Citation Nr: 18150200 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 15-44 636 DATE: November 14, 2018 ISSUES 1. Entitlement to service connection for Scheuermann’s disease with fatigue. 2. Entitlement to service connection for an autoimmune disease, to include as due to an undiagnosed illness. 3. Entitlement to service connection for Sjogren’s syndrome, to include as due to an undiagnosed illness. 4. Entitlement to service connection for a connective tissue disability, to include as due to an undiagnosed illness. 5. Entitlement to service connection for Hashimoto’s disease, variously claimed as sensitivity to cold and autoimmune thyroid disease due to Sjogren’s syndrome, to include as due to an undiagnosed illness. 6. Entitlement to service connection for a heart disability, variously claimed as rapid premature atrial fibrillation with chest pain, to include as due to an undiagnosed illness. 7. Entitlement to service connection for hypothyroidism with fatigue and elevated blood cholesterol, to include as due to an undiagnosed illness, and as secondary to Hashimoto’s disease. 8. Entitlement to service connection for a left shoulder disability, variously claimed as muscle ache and tenderness, joint stiffness, and pain, as secondary to Hashimoto’s disease. 9. Entitlement to service connection for a right shoulder disability, claimed as residual fracture and dislocation, as secondary to Hashimoto’s disease. 10. Entitlement to service connection for constipation, as secondary to Hashimoto’s disease. 11. Entitlement to service connection for a liver lesion, as secondary to Hashimoto’s disease. 12. Entitlement to service connection for a left hip disability, variously claimed as joint stiffness, as secondary to Hashimoto’s disease. 13. Entitlement to service connection for a right hip disability, variously claimed as joint stiffness, as secondary to Hashimoto’s disease. 14. Entitlement to service connection for neuropathy of the right upper extremity, as secondary to Sjogren’s syndrome. 15. Entitlement to service connection for neuropathy of the left upper extremity, as secondary to Sjogren’s syndrome. 16. Entitlement to service connection for neuropathy of the right lower extremity, as secondary to Sjogren’s syndrome. 17. Entitlement to service connection for neuropathy of the left lower extremity, as secondary to Sjogren’s syndrome. 18. Entitlement to service connection for osteoarthritis of the body, as secondary to Sjogren’s syndrome. 19. Entitlement to service connection for Raynaud’s disease, as secondary to Sjogren’s syndrome. 20. Entitlement to service connection for decreased visual acuity, as secondary to Sjogren’s syndrome. 21. Entitlement to service connection for dryness of conjunctiva, also claimed as chronic gritty and burning eyes, as secondary to Sjogren’s syndrome. 22. Entitlement to service connection for a painful jaw disability, as secondary to Sjogren’s syndrome. 23. Entitlement to service connection for a neurological disability, variously claimed as an excessive thirst condition, as secondary to Sjogren’s syndrome. 24. Entitlement to service connection for pruritus, as secondary to Sjogren’s syndrome. 25. Entitlement to service connection for dysphagia with hoarseness and difficulty speaking, as secondary to Sjogren’s syndrome. 26. Entitlement to service connection for gastric ulcers, as secondary to Sjogren’s syndrome. 27. Entitlement to service connection for oral lesions, cracked lips, and ulcers, as secondary to Sjogren’s syndrome. 28. Entitlement to service connection for ataxia, as secondary to Sjogren’s syndrome. 29. Entitlement to service connection for a chronic allergy disability with recurring sinusitis, also claimed as nasal irritation with dryness, as secondary to Sjogren’s syndrome. 30. Entitlement to service connection for white matter lesions on the brain, as secondary to Hashimoto’s disease and Sjogren’s syndrome. 31. Entitlement to service connection for a back disability, variously claimed as a spinal cord disability, as secondary to Scheuermann’s disease. 32. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) with difficulty breathing, as secondary to Scheuermann’s disease. 33. Entitlement to service connection for an acquired psychiatric disorder, claimed as anxiety, and claimed as secondary to rapid premature atrial fibrillation. 34. Entitlement to service connection for an acquired psychiatric disorder, claimed as depression with impaired memory, and as secondary to hypothyroidism. 35. Entitlement to service connection for chronic pain syndrome, with pain, stiffness, and swelling in joints, to include as secondary to hypothyroidism and Hashimoto’s disease. 36. Entitlement to service connection for hypoactive sexual desire disorder, as secondary to hypothyroidism and Hashimoto’s disease. 37. Entitlement to service connection for deformity of the penis, also claimed as erectile dysfunction with loss of erectile power due, and claimed as secondary to Hashimoto’s disease, hypothyroidism, and Scheuermann’s disease. 38. Entitlement to a total disability rating based on individual unemployability (TDIU). 39. Whether clear and unmistakable error (CUE) was committed in a March 2012 rating decision that severed service connection for ORIF, right distal radial fracture with osteoarthritis, wrist, effective June 1, 2012. ORDER Entitlement to service connection for a connective tissue disability, to include as due to an undiagnosed illness, is denied. Entitlement to service connection for a heart disability, variously claimed as rapid premature atrial fibrillation with chest pain, to include as due to an undiagnosed illness, is denied. The motion to revise the March 2012 rating decision on the basis of CUE with respect to severed service connection for ORIF, right distal radial fracture with osteoarthritis, wrist, effective June 1, 2012 is denied. REMANDED Entitlement to service connection for Scheuermann’s disease with fatigue is remanded. Entitlement to service connection for an autoimmune disease, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for Sjogren’s syndrome, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for Hashimoto’s disease, variously claimed as sensitivity to cold and autoimmune thyroid disease due to Sjogren’s syndrome, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for hypothyroidism with fatigue and elevated blood cholesterol, to include as due to an undiagnosed illness, and as secondary to Hashimoto’s disease is remanded. Entitlement to service connection for a left shoulder disability, variously claimed as muscle ache and tenderness, joint stiffness, and pain, as secondary to Hashimoto’s disease is remanded. Entitlement to service connection for a right shoulder disability, claimed as residual fracture and dislocation, as secondary to Hashimoto’s disease is remanded. Entitlement to service connection for constipation, as secondary to Hashimoto’s disease is remanded. Entitlement to service connection for a liver lesion, as secondary to Hashimoto’s disease is remanded. Entitlement to service connection for a left hip disability, variously claimed as joint stiffness, as secondary to Hashimoto’s disease is remanded. Entitlement to service connection for a right hip disability, variously claimed as joint stiffness, as secondary to Hashimoto’s disease is remanded. Entitlement to service connection for neuropathy of the right upper extremity, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for neuropathy of the left upper extremity, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for neuropathy of the right lower extremity, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for neuropathy of the left lower extremity, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for osteoarthritis of the body, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for Raynaud’s disease, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for decreased visual acuity, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for dryness of conjunctiva, also claimed as chronic gritty and burning eyes, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for a painful jaw disability, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for a neurological disability, variously claimed as an excessive thirst condition, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for pruritus, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for dysphagia with hoarseness and difficulty speaking, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for gastric ulcers, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for oral lesions, cracked lips, and ulcers, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for ataxia, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for a chronic allergy disability with recurring sinusitis, also claimed as nasal irritation with dryness, as secondary to Sjogren’s syndrome is remanded. Entitlement to service connection for white matter lesions on the brain, as secondary to Hashimoto’s disease and Sjogren’s syndrome is remanded. Entitlement to service connection for a back disability, variously claimed as a spinal cord disability, as secondary to Scheuermann’s disease is remanded. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) with difficulty breathing, as secondary to Scheuermann’s disease is remanded. Entitlement to service connection for an acquired psychiatric disorder, claimed as anxiety, and claimed as secondary to rapid premature atrial fibrillation is remanded. Entitlement to service connection for an acquired psychiatric disorder, claimed as depression with impaired memory, and as secondary to hypothyroidism is remanded. Entitlement to service connection for chronic pain syndrome, with pain, stiffness, and swelling in joints, to include as secondary to hypothyroidism and Hashimoto’s disease is remanded. Entitlement to service connection for hypoactive sexual desire disorder, as secondary to hypothyroidism and Hashimoto’s disease is remanded. Entitlement to service connection for deformity of the penis, also claimed as erectile dysfunction with loss of erectile power due, and claimed as secondary to Hashimoto’s disease, hypothyroidism, and Scheuermann’s disease is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran had honorable active service in the Southwest Asia theater of operations during the Persian Gulf War. 2. The Veteran does not have a connective tissue disability that is diagnosed or otherwise etiologically related to service. 3. The Veteran is not shown to have any current disability related to the heart, variously claimed as rapid premature atrial fibrillation with chest pain, that is is diagnosed or otherwise etiologically related to service. 4. There is no other disability related to the heart or connective tissue due to undiagnosed illness and medically unexplained chronic multisymptom illnesses. 5. A November 1, 2011 VA Administrative Decision found willful misconduct on behalf of the Veteran. 6. A November 15, 2011 rating decision proposed to severe service connection for right distal radial fracture. 7. A March 6, 2012 rating decision took final action to sever service connection for ORIF, right distal radial fracture with osteoarthritis, wrist, effective June 1, 2012. 8. In October 2017, VA received the Veteran’s CUE motion and request. 9. A May 2018 rating decision confirmed and continued the severance of service connection. 10. The Veteran has not alleged an error of fact in the March 6, 2012 rating decision that compels the conclusion, to which reasonable minds could not differ, that the results would have been manifestly different but for the error. CONCLUSIONS OF LAW 1. A connective tissue disability to include as due to an undiagnosed illness was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1118, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017). 2. A heart disability, variously claimed as rapid premature atrial fibrillation with chest pain, to include as due to an undiagnosed illness was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1118, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017). 3. The March 6, 2012 rating decision, which took final action to sever service connection for ORIF, right distal radial fracture with osteoarthritis, wrist, effective June 1, 2012, was not clearly and unmistakably erroneous. 38 U.S.C. § 5109A; 38 C.F.R. §§ 3.104, 3.105, 20.1403 (2017). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from February 1994 to November 1997, and from November 2001 to September 2003. The Veteran’s second period of service was later upgraded to be characterized as under honorable conditions. This is discussed further below. This matter is before the Board of Veterans Appeals (Board) on appeal from a March 2012 rating decision by the VA RO in Sioux Falls, South Dakota, and August 2013 and October 2014 rating decisions by the VA RO in Muskogee, Oklahoma. Jurisdiction currently lies with the RO in Muskogee, Oklahoma. The Board observes that there are several issues on appeal, most under a theory of secondary service connection. The Board has continued with the characterization of them consistent with the rating decisions and the October 29, 2015 Statement of the Case (SOC). Neither the Veteran nor his attorney have objected to this aspect of the appeal. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that the scope of a mental health disability claim includes any mental health disability that could reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. The Board has recharacterized the appeal as encompassing the issues on the title page. Given how the psychiatric claims were treated as separate claims based upon secondary service connection theories of entitlement, consistent with the RO’s characterization, we have kept them as two separate issues. The Board also observes that a November 2011 rating decision denied service connection for an acquired psychiatric condition to include post-traumatic stress disorder. Consistent with this, in light of the Veteran’s new claims and specific characterization of these as secondary to other disabilities currently on appeal, the Board will continue adjudicating the appeals as new claims for service connection. In a letter dated August 31, 2018 and received by VA on September 7, 2018, the Veteran through his attorney withdrew his hearing request. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection To establish service connection a Veteran must generally 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 or aggravated during service.” Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). For a Veteran who had active service in the Southwest Asia theater of operations during the Persian Gulf War (a Persian Gulf veteran), presumptive service connection may be established for a qualifying chronic disability, which specifically includes a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, such as fibromyalgia. See 38 U.S.C. §§ 1117, 1118 (2012); 38 C.F.R. § 3.317 (2017). Objective indications of a chronic disability include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). 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. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(4). Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317 (b). As noted above, service connection may be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War 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. Here, the Veteran’s DD-215 specifically shows that the Veteran was awarded the Iraq Campaign Medal with one bronze service star, reflecting service in the Southwest Asia theater of operations. 38 C.F.R. § 3.317 (e)(1). If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98. Notwithstanding the foregoing presumptive provisions, the Veteran is not precluded from establishing service connection for a disease averred to be related to Gulf War service, as long as there is proof of such direct causation. See generally Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). The Veteran first underwent a November 2012 Gulf War General Medical Examination. His chief related complaints were hearing loss and tinnitus, sinusitis/rhinitis, respiratory conditions other than tuberculosis and sleep apnea, thoracolumbar spine conditions, ankle, elbow, hip and thigh, knee and lower leg, and shoulder and arm conditions, headaches, and traumatic brain injury (TBI). The VA examiner indicated in the negative for any diagnosed illnesses for which no etiology could be established. The remarks direct to the individual examinations, however, they show, “The Veteran had to receive X-rays during this exam and appeared in a hurry to leave today. He had tremors and a strange odor when he came back from getting his X-rays. I examined him for ranges of motion, functional loss, and then he swung what appeared to be a very heavy and large backpack over his shoulders without any sort of objective evidence of pain and left very quickly.” As with all claims for service-connection, in the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 1. Entitlement to service connection for a connective tissue disability, to include as due to an undiagnosed illness. 2. Entitlement to service connection for a heart disability, variously claimed as rapid premature atrial fibrillation with chest pain, to include as due to an undiagnosed illness. The Board incorporates its discussion from the sections above by reference. By way of background, the Service Treatment Records (STRs) include a Pre-Deployment Health Assessment from April 23, 2003. It shows that the Veteran served on active duty in Iraq as part of Operation Iraqi Freedom. As a threshold matter, the Veteran had active military service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317. The laws and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service, discussed above, thus are applicable in this case. In the Pre-Deployment Health Assessment, the Veteran endorsed that his general health was “excellent.” The Veteran denied any medical or dental problems. He denied any questions or concerns about his health. A health care referral shows “none.” A July 2003 Developmental Counseling Form shows that the Veteran received counseling for communicating a threat, disrespecting a non-commissioned officer, probable cause of having alcohol in his possession – violation of general order one, and endangering the lives of soldiers. In August 2003, the Veteran agreed to be discharged in lieu of court martial. Several documents show that he was in the possession of alcohol and appeared intoxicated on several occasions. An August 27, 2003 document shows that the Veteran was designated for issuance of an Other Than Honorable Discharge. The Veteran was eventually discharged in September 2003. It follows that there was no exit examination, presumably due to these events. Later, an October 2007 Administrative Decision found in part that the Veteran’s “service from 11/01/01 to 9/13/03 was dishonorable for VA purposes, and the veteran is not entitled to receive VA benefits based upon this period of service.” However, the Administrative Decision found that the Veteran’s “service from 2/24/94 to 11/29/97 was honorable for VA purposes, and the veteran is entitled to receive VA benefits based upon this period of service.” However, the Veteran’s DD-214 shows in the remarks, ”Characterization of service upgraded on 14 December 2007 following application dated 10 October 2006.” It shows a character of discharge as “Under Honorable Conditions (General).” The RO has continued to process the claim accordingly, and the Board will not disturb this aspect of the appeal. Ongoing Prison Health Services treatment records from during the Veteran’s period of incarceration were obtained. They show a variety of medical issues and related treatment. In particular, a March 2009 Prison Health Services Inmate Medical Request Form shows, “since being off inderal his raynauds is no better but his heart palpitations are back, no chest pain or sob (sic).” A September 2010 VA Mental Health Examination showed impressions of malingering. An August 2011 VA psychiatric examination confirmed the circumstances surrounding the Veteran’s separation and discharge. It also shows that he was arrested in 2004 for an altercation with police offices. He was sentenced to six years in prison, and was incarcerated from September 11, 2006 to July 28, 2009. A November 2011 Administrative Decision found that the Veteran’s “injuries that occurred as a result of a fall from a 3-story building that occurred in April 2002 were the result of his own willful misconduct.” It cites a May 17, 2002 STR that shows that the Veteran fell from a third story window, with alcohol involved. It also cites a related treatment report received in August 25, 2011that shows that the Veteran had consumed 48 drinks of alcohol on the day in question. The Veteran was afforded a November 2012 VA Gulf War General Medical Examination. There was no indication of cardiovascular disability, including for artery and vein conditions, hypertension, heart disease, and ischemic heart disease. There were no muscle injuries or arthritis. The VA examiner indicated that there was a normal physical examination except for the unrelated conditions that were listed as affected, and for which there were additional Disability Benefits Questionnaires (DBQs). The Veteran’s March 2014 Application for Disability Compensation and Related Compensation Benefits explicitly lists his theory of entitlement for autoimmune disease, Sjogren’s syndrome, connective tissue disorder, Hashimoto’s disease, hypothyroidism, and repaid premature atrial fibrillation as due to “Environmental Hazard in Gulf War.” A June 2014 Health Record Detail shows that the Veteran takes medication for heart palpitations. The Veteran was most recently afforded a September 2014 VA Gulf War General Medical Examination. The VA examiner reviewed the claims file. The VA examiner indicated that there were no diagnosed illnesses for which no etiology was established. The VA examiner noted that the Veteran reported autoimmune conditions. For the signs and symptoms, it shows: The Veteran complains of constipation alternating with diarrhea. He says this started in Kuwait in 2003. He has loose stools several times a week. He has chronic gas and distention and discomfort but gets no relief from these conditions with a bowel movement. He has incomplete emptying and frequently has to go again immediately after a BM. His abdominal pain is present whether there is constipation or diarrhea. He has daily symptoms and there are no episodes. This does not meet the published criteria for diagnosis of IBS. Next, the VA examiner rendered several opinions based upon his review of the claims file. They are addressed in turn below. First, the VA examiner found a clinically normal physical examination. The ear, nose, and throat (ENT) examination was unremarkable, the abdomen was soft without tenderness, distention, or guarding, and the upper and lower extremities were unremarkable. There were shoulder abnormalities which were addressed via a Disability Benefits Questionnaire (DBQ). Next, the Veteran through his previous attorney filed an October 2014 Notice of Disagreement (NOD) with a signed affidavit and letter from his attorney. The letter concludes that the Veteran, “disagrees with all of the above findings relating to service connection of his conditions, and appeals that decision.” In an August 2014 sworn affidavit, the Veteran describes events in July 2003 that resulted in claimed knee, back, shoulder, and hip injuries. His body was thrown out of his seat during an accident on an M88 track vehicle. He also described migraines following an accident in 1994. The Veteran also reported a history of alcohol abuse with PTSD and depression. He reported that he was drinking socially when he fell out of a window in 2002. Regarding chronic asthma, also diagnosed by VA as COPD, the Veteran asserts that he has chewed canned tobacco, with approximately one can every two to four days. He specifically reported, “I began having shortness of breath especially upon exertion while I was deployed in Iraq while on active duty. The symptoms became progressively worse to the point that I would get dizzy because I couldn’t get in enough air to breathe. There was constant sand blowing through the air, sand storms, burn pits, vehicle fires, and the burning of human excrement. JP8 a jet fuel was everywhere on the ground and I was constantly filling up vehicles with this fuel.” He contends that he can no longer take medications since his return, including Tylenol. He asserts that he has multiple environmental allergies. The September 2014 VA examiner highlighted, “There has been a question of malingering on the part of this Veteran by several different Drs at different facilities.” A VA treatment record from October 10, 2014 shows, “HEART REG, NO MURMUR.” On October 10, 2014, the Veteran presented to a VA facility in Tulsa experiencing anxiety with pressure in his chest. His pain level decreased. His heart was regular, with no murmur. His blood pressure also went down after 15 minutes. A VA treatment record from October 15, 2014 shows, “Negative for heart damage but found to have pulmonary emboli, walked in with prescriptions for Xerelto.” A VA Primary Care Note with Vitals from March 17, 2015 shows, “heart sounds are regular, rate is OK, no murmur” and “no carotid bruits.” In December 2015, the Veteran perfected his appeal. He avers in part that the decision review officer (DRO) failed to review medical records from private specialists, and documented incorrect dates, incorrect diagnoses, and incorrect doctors. The Veteran attached a Health Record Detail printed on February 2, 2015, showing various conditions with “Date Assessed” and a date next to them. He also attached various copies of private treatment records. Additional private and VA treatment records are substantially the same. The Veteran contends that he is entitled to service connection for connective tissue disability and a heart disability, variously claimed as rapid premature atrial fibrillation with chest pain; incurred in service and/or disability due to undiagnosed illness and medically unexplained chronic multisymptom illnesses due to environmental hazard exposure in service. Under 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) An undiagnosed illness; (2) a medically unexplained chronic multisymptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection for infectious diseases. The Veteran is competent to report that he experienced symptoms of feeling his heart pounding and chest pain. He is competent to report what he has been told by a physician, including that he was experiencing heart palpitations. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Here, the Board considered the Veteran’s reports of a connective tissue disability and a heart disability. However, as a lay person, he is not competent to determine whether his reported symptoms are attributable to a particular disease entity, and to diagnose that disease entity or entities. The most probative evidence is contemporaneous treatment records, including the STRs, and the September 2014 VA examination with medical opinion. The STRs do not show that the Veteran was diagnosed with a connective tissue disability or heart disability manifested by atrial fibrillation in service. Years later, the September 2014 VA examiner found a clinically normal physical examination, except for the noted disabilities, which did not include diagnostic impressions encompassing the connective tissue or heart. In other words, there was no present disability related to the connective tissue and heart. The Board assigns substantial probative weight to findings of the September 2014 VA examiner. The most recent VA treatment records from 2015 do not show any connective tissue pathology. They do show a clinically normal evaluation of the heart. We note some notations of ongoing heart palpitations and that the Veteran takes related medicine. However, we have found no present impairment due to disease or injury. Any notations of possible heart pathology show that the condition was acute, transitory, and resolved at various times. For example, it went away after 15 minutes on one occasion. In addition, the Board notes other factors, as highlighted by the various treating physicians. No additional, separate disability related to the Veteran’s claimed connective tissue and heart disabilities has been diagnosed. Once again, the Veteran is not competent to state that his subjective complaints are symptoms of a connective tissue disability or heart disability, or an undiagnosed illness, or to provide opinions as to their etiology, as to provide such an opinion requires medical expertise. See Jandreau, 492 F.3d 1372. The basis for these claims appears to be largely conclusory statements. Moreover, as the lay diagnostic statements are not competent, the Board affords them diminished probative weight. Based the competent and credible evidence of record, the Board finds that the claimed connective tissue and heart disability has not been competently and credibly associated with any known etiology or medical diagnosis, and therefore service connection based on the law and regulations pertaining to a possible medically unexplained chronic multisymptom illness or undiagnosed illness incurred due to Persian Gulf service is not warranted. 38 C.F.R. § 3.317. There is no probative evidence to the contrary. Turning to direct and presumptive service connection, as noted above, the VA examiner noted that the Veteran carries no current or previous diagnosis of connective tissue or heart disability. As such, the first necessary element of service connection is not met. There is no probative evidence to the contrary. Consequently, service connection for a connective tissue or heart disability as a separate disability is not warranted on a direct or presumptive basis. 38 C.F.R. §§ 3.303, 3.307, 3.309; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In short, the preponderance of the evidence weighs against a finding that the Veteran’s claimed connective tissue and heart symptoms are manifestations of a medical unexplained or undiagnosed chronic multisymptom illness. We note other factors. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990); 38 C.F.R. § 3.102. For these reasons, service connection is not warranted. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. Whether clear and unmistakable error (CUE) was committed in a March 2012 rating decision that severed service connection for ORIF, right distal radial fracture with osteoarthritis, wrist, effective June 1, 2012 The Board incorporates its discussion from the sections above by reference. Previous determinations which are final and binding, including decisions of service connection, degree of disability, age, marriage, relationship, service, dependency, line of duty, and other issues, will be accepted as correct in the absence of clear and unmistakable error. Where evidence establishes such error, the prior decision will be reversed or amended. 38 C.F.R. § 3.105. A decision by the Secretary under this chapter is subject to revision on the grounds of clear and unmistakable error. If evidence establishes the error, the prior decision shall be reversed or revised. 38 U.S.C. § 5109A. Clear and unmistakable error is a very specific and rare kind of error. It is the kind of error, of fact or of law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the error. Generally, either the correct facts, as they were known at the time, were not before the Board, or the statutory and regulatory provisions extant at the time were incorrectly applied. 38 C.F.R. § 20.143. Thus, even where the premise of error is accepted, if it is not absolutely clear that a different result would have ensued, the error complained of cannot be, ipso facto, clear and unmistakable. Fugo v. Brown, 6 Vet. App. 40 (1993). A determination that a prior determination involved CUE involves the following three-prong test: (1) either the correct facts, as they were known at the time, were not before the adjudicator (i.e., there must be more than a simple disagreement as to how the facts were weighed or evaluated) or the statutory or regulatory provisions extant at the time were incorrectly applied; (2) the error must be undebatable and of the sort which, had it not been made, would have manifestly changed the outcome at the time it was made; and (3) a determination that there was clear and unmistakable error must be based on the record and law that existed at the time of the prior adjudication in question. Damrel v. Brown, 6 Vet. App. 242 (1994); Russell v. Principi, 3 Vet. App. 310 (1992). Further, the error must be “undebatable” and of the sort which, had it not been made, would have manifestly changed the outcome at the time it was made, and a determination that there was CUE must be based on the record and law that existed at the time of the prior adjudication in question. Id. Simply to claim CUE on the basis that the previous adjudication improperly weighed and evaluated the evidence can never rise to the stringent definition of CUE, nor can broad-brush allegations of “failure to follow the regulations” or “failure to give due process,” or any other general, non-specific claim of “error” meet the restrictive definition of CUE. Fugo v. Brown, 6 Vet. App. 40, 44 (1993). Notably, a determination of CUE must be based upon the record and the law that existed at the time of the prior adjudication in question. May v. Nicholson, 19 Vet. App. 310, 313 (2005). Errors that cannot constitute CUE, pursuant to 38 C.F.R. § 20.1403 (d) and (e), include (1) a changed diagnosis, where a “new medical diagnosis... ‘corrects’ an earlier diagnosis considered in a Board decision;” (2) VA’s failure to comply with the duty to assist; (3) a “disagreement as to how the facts were weighed;” and (4) a subsequent change in interpretation of the statute or regulation that was applied in the Board decision. See Jordan v. Nicholson, 401 F.3d 1296, 1298-99 (Fed. Cir. 2005). By way of background, the Service Treatment Records (STRs) from 2002 show treatment for status post right distal radius fracture with ORIF from April 2002. An April 23, 2002 radiological report shows that imaging revealed “interval placement of fixation plates, screws and K-wires through a comminuted distal radial fracture.” STRs show ongoing occupational therapy as a result of falling form the third floor of a building. The Veteran had surgery on the right wrist. He complained of lack of mobility and possible car tissue. A July 9, 2002 Occupational Therapy Intake Questionnaire shows that the Veteran reported falling out of a third story window while drinking. Additional STRs are substantially the same. Next, a March 17, 2010 rating decision granted service connection for right distal fracture with osteoarthritis based upon an STR from April 21, 2002 showing a right wrist fracture from a fall. In April 2011, VA received the Veteran’s VA 21-4176 Report of Accidental Injury in Support of Claim for Compensation. Related to this, a November 1, 2011 VA Administrative Decision found related willful misconduct on behalf of the Veteran. The Veteran reported that while sitting on a window ledge talking on a cell phone, he leaned out of the window for better cell reception and fell from a three-story building, fracturing his right wrist. A November 15, 2011 rating decision proposed to severe service connection for right distal radial fracture. A March 6, 2012 rating decision took final action to sever service connection for ORIF, right distal radial fracture with osteoarthritis, wrist, effective June 1, 2012. Later, service connection for ORIF, right distal radial fracture with osteoarthritis, wrist (nondominant) was severed effective June 1, 2012, the last day of the month in which a 60-day period from the time the final rating action expired. Next, on October 31, 2017, VA received the Veteran’s CUE motion and request. The Veteran through his attorney generally provided an overview of the STRs and private treatment reports showing that the Veteran fell out of the window while intoxicated. They acknowledge the medical evidence generally relied upon by the RO in its decision. Specifically, with respect to private treatment reports from DEXHEIM Community Counseling Center, they take note of the private treatment record’s notation that the Veteran reported consuming 48 drinks prior to the accident. The Veteran through his attorney then made several contentions in support of his CUE motion. First, he asserted, “Drinking alcohol his not unlawful; and therefore, is not a prohibited action nor should it be construed as misconduct. Additionally, [the Veteran] did not deliberately nor intentionally fall out a 3rd floor window. Therefore, VA cannot determined (sic) the Veteran’s sustained injuries were willful misconduct.” Second, the Veteran and his attorney challenged the validity of the private treatment record showing that the Veteran consumed 48 drinks as “absurd.” They cited that this is likely an exaggeration. They therefore averred that reasoning that the Veteran’s alcohol use “likely” contributed to his fall is speculative, and does not legally support severance of service connection. The Veteran through his attorney therefore sought revision of the March 6, 2012 rating decision. A May 2018 rating decision confirmed and continued the severance of service connection. The Veteran through is attorney alleges that VA committed an error of fact in the March 6, 2012 rating decision that compels the conclusion, to which reasonable minds could not differ, that the results would have been manifestly different but for the error. As a preliminary matter, the Board notes that an assertion of CUE is a collateral attack on an otherwise final rating decision by a VA regional office. Smith v. Brown, 35 F.3d 1516, 1527 (Fed. Cir. 1994). As such, there is a presumption of validity that attaches to a final decision, and when such a decision is collaterally attacked the presumption becomes even stronger. Fugo, 6 Vet. App. at 43-44. Therefore, a claimant who seeks to obtain retroactive benefits based on CUE has a much heavier burden than that placed on a claimant who seeks to establish prospective entitlement to VA benefits. Akins v. Derwinski, 1 Vet. App. 228, 23 (1991). The Board has reviewed the record, and ultimately finds that the Veteran has not met this burden. Willful misconduct means an act involving conscious wrongdoing or known prohibited action. A service department finding that injury, disease or death was not due to misconduct will be binding on the Department of Veterans Affairs unless it is patently inconsistent with the facts and the requirements of laws administered by the Department of Veterans Affairs. (1) It involves deliberate or intentional wrongdoing with knowledge of or wanton and reckless disregard of its probable consequences. (2) Mere technical violation of police regulations or ordinances will not per se constitute willful misconduct. (3) Willful misconduct will not be determinative unless it is the proximate cause of injury, disease or death. (See §§ 3.301, 3.302.) 38 C.F.R. § 3.1(n). The simple drinking of alcoholic beverage is not of itself willful misconduct. The deliberate drinking of a known poisonous substance or under conditions which would raise a presumption to that effect will be considered willful misconduct. If, in the drinking of a beverage to enjoy its intoxicating effects, intoxication results proximately and immediately in disability or death, the disability or death will be considered the result of the person’s willful misconduct. 38 C.F.R. § 3.301 (c)(2). An injury or disease incurred during active military, naval, or air service shall not be deemed to have been incurred in line of duty if such injury or disease was a result of the abuse of alcohol or drugs by the person on whose service benefits are claimed. For the purpose of this paragraph, alcohol abuse means the use of alcoholic beverages over time, or such excessive use at any one time, sufficient to cause disability to or death of the user; drug abuse means the use of illegal drugs (including prescription drugs that are illegally or illicitly obtained), the intentional use of prescription or non-prescription drugs for a purpose other than the medically intended use, or the use of substances other than alcohol to enjoy their intoxicating effects. 38 C.F.R. § 3.301 (d). Here, the rating decision dated March 6, 2012, was not clearly and unmistakably erroneous for severing service connection for ORIF, right distal radial fracture with osteoarthritis, wrist, effective June 1, 2012. The Board has considered the November 1, 2011 Administrative Decision, reviewed the claims file, and ultimately finds the rating decision did not commit kind of error, of fact or of law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the error. In rendering its decision, the RO carefully considered the Veteran’s repeated intoxication, including the contemporaneous treatment records surrounding the fall. The Board observes that the RO did not consider, in contravention of VA regulations, that the act of drinking alcohol is itself unlawful. The RO reviewed the Veteran’s actions stemming from drinking excessively, and climbing into a window while intoxicated. The Veteran’s attorney highlights that the simple drinking of alcoholic beverages is itself not willful misconduct. However, that is also distinct from the present case. The facts show that the Veteran drank in excess. The fact that the fall itself was not deliberate or intentional does not change the willful intoxication that was the precipitating event. A consideration of the lawfulness of drinking and falling from a window is also irrelevant to the governing statutes cited by the Veteran and his attorney. “If, in the drinking of a beverage to enjoy its intoxicating effects, intoxication results proximately and immediately in disability or death, the disability or death will be considered the result of the person’s willful misconduct.” 38 C.F.R. § 3.301 (c)(2). Second, the RO considered all of the evidence, and did not just consider the facial plausibility of a notation of specifically consuming 48 drinks, as contended by the Veteran. In other words, while the RO may have speculated that drinking excessively likely contributed to the Veteran’s fall, any level of speculation involved was still grounded in a thorough review of the contemporaneous STRs and Service personnel Records (SPRs). Neither party has disputed that there is ample evidence of intoxication. Such a consideration therefore does not rise to the level of error, of fact or of law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the error. See 38 C.F.R. § 20.1403. The RO gave substantial probative weight to the contemporaneous treatment records, and the Veteran and his attorney have conceded that he had been drinking when he climbed into a third story window during service. They have also not disputed that a fall took place, regardless of intent. The Veteran’s own credibility as a historian is also called into question by his attorney’s admission that he was exaggerating. We note other factors. To the extent there is any other evidence not discussed explicitly by the RO, this was of record at the time of the March 6, 2012 rating decision. We find that the rating decision dated March 6, 2012, was not clearly and unmistakably erroneous for severing service connection for ORIF, right distal radial fracture with osteoarthritis, wrist, effective June 1, 2012. Therefore, CUE was not committed, and revision is not warranted. 38 U.S.C. § 5109A; 38 C.F.R. §§ 3.104, 3.105, 20.1403. Neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In reaching this conclusion, the Board finds that the preponderance of the evidence is against this claim. As such, the benefit of the doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for Scheuermann’s disease with fatigue. The Board incorporates its discussion from the sections above by reference. A remand is necessary for additional development. December 2006 Private treatment reports from Dr. J. M. indicated that the Veteran had findings consistent with Scheuermann’s disease. They did not show a definitive diagnosis or any nexus opinion regarding military service or otherwise. A December 2, 2009 VA examination with imaging revealed back pathology. Shortly thereafter, a February 2010 VA examination shows reports of back pain and back pathology. VA treatment records from November 2012 from the Muskogee VA Medical Center (VAMC) include two spinal images. They revealed diagnostic impressions of “Mild S-shaped scoliosis. Scattered mild disk space height loss with minimal anterior wedging of several of the lumbar vertebral bodies; some of this can be related to etiology such as Scheuermann’s disease. Chronic appearing changes at the anterior/superior L4 vertebral body as above.” In short, there was presence of possible disability since discharge, although no comprehensive, definitive nexus opinion. Next, the September 2014 VA Gulf War examination shows that the VA examiner considered the Veteran’s complaints of lower back pain and Scheuermann’s disease. The VA examination shows that he underwent an L2-L4 microhemilaminectomy on May 28, 2014. The VA examiner found the Veteran’s physical examination to be otherwise clinically normal, absent the described shoulder disabilities, which did not include the back. Additional VA and private treatment records show impressions of back pathology. Here, although there is some evidence of disability, there is no nexus opinion concerning the Veteran’s specific claimed Scheuermann’s disease with fatigue. VA must provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 41 (2006); McLendon v. Nicholson, at 83. As the evidence of record is not sufficient to decide the claim, an additional examination and medical opinion is necessary. Consequently, a remand is warranted. 2. Entitlement to service connection for an autoimmune disease, to include as due to an undiagnosed illness. 3. Entitlement to service connection for Sjogren’s syndrome, to include as due to an undiagnosed illness. 4. Entitlement to service connection for Hashimoto’s disease, variously claimed as sensitivity to cold and autoimmune thyroid disease due to Sjogren’s syndrome, to include as due to an undiagnosed illness. The Board incorporates its discussion from the sections above by reference. An October 31, 2013 private treatment record from the Oklahoma Heart Institute shows a discussion of diseases, “I have explained to the patient that issues (sic) pertaining to autoimmune disorders and specifically Hashimoto’s thyroiditis. He was provided with educational material in this regard as well.” A private treatment record from Tulsa printed on December 11, 2013 shows several “Other ROS Comments.” It shows in part, “Endocrine: Diagnosis of Hashimoto’s thyroiditis. He is told his TSH is jumping up and down. He does have both heat and cold intolerance.” A January 2014 private treatment record from Dr. J. M. shows a diagnostic impression of Hashimoto’s disease. A March 26, 2014 private treatment record from Dr. J. M. E. shows that the Veteran reported that he was recently diagnosed with Sjogren’s. Regarding autoimmune disease, the September 2014 VA examiner’s opinion identifies possible disability, but does not provide a full nexus opinion with reasons and bases. The VA examiner opined: The Veteran has a number of recently diagnosed conditions that are autoimmune based and this includes Hashimoto’s thyroiditis, Raynauds, and Sjogrens syndrome. There has not been a specific diagnosis for all of this but Hashimoto’s is the most common etiology of hypothyroidism in the general population and Sjogren’s is a common condition causing dry mouth and dry eyes and can cause dysphagia. His “Raynauds” was noted to be associated with frostbite. These conditions were diagnosed years after he left the service. Moreover, contrary to the conclusions in the October 2015 Statement of the Case (SOC), there are possible diagnostic impressions of disability. However, the VA examiner did not render complete nexus opinions for each of the claimed conditions. On remand, the status of possible previous diagnostic impressions or actual contemporaneous diagnoses should also be clarified. VA treatment records from the Muskogee VA Medical Center (VAMC) show ongoing impressions of and treatment for Sjogren’s syndrome. They include possible notations of dry mouth and eyes, and joint pain. There is no complete nexus opinion. In December 2015, the Veteran perfected his appeal. He avers in part that the decision review officer (DRO) failed to review medical records from private specialists, and documented incorrect dates, incorrect diagnoses, and incorrect doctors. The Board has considered these contentions. Certain disabilities due to undiagnosed illness and medically unexplained chronic multisymptom illnesses, to include that which may be manifested by signs or symptoms involving skin, fatigue, and more reported symptoms found in the VA and private treatment records, may be subject to service connection for Persian Gulf Veterans serving in particular countries in the Southwest Asia theater of operations. 38 C.F.R. § 3.317. In particular, an undiagnosed autoimmune disease may have a variety of manifestations, and/or those manifestations may be attributable to already diagnosed disease. The Board notes that the list of symptoms contained in the regulation is not exhaustive. On remand, the current symptoms and diagnostic impressions, and how they relate to the various theories of entitlement, should be clarified. Service connection may also be warranted on a direct or presumptive basis. 38 C.F.R. §§ 3.303, 3.307, 3.309. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. We note that if the medical evidence of record is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board is always free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. However, it is not free to substitute its own judgment for that of such an expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Here, the Veteran has continued to submit medical records containing the results of various diagnostic testing. When perfecting his appeal in December 2015, the Veteran highlighted previous treatment records, including some with laboratory results. While the Board encourages the Veteran to submit medical evidence to substantiate his claim, the Board also observes that it is not permitted to make medical determinations as to the nature and etiology of any disability based upon its own interpretation of medical charts or lab results. However, an appropriate medical professional would be competent to interpret these. There is also the complex question of to which disability various laboratory results may be attributable, especially in light of the various disease claims and reported symptoms. Therefore, additional development is necessary. We further note that various treatment records show handwriting in the margins listing possibly diagnosed disease entities or references to discussing them with the Veteran. We note it is not clear who has annotated all of these documents, when the notations were made, or whether they are present diagnostic impressions or simply notations of other claimed disabilities reported by the Veteran and/or found in other treatment records. As such, on remand, this will also be clarified by way of VA examinations. Indeed, VA must provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 41 (2006); McLendon v. Nicholson, at 83. 38 U.S.C. § 5103A (a) requires VA to assist a claimant in obtaining a medical opinion or examination whenever such an opinion is “necessary to substantiate the claimant’s claim” and only excuses VA from making reasonable efforts to provide such assistance, if requested, when “no reasonable possibility exists that such assistance would aid in substantiating the claim.” Wood v. Peake, 520 F.3d 1345, 1348-49 (Fed. Cir. 2008); see also DeLaRosa v. Peake, 515 F.3d 1319, 1322 (Fed. Cir. 2008). As the evidence of record is not sufficient to decide the claim, and given the Veteran’s specific contentions, additional VA examinations with medical opinions are necessary. Lastly, the most recent VA treatment records are from several years ago. The Veteran has received ongoing treatment at VA facilities. Any outstanding VA treatment records since July 2015 should be included in the claims file. See Bell v. Derwinski, 2 Vet. App. 611 (1992). 5. Entitlement to service connection for a back disability, variously claimed as a spinal cord disability, as secondary to Scheuermann’s disease. 6. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) with difficulty breathing, as secondary to Scheuermann’s disease. The Board incorporates its discussion from the sections above by reference. A July 2003 STR from shortly before discharge shows complaints of lower back pain. The Veteran reported that he pulled his back but did not know how. By way of background, a November 2012 VA Gulf War examination rendered a negative nexus opinion regarding COPD. The VA examiner opined, “I conclude, after a review of medical records, taking a history, and performing a physical examination the Chronic Obstructive Pulmonary Disease is less than likely related to environmental hazards due to Gulf War.” The VA examiner noted a history of tobacco use. There is no secondary service connection medical opinion. Here, the Board observes that the Veteran’s March 2014 Application for Disability Compensation and Related Compensation Benefits explicitly lists his theory of entitlement for six disabilities under a theory of “Environmental Hazard in Gulf War.” Two are listed with no theory, but were later combined with other similar symptoms by the RO, as discussed in the introduction. There has been no prejudice to the Veteran in doing so. The remaining disabilities currently on appeal, including COPD and a back disability, are explicitly listed under a theory of secondary service connection, with notations to the various diseases to which they are secondarily claimed. The Board has proceeded accordingly with the Veteran’s theory of entitlement, and neither the Veteran nor his attorney have contended otherwise. Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). Based on the fact that the Scheuermann’s disease with fatigue claim is being remanded, the claims for a back disability and COPD with difficulty breathing cannot at this time be appropriately evaluated, as the Veteran contends that both are secondary to his non-service connected Scheuermann’s disease set to undergo additional development. See March 2014 Application for Disability Compensation and Related Compensation Benefits. The claims are therefore remanded as they are inextricably intertwined with the claim for service connection for Scheuermann’s disease with fatigue. Hunt v. Nicholson, 20 Vet. App. 519, 525 (2005); Harris v. Derwinski, 1 Vet. App. 180, 183-4 (1991), overruled on other grounds; see Tyrues v. Shinseki, 23 Vet. App. 166 (2009). 7. Entitlement to service connection for hypothyroidism with fatigue and elevated blood cholesterol, to include as due to an undiagnosed illness, and as secondary to Hashimoto’s disease. 8. Entitlement to service connection for a left shoulder disability, variously claimed as muscle ache and tenderness, joint stiffness, and pain, as secondary to Hashimoto’s disease. 9. Entitlement to service connection for a right shoulder disability, claimed as residual fracture and dislocation, as secondary to Hashimoto’s disease. 10. Entitlement to service connection for constipation, as secondary to Hashimoto’s disease. 11. Entitlement to service connection for a liver lesion, as secondary to Hashimoto’s disease. 12. Entitlement to service connection for a left hip disability, variously claimed as joint stiffness, as secondary to Hashimoto’s disease. 13. Entitlement to service connection for a right hip disability, variously claimed as joint stiffness, as secondary to Hashimoto’s disease. The Board incorporates its discussion from the sections above by reference. The Veteran submitted several private treatment records. The private treatment records are largely from a decade after discharge. An October 31, 2013 private treatment record from the Oklahoma Heart Institute shows, “I have explained to the patient that issues pertaining to autoimmune disorders and specifically Hashimoto’s thyroiditis.” There was still no conclusive evidence of a relationship to a service connected disability. In perfecting his appeal in December 2015, the Veteran submitted lay argument and highlighted the older medical treatment records showing the possible presence of various disabilities, as demonstrated above. They show ongoing references to and treatment for hypothyroidism. They only conclusively demonstrate that educational information about the disease was provided to the Veteran. Here, based on the fact that the Hashimoto’s disease claim is being remanded, the claims to be considered under a secondary theory of entitlement must be remanded as well, as the Veteran specifically contends that all are secondary to his non-service connected Hashimoto’s disease set to undergo additional development. See March 2014 Application for Disability Compensation and Related Compensation Benefits; 38 C.F.R. § 3.310, supra. The hypothyroidism claim should also be fully developed in light of the references in the private treatment records. The claims are therefore remanded as they are inextricably intertwined with the claim for service connection for Hashimoto’s disease. Hunt v. Nicholson, 20 Vet. App. 519, 525 (2005); Harris v. Derwinski, 1 Vet. App. 180, 183-4 (1991), overruled on other grounds; see Tyrues v. Shinseki, 23 Vet. App. 166 (2009). 14. Entitlement to service connection for neuropathy of the right upper extremity, as secondary to Sjogren’s syndrome. 15. Entitlement to service connection for neuropathy of the left upper extremity, as secondary to Sjogren’s syndrome. 16. Entitlement to service connection for neuropathy of the right lower extremity, as secondary to Sjogren’s syndrome. 17. Entitlement to service connection for neuropathy of the left lower extremity, as secondary to Sjogren’s syndrome. 18. Entitlement to service connection for osteoarthritis of the body, as secondary to Sjogren’s syndrome. 19. Entitlement to service connection for Raynaud’s disease, as secondary to Sjogren’s syndrome. 20. Entitlement to service connection for decreased visual acuity, as secondary to Sjogren’s syndrome. 21. Entitlement to service connection for dryness of conjunctiva, also claimed as chronic gritty and burning eyes, as secondary to Sjogren’s syndrome. 22. Entitlement to service connection for a painful jaw disability, as secondary to Sjogren’s syndrome. 23. Entitlement to service connection for a neurological disability, variously claimed as an excessive thirst condition, as secondary to Sjogren’s syndrome. 24. Entitlement to service connection for pruritus, as secondary to Sjogren’s syndrome. 25. Entitlement to service connection for dysphagia with hoarseness and difficulty speaking, as secondary to Sjogren’s syndrome. 26. Entitlement to service connection for gastric ulcers, as secondary to Sjogren’s syndrome. 27. Entitlement to service connection for oral lesions, cracked lips, and ulcers, as secondary to Sjogren’s syndrome. 28. Entitlement to service connection for ataxia, as secondary to Sjogren’s syndrome. 29. Entitlement to service connection for a chronic allergy disability with recurring sinusitis, also claimed as nasal irritation with dryness, as secondary to Sjogren’s syndrome. The Board incorporates its discussion from the sections above by reference. A March 2009 Prison Health Services Inmate Medical Request Form shows that the Veteran reported, “Allergies acting up bad. Nagging cough, nose & eyes itchy & nose runny (sic).” Here, based on the fact that the Sjogren’s syndrome claim is being remanded, the appeals for disabilities and/or symptoms claimed as secondary to this must be remanded as well. The Veteran specifically contends these symptoms and diseases are secondary to his non-service connected Sjogren’s syndrome set to undergo additional development. See March 2014 Application for Disability Compensation and Related Compensation Benefits; 38 C.F.R. § 3.310 (b), supra. The claims are therefore remanded as they are inextricably intertwined with the claim for service connection for Sjogren’s syndrome. Hunt v. Nicholson, 20 Vet. App. 519, 525 (2005); Harris v. Derwinski, 1 Vet. App. 180, 183-4 (1991), overruled on other grounds; see Tyrues v. Shinseki, 23 Vet. App. 166 (2009). 30. Entitlement to service connection for white matter lesions on the brain, as secondary to Hashimoto’s disease and Sjogren’s syndrome. 31. Entitlement to service connection for an acquired psychiatric disorder, claimed as anxiety, and claimed as secondary to rapid premature atrial fibrillation is remanded. 32. Entitlement to service connection for an acquired psychiatric disorder, claimed as depression with impaired memory, and as secondary to hypothyroidism is remanded. 33. Entitlement to service connection for chronic pain syndrome, with pain, stiffness, and swelling in joints, to include as secondary to hypothyroidism and Hashimoto’s disease is remanded. 34. Entitlement to service connection for hypoactive sexual desire disorder, as secondary to hypothyroidism and Hashimoto’s disease is remanded. 35. Entitlement to service connection for deformity of the penis, also claimed as erectile dysfunction with loss of erectile power due, and claimed as secondary to Hashimoto’s disease, hypothyroidism, and Scheuermann’s disease is remanded. The Board incorporates its discussion from the sections above by reference. VA and private treatment records contain impressions of an acquired psychiatric disability. They generally show ongoing reports of the Veteran feeling anxious and depressed. Here, based on the fact that the primary service connection claims are being remanded, the appeals claimed as secondary to this must also be remanded. See March 2014 Application for Disability Compensation and Related Compensation Benefits; 38 C.F.R. § 3.310, supra. The claims are are inextricably intertwined with the claim for service connection for Sjogren’s syndrome. Hunt v. Nicholson, 20 Vet. App. 519, 525 (2005); Harris v. Derwinski, 1 Vet. App. 180, 183-4 (1991), overruled on other grounds; see Tyrues v. Shinseki, 23 Vet. App. 166 (2009). Given the multiple claimed symptoms and/or disabilities claimed, the Board observes that additional development is necessary to determine the nature and etiology of the symptoms, including to which disability or disabilities they are attributable, if any. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Lastly, the Board observes that the Veteran initially filed over 40 pending claims for service connection. Here, the Board notes that the RO has assisted the Veteran in obtaining additional VA records, while the Veteran, continues to report a relationship between several claimed disabilities, while still lacking nexus opinions. The Board observes that the “The duty to assist is not always a one-way street. If a veteran wants help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence.” Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Nevertheless, VA also observes its duty to, “Make reasonable efforts to help a claimant obtain evidence necessary to substantiate the claim.” 38 C.F.R. § 21.1032 (a)(1)(i). On remand, the Veteran and his attorney are invited to submit any updated private treatment records and an Informal Hearing Presentation. 36. Entitlement to a TDIU is remanded. The Board incorporates its discussion from the sections above by reference. The Veteran’s March 2014 Application for Disability Compensation and Related Compensation Benefits explicitly lists a new claim for a total disability rating based on individual unemployability (TDIU). However, there is no additional information regarding the Veteran’s employment and disability picture as it relates to this claim. As such, additional development is necessary, including the Veteran completing and returning a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. Thereafter, an informed decision may be made with respect to this claim. The Veteran and his attorney are also invited to submit copies of any leave and earnings statements showing adverse effects on his employability due to service connected disability. The Board observes that the additional development requested above, including adjudicating the outstanding claims, may affect his schedular rating. Harris v. Derwinski, 1 Vet. App. 180 (1991). Remand of the inextricably intertwined TDIU claim is therefore required as well. The matter is REMANDED for the following action: 1. Obtain updated copies of the Veteran’s VA treatment records since July 2015, and associate them with the Veteran’s claims folder. 2. If the Veteran identifies other evidence, obtain updated copies of any private treatment records, and associate them with the Veteran’s claims folder. 3. Please schedule the Veteran for a VA examination to determine the nature and etiology of his Scheuermann’s disease with fatigue. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service, to include in his service in the Persian Gulf War. Attention is directed to private treatment records showing possible diagnostic impressions of Scheuermann’s disease from Dr. J. M. in December 2006. The examiner should provide a rationale for all opinions expressed. 4. Please also schedule the Veteran for a VA examination to determine the nature and etiology of his claimed autoimmune disease. a. The examiner is asked to specify whether the Veteran’s report of autoimmune disease represents (1) a currently diagnosed disability, (2) manifestation of an undiagnosed illness, or (3) manifestation of a medically unexplained multi-symptom illness. b. If the Veteran’s autoimmune disease cannot be ascribed to any known clinical diagnosis, specify whether he has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and diagnostic or laboratory tests, that has either existed for 6 months or more, or exhibited intermittent episodes of improvement and worsening over a 6 month period. c. If the Veteran’s autoimmune disease can be ascribed to a known clinical diagnosis, the examiner should determine whether it is at least as likely as not (a 50 percent or greater probability) that the diagnosed disability was incurred in service, or is otherwise attributable to service. The examiner should provide a rationale for all opinions expressed. Attention is directed to the Veteran’s other pending claims that may include manifestations with autoimmune or other related components. These should be differentiated and attributed to a diagnosed disability, undiagnosed illness, or medically unexplained chronic multi-symptom illness. However, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. 5. Please schedule the Veteran for a VA examination to determine the nature and etiology of both his claimed (1) Sjogren’s syndrome, and (2) Hashimoto’s disease variously claimed as sensitivity to cold and autoimmune thyroid disease due to Sjogren’s syndrome. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service, to include in his service in the Persian Gulf War. The examiner should provide a rationale for all opinions expressed. 6. Thereafter, undertake any additional development necessary related to the Veteran’s intertwined claims. If a positive nexus opinion is rendered for any of the four claimed disabilities above (Scheuremman’s, autoimmune, Sjogren’s, Hashimoto’s), then consider the appeals explicitly claimed under a theory of secondary service connection. Then, undertake any additional development necessary related to the Veteran’s intertwined claims. We have listed them below according to each disability to which they are claimed explicitly under a theory of secondary service connection: a. Scheuermann’s Disease i. Entitlement to service connection for a back disability, variously claimed as a spinal cord disability, as secondary to Scheuermann’s disease. ii. Entitlement to service connection for chronic obstructive pulmonary disease (COPD) with difficulty breathing, as secondary to Scheuermann’s disease. b. Sjogren’s Syndrome i. Entitlement to service connection for neuropathy of the right upper extremity, as secondary to Sjogren’s syndrome. ii. Entitlement to service connection for neuropathy of the left upper extremity, as secondary to Sjogren’s syndrome. iii. Entitlement to service connection for neuropathy of the right lower extremity, as secondary to Sjogren’s syndrome. iv. Entitlement to service connection for neuropathy of the left lower extremity, as secondary to Sjogren’s syndrome. v. Entitlement to service connection for osteoarthritis of the body, as secondary to Sjogren’s syndrome. vi. Entitlement to service connection for Raynaud’s disease, as secondary to Sjogren’s syndrome. vii. Entitlement to service connection for decreased visual acuity, as secondary to Sjogren’s syndrome. viii. Entitlement to service connection for dryness of conjunctiva, also claimed as chronic gritty and burning eyes, as secondary to Sjogren’s syndrome. ix. Entitlement to service connection for a painful jaw disability, as secondary to Sjogren’s syndrome. x. Entitlement to service connection for a neurological disability, variously claimed as an excessive thirst condition, as secondary to Sjogren’s syndrome. xi. Entitlement to service connection for pruritus, as secondary to Sjogren’s syndrome. xii. Entitlement to service connection for dysphagia with hoarseness and difficulty speaking, as secondary to Sjogren’s syndrome. xiii. Entitlement to service connection for gastric ulcers, as secondary to Sjogren’s syndrome. xiv. Entitlement to service connection for oral lesions, cracked lips, and ulcers, as secondary to Sjogren’s syndrome. xv. Entitlement to service connection for ataxia, as secondary to Sjogren’s syndrome. xvi. Entitlement to service connection for a chronic allergy disability with recurring sinusitis, also claimed as nasal irritation with dryness, as secondary to Sjogren’s syndrome. c. Hashimoto’s Disease i. Entitlement to service connection for hypothyroidism with fatigue and elevated blood cholesterol, to include as due to an undiagnosed illness, and as secondary to Hashimoto’s disease. ii. Entitlement to service connection for a left shoulder disability, variously claimed as muscle ache and tenderness, joint stiffness, and pain, as secondary to Hashimoto’s disease. iii. Entitlement to service connection for a right shoulder disability, claimed as residual fracture and dislocation, as secondary to Hashimoto’s disease. iv. Entitlement to service connection for constipation, as secondary to Hashimoto’s disease. v. Entitlement to service connection for a liver lesion, as secondary to Hashimoto’s disease. vi. Entitlement to service connection for a left hip disability, variously claimed as joint stiffness, as secondary to Hashimoto’s disease. vii. Entitlement to service connection for a right hip disability, variously claimed as joint stiffness, as secondary to Hashimoto’s disease. d. Other Secondary i. Entitlement to service connection for white matter lesions on the brain, as secondary to Hashimoto’s disease and Sjogren’s syndrome. ii. Entitlement to service connection for an acquired psychiatric disorder, claimed as anxiety, and claimed as secondary to rapid premature atrial fibrillation is remanded. iii. Entitlement to service connection for an acquired psychiatric disorder, claimed as depression with impaired memory, and as secondary to hypothyroidism is remanded. iv. Entitlement to service connection for chronic pain syndrome, with pain, stiffness, and swelling in joints, to include as secondary to hypothyroidism and Hashimoto’s disease is remanded. v. Entitlement to service connection for hypoactive sexual desire disorder, as secondary to hypothyroidism and Hashimoto’s disease is remanded. vi. Entitlement to service connection for deformity of the penis, also claimed as erectile dysfunction with loss of erectile power due, and claimed as secondary to Hashimoto’s disease, hypothyroidism, and Scheuermann’s disease is remanded. The Veteran need not be examined in person unless deemed necessary by the VA examiner. For any secondary service connection VA examinations, the VA examiner should opine whether any diagnosed disability is proximately due to, the result of, or aggravated by the Veteran’s service-connected disabilities, including Scheuermann’s disease, an autoimmune disease, Sjogren’s syndrome, rapid premature atrial fibrillation, and/or Hashimoto’s disease. The examiner should provide a rationale for all opinions expressed. 7. Send the Veteran a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, to be fully completed and returned to VA. If this is not completed and returned, the claim will be adjudicated based upon the evidence of record. 8. Readjudicate the Veteran’s claim for a total disability rating based on individual unemployability (TDIU) in light of all pertinent evidence of record. 9. Review the body of this Remand for compliance with the Board’s directives. Any corrective action should be taken. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his attorney an appropriate supplemental statement of the case (SSOC). Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs