Citation Nr: 1804258 Decision Date: 01/22/18 Archive Date: 01/31/18 DOCKET NO. 10-47 933 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for a left shoulder condition. 2. Entitlement to service connection for a respiratory disorder (alternatively characterized as a lung condition), to include as an unexplained multisymptom illness associated with service in the Persian Gulf, radiation exposure, and asbestos exposure. 3. Entitlement to service connection for left-sided chest pain disorder. 4. Entitlement to service connection for a sleep disorder, to include as an undiagnosed illness associated with service in the Persian Gulf. 5. Entitlement to service connection for headaches, to include as an undiagnosed illness associated with service in the Persian Gulf. 6. Entitlement to service connection for left arm numbness. 7. Entitlement to service connection for left hand numbness. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD B. J. Komins, Associate Counsel INTRODUCTION The Veteran had active service in the United States Navy from September 1992 to August 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The Veteran was scheduled for a Decision Review Officer (DRO) hearing in May 2011 and rescheduled in July 2011. The Veteran failed to appear at his July 2011 DRO hearing. The Board deems his request for a hearing withdrawn. The issues on appeal were remanded to the RO in September 2015 for additional development. After review of points and findings in the evidence of record, the Board has re-characterized the issues of entitlement to service connection for a respiratory disorder and entitlement to service connection for a lung condition, as discussed in the May 2017 Supplemental Statement of the Case (SSOC), as entitlement to service connection for a respiratory disorder (alternatively characterized as a lung condition), to include as an undiagnosed illness associated with service in the Persian Gulf, radiation exposure, and asbestos exposure. Likewise, the Board has re-characterized entitlement to service connection for a sleep disorder as entitlement to service connection for a sleep disorder, to include as an undiagnosed illness associated with service in the Persian Gulf; and entitlement to service connection for headaches as entitlement to service connection for headaches, to include as an undiagnosed illness associated with service in the Persian Gulf. The appeal has returned to the Board for further appellate action. FINDINGS OF FACT 1. A left shoulder condition was not manifest during service. A left shoulder condition is not attributable to service. 2. The Veteran's respiratory disorder is not due to a known clinical entity and there is competent medical evidence that a chronic cough and gastric reflux is a manifestation of an undiagnosed illness arising from service in the Persian Gulf. 3. The Veteran does not have left-sided chest pain disorder. 4. The Veteran's sleep difficulty is a manifestation of a diagnosed mental disorder. 5. The Veteran's headaches are a manifestation of a diagnosed mental disorder. 6. Left arm numbness was not manifest during service. Left arm numbness is not attributable to service. 7. Left hand numbness was not manifest during service. Left hand numbness is not attributable to service. CONCLUSIONS OF LAW 1. A left shoulder condition was not incurred or aggravated by service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 2. Service connection for a respiratory disorder manifesting as chronic cough due to an undiagnosed illness is met. 38 U.S.C. §§ 1110, 1117, 1131 5107 (2012); 38 C.F.R. §3.317 (2017). 3. Left-sided chest pain disorder was not incurred or aggravated by service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 4. A sleep disorder was not incurred or aggravated by service. The criteria for service connection for sleep disorder due to an undiagnosed illness are not met. 38 U.S.C. § 1110, 1117, 1131, 5107 (2014); 38 C.F.R. §§ 3.303, 3.317 (2017). 5. Headaches were not incurred or aggravated by service. The criteria for service connection for headaches due to an undiagnosed illness are not met. 38 U.S.C. § 1110, 1117, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.317 (2017). 6. Left arm numbness was not incurred or aggravated by service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). 7. Left hand numbness was not incurred or aggravated by service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Remand Considerations As noted in the Introduction, the case was remanded to the RO in September 2015 for additional development. The Board is satisfied that there has been substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-67 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1999) (holding that the Board errs as a matter of law when it fails to ensure compliance with its remand orders). II. Duties to Notify and Assist The requirements of 38 U.S.C. §§ 5103 and 5103A (2012) have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA has a duty to notify and to assist the Veteran in the development of his claims. The RO satisfied its duty to notify by way of letters. Specifically, the RO notified the Veteran prior to the rating decision on appeal of the information and evidence needed to substantiate and complete the claims decided here, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, how to substantiate a claim for service connection, and how disability ratings and effective dates are determined. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Regarding the duty to assist, the Veteran's lay evidence as well as medical records, to include service treatment records (STRs) and VA treatment records, have been obtained. In a November 2010 substantive appeal, the Veteran reported that additional classified military records are necessary to decide the appeal. As explained below, the Board finds that the Veteran's contention is not credible and that no assistance in recovering classified records is warranted. Moreover, the Veteran underwent VA examinations during the appeal period, the reports and opinions of which adequately address the issues decided here. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board thus finds that further action is unnecessary under 38 U.S.C.A. § 5103A (West 2014) and 38 C.F.R. § 3.159 (2017). The Veteran will not be prejudiced as a result of the Board's adjudication of the issues below. Service Connection Claims The Veteran served in the United States Navy as a fireman and electronic/mechanical repairman on the USS Nimitz during the Gulf War Era. He contends that a left shoulder condition, a respiratory disorder, left-sided chest pain, a sleep disorder, headaches, left arm numbness, and left hand numbness were incurred in or aggravated by his active duty service from September 1992 to August 1994. Service personnel records show that the Veteran served in the aircraft carrier engineering department and that the ship made one deployment to Southwest Asia during his tour of duty. He was not trained as a nuclear power plant operator but rather was qualified as a watch stander in "shaft alley." Although he was medically screened for possible monitoring for radiation exposure in February 1993 and August 1994, there is no dosimetry record (DD Form 1141) to show actual monitored occupational exposure to ionizing radiation. There is no lay or medical evidence that his duties included the disassembly and maintenance of asbestos insulated piping or components or was in a regular monitoring program for sailors with these duties. Therefore, the Board finds that the Veteran was not exposed to asbestos or ionizing radiation. In a November 2010 substantive appeal, the Veteran contended that he participated in classified operations that were relevant to his appeal and submitted two "Special Operations Forces Incident" questionnaires in which he reported participation in classified ground combat operations in Saudi Arabia, Kuwait, and Afghanistan from 1993 to 1999 as a Navy fireman of paygrade E-6 assigned to special operations teams. The Board finds these reports and contentions are not credible because the Veteran was never promoted above E-3, never trained for any such duty, inconsistent with the existing service personnel records, and not otherwise supported by any service record. Therefore, the Board finds that the Veteran did serve aboard ship in the Persian Gulf and may have gone ashore during port visits but was not engaged in classified combat operations. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (2017). To establish a right to compensation for a present disability, 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 or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be established for a qualifying chronic disability that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2022. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. The term "qualifying chronic disability" means a chronic disability resulting from any of the following (or any combination of the following): an undiagnosed illness; a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders) that is defined as a cluster of signs or symptoms; or, any diagnosed illness that VA determines. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1)(i). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA's Schedule for Rating Disabilities for a disease or injury in which functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a)(2-5). Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, signs or symptoms involving fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurological signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317(b). Among the requirements for service connection for a disability due to an undiagnosed illness is that such disability, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (a)(1)(ii). There must be no affirmative evidence that the disability was not incurred during military service in the Southwest theater of operations. See 38 C.F.R. § 3.317(a)(7). In cases where a Veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C. § 1110 is nevertheless warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Certain chronic diseases (including malignant tumors) may be service connected on a presumptive basis if manifested to a compensable degree within a specified period of time (one year for malignant tumors) following discharge from service. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA will consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to a determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). 1. Left Shoulder Condition A review of the Veteran's STRs reveals that the Veteran reported normal strength and range of motion in his upper extremities in Reports of Medical Examination in February 1993 and August 1994. Also in February 1993 and August 1994, the Veteran reported that he did not have a painful or "trick" shoulder. The Veteran's STRs are otherwise silent as to a left shoulder condition or symptoms indicative of a left shoulder condition. The Board notes that the Veteran and his representative have indicated throughout the period on appeal that other relevant evidence exists to support his claim. However, review of the evidence of record shows that the Veteran has not furnished this evidence. Here, the Board notes that the RO has assisted the Veteran in obtaining additional VA records, while the Veteran, at most, indicated that relevant evidence exists. "The duty to assist is not always a one-way street. If a veteran wants help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). A September 2012 VA treatment record noted that the Veteran reported arthritis or muscle pain. In April 2014, the Veteran underwent VA x-ray imaging of his left shoulder. The radiological report was negative as to findings of either degenerative or traumatic arthritis. In November 2015, the RO sent a letter requesting medical reports and treatment information from the Veteran for all of his claimed disorders, diseases, and disabilities. The letter stipulated that a response was required in 30 days. The evidence of record is silent as to the Veteran's sending any of the requested materials. In March 2016, the Veteran was afforded a VA examination. The examiner reviewed the Veteran's claims file, considered his lay accounts of his symptoms and medical history, and conducted a physical examination. The examiner provided a diagnostic impression of left shoulder strain based upon diagnostic range of motion and repetitive use testing. The functional impact of the strain, according to the examiner, equated to the Veteran's periodic difficulty and pain with repetitive movements of his left arm. The examiner noted that the Veteran reported that he had sustained a left shoulder injury while he was in service in Saudi Arabia, adding that the pain is on-going and continuous. Furthermore, the Veteran reported that "[he] cannot reach over his shoulder." This, according to him, limited his ability to hunt raccoons or rabbits. The examiner opined that the Veteran's left shoulder condition was less likely than not incurred in or caused by an in-service injury, event, or illness. As a rationale for her opinion, the examiner noted there was no documentation whatsoever in the Veteran's STRs about the Veteran's claimed left shoulder injury. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that service connection for the Veteran's left shoulder strain is not warranted. The post-service evidence establishes that the Veteran has left shoulder strain. However, there is no credible evidence that he had a left shoulder injury during service and there is no credible evidence linking left shoulder strain to service. The Veteran's contention that he injured his left should during active service in Saudi Arabia 2007 is inconsistent with the service records and specifically with his denial of any injury or residual in his separation medical history questionnaire. Although the Veteran has maintained that his left shoulder stain was incurred in service, this assertion is inconsistent with other, more probative evidence of record. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). In this regard, the Board finds that the March 2016 VA examination offers the strongest and most persuasive evidence regarding the etiology of the Veteran's left shoulder strain. In summary, the evidence of record does not support that the Veteran's current left shoulder strain was incurred in or aggravated by active service, foreclosing the possibility of nexus between left shoulder condition and active service. The preponderance of evidence is against the Veteran's claim and there is no doubt to be resolved. See 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). 2. Respiratory Disorder/Lung Condition The Veteran contends that a respiratory disorder was incurred in service or alternatively, was caused by or a result of an in-service event of undiagnosed illness and exposure to ionizing radiation. The Veteran has also made periodic contentions that he was exposed to asbestos while in service. A review of the Veteran's STRs reveals that the Veteran reported normal sinuses and lungs in Reports of Medical Examination in February 1993 and August 1994. Also in February 1993 and August 1994, the Veteran reported that he did not have ear, nose or throat problems; sinusitis; tuberculosis; asthma; shortness of breath; pain or pressure in the chest; or chronic cough in these Reports of Medical History. The Veteran's STRs are otherwise silent to a respiratory disorder or symptoms indicative of a respiratory disorder. A review of the Veterans VA treatment records reveals that the Veteran indicated that he had neither pulmonary nor breathing problems when he established care with VA in May 2007. In July 2007, the Veteran reported that he had a productive cough of green secretions and phlegm upon reclining. However, January 2008 x-ray imaging revealed normal lungs and smooth pleural surfaces. November 2010 examination records from the Battle Creek, Michigan Veterans Affairs Medical Center (VAMC) show that the Veteran reported that he had a chronic cough, sometimes productive of yellowish sputum. The Veteran stated that this cough was not evaluated while he was in active service; however, he contended that it had worsened and had become more pronounced over time. Upon examination were followed, an examiner provided a diagnostic impression of no acute cardiopulmonary disease. The examiner opined that the Veteran's claim of chronic cough is less likely as not caused by or a result of an in-service event of undiagnosed illness and exposure to ionizing radiation. As a rationale for this opinion, the examiner underscored that the chest x-ray imaging revealed that the Veteran's lungs were clear and that there were no pleural effusions. A review of 2014 treatment records from the VA facility in Grand Rapids, Michigan shows that examiners opined that the Veteran's lungs were clear. These records also reveal that the Veteran failed to appear for several scheduled appointments. In March 2016, the Veteran was afforded a VA respiratory conditions examination. The examiner reported that the Veteran's contended respiratory disorder did not require the regular use of medication or adjunct therapy-oral bronchodilators, antibiotics, or oxygen. The examiner noted that the Veteran reported that he was unaware of whether he had been exposed to asbestos while in service. The examiner noted that the Veteran had never been diagnosed for a respiratory disorder, although he had an intermittent dry cough. The examiner stated that this cough "could be the result of a number of things," including gastrointestinal reflux, alcohol abuse (ETOH), pets, or the Veteran's use of a wood-burning stove. Findings included clear lungs; unremarkable cardiac and mediastinal contours; a grossly intact bony thorax; no significant pleural effusions; and no acute cardiopulmonary disease. The examiner concluded his examination report by opining that the Veteran did not have a present respiratory disorder and therefore a respiratory disorder did not impact his ability to work. In an addendum, the examiner reported that the Veteran's claim of service connection for chronic cough is less likely as not caused by or the result of in-service events or an undiagnosed illness and ionizing radiation. As a rationale, the examiner noted that the Veteran reported that he developed a chronic cough in 1993, which, as noted above, is sometimes productive of sputum. The Veteran also reported that he was not evaluated while in service and that his cough worsened with time. His chest x-ray imaging yielded normal results and no acute cardiopulmonary disease. While the Veteran did not smoke tobacco; he chewed it since the age of 10, with only a one-year intermission. Moreover, the examiner opined that chronic cough is not a diagnosis, but a symptom. Furthermore, the Veteran denied dyspnea, chest pain, or hemoptysis. The Veteran asserted, according to the examiner, that he did not elevate his head when he slept, making it likely that his chronic cough is related to irritation from gastrointestinal reflux disease or irritation from chewing tobacco. With all of these factors in play, the examiner opined that the Veteran's claim of service connection for chronic cough is less likely as not caused or a result of in-service events or undiagnosed illness and exposure to ionizing radiation. In December 2016, the RO obtained an additional medical opinion. The examiner did not conduct a physical examination. This examiner opined that he did not agree with the prior examiners' findings. This examiner stated that the Veterans symptoms of persistent epigastric distress, reflux, substernal pain, nausea and dry cough are at least as likely as not symptoms of a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as functional gastrointestinal disorders (excluding structural gastrointestinal diseases). This examiner provided an extensive commentary which evaluated the entirety of the Veteran's medical record. He posed the question of whether the Veteran's dry cough was in fact an undiagnosed illness. Alternatively, he posed whether the absence of a specific etiology for the Veteran's dry cough, but with many possible causes, sufficient to attribute the cough to being a manifestation of an undiagnosed illness. Or, as stated above, are the Veteran's symptoms of persistently recurrent epigastric distress, reflux, substernal pain, nausea and dry cough symptoms of a medically unexplained chronic multisystem illness that is defined by a cluster of signs or symptoms, such as functional gastrointestinal disorders (excluding structural gastrointestinal diseases)? As a rationale for a finding in favor of the last posed question, the examiner advanced a well-reasoned and well-supported argument that included references to peer-reviewed medical literature and the specific applicable language of 38 C.F.R. § 3.317. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that service connection for respiratory disorder is warranted. The Veteran's respiratory disorder was not diagnosed during service. However, there is a relatively equal balance of evidence for and against a service-related origin for his symptoms. Moreover, the Board finds the December 2016 VA examiner's opinion to be the more probative medical evidence of record as to the etiology of the Veteran's symptoms of recurrent epigastric distress, reflux substernal pain, nausea, and dry cough do constitute an unexplained chronic multi symptom illness. The opinion addressed all the relevant evidence of record and provided a reasoned argument supported by medical literature. The Board finds that there is doubt as to the inception of the Veteran's respiratory disorder, and such doubt is resolved in favor of the Veteran. In December 2016, the RO granted separate service connection for gastroesophageal reflux disease (GERD). 3. Left-Sided Chest Pain Disorder The Veteran contends that he incurred left-sided chest pain disorder in service. Inasmuch as the evidence noted above pertains to the Veteran's other contentions, the Board incorporates it with added commentary here. As noted above, review of the Veteran's STRs reveals that the Veteran reported normal lung, chest, abdomen, and viscera in Reports of Medical Examination in February 1993 and August 1994. Also in the February 1993 and August 1994 Reports, the Veteran denied pain or pressure in his chest. The Veteran's STRs are otherwise silent as to left-sided chest pain. A review of the Veteran's VA treatment records shows that during routine consultations in June 2006, July 2007, January 2008, July 2008, October 2009, May 2010, November 2010, September 2012, and April 2014, the Veteran responded negatively when queried as to whether he had experienced chest pain in the past 24 hours. As noted above, November 2010 VA x-ray imaging revealed that the Veteran's thorax was grossly intact and that there was no impression of acute cardiopulmonary disease. Exceptions as to chest pain in the file of the VA treatment records occurred in 2007 and 2008. May 2007 VA treatment records show that the Veteran reported that he experienced episodes of anxiety accompanied by a racing heart and feelings that he might die. During these episodes, he added that he sometimes experienced left-sided chest pain. The Veteran stated that he had been prescribed buspirone for these episodes. Progress notes confirm that the Veteran was prescribed 15 milligrams tablets twice daily for anxiety. The Veteran also stated that he was taking a heart pill, which a clinician opined was probably a beta-blocker. Progress notes confirm that the Veteran was prescribed metoprolol tartrate twice daily for his heart and blood pressure. The Veteran also reported that he experienced left rib and left chest in July 2017. Review of the Veterans VA mental health treatment records reveal that he had received a diagnostic impression of generalized anxiety order as early as July 2007. In January 2008, the Veteran sought VA treatment for left side pain. A clinician noted the Veteran's report of an injury at work the previous summer while lifting an object with a crowbar. This report was somewhat ambiguous as it alternates at times between left side pain, left arm pain, and left leg pain. A chest X-ray was normal. There was no diagnosis but the Veteran was prescribed ibuprofen. At this time, the examiner noted that the Veteran had an "active problem" of anxiety. In May 2017, a VA examiner submitted a medical opinion concerning the Veteran's contention of left-sided chest pain disorder. The examiner opined that she had reviewed conflicting medical evidence, as noted above. She also opined that the Veteran had received diagnostic impression of generalized anxiety disorder. While noting that she was not a mental health practitioner, which precluded her from deriving a direct mental health etiology of the left-sided chest pain, she offered an opinion based on other diagnosed disorders. With the Veteran's other medical issues including GERD, according to the examiner, he could have epigastric pain that would feel like chest wall pain. Therefore, the examiner opined that the Veteran's left-sided chest pain disorder is at least as likely due to anxiety. She qualified this by stating that while she is not a mental health provider, the medical evidence of record points to her etiological opinion. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that service connection for left-sided chest pain is not warranted. As discussed above, the Board has reviewed the extensive medical evidence of record and no credible evidence provides a present diagnostic impression of left-sided chest pain attributable to service. To the extent that the Veteran had left-sided chest pain, the record of evidence shows that it was episodic in nature, and the evidence of record makes clear that the last episode occurred almost 10 years ago. Hence, there is no present and separate left-sided chest pain disorder. The Veteran has been granted service connection for GERD and for a recurrent chronic cough for which examiners have cited as causes for recurrent chest pain. In the absence of a disability, compensation may not be awarded. In the absence of evidence of present left-sided chest pain disorder, there can be no grant of service connection under the law. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Diagnosis of such disorder would necessitate on-point medical examinations and commentary. See Jandreau, supra; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). To be clear the Veteran does not have current left-sided chest pain disorder and any assertion to the contrary is not credible. The preponderance of evidence is against the Veteran's claim and there is no doubt to be resolved. See 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, supra. 4. Sleep Disorder The Veteran contends that he is entitled to service connection for sleep disorder, to include as an undiagnosed illness associated with service in the Persian Gulf. In February 1993 and August 1994, the Veteran reported that he did not frequent trouble sleeping in Reports of Medical History. The Veteran's STRs are otherwise silent as to a sleep disorder. Review of the Veteran's VA treatment records reveals that he Veteran responded negatively to inquiries about sleep problems or disturbances during routine consultations in May 2007 and July 2007. However, the Veteran reported that his anti-anxiety medication made him sleepy on or about the same time. In a July 2008 substance abuse screening report, an examiner noted that the Veteran contended that he consumed alcohol to help him sleep without nightmares. The examiner recommended against prescribing sleeping medication. A subsequent progress note indicated that the Veteran agreed to cut back on alcohol consumption once he obtained sleep medication. A progress note from the same month commented upon the Veteran's report of poor sleeping because of concerns about secure windows and doors. This note also mentioned that he was consuming alcohol. In a psychiatry note from July 2008, an examiner noted that the Veteran slept in two hour blocks at a time, getting a total of 4 to 5 hours of sleep a night. At this time, the Veteran also reported that he woke feeling rested, "wired and nervous." In November 2010, the Veteran was afforded a VA examination for chronic fatigue syndrome. The examiner noted that the Veteran stated that he developed "sleep impairment" in 1993 or 1994 during service. The Veteran further stated that he did not receive treatment for the claimed impairment in service; moreover, the Veteran did not recall telling anyone about the impairment contemporaneously. The examiner conveyed that the Veteran was taking trazodone to treat the impairment, but he avoided taking it regularly because it caused him to sleep too deeply. The examiner provided a diagnostic impression of sleep impairment. As to the etiology of sleep impairment, the examiner opined that it is less likely as not caused by or the result of in-service events, undiagnosed illness and exposure to ionizing radiation. The examiner based his findings upon the lack of sleep apnea in service, lack of daytime somnolence in service, and no documentation of insomnia during service. In VA treatment progress notes from 2011, a mental health clinician opined that the Veteran indicated that he experienced auditory and visual hallucinations upon awakening or falling asleep. The Veteran also indicated that he was prone to napping and had engaged in sleep walking in the past. VA mental health records from 2013 and 2014 included reports of decreased depression and anxiety; improved anger management; and improved sleep. In large part, earlier points as to mental health and sleep patterns were reiterated. A March 2016 VA examination and opinion evaluated this Veteran's sleep disorder. After her review, the examiner opined that the Veteran's claimed sleep disorder was less likely than not incurred in or caused by an in-service injury, event, or illness. As a rationale, the examiner noted that the Veteran has never received a diagnostic impression of sleep apnea; and, moreover, did not and does not have symptoms of sleep apnea. Whereas, he has experienced insomnia and broken sleep cycles, attributed to his diagnosed anxiety disorder. The examiner also reported that the Veteran had no documented exposure to asbestos while in service, which ruled out any connection to his contended sleep disorder. In concluding remarks, the examiner stated that the Veteran did not require a sleep study because there is no evidence of record to support that he has or ever had sleep apnea. The examiner reported that the Veteran's sleep disorder did not impact his ability to work. Review of 2016 Battle Creek VAMC treatment records, consultations, and notes reveals that examiners reported that the Veteran had a problem of insomnia related to another mental disorder. As to this mental disorder, the VAMC records largely reitered findings and points in prior VA treatment records. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that service connection for the Veteran's sleep disorder, to include as an undiagnosed illness associated with service in the Persian Gulf.is not warranted. The post-service evidence establishes that the Veteran experiences sleep impairment, which is episodic in nature. However, there is no credible evidence that he had a sleep disorder of any kind-sleep apnea, chronic fatigue syndrome, insomnia, or sleep impairment-during service and there is no credible evidence linking a sleep disorder to service. Moreover, no credible medical evidence has supported the contention that sleep disorder is an undiagnosed illness associated with service in the Persian Gulf (or for that matter the result of radiation or asbestos exposure). The Veteran's contention that developed "sleep impairment" in 1993 or 1994 during service is inconsistent with the service records. Although the Veteran has maintained that his sleep disorder was incurred in service, this assertion is inconsistent with other, more probative evidence of record. See Caluza, supra. In this regard, the Board finds that the March 2016 VA examination report offers the strongest and most persuasive evidence regarding the etiology of the Veteran's sleep disorder. As set forth above, the March 2016 VA examiner opined that the Veteran's the Veteran's sleep disorder was less likely than not incurred in or caused by an in-service injury, event, or illness. Moreover, the examiner noted that the Veteran has never received a diagnostic impression of sleep apnea; and, moreover, did not and does not have symptoms of sleep apnea. Insomnia and broken sleep cycles, according to the examiner, are symptoms of the Veteran's diagnosed anxiety disorder, with no connection to active service. In summary, the evidence of record does not support that the Veteran's sleep disorder was incurred in or aggravated by active service, foreclosing the possibility of nexus between sleep disorder and active service. And, the evidence of record does not support a finding that slap disorder us an undiagnosed illness associated with service in the Persian Gulf. The preponderance of evidence is against the Veteran's claim and there is no doubt to be resolved. See 38 U.S.C. § 5107(b) (2012); Gilbert, supra. 5. Headaches The Veteran contends that he is entitled to service connection for headaches, to include as an undiagnosed illness associated with service in the Persian Gulf. Inasmuch as the evidence noted above pertains to the Veteran's other contentions, the Board incorporates it with added commentary here. Review of the Veteran's STRs reveals that the Veteran reported a normal neuralgic condition in Reports of Medical Examination in February 1993 and August 1994. Also in February 1993 and August 1994, the Veteran reported that he did not have dizziness or fainting spells or a head injury. The Veteran's STRs are otherwise silent as to headaches. Review of the Veteran's VA treatment records reveal that he reported that he did not suffer from headaches in February 2006, May 2007, July 2007, July 2008, and September 2008. At the November 2010 VA examination, noted above, the Veteran stated that he first developed headaches in 2000 (six years after active duty). However, the examiner also noted that the Veteran claimed that headaches occurred in service and were evaluated by a medic; however, the Veteran did not remember whether a diagnosis was provided. Moreover, according to the examiner, the Veteran attributed these in-service headaches to problems associated with the removal of his wisdom teeth which occurred during service. The Veteran stated that his headaches usually began in the occipital zone and radiated forward. The Veteran reported that his current headaches occurred 3 to 4 times a week and lasted from 60 minutes to 90 minutes. He reported that he took ibuprofen and etodolac (occasionally) for pain and occasionally experienced nausea. The headaches, according to the examiner, were not of a type, severity, or pattern that was different from a premorbid state. The examiner opined that the Veteran's headaches, likely tension headaches, are less likely as not caused by or the result of an in-service event or undiagnosed illness and radiation exposure. VA treatment records from September 2012 and April 2014 reported that the Veteran did not have a systemic problem of headaches. Review of Battle Creek VAMC treatment records, consultations, and notes from 2014 to 2016, reveal that the Veteran complained of headache symptoms. These records include a diagnostic impression of cluster headaches. In the March 2016 VA examination opinion, noted above, the examiner opined that the Veteran headaches are less likely than not incurred in or caused by the claimed in-service injury, event or illness. After a comprehensive review of the claims file, the examiner noted that the Veteran reported that headaches were present with increases in anxiety, lasting up to 30 minutes. While the Veteran claimed an in-service head injury, the examiner reported that his STRs were silent for reports or treatment for any head injury. Furthermore, the examiner opined that VA had never treated the Veteran for headaches per se. The Veteran himself contended that headaches occur with increased anxiety. As such, anxiety itself was both the cause and the etiology of headaches. Finally, there is no evidence of record as to chronicity of care or treatment and the Veteran has not been in service since 1994. In March 2017, VA obtained a supplemental opinion concerning the etiology of the Veteran's headaches. The examiner opined that after a total reexamination of all of the Veteran's VA treatment records and VA examination reports, there were no clinical documents to confirm or deny that headaches were present in service. Therefore, according to the examiner, it is less likely as not that his claimed headaches had their onset in service. Even though the Veteran claimed that his headaches occurred in service, he did not supply any documentation from either civilian providers or from the VAMC relating to a headache disorder. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that service connection for the Veteran's headaches, to include as an undiagnosed illness associated with service in the Persian Gulf is not warranted. The post-service evidence establishes that the Veteran experiences headaches when his anxiety level escalates. However, there is no credible evidence that he had headaches of any kind during service and there is no credible medical evidence linking headaches to service. Moreover, no credible evidence has supported the contention that headache is an undiagnosed illness associated with service in the Persian Gulf (or for that matter the result of radiation or asbestos exposure). The Veteran's contention that he experienced headaches during service is inconsistent with the service records. Although the Veteran has maintained that his headache was incurred in service, this assertion is inconsistent with other, more probative evidence of record. See Caluza, supra. In this regard, the Board finds that the March 2016 VA examination report and March 2017 supplemental opinion, taken as a whole, offers the strongest and most persuasive evidence regarding the etiology of the Veteran's headaches. As set forth above, the March 2016 VA examiner, who also authored the March 2017 supplemental opinion, opined that the Veteran's headaches are less likely than not incurred in or caused by claimed in-service injury, event or illness. Furthermore, the examiner wrote that VA had never treated the Veteran for headaches per se. The Veteran himself contended that headaches occurred with increased anxiety. As such, according to the reasoning of the examiner, anxiety itself was both the cause and the etiology of headaches. Finally, there is no evidence of record as to chronicity of care or treatment and the Veteran has not been in service since 1994 In summary, the evidence of record does not support that the Veteran's headaches were incurred in or aggravated by active service, foreclosing the possibility of nexus between headaches and active service. And, the medical evidence of record does not support a finding that the Veteran's headache is an undiagnosed illness associated with service in the Persian Gulf. The preponderance of evidence is against the Veteran's claim and there is no doubt to be resolved. See 38 U.S.C.A. § 5107(b) (West 2014); Gilbert, supra. 6. Left Arm Numbness and Left Hand Numbness The Veteran contends that left arm numbness and left hand numbness were incurred in or aggravated by service. As both the lay and medical evidence of record address these issues conjunctively, the Board analyzes these two issues in one section of this decision. Review of the Veteran's STRs reveals that the Veteran reported normal upper extremities in Reports of Medical Examination in February 1993 and August 1994. Also in February 1993 and August 1994, the Veteran reported that he did not have bone, joint, or other deformities. The Veteran's STRs are otherwise silent as left arm numbness or left hand numbness or assessments indicative of left arm numbness or left hand numbness. Review of the Veteran's VA treatment records reveals that there were no complaints or concerns about left arm numbness, left hand numbness, or joint numbness altogether in June 2006, May 2007, July 2007, or July 2008. A January 2008 VA radiology report noted that the Veteran reported a clinical history of numbness in his left arm and his left hand. A subsequent VA treatment from the same month noted that the Veteran indicated that he injured himself at work the previous summer. He reported that he had sharp pain in the left side and lost grip in his left hand. He also indicated that his left arm tends to go numb while he is asleep. Subsequent VA progress notes and reports from September 2012 and April 2014 also reveal there were no complaints or concerns about left arm numbness, left hand numbness, or joint numbness altogether In the March 2016 VA examination, the examiner addressed both the Veteran's left arm contention and his left hand contention. The examiner provided a diagnostic impression of left hand numbness and neuralgia. The examiner noted that the Veteran stated that he has experienced left hand numbness that radiated into his left forearm every day since service. However, the Veteran did not report that he experienced peripheral nerve pain. Upon examination, the left hand's range of motion yielded abnormal results; however, the same results did not result after repetitive use. The examiner indicated that this numbness had the functional impact of presenting difficulty "picking up things or doing things" when the left hand and left forearm when numbness were present. In a subsequent opinion, the examiner opined that the numbness in the Veteran's left hand that radiates to his left forearm was less likely than not incurred in or caused by the claimed in-service, injury, event, or illness. The examiner opined that there was no documentation in the Veteran's STRs as to either left arm numbness or left hand numbness. The examiner further opined that the record contains no medical evidence that would indicate chronicity of either condition. Moreover, x-ray imaging of the affected regions yielded essentially normal results. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that service connection for both the Veteran's left arm numbness and left hand numbness are not warranted. Post-service evidence establishes that the Veteran has received diagnostic impressions of left hand numbness and neuralgia. This medical evidence also establishes that numbness radiates to his left forearm. However, there is no credible evidence that he had either left arm numbness or left hand numbness of any kind during service and there is no credible medical evidence linking either left arm numbness or left hand numbness to service. The Veteran's contention that he experienced left arm numbness and left hand numbness during service is inconsistent with the service records. Although the Veteran has maintained that his left arm numbness and left hand numbness were incurred in service, this assertion is inconsistent with other, more probative evidence of record. See Caluza, supra. In this regard, the Board finds that the March 2016 VA examination report offers the strongest and most persuasive evidence regarding the etiology of the Veteran's left arm numbness and left hand numbness. As set forth above, the March 2016 VA examiner opined that the Veteran's left arm numbness and left hand numbness were less likely than not incurred in or caused by claimed in-service injury, event or illness. Furthermore, the examiner wrote that the Veteran's STRs are silent as to any complaints of or treatment for either left hand numbness or left hand numbness. Finally, there is no evidence of record as to chronicity of care or treatment. In summary, the evidence of record does not support that either the Veteran's left arm numbness or left hand numbness were incurred in or aggravated by active service, foreclosing the possibility of nexus between left arm numbness and left hand numbness and active service. The preponderance of evidence is against the Veteran's claim and there is no doubt to be resolved. See 38 U.S.C. § 5107(b) (2012); Gilbert, supra. ORDER Entitlement to service connection for a left shoulder condition is denied. Entitlement to service connection for a respiratory disorder (alternatively characterized as a lung condition), to include as an undiagnosed illness associated with service in the Persian Gulf, is granted. Entitlement to service connection for left-sided chest pain disorder is denied. Entitlement to service connection for a sleep disorder, to include as an undiagnosed illness associated with service in the Persian Gulf, is denied. Entitlement to service connection for headaches, to include as an undiagnosed illness associated with service in the Persian Gulf, is denied. Entitlement to service connection for left arm numbness is denied. Entitlement to service connection for left hand numbness is denied. ____________________________________________ J. W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs