Citation Nr: 18157433 Decision Date: 12/12/18 Archive Date: 12/12/18 DOCKET NO. 15-11 524 DATE: December 12, 2018 ORDER New and material evidence having been submitted, the claim of entitlement to service connection for joint and muscle pain is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for fatigue is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for a sleep disorder is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for a liver disorder, to include liver steatosis is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for memory loss is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for headaches is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for depression is reopened. Entitlement to service connection for an undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles is granted. Entitlement to a compensable rating for bilateral hearing loss prior to January 13, 2014 is denied. REMANDED Entitlement to service connection for bilateral patellofemoral syndrome is remanded. Entitlement to service connection for bilateral rotator cuff impingement syndrome is remanded. Entitlement to service connection for back pain, to include due to an undiagnosed illness is remanded. Entitlement to service connection for neck pain, to include due to an undiagnosed illness is remanded. Entitlement to service connection for fatigue, to include due to an undiagnosed illness is remanded. Entitlement to service connection for a sleep disorder, to include due to an undiagnosed illness is remanded. Entitlement to service connection for memory loss, to include due to an undiagnosed illness is remanded. Entitlement to service connection for headaches, to include due to an undiagnosed illness is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a liver disorder, to include liver steatosis is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include depression is remanded. Entitlement to a compensable rating for bilateral hearing loss since January 13, 2014 is remanded. FINDINGS OF FACT 1. An unappealed December 1997 rating decision denied entitlement to service connection for joint and muscle pain. 2. Evidence received since the December 1997 rating decision relates to unestablished facts necessary to substantiate the claim of entitlement to service connection for joint and muscle pain. 3. An unappealed December 1997 rating decision denied entitlement to service connection for fatigue. 4. Evidence received since the December 1997 rating decision relates to unestablished facts necessary to substantiate the claim of entitlement to service connection for fatigue. 5. An unappealed December 1997 rating decision denied entitlement to service connection for a sleep disorder. 6. Evidence received since the December 1997 rating decision relates to unestablished facts necessary to substantiate the claim of entitlement to service connection for a sleep disorder. 7. An unappealed December 1997 rating decision denied entitlement to service connection for a liver disorder. 8. Evidence received since the December 1997 rating decision relates to unestablished facts necessary to substantiate the claim of entitlement to service connection for a liver disorder. 9. An unappealed December 1997 rating decision denied entitlement to service connection for memory loss. 10. Evidence received since the December 1997 rating decision relates to unestablished facts necessary to substantiate the claim of entitlement to service connection for memory loss. 11. An unappealed December 1997 rating decision denied entitlement to service connection for headaches. 12. Evidence received since the December 1997 rating decision relates to unestablished facts necessary to substantiate the claim of entitlement to service connection for headaches. 13. An unappealed December 1997 rating decision denied entitlement to service connection for depression. 14. Evidence received since the December 1997 rating decision relates to unestablished facts necessary to substantiate the claim of entitlement to service connection for depression. 15. The appellant is a Persian Gulf veteran and he has an undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles. 16. Since January 13, 2014, the Veteran’s bilateral hearing loss has been manifested by no worse than Level I hearing loss bilaterally. CONCLUSIONS OF LAW 1. The December 1997 rating decision is final; new and material evidence has been received to reopen the claim of entitlement to service connection for a joint and muscle pain. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.1103. 2. The December 1997 rating decision is final; new and material evidence has been received to reopen the claim of entitlement to service connection for fatigue. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.1103. 3. The December 1997 rating decision is final; new and material evidence has been received to reopen the claim of entitlement to service connection for a sleep disorder. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.1103. 4. The December 1997 rating decision is final; new and material evidence has been received to reopen the claim of entitlement to service connection for a liver disorder. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.1103. 5. The December 1997 rating decision is final; new and material evidence has been received to reopen the claim of entitlement to service connection for memory loss. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.1103. 6. The December 1997 rating decision is final; new and material evidence has been received to reopen the claim of entitlement to service connection for headaches. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.1103. 7. The December 1997 rating decision is final; new and material evidence has been received to reopen the claim of entitlement to service connection for a depression. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.1103. 8. Resolving reasonable doubt in the Veteran’s favor, an undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles is presumed to have been incurred during active service. 38 U.S.C. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.317. 9. Since January 13, 2014, the criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.385, 4.1, 4.2, 4.3, 4.7, 4.10, 4.85, 4.86, Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1986 to March 1992.   New and Material Evidence A claim that has been denied in an unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is evidence not previously submitted to agency decisionmakers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). The phrase “raises a reasonable possibility of substantiating the claim” is meant to create a low threshold that enables, rather than precludes, reopening. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). New and material evidence Joint and muscle pain, fatigue, a sleep disorder, a liver disorder, memory loss and headaches. Entitlement to service connection for joint and muscle pain, fatigue, a sleep disorder, a liver disorder, memory loss and headaches were denied in a December 1997 rating decision on the basis, in part, that the evidence did not demonstrate that these disorders were incurred in or otherwise related to service. The December 1997 rating decision was not appealed, and it is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The Veteran submitted a claim to reopen these issues in August 2012. In October 2014 the Veteran submitted a July 1997 letter from the Special Assistant for Gulf War Illness, which notified the Veteran that his unit may have been exposed to the nerve agents sarin and cyclosarin as a result of weapons demolition near Khamisiyah, Iraq. The Veteran was advised that if he had health concerns related to his Gulf War service, he should request medical evaluation. This evidence bears on the contested issue of an inservice etiology of the Veteran’s joint and muscle pain, fatigue, sleep disorder, liver disorder, memory loss and headaches, which the Veteran contends are related to toxic exposure during his service in the Persian Gulf. Additionally, in March 2016 the Veteran was provided a VA examination to consider his complaints of joint and muscle pain and weakness. This examination, in pertinent part, resulted in a finding that the Veteran suffered from myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles for which no etiology or diagnosis was provided. This evidence supports the Veteran’s contention that he suffers from an undiagnosed illness. Thus, the Board finds that new and material evidence has been submitted which relates to the unestablished etiological element, necessary to substantiate these claims. As this evidence raises a reasonable possibility of substantiating the claims, it is new and material. The claims of entitlement to service connection for joint and muscle pain, fatigue, a sleep disorder, a liver disorder, memory loss and headaches are reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). Depression Entitlement to service connection for depression was denied in December 1997 on the basis that the evidence did not demonstrate that the disorder was incurred in or otherwise related to service. The December 1997 rating decision was not appealed, and is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The Veteran submitted a claim to reopen the issue of entitlement to service connection for depression in August 2012. In statements to include in October 2013 and February 2014, the Veteran provided information pertaining to certain traumatic incidents he allegedly experienced while stationed in Southwest Asia. This evidence bears on the contested issue of an inservice etiology of the Veteran’s depression. Thus, the Board finds that there is new and material evidence of record which relates to the unestablished etiological element, necessary to substantiate the appellant’s claim. As this evidence raises a reasonable possibility of substantiating the claim, it is new and material. The claim of entitlement to service connection for depression is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). Service Connection Service connection is established on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d). Service connection for certain chronic diseases, to include degenerative joint disease, may be established on a presumptive basis if the disorder was manifested to a compensable degree within one year following discharge from active duty. 38 C.F.R §§ 3.307, 3.309(a). Because the Veteran served in the Southwest Asia Theater of operations, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a specific illness prescribed under 38 U.S.C. 1117 (d). 38 C.F.R. § 3.317. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117; 38 C.F.R. § 3.117, unlike those for “direct service connection,” there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). A medically unexplained chronic multi symptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi symptom illness. 38 C.F.R. § 3.317 (a)(2)(ii). Joint and muscle pain, to include secondary to an undiagnosed illness The Veteran contends that his joint and muscle pain are a result of toxic or environmental exposures during his active-duty service in Southwest Asia, to include due to an undiagnosed illness. The Board concludes that the Veteran has an undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles, which is presumed to have been incurred in service. While the Veteran was not diagnosed with these disorders during service, the March 2016 VA examiner found that the Veteran exhibited myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles. The examiner further indicated that the Veteran suffered from a “partially diagnosed inflammatory disease with symmetrical myalgia and polyarthralgia.” While the examiner ultimately opined that the Veteran’s muscle and joint pain was not the result of an undiagnosed illness, the Board finds that the examiner’s ultimate conclusions are favorable to the Veteran. In this regard, the Board notes that arthralgia is defined as “pain in a joint.” See DORLAND’S ILLUSTRATED MEDICAL DICTIONARY, 150 (32d ed. 2012). Joint and muscle pain are explicitly listed as manifestation of an undiagnosed illness or medically unexplained chronic multi-symptom illness under 38 C.F.R. § 3.317(b). The examiner stated that the Veteran’s myofascial pain was not associated with a myofascial pain syndrome, and provided no other diagnosis or etiology to explain the symptoms of myofascial pain or arthralgias. The Board further notes that the Veteran has consistently reported joint and muscle pain beginning approximately two years after service. Pertinently, an April 1996 VA examination noted complaints of multiple joint pain with an onset of two to two and a half years prior. At that time, the Veteran was diagnosed with arthralgias of an undetermined etiology. As the evidence of record indicates that the Veteran has suffered from chronic joint and muscle pain and weakness which has not been attributed to an identified underlying pathology, the evidence is at least in equipoise as to whether these symptoms are manifestations of an undiagnosed illness. Thus, the Board will resolve reasonable doubt and find that myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles are manifestations of an undiagnosed illness. As the Veteran is a “Persian Gulf veteran,” entitlement to presumptive service connection under 38 C.F.R. § 3.317 (e) for an undiagnosed illness is warranted. The Board also finds, however, that service connection is not warranted for a bilateral hip strain, right third distal interphalangeal joint degenerative joint disease, bilateral acromioclavicular degenerative joint disease, bilateral flat foot, plantar fasciitis or calcaneal spurs. In this regard, the evidence preponderates against finding that these disorders are manifestations of an undiagnosed illness or a medically unexplained chronic multi-symptom illness. On the contrary, the March 2016 VA examiner diagnosed a bilateral hip strain, right third distal interphalangeal joint degenerative joint disease, bilateral acromioclavicular degenerative joint disease, bilateral flat foot, plantar fasciitis and calcaneal spurs, and opined that those disorders had a clear and specific etiology and diagnosis. There is no contrary medical evidence of record. The Board further concludes that, while the Veteran has right third distal interphalangeal joint degenerative joint disease and bilateral acromioclavicular degenerative joint disease which are chronic diseases under 38 C.F.R. § 3.309(a), they were not chronic in service or manifested to a compensable degree within one year of separation from active duty. The Veteran was not diagnosed with right third distal interphalangeal joint degenerative joint disease or acromioclavicular degenerative joint disease until many years after his separation from service and many years outside of the applicable presumptive period. Furthermore, the Veteran has not contended that these disorders began during service or during the presumptive period. Rather, the Veteran has generally stated that his current joint pain began approximately two years after service. Nonetheless, to the extent that the Veteran has alleged joint pain during service or within the presumptive period, the Veteran is not competent to provide a diagnosis in this case or determine that his symptoms were manifestations of degenerative joint disease as the etiology of that disorder is medically complex. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board gives more probative weight to the April 1996 VA examiner’s findings that physical examination of all joints was normal at that time. Additionally, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s bilateral hip strain, right third distal interphalangeal joint degenerative joint disease, bilateral acromioclavicular degenerative joint disease, bilateral flat foot, plantar fasciitis and calcaneal spurs and an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d). In this regard, the March 2016 VA examiner opined that these disorders were less likely than not related to environmental or toxic exposure in Southwest Asia. The examiner reasoned that the Veteran reported a symptom onset for his joint pain which began a few years after completion of service in Southwest Asia, and that symptoms had subjectively progressed even though any Southwest Asia exposure ended in 1991. With regard to the noted foot disorders, the examiner noted that the Veteran suffered a left foot injury during service in 1986, but that injury was objectively resolved on examination. Again, an April 1996 VA examination specifically found that physical examination of all joints was entirely normal. Such medical evidence tends to weigh against finding that the diagnosed orthopedic disorders were incurred in or are otherwise related to the Veteran’s active-duty service. The Veteran has not specifically argued that bilateral hip strain, right third distal interphalangeal joint degenerative joint disease, bilateral acromioclavicular degenerative joint disease, bilateral flat foot, plantar fasciitis and calcaneal spurs are related to his active-duty service. Rather, the Veteran’s contention has been that he suffers from joint and muscle pain as a result of an undiagnosed illness. The Veteran, however, is not competent to provide a nexus opinion in this case. This issue is medically complex, as it requires specialized medical education. Jandreau, 492 F.3d at 1377. Consequently, the Board gives more probative weight to the competent medical evidence. As such, the evidence of record preponderates against finding that bilateral hip strain, right third distal interphalangeal joint degenerative joint disease, bilateral acromioclavicular degenerative joint disease, bilateral flat foot, plantar fasciitis and calcaneal spurs were incurred in or are otherwise related to active-duty service. Based on the foregoing, entitlement to service connection for an undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles is granted. Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) ("By requiring only an 'approximate balance of positive and negative evidence' . . ., the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding . . . benefits.")   Increased Rating Disability evaluations are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1999). Nevertheless, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. See Hart v. Mansfield,21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119, 126 (1999). The analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods within the period on appeal. Where there is a question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Bilateral hearing loss prior to January 13, 2014 The Veteran asserts that a compensable rating is warranted for his bilateral hearing loss. The Veteran was initially awarded service connection for hearing loss in March 2014 rated noncompensable effective August 17, 2012. The Veteran appealed from that initial rating. The Board concludes entitlement to a compensable rating for hearing loss is not warranted prior to January 13, 2014. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85. To evaluate the degree of disability from defective hearing, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. §§ 4.85, Tables VI and VII, Diagnostic Code 6100. Disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86 (a). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. On the authorized audiological evaluation on January 13, 2014, pure tone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 AVG RIGHT 40 45 50 45 45 LEFT 35 40 50 50 44 Speech audiometry revealed speech recognition ability of 96 percent in the right ear and of 94 in the left ear. The examiner noted the functional effect of hearing loss was difficulty hearing. Application of the findings of the January 2014 examination to Tables VI and VIA in 38 C.F.R. § 4.85 yields a finding of Level I hearing loss bilaterally, which warrants a noncompensable rating. The Board acknowledges the Veteran’s complaints regarding the impact of hearing loss on his daily life, but the assignment of disability ratings for hearing impairment is primarily derived from a mechanical formula based on levels of pure tone threshold average and speech discrimination. Lendenmann. The Veteran reported having difficulty hearing conversation, but that is a functional difficulty that would be expected to be caused by his recorded levels of hearing loss. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (Manifestations such as difficulty hearing speech are the types of difficulties contemplated by the schedular criteria for hearing loss.). Thus, the most probative medical evidence as to the severity of the Veteran’s hearing loss for the period discussed herein is the January 2014 audiometric findings. Those reveal that the Veteran’s hearing loss does not warrant a compensable rating for the period prior to January 13, 2014. As the Veteran does not have the education or training to offer a medical opinion challenging the adequacy of the testing, and as there is nothing in the record to support his assertion that his hearing loss is, in fact, more severe than indicated on examination, the Veteran’s assertions are not probative. Jandreau. The Board concludes that the medical findings on examination are of greater probative value than the Veteran’s lay allegations regarding the severity of his hearing loss and that his functional impairment is adequately reflected by those medical findings. Thus, the preponderance of the competent and probative evidence shows that the Veteran’s hearing loss was manifested by no worse than a Level I disability bilaterally. Therefore, entitlement to a compensable rating for bilateral hearing loss, prior to January 13, 2014 is denied. REASONS FOR REMAND Service connection Bilateral patellofemoral syndrome The March 2016 VA examiner diagnosed bilateral patellofemoral syndrome, however, the examiner did not provide an opinion as to whether the diagnosed bilateral patellofemoral syndrome was related to the in-service complaints of knee pain in April 1988. Remand is required to obtain a medical opinion addressing this issue. Bilateral rotator cuff impingement syndrome The March 2016 VA examiner diagnosed rotator cuff impingement syndrome second to disuse secondary to chronic arthralgias and degenerative joint disease. However, the examiner did not specify the degree to which the rotator cuff impingement syndrome was caused or aggravated by the Veteran’s service-connected arthralgias, for which service-connection has been awarded herein. Remand is required to obtain a medical opinion addressing this issue. Back and neck pain, to include due to an undiagnosed illness. A March 2014 VA examination noted that the Veteran complained of neck and lower back pain. However, the March 2016 joint and muscle examination failed to address whether the Veteran had any diagnosed neck or low back disorders, or whether neck or low back pain were due to an undiagnosed illness. Remand is required to obtain a medical opinion addressing these issues. Fatigue, to include due to an undiagnosed illness The March 2014 examiner failed to clearly state whether the Veteran’s fatigue was due to a known clinical diagnosis or whether it was due to an undiagnosed illness or medically unexplained chronic multi-symptom illness. Remand is necessary to obtain a medical opinion addressing this issue. Furthermore, as entitlement to service connection for an undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles is granted herein, remand is necessary to obtain a medical opinion addressing whether fatigue is related to this disorder.   Sleep disorder, to include sleep apnea, due to an undiagnosed illness The Veteran has not been provided an examination to address the etiology of his claimed sleep disorder. He has alleged that his sleep disorder is related to environmental or toxic exposure during his Southwest Asia service, including sarin, cyclosarin, anthrax vaccines, anti-nerve agent pills, debris from SCUD missiles and burning oil wells. Remand is necessary to obtain a medical opinion addressing this issue. Memory loss to include due to an undiagnosed illness The Veteran has not been provided an examination to address the etiology of his claimed memory loss. The Veteran has qualifying Persian Gulf service, and neurological and neuropsychological symptoms are explicitly listed as a manifestation of an undiagnosed illness or medically unexplained chronic multi-symptom illness under 38 C.F.R. § 3.317 (b). Thus, remand is necessary to obtain a medical opinion addressing whether it is due to an undiagnosed illness or medically unexplained chronic multi-symptom illness. Headaches to include due to an undiagnosed illness As entitlement to service connection for an undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles is granted herein, remand is necessary to obtain a medical opinion addressing whether headaches are related to this disorder. Liver disorder, to include liver steatosis and the residuals of an elevated liver function test The March 2014 VA examiner diagnosed the Veteran with liver steatosis, but opined that the condition was not related to any specific exposure event in Southwest Asia. The examiner’s rationale was based entirely on a VA webpage stating that liver steatosis was not a presumptively service-connected disease based on Persian Gulf service. However, the Veteran has alleged specific exposures during his Southwest Asia service, including sarin, cyclosarin, anthrax vaccines, anti-nerve agent pills, debris from SCUD missiles and burning oil wells. Remand is required to obtain a medical opinion addressing this issue. Hypertension A March 2014 examiner diagnosed the Veteran with hypertension, but did not opine whether that disorder was related to in-service environmental or toxic exposures, to include sarin, cyclosarin, anthrax vaccines, anti-nerve agent pills, debris from SCUD missiles or burning oil wells. Remand is required to obtain a medical opinion addressing this issue. An acquired psychiatric disorder to include depression and an adjustment disorder A January 2014 VA examiner diagnosed the Veteran with an adjustment disorder with depressed mood, moderate alcohol use disorder, and other specified trauma-and stressor related disorder. A March 2014 VA examiner diagnosed an unspecified depressive disorder. However, neither examiner provided an opinion as to the etiology of the Veteran’s adjustment disorder, other specified trauma-and stressor related disorder or unspecified depressive disorder. As the Veteran has provided statements detailing numerous alleged traumatic incidents during his active-duty service, remand is required to obtain a medical opinion addressing the etiology of any and all diagnosed psychiatric disorders. Additionally, at the April 2017 hearing, the Veteran’s testimony indicated that his alcohol use disorder may have been caused or aggravated by service-connected disability, to include his undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles. Thus, a medical opinion should also be obtained addressing this issue.   Increased rating Hearing loss since January 13, 2014 At the April 2017 Board hearing, the Veteran reported undergoing audiological examination approximately six months prior. As the most recent VA treatment records associated with the Veteran’s file are from February 2016, remand is required to obtain updated VA treatment records, to include any record of the referenced audiological evaluation. On remand, the Veteran should also be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his hearing loss. Accordingly, the matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from February 2016 to the present, as well as any outstanding VA treatment records dated prior to August 21, 1995. Additionally, obtain any outstanding treatment records from the South Texas Veterans Healthcare System which are not currently associated with the record. If the RO cannot locate any such federal records, it must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 2. Thereafter, obtain an addendum opinion from the examiner who conducted the March 2016 VA joints examination, or from a qualified physician examiner if this examiner is not available. The examiner must opine whether the Veteran’s bilateral patellofemoral syndrome is at least as likely as not related to active-duty service, to include the April 1988 complaints of knee pain. The examiner must opine whether it is at least as likely as not that a bilateral patellofemoral syndrome was caused or aggravated by the Veteran’s service-connected undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 3. After completing directive one, obtain an addendum opinion from the examiner who conducted the March 2016 VA joints examination, or from a qualified physician examiner if this examiner is not available. The examiner must opine whether it is at least as likely as not that the Veteran’s bilateral rotator cuff impingement syndrome was caused or aggravated by a service-connected undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles. If the examiner finds that a bilateral rotator cuff impingement syndrome was aggravated by a service-connected disability, the examiner is asked to attempt to estimate the degree of disability prior to aggravation. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 4. After completing directives one and two, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any back and neck symptoms. The examiner is to indicate whether the Veteran’s back and neck complaints are due to a known clinical diagnosis or whether they are due to an undiagnosed illness or medically unexplained chronic multi-symptom illness. If the complaints are related to a known clinical diagnosis, the examiner must opine whether any diagnosis is at least as likely as not related to active service or events therein, to include exposure to sarin, cyclosarin, anthrax vaccines, anti-nerve agent pills, debris from SCUD missiles and burning oil wells. The examiner must further opine whether it is at least as likely as not that a back or neck disorder was caused or aggravated by another service-connected disorder, to include the Veteran’s service-connected undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 5. After completing directives one and four, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of fatigue, a sleep disorder, memory loss, and headaches. The examiner is to indicate whether the Veteran’s fatigue, sleep disorder, memory loss, and headaches are due to a known clinical diagnosis or whether they are due to an undiagnosed illness or medically unexplained chronic multi-symptom illness. If the complaints are related to a known clinical diagnosis, the examiner must opine whether any diagnosis is at least as likely as not related to active service or events therein, to include exposure to sarin, cyclosarin, anthrax vaccines, anti-nerve agent pills, debris from SCUD missiles and burning oil wells. The examiner must further opine whether it is at least as likely as not that fatigue, a sleep disorder, memory loss, and headaches were caused or aggravated by another service-connected disorder, to include the Veteran’s service-connected undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles A complete, well-reasoned rationale must be provided for any opinion offered. If any requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 6. After completing directives one through five, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed acquired psychiatric disorder. For each diagnosed acquired psychiatric disorder, other than an alcohol use disorder, diagnosed at any time since August 2012, the examiner must opine whether it is at least as likely as not incurred in or otherwise related to active duty. The examiner must further opine whether it is at least as likely as not that any acquired psychiatric disorder diagnosed at any time since August 2012, to include an alcohol use disorder was caused or aggravated by a service-connected disorder, to include an undiagnosed illness manifested by myofascial pain of the upper and lower extremities, arthralgias of the hands and multiple finger joints with right dominant hand grip weakness, and arthralgias of the elbows and ankles, or any other acquired psychiatric disorder which the examiner finds to be service-connected. A complete, well-reasoned rationale must be provided for any opinion offered. If any requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 7. After completing directive six, obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension is at least as likely as not related to environmental or toxic exposure during active duty, to include sarin, cyclosarin, anthrax vaccines, anti-nerve agent pills, debris from SCUD missiles and burning oil wells. If, and only if, medical evidence demonstrates that the Veteran has an acquired psychiatric disorder which is related to service, the examiner must opine whether the Veteran’s hypertension is at least as likely as not caused or aggravated by an acquired psychiatric disorder. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 8. After completing directive six, obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s liver steatosis is at least as likely as not related to environmental or toxic exposure during active duty, to include sarin, cyclosarin, anthrax vaccines, anti-nerve agent pills, debris from SCUD missiles and burning oil wells. If, and only if, medical evidence demonstrates that the Veteran’s alcohol use disorder was caused or aggravated by a service-connected disorder, the examiner must opine whether liver steatosis is at least as likely as not caused or aggravated by an alcohol use disorder. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 9. Schedule the Veteran for an audiological examination to determine the current severity of his bilateral hearing loss. The examiner must provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. To the extent possible, the examiner must identify any symptoms and functional impairments due to hearing loss and discuss the effect of the disability on the appellant’s occupational functioning and activities of daily living. DEREK R. BROWN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Paul J. Bametzreider, Associate Counsel