Citation Nr: 1647194 Decision Date: 12/19/16 Archive Date: 12/30/16 DOCKET NO. 14-15 874 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for erectile dysfunction, to include as associated with exposure to Gulf War environmental hazards. 2. Entitlement to service connection for acid reflux disease, to include as associated with exposure to Gulf War environmental hazards. 3. Entitlement to service connection for moles, to include as associated with exposure to Gulf War environmental hazards. 4. Entitlement to service connection for styes, to include as associated with exposure to Gulf War environmental hazards. 5. Entitlement to service connection for left index finger hyperkeratosis (claimed as wart), to include as associated with exposure to Gulf War environmental hazards. 6. Entitlement to service connection for psoriasis, to include as associated with exposure to Gulf War environmental hazards. 7. Entitlement to service connection for a bone condition, to include as associated with exposure to Gulf War environmental hazards. 8. Entitlement to service connection for polyarticular arthritis, to include as associated with exposure to Gulf War environmental hazards. 9. Entitlement to service connection for right deQuervain's syndrome (claimed as right wrist), to include as associated with exposure to Gulf War environmental hazards. 10. Entitlement to service connection for right second finger swelling, to include as associated with exposure to Gulf War environmental hazards. 11. Entitlement to service connection for right third finger swelling, to include as associated with exposure to Gulf War environmental hazards. 12. Entitlement to service connection for right fourth finger swelling, to include as associated with exposure to Gulf War environmental hazards. 13. Entitlement to service connection for left elbow, to include as associated with exposure to Gulf War environmental hazards. 14. Entitlement to service connection for right hand dystonia, to include as associated with exposure to Gulf War environmental hazards. 15. Entitlement to service connection for a right knee disability to include right patellofemoral syndrome due exposure to Gulf War environmental hazards. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD J.A. Williams, Associate Counsel INTRODUCTION The Veteran served on active military duty October 1990 to May 1991 and also served for over 20 years in the United States Army Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Notably, the April 2011 rating decision also denied the Veteran's claim of entitlement to service connection for PTSD and depersonalization disorder. The Veteran filed a Notice of Disagreement (NOD) in January 2012. A Statement of the Case (SOC) addressing all the issues was issued in September 2012. In the Veteran's September 2012 VA Form 9, the Veteran listed all numbered issues that he wanted to appeal and omitted the PTSD and depersonalization disorder claims. Although the Veteran's representative referred to the Veteran's psychiatric claims in a September 2016 letter, the Board finds that the Veteran's intention not to appeal his psychiatric claims is clear. Therefore, those issues are not before the Board. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran has asserted that his disabilities are a result of exposure to environmental hazards during the Gulf War. See March 2010 Report if General Information. Because the Veteran served in the Southwest Asia Theater of Operations, the presumptions of 38 U.S.C.A. § 1117 (West 2014); 38 C.F.R. § 3.317 (2015) are applicable. Presumptive service connection is provided for an undiagnosed illness or a medically unexplained chronic multisymptom illness defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases). A medically unexplained illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(2)(i)(B)-(ii) (2015). The record indicates that the Veteran's complete service treatment records from active duty were unavailable. See August 2010 Formal Finding of Unavailability. In a May 1999 treatment note, private physician Dr. J.P. stated, "[The Veteran] was involved in Desert Storm and seemed to have some of the side effects from war." The Veteran was afforded a Gulf War VA examination in April 2011. The examiner discussed the diagnoses and symptoms associated with the Veteran's claimed disabilities. The examiner also reported that not all of the Veteran's symptoms, abnormal physical findings, and abnormal laboratory test results were determined to be part of a known clinical diagnosis. However, the examiner did not determine which of the Veteran's diagnoses have an unclear etiology or opine as to whether the Veteran's disabilities were related to multisymptom chronic illness. Thus, a medical opinion is necessary to determine which symptoms, if any, are the result of an undiagnosed illness and which, if any, are part of a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology. The Veteran claimed entitlement to service connection for several skin disabilities including styes, moles, hyperkeratosis, and psoriasis. While the April 2011 VA examination addressed left finger hyperkeratosis and psoriasis, the examiner did not discuss moles or styes. A January 2009 private treatment note indicates that the Veteran had 6 growths on the skin. The medical service provider described an unusual melanocytic lesion and ruled out melanoma, verrucous keratosis, and squamous cell carcinoma. Similarly, in June 2000 and October 2000 private treatment notes, show treatment for sties in the left eye. Under 38 C.F.R. § 3.159(c)(4), an examination or opinion is necessary if the evidence of record: (A) contains competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of a disability; and (B) establishes that the Veteran suffered an event, injury, or disease in service; and (C) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service, but the record does not contain sufficient medical evidence for the Secretary to make a decision on the claim. As the medical evidence of record shows diagnoses of sties and skin growths, VA has a duty to obtain a medical opinion to address whether or not his skin disabilities are related to service. See 38 C.F.R. § 3.159(c)(4). With regards to the Veteran's right knee disability, the Veteran initially filed a claim of entitlement to service connection for a bilateral knee disability. The Veteran is service connected for left patellofemoral syndrome. See April 2011 Rating Decision; April 2017 VA Examination Report. The evidence is conflicting as to whether the Veteran had a current right knee disability. See April 2011 VA Examination Report. The April 2011 VA examiner noted bilateral knee sub patellar crepitus and a mass in the right popliteal space. The examiner also noted that there was no acute fracture or dislocation, no intra-articular loose body or significant joint space calcification. The examiner reported that the right knee imaging was unremarkable but also found a tender posterolateral joint line of the right knee. The examiner also noted sub patellar tenderness and meniscus abnormality. Furthermore, the examiner provided a nexus opinion and rationale regarding the left knee but did not render an opinion regarding the right. Thus, a new examination is warranted to determine if the Veteran has a right knee disability that is related to service. Finally, the record indicates that the Veteran consistently sought treatment from private service providers and the VA Medical Center. The Veteran's most recent VA treatment records are from December 2013 and his most recent private treatment records are from 2010. Thus, any recent medical treatment records should be obtained and associated with the claims file. Accordingly, the case is REMANDED for the following actions: 1. Obtain copies of records pertaining to any relevant treatment the Veteran has received at the VA medical center since 2014. The evidence obtained, if any, should be associated with the claims file. 2. Contact the Veteran and ask that he provide a release for VA to secure any private records of treatment he received that have not been associated with the claims file. The Veteran is to be notified of any unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. 3. Afford the Veteran a new VA examination(s). Following a review of the record, the examiner should express opinions as to each the following: * Is the Veteran's erectile dysfunction considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Is the Veteran's acid reflux disease considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Are the Veteran's moles considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Are the Veteran's styes considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Is the Veteran's left index finger hyperkeratosis considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Is the Veteran's psoriasis considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Is the Veteran's bone condition considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Is the Veteran's polyarticular arthritis considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Is the Veteran's deQuervain's syndrome considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Is the Veteran's right third finger swelling considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Is the Veteran's right fourth finger swelling considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Is the Veteran's left elbow considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Is the Veteran's right hand dystonia considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Is the Veteran's right finger swelling considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? * Is the Veteran's right knee disability caused by an event or injury in service? Is the Veteran's right knee disability considered a diagnosed illness without conclusive pathophysiology or etiology that is characterized overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities? The Veteran's claim file should be made available for review. A rationale is requested for any opinions provided. 4. Readjudicate the appeal. 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 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). _________________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2015).