Citation Nr: 18150189 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 16-03 520 DATE: November 14, 2018 ORDER Entitlement to service connection for Lyme disease is dismissed. Entitlement to service connection for a respiratory disability to include scarring in lungs, as due to an undiagnosed illness is dismissed. Entitlement to service connection for endocarditis, pericarditis and myocarditis as due to an undiagnosed illness is dismissed. Entitlement to service connection for status post laparoscopic cholecystectomy from chronic cholecystectomy with scars (claimed as gall bladder disease to include removal and stomach condition) is dismissed. Entitlement to service connection for chronic diarrhea is dismissed. Entitlement to service connection for urinary stricture is dismissed. Entitlement to service connection for scar, left index finger is dismissed. Entitlement to service connection for scar, right index finger is dismissed. Entitlement to a compensable rating for gastroesophageal reflux disease (GERD) is dismissed. Entitlement to service connection for a neurological disability to include decline in fine motor skills, tremors in face, hand and eyelids, and neuropathy to include tingling sensations all over body with numbness in face, thighs and arms, as due to an undiagnosed illness is granted. Entitlement to service connection for a left knee disability as due to an undiagnosed illness is granted. Entitlement to service connection for a right knee disability as due to an undiagnosed illness is granted. Entitlement to service connection for left elbow joint pain as due to an undiagnosed illness is granted. Entitlement to service connection for right elbow joint pain as due to an undiagnosed illness is granted. Entitlement to service connection for a left ankle disability, as due to an undiagnosed illness is granted. Entitlement to service connection for a right ankle disability, as due to an undiagnosed illness is granted. REMANDED Entitlement to service connection for headaches, to include as due to an undiagnosed illness is remanded. Entitlement to service connection for a bilateral eye disability to include tearing, loss of depth perception, light sensitivity and difficulty focusing, as due to an undiagnosed illness is remanded. Entitlement to service connection for left femur condition to include impact fracture and fibrous cortical defect, as due to an undiagnosed illness, is remanded. Entitlement to service connection for right foot malleolus fracture, to include as due to an undiagnosed illness, is remanded. Entitlement to an initial rating in excess of 20 percent for chronic fatigue syndrome (CFS) is remanded. Entitlement to an initial rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is remanded. FINDINGS OF FACT 1. At his November 2018 Video Conference hearing, the Veteran stated on the record that he wished to withdraw his appeal of the issues of service connection for Lyme disease, a respiratory disability, endocarditis pericarditis and myocarditis, a gall bladder disability, chronic diarrhea, urinary stricture, and left and right index finger scars and the issue of an increased rating for GERD. 2. The Veteran had active service in Southwest Asia during Operation Desert Shield/Desert Storm. 3. The Veteran’s neurological disability has manifested to a degree of 10 percent and is due to an undiagnosed illness. 4. The Veteran’s left knee disability is due to an undiagnosed illness. 5. The Veteran’s right knee disability is due to an undiagnosed illness. 6. The Veteran’s left elbow joint pain is due to an undiagnosed illness. 7. The Veteran’s right elbow joint pain is due to an undiagnosed illness. 8. The Veteran’s left ankle disability is due to an undiagnosed illness. 9. The Veteran’s right ankle disability is due to an undiagnosed illness. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal of the issue of service connection for Lyme disease have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 2. The criteria for withdrawal of the appeal of the issue of service connection for a respiratory disability have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 3. The criteria for withdrawal of the appeal of the issue of service connection for endocarditis, pericarditis and myocarditis have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 4. The criteria for withdrawal of the appeal of the issue of service connection for a gall bladder disability have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 5. The criteria for withdrawal of the appeal of the issue of service connection for chronic diarrhea have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 6. The criteria for withdrawal of the appeal of the issue of service connection for urinary stricture have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 7. The criteria for withdrawal of the appeal of the issue of service connection for scar, left index finger have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 8. The criteria for withdrawal of the appeal of the issue of service connection for scar, right index finger have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 9. The criteria for withdrawal of the appeal of the issue of an increased rating for GERD have been met. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 20.204 (2017). 10. The criteria for service connection for a neurological disability due to an undiagnosed illness have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.317(a)(1) (2017). 11. The criteria for service connection for a left knee disability as due to an undiagnosed illness have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.317(a)(1) (2017). 12. The criteria for service connection for a right knee disability as due to an undiagnosed illness have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.317(a)(1) (2017). 13. The criteria for service connection for left elbow joint pain as due to an undiagnosed illness have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.317(a)(1) (2017). 14. The criteria for service connection for right elbow joint pain as due to an undiagnosed illness have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.317(a)(1) (2017). 15. The criteria for service connection for a left ankle disability, as due to an undiagnosed illness have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.317(a)(1) (2017). 16. The criteria for service connection for a right ankle disability, as due to an undiagnosed illness have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.317(a)(1) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1987 to July 1991. This matter came before the Board of Veterans Appeals (Board) on appeal from an August 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veteran’s Law Judge during a November 2018 Video Conference hearing. Withdrawal 1. Entitlement to service connection for Lyme disease 2. Entitlement to service connection for a respiratory disability to include scarring in lungs, as due to an undiagnosed illness 3. Entitlement to service connection for endocarditis, pericarditis and myocarditis as due to an undiagnosed illness 4. Entitlement to service connection for status post laparoscopic cholecystectomy from chronic cholecystectomy with scars (claimed as gall bladder disease to include removal and stomach condition) 5. Entitlement to service connection for chronic diarrhea 6. Entitlement to service connection for urinary stricture 7. Entitlement to service connection for scar, left index finger 8. Entitlement to service connection for scar, right index finger 9. Entitlement to a compensable rating for gastroesophageal reflux disease (GERD) An appeal may be withdrawn by an appellant or his or her authorized representative as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. At the November 2018 Video Conference Hearing, the Veteran confirmed on the record that he wished to withdraw his appeal of the issues of service connection for Lyme disease, a respiratory disability, endocarditis pericarditis and myocarditis, a gall bladder disability, chronic diarrhea, urinary stricture, and left and right index finger scars and the issue of an increased rating for GERD. The undersigned Veteran’s Law Judge advised the Veteran of the impact of such a withdrawal and the Veteran confirmed his wish to withdraw. As the Veteran confirmed on the record that he wished to withdraw his appeal regarding these issues after being advised of the impact of the withdrawal, the Board finds that the withdrawal was explicit, unambiguous and done with the full understanding of the consequences of such an action. See DeLisio v. Shinseki, 25 Vet. App. 45 (2011). Accordingly, the Board does not have jurisdiction to review the issues of service connection for Lyme disease, a respiratory disability, endocarditis pericarditis and myocarditis, a gall bladder disability, chronic diarrhea, urinary stricture, and left and right index finger scars and the issue of an increased rating for GERD, and the appeal as it pertains to those issues is dismissed. 38 C.F.R. § 20.204. Service Connection Service connection may be established for a Persian Gulf Veteran for a qualifying chronic disability which manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2021, and which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1). A “Persian Gulf Veteran” is a veteran with active service in the Southwest Asia theater of operations during the Persian Gulf War. A “qualifying chronic disability” means a chronic disability resulting from any of the following (or any combination of the following): an undiagnosed illness; the following medically unexplained chronic multi-symptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders. 38 C.F.R. § 3.317(a)(2)(i). 10. Entitlement to service connection for a neurological disability to include decline in fine motor skills, tremors in face, hand and eyelids, and neuropathy to include tingling sensations all over body with numbness in face, thighs and arms, as due to an undiagnosed illness The Veteran contends that his neurological disability is due to an undiagnosed illness related to his Persian Gulf service. The Board concludes that the Veteran is a Persian Gulf veteran with a neurological disability manifested to a degree of 10 percent or more that is due to an undiagnosed illness. Service connection is therefore warranted. 38 C.F.R. § 3.317(a)(1). The Veteran’s DD-214 indicates that he had active service in Southwest Asia during Operation Desert Shield/Desert Storm and received the Southwest Asia Service Medal. The Board therefore finds that he is a Persian Gulf Veteran. The Veteran’s private treatment records indicate that he underwent substantial evaluation for his neurological symptoms. September 2000 private treatment records note tingling in his left and right arm and in his face around the lips. Additional September 2000 records contain an impression of bilateral arm dysthesias, but also noted essentially normal clinical examination and unremarkable nerve conduction studies. December 2000 private treatment records state that the Veteran had a “symptom complex” involving paresthesias and he was referred for neurological evaluation. April 2007 private treatment records note that he was also checked for multiple sclerosis and Lyme disease. July 2007 VA treatment records note pin and needle sensations in the entire left arm, inner half of right arm, cheeks and thighs, but that MRI and nerve conduction studies were normal. The VA provider observed that the neurologic symptoms did not fit any specific pattern of radicular or peripheral nerve syndromes. A Persian Gulf Registry Exam was conducted in April 2001. The VA provider noted the Veteran’s complaint of sensory symptoms and noted that the Veteran had developed strange pins and needles, tingling in face, thighs, half of right arm and all over left arm. The examiner diagnosed unusual sensory symptoms. A January 2002 letter regarding the examination results stated that the provider had no explanation for the Veteran’s unusual sensory symptoms. The provider further stated that he would characterize the Veteran’s symptoms as an undiagnosed illness. A July 2013 VA examination noted the Veteran’s complaints of tingling all over his body and numbness in his face, thighs and arms. He also noted tremors in the face hands and eyelids and found mild bilateral upper and lower extremity paresthesias and numbness. The exam of the peripheral nerves was found to be normal and the examiner stated that there was no pathology associated with the Veteran’s symptoms and no diagnosis. At the outset, the Board finds that the VA and Persian Gulf Registry examinations are adequate for appellate review and entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302–05 (2008). The Board finds that the competent medical evidence of record indicates that the Veteran’s neurological disability is due to an undiagnosed illness. The Veteran’s private and VA treatment records indicate that he has undergone multiple evaluations for his persistent symptoms and that no clear diagnosis has been identified. The January 2002 opinion from the Persian Gulf Registry examiner explicitly found that the Veteran’s sensory symptoms were due to an undiagnosed illness. The July 2013 VA examiner found mild bilateral paresthesias and numbness upon examination, and found that there was no clear peripheral nerve diagnosis or pathology associated with the Veteran’s symptoms. The Board also finds that the July 2013 examiner’s findings of mild neurological symptoms would warrant a compensable evaluation under the ratings for peripheral nerves. While not assigning a particular rating to the Veteran’s disability, the Board notes that under the Diagnostic Code pertaining to the median nerve, mild incomplete paralysis, neuritis or neuralgia warrants a rating of 10 percent. 38 C.F.R. § 4.124a, DC 8515. The Board therefore finds that the Veteran is a Persian Gulf veteran whose neurological disability is due to an undiagnosed illness and that it manifested to a compensable degree prior to December 31, 2021. Service connection is therefore warranted. 38 C.F.R. § 3.317(a)(1). 11. Entitlement to service connection for a left knee disability, as due to an undiagnosed illness 12. Entitlement to service connection for a right knee disability, as due to an undiagnosed illness 13. Entitlement to service connection for a left ankle disability, as due to an undiagnosed illness 14. Entitlement to service connection for a right ankle disability, as due to an undiagnosed illness 15. Entitlement to service connection for left elbow joint pain as due to an undiagnosed illness 16. Entitlement to service connection for right elbow joint pain as due to an undiagnosed illness The Veteran contends that his joint pain disabilities, including his bilateral knee pain, bilateral ankle pain and bilateral elbow pain, are due to an undiagnosed illness related to his Persian Gulf service. The Board concludes that the Veteran is a Persian Gulf veteran with left and right knee disabilities, left and right ankle disabilities and left and right elbow disabilities that began in service and are due to an undiagnosed illness. Service connection is therefore warranted. 38 C.F.R. § 3.317(a)(1). As discussed above, the Veteran is a Persian Gulf veteran. The Veteran’s private treatment records document repeated evaluations for joint pain without identification of a clear diagnosis or etiology. April 1999 records note right ankle discomfort without history of injury and the provider stated that he was not certain of the cause of the Veteran’s complaints. December 2000 records note bilateral knee aches dating to 1993 and note that the Veteran had no specific arthritis or acute joint complaints. The examination showed no obvious bone or joint changes. The provider recorded an impression of a “symptom complex.” April 2007 private records note symptoms of joint pains beginning in 1991 and that the Veteran had been checked for multiple sclerosis and Lyme disease. The Veteran was assessed with arthralgias. April 2012 private records note a history of chronic joint pain but do not contain any joint diagnoses. July 2007 VA treatment records note that the Veteran had mild joint pains that began after his return from the Gulf War in 1991. The provider noted the Veteran’s history of a broken right ankle and left arm, but found that all joints were normal upon examination. The April 2001 Person Gulf Registry Exam noted that the Veteran reported mild persistent joint pain beginning after his return from the Gulf War in 1991. The provider also noted the extensive evaluations the Veteran had undergone with private infectious disease specialists and neurologists. The provider diagnosed diffuse migratory arthralgias and noted that the Veteran reported symptoms in all joints except the elbows, hips and toes. A January 2002 VA letter regarding the Registry Exam results stated that the provider had no explanation for the Veteran’s symptoms of arthralgias. The provider further stated that he would characterize them as an undiagnosed illness. The July 2013 VA examiner completed reports on the knees, ankles and elbows. In the knee report, the examiner noted the Veteran’s reports that he developed pain in his knees while on active duty. The examiner diagnosed bilateral patellofemoral syndrome, or pain around the kneecap. No specific knee pathology or etiology was identified and no etiological opinion was provided. In the ankle report, the examiner noted an old left ankle fracture without residuals, but stated that there was no specific injury to the left ankle. Regarding the right ankle the examiner found that there was no pathology and no diagnosis. In the elbow report, the examiner noted the Veteran’s reports of pain in his elbows beginning in 1991, but found that there was no elbow pathology and no diagnosis. At the outset, the Board finds that the VA examinations are adequate for appellate review and entitled to significant probative weight with respect to the Veteran’s joint disabilities at the time of the examinations. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302–05 (2008). The Veteran also testified at his November 2018 hearing that his knee, elbow and ankle pains began during service in the Persian Gulf. The Board notes that the Veteran is competent to report the onset and persistence of symptoms such as pain and accords his statements significant probative weight. The Board finds that the competent medical evidence of record indicates that the Veteran’s left and right knee, left and right ankle and left and right elbow arthralgia began in service and are due to an undiagnosed illness. The January 2002 opinion from the Persian Gulf Registry examiner explicitly found that the Veteran’s arthralgias were due to an undiagnosed illness. The Veteran’s private and VA treatment records indicate that he has undergone multiple evaluations for persistent joint pains that began in service and that no clear diagnosis, pathology or etiology has been identified. The July 2013 VA examiner noted reports of pain in the elbows and ankles but found no associated pathology or diagnosis. The Board acknowledges that the July 2013 examiner diagnosed bilateral patellofemoral syndrome of the knees, but notes that the examiner did not indicate the basis of this diagnosis and that no etiology or pathology was identified. The Board also notes that the bulk of the medical evidence of record, including the January 2002 Gulf War Registry opinion, indicates that there is no clear diagnosis, pathology or etiology that accounts for the Veteran’s symptoms despite extensive testing. In particular, the Board notes the numerous evaluations conducted by the Veteran’s private providers and noted by the Persian Gulf examiner, which included neurological, infectious disease and orthopedic assessments, and which did not identify a knee diagnosis. The Board therefore gives more weight to the opinion of the Veteran’s private providers and the Persian Gulf Registry Examiner, who characterized the Veteran’s joint complaints as symptom complexes and diffuse arthralgias due to an undiagnosed illness, as they are based on extensive testing and evaluations. While the Veteran did not report elbow pain at his Gulf War Registry examination, the July 2007 VA treatment records note left arm pain and the July 2013 VA examination documents reports of persistent elbow pain. The Veteran also reported elbow pain at his 2018 hearing. As no distinct pathology or etiology regarding the elbows has been identified, the Board finds no basis upon which to dissociate the Veteran’s competent reports of persistent elbow pain from his other arthralgias. The Board therefore finds that the Veteran is a Persian Gulf veteran whose bilateral knee, ankle and elbow arthralgias began in service and are due to an undiagnosed illness. Service connection for bilateral knee disabilities, bilateral ankle disabilities and bilateral elbow disabilities is therefore warranted. 38 C.F.R. § 3.317(a)(1). REASONS FOR REMAND 1. Entitlement to service connection for headaches, to include as due to an undiagnosed illness is remanded. The Veteran contends that his headaches are due to an undiagnosed illness and that they began in service when he began taking pyridostigmine bromide (PB) nerve agent pills. As the July 2013 VA examination did not address the question of whether the Veteran’s headaches were caused by taking PB pills in service, remand for a new examination is required. The Board also notes that while the Persian Gulf Registry examiner stated in a January 2002 letter that the Veteran’s headaches were part of an undiagnosed illness, the July 2013 examiner diagnosed tension headaches but did not indicate the rationale for his diagnosis. Clarification regarding these conflicting opinions should be obtained upon remand. In addition, while the Veteran reported at his November 2018 hearing that he receives ongoing VA treatment, the Board’s review indicates that with the exception of an August 2013 VA opinion, the most recent VA treatment records associated with the file date from July 2007. Remand for outstanding VA treatment records is therefore required. 2. Entitlement to service connection for a bilateral eye disability to include tearing, loss of depth perception, light sensitivity and difficulty focusing, as due to an undiagnosed illness is remanded. The Veteran contends that his bilateral eye condition began during service in the Gulf War and that it is due to taking PB pills during service. The Veteran has not yet been afforded a VA examination regarding this issue. The Board notes August 1987 service treatment records finding a possible louse infestation of the eyelids. July 2007 VA treatment records stated that his eyes were sometimes dilated or constricted and at his November 2018 hearing, he testified that he has double vision and loss of depth perception that began in service. Remand for an VA examination is therefore required. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 3. Entitlement to service connection for left femur condition to include impact fracture and fibrous cortical defect, as due to an undiagnosed illness The Veteran’s service treatment records document a November 1987 left femur injury and a diagnosis of left femur fibrous cortical defect. At his November 2018 hearing, the Veteran reported that he has ongoing aching pain in his left femur. The Board notes that the Veteran is competent to report symptoms such as pain. The July 2013 VA examiner stated that the Veteran had never had a hip or thigh condition. The examiner noted the Veteran’s report of a 1987 left femur fracture and then stated that the Veteran had no current problem in his left femur. The examiner found that there was no pathology and no diagnosis. The Board notes that while the examiner noted the Veteran’s report of a 1987 fracture, there is no indication in the report that the examiner considered the in-service diagnosis of left femur fibrous cortical defect. In addition, the examiner’s finding that the Veteran had never had a hip or thigh condition is inconsistent with the medical evidence of the in-service diagnosis. Remand for a new examination that considers the Veteran’s in-service diagnosis is therefore required. 4. Entitlement to service connection for right foot malleolus fracture, to include as due to an undiagnosed illness At the November 2018 Video Hearing, the Veteran testified that he fractured his right foot in 2006 due to his service-connected CFS. The Veteran reported that it was a day that he was feeling extreme fatigue and he turned over his foot while taking out the trash due ot his impaired condition. The Veteran reports that he continues to experience residuals in his tendons. The Board therefore finds that a remand for a VA examination is required to determine whether the Veteran’s current right foot disability is secondary to his service-connected CFS. 5. Entitlement to a rating in excess of 20 percent for chronic fatigue syndrome (CFS) is remanded. At the November 2018 Video Hearing, the Veteran stated that his CFS has worsened since his last VA examination in July 2013. Specifically, he testified that his fatigue has caused increased restrictions on his pre-illness level of function, stating that his brain stops functioning and he forgets where he is for as long as 2 hours at a time. As the evidence of record suggests his service-connected disability has increased in severity since the most recent VA examination in 2013, the Board finds that the Veteran should be afforded a new examination. See Snuffer v. Gober, 10 Vet. App. 400 (1997). 6. Entitlement to a rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is remanded. At the November 2018 Video Hearing, the Veteran stated that his PTSD has worsened since his last VA examination in July 2013. Specifically, he testified that he is in a constant high-stress mode and that he has increased flashbacks. As the evidence of record suggests his service-connected disability has increased in severity since the most recent VA examination in 2013, the Board finds that the Veteran should be afforded a new examination. See Snuffer v. Gober, 10 Vet. App. 400 (1997). The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from July 2007 to the Present. 2. Ask the Veteran to complete a VA Form 21-4142 for all private providers who treat him for his disabilities, including all hospitals where he has received treatment. Make two requests for the authorized records from all identified providers, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current headache disability. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current headache disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service, to include whether it is a symptom of an undiagnosed illness or due to taking nerve agent pills in service. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of his symptoms. Attention is also requested to the January 2002 Persian Gulf Registry letter attributing the Veteran’s symptoms to an undiagnosed illness and to the July 2013 VA examination which diagnosed tension headaches. 4. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current eye disability. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current eye disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service, to include whether it is a symptom of an undiagnosed illness or due to taking nerve agent pills in service. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of his symptoms. 5. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current left femur disability. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current left femur disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service, to include the November 1987 left femur fracture and diagnosis of fibrous cortical defect. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of his symptoms. 6. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current right foot disability, to include residuals of right foot malleolus fracture. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current right foot disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s service-connected chronic fatigue syndrome. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding his foot injury. 7. Schedule the Veteran for an appropriate VA examination to determine the current level of severity of his chronic fatigue syndrome. The examiner should review the file and provide a complete rationale for all opinions expressed. 8. Schedule the Veteran for an appropriate VA examination to determine the current level of severity of his PTSD. The examiner should review the file and provide a complete rationale for all opinions expressed. 9. If upon completion of the above action the appeal remains denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Arnold, Associate Counsel