Citation Nr: 18151247 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 16-48 257 DATE: November 16, 2018 REMANDED Entitlement to service connection for musculoskeletal pain, including of the feet and toes, ankles, hips, and tailbone, to include as due to undiagnosed illness, is remanded. Entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to undiagnosed illness, is remanded. Entitlement to service connection for allergic rhinitis, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depression, and anxiety, is remanded. REASONS FOR REMAND The Veteran had active service from July 2000 to September 2000, from March 2003 to May 2004, and from October 2010 to November 2010. The Veteran’s current claim for service connection for PTSD has been interpreted to include all acquired psychiatric disorders. Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. Entitlement to service connection for musculoskeletal pain, including of the feet and toes, ankles, hips, and tailbone, to include as due to undiagnosed illness. The Veteran asserts that he has musculoskeletal pain that is due to his active service, to include as due to undiagnosed illness. He further asserts that he has had continual pain symptoms since service discharge. While no service treatment records specifically note joint pain complaints or diagnoses, the Board notes of record is a May 2016 memorandum indicating a formal finding on the unavailability of the Veteran’s complete service treatment records. In situations where the service records are incomplete, lost, or presumed destroyed through no fault of the veteran, VA has a heightened duty to assist in the development of the case, as well as a heightened obligation to explain findings and conclusions and to consider carefully the benefit of the doubt doctrine. Marciniak v. Brown, 10 Vet. App. 198, 200 (1997), citing O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). A February 2013 Gulf War examination found that the Veteran had no undiagnosed illness or medically unexplained chronic multisystem illness and acknowledged symptoms of pain, stiffness, flares of feet and hands, and joint pain. However, there is no direct etiological opinion of record for the Veteran’s documented joint pain. A remand for such medical opinion is thus necessary. 2. Entitlement to service connection for chronic fatigue syndrome (CFS), to include as due to undiagnosed illness. 3. Entitlement to service connection for allergic rhinitis, to include as due to undiagnosed illness. April 2004 service treatment records reflect that the Veteran complained of fatigue while in active service. Specifically, the Veteran reported fatigue and symptoms of insomnia which occurred for three months consecutively since November 2003 and occurred occasionally thereafter. A February 2013 Gulf War examination noted generalized fatigue as well as the Veteran’s endorsement of feeling tired all the time. The examiner opined that the Veteran had a history of fatigue which did not fit the criteria for chronic fatigue syndrome and that there was no evidence of an undiagnosed illness. However, the examiner gave no medical opinion as to whether or not the Veteran’s documented fatigue was related to his active service, and as such, the Board finds that a remand is required to obtain an etiological opinion for his claimed fatigue. A February 2013 VA Gulf War examination report diagnosed the Veteran with occasional pharyngitis with upper respiratory infections of the sinus and allergic rhinitis. While the examiner opined that the Veteran’s sinusitis and allergic rhinitis were not caused by his specific exposure events experienced in Southwest Asia, there is no medical opinion of record as to whether such disability is otherwise related to his service on a direct basis. As such, a remand is required to obtain a direct medical opinion for the Veteran’s claimed sinus condition. 4. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depression, and anxiety. The Veteran was afforded a VA psychological examination in February 2013. At that time the examiner concluded that the Veteran did not have a diagnosis of PTSD. As rationale, she indicated that, while the Veteran reported exposure to trauma while in the military, he did not meet the full criteria for PTSD under DSM IV. She further described that there were no psychiatric symptoms or mental health concerns endorsed by the Veteran on his March 2004 post-deployment assessment or in his service treatment records. However, April 2004 service treatment records reflect that the Veteran reported symptoms of anxiety, and the treating physician diagnosed PTSD with situational depression. Further, the Veteran’s November 2004 post-deployment examination reflects that the Veteran endorsed depression, excessive worry, and having a hard time with school after returning from Iraq. The post-deployment examiner also noted that the Veteran had anxiety after deployment. The examiner did not address the Veteran’s service treatment records, his documented in-service anxiety symptoms, or any association between the Veteran’s previous diagnosis of depression with active service in his February 2013 opinion. Based on the foregoing, the Board finds that an additional medical examination is needed regarding the Veteran’s claim for a psychiatric disorder, to include anxiety, depression, and PTSD. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination for a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). In the medical opinion, the examiner should state whether or not the Veteran’s diagnosed anxiety and depression—as well as any diagnosed PTSD—was etiologically related to active service. In this regard, because the Veteran’s claim was certified for appeal before the Board after August 4, 2014, on remand, any diagnostic criteria used to determine whether or not the Veteran has a current diagnosis of PTSD needs to be in accordance with DSM-V. See 38 C.F.R. § 4.125 (a); 80 Fed. Reg. 14308 (March 15, 2015) (final rule amending 38 C.F.R. § 4.125). The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. Request that the Veteran identify any recent private treatment pertinent to his claims and provide information and authorization sufficient for VA to assist him in obtaining any pertinent medical records not yet associated with the record. 2. Upon receipt of all additional records, schedule the Veteran for the following examinations. In this regard, the record, including a complete copy of this remand, must be made available to each examiner for review, and each examiner must indicate in the appropriate examination report that the record was reviewed in conjunction with the examination, including for the history of the claimed disability. a. The Veteran should be scheduled for a VA psychiatric examination for his claimed acquired psychiatric disorder with an individual who did not conduct his February 2013 PTSD examination. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed acquired psychiatric disorder, to include depression, anxiety, and PTSD, had onset during the Veteran’s service or within one year of service discharge or is otherwise etiologically related to service. The examiner must specifically consider all lay statements given by the Veteran. b. Also, schedule the Veteran for VA examinations for his fatigue, musculoskeletal pain, and allergic rhinitis by an appropriate examiner. Each examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed fatigue, musculoskeletal pain, and rhinitis had onset during the Veteran’s service or within one year of service discharge or is otherwise etiologically related to service. Each examiner must specifically consider all lay statements given by the Veteran. A complete and thorough rationale must be provided for all opinions. If the examiner cannot provide an opinion without resorting to speculation, then he or she must provide a complete and thorough rationale as to why an opinion cannot be provided. 3. Then readjudicate the claim in light of this and all other additional evidence. If the claims continue to be denied or are not granted to the Veteran’s satisfaction, send him a Supplemental Statement of the Case and give him and his representative opportunity to respond to it before returning the file to the Board for further appellate consideration of the claim. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Peden, Associate Counsel