Citation Nr: 18157960 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 16-34 431 DATE: December 13, 2018 REMANDED Entitlement to service connection for joint pains is remanded. Entitlement to service connection for muscle pain is remanded. Entitlement to service connection for hypertension, to include as secondary to the service-connected posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for chronic fatigue syndrome is remanded. Entitlement to service connection for a heart condition (claimed as cardiovascular symptoms) is remanded. Entitlement to service connection for headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1989 to July 1993. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a May 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for joint pain is remanded. 2. Entitlement to service connection for muscle pain is remanded. Regarding the Veteran’s claim, he asserts his claimed muscle/joint pains are related to his Persian Gulf War service. Both VA and private treatment records show muscle and joint pain associated with gout and/or osteoarthritis. X-rays show degenerative changes in the ankles and feet. The Veteran underwent VA examination in November 2010. The examiner opined that the Veteran’s muscle and joint pains are unexplained symptoms and stated that it was not possible to attribute them to a known clinical diagnosis. However, no rationale was provided and the conclusion is inconsistent with the notations in the treatment records. In light of the above, a new examination and an addendum medical opinion should be obtained on remand. 3. Entitlement to service connection for hypertension, to include as secondary to the service-connected posttraumatic stress disorder (PTSD) is remanded. Regarding the Veteran’s claim for hypertension, he has claimed his hypertension is secondary to his service-connected PTSD. The Board finds a VA hypertension examination would be helpful in adjudicating the claim. 4. Entitlement to service connection for chronic fatigue syndrome is remanded. 5. Entitlement to service connection for a heart condition (claimed as cardiovascular symptoms) is remanded. 6. Entitlement to service connection for headaches is remanded. As a final matter, regarding all of the Veteran’s claims, it appears he has applied for Social Security Administration (SSA) benefits. Accordingly, such records should be obtained upon remand as well as updated treatment records. The matters are REMANDED for the following actions: 1. Request all documents pertaining to any application by the Veteran for SSA disability benefits, including the medical records considered in deciding the claim. If the requested records are not available, the Veteran should be notified of such. 2. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran and his representative should be notified of such. 3. After records development is completed, schedule the Veteran for an orthopedic examination, to address his claim for muscle and joint pain. The claims file should be reviewed by the examiner. After review of the claims file and examination of the Veteran, the examiner should respond to the following: (a.) Identify any disability manifested by joint and/or muscle pain and state whether it is at least as likely as not (50 percent probability or greater) that such arose during service or are otherwise related to service, to include his service in the Persian Gulf. (b.) If there are no diagnoses to account for the Veteran’s joint and/or muscle pain symptoms, the examiner should indicate whether there are objective indications of disability and whether such indications represent undiagnosed illnesses consistent with service in the Persian Gulf. A rationale for all opinions expressed should be provided. 4. Schedule the Veteran for a VA hypertension examination to determine the nature of his hypertension and to obtain an opinion as to whether such is possibly related to service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to the following: (a.) Is it at least as likely as not (50 percent probability or greater) that his hypertension arose during service or is otherwise related to service. (b.) If not related to service, is it at least as likely as not (50 percent probability or greater) that hypertension was caused by the service-connected PTSD? (c.) If not caused by the service-connected PTSD, is it at least as likely as not that the Veteran's hypertension is worsened beyond natural progression (aggravated) by his service-connected PTSD? If the examiner finds that the Veteran's hypertension was aggravated by his service-connected PTSD, the examiner should attempt to quantify the level of aggravation beyond the baseline level of the hypertension. A rationale for all opinions expressed should be provided. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Medina, Associate Counsel