Citation Nr: 18143631 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 15-39 347 DATE: October 19, 2018 ORDER New and material evidence has not been received to reopen the claim of entitlement to service connection for bilateral carpal tunnel syndrome. New and material evidence has been received to reopen the claim of entitlement to service connection for a heart disability. New and material evidence has been received to reopen the claim of entitlement to service connection for a prostate disability. Entitlement to service connection for a vision disorder, claimed as vision loss, to include as an undiagnosed illness due to service in the Persian Gulf, is denied. Entitlement to service connection for a dental disability, claimed as bleeding gums, to include as an undiagnosed illness due to service in the Persian Gulf, is denied. REMANDED Entitlement to service connection for a heart disability, to include as an undiagnosed illness due to service in the Persian Gulf War, is remanded. Entitlement to service connection for a prostate disability, to include as an undiagnosed illness due to service in the Persian Gulf War, is remanded. Entitlement to service connection for chronic fatigue, to include as an undiagnosed illness due to service in the Persian Gulf War, is remanded. Entitlement to service connection for muscle weakness, to include as an undiagnosed illness due to service in the Persian Gulf War, is remanded. Entitlement to service connection for hair loss, to include as an undiagnosed illness due to service in the Persian Gulf, is remanded. Entitlement to service connection for memory loss, to include as an undiagnosed illness due to service in the Persian Gulf, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. An unappealed November 1999 rating decision denied service connection for bilateral carpal tunnel syndrome. 2. Evidence received since the November 1999 rating decision is cumulative and redundant of evidence at the time of the prior decision, and does not raise a reasonable possibility of substantiating the Veteran’s claim for entitlement to service connection for bilateral carpal tunnel syndrome. 3. A March 2002 rating decision denied service connection for chest pains and prostatitis; the Veteran did not appeal that decision, and new and material evidence was not received within one year of notice of its issuance. 4. Evidence received more than one year since the March 2002 rating decision is neither cumulative nor redundant of evidence already of record, and raises a reasonable possibility of substantiating the Veteran’s claims for entitlement to service connection for heart and prostate disabilities. 5. The Veteran’s vision disorders, claimed as vision loss, are diagnosable conditions with clear and specific etiologies and did not have their onset in service and are not otherwise related to service. 6. The Veteran’s oral conditions, claimed as bleeding gums, are due to periodontal disease, which is not subject to service connection for compensation purposes. CONCLUSIONS OF LAW 1. The November 1999 and March 2002 rating decisions denying the claims of entitlement to service connection for bilateral carpal tunnel syndrome, chest pains, and prostatitis are final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. 2. New and material evidence has not been received to reopen the claim of entitlement to service connection for bilateral carpal tunnel syndrome. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. New and material evidence has been received to reopen the claims of entitlement to service connection for heart and prostate disabilities. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 4. The criteria for entitlement to service connection for a vision disorder, claimed as vision loss, to include as an undiagnosed illness due to service in the Persian Gulf, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317, 4.9. 5. The criteria for entitlement to service connection for a dental disability, claimed as bleeding gums, to include as undiagnosed illness due to service in the Persian Gulf, are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.317, 3.381, 4.150, 17.161. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1988 to June 1998, including service in Southwest Asia during the Persian Gulf War. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2016, the Veteran and his spouse testified during a Board hearing before the undersigned Veterans Law Judge. In June 2012, the Veteran filed a claim for entitlement to service connection for diabetes, but it has not yet been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over the claim, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b). New and Material Evidence 1. New and material evidence has not been received to reopen the claim of entitlement to service connection for bilateral carpal tunnel syndrome. 2. New and material evidence has been received to reopen the claim of entitlement to service connection for a heart disability. 3. New and material evidence has been received to reopen the claim of entitlement to service connection for a prostate disability. A decision of the RO becomes final and is not subject to revision on the same factual basis unless a notice of disagreement is filed within one year of the notice of the decision, or new and material evidence is received during the appeal period after the decision. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.302, 20.1103. If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108; see Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). New evidence is defined as existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The RO denied the Veteran’s claims for service connection for bilateral carpal tunnel syndrome in a November 1999 rating decision based on lack of in-service incurrence of the disability and in a March 2002 rating decision for chest pains and prostatitis based on lack of a current disability. The Veteran was informed of these decisions in November 1999 and March 2002, respectively, he did not appeal the decisions, and new and material evidence was not received within one year of notice of either decision. Thus, the November 1999 and March 2002 rating decisions became final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.1103; Buie v. Shinseki, 24 Vet. App. 242, 252 (2010). Evidence received more than one year since the November 1999 rating decision does not constitute new and material evidence in regards to the Veteran’s bilateral carpal tunnel syndrome claim. The RO noted the Veteran’s service treatment records (STRs) were unavailable for review at the time of the decision, although some records were in VA’s constructive possession since August 1998. However, upon reviewing these STRs and STRs subsequently received, the Board finds they are silent for complaints, diagnosis, or treatment for symptoms of bilateral carpal tunnel syndrome and therefore reconsideration of the claim is not warranted. 38 C.F.R. § 3.156(c)(noting that at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim) (emphasis added). Moreover, the Veteran’s representative indicated during the February 2016 Board hearing that new and material evidence has not been submitted with respect to the bilateral carpal tunnel syndrome claim and that there is only evidence showing that “it could have been in existence early on.” See February 2016 Board Hearing Transcript at 4. The Board has reviewed all the evidence of record since the final November 1999 rating decision; however, it does not create a reasonable possibility of substantiating the Veteran’s claims nor does it trigger VA’s duty to assist by obtaining medical opinions or examinations; and therefore, the new evidence is not material. The Board acknowledges that the threshold for reopening a claim is low, but it is a threshold nonetheless. Shade v. Shinseki, 24 Vet. App. 110 (2010). Here, the threshold has not been met and the previously denied claim of entitlement to service connection for bilateral carpal tunnel syndrome is not reopened because new and material evidence has not been submitted. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). As new and material evidence to reopen the finally disallowed claim has not been received, the benefit-of-the-doubt doctrine is not applicable. On the other hand, evidence received more than one year since the March 2002 rating decision does constitute new and material evidence in regards to the Veteran’s heart and prostate disability claims. Specifically, an August 1998 private treatment record (received by VA in July 2012) diagnosing chest pains and borderline hypoxia; a December 2012 VA examination report currently diagnosing coronary artery disease and noting an in-service diagnosis of costochondritis; June 2012 through November 2012 and July 2015 VA treatment records showing urinary frequency; and the Veteran’s wife testimony during the February 2016 Board hearing indicating his prostate/urine flow problems are due to metal clips from an in-service vasectomy. This evidence is new as it was not previously considered by the RO. The evidence is also material, as it is not cumulative or duplicative of evidence previously considered and it raises a reasonable possibility of substantiating the claims. As such, the Veteran has presented new and material evidence to reopen the previously denied claims of entitlement to service connection for heart and prostate disabilities and the claims are reopened. Service Connection Service connection may be established for a disability resulting from injury or disease incurred during active service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in- service. 38 C.F.R. § 3.303(d). Generally, to establish service connection the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The Veteran served in the Southwest Asia Theater of Operations after August 2, 1990, and is therefore a Persian Gulf War veteran. See 38 C.F.R. § 3.2(i). Service connection may be established for a Persian Gulf veteran who has a qualifying chronic disability that became manifest during service or to a degree of 10 percent or more not later than December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A “qualifying chronic disability” includes: (A) an undiagnosed illness, or (B) a medically unexplained chronic multi-symptom illness, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal disease). 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i). The term “medically unexplained chronic multi-symptom 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 multi-symptom 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). Disabilities that have existed for six months or more, and disabilities that exhibit intermittent episodes of improvement and worsening over a six- month period, will be considered chronic. 38 C.F.R. § 3.317(a)(4). A qualifying chronic disability shall be considered service- connected. 38 C.F.R. § 3.317(a)(6). Compensation shall not be paid for a qualifying chronic disability if there is affirmative evidence that the disability was caused by a supervening condition or event that occurred between the Veteran’s most recent Southwest Asia duty and the onset of the disability. 38 C.F.R. § 3.317(a)(7)(ii). 4. Entitlement to service connection for a vision disorder, claimed as vision loss, to include as an undiagnosed illness due to service in the Persian Gulf, is denied. The Veteran seeks service connection for vision loss, which he maintains is related to his service in the Gulf War. See June 2012 VA Form 21-526(b) and corresponding Veteran Statement. There are current diagnoses of several vision disorders, including corneal scar, irregular cornea, status post trauma, presbyopia, astigmatism OD, hyperopia OU, and refractive error. See January 2012 and November 2012 VA treatment records. Thus, element one is established. Notably, refractive errors, including astigmatism, presbyopia and hyperopia, are not considered diseases or injuries for VA purposes, and the Veteran does not allege, and the record does not otherwise support, any superimposed disease or injury on such refractive errors resulting in additional disability during service. 38 C.F.R. §§ 3.303(c), 4.9; see also VAOPGCPREC 82-90 (1990). Thus, these disabilities are not available for service connection and will not be further addressed. Moreover, the Veteran’s other diagnosed eye disorders were not incurred in or otherwise related to service, as the Veteran specifically stated that his vision loss is from a childhood injury and that “nothing on active duty occurred to make it permanently worse” in correspondence where he expressed his desire to withdraw the claim (his STRs note refractive error at entry, during service, and at separation, the Veteran’s indication that he wears glasses on his Report of Medical History at entry, and his endorsement of lack of vision and eye trouble on his Report of Medical History at service separation). See November 2012 Veteran Statement and December 1987, September 1995, and April 1998 STRs. Accordingly, elements two and three are not established. As the preponderance of the evidence is against the claim, the benefit of doubt rule is not applicable and service connection for a vision disorder, including as an undiagnosed illness due to service in the Persian Gulf, is not warranted. Lastly, the Board acknowledges that the Veteran has not been afforded a VA examination regarding his vision loss claim. However, there is no indication that any of the Veteran’s current vision disorders are related to service, therefore VA’s duty provide a VA examination is not triggered and its duty to assist has been fulfilled. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 5. Entitlement to service connection for a dental disability, claimed as bleeding gums, to include as an undiagnosed illness due to service in the Persian Gulf, is denied. The Veteran seeks service connection for a dental disorder described as bleeding gums. He maintains that his bleeding gums are due to an undiagnosed or unexplained multi-symptom illness from his service during the Persian Gulf War, including exposures to environmental toxins such as uranium, tritium, oil fires, and burn pits. See December 2012 Informal Claim, May 2013 and July 2015 Veteran Statements, and February 2016 Board Hearing Transcript at 12. Here, the Veteran has current diagnoses of unspecified disorder of the teeth and supporting structures, periodontal disease, chronic gingivitis (plaque-induced), and loss of teeth due to caries. See November 2012 VA treatment record and July 2015 VA examination report. Additionally, STRs note the Veteran’s complaints of sensitive teeth and pain, that he does not floss his teeth, heavy plaque build- up, that a tooth broke off, and generalized bone loss. See January 1994, August 1995, and January 1997 STRs. No references to bleeding gums are documented and the Veteran’s April 1998 separation examination report did not note any dental defects or diseases. In July 2015, the Veteran was afforded a VA dental examination. The VA examiner acknowledged the Veteran’s statements that he first noticed his bleeding gums after returning from deployment to Southwest Asia in 1995. He found that the Veteran had plaque-induced generalized gingivitis with area of mild periodontal disease and thus has a disease with a clear and specific etiology and diagnosis. In support of his opinion, he reasoned that the Veteran stated he only brushes his teeth two to three times per week and only uses floss to remove meat stuck between his teeth. He also noted the Veteran has a history of dental caries and tooth abscesses, which combined with his current amount of dental caries (tooth decay) substantiate the diagnosis of dental plaque-induced etiology for his bleeding gingiva and that while it is possible that there are other/multiple etiologies for his bleeding gingiva, the evidence points to a lack of oral hygiene resulting in plaque build-up as the etiology of his bleeding gingiva. Additionally, the VA examiner opined that it is at least as likely as not that his dental disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during his service in Southwest Asia. In support of his opinion, he noted that the Veteran has a long history of dental caries (a plaque-induced disease) and that dental plaque also causes gingivitis and eventually periodontal disease, which have symptoms of gingival bleeding, gingival erythema, swelling and pain/discomfort upon manipulation (e.g. brushing). He noted that with a lack of oral hygiene, this disease is extremely common and an estimated at least 50 percent of the population has gingivitis and that it is also very common with deployed military troops to experience dental issues due to lack of oral hygiene while deployed. Thus, he concluded that with the Veteran’s long history of a lack of sufficient oral hygiene and a lack of professional dental care since 1998, “it is with near certainty” that his gingival bleeding is dental plaque-induced and therefore not the result of service. Dental disorders are treated differently than other medical disorders in the VA benefits system. See 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 17.161. As provided by VA regulations, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses and periodontal disease are not considered disabling conditions, and may be considered service-connected solely for establishing eligibility for VA outpatient dental treatment. See 38 C.F.R. §3.381(a). Under current VA regulations, compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150. These conditions include various problems of the maxilla, mandible, or temporomandibular articulation, loss of whole or part of the ramus, loss of the condyloid process or coronoid process, loss of the hard palate, or loss of teeth due to loss of substance of the body of the maxilla or mandible due to trauma or disease such as osteomyelitis rather than as a result of periodontal disease. See id. Here, the Veteran has perfected his appeal under a theory of service connection for compensation benefits and has not argued that he is seeking VA treatment benefits. This appeal has been developed solely on the basis of entitlement to VA compensation based on a grant of service connection. Thus, the issue of entitlement to eligibility for VA dental treatment on an outpatient basis is not before the Board. Should he wish to seek VA dental treatment, he is encouraged to apply for this benefit through his closest VA Medical Center. To this end, the medical evidence of record establishes that the Veteran’s bleeding gums are due to periodontal disease, which is a known clinical diagnosis with a clear and specific etiology and, as such, is not subject to service connection under 38 U.S.C. § 1117. To the extent the Veteran argues otherwise, the Board places greater probative weight to the opinion of the VA dentist, who has greater expertise and training than the Veteran, who is not competent to diagnose the cause of his bleeding gums. While service connection may be established for treatment purposes for replaceable missing teeth and periodontal disease, the regulations listed above clearly prohibit service connection for purposes of compensation where the disability involves periodontal disease. As this condition is recognized by the applicable regulations as a disability for which VA compensation may not be granted, the Veteran’s claim is not warranted. See 38 C.F.R. 3.381 (periodontal disease is not a disability for compensation purposes). Consequently, there is no basis for entitlement to service connection for the Veteran’s claimed bleeding gum disorder. Moreover, there is no indication in the record of any dental or oral conditions present listed under 38 C.F.R. § 4.150 for which VA compensation can be granted. For all of the foregoing reasons, the Board finds that the claim for service connection for a dental disability including bleeding gums as an undiagnosed illness due to service in the Persian Gulf, must be denied. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a heart disability, to include as an undiagnosed illness due to service in the Persian Gulf, is remanded. The Veteran asserts that his heart disability began in service manifested by chest pains and shortness of breath (treated with Motrin in service) and continued post-service for which he sought treatment. See November 2012 Veteran Statement and February 2016 Board Hearing Transcript at 9. He also maintains that his heart disability is part of an undiagnosed or unexplained multi-symptom illness due to his service in the Gulf War. See June 2012 VA Form 21-526b and June 2012 and December 2012 Veteran Statements. The Veteran was afforded a VA examination in December 2012. The VA examiner found a current diagnosis of coronary artery disease and noted that the Veteran was previously diagnosed with costochondritis during service, but indicated there was currently no evidence of the disorder upon examination. Additionally, the examiner noted that costochondritis was not caused by or related to the Gulf War as the disorder has a clear and specific etiology. The examiner also endorsed multiple disorders, including heart disease, that could be related to an undiagnosed illness, but found that all the diagnoses had clear and specific etiologies. However, no nexus opinion on coronary artery disease for direct service connection was rendered. Thus, on remand an addendum opinion that addresses this question is warranted. 7. Entitlement to service connection for a prostate disability, to include as an undiagnosed illness due to service in the Persian Gulf, is remanded. The Veteran asserts that his prostate disability is a result of an undiagnosed or unexplained multi-symptom illness due to service in the Gulf War. Specifically, he maintains that his exposure to environmental toxins such as uranium, tritium, oil fires, and burn pits are responsible for his medical issues. See May 2013 and July 2015 Veteran Statements. Alternatively, the Veteran’s wife raised the issue of his prostate problems (urine flow) being related to metal clips left inside his scrotum from his in-service vasectomy. See July 2015 Veteran Statement and February 2016 Board Hearing Transcript at 27. The Veteran’s STRs note “early prostatitis” and a vasectomy with metal clips inserted and post-service VA treatment records note urinary frequency. See August 1991 and April 1992 STRs and June 2012 through November 2012 and July 2015 VA treatment records. Thus, given the Veteran’s and his wife’s statements and his current urinary problems, the low threshold detailed in McLendon is met and a VA examination and medical nexus opinion is warranted. McLendon, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for chronic fatigue, to include as an undiagnosed illness due to service in the Persian Gulf, is remanded. 3. Entitlement to service connection for muscle weakness, to include as an undiagnosed illness due to service in the Persian Gulf, is remanded. 4. Entitlement to service connection for hair loss, to include as an undiagnosed illness due to service in the Persian Gulf, is remanded. 5. Entitlement to service connection for memory loss, to include as an undiagnosed illness due to service in the Persian Gulf, is remanded. 6. Entitlement to a TDIU is remanded. The Veteran asserts that his chronic fatigue, muscle weakness, hair loss, and memory loss disabilities began in service following his return from the Gulf War and that they are due to an undiagnosed or unexplained multi-symptom illness that he continues to experience post-service. See December 2012 Veteran Claim, May 2013 Veteran Statement, and February 2016 Board Hearing Transcript at 12, 19. Specifically, as noted above, he maintains that his exposure to environmental toxins such as uranium, tritium, oil fires, and burn pits are responsible for his medical issues. See May 2013 and July 2015 Veteran Statements. The Veteran was afforded VA examinations in July 2015. The examiner found no current diagnoses of chronic fatigue syndrome or hair loss and noted his complaints of fatigue, hair loss, muscle weakness, and memory loss are subjective. The examiner also noted several other pathologies for his fatigue and noted mild memory loss as a symptom of non-service connected adjustment disorder with mixed anxiety and depression and found that all diagnoses had established etiologies. However, the Veteran and his wife assert the examinations were inadequate, as he could not understand the questions and the examiner cut his responses off, reported incorrect answers, and did not ask him all the questions reported. Additionally, the examiner failed to comment on the Veteran’s statements regarding his exposure to environmental toxins. Thus, on remand new VA examinations and medical opinions are warranted from a different examiner. Finally, as the TDIU claim is inextricably intertwined with the other claims remaining on appeal, adjudication on the TDIU claim is deferred pending the above developments. Additionally, information regarding the nature of his previous employment is needed on remand via completion of a VA Form 21-8940. Updated treatment records should also be secured. The matters are REMANDED for the following action: 1. Request that the Veteran complete and return VA Form 21-8940. 2. Obtain any outstanding VA treatment records. 3. With any necessary assistance from the Veteran, obtain any relevant outstanding private treatment records. 4. Then, return the claims file to the December 2012 VA examiner (or another qualified examiner, if unavailable) for preparation of an addendum opinion. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. The claims file, including a copy of this remand, must be provided to the examiner in conjunction with the requested opinion. The examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s coronary artery disease had its onset in service or within one year from separation from service, or is otherwise related to service, to include as a result of conceded exposure to environmental toxins in the Persian Gulf. In addressing this question, the examiner should comment on the Veteran’s in-service complaints of chest pain and discomfort when breathing “very deep” and a diagnosis of costochondritis, and a post-service private treatment record, immediately following service, diagnosing chest pain and borderline hypoxia. See May 1991 and June 1995 STRs and August 1998 private treatment record. A complete rationale must be provided for all opinions and conclusions expressed. If unable to provide a medical opinion, provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 5. Then schedule the Veteran for VA examinations with an examiner other than the July 2015 examiner to determine the nature and etiology of his claimed prostate, chronic fatigue, muscle weakness, hair loss, and memory loss disabilities. All indicated tests and studies should be conducted. The claims file, to include a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was accomplished. The examiner is requested to answer the following: (a) Please state whether the symptoms of each claimed condition (prostate, chronic fatigue, muscle weakness, hair loss, and memory loss) are attributable to a known clinical diagnosis, and if so, identify the same. (b) Is the Veteran’s disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, (2) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? (c) If, after examining the Veteran and reviewing the claims file, you determine that the Veteran’s disability pattern is either a diagnosable chronic multi-symptom illness with a partially explained etiology ((b)(2) above), or a disease with a clear and specific etiology and diagnosis ((b)(3) above), then please opine as to whether it is at least as likely as not (50 percent probability or greater) related to presumed environmental exposures during the Veteran’s service in Southwest Asia. (d) Is it at least as likely as not (50 percent probability or greater) that any diagnosed disorder had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service? (e) For any diagnosed prostate disability, please opine as to whether it is at least likely as not (50 percent probability or greater) that such disability had its onset during service or is otherwise related to service, to include as a result of a vasectomy. In addressing this question, the examiner should acknowledge and comment on the in-service notation of “early prostatitis” and the insertion of metal clips during the Veteran’s vasectomy. See August 1991 and April 1992 STRs. (f) For any diagnosed hair loss disability, in addition to inquiry (d), please opine as to whether it is at least likely as not (50 percent probability or greater) that such disability is (i) proximately due to or (ii) has been aggravated (worsened beyond natural progression) codeby service-connected subcutaneous nodules, inclusion cysts of the scalp. In addressing these questions, the examiner is advised that the Veteran is competent to report symptoms and injuries, as well as diagnoses provided to him by physicians, and that his reports (lay observations) must be considered in formulating the requested opinion. If the Veteran’s reported history is discounted, the examiner should provide a reason for doing so. The Veteran’s statements may not be discounted solely on the basis of the lack of confirmation in the medical records. The examiner is specifically asked to comment on the Veteran’s post-service symptomatology including urinary frequency, fatigue, short term memory loss, muscle weakness, and diarrhea. See June 2012 through July 2015 VA treatment records. The examiner must provide a complete rationale for all opinions and conclusions expressed. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. S. BUSH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Asante, Associate Counsel