Citation Nr: 1808867 Decision Date: 02/13/18 Archive Date: 02/23/18 DOCKET NO. 16-29 451 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for chronic fatigue syndrome, to include as a result of Gulf War service. 2. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as a result of Gulf War service. (The issue of entitlement to service connection for bilateral shoulder disabilities is discussed in a separate Board decision). REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Eric Struening, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1985 to November 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In August 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran testified that he first experienced symptoms of GERD during service and the symptoms have continued. He further testified that he sought treatment from a private physician within months of separation from service, but those records are unavailable. The Veteran also testified that he received medical treatment for both claimed disabilities from private providers, records of which have not been associated with the record before the Board. He testified that he sees a gastroenterologist at Piedmont Fayette Hospital in Fayetteville, Georgia for his GERD, and that his private primary care provider, Dr. H.S. has treated him for both GERD and chronic fatigue syndrome. On remand, the Veteran should identify all treatment providers and then those records should be obtained. The Veteran testified that Dr. H.S. diagnosed chronic fatigue syndrome and had informed the Veteran that both his GERD and chronic fatigue syndrome were related to his service in the Gulf War. The Veteran was afforded a VA examination in November 2013 for both GERD and chronic fatigue syndrome, but the Board finds the VA medial opinions are inadequate. The examiner diagnosed GERD but opined that it was less likely than not related to any specific exposure event experienced by the Veteran during his service in Southeast Asia. The opinion is inadequate because it does not address whether the currently diagnosed GERD is directly related to service. Regarding the Veteran's claim for chronic fatigue syndrome, the examiner noted the Veteran had symptoms of fatigue, sleep disturbance, and headaches, but concluded that he did not meet the diagnostic criteria for chronic fatigue syndrome. The examiner concluded that the Veteran's fatigue is related to poor sleep and his mental disorder and noted that chronic fatigue was not documented in his treatment records. The Board points out that the Veteran's VA treatment records indicate findings of clinically significant levels of fatigue, sleep maintenance problems, insomnia, and daytime sleepiness. While those symptoms may be related to the Veteran's service-connected posttraumatic stress disorder (PTSD), they also may be manifestations of an undiagnosed illness or medically unexplained chronic multisystem illness. A medical opinion is required to answer that question. See 38 C.F.R. §§ 3.159 (c)(4), 3.317 (2017). All outstanding VA medical records should also be obtained. See 38 C.F.R. § 3.159. See also Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain the name and addresses of all medical care providers who treated the Veteran for GERD or chronic fatigue syndrome since service. After securing the necessary release, take all appropriate action to obtain these records, including records from his primary care provider Dr. HS and his gastroenterologist at Piedmont Fayette Hospital in Fayetteville, Georgia. Additional VA treatment records since October 2017 should also be obtained. 2. After the completion of the above, schedule the Veteran for an appropriate examination to determine the current nature and likely etiology of GERD. Copies of all pertinent records should be made available to the examiner for review. Based on the record, the examiner should provide an opinion to the following: Is it at least as likely as not that the Veteran's GERD is related to his active duty service? The examiner is specifically requested to consider that the Veteran competently reported having stomach pain during service that has continued since. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. 3. After the completion of (1), schedule the Veteran for an appropriate examination to determine the current nature and likely etiology of any disabilities manifested by fatigue, sleep disturbance, insomnia, daytime sleepiness, and headaches. Copies of all pertinent records should be made available to the examiner for review. Based on the examination and review of the record, the examiner should provide an opinion to the following: (a) Are all of the Veteran's reported symptoms of fatigue; sleep disturbance; insomnia, daytime sleepiness, and headaches, when considered independently or together with other symptoms, due to known clinical diagnoses? The examiner is asked to consider and discuss, as necessary, the notations in VA treatment records of clinically significant levels of fatigue, sleep maintenance problems, insomnia, daytime sleepiness. (July 2012, March 2013). (b) If the answer to (a) is no, do the symptoms (either independently or together) present objective indications of: (i) A chronic disability that by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis; OR (ii) A medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as fibromyalgia; OR (iii) No chronic disability at all? (iv) If no chronic disability related to fatigue is diagnosed, are the Veteran's reports of fatigue and sleep disturbance symptoms of his service-connected PTSD? (c) If the answer to (a) is yes, please identify each such diagnosis along with the symptoms attributable to it, and for each disability entity diagnosed, indicate as due to environmental exposures in Southwest Asia. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. 4. The AOJ should then review the record and re-adjudicate the claims. If any benefit remains denied, the AOJ should issue an appropriate supplemental statement of the case and afford the Veteran and his representative opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2012). _________________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (West 2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).