Citation Nr: 1620563 Decision Date: 05/20/16 Archive Date: 05/27/16 DOCKET NO. 11-14 728 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for chronic fatigue syndrome. 2. Entitlement to service connection for joint pain with fibromyalgia. 3. Entitlement to service connection for chronic headaches. 4. Entitlement to service connection for a disorder manifested by difficulty breathing, including as the result of undiagnosed illness. 5. Entitlement to service connection for acid reflux, claimed as gastroesophageal reflux disease (GERD), including as the result of undiagnosed illness. 6. Entitlement to an increased rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with anxiety disorder. 7. Entitlement to an increased rating in excess of 10 percent for irritable bowel syndrome (IBS). 8. Entitlement to an increased rating in excess of 10 percent for residuals of a stress fracture of the left hip. 9. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Christopher Loiacano, Agent WITNESSES AT HEARING ON APPEAL Appellant (the Veteran) and T. P. ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty for training from November 1987 to May 1988 and on active duty from December 1990 to July 1991. This case comes to the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Winston-Salem, North Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA). In March 2016, a travel board hearing was held before the undersigned in Winston-Salem, North Carolina. A transcript of the hearing is associated with the Veteran's claims file. The issues of service connection for chronic fatigue syndrome, joint pain with fibromyalgia, chronic headaches, a disorder manifested by difficulty breathing, acid reflux claimed as GERD, and an increased rating for PTSD with anxiety are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. During the March 2016 Board hearing, prior to the promulgation of a decision in the appeal, the Veteran's representative indicated that the Veteran wished to withdraw his appeal seeking TDIU; there are no questions of fact or law remaining before the Board in this matter. 2. Throughout the Veteran's appeal, his IBS has been manifested by symptoms of diarrhea four to six times per day with fecal incontinence four to six times per month, which is productive of severe impairment. 3. Throughout the Veteran's appeal, the residuals of a left hip stress fracture were manifested by a normal gait; range of motion of flexion from 0 to 80 to 90 degrees, extension from 0 to 15 degrees, and abduction from 0 to 25 or 30 degrees; without indications of ankylosis. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a Substantive Appeal by the Veteran are met; the Board has no further jurisdiction in the matter of entitlement to TDIU. 38 U.S.C.A. §§ 7104, 7105(d)(5) (West 2014); 38 C.F.R. §§ 20.101, 20.202, 20.204 (2015). 2. The criteria for an increased rating of 30 percent for IBS have been met throughout the appeal. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.114, Diagnostic Code (Code) 7319 (2015). 3. The criteria for an increased rating in excess of 10 percent for residuals of a stress fracture of the left hip have not been met for any period. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Code 5019 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). Regarding the issue dismissed herein, the facts are not in dispute and resolution of the claim is wholly dependent on interpretation of the applicable laws and regulations. Accordingly, VA's duties to notify and assist are inapplicable. See Smith v. Gober, 14 Vet. App. 227, 231-32 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002), cert. denied, 537 U.S. 821 (2002). See also 38 C.F.R. § 3.159(b)(3)(ii) (VCAA notice not required when, as a matter of law, entitlement to the benefit claimed cannot be established); 38 C.F.R. § 3.159(d)(3) (VA will refrain from or discontinue assistance with regard to a claim requesting a benefit to which the claimant is not entitled as a matter of law). Regarding the issues of increased ratings decided herein, in a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim; namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to the initial adjudication of the claims. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). An August 2009 letter explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. The Veteran has had ample opportunity to respond or supplement the record. With regard to the duty to assist, the Veteran's service treatment records (STRs) have been secured or certified as being unavailable. Pertinent post-service treatment records have also been secured. The Veteran was afforded VA medical examinations, most recently in June 2013. The Board finds that the opinions obtained are adequate. The opinions were provided by qualified medical professionals and were predicated on a full reading of all available records. The examiners also provided a detailed rationale for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor the representative has challenged the adequacy of the examinations obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2015). Withdrawal of Issue The Board has jurisdiction where there is a question of law or fact on appeal to the Secretary. 38 U.S.C.A. § 7104; 38 C.F.R. § 20.101. Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. Except for appeals withdrawn on the record at a hearing, a Substantive Appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. During the Veteran's March 2016 Board hearing, his representative stated that the Veteran wished to withdraw his appeal regarding the issue of TDIU. Hence, there are no allegations of error of fact or law for appellate consideration on this claim. Accordingly, the Board does not have jurisdiction to consider the appeal in this matter, and it is dismissed. Increased Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2015). Where there is a question as to which of two evaluations shall be applied, the higher rating 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 (2010). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2015). The United States Court of Appeals for Veterans Claims (Court) has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Lay statements may support a claim for service connection by establishing the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), they are not competent to provide opinions on medical issues that fall outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d 1372. Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). IBS Service connection IBS was granted by the RO in a March 2007 rating decision. The 10 percent disability rating was awarded under the provisions of Code 7319 The Veteran claimed an increased rating in 2009. The Veteran contends that his service-connected IBS is more disabling than currently evaluated. During the Board hearing in March 2016, he testified that he did not wear an absorbent pad because to do so would cause him too much embarrassment. He stated that he did bring a change of clothes to work in case he had an accident. An examination was conducted by VA in December 2009. At that time, the Veteran described the onset of diarrhea in the military in 1991. The symptoms had persisted with urgency at times and fecal incontinence that occurred four to six times per month. He had started taking underwear to work, but was on no treatment. He did not have a history of nausea, vomiting or constipation, but of persistent diarrhea four to six times daily. There was no history of other symptoms. Examination showed that the Veteran stood 66 inches tall and weighed 183 pounds. He had not had any weight change and there was no sign of malnutrition or anemia and no abdominal tenderness. The diagnosis was IBS with intermittent fecal incontinence. An examination was conducted by VA in June 2013. At that time, the diagnosis was IBS. The Veteran stated that he started having trouble, including vomiting after eating, diarrhea, bloating, gas and occasional constipation that happened when his "nerves get bad." He had had testing for GERD and dysphagia symptoms that was reported as normal. He was on the medication Prilosec for control of his intestinal condition. He reported having diarrhea 90 percent of the time and constipation 10 percent of the time. He had abdominal distention, gas and bloating, about three to four times per week. He also had daily nausea after eating. He described frequent episodes of bowel disturbance with abdominal distress, but no weight loss or malnutrition. An EGD study was normal and X-ray studies showed no evidence of bowel obstruction. Functional impact included having to go to the bathroom all the time. He had to carry extra cloths as he would have accidents frequently. The examiner stated that there was no new evidence of increasing problems found in the Veteran's medical records. Diagnostic Code 7319 provides ratings for irritable colon syndrome (spastic colitis, mucous colitis, etc.). Mild irritable colon syndrome, with disturbances of bowel function with occasional episodes of abdominal distress, is rated noncompensably (0 percent) disabling. Moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress, is rated 10 percent disabling. Severe irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, is rated 30 percent disabling. 38 C.F.R. § 4.114. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the diagnostic code that reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Diagnostic Code 7332 provides ratings based on impairment of sphincter control. Healed or slight impairment of sphincter control, without leakage, is rated noncompensably (0 percent) disabling. Constant slight impairment of sphincter control, or occasional moderate leakage, is rated 10 percent disabling. Occasional involuntary bowel movements, necessitating wearing of pad, are rated 30 percent disabling. Extensive leakage and fairly frequent involuntary bowel movements are rated 60 percent disabling. Complete loss of sphincter control is rated 100 percent disabling. 38 C.F.R. § 4.114. Throughout the Veteran's appeal, his IBS has been manifested by symptoms of diarrhea four to six times per day with fecal incontinence four to six times per month. On examination and during testimony before the undersigned, he admitted that he kept a change of clothes with him at all times and did not use a pad only because of potential embarrassment. On examination in 2013, alternating diarrhea and constipation were noted. After review of the record the Board finds that the Veteran's disability is productive of severe impairment. As such, a rating of 30 percent is shown to be warranted. The Veteran has not shown signs of extensive leakage with fairly frequent involuntary bowel movements. As such, there is no basis upon which a 60 percent rating may be awarded. Residuals of a Left Hip Stress Fracture Service connection for residuals of a stress fracture of the left hip was granted by the RO in a May 2007 rating decision. The 10 percent disability rating was awarded as bursitis under the provisions of Code 5019. The diseases under Diagnostic Codes 5013 through 5024 include osteoporosis with joint manifestations (DC 5013), osteomalacia (DC 5014), benign new growths of bones (DC 5015), osteitis deformans (DC 5016), intermittent hydrarthrosis (DC 5018), bursitis (DC 5019), synovitis (DC 5020), myositis (DC 5021), periostitis (DC 5022), myositis ossificans (DC 5023), and tenosynovitis (DC 5024). The diseases under Diagnostic Codes 5013 through 5024 will be rated on limitation of motion of affected parts as degenerative arthritis (except gout, Diagnostic Code 5017, which will be rated under Diagnostic Code 5002). Although these disabilities are to be rated as degenerative arthritis (Diagnostic Code 5003), Note (2) to Diagnostic Code 5003 provides that the 20 percent and 10 percent ratings based on X-ray findings with no limitation of motion of the joint or joints will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. 38 C.F.R. § 4.71a. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Normal ranges of motion of the hip are from hip flexion from 0 degrees to 125 degrees, and hip abduction from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5250 provides for rating the hip on the basis of ankylosis. Favorable ankylosis of the hip in flexion at an angle between 20 degrees and 40 degrees and slight adduction or abduction is to be rated 60 percent disabling; intermediate ankylosis of the hip is to be rated 70 percent disabling; and extremely unfavorable ankylosis, with the foot not reaching ground, crutches necessitated, is to be rated 90 percent disabling and is entitled to special monthly compensation. 38 C.F.R. § 4.71a. Diagnostic Code 5251 provides a 10 percent disability rating for limitation of extension of the thigh that is limited to 5 degrees. 38 C.F.R. § 4.71a. Diagnostic Code 5252 provides ratings based on limitation of flexion of the thigh. A 10 percent disability rating is for flexion of the thigh that is limited to 45 degrees; a 20 percent rating is for flexion of the thigh that is limited to 30 degrees; a 30 percent rating is for flexion of the thigh that is limited to 20 degrees; and a 40 percent rating is for flexion of the thigh that is limited to 10 degrees. 38 C.F.R. § 4.71a. More generally, disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. In addition, the intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. This regulation also provides that the intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and that crepitation should be noted carefully as points of contact which are diseased. Thus, when assessing the severity of a musculoskeletal disability that, as here, is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The Court has also held that VA's regulations pertaining to whether a compensable rating is warranted for pain (as shown by adequate pathology and evidenced by the visible behavior in undertaking motion), 38 C.F.R. §§ 4.40 and 4.59, apply regardless of whether the painful motion is related to arthritis. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the function affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20 (2015). An examination was conducted by VA in December 2009. At that time, it was noted that the Veteran had sustained a fracture of the left hip during service. He stated that he had done well for a while, but then began having pain in the left hip that had been progressive. He now had pain and stiffness that had affected his life in that he had decreased his activities. The Veteran related that he had pain and stiffness, and that his hip felt tired. He related flare-ups of moderate severity on a weekly basis that lasted three to seven days. These were precipitated by increased strenuous activity, especially at work. Bending, squatting, and stooping aggravated his disability. Gait was normal. Range of motion of the left hip was flexion from 0 to 80 to 90 degrees, extension from 0 to 15 degrees, and abduction from 0 to 25 or 30 degrees. The Veteran could cross his left leg over the right. There was no objective evidence of pain following repetitive motion. X-ray studies were normal. The diagnosis was stress fracture of the left hip. An examination was conducted by VA in June 2013. The diagnosis was stress fracture of the left hip. The Veteran reported that he had flare-ups if he stood for a long period of time. He had pain in the hip that was aggravated by excessive walking and standing and alleviated by rest, pain medication and heat therapy. On examination, the examiner was unable to measure range of motion. It was reported that the Veteran would not relax or let his hip be examined. He was constantly keeping his left leg very stiff and inflexible. The Veteran did not walk with any limp or adverse gait, nor did he sit with any decrease in range of motion. He was able to perform strength testing without any problems. The Veteran did not have ankylosis of the left hip joint or malunion or nonunion of the femur. The examiner noted that a June 2012 private treatment record showed that the Veteran's left hip condition and pain were in good control. X-ray studies of the left hip showed no substantial residual deformity of the left hip or degenerative or traumatic arthritis. The examiner remarked that, although the Veteran did not cooperate with the range of motion examination, he did not elicit any problems with observed walking or sitting. The Veteran's left hip disability was shown, on examination in 2009, to cause some limitation of motion that is considered noncompensable under the schedular diagnostic codes for evaluation of hip disability. His disability has been rated as analogous to bursitis, which, in turn, is evaluated as degenerative or traumatic arthritis. Under the criteria for evaluation of arthritis, limitation of motion that is not compensable under the regular schedular codes is to be rated as 10 percent disabling. As such, the 10 percent rating that was continued was appropriate. On examination in 2013, however, range of motion could not be tested due to, in the examiner's opinion, noncooperation. While the Veteran essentially could not voluntarily move his leg for range of motion studies, no ankylosis or limitation of motion on strength testing was noted. Significantly, the private treatment records dated one year earlier showed the left hip disability to be controlled by medication. Under these circumstances, the Board finds that the June 2013 examination does not provide a basis upon which a rating in excess of 10 percent may be assigned. Extraschedular Considerations The Board also considered whether the Veteran's IBS and left hip fracture residuals warrant referral for extra-schedular consideration. In exceptional cases where schedular disability ratings are found to be inadequate, consideration of an extra-schedular disability rating is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular disability rating is appropriate. See Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. In this case, the evidence does not show that the Veteran's disability presents an exceptional disability picture, insofar as his symptoms are expressly contemplated by the rating schedule. With respect to the IBS, the applicable diagnostic code fully contemplates the Veteran's symptoms of diarrhea, constipation and fecal incontinence. He had no other IBS symptomatology that is not compensated elsewhere. Regarding the left hip fracture residuals, the noncompensable range of motion is specifically contemplated for evaluation of bursitis, which is rated as arthritis. While the Veteran had no range of motion on examination in 2013, the Board finds that this was due to noncooperation with the examiner. This finding is based on the specific opinion made by the examiner. Additionally, the Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual condition fails to capture all the service-connected disabilities experienced. In this case, even after applying the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional symptoms that have not been attributed to a specific service-connected condition. This includes the Veteran's service-connected PTSD, which is addressed in the remand portion of this decision. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Thus, referral for assignment of an extraschedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). Finally, the Veteran has withdrawn his appeal for TDIU. Consequently, this matter is not raised by the Veteran or the evidence of record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER The appeal for TDIU is dismissed. An increased rating of 30 percent for IBS is granted, subject to the controlling regulations governing the payment of monetary benefits. An increased rating in excess of 10 percent for residuals of a left hip fracture is denied. REMAND Regarding the issue of service connection for chronic fatigue syndrome, the Veteran testified at his hearing in March 2016 that he had recently received treatment for this disability at a private facility. These records should be associated with the claims folder prior to appellate consideration. Regarding the issue of service connection for fibromyalgia, the Veteran has not been afforded an examination by VA to ascertain the etiology of this disability. After considering the statements in the record, the Board finds that a medical examination is warranted. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (Setting forth the criteria under which VA is required to obtain an examination.) Regarding the issue of service connection for headaches, the Board notes that, while the Veteran was afforded an examination that diagnosed this disability in September 2005, no opinion regarding the etiology was rendered. It is noted that the Veteran testified at the March 2016 hearing that he had headaches during service and in the years after his discharge from active duty. After considering the statements in the record, the Board finds that a medical examination is warranted. Id. Regarding the issue of service connection for a disability manifested by difficulty breathing, it is noted that, while the Veteran was examined for a respiratory disorder in 2015, this evaluation was for sleep apnea and no other respiratory disorder was diagnosed. VA outpatient treatment records show that the Veteran was assessed as having bronchitis, by history, for which he was prescribed medication. No affirmative diagnosis of a chronic respiratory disorder has been made. The Veteran has not been afforded an examination to ascertain whether he has a chronic respiratory disorder as a result of undiagnosed illness. After considering the statements in the record, the Board finds that a medical examination is warranted. Id. Regarding the issue of service connection for acid reflux, claimed as GERD, it is noted that VA examinations have not included a diagnosis of GERD, but only IBS. While the Veteran was afforded an examination in July 2015 that included an opinion that the Veteran's acid reflux was not related to his IBS, there is no opinion regarding whether his symptoms could be related to the complaints of epigastric pain noted on redeployment examination while the Veteran was on active duty in 1991. After considering the statements in the record, the Board finds that a medical examination is warranted. Id. Regarding the issue of the evaluation of the Veteran's PTSD, the Board notes that the Veteran was hospitalized in August 2013 for his psychiatric disease. He has not been afforded a compensation examination subsequent to this period of hospitalization. In order to ascertain his current symptoms, the Board finds that an additional examination is warranted. Accordingly, the case is REMANDED for the following action: 1. The AOJ should contact the Veteran and request that he provide a list of providers from whom he has received treatment for his claimed disabilities. After obtaining any necessary consent, the AOJ should contact the private medical care providers and request copies, for association with the claims folder, of any and all records of treatment that the Veteran recently received. Similarly, any records of VA treatment should also be obtained. 2. The AOJ should arrange for the Veteran to undergo a medical examination to ascertain the current nature and etiology of any CFS, fibromyalgia, headaches, a disorder manifested by difficulty breathing, and acid reflux. The examiner should be requested to render an opinion regarding whether it is at least as likely as not (probability 50 percent or more) that any of these disorders is related to service or the result of undiagnosed illness that may be presumed to be the result of the Veteran's service in the Persian Gulf. The claims folder should be made available for review in connection with these examinations. The examiners should provide complete rationale for all conclusions reached. 3. The Veteran should be afforded a VA mental disorders examination for the purpose of ascertaining the severity of his service-connected PTSD with anxiety disorder. All necessary special studies or tests are to be accomplished. The claims files should be made available to the examiner for review in connection with the examination. For any psychiatric disorder other than PTSD with anxiety disorder that is identified, the examiner should state what, if any, additional disability is associated with the disability. All opinions should be supported by a written rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. Thereafter, the AOJ should readjudicate the issues on appeal. If the determination remains unfavorable to the Veteran, he and his representative should be provided with a supplemental statement of the case (SSOC) that addresses all relevant actions taken on the claims for benefits, to include a summary of the evidence and applicable law and regulations considered. They should be given an opportunity to respond to the SSOC prior to returning the case to the Board for further review. 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). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2015). 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). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs