging of the paranasal sinuses concluding with an impression of unremarkable paranasal sinus series. The report does not directly address the presence of any upper respiratory disorder. During a June 2010 VA otolaryngology consultation the Veteran complained of gustatory rhinorrhea. Examination of the nose showed the Veteran to have very large inferior turbinates. The report concluded with a diagnosis of gustatory rhinitis, to be treated with Atrovent nasal inhaler. On review of the evidence above the Board finds that the criteria for service connection for an upper respiratory disorder of chronic rhinitis have been met. Although the record includes evidence both in favor of and against the Veteran's claim, the evidence in his favor is more persuasive and probative. In a statement received in April 2010, the Veteran reported that while on active duty in 2005 at Balad Air Base, Iraq, he was exposed to contaminants from the burn pit and from pesticides used there. The Veteran referenced a December 20, 2006 memorandum on file on the subject of burn pit health hazards, by the Bioenvironmental Engineering Flight Commander, at Balad Air Base, Iraq; the cited memorandum noted that the burn pit at Balad Air Base had been identified as a health concern due to exposure to the smoke resulting from open burning of solid wastes identified therein. The author opined that there was an acute health hazard for individuals and the possibility for chronic health hazards associated with the smoke exposure. The medical evidence on file shows that during his period of active service in 2005, soon after arriving at the Balad Air Base in Iraq the Veteran developed upper respiratory symptoms. Service treatment providers at that time diagnosed rhinitis and a July 2005 post-deployment health assessment linked the upper respiratory symptoms to the dust and smoke the Veteran was exposed to during the 2005 deployment. The Veteran is competent to report the upper respiratory symptoms first experienced in service, and to report the continuity of those symptoms since service, which have been diagnosed as rhinitis during the appeal period. On that basis, and after resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence overall establishes the etiological relationship of the Veteran's chronic rhinitis to his period of active service in 2005. See 38 C.F.R. § 3.310. III. Initial Disability Rating for GERD Legal Criteria Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155. Evaluations of a service-connected disability require review of the entire medical history regarding the disability. 38 C.F.R. §§ 4.1, 4.2. If there is a question that arises as to which evaluation to apply, the higher evaluation is for application if the disability more closely approximates the criteria for that rating; otherwise, the lower rating is for assignment. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). However, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14; Fanning v. Brown, 4 Vet. App. 225 (1993). When a disability is not specifically listed in the Rating Schedule, it may be rated under a closely related injury in which the functions affected and the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2014). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran is competent to report complaints regarding symptoms capable of lay observation. 38 C.F.R. § 3.159(a)(2). However, these statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002). 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. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2015). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). The Veteran's service-connected GERD is evaluated under provisions of the rating schedule pertaining to the digestive system. For purposes of evaluating digestive system conditions under C.F.R. § 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer; and the term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. The term "inability to gain weight" means that there has been substantial weight loss with inability to regain it despite appropriate therapy. "Baseline weight" means the average weight for the two-year-period preceding onset of the disease. C.F.R. § 4.112. There are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in C.F.R. §4.14. During the appeal period, the Veteran's service-connected GERD is evaluated as 10 percent disabling during the appeal period since January 11, 2010, pursuant to hyphenated Diagnostic Code 8873-7346. Diagnostic Code 8873 is used for tracking purposes when rating an undiagnosed illness for a Persian Gulf War veteran by analogy to one of the gastrointestinal diseases found in VA's Rating Schedule. Ratings under C.F.R. § 4.114, Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. The Veteran's GERD is evaluated as analogous to hiatal hernia under 38 C.F.R. § 4.114, Diagnostic Code 7346. GERD, or gastroesophageal reflux disease, is a condition noted clinically or histopathologically that results from gastro-esophageal reflux (flowing back of stomach content from the stomach to the esophagus), with principal characteristics of heartburn and regurgitation, which can result in damage to the esophageal epithelium (reflux esophagitis). See Dorland's Illustrated Medical Dictionary 533, 764 (32nd ed. 2012). Pursuant to Diagnostic Code 7346, a 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, Diagnostic Code 7346 (2014). A 30 percent rating is warranted for persistent recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Id. A 10 percent rating is warranted if with two or more of the symptoms for the 30 percent evaluation of less severity. Id. In analyzing the evidence, the Board will consider whether any other diagnostic code is more appropriate to use in rating the Veteran's disability. Given the evidence on file regarding associated diarrhea or loose stools, consideration by analogy to criteria under Diagnostic Code 7319 is an appropriate alternative with the objective of providing the maximum rating warranted. Under 38 C.F.R. § 4.114, Diagnostic Code 7319 irritable colon syndrome (spastic colitis, mucous colitis, etc.) is evaluated as 30 percent for severe symptoms; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. A 10 percent evaluation is warranted for moderate symptoms; frequent episodes of bowel disturbance with abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. Evidence and Analysis The Veteran was afforded a Gulf War Guidelines examination in April 2010. The Veteran reported that his GERD began in 1976 and had been stable since onset. The response to current medications (Omeprazole) was good with no side effects. On review of the abdomen/gastrointestinal system, the report records a history of nausea, diarrhea, indigestion, and heartburn (pyrosis). There was no history of vomiting, constipation, hemorrhoids, hernia, abdominal mass, abdominal swelling, regurgitation, jaundice, fecal incontinence, post-prandial symptoms after ulcer surgery, dysphagia, hematemesis, melena, pancreatitis, gallbladder attacks, or abdominal pains. On review of systems involving the mouth and throat, the report records that symptoms consisted of swallowing difficulty. The report contains a diagnosis of GERD. The examiner concluded that the symptoms associated with this diagnosis were loose stools, which had effects on the Veteran's usual occupation (farmer), and resulted in work problems requiring assignment to different duties. The effects included lack of stamina, and weakness or fatigue; and the Veteran reported that the effects keep him close to the bathroom. The examination report also contains a diagnosis of diarrhea, which the examiner associated with loose stools. The examiner found that there were no abnormal physical findings associated with the diagnosis. The examiner also found that the diagnosis resulted in occupational and usual daily activity effects of decreased mobility. On review of the evidence, the Board notes at the outset that the April 2010 VA examination report does not show that the Veteran's GERD is productive of persistent recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. The examination specifically found no regurgitation or dysphagia. The findings also do not show substernal or arm or shoulder pain or suggest that the Veteran's GERD symptoms are productive of considerable impairment of health. The examiner determined that the symptoms associated with the Veteran's GERD were loose stools, which the examiner also associated with a diagnosis of diarrhea. While such symptoms are not contemplated under Diagnostic Code 7346 for hiatal hernia, an evaluation is feasible under diagnostic criteria as analogous to irritable colon syndrome. See 38 C.F.R. § 4.114, Diagnostic Code 7319. The symptoms of the Veteran's loose stools/diarrhea associated with his GERD have been described as intermittent with remissions, and the Veteran has reported that he was not under treatment specifically for diarrhea. The evidence of this aspect of the Veteran's GERD also shows that it has resulted in occupational and usual daily activity effects of a decreased mobility due to the requirement to be close to a restroom. The evidence clearly does not show that the loose stools or diarrhea associated with the GERD is productive of severe symptoms, with more or less constant abdominal distress, given that the evidence reflects that the loose stools have been intermittent with remissions, and the Veteran was not under treatment specifically for any diarrhea. On that basis a rating higher than 10 percent is not warranted under 38 C.F.R. § 4.114, Diagnostic Code 7319 for loose stools or diarrhea symptoms associated with the service-connected GERD. However, on consideration of the overall disability resulting from the Veteran's GERD including nausea, diarrhea, indigestion, heartburn, and associated loose stools and diarrhea, productive of considerable impairment of health, the overall disability of the GERD warrants elevation to the next higher evaluation under Diagnostic Code 7319-7346. Therefore, based on the foregoing, an initial schedular disability rate of 30 percent is warranted for the Veteran's service-connected GERD. The Board has considered whether an initial rating higher than 30 percent may be warranted, but finds the evidence does not show the overall disability due to GERD to be productive of severe impairment of health so as to meet criteria under Diagnostic Code 7346 for a 60 percent rating. The Board has also considered whether a rating higher than 30 percent may be assignable under an alternative diagnostic code, but review of all other digestive system diagnostic code criteria relevant to the esophagus and stomach part, in relation to the clinical evidence on file, shows no other relevant conditions or symptoms associated with the service-connected GERD that would warrant a higher or separate schedular rating. See 38 C.F.R. § 4.114, Diagnostic Codes 7203-7310, 7321-7330. In sum, for the entire period since the effective date of service connection on January 11, 2010, a schedular disability rating of 30 percent but no higher is warranted under 38 C.F.R. § 4.114, Diagnostic Code 7346. The preponderance of the evidence is against the grant of any higher initial disability rating for GERD, for any period since January 11, 2010; there is no doubt to be resolved; and a higher initial disability rating is not warranted at any time during the appeal period. Other Considerations Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for a rating. Consideration has been given regarding whether the schedular rating is inadequate for the service-connected GERD, requiring that the RO refer a claim to the Chief Benefits Director or the Director of the Compensation Service for consideration of extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2014). First, a determination must be made as to whether the schedular criteria reasonably describe the severity and symptoms of the claimant's disability. If the schedular rating criteria reasonably describe the severity and symptoms of the claimant's disability, referral for extraschedular consideration is not required and the analysis stops. Second, if the schedular rating criteria do not reasonably describe a veteran's level of disability and symptomatology, a determination must be made as to whether an exceptional disability picture includes other "related factors," such as marked interference with employment and frequent periods of hospitalization. If an exceptional disability picture including such factors as marked interference with employment and frequent periods of hospitalization exists, the matter must be referred to the Under Secretary for Benefits or the Director of the Compensation Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element is not satisfied. The Veteran's service-connected digestive system disorder is manifested by signs and symptoms such as nausea, diarrhea, indigestion, and heartburn, along with the associated loose stools and diarrhea. These signs and symptoms, and their resulting impairment, are explicitly contemplated by the rating schedule under 38 C.F.R. § 4.114, Diagnostic Codes 7319, 7346. In short, there is nothing exceptional or unusual about the Veteran's digestive system disorder. Accordingly, referral for extraschedular consideration is not required and the analysis stops under Thun. A total disability rating based on individual unemployability (TDIU) is a part of a claim for a higher initial rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim 'identify the benefit sought' has been satisfied and VA must consider whether the veteran is entitled to a TDIU. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The April 2010 VA examination report shows that the Veteran was currently self-employed as a farmer with current employment of two-to-five years duration. During a more recent VA examination in August 2012, the report records that the Veteran was still currently working on his farm. There is no indication that the Veteran is not currently working in that role. The Veteran has made no explicit claim that he is unemployable due to his service-connected GERD. The record does not show that the Veteran is unable to secure or follow a substantially gainful occupation as a result of the GERD. As such, the Board finds that a claim for TDIU is not raised by the record. ORDER Service connection for rhinitis is granted. A disability rating of 30 percent for gastroesophageal reflux disease since January 11, 2010 is granted, subject to the statutes and regulations governing the payment of monetary awards. REMAND The Veteran has claimed entitlement to service connection for diabetes mellitus, sleep apnea, and shortness of breath. He also claims service connection for memory loss to include as related to the sleep apnea. One of the Veteran's theories of entitlement is that the disorders were caused by his exposure to smoke from a burn pit in Balad Air Base during his active service in 2005. He maintains that associated symptoms began following that period of active service. As explained by a Bioenvironmental Engineering Flight Commander in a December 2006 risk assessment memorandum pertaining to the burn pits at Balad Air Base, Iraq, the smoke hazards were associated with burning: plastics, Styrofoam, paper, wood, rubber, POL (petroleum, oil, lubricants) products, non-medical waste, some metals, some chemicals (paints, solvents, etcetera) and incomplete combustion products. The author of the memorandum noted that the solid wastes burned contain materials that can create hazardous compounds, and noted that a list of possible contaminants included: acetaldehyde, acrolein, arsenic, benzene, carbon dioxide, carbon monoxide, dichlorofluoromethane, ethylbenzene, formaldehyde, hydrogen cyanide, hydrogen chloride, hydrogen fluoride, various metals, nitrogen dioxide, phosgene, sulfuric acid, sulfur dioxide. The author noted that many of these chemical compounds had been found during past air sampling. The author opined that there was an acute health hazard and the possibility for chronic disorder health hazards associated with the smoke. In addition, given the nature of the Veteran's active service in 2005 in Southwest Asia, provisions of specific legislation enacted to assist veterans of the Persian Gulf War, are applicable regarding symptoms of any undiagnosed illnesses. Under the provisions of specific legislation enacted to assist veterans of the Persian Gulf War, service connection may be established for a qualifying chronic disability which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1)(i). The report of the April 2010 VA examination conducted in connection with the claims on appeal did not provide an opinion with respect to whether the etiology of any diabetes mellitus, disability associated with shortness of breath, or sleep apnea, may be related to his period of active service in 2015, to specifically include exposure to smoke from the burn pits at Balad Air Base, Iraq. The Veteran has been diagnosed with diabetes mellitus; and with complex sleep apnea, including both obstructive sleep apnea and central sleep apnea. It is not clear as to whether there is a diagnosis associated with the Veteran's claimed shortness of breath, but the Veteran is competent to report the onset and continuity of symptoms. In his application for benefits claiming service connection for memory loss the Veteran asserted that his memory loss is due to sleep apnea or medication. Thus, the claims for service connection for memory loss and for sleep apnea are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App 180, 183 (1991) (two issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue); Parker v. Brown, 7 Vet. App. 116, 118 (1994). In a February 2013 rating decision, the RO denied service connection for chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome. In a statement received in March 2013, the Veteran expressed his disagreement as to all three denials. Because the RO has not yet issued a statement of the case on these claims, remand is required. See Manlincon v. West, 12 Vet. App. 238 (1999). Additionally, any outstanding treatment records relevant to these four claims should be obtained on remand. Accordingly, the case is REMANDED for the following action: 1. Obtain pertinent outstanding VA and private medical records of treatment of the Veteran for the claimed diabetes mellitus, shortness of breath, sleep apnea, and memory loss. 2. Thereafter, the Veteran should be afforded VA examinations to determine the nature and etiology of any diabetes mellitus, sleep apnea, and shortness of breath conditions that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records and the December 2006 Memorandum pertaining to burn pits at Balad Air Base. The examiner should identify all current diabetes mellitus, sleep apnea, and shortness of breath disorders. For each diagnosis identified, the examiner should state whether it is at least as likely as not (a 50 percent or greater probability) that the current disorder is causally or etiologically related to any in-service symptomatology or is otherwise related to service, to specifically include exposure to smoke from the burn pits at the Balad Air Base in Iraq. If the Veteran has symptomatology that is not attributable to a known clinical diagnosis, the examiner should opine whether it is at least as likely as not that such symptoms are due to an undiagnosed illness resulting from service in Southwest Asia during the Gulf War. 3. Then, readjudicate the appeal. If a benefit sought remains denied, the Veteran and his representative must be furnished a supplemental statement of the case and be given an opportunity to submit written or other argument in response before the claims file is returned to the Board for further appellate consideration. 4. Also, issue to the Veteran a statement of the case on his claims for entitlement to service connection for chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, so that he may have the opportunity to complete an appeal on these three issues by filing a timely substantive appeal. These issues should only be returned to the Board if a timely substantive appeal is filed. 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 2014). ______________________________________________ JOHN H. NILON Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs