Citation Nr: 18142975 Decision Date: 10/17/18 Archive Date: 10/17/18 DOCKET NO. 10-41 797 DATE: October 17, 2018 ORDER Entitlement to an initial evaluation in excess of 20 percent for the residuals of a right shoulder injury for the period prior to July 6, 2010, is denied. Entitlement to an evaluation of 30 percent, and no higher, for the residuals of a right shoulder injury for the period beginning July 6, 2010, is granted. Entitlement to an initial evaluation in excess of 10 percent for a chronic right knee strain is denied. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) for the period prior to September 23, 2011, is denied. REMANDED Entitlement to service connection for a pelvic disability, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a disability manifested by muscle and joint pain (to include fibromyalgia), to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a right elbow disability, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a back disability, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a left knee disability, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a disability manifested by fevers and chills, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a disability manifested by immune weakness, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for rhinitis, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a lung disability, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a heart disability, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a gastrointestinal disability, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a kidney disability, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a disability manifested by weight gain, to include as due to an undiagnosed illness, is remanded. FINDINGS OF FACT 1. For the period prior to July 6, 2010, the Veteran’s dominant right arm shoulder disability did not limit his arm to midway between his side and his shoulder level. 2. Resolving all reasonable doubt in the Veteran’s favor, for the period beginning July 6, 2010, the Veteran’s dominant right shoulder disability has caused limitation in motion in that arm that more closely approximates a limitation in motion of that arm to midway between his side and shoulder level than it does a limitation in motion of that arm to shoulder level. 3. The Veteran’s chronic right knee strain has not been manifested by a limitation of flexion to 30 degrees or any limitation in flexion, and it has not been manifested by limitation in extension, dislocation of the semilunar cartilage with frequent episodes of “locking,” pain, and effusion, recurrent subluxation or lateral instability, ankylosis, impairment of the tibia and fibula with knee or ankle disability, or genu recurvatum. 4. For the period prior to September 23, 2011, the Veteran’s PTSD did not result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and an inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 20 percent for the residuals of a right shoulder injury for the period prior to July 6, 2010, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DC or Code) 5201, 5203. 2. The criteria for entitlement to an evaluation of 30 percent, and no higher, for the residuals of a right shoulder injury for the period beginning July 6, 2010, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5201, 5203. 3. The criteria for entitlement to an initial evaluation in excess of 10 percent for a chronic right knee strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256-5263. 4. The criteria for entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder for the period prior to September 23, 2011, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty in the United States Army from March 1995 to January 2002 and from December 2003 to March 2005. This matter comes before the Board of Veterans’ Appeals (Board) from rating decisions issued by a Regional Office (RO) of the Department of Veterans Affairs (VA) in July 2008, September 2008, September 2010, December 2010, and May 2012. In July 2018, the Board received a motion to advance the Veteran’s claim on the docket due to financial hardship. In light of the supporting documentation provided by the Veteran, the Board grants the motion to advance the appeal on the docket. The Board previously considered the Veteran’s appeal in May 2016. At that time, the Board granted an evaluation of 70 percent for PTSD for the period from September 23, 2011, through September 1, 2015, but denied the claim for an evaluation higher than 50 percent for PTSD for the period prior to September 23, 2011. The Board also remanded the other issues on appeal. The Veteran appealed the denial of an evaluation in excess of 50 percent for PTSD prior to September 2011 to the United States Court of Appeals for Veterans Claims (Court). In October 2017, the Court issued a memorandum decision that set aside the portion of the May 2016 Board decision that denied an initial evaluation in excess of 50 percent for PTSD for the period prior to September 23, 2011, and remanded the matter to the Board for readjudication. Recent correspondence from the Veteran also indicates that he no longer wishes to proceed with his other appeals for VA compensation. In April 2017, the RO attempted to schedule examinations pursuant to the Board’s May 2016 remand directives. However, in a telephone conversation with a VA employee that occurred the following month, the Veteran stated that he would not attend further VA medical examinations. He stated that he did not wish to pursue any other issues with VA for compensation purposes after the promulgation of a rating decision awarding benefits resulting in a retroactive award of greater than $100,000. That VA employee explained that a letter would be sent to him requesting a written statement regarding his wish to withdraw his claims. No response to that correspondence appears in the record. As a withdrawal of claims must be either in writing or on the record at a hearing, the Board may not dismiss the remaining claims and must adjudicate the claims that are properly before the Board on the merits. 38 C.F.R. § 20.204. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2016). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). On a claim for increased rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found; such separate disability ratings are known as staged ratings. Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. 1. Entitlement to an initial evaluation in excess of 20 percent for the residuals of a right shoulder injury for the period prior to July 6, 2010 The Veteran’s right shoulder disability was initially evaluated pursuant to Diagnostic Code 5203, which is used for impairment of the clavicle or scapula. It was subsequently evaluated under DC 5201, which is used for limitation of motion of the arm. Under DC 5203, a 20 percent evaluation is assigned with signs of nonunion with loose movement of the clavicle or scapula or with dislocation of the clavicle or scapula. A 20 percent evaluation under Code 5201 is assigned when there is limitation of movement at shoulder level. When the shoulder in question is the dominant extremity, a 30 percent evaluation is warranted under DC 5201 when there is limitation of motion of the arm midway between side and shoulder level. Finally, DC 5201 includes a 40 percent evaluation when the limitation of the dominant arm is to 25 degrees from the side. 38 C.F.R § 4.71a. The record indicates that the Veteran has primarily cited pain as the most significant shoulder-related symptom he experiences. At the January 2008 VA medical examination, the Veteran noted that there had been a recent progression in his severe pain and dysfunction. He also indicated that his pain impaired his ability to work overhead with his right arm, lift, reach, and throw and stated that he had more shoulder pain in cold weather. In a statement from the Veteran’s former spouse from the same month, she explained that the Veteran’s right shoulder injury continued to give him problems and pain. The Veteran has been consistent in his reports of right shoulder pain and the Board finds no reason to doubt the credibility of his or his former spouse’s statements and they are clearly competent to report the observable symptoms of pain and difficulty with activities such as lifting, reaching, throwing, and overhead work. A review of the record, however, fails to uncover any evidence that either has suggested that the specific criteria for a rating in excess of 20 percent had been met for the period prior to July 6, 2010. Ultimately, the clinical records and examination reports do not contain any probative, competent, and credible evidence that those criteria are met and the Board finds that it must deny the claim for an increased evaluation for a right shoulder disability with respect to the period prior to July 6, 2010. For instance, at the January 2008 medical examination at which the Veteran reported difficulty with overhead reaching and cold-weather pain, he did exhibit pain and limitation of motion. Range of motion testing found him to be able to forward flex to 125 degrees, he could abduct to 122 degrees with pain beginning at 95 degrees, and he was able to both internally and externally rotate his right arm to 90 degrees. After three repetitions, the Veteran’s forward flexion was limited to 102 degrees and his abduction to 83 degrees, but he had no change in the motion of his internal or external rotation. The Veteran also was found to have 4/5 strength of his abductor and adductors in addition to tenderness to palpation and swelling. These clinical findings most closely approximate the criteria for a 20 percent rating. Namely, the Veteran was found to be most impaired in his abduction to 83 degrees after repetitive motion testing, which on its face appears significantly closer to the criteria for a 20 percent evaluation under DC 5201 of limitation to shoulder level than the criteria for a 30 percent evaluation under that Code of limitation in the dominant arm to midway between side and shoulder level. Similarly, there is no evidence in that examination report that the Veteran had recurrent dislocation with frequent episodes and guarding of all arm movements, as would be required to warrant a higher evaluation under DC 5202. The remainder of the examination reports relating to the period prior to July 6, 2010, include similar or even milder clinical abnormalities of the right shoulder. For instance, although the Veteran was found to have a painful arc at 70 degrees in his shoulder at a May 2008 clinical evaluation, that abnormal finding again appears to more closely approximate the criteria for a 20 percent evaluation, which is assigned with limitation of a dominant arm’s motion to shoulder level. Likewise, at clinical evaluations in August and December 2008, the Veteran had less limitation in the abduction of his shoulder, with full range of motion at the August examination and pain triggered only at 90 degrees at the December evaluation. At a subsequent VA medical visit in July 2009, the Veteran again had a mild painful arc in addition to mild subacromial bursa bilaterally in the shoulder, but there was no report of limitation of motion in the right arm’s abduction to midway between the side and shoulder level. Despite the Veteran’s pain and other symptoms, these consistent examination reports and clinical findings represent significant probative and competent evidence that the Veteran was able to raise his right arm to roughly shoulder level throughout the period prior to July 6, 2010. The Board acknowledges that he did demonstrate pain on occasion beyond 70 degrees, however even at that clinical evaluation, that overall disability picture and functional deficit appears to most closely approximate the criteria for a 20 percent evaluation. More specifically, 70 degrees of abduction is closer to the ability to move the arm to shoulder level than it is to a limitation to moving the arm only to midway between side and shoulder level. That May 2008 examination appears to demonstrate the most severe limitation of motion in the Veteran’s right arm at any point prior to July 6, 2010. Given this probative evidence and the consistently modest losses of range of motion demonstrated in the clinical record, the Board finds that the preponderance of the credible and probative evidence is against a finding that the criteria for an evaluation in excess of 30 percent were met prior to July 6, 2010. In making this finding, the Board has considered the holding in DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). That decision emphasizes that the Board must also consider whether weakness, pain, incoordination, or fatigability caused by repetitive use or flare-ups contribute to functional loss and warrant a higher evaluation. However, the evidence relating to the period prior to July 6, 2010, does not contain any contention or competent statement that the Veteran experienced additional loss of function in his arm either after repetitive use or during a flare-up. With no competent reports of such pain, weakness, incoordination, or fatigability and their resulting functional limitations, the Board does not find that a higher evaluation pursuant to DeLuca is warranted with respect to the period prior to July 6, 2010. 2. Entitlement to an evaluation in excess of 20 percent for the residuals of a right shoulder injury for the period beginning July 6, 2010 In contrast to the period prior to July 6, 2010, the evidence relating to the Veteran’s right shoulder beginning on that date suggest additional limitation in the functioning of that joint. At that time, the Veteran attended a VA medical examination at which he reported that his pain had progressively gotten worse since his initial injury and that he used NSAIDs and heat and cold treatments for relief. While he did report giving way, instability, stiffness, weakness, and decreased speed of motion, there were no reports at that examination of incoordination, episodes of dislocation or subluxation, deformity, effusions, or locking episodes. The Veteran also reported severe flare-ups in his symptoms that he described as occurring daily, lasting several hours in duration, and which were brought on with driving, any lifting, and any above-shoulder activity. Upon examination, the Veteran was not noted to have recurrent shoulder dislocations, but he did have crepitus, tenderness, pain at rest, and guarding of movement. Initial range of motion testing found the Veteran to be able to flex his right shoulder to 85 degrees, abduct to 80 degrees, rotate internally to 50 degrees, and rotate externally to 65 degrees. Notably, after repetitive use testing there was substantial additional loss of motion, with the Veteran’s abduction being further limited to only 0 to 60 degrees. The record does not contain significant ongoing reports of treatment for a right-shoulder disability in the subsequent year, but at a clinical evaluation in January 2016, he again was found to have decreased abduction with pain. Pursuant to the Board’s remand, the Veteran attended an additional VA medical examination to evaluate the severity of his right shoulder disability in September 2016. The Veteran again reported ongoing worsening of his shoulder pain in addition to difficulty making throwing motions or reaching forward with his dominant right arm. He also endorsed constant pain and loss of range of motion which caused him to avoid lifting heavy loads. Although he had reported experiencing flare-ups at the July 2010 VA examination, he was noted to have denied any such episodes at the September 2016 evaluation. Initial range of motion testing found forward flexion to 70 degrees, abduction to 65 degrees, external rotation to 40 degrees, and internal rotation to 90 degrees. Pain was also reported with passive motion along with localized tenderness or pain on palpation of the shoulder. Although the Veteran was evaluated after repeated use over time, the examiner stated that such use did not cause additional significant functional limitation due to pain, weakness, fatigability, or incoordination. In addition, the Veteran had a positive impingement test, external rotation test, and cross-body test but was not able to perform an empty can test or lift-off test. Finally, the examiner reported that the Veteran had no instability, dislocation, or labral pathology and that he did not have moderate or marked deformity of the humerus or loss of head, nonunion, or fibrous union of the humerus. Viewed as a whole, the Board finds that the probative, competent, and credible evidence relating to the functioning of the Veteran’s right shoulder since July 6, 2010, has been somewhat inconsistent. Specific range of motion testing of the Veteran’s ability to abduct his right shoulder also appears to fall between the criteria for a 20 percent evaluation and a 30 percent evaluation. While the 60 degrees measured at the July 2010 examination and the 65 degrees measured at the September 2016 evaluation appear to both be between shoulder level and midway between side and shoulder level, the Board finds that they are slightly closer to the presumable 45 degrees of the midway point between the Veteran’s side and shoulder level than they are to the 90 degrees of his shoulder level. This clinical evidence and the competent and credible reports from the Veteran that he has difficulty lifting heavy objects or reaching with his right arm lead the Board to find that the evidence is at least in equipoise regarding whether the overall disability picture more closely approximated the criteria for a 30 percent evaluation rather than a 20 percent evaluation since July 6, 2010. Resolving all reasonable doubt in the Veteran’s favor, the Board therefore finds that a rating of 30 percent, and no higher, is warranted since for the period beginning July 6, 2010. Although the Veteran has not specifically alleged that the criteria for a rating higher than 30 percent is warranted, the Board has nonetheless considered whether the evidence shows that those criteria are met. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). However, there is no competent report, contention, or statement that the Veteran is limited in moving his arm to 25 degrees or less to his side even during a flare-up in his symptoms or after repetitive use over time. As such, an evaluation in excess of 30 percent for the Veteran’s right-shoulder disability is not warranted at any point. 3. Entitlement to an initial evaluation in excess of 10 percent for a chronic right knee strain The Veteran’s chronic right knee strain has been assigned a 10 percent rating for the entire period on appeal under DC 5260. That code assigns different evaluations based upon the limitation in flexion of the leg. A noncompensable evaluation is assigned when there is limitation in flexion to 60. A 10 percent evaluation is warranted with flexion limited to 45 degrees. A 20 percent rating is assigned when there is limitation to 30 degrees. Finally, the criteria for a 30 percent evaluation are met when flexion is limited to 15 degrees. 38 C.F.R § 4.71a. A review of the record indicates that pain is the most significant symptom that the Veteran has attributed to his service-connected chronic right knee strain. At the July 2010 VA medical examination, he stated that his symptoms also included decreased speed, tenderness, and swelling, and he indicated that he experienced severe daily flare-ups in symptoms that lasted for minutes at a time and could occur with getting in and out of a car, going up and down stairs, or with prolonged sitting or standing. The Veteran also commented that his knee condition limited him to standing for only 15 minutes and he noted that he could walk more than one quarter of a mile but less than one mile. Despite these symptoms, the examiner reported that the Veteran did not endorse deformity, giving way, instability, stiffness, weakness, or incoordination. A review of the examination findings also indicates that despite the Veteran’s pain and other symptoms, the criteria for an evaluation in excess of 10 percent at that time were not met. Upon examination, the Veteran was found to have tenderness, guarding of movement, and positive clicks, snaps, and crepitus. However, he did not exhibit grinding, a mass behind the knee, instability, an abnormal gait or weight bearing, or any patellar or meniscus abnormality. X-ray images were also reportedly unremarkable. Range of motion testing found pain with active motion and the Veteran was able to flex from 0 to 95 degrees with normal extension. At primary care visits or evaluations at VA facilities for other treatment in October 2011 and January 2012, there were no reports of any of the limitation in motion in the Veteran’s knee. Rather, the Veteran was found to have full range of motion at each evaluation. He was again found to have full range of motion in his lower extremities at a clinical evaluation in July 2016. He also at that time had a symmetrical gait and was noted to be able to walk on heels, toes, and tandem walk without difficulty. Pursuant to the Board’s May 2016 remand, the Veteran attended an additional VA medical examination in September of that year. At that time, the Veteran reported continued pain in this joint along with swelling, increased intermittent warmth, and pain with motion. He also repeated that he does experience flare-ups in his symptoms that are accompanied by increased pain, swelling, and redness. The Veteran indicated that these flare-ups limit activity but were not related to activities, occur approximately twice per month, and last for approximately one day. The examiner who conducted that evaluation indicated that diagnostic imaging did not contain evidence of arthritis. Range of motion testing found the Veteran able to flex from 0 to 80 and extend from 80 to 0, with the limitation of motion found to also limit the speed that he can walk. The examiner also reported pain with both flexion and extension including with passive motion, pain with weight bearing, a small effusion in the right knee, tenderness to palpation or localized tenderness of the soft tissue, and crepitus. However, the Veteran did not have additional loss of range of motion after repetitive use testing and the examiner stated that although the examination occurred after repeated use of the right knee over time, there was no significant functional limitation due to pain, weakness, fatigability, or incoordination. The Veteran reported that he experienced intermittent swelling that the examiner stated did contribute to disability, but the examiner also explained that the history shin splints that the Veteran had did not affect his range of motion and actually had no current symptoms of shin splints. Finally, the examiner reported that the Veteran had no signs of instability and that there was no history of recurrent subluxation or lateral instability. The Board does not doubt the sincerity of the Veteran regarding the pain he experiences and finds that he is competent to report those observable symptoms. As such, his contentions regarding the severity of his right knee disability are entitled to some degree of probative weight. However, the Veteran’s contentions and the arguments presented by his representative must be evaluated in the context of the entire record. Here, the record contains numerous clinical examinations at which the Veteran had greater than 60 degrees of flexion and normal extension. The claims file is simply devoid of any competent reports from any examining or treating clinician that he has demonstrated the limitation in flexion to 30 degrees that would be necessary for the criteria for a higher evaluation under DC 5260 to be met. The Board finds these relatively consistent examination findings to be the most probative with respect to the question of whether those criteria are met. Given that there is no competent evidence that the Veteran has extension limited to 10 degrees or greater, the Board also finds that the criteria for a separate compensable rating for limitation of extension under DC 5261 are also not met. The Board has similarly considered whether separate ratings are warranted under Code 5257, due to recurrent subluxation or lateral instability, under DC 5258, due to dislocated semilunar cartilage, under DC 5262 due to impairment of the fibula and tibia, and DC 5263 for genu recurvatum. Although the Veteran suggested at the April 2009 hearing before a decision review officer that he had a meniscal condition, the exact diagnosis of his right knee disability is a medically complex question and there is no evidence in the record that the Veteran possesses the medical knowledge, training, or experience to provide a competent opinion on the precise diagnosis of his right knee disability. On the contrary, as stated above, the September 2016 VA medical examiner explicitly stated that the Veteran did not have a meniscus condition. As the record is otherwise devoid of any competent evidence showing ankylosis of the knee, recurrent subluxation or lateral instability, frequent episodes of “locking,” pain, and effusion into the joint due to dislocated semilunar cartilage, impairment of the tibia and fibula with even slight knee or ankle disability, or genu recurvatum, the Board does not find that separate compensable evaluations are warranted under DCs 5257, 5258, 5262, and 5263. The Board does not find that a higher evaluation is warranted due to any functional loss caused by pain, weakness, incoordination, or fatigability. On the contrary, the examiner who completed the September 2016 medical evaluation explicitly stated that the evaluation was occurring after repeated use over time of the right knee and that there was no such weakness, pain, incoordination, or fatigability contributing to functional loss. The Board also recognizes that that examiner also stated that flare-ups would in fact cause significant functional limitation due to pain, but that she was not able to describe the functional limitation in terms of range of motion because to do so would call for speculation given that the examination did not occur during a flare-up. Although the Veteran reported relatively rare instances of flare-ups at that September 2016 examination, he also reported much more frequent flare-ups in his symptoms at the July 2010 VA medical examination, as described above. Notwithstanding these reports, the Board ultimately does not find that such functional limitation warrants a higher limitation. Despite the reported at times daily flare-ups in symptoms, the claims file includes substantial evidence of medical treatment the Veteran has received in which there are no reports of significant functional deficits attributable to flare-ups in right knee symptoms. On the contrary, the Veteran has appeared to receive relatively infrequent care for knee-related symptoms despite receiving much more frequent care for other medical conditions and statements to treatment providers do not include any contentions that the Veteran experiences the frequency of severe flare-ups that were reported at the July 2010 VA medical examination. Given this evidence and reports in VA treatment notes that the Veteran has been able to maintain work as a cab driver, go hiking, and go to the movies with his family notwithstanding his flare-up in symptoms, the Board finds that the preponderance of probative evidence is against a finding that a higher evaluation is warranted. The Board has also considered the holding in Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). In that case, the Court found that if an examiner states that s/he cannot provide an opinion as to additional loss of motion during a flare-up without resorting to mere speculation because the examination is not being conducted during a flare-up, the examiner must make clear that s/he has considered all procurable data (i.e., the information regarding frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups elicited from the Veteran), but any member of the medical community at large could not provide such an opinion without resorting to speculation. Although the September 2016 examination report would appear at first glance to run afoul of the holding in Sharp, the Board ultimately does not find that a remand is warranted in this claim for corrective action. Namely, as explained above, the Veteran has stated that he no longer wishes to attend additional VA medical examinations or pursue any other claims for compensation purposes after the finalization of a May 2017 award for benefits in excess of $100,000. Given this clear statement regarding the Veteran’s desire to no longer attend VA medical examinations for compensation benefits, the Board finds that remanding the issue of entitlement to an increased evaluation for a right knee strain for the purposes of clarifying the effect of flare-ups would be fruitless and result in no additional benefit to the Veteran. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). Ultimately, for the reasons stated above, the Board finds that the preponderance of the probative, competent, and credible evidence is against a finding that the criteria for an evaluation in excess of 10 percent for a right knee strain have been met. As such, the Veteran’s claim must be denied and the doctrine of the benefit of the doubt is not for application. 4. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder for the period prior to September 23, 2011 For the period prior to September 23, 2011, the Veteran has been assigned a 50 percent evaluation for his PTSD pursuant to Diagnostic Code 9411, which is part of the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under the General Rating Formula, a 50 percent evaluation is warranted where the disorder is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory for example, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where the disorder is manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and an inability to establish and maintain effective relationships. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. A veteran “may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Symptoms listed in the General Rating Formula serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. They are not intended to constitute an exhaustive list. Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). In determining the appropriateness of the evaluations assigned to the Veteran’s disability, the Global Assessment of Functioning (GAF) scores assigned by medical providers will be discussed. However, while GAF scores are probative of the Veteran’s level of impairment, they are not to be viewed outside of the context of the entire record. Therefore, they will not be relied upon as the sole basis for an increased disability evaluation. A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41-50 contemplates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See DSM-IV at 44-47. A GAF score of 51-60 contemplates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). A GAF score of 61-70 contemplates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Id. As noted above, the Veteran seeks an increase in the 50 percent rating that has currently been assigned to his PTSD for the period prior to September 23, 2011. In a January 2008 statement, the Veteran contended that he has had anxiety attacks on the job and at an April 2008 VA medical examination he endorsed problems with hypervigilant behavior, difficulty relaxing, an exaggerated startle response, and problems sleeping. After returning to work in December 2008 after a short period on short-term disability, the Veteran explained to his treating VA clinician that he continued to be avoidant and withdrawn socially and got upset when officers he worked with were hurt or were involved in incidents. By March 2009, the Veteran stated that he was experiencing panic attacks several times per week, was jumpy most of the time, had difficulty with crowds and racing thoughts, and was angry and snapping at his children. The Veteran’s subsequent VA clinical records included similar reports of psychological symptoms through August 2011. The claims file also includes a March 2009 affidavit from the Veteran’s former spouse, in which she reported largely similar symptoms. She explained that the Veteran experienced panic attacks when in crowds, hearing loud noises, or seeing bright flashes. She also stated that the Veteran had social phobia with very few friends, had difficulty sleeping, and had mood swings or became irritable at the drop of a hat. The Board finds no reason to doubt the sincerity of either the Veteran or his former spouse in their reports and acknowledges that they are competent to report these observable psychological symptoms. As such, their reports of the Veteran’s psychological symptoms and functioning are entitled to some degree of probative weight. However, their statements must be considered in light of the entire record and all of the credible, competent, and probative evidence regarding the Veteran’s psychological functioning before September 2011. Although the record suggests that the Veteran had significant psychological symptoms before that time, the Board finds that the preponderance of the probative evidence of record indicates that the Veteran’s psychological functioning most closely match the signs, symptoms, and level of dysfunction described by a 50 percent evaluation under DC 9411. For instance, at a VA psychological evaluation in March 2008, the Veteran had a flat affect and reported many of the same psychological symptoms described above. However, the examining clinician also reported that the Veteran had normal and spontaneous speech, had relevant and coherent thoughts, and that he had intact judgment and insight. At that time there was also no evidence of suicidal or homicidal ideation or any signs of hallucinations or delusions. At a follow-up visit the following month, the Veteran did present with some psychomotor retardation and a droning voice. Notably, despite these abnormalities, there is no evidence in any of the clinical records from that period that the Veteran had the type or severity of symptoms such as those described in the criteria for a 70 percent evaluation. More specifically, there is no evidence that the Veteran had obsessional rituals that interfered with routine activities, illogical, obscure, or irrelevant speech, near-continuous panic, spatial disorientation, or neglect of personal appearance or hygiene. To evaluate the Veteran’s claim, he was afforded VA psychological examinations in April and June of 2008. Despite the hypervigilance, exaggerated startled response, and abnormal mood and affect noted in the April 2008 examination report, the Veteran at that time was also reportedly able to manage his own personal hygiene and grooming, socialized with immediate family members, and denied suicidal ideation. He also had a satisfactory memory, normal speech, goal directed and relevant thoughts, satisfactory abstract and concentration abilities, and was fully oriented. At the June 2008 evaluation, the Veteran stated that he continued to argue with his spouse and endorsed feelings of hopelessness and worthlessness in addition to sleep disturbance. However, he also stated that inappropriate behavior continued not to be a significant problem and that he was able to maintain his personal hygiene, grooming, and activities of daily living. Although the Veteran did state that he had short-term memory deficits at that time, upon examination he was found to have a satisfactory memory. The examiner also observed the Veteran to have a neat, clean, and casual appearance and noted that the Veteran had normal rate and volume of speech and adequate thought processes production. Despite the Veteran’s depressed mood and restricted affect, he also reportedly displayed no signs of delusions or suicidal ideation, and he had satisfactory abstract and concentration ability. The Board finds that these symptoms largely match the level of impairment described by the criteria for a 50 percent evaluation and, in certain cases such as the chronic sleep impairment, depressed mood, and mild memory loss, appear to more closely approximate the criteria for a 30 percent evaluation under the General Rating Formula for Mental Disorders. The clinical records from late 2008 through September 2011 follow a similar pattern. The Veteran reported increased symptoms at a clinical evaluation in December 2008 after returning to work in October of that year, explaining that he was social withdrawn and was daydreaming about past experiences. Notably, despite these symptoms and the Veteran’s flat affect, muted mood, and standoffish appearance, the Veteran continued to be alert and oriented, have a normal speech rate, and exhibited no signs of delusions. Similarly, although the Veteran did endorse several panic attacks per week, rumination, yelling at his children, difficulty with crowds, and a jumpy behavior at a follow-up visit in March 2009, he also continued to be neatly dressed and have no signs of hallucinations. The Veteran did exhibit poor eye contact, a depressed mood, and a constricted affect upon examination. However, as was the case with earlier clinical treatment notes, the Veteran did not exhibit the type or degree of psychological abnormality or dysfunction described in the criteria for a 70 percent evaluation. On the contrary, his treating clinician commented that the Veteran was neatly dressed, had normal speech, maintained clear and goal-directed thoughts, had good insight and judgment, and was cognitively intact. In evaluating the Veteran’s claim, the Board has also considered a non-VA psychological examination report from April 2009. The psychologist who evaluated the Veteran at that time stated that an interview with his spouse had also been conducted and the report suggests that they reported significantly more severe psychological symptoms and dysfunction at that time. For instance, his spouse noted that she had virtually no interaction with the Veteran and that he similarly ignored his children. She also explained that in one month the Veteran remained in his room for five straight days. The Veteran also explained at that time that he found it hard to go to crowded places, experienced frequent nightmares, and that at certain points became so startled that he nearly struck a coworker and his daughter. These symptoms appear significantly more severe than those described in the clinical treatment records both before and shortly after this private examination report. For instance, at a VA mental health treatment visit conducted less than four weeks after the private psychological evaluation, the Veteran continued to be neatly dressed, have normal speech, and maintain clear and goal-directed thoughts. The Veteran also maintained his employment and, although he again reported recurring panic attacks, startled response, and anxiety attacks, he was again described to be cognitively intact, had good insight and judgment, and had neither suicidal ideation nor hallucinations. Ultimately, the private psychologist who completed the April 2009 stated that it was much more likely than not that the Veteran would have great difficulty maintaining employment other than his employment as a police officer, that it was possible that his symptoms could continue to lead to further deterioration in his present occupation, and that he was essentially totally disabled in his social functioning, describing the Veteran as having virtually no social life, no personal life, a severely constrained range of interests, and a dramatically reduced and disrupted relationship with his wife and children. Notably, despite these reports of severe social and occupational dysfunction, the examiner also stated that the Veteran was able to achieve consistently high performance reviews at work. Given this reportedly good work performance and the apparently significant inconsistencies between the level of functioning described in that examination report and the clinical signs and findings reported by treating clinicians both shortly before and after that private examination, the Board finds that it is of limited probative weight. The Veteran attended another VA psychological evaluation in June 2010. At that time, the Veteran reported that he had separated from his wife and did not do anything with his time, preferring to stay at home. However, the Veteran reported that he got along “okay” with his children and stated that although he frequently became upset when he came to a VA facility, he reportedly denied getting angry or upset at other times. The Veteran also continued to report worrying about life, motivational struggles, sleeping difficulties, and depression. Nonetheless, he continued to work full time and stated that he had received reprimands at work for his inability to perform, he had not lost time from work due to mental health issues. As was the case with the numerous clinical evaluation notes described above, the objective examination results at this June 2010 evaluation suggest relatively mild psychological dysfunction. Although the Veteran again had an abnormally dysphoric mood and a restricted and guarded affect, he continued to be both alert and fully oriented. Similarly, despite his reports that his stress interfered with his ability to maintain grooming and dressing, he was found to be adequately groomed at the examination. The Veteran also maintained appropriate eye contact, exhibited no psychomotor abnormalities, had a logical and goal oriented thought process, and had a normal rate and tone to his speech despite the limited amount of speech. Likewise, he continued to have signs of an intact memory and although his judgment and insight was limited, the Veteran again denied the suicidal or homicidal ideation that are suggestive of an evaluation in excess of 50 percent. The clinical treatment notes that followed are remarkably similar in content. They suggest that the Veteran continued to have a depressed mood and a strained relationship with his wife. However, he was able to continue to retain the social and occupational skills to maintain employment. The objective clinical results from those subsequent treatment notes also were largely identical and do not contain evidence of the suicidal ideation, obsessional rituals, near-continuous panic or depression, illogical or otherwise abnormal speech, or spatial disorientation that are identified in the rating criteria as indicative of a 70 percent evaluation. Ultimately, while the Veteran had some deficiencies in his occupational and social functioning, to include with respect to his family relations and mood and the conflicting reports of a physical confrontation with the Veteran’s stepson, the Board finds that the Veteran’s ability to maintain high marks at work despite his panic attacks suggest that he had little to no deficiencies in the area of work. Moreover, the Board observes that the frequency of panic attacks noted appears to explicitly match those in the criteria for an evaluation of 50 percent. There is also no doubt that the Veteran had a repeatedly abnormal mood. However, taken with the almost uniform reports of the Veteran’s judgment and thinking and the lack of the type or frequency of severe symptoms identified as illustrative examples of a 70 percent evaluation, the Board finds that the criteria for such a rating for the period prior to September 23, 2011, are not met. In evaluating the claim, the Board has considered the various GAF scores that have been assigned to the Veteran. For the period currently before the Board, the Veteran has been assigned scores ranging from 50 to 65, which is indicative of anywhere from severe to moderate overall dysfunction. A GAF score can fluctuate from day to day and does not describe the degree of impairment in specific clinical details that are useful for an assignment of an evaluation in accordance with the General Rating Formula. Given their lack of specificity, the Board finds that the symptoms and clinical findings in the Veteran’s treatment records and examination reports are more probative in determining the proper evaluation for the Veteran’s PTSD. The Board recognizes that there is probative, competent, and credible evidence in the record indicating the Veteran had significant occupational and social dysfunction. However, when assembled against all of the relevant, probative, and competent evidence of record, the Board finds that the routinely normal clinical findings regarding the Veteran’s speech, orientation, personal appearance and hygiene, thought processes, and lack of suicidal or homicidal ideation suggest that the Veteran’s psychological dysfunction did not rise to the level of a 70 percent evaluation prior to September 23, 2011. The consistency of these clinical findings and the Veteran’s ability to maintain employment suggest that the Veteran’s psychological functioning at that time resulted only in occupational and social impairment with reduced reliability and productivity. As such, the Board does not find that the criteria for a 70 percent evaluation for the period prior to September 23, 2011. With the preponderance of the evidence against the Veteran’s claim, the Board finds that the doctrine of the benefit of the doubt is not for application and the claim for an increased rating for PTSD for that period must be denied. REASONS FOR REMAND 1. Entitlement to service connection for a pelvic disability, a disability manifested by muscle and joint pain (to include fibromyalgia), a right elbow disability, a back disability, and a left knee disability, to include as due to an undiagnosed illness, is remanded. As stated above, these issues were previously remanded by the Board in May 2016 to, in part, obtain medical examinations and opinions regarding the nature and etiology of these claimed conditions. Pursuant to that remand, the Veteran attended numerous VA medical examinations in September 2016. Unfortunately, it does not appear that these examination reports contain sufficiently clear information regarding the nature of the claimed disabilities. Specifically, the examiner who evaluated the Veteran at that time completed a disability benefits questionnaire relating to non-degenerative arthritis. In that form, she noted that the Veteran endorsed symptoms of pain in his shoulders, elbows, hands, knees, feet, neck, and back, which he reported began in 2005 after his return from a deployment in Iraq. She confirmed that the Veteran also had a diagnosis of seronegative spondyloarthropathy, but explained that he also had a diagnosis of chronic fatigue syndrome and that it was difficult to distinguish which of his conditions is most responsible for the joint pains. Of particular relevance, the Veteran was granted service connection for chronic fatigue syndrome shortly after that examination. In the questionnaire she completed that was centered on chronic fatigue syndrome, the examining VA physician again explained that the history of this condition included a report of chronic widespread myalgias and arthralgias. Although the RO obtained an addendum opinion in May 2017 to address the question of whether these disabilities represented manifestations of an undiagnosed illness pursuant to 38 C.F.R. § 3.317, that opinion did not attempt to differentiate the joint or muscle symptoms that are related to the Veteran’s service-connected chronic fatigue symptom with those related to his spondyloarthropathy. As the etiology of the Veteran’s joint and muscle symptoms is central to the claim for service connection, the Board finds that it does not have sufficient medical information with respect to the question of service connection for these claimed disabilities and must again remand the claim. As explained above, the Veteran appears unwilling to participate in further evidentiary development in the resolution of these claims. As such, the Board finds it that it would be fruitless to attempt to arrange for another in-person medical examination, but will instead direct the RO to obtain an additional addendum opinion. 2. Entitlement to service connection for a disability manifested by fevers and chills, immune weakness, and weight gain, to include as due to an undiagnosed illness, is remanded. The Board also remanded these claimed conditions in May 2016 for further evidentiary development. Although the Veteran was afforded VA medical examinations for the disabilities manifested by joint or muscle pain, the record does not indicate that the Veteran has been provided a medical examination to address the claimed disabilities manifested by chills and fevers, immune weakness, and weight gain. The Board recognizes that the Veteran has expressed his desire not to attend additional medical examinations. However, the Board finds that it has insufficient medical examination to adjudicate the claim for a disability manifested by these symptoms and must remand the claims to obtain a medical opinion with respect to the Veteran has a disability with a distinct and identifiable disability manifested by fevers and chills, immune weakness, and weight gain that are etiologically related to service, or if any such symptoms represent objective indications of a chronic disability resulting from an undiagnosed illness related to the Veteran’s service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms. 3. Entitlement to service connection for rhinitis, to include as due to an undiagnosed illness, is remanded. Pursuant to the Board’s May 2016 remand directives, the Veteran was afforded a VA medical examination to determine the etiology of any current disability of rhinitis. Included in those directives was an explicit request that the examiner comment on the Veteran’s reports of rhinitis in service. In providing her negative opinion, the examiner stated that there was no evidence that the Veteran received treatment or evaluation for sinusitis or rhinitis and that a diagnosis of allergic rhinitis is not documented in the medical records until 2007. A review of the medical evidence from shortly after the Veteran’s March 2005 discharge from active duty service, however, includes evidence from August of that year indicating that the Veteran received private treatment for symptoms of allergies. Given that this evidence could suggest a far earlier onset in the Veteran’s rhinitis and appears to contradict the factual basis underpinning the medical examiner’s opinion, the Board finds that it must return the examination for corrective action. 4. Entitlement to service connection for a lung disability, to include as due to an undiagnosed illness, is remanded. The Veteran was also evaluated by a VA physician in September 2016 to determine the etiology of disability of the lung condition that had been present since the Veteran filed his claim for service connection. An addendum opinion was obtained from that clinician in May 2017. She ultimately concluded that the Veteran’s condition was not due to service because it was a specific infection that was prevalent in the area of the United States in which the Veteran resided at the time of the diagnosis. Unfortunately, this opinion does not address the argument of the Veteran’s representative that he may have contracted the infection while serving on active duty in Iraq. In furtherance of that argument, the Veteran’s representative submitted an internet article extrapolating statistics regarding the incidence of coccidioidomycosis in the world which suggested that this infectious disease was active in Iraq. An additional opinion must be secured to address this argument. 5. Entitlement to service connection for a heart disability, to include as due to an undiagnosed illness, is remanded. The Veteran also attended a VA medical examination to address the nature and etiology of any cardiac condition in September 2016. Unfortunately, although the Board’s May 2016 remand explicitly asked the examiner to clarify whether any such condition was a developmental defect or a developmental disease, the physician who examined the Veteran only described this disability as a congenital “condition.” As congenital defects are not “disabilities” that may be service connected under VA’s regulations, this question is central to the Veteran’s claim and the Board has insufficient competent medical evidence to resolve this issue. Therefore, this claim must also be remanded. 6. Entitlement to service connection for a gastrointestinal disability, to include as due to an undiagnosed illness, is remanded. As was the case with the Veteran’s claim for service connection for a heart disability, the Board finds that the VA medical examination and addendum opinion that occurred in response to the Board’s remand directives does not directly address a central question that was asked by the Board in May 2016. Specifically, the Board asked the examiner to address whether any current gastrointestinal disability was related to the reports of gastrointestinal treatment and symptoms during active duty service. Although the September 2016 examiner did identify those 1995 symptoms and episode of care in her report of the Veteran’s medical history, she did not address whether those symptoms could have caused or led to the subsequent development of any current gastrointestinal disability. Therefore, the Board must also remand this claim for corrective action. 7. Entitlement to service connection for a kidney disability, to include as due to an undiagnosed illness, is remanded. Finally, the Board finds that it must also obtain an opinion regarding the etiology of any current kidney disability. As was the case with several of the other disabilities on appeal such as those manifested by fever and chills or weight gain, the Veteran has not yet been afforded an examination regarding this issue. Although the Veteran has stated his desire not to attend any further medical examinations in connection with his appeal for VA compensation, the Board cannot find that VA’s duty to assist him in developing his claim has been extinguished. As a recent May 2017 VA treatment note suggests that there are now current kidney-related symptoms, the Board finds that VA should obtain a medical opinion to determine whether any disability manifested by kidney-related symptoms is etiologically related to active duty service, to include determining whether any such symptoms represent a clear and distinct disability or whether they represent objective indications of a chronic disability resulting from an undiagnosed illness related to the Veteran’s service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms. The matters are REMANDED for the following action: 1. Obtain any outstanding and pertinent VA treatment records and associate them with the Veteran’s claims file. 2. Obtain an addendum opinion from a qualified medical professional to determine the nature and etiology of the Veteran’s claimed conditions of a back disability, a left knee disability, a right elbow disability, a disability of the pelvis, and joint pain and muscle pain. As there is some confusion in the record regarding whether these disabilities and/or symptoms are related to spondyloarthropathy or the Veteran’s service-connected chronic fatigue syndrome, the clinician is asked to provide a statement regarding the following questions: (a.) Is it at least as likely as not that any of these claimed conditions or disabilities manifested by these claimed symptoms are proximately due to the Veteran’s service-connected chronic fatigue symptom or represent manifestations of this disability? In answering this question, the examiner is asked to consider the May 2017 addendum opinion and September 2016 VA medical examination in which it was suggested that these claimed symptoms and/or disabilities could be attributable to the Veteran’s chronic fatigue syndrome. If the examiner is not able to provide an answer to this question without resorting to speculation, the examiner should explain why (e.g. the question is beyond the limits of current medical knowledge). (b.) Is it at least as likely as not that any of these claimed conditions or disabilities manifested by these claimed symptoms have been aggravated by (worsened in severity beyond the natural progression of the disease) the Veteran’s service-connected chronic fatigue syndrome? In answering this question, the examiner is asked to consider the May 2017 addendum opinion and September 2016 VA medical examination in which it was suggested that these claimed symptoms and/or disabilities could be attributable to the Veteran’s chronic fatigue syndrome. If the examiner is not able to provide an answer to this question without resorting to speculation, the examiner should explain why (e.g. the question is beyond the limits of current medical knowledge). 3. Obtain a medical opinion from a qualified medical professional to address the nature and etiology of any disability manifested by fevers and chills, immune weakness, weight gain, and kidney disease. The examiner is asked to provide an opinion regarding the following questions: (a.) Are any of the Veteran’s current symptoms relating to fevers and chills, immune weakness, weight gain, and kidney disease related to a distinct and identifiable disability? (b.) If any current symptoms of fevers and chills, immune weakness, weight gain, and kidney disease is related to a distinct and identifiable disability, is it at least as likely as not that any such current disability had its onset during either period of active duty service or is otherwise etiologically related to either period of active duty service? (c.) If any current symptoms of fevers and chills, immune weakness, weight gain, and kidney disease is not due to a distinct and identifiable disability, is it at least as likely as not that any such symptom represents an objective indication of a chronic disability resulting from an undiagnosed illness related to the Veteran’s service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs and symptoms? 4. Obtain an addendum opinion from a qualified medical professional to determine the nature of the Veteran’s rhinitis. The examiner is asked to provide an opinion regarding whether it is at least as likely as not that the Veteran’s current rhinitis arose in or is otherwise etiologically related to active duty service. The examiner is also reminded that the Veteran’s second period of active duty service ended in March 2005 and is asked to specifically comment on and address the August 2005 reports of private treatment for allergy-related symptoms. 5. Obtain an addendum opinion from a qualified medical professional to determine the nature of the Veteran’s current cardiac disability. The examiner is asked to provide an opinion regarding whether the Veteran’s cardiac disability is a congenital disease or a congenital defect. 6. Obtain an addendum opinion from a qualified medical professional to determine the nature and etiology of any current gastrointestinal disability. The examiner is asked to provide an opinion regarding whether it is at least as likely as not that the Veteran’s current disability is etiologically related to the in-service reports of gastroenteritis. In providing this opinion, the examiner should address whether it is at least as likely as not that those in-service symptoms caused the subsequent development of any current gastrointestinal disability. 7. Obtain an addendum opinion from a qualified medical professional to determine the nature and etiology of any current lung disability. The examiner is asked to provide an opinion regarding whether it is at least as likely as not that the Veteran contracted an infection of coccidioidomycosis while serving on active duty service, to include in Iraq. In providing this opinion, the examiner should address the reports submitted by the Veteran’s representative that this infection was also active in the general population in Iraq. M. Tenner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Whitelaw, Associate Counsel