Citation Nr: 1806160 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 12-13 747 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUES 1. Entitlement to service connection for joint pain, to include claimed as due to an undiagnosed illness or as a medically unexplained chronic multisystem illness (MUCMI). 2. Entitlement to service connection for chronic fatigue, to include as due to an undiagnosed illness or as a MUCMI. 3. Entitlement to service connection for a sleep disorder, to include as due to an undiagnosed illness or as a MUCMI. 4. Entitlement to service connection for a gastrointestinal disorder, to include as due to an undiagnosed illness or as a MUCMI. 5. Entitlement to service connection for weight loss, to include as due to an undiagnosed illness or as a MUCMI. 6. Entitlement to service connection for a skin disorder, to include as due to an undiagnosed illness or as a MUCMI. 7. Entitlement to service connection for a chest/cardiovascular disorder, to include as due to an undiagnosed illness or as a MUCMI. 8. Entitlement to service connection for headaches, to include as due to an undiagnosed illness or as a MUCMI. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from May 1987 to December 1987 and from November 1990 to April 1991, and had additional service in the United States Marine Corps Reserves. These matters are before the Board of Veterans' Appeals (Board) on appeal from May 2010 and August 2010 rating decisions by the Albuquerque, New Mexico Regional Office (RO) of the Department of Veterans Affairs (VA). In December 2016, the case was remanded (by a Veterans Law Judge other than the undersigned-the case is now assigned to the undersigned) for additional development. The December 2016 Board remand also addressed a claim for service connection for a right ankle disorder. May 2017 (by the AMC) and August 2017 (by the RO) rating decisions granted the Veteran service connection for a right ankle disability and a related surgical scar, resolving that matter. The issue of service connection for a gastrointestinal disorder is being REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action on his part is required. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War Era. 2. The Veteran's chronic joint pain is not shown to be a manifestation of an "undiagnosed" illness, and is not shown to be etiologically related to his service. 3. The Veteran's claimed chronic fatigue or sleep disorder are not shown to be manifestations of an "undiagnosed" illness, and are not shown to be etiologically related to his service; he does not have a diagnosis of chronic fatigue syndrome. 4. The Veteran is not shown to have a disability manifested by weight loss. 5. The Veteran's chronic skin disorder is not shown to be a manifestation of an "undiagnosed" illness, and is not shown to be etiologically related to his service. 6. The Veteran's chronic chest or cardiovascular disorder is not shown to be a manifestation of an "undiagnosed' illness, and is not shown to be etiologically related to his service. 7. The Veteran's headaches are not shown to be a manifestation of an "undiagnosed" illness, and are not shown to be etiologically related to his service. CONCLUSIONS OF LAW 1. Service connection for a disability manifested by joint pain is not warranted. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131, 1137, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.317 (2017). 2. Service connection for chronic fatigue is not warranted. 38 U.S.C. §§ 1110, 1117, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2017). 3. Service connection for a sleep disorder, to include as due to an undiagnosed illness or MUCMI, is not warranted. 38 U.S.C. §§ 1110, 1117, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2017). 4. Service connection for a disability manifested by weight loss is not warranted. 38 U.S.C. §§ 1110, 1117, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2017). 5. Service connection for a skin disorder, to include as due to an undiagnosed illness or MUCMI, is not warranted. 38 U.S.C. §§ 1110, 1117, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2017). 6. Service connection for a chest or cardiovascular disorder, to include as due to an undiagnosed illness or MUCMI, is not warranted. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131, 1137, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.317 (2017). 7. Service connection for a disability manifested by headaches is not warranted. 38 U.S.C. §§ 1110, 1117, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. VA's duty to notify was satisfied by correspondence in September 2009, October 2009, and December 2009. See 38 U.S.C. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159. The claims file includes a May 2017 deferred rating decision noting the Board's December 2016 remand instruction that the VA examiners must address the January 2010 VA examination report suggesting a relationship between many of the Veteran's current symptoms and posttraumatic stress disorder (PTSD), which is service connected, and rated 100 percent. A January 2017 VA examiner advised that whether any of the claimed disorders is caused or aggravated by the service-connected PTSD is in the province of a behavioral health specialist and deferred to such provider. The AOJ then sought to have the Veteran scheduled for an examination by a behavioral health specialist. In July 2017 the Veteran refused to appear for such examination, and it is assumed that he does not wish to pursue that secondary service connection theory of entitlement with respect to the matters addressed herein. The Veteran has not raised any other issues with VA's duties to notify and assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) ("the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). The Board finds there has been substantial compliance with its December 2016 remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Legal Criteria, Factual Background, and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail every piece of evidence. See Gonzales v. West, 218 F, 3d, 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as deemed appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claims. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Disorders first diagnosed after discharge may be service connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Lay evidence may be competent evidence to establish in-service incurrence of an observable medical condition, injury, or event. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). For veterans who served in the Southwest Asia theater of operations during the Persian Gulf Era, service connection on a presumptive basis may be established for a qualifying chronic disability that became manifest during active duty or became manifest to a compensable degree within a prescribed presumptive period. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (e)(2). The term 'qualifying chronic disability' means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; or (B) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders (excluding structural gastrointestinal diseases). 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317 (a)(2)(i). The term "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). There must be "objective indications of a qualifying chronic disability," which 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. 38 C.F.R. § 3.317 (a)(1) and (3). A disability is considered "chronic" if it has existed for six months or more or if the disability exhibits intermittent episodes of improvement and worsening over a six-month period. The sixth 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. 38 C.F.R. § 3.317 (a)(4). Signs or symptoms which may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, fatigue, unexplained rashes or other dermatological signs or symptoms, headaches, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317 (b). With claims for service connection for a qualifying chronic disability under 38 C.F.R. § 3.317, the Veteran is not required to provide competent evidence linking a current disability to an event during service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Laypersons are competent to report objective signs of illness such as joint pain or fatigue. Id. at 9-10. The symptom is presumed to be related to service, and unlike a claim of "direct service connection," VA cannot impose a medical nexus requirement. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Undiagnosed pain may be the basis of an award of compensation under 38 U.S.C. § 1117. Joyner v. McDonald, 766 F.3d 1393, 1395 (Fed. Cir. 2014). Compensation shall not be paid for a chronic disability: (1) if there is affirmative evidence that the disability was not incurred during active military, naval, or air service in the Southwest Asia theater of operations; or (2) if there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations and the onset of the disability; or (3) if there is affirmative evidence that the disability is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 U.S.C. § 3.317(a)(7). The Veteran's service personnel records reflect that he served in the Southwest Asia Theater of operations during the Persian Gulf War Era. Joint pain The Veteran's STRs show complaints of various joint pains including knee pain in June 1987 at which time the assessment was right medial collateral ligament strain, and back pain in November 1987 at which time the assessment was lumbosacral strain. The STRs are otherwise silent for complaints, findings, treatment or diagnosis of joint pain. On February 2009 treatment, the Veteran reported nodules on his fingers with pain in the joints, and he was noted as being followed by rheumatology. On January 2010 VA examination, the Veteran reported intermittent stiffness and limited motion to his hands, feet, and shoulders, occurring every 3 to 4 months and lasting for 1 to 2 days, and that the symptoms occurred spontaneously. He reported intermittent mild back or neck pain. On physical examination, the results of motor, sensory, and reflex exams were normal; there were no abnormalities of spinal muscle; there was full range of thoracolumbar spine motion and there was no pain on motion; all four extremities were normal. In an August 2010 addendum, a reviewing VA examiner noted that the Veteran had no joint complaints on January 2010 examination. The diagnosis was that no joint complaints or findings were noted. On January 2017 VA examination, it was noted that the Veteran was treated for mild low back pain in April 2016 (after thrashing from nightmares) and for left thumb pain in November 2016. He reported that he was deployed during the Gulf War in 1990-1991 and saw combat. He reported that he first had a bilateral knee condition (which he attributed to training and duties)during boot camp in 1988-89 , He reported that he first had a back condition in 1991 related to nightmares, anxiety, and the circumstances of his deployment. On examination, he reported having bilateral knee pain 2 to 3 days per week lasting the balance of the day, and back pain 6 to 7 times a month possibly related to nightmares and usually lasting 48 hours. He reported formerly having sciatic symptoms in both legs but none in the past 3 years. Lumbar spine X-rays showed mild L5-S1 disc space narrowing. Right knee X-rays showed a proximate tibia osteochondroma, and left knee X-rays were unremarkable. Following a physical examination, the diagnoses included lumbar spine degenerative disc disease and bilateral knee strain. The examiner opined that these are conditions with a clear and specific etiology and diagnosis or diagnosable chronic multisymptom conditions with a partially explained etiology. The examiner stated that he was unable to relate the conditions to a specific substance exposure event experienced by the Veteran during service in Southwest Asia without resorting to mere speculation because he had no information of exposure to a specific substance known to cause the condition. Regarding the diagnosed conditions of back and bilateral knee joint pain, the examiner opined that these are less likely than not caused by or aggravated by or related to the Veteran's military service because there are no currently available records for the period 1992 to 2008 by which to establish chronicity of these conditions for that interval or to be able to establish a causal link between the conditions in service and the current conditions. The examiner noted that the post-service treatment records show intermittent back pain and remote hand pain with callouses and mention no other joint pains except for one mention of thumb pain. The Veteran is not shown to have an undiagnosed illness manifested by joint pain, nor is the claimed disability shown to be a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders). The VA examiner diagnosed lumbar spine degenerative disc disease and bilateral knee strain. Examination did not find objective signs or symptoms which may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness; the Veteran's reports of such are strictly subjective and have not been independently verified. 38 C.F.R. § 3.317 (a)(1) and (3). Accordingly, service connection for the claimed joint pain disability on a presumptive basis (as an undiagnosed illness/medically unexplained chronic multisymptom illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317) is not warranted. The Board finds that the service and postservice evaluation and treatment records, overall, provide evidence against this claim, indicating that the Veteran's current joint pain is not related to his service. The more probative evidence in the record is against a finding that any current joint pain was incurred in or caused by the Veteran's active service. Regarding the Veteran's contention that his joint pain is related to his service, he is a layperson and has not demonstrated or alleged expertise in establishing, or determining the cause of, a complex medical issue such as identifying the cause of such disability. This is a medical question beyond the realm of common knowledge and incapable of resolution by lay observation. The Veteran has not provided supporting medical opinion or medical treatise evidence; does not cite to supporting factual data; and does not provide an explanation for his opinion that his condition is related to his military service. Therefore, his lay opinion cannot be assigned any significant probative value. While a layperson is qualified to testify about observable matters (see Davidson, supra), the cause of a specific medical condition is a question beyond the scope of common knowledge or lay observation and requires medical training and expertise (see Jandreau, supra). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the claim of service connection for joint pain. Accordingly, the appeal in the matter must be denied. Chronic fatigue and a sleep disorder The Veteran's STRs are silent for any complaints, findings, treatment or diagnosis of chronic fatigue or a sleep disorder. On January 2010 VA examination, the Veteran reported having poor sleep that was improved on medications but he had nightmares and physical injuries in bed, with no memory of the episodes. He reported constant fatigue and sleepiness, with irritability at times, and no muscle aches or joint complaints. He reported that stress initiated his symptoms. Following a physical examination, the diagnoses included chronic fatigue, stress induced irritability, insomnia with poor sleep habits, and undiagnosed sleep disturbances due to PTSD. In an August 2010 addendum, a reviewing VA examiner noted the reported problems of constant fatigue, sleepiness, and being irritable at times, with no muscle ache or joint complaints, and the Veteran's report that stress initiated the symptoms. No further opinion was offered. On January 2017 VA examination, the Veteran reported that he first had a sleep and fatigue condition in 1991; he attributed the onset of the condition to the stress of deployment because he felt that he always had to be "on guard". He reported being unable to sleep for more than 4 hours per night for 25 years, with problems both falling and staying asleep 5 out of 7 nights per week. He reported being unable to sleep until 3:00 in the morning and only accomplishing about 50 percent of a normal day's activities. He reported daytime sleepiness. He reported being impaired by depression some days in getting things done. He reported that his symptoms varied depending on how well he has slept during the previous night. His girlfriend reported within the previous 6 months that he snored some but not every night, and no apnea spells were reported. He had not undergone a sleep study. The examiner noted that the Veteran did not have any findings, signs or symptoms attributable to chronic fatigue syndrome. On physical examination chronic fatigue syndrome was not diagnosed. The diagnosis was other malaise and fatigue with insomnia. The examiner opined that this is a condition with a clear and specific etiology and diagnosis or diagnosable chronic multisymptom condition with a partially explained etiology. The examiner stated that he was unable to relate the condition to a specific substance exposure event experienced by the Veteran during service in Southwest Asia without resorting to mere speculation because he had no information of exposure to a specific substance known to cause the condition. Regarding the diagnosed conditions of other malaise and fatigue with insomnia, the examiner opined that it is less likely than not caused by or aggravated by or related to the Veteran's military service because there are currently available no records for the period 1992 to 2008 by which to establish chronicity of the condition for that interval or to be able to establish a causal link between the in-service condition and the current condition. The Veteran is not shown to have an undiagnosed illness manifested by fatigue or sleep problems, nor is the claimed disability shown to be a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders). The VA examiner diagnosed other malaise and fatigue with insomnia. Examination did not find objective signs or symptoms which may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness; the Veteran's reports of such are strictly subjective and have not been independently verified. 38 C.F.R. § 3.317 (a)(1) and (3). Notably, chronic fatigue syndrome has not been diagnosed. Accordingly, service connection for the claimed chronic fatigue or sleep disorder on a presumptive basis (as undiagnosed illnesses/medically unexplained chronic multisymptom illnesses under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317) is not warranted. The Board finds that the service and postservice evaluation and treatment records, overall, provide evidence against these claims, indicating that the Veteran's current other malaise and fatigue with insomnia is not related to his service. The more probative evidence in the record is against a finding that any current chronic fatigue or sleep disorder was incurred in or caused by the Veteran's active service. Neither chronic fatigue nor a sleep disorder was manifested in service or clinically noted postservice prior to 2010, and service connection for either claimed disability on the basis that it became manifest in service and persisted is not warranted. Regarding the Veteran's contention that he has chronic fatigue or a sleep disorder that is related to his service, he is a layperson and has not demonstrated or alleged expertise in establishing, or determining the cause of, a complex medical issue such as identifying the cause of such disabilities. This is a medical question beyond the realm of common knowledge and incapable of resolution by lay observation. The Veteran has not provided supporting medical opinion or medical treatise evidence; does not cite to supporting factual data; and does not provide an explanation for his opinion that his condition is related to his military service. Therefore, his lay opinion cannot be assigned any significant probative value. While a layperson is qualified to testify about observable matters (see Davidson, supra), the cause of a specific medical condition is a question beyond the scope of common knowledge or lay observation and requires medical training and expertise (see Jandreau, supra). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the claims of service connection for chronic fatigue and a sleep disorder. Accordingly, the appeal in the matters must be denied. Weight loss The Veteran's STRs are silent for complaints, findings, treatment, or diagnosis of a disability manifested by weight loss. On January 2009 treatment, the Veteran denied any changes in weight. On January 2010 VA examination, the Veteran reported that his weight was variable with his PTSD symptoms; he reported that he would stop eating with episodes of anxiety, and in the previous year he had gained weight since being on medication. The examiner stated that no weight loss was confirmed on examination; the Veteran had in fact gained weight over the previous 6 months. Metabolic lab results were normal. There was no diagnosis of a disability manifested by weight loss. On October 2014, February 2015, August 2015, April 2016, and November 2016 treatment, the Veteran denied any weight loss. On January 2017 VA examination, the Veteran reported that his weight had fluctuated over the years, up and down by 10 pounds, and he had tried to lower his weight in the previous 5 years because he has diabetes. The examiner noted that in 2008 the Veteran's weight was 220 pounds, in 2009 it had increased to 242 pounds , and currently it was 225 pounds. He was being treated and monitored for diabetes mellitus. The examination found no current diagnosis of unintentional or pathologic weight loss. As noted by VA examiners the Veteran is not shown to have a disability manifested by weight loss-while his weight fluctuates, a disability manifested by weight loss simply is not shown. On the contrary, it appears that the Veteran is prone to undesired weight gain, and has sought to manage it as part of treatment for a disease (diabetes). Accordingly, he has not met the initial threshold requirement for substantiating a claim of service connection (evidence of the disability for which service connection is sought), and has not presented a valid claim of service connection in this matter. Skin disorder The Veteran's STRs note complaints of skin problems in September 1987, when the assessment was acute urticaria, and in January 1991, when the assessment was inguinal folliculitis. The STRs are otherwise silent for complaints, findings, treatment or diagnosis of a skin disorder. On January 2010 VA examination, the Veteran reported recurrent folliculitis on his hands, back, neck, and face, particularly around petroleum products, to which he reported having heavy exposure while serving in Kuwait. He took 4 showers per day and using Beta C cream with poor response, and overwashing precipitated his symptoms. On physical examination, a rash or other lesions were noted on the neck and anterior and posterior trunk, and folliculitis was noted on the extensor surface of the extremities. The diagnoses included folliculitis of the neck, trunk and extremities. On February 2015, August 2015, April 2016, and November 2016 treatment, the Veteran denied any skin rash. On January 2017 VA examination, the Veteran reported that after he returned from Desert Storm, he noticed that he was breaking out in rashes on the knuckles, hands, wrists, and back. On examination, he reported a condition recurring twice per month with bumps on the wrists and knuckles, usually lasting about a week, and below both breasts that are tender for 7 to 10 days. He reported using Icy Hot or Tiger Balm for over 6 weeks in the previous year. He reported that the wrist lesions were intermittent and those below the breasts were constant, and the conditions in both locations were diagnosed as cysts, which were red and tender. On physical examination, no skin lesions were found in the reported areas; rather, the Veteran had a right breast subcutaneous lump, a left breast fibrocystic consistency, and a hypertrophied left ulnar styloid process which the examiner opined is likely congenital. A left wrist X-ray was normal. Following a physical examination, there was no current diagnosis of skin pathology, and a current skin condition was not found. The examiner stated that a Gulf War opinion was not applicable as no skin pathology was diagnosed. Regarding the diagnosed conditions of right breast lump and fibrocystic left breast, the examiner opined that these are less likely than not caused by or aggravated by or related to the Veteran's military service because there are currently available no records for the period 1992 to 2008 by which to establish chronicity of these conditions for that interval or to be able to establish a causal link between the in-service conditions and the current conditions. The Veteran is not shown to have an undiagnosed illness manifested by skin symptoms, nor is the claimed disability shown to be a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders). The VA examiner diagnosed right breast lump and fibrocystic left breast. Examination did not find objective signs or symptoms which may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness; the Veteran's reports of such are strictly subjective and have not been independently verified. 38 C.F.R. § 3.317 (a)(1) and (3). Accordingly, service connection for the claimed skin disorder on a presumptive basis (as an undiagnosed illness/medically unexplained chronic multisymptom illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317) is not warranted. The Board finds that the service and postservice evaluation and treatment records, overall, provide evidence against this claim, indicating that the Veteran's current skin disorder is not related to his service. The more probative evidence in the record is against a finding that any current skin disorder was incurred in or caused by the Veteran's active service. A chronic skin disorder was not manifested in service or clinically noted postservice prior to 2010, and service connection for a skin disorder on the basis that it became manifest in service and persisted is not warranted. Regarding the Veteran's contention that he has a skin disorder that is related to his service, he is a layperson and has not demonstrated or alleged expertise in establishing, or determining the cause of, a complex medical issue such as identifying the cause of such disability. This is a medical question, beyond the realm of common knowledge and incapable of resolution by lay observation. The Veteran has not provided supporting medical opinion or medical treatise evidence; does not cite to supporting factual data; and does not provide an explanation for his opinion that his condition is related to his military service. Therefore, his lay opinion cannot be assigned any significant probative value. While a layperson is qualified to testify about observable matters (see Davidson, supra), the cause of a specific medical condition is a question beyond the scope of common knowledge or lay observation and requires medical training and expertise (see Jandreau, supra). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the claim of service connection for a skin disorder. Accordingly, the appeal in the matter must be denied. Chest or cardiovascular disorder The Veteran's STRs are silent for complaints, findings, treatment or diagnosis of a chest or cardiovascular disorder. On June 1994 treatment, the Veteran complained of mid-sternal discomfort that began over the weekend; he had no prior history of cardiac problems; the impression was chest pain, probably chest wall pain or mild pleurisy. On January 2010 VA examination, the Veteran reported intermittent recurrent chest pains. He was examined with an EKG and was noted to have high cholesterol and was placed on Simvastatin. He reported that the condition seemed to be related to stress, rage, and yelling, and he had no problems with vigorous exercise. He reported having a stress test with thallium that was negative. On physical examination, there was no evidence of congestive heart failure or pulmonary hypertension; heart sounds of S1 and S2 were present and rhythm was regular. Heart size was shown to be normal by X-ray. March 2009 ECG/Holter/Echo laboratory findings were cited as showing a normal myocardial perfusion scan and normal resting systolic function. The diagnoses included stress induced chest discomfort, non-cardiac. On February 2015, August 2015, April 2016, and November 2016 treatment, the Veteran denied any chest pain. On January 2017 VA examination, the Veteran reported that he first had a chest symptom condition in 1989 associated with dyspnea after running while in service. He reported that the condition was worse after deployment, which attributed to possibly breathing chemicals and fumes. He reported that the condition had stayed the same over the years. The examiner noted that the Veteran has not been diagnosed with any heart or vascular disease. The Veteran reported that he had had a normal stress test, and that his mother has myocardial bridging and experiences chest tightness. On examination, he reported that once a week he gets shortness of breath and chest pain during moderate exertion lasting 30 to 60 minutes after activity severity of 7/10, after 30 minutes on the treadmill or with brisk walking; the pain is below and between both breasts with no radiation. He reported also having nausea, weakness in the limbs, throbbing in the legs, and weakness in the hands. He reported that the condition is also associated with anxiety. An EKG was normal. Following a physical examination, no diagnosis of heart pathology was rendered; the diagnosis was thoracic muscle strain. The examiner opined that this is a condition with a clear and specific etiology and diagnosis or diagnosable chronic multisymptom condition with a partially explained etiology. The examiner opined that he was unable to relate the condition to a specific substance exposure event experienced by the Veteran during service in Southwest Asia without resorting to speculation because he was disposed of no information of exposure to a specific substance known to cause the condition. Regarding the diagnosed condition of thoracic muscle strain, the examiner opined that it is less likely than not caused by or aggravated by or related to the Veteran's military service because there are currently available no records for the period 1992 to 2008 by which to establish chronicity of the condition for that interval or to be able to establish a causal link between the in-service condition and the current condition. The examiner noted that postservice treatment records do not show that chronic or recurrent chest pain was reported. The Veteran is not shown to have an undiagnosed illness manifested by chest or cardiovascular symptoms, nor is the claimed disability shown to be a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders). The VA examiner diagnosed thoracic muscle strain. Examination did not find objective signs or symptoms which may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness; the Veteran's reports of such are strictly subjective and have not been independently verified. 38 C.F.R. § 3.317 (a)(1) and (3). Accordingly, service connection for the claimed chest or cardiovascular disability on a presumptive basis (as an undiagnosed illness/medically unexplained chronic multisymptom illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317) is not warranted. The Board finds that the service and postservice evaluation and treatment records, overall, provide evidence against this claim, indicating that the Veteran's current chest or cardiovascular disorder is not related to his service. The more probative evidence in the record is against a finding that any current chest or cardiovascular disorder was incurred in or caused by the Veteran's active service. A chest or cardiovascular disorder was not manifested in service or clinically noted postservice prior to 1994, and service connection for a chest or cardiovascular disorder on the basis that it became manifest in service and persisted is not warranted. Regarding the Veteran's contention that his chest or cardiovascular disorder is related to his service, he is a layperson and has not demonstrated or alleged expertise in establishing, or determining the cause of, a complex medical issue such as identifying the cause of such disability. This is a medical question, beyond the realm of common knowledge and incapable of resolution by lay observation. The Veteran has not provided supporting medical opinion or medical treatise evidence; does not cite to supporting factual data; and does not provide an explanation for his opinion that his condition is related to his military service. Therefore, his lay opinion cannot be assigned any significant probative value. While a layperson is qualified to testify about observable matters (see Davidson, supra), the cause of a specific medical condition is a question beyond the scope of common knowledge or lay observation and requires medical training and expertise (see Jandreau, supra). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the claim of service connection for a chest or cardiovascular disorder. Accordingly, the appeal in the matter must be denied. Headaches The Veteran's STRs are silent for complaints, findings, treatment, or diagnosis of headaches. On January 2010 VA examination, the Veteran reported having stress headaches every 2 days, mostly frontal and bilateral. He reported that in the previous 2 to 3 years, with an increase in PTSD symptoms, he had headaches once per week and he stressed over his general condition. On physical examination, neurologic findings were normal. The diagnoses included classic tension headaches, improving, specified as frontal-occipital headaches during times of stress. In June 2012 the Veteran sought emergency room treatment for complaints of a frontal headache, blurred and double vision, lethargy and depression for 6 weeks; he reported that he did not normally get headaches. On February 2015, August 2015, April 2016, and November 2016 treatment, he denied any headaches. On January 2017 VA examination, the Veteran reported that he first had a headache condition in 1992-1993; he attributed the onset of the condition to concussions, the first of which he incurred in 1981 prior to service playing volleyball in high school, the second of which he incurred in basic training but it was not documented, and the third of which he incurred during IT training from falling off a bunk bed. He reported that he felt dizzy for 3 days after the fall but he did not see a medical provider, and the condition never completely resolved. He reported getting a headache 6 to 10 times per month, usually lasting about 10 to 12 hours, with one incapacitating headache per month with interruption of activity lasting about an hour. He reported that the headaches are triggered by anxiety spells. He took ibuprofen, gabapentin, and buspirone. The diagnosis was nonspecific headaches. The examiner opined that this is a condition with a clear and specific etiology and diagnosis or diagnosable chronic multisymptom condition with a partially explained etiology. The examiner stated that he was unable to relate the condition to a specific substance exposure event experienced by the Veteran during service in Southwest Asia without resorting to mere speculation because he was disposed of no information of exposure to a specific substance known to cause this condition. Regarding the diagnosed condition of headaches, the examiner opined that it is less likely than not caused by or aggravated by or related to the Veteran's military service because there are currently available no records for the period 1992 to 2008 by which to establish chronicity of the condition for that interval or to be able to establish a causal link between the in-service condition and the current condition. The Veteran is not shown to have an undiagnosed illness manifested by headaches, nor is the claimed disability shown to be a medically unexplained chronic multi-symptom illness. The VA examiner diagnosed nonspecific headaches. Examination did not find objective signs or symptoms which may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness; the Veteran's reports of such are strictly subjective and have not been independently verified. 38 C.F.R. § 3.317 (a)(1) and (3). Accordingly, service connection for the claimed headache disability on a presumptive basis (as an undiagnosed illness/medically unexplained chronic multisymptom illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317) is not warranted. The Board finds that the service and postservice evaluation and treatment records, overall, provide evidence against this claim, indicating that the Veteran's current headaches are not related to his service. The more probative evidence in the record is against a finding that any current headache disorder was incurred in or caused by the Veteran's active service. A chronic headache disability was not manifested in service or clinically noted postservice prior to 2010, and service connection for headaches on the basis that it became manifest in service and persisted is not warranted. Regarding the Veteran's contention that his headaches are related to his service, he is a layperson and has not demonstrated or alleged expertise in establishing, or determining the cause of, a complex medical issue such as identifying the cause of such disability. This is a medical question beyond the realm of common knowledge and incapable of resolution by lay observation. The Veteran has not provided supporting medical opinion or medical treatise evidence; does not cite to supporting factual data; and does not provide an explanation for his opinion that his condition is related to his military service. Therefore, his lay opinion cannot be assigned any significant probative value. While a layperson is qualified to testify about observable matters (see Davidson, supra), the cause of a specific medical condition is a question beyond the scope of common knowledge or lay observation and requires medical training and expertise (see Jandreau, supra). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the claim of service connection for headaches. Accordingly, the appeal in the matter must be denied. ORDER Service connection for joint pain, to include as due to an undiagnosed illness or MUCMI, is denied. Service connection for chronic fatigue, to include as due to an undiagnosed illness or MUCMI, is denied. Service connection for a sleep disorder, to include as due to an undiagnosed illness or MUCMI, is denied. Service connection for weight loss, to include as due to an undiagnosed illness or MUCMI, is denied. Service connection for a skin disorder, to include as due to an undiagnosed illness or MUCMI, is denied. Service connection for a chest or cardiovascular disorder, to include as due to an undiagnosed illness or MUCMI, is denied. Service connection for headaches, to include as due to an undiagnosed illness or MUCMI, is denied. REMAND Under 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317 (a)(2)(i), service connection for irritable bowel syndrome (IBS) may be established on a presumptive basis if a veteran with such diagnosis served in the Southwest Asia Theater of operations during the Persian Gulf War Era. Here, the Veteran served in Southwest Asia during the Persian Gulf War Era. However, with respect to his claim of service connection for a gastrointestinal disorder, there is conflicting evidence as to whether or not he has IBS. On January 2010 VA gastrointestinal examination, IBS was diagnosed; colonoscopy was noted to have found polyps and mentioned irritable bowel syndrome. Subsequent VA treatment/examination records do not show a diagnosis of IBS. On January 2017 VA examination, the Veteran reported that he had colitis during deployment in 1991 (and that he underwent diagnostic studies about 6 or 7 years prior to the examination, including colonoscopy which showed colitis). There was no current diagnosis of irritable bowel syndrome or other functional gastrointestinal disorder. The examiner did not comment on the January 2010 diagnosis of IBS (or indicate why the diagnosis may have been invalid). A clarifying medical opinion to reconcile the conflicting medical evidence is necessary. Accordingly, the case is REMANDED for the following: 1. The Veteran's claims file should be returned to the January 2017 VA examiner for review and an addendum opinion that addresses the medical question remaining. [If further examination of the Veteran is deemed necessary for the opinion sought, such should be arranged.] Based on a review of the record (and examination/interview of the Veteran, if such was found necessary), the examiner should offer an opinion that responds to the following: Does the Veteran have (or at any time during the pendency of this claim is he shown to have had) IBS? If so, please identify the manifestations that establish that diagnosis. If not, please identify the manifestations necessary to establish for that diagnosis that are found lacking. The must explain the rationale for the opinion in detail (specifically expressing, with rationale as sought above) agreement or disagreement with the January 2010 diagnosis of IBS [i.e., if that diagnosis is invalid, explaining why that is so]. If the January 2017 VA examiner is unavailable, another the record should be forwarded to another appropriate physician for review (and the opinion requested), with a new VA examination scheduled only if deemed necessary by the provider. 2. The AOJ should then review the record, ensure that the development sought is completed as requested, and readjudicate the claim. If the benefit sought remains denied, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and his representative opportunity to respond, and return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs