Citation Nr: 1804685 Decision Date: 01/24/18 Archive Date: 02/05/18 DOCKET NO. 13-00 566 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a skin disorder of the hands and feet (claimed as rashes and blisters of the hands and feet). 2. Entitlement to service connection for fatigue. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD K.M. Walker, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from July 1989 to May 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2011 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board notes that the RO previously denied the claims for service connection for a skin disorder and fatigue in April 2004 and March 2010 rating decisions. In May 2010, the Veteran requested that his claims be reopened and submitted a military personnel record showing that that he had service in Saudi Arabia, which was not established at the time of the prior rating decisions. Therefore, new and material evidence is not needed to reopen the previously denied claims. Rather, the claims must be reviewed on a de novo basis. 38 U.S.C. § 7105; 38 C.F.R. § 3.156(c). The Veteran had requested a hearing before the Board. However, the Veteran withdrew his hearing request in November 2015. Thus, there is no outstanding hearing request. The Board remanded the claims for further development in November 2016. The case has since been returned for appellate review. The Board also notes that the Veteran's appeal originally included the issue of entitlement to service connection for microcytosis. However, the Board denied that claim in a November 2016 decision. Therefore, the issue is not currently before the Board. This appeal was processed using the Veterans Benefits Management System (VBMS) electronic claims processing systems. Accordingly, any future consideration of this Veteran's case should take into account the existence of these electronic records. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran was afforded a VA examination in September 2017 in connection with his claim for service connection for a skin disorder. The examiner diagnosed him with dyshidrotic eczematous dermatitis of the hands and tinea pedis and noted that both disorders are medically explainable medical conditions. She opined that both disorders were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In so doing, she indicated that the service treatment records did not document tinea manus or tinea pedis or symptoms of such disorders. She also noted that the Veteran did not have tinea manus on examination, but rather had dyshidrotic eczematous dermatitis of the hands. The examiner concluded that there was no cause or relationship between the Veteran's current skin disorder and his military service, referenced medical literature, and cited to other causes, including allergens and irritants. However, the examiner did not address whether the Veteran's current skin disorders could be related to any environmental exposures during his service in Saudi Arabia. See e.g. July 2009 VA Form 21-526; July 2010 VA examination report (exposed to smoke in Saudi Arabia). Therefore, the Board finds that an additional medical opinion is needed. The Veteran was also afforded a VA examination in May 2017 in connection with his claim for service connection for fatigue. The examiner stated that she could not resolve this issue without resort of mere speculation due to the fact that the Veteran has other chronic medical conditions that can present with fatigue, such as very poorly controlled diabetes, hypothyroidism, depression, alcohol abuse, autonomic neuropathy, and nephropathy. However, she also noted that the onset of most of those conditions was many years after the onset of his fatigue. Contrarily, later in the report, she concluded that it was less likely than not that the Veteran's fatigue was incurred in or caused by the claimed in-service injury, illness, or event in service. In so doing, the examiner indicated that she unable to identify any objective evidence in the service treatment records documenting continuous medical evaluation, management, or treatment for any medical conditions that might be related to the current complaints of fatigue. Nevertheless, the Board notes that the examiner did not address the Veteran's claim that he had fatigue in service for which he was disciplined. See September 2009 statement. Nor did she discuss whether his current fatigue could be related to any environmental exposures during his service in Saudi Arabia. See e.g. July 2009 VA Form 21-526; July 2010 VA examination report (exposed to smoke in Saudi Arabia). Therefore, the Board finds that an additional medical opinion is needed. In addition, the Veteran has reported receiving treatment through VA since shortly after his separation from service, and the September 2017 VA examiner referenced a November 1993 VA treatment record pertaining to a skin medication. However, the claims file does not appear to contain any VA medical records dated prior to September 2001. Thus, on remand, the AOJ should secure any outstanding records. Accordingly, the case is REMANDED for the following action: 1. The AOJ should request the Veteran provide the names and addresses of any and all healthcare providers who have provided treatment for his skin and fatigue. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims files. The AOJ should also secure any outstanding VA treatment records, to include any records dated from May 1992 to September 2001. 2. After completing the preceding development, the Veteran should be afforded a VA examination to determine the nature and etiology of any skin disorder of the hands and feet that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not the Veteran has a skin disorder of the hands and feet that is related to his military service, to include any symptomatology therein and any environmental exposures while serving in Saudi Arabia. See e.g. July 2009 VA Form 21-526; July 2010 VA examination report (exposed to smoke in Saudi Arabia). In rendering the opinion, the examiner should not resort to mere speculation, but rather should consider that the phrase "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. Thus, unless the examiner concludes that the current disability is either likely or unlikely the result of an event, injury, or disease incurred in service, the examiner should state whether it is at least as likely that the current disability is the result of an event, injury, or disease incurred in service as opposed to its being the result of some other factor or factors. A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability is viewed about its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. After obtaining any outstanding records, the Veteran should be afforded a VA examination to determine the nature and etiology of any fatigue that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should indicate whether the criteria are met for a diagnosis of chronic fatigue syndrome. If not, the examiner should identify any other diagnosis pertaining to his fatigue. For any diagnosis identified for fatigue, the examiner should opine as to the likelihood (likely, unlikely, at least as likely as not) that the disorder manifested during active service or is otherwise causally or etiologically related to his active service, to include any symptomatology therein and any environmental exposures while serving in Saudi Arabia. See e.g. July 2009 VA Form 21-526; July 2010 VA examination report (exposed to smoke in Saudi Arabia). In so doing, the examiner should address the Veteran's contention that he had fatigue in service for which he was disciplined. See September 2009 statement and military personnel records. If any symptomatology cannot be attributed to a known clinical diagnosis, the examiner should describe pertinent objective findings related to such symptomatology. In rendering the opinion, the examiner should not resort to mere speculation, but rather should consider that the phrase "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. Thus, unless the examiner concludes that the current disability is either likely or unlikely the result of an event, injury, or disease incurred in service, the examiner should state whether it is at least as likely that the current disability is the result of an event, injury, or disease incurred in service as opposed to its being the result of some other factor or factors. A clear rationale for all opinions would be helpful, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability is viewed about its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. After completing the above actions, the AOJ should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. 5. When the development requested has been completed, the case should be reviewed by the AOJ on the basis of additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ J.W. ZISSIMOS 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) (2017).