Citation Nr: 1603301 Decision Date: 02/02/16 Archive Date: 02/11/16 DOCKET NO. 10-04 387 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a reproductive condition. 2. Entitlement to service connection for reaction to flu vaccine. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression. 4. Entitlement to service connection for gastroesophageal reflux disorder (GERD). 5. Entitlement to service connection for a back and neck injury. 6. Entitlement to service connection for fatigue, to include as secondary to an acquired psychiatric disorder. 7. Entitlement to service connection for chest pain, to include as secondary to an acquired psychiatric disorder. 8. Entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disorder. 9. Entitlement to a total rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Charles Binder, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD B. Muetzel, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1977 to October 1978. These matters come on appeal before the Board of Veterans' Appeals (Board) from a September 2008 and a May 2010 rating decision, both of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The September 2008 rating decision denied the Veteran's claims of entitlement to service connection for a reproductive condition, reaction to the flu vaccine, PTSD, depression, GERD, a back and neck injury, fatigue, chest pain, and hypertension. The Veteran filed a Notice of Disagreement in June 2009 and the RO issued a Statement of the Case in November 2009. The Veteran filed a timely Substantive Appeal in January 2010 and the RO issued Supplemental Statements of the Case in June 2010 and August 2014. The May 2010 rating decision denied the Veteran's claim of entitlement to a TDIU. The Veteran filed a Notice of Disagreement in January 2011 and the RO issued a Statement of the Case in August 2011. The Veteran filed a timely VA Form 9, Substantive Appeal in November 2011. The Veteran's claims for psychiatric conditions on appeal have been characterized as a claim of service connection for PTSD and service connection for depression. The Board notes that the United States Court of Appeals for Veterans Claims (Court) held that when a claimant identifies an acquired psychiatric disorder without more, the claim may not be limited to that diagnosis, but rather must be considered a claim for any mental disability that may reasonably be encompassed by several factors including the claimant's description of the claim, the symptoms the claimant describes, and the information the claimant submits or that VA obtains in support of the claim. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (finding that the claimant did not file a claim to receive benefits only for a particular diagnosis, but for the affliction or symptoms that his mental condition, whatever it is, causes him). Treatment records indicate that the Veteran has been diagnosed with depression, anxiety disorder, and PTSD. Accordingly, the Veteran's claim is not limited solely to PTSD or depression; rather, the claim is properly characterized broadly as a claim of service connection for an acquired psychiatric disorder, to include PTSD and depression. A travel Board hearing was held at the RO in June 2015 before the undersigned Veterans Law Judge and a copy of the hearing transcript has been added to the record. The current claim has been processed through the Veterans Benefits Management System (VBMS). As such, any further consideration of this Veteran's case should take into consideration the existence of these electronic records. The issues of entitlement to service connection for GERD, a neck and back injury, fatigue, chest pain, and hypertension as well as entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. There is no probative evidence that the Veteran has a current reproductive condition that manifested during, or as a result of, active military service. 2. There is no probative evidence that the Veteran has current residuals from a reaction from a flu vaccine that manifested during, or as a result of, active military service. 3. There is probative evidence diagnosing depression, anxiety, and PTSD, credible supporting evidence that the claimed in-service stressor occurred, and a link, established by probative evidence, between current symptoms and an in-service stressor. CONCLUSIONS OF LAW 1. The criteria establishing entitlement to service connection for a reproductive condition are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2015). 2. The criteria establishing entitlement to service connection for reaction to a flu vaccine are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2015). 3. The criteria for entitlement to service connection for depression, anxiety, and PTSD have been met. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.304(f)(5) (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2015). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). The Veteran was provided notice in letters dated in June 2007 and April 2010, which addressed what information and evidence is needed to substantiate her claim for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. These letters also informed the Veteran of what information and evidence must be submitted by the appellant and what information and evidence would be obtained by VA. The letters also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations. The letters were sent to the Veteran prior to the adjudication of the issue on appeal, and thus, it met the VCAA's timing of notice requirement. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent evidence associated with the claims file consists of service treatment records, VA and private treatment records, reports of VA examination, and the statements from the Veteran, her family, and her representative. The Board notes that the Veteran has not been provided a VA examination for her claim of entitlement to service connection for a reproductive disorder and a reaction to a flu vaccine reaction. However, a VA examination is not needed in every case. In McLendon v. Nicholson the Court held that the Secretary must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A (d)(2), 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. Id. at 83. In this case, there is no credible evidence of symptoms of a disability that have been present ever since service associated with a reaction to a flu vaccine. Statements from the Veteran show that she is speculating on the existence of a disability and a nexus to service. Also, the Veteran's generalized, conclusory statements that she has a reproductive disorder or residuals from a flu vaccine related to service do not meet the requirement that the disability may be associated with the Veteran's service or low threshold of an "indication" that a claimed disability is due to an in-service event. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (rejecting the theory that medical examinations are to be routinely and virtually automatically provided to all veterans in disability cases involving nexus issues). The Veteran has been repeatedly advised that she should submit any documentation in support of her claim, but she has not done so. Thus, the duty to obtain a VA examination and opinion is not triggered. Further, as noted above, the Veteran has been medically evaluated in conjunction with her claim of service connection for an acquired psychiatric disorder in March 2012 and an addendum opinion was provided in August 2012. The Board notes that the VA examiners correctly recited the Veteran's pertinent medical history and examined the Veteran's disability. It is thus clear that the examiners had the information required to properly consider the relevant inquiries. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As is discussed below, the March 2012 medical opinion is considered adequate for adjudication purposes as it was based on consideration of the Veteran's medical history and describes the relevant disability in sufficient detail to enable the Board to reach a fully informed decision, and is supported by a rationale. See Floyd v. Brown, 9 Vet. App. 88, 93 (1996); Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate this claim, the avenues through which she might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 539, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. 1110, 1131 (West 2014); 38 C.F.R. 3.303(a) (2015). In order to establish service connection, a veteran must show: (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 in or aggravated during service (i.e., the nexus requirement). See, Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). In addition, service connection may also be established 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). In addition to the elements of direct service connection, service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); Wallin v. West, 11 Vet. App. 509, 512 (1998). When considering evidence supporting a service-connection claim, the Board must consider, on a case-by-case basis, the competence and sufficiency of lay evidence offered to support a finding of service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (reiterating that "'[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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.'") (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 Fed. Cir. 2007)). Reproductive condition and reaction to flu vaccine The Veteran is seeking service connection for a reproductive disorder on the basis that she developed the condition as a result of her military service. The Veteran also seeks service connection for a reaction to a flu vaccine. The Veteran's service treatment records are silent for complaints, diagnoses, or treatment for any problems related to her reproductive system. The Veteran's service treatment records are also absent any complaints, diagnoses, or treatment for any reaction related to a flu vaccine. After the RO denied her claims for both issues in September 2008, the Veteran filed a timely Notice of Disagreement, but she did not provide any additional information regarding her claim for either condition. The Board notes that the Veteran's VA treatment records indicate that in December 2009, the Veteran reported complaints that she was having a reaction to a N1H1 vaccine. During her June 2015 hearing, the Veteran indicated that she did not recall seeking service connection for a reproductive condition. She did not advance any argument in support of her claim. Regarding her claim for a reaction to a flu vaccine, the Veteran indicated that she was hospitalized in late 1977 or early 1978 for the reaction. In terms of symptoms, she indicated that they included fatigue. She did not put forth any additional arguments regarding any symptoms related to this claim. The Board notes that there is an indication in the Veteran's service treatment records that she was hospitalized in December 1977. However, the record makes no note of a flu vaccine or any other evidence that supports the Veteran's theory that she had an adverse reaction to a flu vaccine. The Board notes that the Veteran has maintained that she has a reproductive condition and a reaction from a flu vaccine related to service. As noted at the Board hearing, however, she did not recall seeking service connection for a reproductive condition. Thus, there is no persuasive probative evidence of a current disability, much less persuasive probative evidence of a current disability linked to service. Also, the mere fact of an in-service injury is not enough. Rather, there must be a chronic disability resulting from that injury. Here, there is no persuasive probative evidence of a current disability or symptoms of a current disability experienced ever since service associated with an adverse reaction to a flu vaccine manifesting during service. Moreover, while the Board recognizes that there are instances in which lay testimony can provide probative evidence in medical matters, such as describing symptoms observable to the naked eye, or even diagnosing simple conditions such as a broken bone, it is now well established that lay persons without medical training, such as the Veteran, are not competent to opine on matters requiring medical expertise, such as the diagnosis or etiology of either a reproductive condition or a reaction to a flu vaccine. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). As a lay person, the Veteran is not competent to offer testimony on a complex medical question such as linking a reproductive condition and reaction to a flu vaccine to service. Thus, the persuasive value of her lay contentions is low because the overall factual picture is complex. Based on the foregoing reasons and bases, the Board concludes that the preponderance of the evidence is against a finding that the Veteran has a reproductive condition or a reaction to a flu vaccine related to her military service. In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against this claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, entitlement to service connection for a reproductive condition and residuals from a flu vaccine is not warranted. Acquired psychiatric disorder The Veteran is seeking service connection for an acquired psychiatric disorder, to include PTSD and depression on the basis that she developed the condition as a result of military sexual trauma Generally, service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) (2015). If a PTSD claim is based on in-service personal assault, evidence from sources other than a veteran's service records may corroborate his account of the stressor incident. 38 C.F.R. § 3.304(f)(5) (2015). Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Id. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance, substance abuse, episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. Moreover, it is well established that if a PTSD claim is based on an in-service personal assault, medical opinion evidence may be submitted for use in determining whether the occurrence of a stressor is corroborated. Menegassi v. Shinseki, 638 F.3d 1379, 1382 (Fed. Cir. 2011). Specifically, 38 C.F.R. § 3.304(f)(5), allows Veterans claiming PTSD from an in-service military assault to submit evidence other than in-service medical records to corroborate the occurrence of a stressor, and this includes medical opinion evidence. Menegassi, 638 F.3d at 1382; see also 67 Fed. Reg. 10,330, 10,330-31 (Mar. 7, 2002). In this case, the Veteran seeks service connection for PTSD on the basis of an in-service sexual assault. Specifically, the Veteran claims that she experienced two military sexual assaults while on active duty. The Veteran did not report these incidents and she indicated during her March 2012 examination that she did not seek medical treatment. The Board notes that the Veteran's report of in-service sexual and physical assault falls within a category of situations in which it is not unusual for there to be an absence of service records documenting the events of which the Veteran complains. The Veteran was afforded a VA examination in conjunction with her claim in March 2012 and an addendum opinion was provided in August 2012. In March 2012, the examiner, after conducting a full examination and interview of the Veteran, diagnosed the Veteran with depression, anxiety, and PTSD. The examiner reviewed the claims file and the electronic medical records. The examiner noted the Veteran's medical history, including the medical diagnosis of PTSD. The examiner noted that the Veteran's fatigue, anhedonia, and social isolation and withdrawal are related to her diagnoses. The examiner found that the Veteran's symptoms cause occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, and/or mood. The Veteran reported that her stressors included an incident where her recruiter came to her house to make a "home visit" in 1977. She reported that he got her into the bathroom and "came on" to her. She reported that he had undressed her partially and that he was "exposed." She stated that "he tried to enter" her, but that she stopped him. She indicated that she never heard from the recruiter again. In addition, she reported that while she was in technical school at Chanute Air Force Base, she walked on base and was detained at a "guard shack" because the base was closed due to a blizzard. While at the guard shack, she stated an officer offered her a ride to the Red Cross on base. On the way, to the Red Cross, the officer stated he needed to stop at his home and get something. The Veteran stated the officer told her to come in. Once she was in the house, the officer offered her drink and had intercourse with her. She reported that she does not remember much after that. She indicated that she did not remember how she got back home. The examiner indicated that the stressors were sufficient to meet the criteria to support a diagnosis of PTSD. The examiner noted that the Veteran's symptoms include depressed mood, chronic sleep impairment, mild memory loss, flattened affect, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, neglect of personal appearance and hygiene. The examiner opined that the Veteran meets the diagnostic criteria for PTSD, due to sexual assault that occurred while in the military. The examiner noted that the Veteran endorsed avoidance, increased arousal, and persistent reexperiencing. Therefore, the examiner found that the Veteran's PTSD is at least as likely as not related to her military sexual trauma. In August 2012, an additional opinion was requested. At that time, the examiner reviewed the Veteran's claims and the March 2012 examination report that found that the Veteran had PTSD and met the criteria for PTSD. The examiner noted that the Veteran's teenaged son committed suicide, and indicated that this may have exacerbated her anxiety and depression. The examiner noted that the Veteran denied disciplinary incidents during her examination, but the examiner noted that the Veteran had approximately seven incidents where she was tardy or absent in reporting to her duty station. The examiner further noted that the Veteran's Staff Sergeant indicated that the Veteran was performing below Air Force Standards and that her Captain reported that she consistently performed below standards, had difficulty with on-the-job training, and had a below average attitude. The examiner conceded that this data may serve as behavioral markers of military sexual trauma, but opined that the Veteran's history affects her reliability. He noted that the Veteran was also abused by her mother, and opined that it is uncertain to what extent the abuse impacted her mental health. He further indicated that this prior abuse may have impacted the Veteran's reliability during her active duty service. The examiner thus opined that he could not resolve the issue of whether the Veteran's PTSD is related to her reported in-service military sexual trauma without mere speculation. The Veteran submitted a statement from a friend in June 2007 in support of her claim for depression. The statement indicated that the Veteran does not trust people, is depressed, often cries, is anxious, and is emotionally detached from people. In September 2014, the Veteran submitted buddy statements from two additional friends and from her mother, all of whom indicated that the Veteran underwent a change after her reported trauma. The Veteran's friends and family members indicated that the Veteran was happy and outgoing, but that since her discharge, she isolates herself, is depressed, and does not like to be with family and friends. During her June 2015 hearing, the Veteran reported her stressor involving the night where an officer picked her up from the guard shack. She further indicated that the officer, who was of a higher rank than she was, told her not to tell anyone because she would get into trouble. The Veteran testified that she wanted to undergo a polygraph test because what she reported was true. The Board places great probative value on the March 2012 VA mental health examination, which was conducted by a VA psychologist. The psychologist interviewed the Veteran and found her to be credible; she also opined that the Veteran's PTSD is linked to the in-service event, despite the Veteran's history of abuse and disciplinary problems in the military. Furthermore, VA treatment records and the Veteran's lay statements indicate that the Veteran has been in VA outpatient treatment for a number of years. Additionally, the Board notes that the Veteran's service treatment records indicate that, in March and April 1978, the Veteran made several requests for humanitarian reassignment. No reasoning for this request is provided in the notations, but it appears that the treating providers agreed to write recommendation letters in support of a reassignment. Generally speaking, a diagnosis of an acquired psychiatric disorder, to include depression and PTSD does not by itself corroborate the claimed stressor. See Patton. However, in the context of personal assault claims, the U.S. Court of Appeals for the Federal Circuit has specifically held that 38 C.F.R. § 3.304(f)(5) specifically contemplates medical opinions as probative evidence that may corroborate a past assault stressor. Menegassi v. Shinseki, 638 F.3d 1379 (2011). Therefore, the Board finds that the evidence of record, including the VA psychologist's opinion is sufficient to corroborate the Veteran's reported in-service military sexual trauma stressors. There is competent and credible positive medical opinion evidence from a VA psychologist that the Veteran's depression, anxiety, and PTSD is due to service. As such, the Board resolves all reasonable doubt in favor of the Veteran and finds that her acquired psychiatric disorder is the result of military sexual trauma. See 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2014); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Accordingly, service connection for an acquired psychiatric disorder is warranted. ORDER Entitlement to service connection for a reproductive condition is denied. Entitlement to service connection for a reaction to a flu vaccine is denied. Entitlement to service connection for depression, anxiety, and PTSD is granted. REMAND While further delay is regrettable, the Board observes that additional development is required prior to adjudicating the Veteran's claims of entitlement to service connection for GERD, a neck and back injury, fatigue, chest pain, hypertension, and entitlement to TDIU. GERD The Veteran is seeking service connection for GERD on the basis that she developed the condition while she was in active duty. The Veteran's service treatment records indicate that she had stomach problems while on active duty. In March 1978, the Veteran complained of vomiting and diarrhea that started the night before. She indicated that she thought she had eaten some tuna fish that was probably the cause of the illness. She was diagnosed with gastroenteritis and treated with Donnagel. In April 1978, the Veteran complained of stomach pain with nausea and vomiting. She also complained of diarrhea. She was given Mylanta as treatment and was doing well on a recheck. In May 1978, the Veteran reported abdominal pain in the left upper quadrant without radiation and some bloody stools; she was diagnosed with functional bowel syndrome. In June 1978, she was seen for diarrhea and was diagnosed at that time with urinary tract infection and was given Macrodantin and Peridium, and e-coli was present on a culture. In September 1978, another diagnosis of gastroenteritis was made. The Veteran was provided a VA examination in conjunction with her claim of service connection in August 2008. At that time, she reported that she has some bright red blood on tissue after a bowel movement but some of her medications cause constipation problems. She also reported some regurgitation of food; she told the examiner that she had begun eating very lightly at dinnertime with cereals or food with wheat. She reported some nausea in association with her headaches that she frequently experienced. She told the examiner that her current treatment for her stomach includes Omeprazole and the avoidance of fatty foods. She reported that the only trauma she had to the area was as a child, when someone hit her in the throat. The Veteran indicated that her stomach problem affects her occupational functioning but admitted that the medication controls her symptoms; she reported that she thinks that her stomach problems are now more related to her mental health medications than to the reflux. The examiner noted that the Veteran had not had an endoscopy or any GI evaluations performed. The Veteran complained of having a lot of gas in her abdomen and some bloating; she reported that she has abdominal pain about once per month. The examiner diagnosed the Veteran with gastroesophageal reflux, which he indicated was controlled with medication. The examiner indicated that there was no evidence to suggest an ulcer disease. The examiner opined that it is less likely than not that the Veteran's current stomach condition is related to the conditions noted during service. No rationale was provided. The Veteran also contends that she has continued to have the same problems with her stomach since service. During her June 2015 hearing, the Veteran reported that she has had trouble periodically over the years and that she has self-medicated with over-the-counter medication. She also noted that she was prescribed medications in service but that she did not recall what they were. She reported that she has had treatment from the Dallas VA Medical Center, beginning in approximately 2007. In Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007), the Court held that when VA provides a veteran with a medical examination, it must be adequate. In this case, the Veteran has consistently contended that her gastrointestinal problems are related to her period of service. Additionally, the evidence of record shows that she began seeking treatment for stomach issues in service and that she has a current diagnosis of GERD. However, the examiner did not provide a rationale to support his opinion that the Veteran's in-service stomach complaints are not related to his current GERD. Accordingly, the Board finds that the August 2008 VA examination is inadequate to this extent. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value to a medical opinion). A new examination should be provided, with consideration given to the in-service complaints related to the Veteran's stomach and digestive system as well as her lay statements that indicate she has had symptoms related to her stomach and digestive issues ever since service. Neck and back injury The Veteran seeks service connection for a neck and back injury on the basis that she developed the condition in service. The Veteran's service treatment records indicate that she complained of both neck and back pain in service; treatment notes dated in June 1978, September 1978, and October 1978 show that the Veteran sought treatment for these symptoms. At separation in October 1978, the Veteran reported in her report of medical history that she was prescribed medication for her back. The Veteran was afforded a VA examination in April 2008 and at that time, the examiner reviewed the claims file and noted the Veteran's history. The examiner indicated that the Veteran reported she hurt her neck playing Frisbee in 1978 at Altus Air Force Base in Oklahoma. She told the examiner that she also strained her low back by moving oil drip pans in the hanger under jet engines in 1978. Both of these conditions were treated conservatively, to include physical therapy, at that time. The Veteran denied any invasive treatment for her cervical or lumbar spine since. The Veteran reported chiropractic treatment for both conditions and indicated that she has had chronic, intermittent, mechanical neck and low back pain symptoms ever since these incidents. With regard to her cervical spine, the Veteran reported that, over the last 12 months, she had experienced daily mechanical neck pain in the occipital insertion of the left trapezius muscle that was six out of ten in severity. The Veteran stated that she has experienced similar flare up pain that was eight out of ten in severity approximately three or four times each month, each time lasting for about one or two days. Regarding her lumbar spine, the Veteran reported that she experiences daily low back pain that is seven out of ten in intensity. The Veteran reported similar flare ups with pain symptoms increasing to nine out of ten in severity, which is associated with weightbearing. This, she stated, lasts for about 15 or 20 minutes. The Veteran also reported left lower extremity paresthesias and dysesthias in "a vaguely L5 radicular pattern" after sitting. The Veteran denied any physician-prescribed bedrest in the last 12 months. After conducting a physical examination of the cervical spine and lumbar spine, as well as providing diagnostic testing, the examiner diagnosed the Veteran with cervical degenerative disc and joint disease of C5-C6 and lumbar degenerative joint disease, mild, with subcutaneous lipoma. The examiner provided the opinion that it is less likely than not that the Veteran's current cervical and lumbar spine conditions are related to her military service. By way of rationale, the examiner stated that the Veteran's separation report of medical history and physical examination, conducted in October 1978, revealed no complaints of recurrent back pain or any other musculoskeletal complaint and the examination was within normal limits. During her June 2015 Board hearing, the Veteran explained that she developed back and neck pain while in service due to her duties, which required her to carry heavy objects such as jet fuel. She indicated that her first problems with her neck or back occurred in service and that she has not had any intercurrent injuries. As noted, when VA provides an examination, it must be adequate. See Barr, 21 Vet. App. 303. The rationale provided by the examiner is not sufficient for the purpose of determining whether the Veteran's current cervical and lumbar spine conditions are related to service. See Nieves-Rodriguez, 22 Vet. App. 295. While the examiner noted that the Veteran's spine was normal on separation, he did not address the Veteran's in-service complaints of neck and back pain, or her contention that the symptomatology has continued to present. As such, a new examination should be provided, with consideration given to the in-service complaints of neck and back pain as well as her lay statements that indicate she has had symptoms ever since service. Fatigue, chest pain, hypertension The Veteran seeks service connection for fatigue, chest pain, and hypertension, to include as secondary to her acquired psychiatric disorder. During her June 2015 hearing, the Veteran reported that she began to have fatigue in service and indicated that she sought treatment for the symptoms in the 1990s. She also indicated that she is treated for it currently, and receives Vitamin D to help the symptoms. Finally, she testified that she believes the fatigue symptoms she currently experiences are associated with her depression and PTSD. With regard to her claim for chest pain, the Veteran reported that she believed this is also related to her PTSD and anxiety attacks. She reported being hospitalized in July 2014 due to chest pain symptoms. She indicated that she thought this condition may also be related to her hypertension. VA treatment records indicate that the Veteran has received treatment for "atypical" chest pain. The Veteran also testified about her hypertension at her June 2015 hearing. At that time, she indicated that she has panic attacks related to her acquired psychiatric disorder and that she believes her higher blood pressure is related to that. She stated that she has medication and keeps track of her blood pressure readings at home. VA treatment records indicate that the Veteran has a current diagnosis of hypertension. Given the above, in addition to the Board's grant of the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, a remand is required in order to determine whether any of the Veteran's claimed conditions are related to her service-connected acquired psychiatric disorder. TDIU In this case, the claim for a TDIU is inextricably intertwined with the Veteran's claims of service connection for GERD, a neck and back injury, fatigue, hypertension, and chest pain. This is so because any grant of service connection for a disability could affect the issue of whether the Veteran meets the requirements for a TDIU under 38 C.F.R. § 4.16(a) or, in the alternative, whether the Veteran is entitled to a TDIU on an extraschedular basis. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are inextricably intertwined when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Therefore, the appropriate remedy is to defer consideration of the TDIU claim. The Veteran reported receiving VA treatment in July 2014 at her June 2015 hearing. The Board notes that the most recent VA treatment records are dated from 2014. On remand the RO/AMC should ensure that any and all VA treatment records are associated with the file. 38 U.S.C.A. § 5103A(c) (West 2014); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Additionally, all ongoing private treatment records should be obtained and added to the claims file. See 38 U.S.C.A. § 5103A(a)(1), (b)(1), (c)(1) (West 2014). Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran for the appropriate release to obtain any outstanding private treatment records. With the Veteran's authorization, the RO/AMC should then obtain the Veteran's recent private treatment records. If no additional records are located, the Veteran must be notified and a written statement to that effect should be requested for incorporation into the record. The RO/AMC should also obtain any outstanding VA treatment records dated from July 2014. All efforts to obtain these records must be documented in the claims file. 2. After all records and/or response(s) from each contacted entity have been associated with the claims file, arrange for the Veteran to undergo a gastrointestinal examination. The claims file must be provided to and be reviewed by the examiner in conjunction with the examination. The examination should include any testing the examiner deems necessary. The examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that any gastrointestinal disability diagnosed during the pendency of the Veteran's appeal, is (A) etiologically related to any symptomatology noted in service, or (B) caused by OR aggravated by her acquired psychiatric disorder (medications). If aggravation by a service-connected disability is found, then the examiner should quantify the degree of such aggravation beyond the baseline of the disability. In formulating the above opinion, the examiner should consider (i) the in-service complaints related to her gastrointestinal and digestive systems, (ii) the in-service diagnosis of gastroenteritis, and (iii) the Veteran's lay assertions regarding chronic and continued symptomatology ever since service. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If it is not possible to provide the requested opinion without resort to speculation, the examiner should state why speculation would be required in this case (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc.). If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist's opinion, or other information needed to provide the requested opinion. 3. Arrange for the Veteran to undergo a VA spine examination regarding her claims for service connection for a cervical spine and a lumbar spine condition. The claims file must be provided to and be reviewed by the examiner in conjunction with the examination. The examination should include any testing the examiner deems necessary. The examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that any cervical spine and/or lumbar spine condition diagnosed during the pendency of the Veteran's appeal, is etiologically related to any symptomatology noted in service. In formulating the above opinion, the examiner should consider (i) the in-service complaints related to her neck and back, (ii) and the Veteran's lay assertions regarding chronic and continued symptomatology ever since service. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If it is not possible to provide the requested opinion without resort to speculation, the examiner should state why speculation would be required in this case (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc.). If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist's opinion, or other information needed to provide the requested opinion. 4. Schedule the Veteran for an appropriate VA examination to determine whether she suffers from a disability manifested by fatigue and to obtain an opinion as to whether her current complaints are related to service, or to her service-connected acquired psychiatric disorder. The claims file must be provided to and be reviewed by the examiner in conjunction with the examination. The examination should include any testing necessary to determine whether a diagnosed disability is present. After examining the Veteran and reviewing the claims file and test results, the examiner should respond to the following: (a) Can the Veteran's fatigue complaints be attributed to a known clinical diagnosis? If so, please provide the diagnosis. (b) The examiner should then indicate whether it is at least as likely as not (50 percent or greater probability) that the diagnosed disorder is related to the Veteran's active military service. (c) If the Veteran's fatigue disability is not caused by or related to service, the examiner should provide an opinion as to whether any current fatigue disability was caused by or related to the service-connected acquired psychiatric disorder. (d) If the Veteran's fatigue is not caused by or related to the service-connected acquired psychiatric disorder, the examiner should provide an opinion as to whether the Veteran's fatigue disability is aggravated (permanent worsening of the underlying disability beyond natural progress) by the service-connected acquired psychiatric disorder. If aggravation by a service-connected disability is found, then the examiner should quantify the degree of such aggravation beyond the baseline of the disability. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If it is not possible to provide the requested opinion without resort to speculation, the examiner should state why speculation would be required in this case (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc.). If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist's opinion, or other information needed to provide the requested opinion. 5. Schedule the Veteran for an appropriate VA examination to determine whether she suffers from a disability manifested by chest pain and to obtain an opinion as to whether her current complaints are related to service. The claims file must be provided to and be reviewed by the examiner in conjunction with the examination. The examination should include any testing necessary to determine whether a diagnosed disability is present. After examining the Veteran and reviewing the claims file and test results, the examiner should respond to the following: (a) Can the Veteran's chest pain complaints be attributed to a known clinical diagnosis? If so, please provide the diagnosis. (b) If so, the examiner should then indicate whether it is at least as likely as not (50 percent or greater probability) that the diagnosed chest pain disorder is related to the Veteran's active military service. (c) If the Veteran's chest pain is not caused by or related to service, the examiner should provide an opinion as to whether any current chest pain was caused by or related to the service-connected acquired psychiatric disorder. (d) If the Veteran's chest pain is not caused by or related to the service-connected acquired psychiatric disorder, the examiner should provide an opinion as to whether the Veteran's chest pain disability is aggravated (permanent worsening of the underlying disability beyond natural progress) by the service-connected acquired psychiatric disorder. If aggravation by a service-connected disability is found, then the examiner should quantify the degree of such aggravation beyond the baseline of the disability. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If it is not possible to provide the requested opinion without resort to speculation, the examiner should state why speculation would be required in this case (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc.). If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist's opinion, or other information needed to provide the requested opinion. 6. Schedule the Veteran for an appropriate VA examination to determine the etiology of her hypertension. The claims file must be provided to and be reviewed by the examiner in conjunction with the examination. The examination should include any testing necessary to determine whether a diagnosed disability is present. After examining the Veteran and reviewing the claims file and test results, the examiner should respond to the following: (a) The examiner should then indicate whether it is at least as likely as not (50 percent or greater probability) that the diagnosed hypertension is related to the Veteran's active military service. (b) If the Veteran's hypertension is not caused by or related to service, the examiner should provide an opinion as to whether hypertension was caused by or related to the service-connected acquired psychiatric disorder. (c) If the Veteran's hypertension is not caused by or related to the service-connected acquired psychiatric disorder, the examiner should provide an opinion as to whether the Veteran's hypertension is aggravated (permanent worsening of the underlying disability beyond natural progress) by the service-connected acquired psychiatric disorder. If aggravation by a service-connected disability is found, then the examiner should quantify the degree of such aggravation beyond the baseline of the disability. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If it is not possible to provide the requested opinion without resort to speculation, the examiner should state why speculation would be required in this case (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc.). If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist's opinion, or other information needed to provide the requested opinion. 7. Review all evidence received since the last prior adjudication and readjudicate the Veteran's claims of service connection and entitlement to TDIU. If the determination remains unfavorable to the Veteran, then the RO should issue a supplemental statement of the case. An appropriate period of time should be allowed for response by the Veteran and his representative. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. 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). (CONTINUED ON NEXT PAGE) 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). ______________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs