Citation Nr: 18144787 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 17-01 278 DATE: October 25, 2018 REMANDED Entitlement to service connection for a gastrointestinal disorder, to include irritable bowel syndrome (IBS) or chronic disability manifested by diarrhea and loose stools several times daily, nausea, vomiting, abdominal pain and cramping, to include as due to an undiagnosed illness is remanded. Entitlement to service connection for an esophageal disorder, to include gastroesophageal reflux disease (GERD) or chronic disability manifested by heartburn and indigestion, to include as due to an undiagnosed illness is remanded. Entitlement to service connection for a genitourinary disorder or chronic disability manifested by frequent urination to include as due to an undiagnosed illness is remanded. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had active duty from January 2005 to April 2005, August 2005 to November 2006 and February 2009 to March 2010, to include combat service in the Southwest Asia theater of operations. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an October 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston Salem, North Carolina. While the RO denied service connection for GERD and IBS, the Veteran has reported a variety of symptoms and served in the Southwest Asia theater of operations. Therefore, the Board recharacterized such claims as entitlement to service connection for a gastrointestinal disorder and an esophageal disorder to fully encompass the Veteran’s contentions. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009). 1. Entitlement to service connection for a gastrointestinal disorder, to include IBS or chronic disability manifested by diarrhea and loose stools several times daily, nausea, vomiting, abdominal pain and cramping, to include as due to an undiagnosed illness or service-connected disability is remanded. Service treatment records show that the Veteran sought treatment for diarrhea, nausea, vomiting, abdominal pain, which was diagnosed as gastroenteritis, on June 13, 2009. Additionally, a post deployment health assessment shows that he gave a history of diarrhea in service. Within six months after separation from service, a VA examination for spine, ankle, and arm, shows that the Veteran reported loose stool two to three times daily, stimulated by oral food intake. In September 2015, a VA examiner noted the Veteran’s report of IBS and stomach cramping five to six times daily. The examiner found that there was no objective evidence to render a diagnosis for the claimed IBS condition. Given the Veteran’s service in the Southwest Asia theater of operations, reexamination is needed to address whether the Veteran’s reported symptoms are attributable to a known clinical diagnosis related to service or an undiagnosed illness. 2. Entitlement to service connection for an esophageal disorder, to include GERD or chronic disability manifested by heartburn and indigestion, to include as due to an undiagnosed illness or service-connected disability is remanded. Service treatment records show that the Veteran reported frequent indigestion and heartburn. See Post Deployment Health Assessment (June 13, 2010). On VA examination in September 2015, the Veteran reported heartburn since service, which he has treated with over-the-counter medication. The examiner found that there was no objective evidence to render a diagnosis related to the claimed GERD condition. Given the Veteran’s service in the Southwest Asia theater of operations, reexamination is needed to address whether the Veteran’s reported symptoms are attributable to a known clinical diagnosis related to service or an undiagnosed illness. 3. Entitlement to service connection for a genitourinary disorder or chronic disability manifested by frequent urination to include as due to an undiagnosed illness or service-connected disability is remanded. On VA examination in September 2015, the Veteran reported frequent urination, 10 to 15 times daily. The examiner found that there was no objective evidence to render a diagnosis for a frequent urination condition. Given the Veteran’s service in the Southwest Asia theater of operations, an addendum opinion is needed to address whether the Veteran’s reported symptoms are attributable to a known clinical diagnosis related to service or an undiagnosed illness. 4. Entitlement to service connection for sleep apnea is remanded. Service treatment records show several reports of difficulty breathing, daytime sleepiness, trouble concentrating and forgetfulness, and feeling tired after sleeping. See Post Deployment Health Assessment (October 20, 2006; June 13, 2010). A post service treatment note for an unrelated condition shows that the Veteran’s friend reported that he snores and moves throughout the night. See VA treatment record (November 23, 2012). A November 2013 VA polysomnogram revealed obstructive sleep apnea. On VA examination in September 2015, a VA examiner opined that it is less likely as not that the Veteran’s obstructive sleep apnea is proximately due to or the result of the Veteran’s service connected PTSD as obstructive sleep apnea was a very common condition caused by a blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep. The examiner further reasoned that the Veteran has the risk factors of being male and overweight. Notwithstanding the fact that the September 2015 VA medical opinion lacks rationale or detail regarding when the Veteran’s symptoms began, the examiner failed to provide an opinion as to direct service connection, to include exposure to environmental hazards while serving several tours in the Southwest Asia theater of operations. Moreover, the examiner failed to address whether the Veteran’s risk factor of being “overweight” began in service. Indeed, service treatment records show that the Veteran weighed 230 pounds in service. Lastly, the Veteran reports that he received treatment for the above-discussed disorders at Fayetteville VA Medical Center (VAMC) immediately following separation from service. Significantly, the RO was unable to obtain records from Fayetteville VAMC covering the period from January 2010 to September 2012. The Veteran should also be asked to furnish, or to furnish an authorization to enable VA to obtain, any additional private treatment records from providers who treated him for his claimed disorders. Additionally, given the time that will pass during the processing of this remand, updated VA treatment records should be associated with the record. The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained. These VA treatment records include updated VA treatment records dated from June 2017 to the present as well as those from the Fayetteville VA Medical Center covering the period from January 2010 to September 2012. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford her an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. After obtaining any outstanding records, return the claims file, to include a copy of this remand, to the September 2015 examiner for an addendum opinion as to the nature and etiology of the claimed gastrointestinal, esophageal and genitourinary disorders. If the examiner who drafted the September 2015 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner shall respond to the following questions: (A) State whether the symptoms of each claimed gastrointestinal, esophageal and genitourinary symptoms are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had any such disorder, when did that disorder resolve? (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 reviewing the claims file, you determine that the Veteran’s disability pattern is either (2) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis, then please provide an expert opinion as to whether it is related to presumed environmental exposures experienced by the Veteran during service in Southwest Asia. (d) Is it at least as likely as not that any such diagnosed disorder had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War? The examiner should specifically address the Veteran’s reports of frequent indigestion, heartburn and diarrhea during service In offering such opinion, the examiner should consider the Veteran’s statements regarding the incurrence of his disability. The examiner must provide a complete rationale for all opinions and conclusions reached. 3. After obtaining any outstanding records, return the claims file, to include a copy of this remand, to the September 2015 examiner for an addendum opinion as to the nature and etiology of the obstructive sleep apnea. If the examiner who drafted the September 2015 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner shall respond to the following questions: (a) Is it at least as likely as not that the Veteran’s obstructive sleep apnea is related to an in-service injury, event, or disease, including environmental exposures during service in Southwest Asia during the Persian Gulf War? The examiner should specifically address the impact, if any, of the Veteran’s weight during service on the development of obstructive sleep apnea. (b) Is it at least as likely as not that the Veteran’s obstructive sleep apnea caused by a service-connected PTSD? (c) Is it at least as likely as not that the Veteran’s obstructive sleep apnea aggravated by a service-connected PTSD? In offering such opinion, the examiner should consider the Veteran’s statements regarding the incurrence of his disability. The examiner must provide a complete rationale for all opinions and conclusions reached. 4. After completing the above actions, to include any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. KRISTY L. ZADORA Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Joshua Castillo, Counsel