Citation Nr: 18153327 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 14-23 814 DATE: November 27, 2018 REMANDED Entitlement to service connection for chronic fatigue syndrome and headaches as due to an undiagnosed illness due to Gulf War Syndrome, and as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from August 2001 to August 2005. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the Board at a hearing in September 2017. The Board notified the Veteran in January 2018 that a transcript of his September 2017 hearing could not be produced. Therefore, the Board offered the Veteran an opportunity to appear at an additional Board hearing. The Veteran responded in March 2018 that he wished to appear at such hearing. Following proper notice of the September 2018 hearing, the Veteran did not appear for the hearing. Therefore, his hearing request is considered to be withdrawn. 38 C.F.R. § 20.704(d). Entitlement to service connection for chronic fatigue syndrome and headaches as due to an undiagnosed illness due to Gulf War Syndrome, and as secondary to service-connected PTSD, is remanded. The Veteran underwent a VA examination in June 2013 for an evaluation of his Gulf War Syndrome claim. Following the examination, the VA examiner diagnosed the Veteran with chronic daily headaches that are likely related to chronic fatigue associated with reported sleep apnea. In addition, the examiner stated the Veteran’s headache condition likely has a clear and specific etiology and the diagnosis does not represent an undiagnosed illness, a diagnosable but medically unexplained chronic multi symptom illness of unknown etiology, or a diagnosable chronic multi symptom illness with a partially explained etiology. With regard to the Veteran’s chronic fatigue syndrome, the VA examiner diagnosed the Veteran with chronic fatigue that is likely related to his reported sleep apnea. In addition, the VA examiner stated the Veteran’s chronic fatigue likely has a clear and specific etiology and the diagnosis does not represent an undiagnosed illness, a diagnosable but medically unexplained chronic multi symptom illness of unknown etiology, or a diagnosable chronic multi symptom illness with a partially explained etiology. However, following the June 2013 VA examination, the Veteran reported in his May 2014 VA Form 9, Substantive Appeal, that he had used his CPAP machine since April 2014 to help with his symptoms, but it has only helped relieve some of the fatigue and headache symptoms. This statement is pertinent evidence that was not before the VA examiner and provides a potential etiology of the Veteran’s symptoms different from what the VA examiner concluded. Thus, an additional VA examination and opinion is necessary. Upon remand, the VA examiner will be asked to address the Veteran’s June 2013 statement that his Gulf War illnesses were caused by vaccinations and exposure to burn pits from deployment in Kuwait and Iraq. In addition, the Veteran’s May 2014 statement reflecting use of a CPAP machine indicates there may be outstanding VA or private treatment records. A July 2013 VA treatment note reflects that a CPAP machine was not recommended, but the treatment note also reflects that a full sleep study was scheduled for October 2013. However, there are no VA treatment notes in the record after August 2013. There are private treatment records from Western dated December 2016 through June 2017, but these records do not address the Veteran’s sleep impairment. Therefore, development for any outstanding VA treatment and private treatment records is necessary upon remand. Lastly, the Veteran is service connected for PTSD, and a May 2013 VA treatment note reflects a diagnosis of fatigue/malaise and in part that PTSD might be contributing. Thus, the theory of secondary service connection has been raised by the record. Therefore, a VA opinion is necessary to determine if the Veteran’s service-connected PTSD has caused or aggravated his chronic fatigue. The matter is REMANDED for the following actions: 1. Obtain and associate with the Veteran’s electronic record VA treatment records from August 2013 to the present. Contact the Veteran and afford him the opportunity to identify or submit any pertinent evidence in support of his claims, to include records of any private treatment. Based on his response, attempt to procure copies of all records which have not been obtained from identified treatment sources. If any of the records requested are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e). 2. After completing the development requested in item (1), provide the Veteran an appropriate VA examination to determine the nature, extent, and etiology of the Veteran’s chronic fatigue and headaches. His electronic claims file, including a copy of this decision and remand, must be made available to the examiner for review in connection with the examination. All indicated tests should be conducted, and the reports of any such studies incorporated into the examination reports to be associated with the claims file. A) The examiner should provide an opinion on the following as it relates to the Veteran’s chronic fatigue: i) Is it at least as likely as not (a 50% or greater probability) that his chronic fatigue is related to his service, to include service in Iraq and Kuwait and exposure to vaccinations and burn pits? In responding to this question, the examiner is to specifically address the Veteran’s May 2014 statement that he had been using a CPAP machine for approximately one month, but it helped to relieve only some of his fatigue and headache symptoms. ii) Is it at least as likely as not (a 50% or greater probability) that the Veteran’s chronic fatigue was caused by his service-connected PTSD? iii) Is it at least as likely as not (a 50% or greater probability) that the Veteran’s chronic fatigue was aggravated (that is, any increase in severity beyond the natural progress of the condition as shown by comparing the current disability to medical evidence created prior to any aggravation) by his service-connected PTSD? iv) If the Veteran has symptoms of fatigue that are not attributable to a known clinical diagnosis, then provide the following opinion: Does he have objective indications, as established by history, physical examination, and laboratory tests, of an undiagnosed illness or a medically unexplained chronic multi-symptom illness, manifested by symptoms that have existed for 6 months or more or exhibited intermittent episodes of improvement and worsening over a 6-month period? A “medically unexplained chronic multi-symptom illness” is defined as a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. The examiner must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. B) The examiner should provide an opinion on the following as it relates to the Veteran’s headaches: i) Is it at least as likely as not (a 50% or greater probability) that his headaches are related to his service, to include service in Iraq and Kuwait and exposure to vaccinations and burn pits? In responding to this question, the examiner is to specifically address the Veteran’s May 2014 statement that he had been using a CPAP machine for approximately one month, but it helped to relieve only some of his fatigue and headache symptoms. iv) If the Veteran has symptoms of headaches that are not attributable to a known clinical diagnosis, then provide the following opinion: Does he have objective indications, as established by history, physical examination, and laboratory tests, of an undiagnosed illness or a medically unexplained chronic multi-symptom illness, manifested by symptoms that have existed for 6 months or more or exhibited intermittent episodes of improvement and worsening over a 6-month period? A “medically unexplained chronic multi-symptom illness” is defined as a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. The examiner must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Breitbach, Associate Counsel