Citation Nr: 1751659 Decision Date: 11/13/17 Archive Date: 11/22/17 DOCKET NO. 13-28 741A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for chronic fatigue syndrome. 2. Entitlement to service connection for chronic obstructive pulmonary disease (COPD). 3. Entitlement to service connection for an acquired psychiatric disability, to include anxiety. 4. Entitlement to service connection for a circulation disorder. 5. Entitlement to an increased initial evaluation for sinusitis, currently rated as 50 percent disabling. 6. Entitlement to an increased initial evaluation for amnestic disorder, currently rated as 50 percent disabling. 7. Entitlement to an increased initial evaluation for atypical constipation, currently rated as 10 percent disabling. 8. Entitlement to a separate evaluation for hemorrhoids. 9. Entitlement to a compensable initial evaluation for residuals of myofascial lumbar spasm. 10. Entitlement to an increased initial evaluation for fibromyalgia, currently rated as 40 percent disabling. REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD M. Bilstein, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1988 to September 1992 with service in Kuwait. He was awarded the Southwest Asia Service Medal with two stars, Kuwait Liberation Medal, and National Defense Service Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2012, September 2012, October 2014, and December 2016 rating decisions from the Department of Veteran's Affairs (VA) Regional Office (RO). In July 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is of record. The Board notes that the Veteran submitted an October 2012 claim for an increased initial evaluation for his service-connected atypical constipation. The claim was developed as such. However, as the Veteran also contends hemorrhoids associated with constipation, which is not a separate condition from atypical constipation but rather a progression of the disease, the Board has characterized the claim as claims for entitlement to an increased initial evaluation in excess of 10 percent for atypical constipation and entitlement to a separate evaluation for hemorrhoids, as reflected in the title page. The issues of entitlement to service connection for circulation disorder; entitlement to an increased initial evaluation in for fibromyalgia, currently rated as 40 percent disabling; and entitlement to a compensable initial evaluation for residuals of myofascial lumbar spasm are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). VETERAN'S CONTENTIONS The Veteran contends that he suffers from chronic fatigue syndrome caused by active duty service and, thus, that service connection is warranted. He reported that he experiences fatigue after physical exertion that may last up to two days, joint pain, and difficulty with sleep. He also stated the despite sleeping for hours, he still feels tired upon waking up. The Veteran also contends that service connection is warranted for COPD, which he attributes to his service in Kuwait during the Persian Gulf War after he was exposed to oil well fires, smoke, and sand storms. The Veteran also seeks service connection for anxiety disorder, which he contends is related to his deployment in Kuwait. He reported anxiety in social situations and with superiors at work and increased irritability. See July 2017 Board Hearing Transcript. Furthermore, the Veteran seeks an increased evaluation for his service-connected sinusitis. He asserts that he has chronic symptoms of sinusitis, including headaches, facial and sinus pressure, discharge, and grogginess. See March 2017 Substantive Appeal and November 2016 VA Sinusitis Examination. The Veteran also argues that an increased evaluation is warranted for his service-connected amnestic disorder. He asserts he has no recollection of recent experiences and has difficulty remembering words and names. See July 2017 Board Hearing Transcript and March 2017 Substantive Appeal. Finally, the Veteran also contends that his service-connected atypical constipation warrants an increased evaluation. In support of this contention, he asserts that he has constant constipation and irregular bowel movements that are difficult to control. Despite his herbal supplement, he does not feel empty. He further states that his constipation has resulted in hemorrhoids and he has begun to have episodes of diarrhea. He also reported abdominal distension, bloating, and nausea. See July 2017 Board Hearing Transcript and March 2017 Substantive Appeal. FACTUAL FINDINGS 1. The Veteran had active military service in the Southwest Asia Theater of operations, on or after August 2, 1990. 2. The Veteran's chronic fatigue syndrome resulted from a medically unexplained chronic multisymptom illness and has manifested to a compensable degree. See March 2012, June 2012, and September 2012 VA Examinations. 3. The Veteran's COPD resulted from a medically unexplained chronic multisymptom illness and has manifested to a compensable degree. See November 2016 VA Sinusitis Examination and November 2016 VA Respiratory Conditions Examination. 4. The Veteran's current disability of anxiety disorder had its onset during service. See March 2012 VA Mental Disorders Examination and June 2012 VA Mental Disorders Examination. 5. Throughout the pendency of the appeal, the Veteran's service-connected sinusitis has been manifested as near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus. See March 2017 Substantive Appeal and November 2016 VA Sinusitis Examination. 6. Throughout the pendency of the appeal, the Veteran's service-connected sinusitis has been rated as 50 percent disabling, the maximum schedular rating available pursuant to 38 C.F.R. § 4.97, Diagnostic Code 6513 (2017). 7. A March 2012 VA infectious disease examination documented that the Veteran has fatigue on a weekly basis that limits his ability to work. 8. During a March 2012 VA mental disorders examination, the Veteran was diagnosed with amnestic disorder and anxiety disorder. The Veteran endorsed panic attacks, loss of interest, feeling distant from others, sleep disturbances, irritability, anger outbursts, and an exaggerated startle response. He also has a memory impairment manifested by the inability to recall previously learned information and conversations. The examiner also determined the Veteran experiences anxiety, panic attacks more than once a week, chronic sleep impairment, mild memory loss, impairment of short and long-term memory, memory loss for names of close relatives or own occupation, gross impairment in thought processes or communication, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting. See also July 2017 Board Hearing Transcript at 4-11. 9. At private treatment visits from April 2012 to August 2012, the Veteran endorsed anxiety, mood swings, and insomnia. 10. During a July 2017 VA Contractor mental disorders examination, the examiner determined that the Veteran's amnestic disorder results in problems with attention and memory and increased anxiety in work and social situations. The examiner determined the Veteran has symptoms of anxiety, panic attacks that occur weekly or less often, chronic sleep impairment mild memory loss, difficulty in understanding complex command, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. 11. Throughout the pendency of the appeal, the Veteran's amnestic disorder, anxiety disorder, and chronic fatigue syndrome have resulted in functional limitation most closely approximating occupational and social impairment with deficiencies in most areas. Specifically, the evidence demonstrates social and occupational impairment with deficiencies in mood, work, family relations, judgment, and thinking. 12. The Veteran has denied hallucinations, delusions, and homicidal or suicidal ideations, and the examiners did not observe such. 13. Throughout the pendency of the appeal, the Veteran's amnestic disorder, anxiety disorder, and chronic fatigue syndrome have not been productive of total social and occupational impairment. 14. Throughout the pendency of the appeal, the Veteran's service-connected atypical constipation has manifested as severe, alternating diarrhea and constipation, with more or less constant abdominal distress. See March 2012 VA examination, May 2014 Letters, March 2017 Substantive Appeal, July 2017 Board Hearing Transcript, and July 2017 VA Contractor Intestinal Conditions Examination. 15. Throughout the pendency of the appeal, the Veteran's hemorrhoids have manifested as mild or moderate. They have not been manifested as large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences; or with persistent bleeding and with secondary anemia, or with fissure. See May 2014 Letters, August 2015 Colonoscopy Report, March 2017 Substantive Appeal, July 2017 Board Hearing Transcript, and July 2017 VA Contractor Intestinal Conditions Examination. LEGAL CONCLUSIONS 1. The criteria for service connection for chronic fatigue syndrome are met. 38 U.S.C. §§ 1110, 1112, 1117, 1118, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317, 4.88a, 4.88b, Diagnostic Code 6354 (2017). 2. The criteria for service connection for COPD are met. 38 U.S.C. §§ 1110, 1112, 1117, 1118, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.1029, 3.303, 3.317, 4.97, Diagnostic Code 6604 (2017). 3. The criteria for service connection for anxiety disorder are met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. Throughout the pendency of the appeal, the criteria for an initial evaluation in excess of 50 percent for sinusitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.21, 4.97, Diagnostic Code 6513 (2017). 5. Throughout the pendency of the appeal, the criteria for an initial evaluation of 70 percent, but no higher, for amnestic disorder have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.21, 4.130, Diagnostic Code 9310 (2017). 6. Throughout the pendency of the appeal, the criteria for an initial evaluation of 30 percent, but no higher, for atypical constipation have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.21, 4.114, Diagnostic Code 7319 (2017). 7. Throughout the pendency of the appeal, the criteria for a separate noncompensable evaluation, but no higher, for hemorrhoids are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.21, 4.114, Diagnostic Code 7336 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). Chronic Fatigue Syndrome Pursuant to 38 C.F.R. § 3.303(b) when a chronic condition is present, a claimant may establish the second and third elements of service connection by demonstrating continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Certain chronic diseases also may be presumptively service connected if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2017). The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, on or after August 2, 1990. 38 U.S.C. § 1110. Service connection may also be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent or more prior to December 31, 2021. 38 U.S.C. § 1117 (2012); 38 C.F.R. § 3.317 (2017). For purposes of section 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). As an initial matter, the Board notes that the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War and has been diagnosed during the course of the appeal with a medically unexplained chronic multisymptom illness, chronic fatigue syndrome. 38 C.F.R. §§ 3.303, 3.3179(a)(2), 4.88a. The outcome of the case, therefore, turns on whether chronic fatigue syndrome has manifested to a compensable degree prior to December 31, 2021. In addressing this question, the Board considers the September 2012 VA medical opinion to carry the greatest probative weight of the entirety of the evidence of record. By way of history, the Veteran's service treatment records are absent complaints of or treatment for chronic fatigue. Post-service treatment records document complaints of fatigue. At a March 2012 VA examination, the Veteran reported he has experienced fatigue since his return from Kuwait but his doctor treated him for depression instead, which was not effective. The examiner diagnosed the Veteran with active chronic fatigue syndrome. He opined that the Veteran's condition functionally limits his ability to work periodically with the onset of fatigue and that this occurs on a weekly basis. In a June 2012 addendum opinion, the VA examiner explained that the diagnostic criteria for chronic fatigue syndrome were met, including fatigue lasting 24 hours or longer and sleep disturbances, as the Veteran has been observed to have sleep difficulties since 1994 with unsuccessful treatment. The examiner also determined that the Veteran's condition is moderately severe due to its chronicity and its impact on his ability to work. At an addendum September 2012 VA examination, the examiner determined that the Veteran's symptoms waxed and waned, and did not result in periods of incapacitation. However, the same examiner also determined that the Veteran's symptoms restrict routine daily activities to 50 percent to 75 percent of the pre-illness level. As such, the Board finds that the evidence is at least in equipoise as to whether the Veteran's chronic fatigue syndrome has manifested to a compensable degree. 38 C.F.R. § 4.88b, Diagnostic Code 6354. Accordingly, the claim for service connection for chronic fatigue syndrome is granted pursuant to 38 C.F.R. § 3.317 (2017). 38 U.S.C. § 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Chronic Obstructive Pulmonary Disease (COPD) As discussed above, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1). Signs and symptoms of undiagnosed illness and medically unexplained chronic multi-symptom illnesses include, but are not limited to, signs or symptoms involving the respiratory system (upper or lower). 38 C.F.R. § 3.317(b)(8). As an initial matter, the Board notes that the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War and has been diagnosed during the course of the appeal with COPD. Furthermore, the November 2016 examiner opined that the Veteran's COPD is a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, as the Veteran has no history of tobacco exposure. See November 2016 VA Respiratory Conditions Examination. The outcome of the case, therefore, turns on whether COPD has manifested to a compensable degree prior to December 31, 2021. In addressing this question, the Board considers the March 2012 VA medical examination to carry the greatest probative weight of the entirety of the evidence of record. At a March 2012 VA examination, the Veteran reported that he noticed shortness of breath during drills and had problems keeping up with his fellow soldiers. The VA examiner reported that January 2012 pulmonary function testing revealed a FEV1/FVC ratio of 79 percent. The VA examiner also determined that the Veteran's pulmonary function testing resulted in a FEV-1 of 71 to 80 percent predicted. As such, the Board finds that the evidence is at least in equipoise as to whether the Veteran's COPD has manifested to a compensable degree. 38 C.F.R. § 4.97, Diagnostic Code 6604. Accordingly, the claim for service connection for COPD is granted pursuant to 38 C.F.R. § 3.317 (2017). 38 U.S.C. § 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Anxiety Disorder As an initial matter, the Board notes that post-service treatment records show the Veteran has been diagnosed during the course of the appeal with various psychiatric conditions, including depression, anxiety, and episodic mood disorder. Accordingly, the first criterion for establishing service connection has been met. The outcome of the case, therefore, turns on whether the psychiatric disorder is related to service. The Veteran's service treatment records are absent complaints of or treatment for a psychiatric condition. However, at the March 2012 VA examination, the Veteran was diagnosed with anxiety disorder and amnestic disorder. The examiner determined that it is possible to differentiate which symptoms are attributed to anxiety disorder, which include panic attacks, anhedonia, exaggerated startle response, anger outbursts, and irritability. The examiner opined that the Veteran's anxiety disorder was at least as likely as not incurred in or caused by service, specifically his experience in Kuwait. He explained that although the Veteran did not endorse a specific traumatic event, he endorsed chronic stress and tension when stationed in Kuwait. Additionally, the Veteran endorsed avoidance and increased arousal symptoms that had their onset short after returning from Kuwait and after discharge from service. The examiner further reasoned that the Veteran did not have a history of a mental health disorder prior to service and that he reported first experiencing significant symptoms of anxiety and panic attacks since discharge. At a June 2012 VA examination, the same VA examiner also opined that the Veteran's anxiety disorder was at least as likely as not incurred in or caused by service. The examiner reasoned that the Veteran's symptoms had their onset shortly after returning from deployment to Kuwait during the Gulf War. He determined that given the timing of the onset of symptoms they were caused by the chronic tension and stress related to the fear of hostile military or terrorist activity he experienced in Kuwait. After review of the record, the Board finds that service connection for anxiety disorder is warranted. Here, the Board finds the Veteran's report of his experience in service and the subsequent onset of his symptoms both competent and credible. Layno v. Brown, 6 Vet. App. 465, 470 (1994); Owens v. Brown, 7 Vet. App. 429 (1995); Elkins v. Gober, 229 F.3d 1369 (Fed. Cir. 2000); Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997); Guimond v. Brown, 6 Vet. App. 69 (1993); Hensley v. Brown, 5 Vet. App. 155 (1993); Caluza v. Brown, 7 Vet. App. 498 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991). The Board also finds that the March 2012 and June 2012 positive opinions of the VA examiner, provided after reviewing the entirety of the claims file, are highly probative as they reflect consideration of all relevant facts. The examiner provided detailed rationales for the conclusions reached. His conclusions were supported by the medical evidence of record, which includes post-service treatment records documenting mental health symptoms and diagnoses and service personnel records corroborating the Veteran's experiences. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). II. Increased Initial Evaluation Sinusitis By way of history, service connection for sinusitis was granted in a December 2016 rating decision, with a 50 percent rating assigned effective October 15, 2013. The Veteran's sinusitis is rated under Diagnostic Code 6513, sinusitis, maxillary, chronic. Diagnostic Codes 6510 through 6514 pertain to various types of sinusitis, each of which is rated based on the criteria in a General Rating Formula for Sinusitis (General Formula). Under the General Formula, a 50 percent evaluation is assigned following radical surgery with chronic osteomyelitis; or near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. A note following this section provides that an incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. 38 C.F.R. § 4.97. Although the Veteran contends he has chronic symptoms of sinusitis, including headaches, facial and sinus pressure, drainage that causes coughing and phlegm, and a foggy mind, all his symptoms are taken under consideration under the currently assigned maximum rating. As the Veteran is in receipt of the maximum rating assignable for his sinusitis, the claim for an increased schedular rating is denied based on a lack of entitlement under the law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Although higher ratings are possible under Diagnostic Codes 6516, 6519, and 6524, these diagnostic codes are not for application, as the Veteran does not manifest laryngitis or granulomatous rhinitis. See March 2012 VA Examination and November 2016 VA Sinusitis Examination; 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Amnestic Disorder The Veteran asserts that a higher initial rating is warranted for his service-connected amnestic disorder, currently rated as 50 percent disabling, effective June 24, 2011. The Veteran's amnestic disorder is rated under Diagnostic Code 9310. See 38 C.F.R. § 4.130. As discussed and decided above, the Veteran also has service-connected anxiety disorder and chronic fatigue syndrome. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's symptoms of chronic fatigue syndrome, anxiety disorder, and amnestic disorder have significant overlap and cannot be distinguished. See July 2017 VA Contractor Mental Disorders Examination. Furthermore, all psychiatric disorders are to be evaluated pursuant to a General Rating Formula for Mental Disorders (General Rating Formula) used to rate psychiatric disabilities, other than eating disorders. 38 C.F.R. § 4.130 (2017). Here, the rating criteria for amnestic disorder (Diagnostic Code 9310) and anxiety disorder (Diagnostic Code 9413) are the same under the General Rating Formula. Id. To provide separate evaluations for various service-connected psychiatric disabilities would violate the prohibition against pyramiding found at 38 C.F.R. § 4.14 (2017). See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). As indicated above the Board concludes that the Veteran's symptoms most closely approximate the criteria for a 70 percent rating for the entirety of the appeal period. The Veteran's symptoms did not at any time, however, more nearly approximate the total occupational and social impairment required for a 100 percent rating. The March 2012 and July 2017 examiners did not determine that the Veteran's symptoms cause total occupational and social impairment. Moreover, the record does not reflect that the Veteran has at any point demonstrated the symptoms associated with a 100 percent rating, or other symptoms of similar severity, frequency, and duration. Persistent delusions or hallucinations have not been shown, nor has that Veteran been shown to have grossly inappropriate behavior, an inability to perform activities of daily living, or any of the other markers of total occupational and social impairment due to his service-connected amnestic disorder. Although the record reflects that the Veteran demonstrated gross impairment in thought processes or communication and memory loss for names of close relatives, own occupation, or own name, the evidence of record does not reflect that these symptoms approached the severity, frequency, and duration to cause total occupational and social impairment, such that a 100 percent disability rating is warranted. The Veteran's treatment records document that he maintains ongoing relationships with his wife and children and despite his amnestic disorder, anxiety disorder, and chronic fatigue syndrome, the Veteran continues to work as a log scaler. In sum, the Board finds that a rating of 70 percent, but not higher, for the Veteran's amnestic disorder is warranted. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Atypical Constipation By way of history, service connection for atypical constipation was granted in a May 2012 rating decision, currently rated as 10 percent disabling effective June 24, 2011. The Veteran's atypical constipation is rated under 38 C.F.R. § 4.114, Diagnostic Code 7319. A 10 percent rating is assigned under Diagnostic Code 7319 for moderate irritable colon syndrome with frequent episodes of bowel disturbance with abdominal distress. A maximum 30 percent rating is assigned for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. Id. Resolving reasonable doubt in the Veteran's favor, the Board finds that a 30 percent rating under Diagnostic Code 7319 is warranted for atypical constipation based on his reports of difficulty initiating bowel movements since his discharge from service, bowel movements every two days, daily abdominal distension, constant bloating, episodes of diarrhea, and nausea. See March 2012 VA Examination, May 2014 Letters, July 2017 Board Hearing Transcript at 24-25, and July 2017 VA Contractor Intestinal Conditions Examination; see also 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. 4.114, Diagnostic Code 7319 (2017). As a result, the Board is granting the maximum 30 percent rating for atypical constipation throughout the pendency of the appeal. The Board has also considered whether separate ratings could be assigned for the Veteran's atypical constipation under any other applicable diagnostic codes. As an initial matter, the Board notes that the RO rated the Veteran's atypical constipation under Diagnostic Code 7319. However, the Board finds that a separate rating for hemorrhoids under DC 7336 is warranted. Pursuant to Diagnostic Code 7336, a noncompensable, zero percent rating is warranted where the hemorrhoids are found to be mild or moderate in nature. A 10 percent rating is warranted where the hemorrhoids are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating, the highest rating available pursuant to Diagnostic Code 7336, is warranted for hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. Resolving reasonable doubt in the Veteran's favor, the Board finds that a noncompensable rating under Diagnostic Code 7336 is warranted for hemorrhoids based on his reports of rectal bleeding and bloody stools. Furthermore, an August 2015 colonoscopy report determined that the Veteran had a normal examination other than hemorrhoids that caused intermittent bleeding. The Veteran also reported improvement in his hemorrhoids with the use of creams. See May 2014 Letters, March 2017 Substantive Appeal, July 2017 Board Hearing Transcript at 24-25, and July 2017 VA Contractor Intestinal Conditions Examination; see also 38 U.S.C.S. §§ 1155, 5107 (2012); 38 C.F.R. § 4.114, Diagnostic Code 7336 (2017). The Board does not find, however, that a compensable rating under Diagnostic Code 7336 is warranted for either of the Veteran's hemorrhoids at any point during the claim period. In that regard, the medical evidence of record does not document large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences; or with persistent bleeding and with secondary anemia, or with fissure. See May 2014 Letters, August 2015 Colonoscopy Report, March 2017 Substantive Appeal, July 2017 Board Hearing Transcript, and July 2017 VA Contractor Intestinal Conditions Examination. ORDER Service connection for chronic fatigue syndrome is granted. Service connection for COPD is granted. Service connection for anxiety disorder is granted. An initial evaluation in excess of 50 percent for sinusitis is denied. An initial evaluation of 70 percent for amnestic disorder is granted. An initial evaluation of 30 percent for atypical constipation is granted. A separate noncompensable evaluation for hemorrhoids is granted. REMAND Although further delay is regrettable, the Board finds that additional development is required before the remainder of the Veteran's claims are decided. Circulation Disorder The Veteran asserts that service connection for a circulation disorder is warranted as a result of his deployment to Kuwait during the Persian Gulf War. He specifically asserts that he has numbness and swelling in his hands and feet and coldness in his feet. See March 2017 Substantive Appeal and July 2017 Board Hearing Transcript at 32-33. The Veteran has not yet been afforded a VA examination in connection with his service connection claim for a circulation disorder. VA must provide an examination when there is competent evidence of a disability (or persistent or recurrent symptoms of a disability) that may be associated with an in-service event, injury, or disease, but there is insufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Lay testimony as to continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service, and the threshold for finding that the disability (or symptoms of a disability) may be associated with service is low. Id. at 83. Furthermore, the Veteran is competent to testify to in-service injuries, symptoms, and events. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Given the Veteran's reports attributing his current condition to service, the Board finds that the low threshold of the McLendon standard has been met in this instance, and that the Veteran should be afforded a VA examination and opinion prior to adjudication of the claim. See McLendon, 20 Vet. App. 79, 81 (2006). Myofascial Lumbar Spasm The Veteran also contends that he is entitled to an initial compensable evaluation for residuals of myofascial lumbar spasm. The Veteran asserts that his back pain and range of motion has worsened. He also endorsed numbness and tingling in his lower legs. He indicated that he has missed work due to his back disability. He also stated that the March 2012 VA examination is not consistent with his activities of daily living. See Board Hearing Transcript at 27-32. In light of the foregoing, and considering that the thoracolumbar spine VA examination was in March 2012, the Board finds that the Veteran should be afforded an additional opportunity to undergo an examination in furtherance of his claim. 38 C.F.R. § 3.327 (2017); Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). The VA examination should be performed in accordance with the range of motion testing required by the United States Court of Appeals for Veterans Claims (Court) in Correia v. McDonald, 28 Vet. App. 158 (2016). In Correia, the Court found that 38 C.F.R. § 4.59 requires that VA joint examinations must, where possible, include range of motion results for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. Id. at 168-169. The examiner should also render a retrospective opinion on the measurements required by Correia. Fibromyalgia The Veteran also seeks an initial increased evaluation for fibromyalgia, currently rated as 40 percent disabling, the maximum scheduler rating pursuant to 38 C.F.R. §4.71a, Diagnostic Code 5025. In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321. Here, the Board recognizes that the Veteran's disability manifests in extraschedular symptoms and effects. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008); see also Fanning v. Brown, 4 Vet. App. 225, 229 (1993). These potentially include difficulty performing his work duties, inefficiency at work, loss of concentration, and limitations with prolonged standing and walking or lifting over 25 pounds. See August 2014 VA Examination, March 2017 Substantive Appeal, and July 2017 Board Hearing Transcript at 33-37. Accordingly, the Board will refer the Veteran's claim to the Director, Compensation, for consideration of whether an extraschedular rating is warranted. 38 C.F.R. § 3.321(b). At the July 2017 hearing, the Veteran also reported that he received private treatment at Cow Creek Health and Wellness and with Dr. Thomas at Mountain View Family Practice. Those treatment records, as well as updated private and VA treatment records should also be requested. 38 U.S.C. § 5103A(c) (2012); 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). Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of any medical providers who have recently treated him for his circulation disorder, fibromyalgia, and back and to provide releases for those clinicians. After securing the necessary releases, obtain any relevant records. The AOJ should also attempt to obtain any VA treatment records dating from June 2017 to the present. If any requested records are unavailable, the claims file should be annotated as such and the Veteran and his representative notified of such. 2. After completing the above actions and associating any additional records with the claims file, schedule the Veteran for a VA examination to determine the etiology of his circulation disorder. The Veteran's claims file, including a copy of this remand, must be made available to the examiner. All diagnostic testing deemed to be necessary by the examiner should be accomplished. The examiner should address the following: a. With respect to any diagnosed circulation disorder, is it at least as likely as not (50 percent probability or greater) that the disability arose during service or is otherwise related to any incident of service? Please explain why or why not. In providing this opinion, please comment on the significance, if any, on the Veteran's service in Kuwait during the Persian Gulf War. If the criteria for a distinct diagnosis of a circulation disorder, are not met, please state as such. A rationale for any opinions expressed should be set forth. If the examiner cannot provide an above opinion without resorting to speculation, he/she should explain why an opinion cannot be provided (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). 3. Schedule the Veteran for a VA thoracolumbar spine examination to determine the current severity of his service-connected myofascial lumbar spasm. The claims file should be made available to and reviewed by the examiner. Range of motion should be reported, including whether and the extent to which such motion is affected by pain, weakness, fatigue, lack of endurance, incoordination or other symptoms resulting in functional loss. The examiner should also test the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing, for both the joint in question and any paired joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. All objective and subjective symptoms should be reported in detail. The examiner should also provide an opinion as to the range of motion throughout the appeal period (since June 2011) of the low back disability in (1) active motion, (2) passive motion, (3) in weight-bearing, (4) in nonweight-bearing, and (5) with the range of the opposite undamaged joint. A rationale for any opinions expressed should be set forth. If the examiner cannot provide an opinion without resorting to speculation, he/she should explain why an opinion cannot be provided (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). Finally, the examiner should provide opinion as to the functional limitations the Veteran has experienced as a result of his service-connected myofascial lumbar spasm, and what impact, if any, those have on his occupational functioning. 4. Refer to the Director, Compensation, the issue of entitlement to an extraschedular rating for fibromyalgia. 5. After completing the requested actions, and any additional action deemed warranted, readjudicate the claims on appeal. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ S.C. KREMBS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs