Citation Nr: 20044064 Decision Date: 06/30/20 Archive Date: 06/30/20 DOCKET NO. 18-34 082A DATE: June 30, 2020 ORDER 1. Entitlement to service connection for Crohn’s disease as a medically unexplained chronic multisymptom illness (MUCMI), manifested by the Veteran’s joint pains, stomach symptoms, and abnormal weight loss, is denied. 2. Entitlement to service connection for joint pains, to include a right knee patellofemoral pain syndrome and finger pain, is denied. 3. Entitlement to service connection for a skin disability, to include eczema, is denied. 4. Entitlement to service connection for a gastrointestinal disability, to include chronic diarrhea, is denied. 5. Entitlement to service connection for abnormal weight loss is denied. 6. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and adjustment disorder with acute anxiety, is denied. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had Crohn’s disease at any time during or since her active service in the Southwest Asia theater of operations. 2. Right knee patellofemoral pain syndrome did not have its onset in service and is not otherwise related to service. 3. A skin disability, to include eczema, did not have its onset in service and is not otherwise related to service. 4. Chronic diarrhea did not have its onset in service and is not otherwise related to service. 5. The preponderance of the evidence of record is against finding that the Veteran has had abnormal weight loss at any time during, or approximate to, the pendency of the claim that causes functional impairment of earning capacity. 6. The Veteran has not been diagnosed with PTSD. 7. A psychiatric disorder, to include adjustment disorder with acute anxiety, did not have its onset in service and is not otherwise related to service. CONCLUSIONS OF LAW 1. The criteria to establish service connection for Crohn’s disease as a MUCMI, manifested by joint pains, stomach symptoms, and abnormal weight loss, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. The criteria to establish service connection for joint pains, to include a right knee patellofemoral pain syndrome, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 3. The criteria to establish service connection for a skin disability, to include eczema, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 4. The criteria to establish service connection for a gastrointestinal disability, to include chronic diarrhea, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 5. The criteria to establish service connection for abnormal weight loss have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. 6. The criteria to establish service connection for a psychiatric disorder, to include PTSD and an adjustment disorder with acute anxiety, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 2008 to September 2011. For her service, the Veteran earned an Iraq Campaign Medal. See DD-214 Form. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), which denied the Veteran service connection for joint pains, eczema, a stomach condition, abnormal weight loss, and PTSD. The Veteran was also denied service connection for Crohn’s disease, but she does not wish to appeal this matter. See July 2018 VA Form 9; March 2019 correspondence. In July 2019, the Board remanded the Veteran’s claims to the Agency of Original Jurisdiction (AOJ) for further action consistent with the Board’s remand directives. Specifically, the Board remanded the claims to afford the Veteran VA examinations related to an undiagnosed illness, obtain new etiological opinions, and provide an additional opportunity for the Veteran to appear for VA examinations. The claims are back before the Board for further appellate proceedings. The Board finds there has been substantial compliance with its remand directives, and the claims are ripe for adjudication. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be warranted for a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than not later than December 31, 2021. 38 C.F.R. § 3.317(a). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multisymptom illness (MUCMI); and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). Signs or symptoms that may be a manifestation of an undiagnosed illness or MUCMI include joint pain, signs or symptoms involving skin, gastrointestinal signs or symptoms, and abnormal weight loss. 38 C.F.R. § 3.317(b). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. 38 C.F.R. § 3.317(a)(4). Further, in Stewart v. Wilkie, the United States Court of Appeals for Veterans Claims (Court) held that an undiagnosed illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive as to the individual Veteran. See Stewart v. Wilkie, 30 Vet. App. 383, 390-92 (2018). The Veteran served in Iraq from June 2009 to December 2009. See STR, service record. Thus, she is a Persian Gulf Veteran for purposes of 38 C.F.R. § 3.317. See 38 C.F.R. § 3.317(e)(1). Additionally, the Board notes that in the absence of proof of a present disability, to include symptoms that cause functional impairment of earning capacity, there can be no valid claim. Degmetich v. Brown, 104 F.3d 1328, 1332 (1997). However, the requirement for service connection that a current disability be present is satisfied when a veteran has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary’s adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 322-23 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). 1. Entitlement to service connection for Crohn’s disease as a MUCMI, manifested by joint pains, stomach symptoms, and abnormal weight loss The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of service connection for Crohn’s disease. The reasons follow. In its July 2019 decision, the Board remanded the claims for service connection for joint pain, abnormal weight loss, and stomach symptoms for further development as an undiagnosed condition; these claims are further addressed separately in the sections that follow. However, in a January 2020 VA examination report, an examiner opined that the Veteran’s joint pains, stomach symptoms, and abnormal weight loss could be manifestations of Crohn’s disease, which the examiner documented that the Veteran asserted she was diagnosed with in 2015. See January 2020 VA examination report. The January 2020 examiner classified Crohn’s disease as a MUCMI. Id. For the purposes of analyzing Crohn’s disease as a MUCMI only, the Board will assume arguendo that the Veteran has abnormal weight loss As to the Veteran’s assertion that she was diagnosed with Crohn’s disease, the Board makes several observations. The Veteran first asserted in 2018 that she was diagnosed with Crohn’s disease in 2008 or 2009, before asserting to the examiner that she was diagnosed in 2015. Id.; see August 2019 VA treatment records. As noted above, her claim for service connection for Crohn’s disease was first denied in the same rating decision on appeal here. See July 2017 VA Form 21-526EZ, March 2018 rating decision. She did not wish to perfect her appeal to the Board. See July 2018 VA Form 9, March 2019 correspondence. In a November 2019 psychological VA examination, the Veteran reported that she had thought she had Crohn’s disease but later learned she had irritable bowel syndrome. See January 2020 VA treatment records. While the Veteran is competent to report her own diagnosed condition, these observations weigh against the Veteran’s credibility as her assertions are inconsistent and wavering. The January 2020 VA examiner noted that the diagnosis of Chron’s disease may be in medical records requested from Valdosta Gastroenterology, but those records were not yet part of the Veteran’s claims file. See January 2020 VA examination report. The Veteran submitted a VA Form 21-4142 to have her medical records from Valdosta Gastroenterology associated with the claim’s file. See September 2017 VA Form 21-4142. In October 2017, Valdosta Gastroenterology requested that the Veteran sign a medical records release form on its own prescribed form. See October 2017 private medical records and correspondence. Subsequently, the RO notified the Veteran that Valdosta Gastroenterology required the form, attached the form to the notification, and requested that the Veteran fill it out and return it to the RO. See October 2017 subsequent development letter. Ultimately, the form was never completed and returned to the RO. In November 2017, the Veteran submitted a 5103 Notice response that she had enclosed all remaining information or evidence to support her claim or otherwise had no other information or evidence to provide. See November 2017 5107 Notice Acknowledgment. In her notice of disagreement to the March 2018 rating decision, she stated that she was “aware that the decisions made were done so without complete medical records from . . . VA Gastroenterology.” See April 2018 notice of disagreement. She did not request that the RO make further attempts to collect these medical records, did not complete the prescribed form from Valdosta Gastroenterology, and, ultimately, ended her appeal of this claim. The Board notes that the duty to assist a claimant is not a one-way street and the Veteran has failed to cooperate to the full extent in the development of her claim. Wood v. Derwinski, 1 Vet. App. 406 (1991); 38 U.S.C. § 5107(a). Thus, VA substantially performed its duty to assist the Veteran in requesting these medical records. Without the medical records, there is no competent evidence of record to corroborate the Veteran’s assertion that she was diagnosed with Crohn’s disease. The Board finds that the Veteran is not credible in her report of Crohn’s disease as a diagnosis. As explained above, her assertions of when she was diagnosed is inconsistent, her contention that she has Crohn’s disease has wavered, and she has not cooperated with VA to retrieve medical records that could support her assertion. Therefore, the Board assigns no probative value to the Veteran’s contention that she was diagnosed with Crohn’s disease. Without a diagnosis, the Board’s cannot find that Crohn’s disease as a MUCMI for the purposes of a § 3.317 presumption is applicable to the Veteran’s claims. See 38 C.F.R. § 3.317(ii) (defining MUCMI as a “diagnosed illness”). The preponderance of the evidence is against finding that the Veteran has Crohn’s disease or a MUCMI associated with her joint pains, stomach symptoms, and abnormal weight loss. Moreover, and as more fully discussed in the sections that follow, the signs and symptoms associated with the manifested joint pains and stomach symptoms relate to a diagnosed illness. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the claim for service connection for Crohn’s disease as a MUCMI, manifested by joint pains, stomach symptoms, and abnormal weight loss, is denied. 2. Entitlement to service connection for joint pains. The Veteran contends generally that her joint pains are a result of active service. See July 2017 VA Form 21-526EZ; April 2018 notice of disagreement; July 2018 VA Form 9. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim of service connection for joint pains, to include a right knee patellofemoral pain syndrome and finger pain. Specifically, the Board finds that the preponderance of the evidence is against a finding that the Veteran has any uncompensated joint pains that had its onset in service, is entitled to any presumption, or is otherwise related to service. The reasons follow. Preliminarily, the Board notes that the Veteran is service connected for lumbosacral strain and left knee strain with left knee patellofemoral pain syndrome. Thus, the Board’s analysis is focused on entitlement to service connection for joint pains other than the service-connected lumbosacral strain and left knee strain with left knee patellofemoral pain syndrome. The Board will first address the (A) applicability of § 3.317, then the entitlements to direct service connection as to the Veteran’s (B) finger disability, and, finally, the Veteran’s entitlement to her (C) right knee patellofemoral pain syndrome. A. Applicability of 38 C.F.R. § 3.317 As noted above, the Veteran is a Persian Gulf Veteran for the purposes of § 3.317. Thus, she is entitled to a presumption of service connection for certain qualifying chronic diseases. Importantly, here, a “chronic” disability is one that has “existed for 6 months or more” exhibiting “intermittent episodes of improvement and worsening over a 6-month period . . . . measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest.” 38 C.F.R. § 3.317(ii)(4). The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim of service connection for joint pains on a presumptive basis under § 3.317. Specifically, the Board finds that the preponderance of the evidence is against a finding that the Veteran has an undiagnosed, chronic joint pain or a diagnosed illness characterized by overlapping signs or symptoms. The reasons follow. As to the Veteran’s finger disability characterized generally as pain, the evidence establishes that it first became manifest in October 2018 with no subsequent reports of improvement, worsening, or continued complaints within 6 months. See August 2019 VA treatment records. Thus, the Veteran’s finger disability is not considered chronic for the purposes of § 3.317 and the Veteran is not availed its presumption. As to the Veteran’s right knee patellofemoral pain syndrome, the evidence establishes that a right knee patellofemoral pain syndrome first became manifest in January 2010 with two encounters with physicians. See STRs. Initially, the Veteran’s right knee pain was characterized generally as joint pain and the Veteran was placed on a two-week profile. Id. When it did not improve thirteen days later, a second physician extended her profile and characterized the pain as a right knee patellofemoral syndrome. Id. The second physician noted that the Veteran had a normal right knee outside the Veteran’s complaints of pain. Id. The evidence of record does not show any other right knee complaints until October 2018. See August 2019 VA treatment records. Indeed, the Veteran did not complain of pain in her right knee at her separation examination, August 2013 Medical Board reassessment, or the November 2017 bilateral knee and lower leg VA examination, which tends to show that the Veteran knew she was not experiencing pain in her right knee. See STRs, November 2017 VA examination report. The Board finds that the preponderance of the evidence is against finding that the Veteran’s right knee patellofemoral syndrome was chronic prior to October 2019 for the purposes of § 3.317. After October 2019, the evidence shows that the right knee patellofemoral syndrome was active for at least 6 months. However, the evidence does not indicate, nor does the Veteran argue, that this diagnosed condition has any overlapping symptoms or signs. Indeed, a November 2019 examiner further opined that the Veteran did not have any additional signs and/or symptoms that may represent an undiagnosed illness or MUCMI. See November 2019 VA examination report. Thus, the Board finds that the preponderance of the evidence is against finding that the Veteran’s right knee patellofemoral syndrome is a MUCMI for the purposes of § 3.317. As stated above, the Veteran is already service connected for her diagnosed conditions, lumbosacral strain and left knee strain with left knee patellofemoral pain syndrome. No other complaints of joint pain exist in the record. Therefore, § 3.317 is not applicable to the Veteran’s asserted entitlement to service connection for joint pains. B. Finger, Joint Pain The Veteran has not asserted any particular contentions as to her finger, joint pain, its onset, or any associated injury or disease. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a finger, joint pain disability. Specifically, the Board finds that the preponderance of the evidence is against a finding that the Veteran has a finger, joint pain disability, to include symptoms thereof, that cause functional impairment of earning capacity. The reasons follow. The Board finds that the Veteran has not had a current disability for the purposes of the contended finger, joint pain disability at any time during the pendency of the claim or recent to the filing of the claim that causes functional impairment of earning capacity. Thus, the initial requirement for service connection for a finger, joint pain disability is not met. Degmetich, 104 F.3d at 1332; McClain, 21 Vet. App.at 322-23. As noted above, the Veteran first complained of finger, joint pain in October 2018. See August 2019 VA treatment records. Importantly, she has not asserted any functional impairment in earning capacity as a result of her finger, joint pain at any time. Moreover, the Veteran’s service treatment records do not document a finger, joint pain disability or symptoms indicative thereof. The separation examination showed that her musculoskeletal symptoms were absent of any abnormalities. See STRs. The Board notes that VA has not provided the Veteran with an examination or opinion in connection with the claim for service connection for a finger, joint disability. VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the evidence does not show competent evidence of a current disability or persistent or recurrent symptoms of a disability. For a VA examination to be warranted, all the McLendon criteria have to be met, and at least one of the criteria is not met. Therefore, entitlement to a VA examination is not warranted for this service-connection claim. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the claim for service connection for a finger, joint pain disability is denied. C. Right Knee Patellofemoral Pain Syndrome The Veteran contends generally that her joint pains are a result of active service. See July 2017 VA Form 21-526EZ; April 2018 notice of disagreement; July 2018 VA Form 9. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim of service connection for a right knee patellofemoral pain syndrome. Specifically, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s right knee patellofemoral pain syndrome had its onset in service or is otherwise related to service. The reasons follow. As to evidence of a current disability, a November 2019 VA examination report shows that the Veteran was diagnosed with a right knee patellofemoral pain syndrome. Therefore, the Veteran meets the first element of a service-connection claim. As to evidence of an in-service disease or injury, the service treatment records show that the Veteran sustained an injury to her right knee in August 2009, while she was in service in Southwest Asia. See STRs. Thus, the Veteran meets the second element of a service-connection claim. As to evidence of a nexus between the current disability and service, the Board finds that the preponderance of the evidence is against a nexus. For example, the Veteran’s separation exam and August 2013 Medical Board assessment did not note any abnormalities of her right knee. See STRs. Nor did the Veteran complain of any right knee symptoms during her November 2017 VA examination. See November 2017 VA examination report. As noted above, her renewed complaint of right knee pain was asserted in October 2018. See August 2019 VA treatment records. The November 2019 VA examiner reviewed the Veteran’s contentions, medical history, and service history to opine that the Veteran’s right knee patellofemoral pain syndrome is not related to any event experienced during service in Southwest Asia. The Board finds the examiner’s opinion highly probative, as the examiner reviewed the file, physically examined the Veteran, and explained the conclusion reached. Thus, the Veteran does not meet the third element of a service-connection claim. While the Veteran is competent to report symptoms that she has experienced in service and since service, she is not competent to directly link patellofemoral syndrome to service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. At the present time, there is no competent evidence to weigh against the negative VA opinion. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the claim for service connection for a right knee patellofemoral pain syndrome is denied. 3. Entitlement to service connection for a skin disability, to include eczema. Preliminarily, the Board notes that the Veteran is service connected for acne. The Veteran contends generally that her eczema is a result of active service. See July 2017 VA Form 21-526EZ; April 2018 notice of disagreement; July 2018 VA Form 9. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim of service connection for a skin disability, to include eczema. Specifically, the Board finds that the preponderance of the evidence is against a finding that the Veteran eczema had its onset in service or is otherwise related to service. The reasons follow. As to evidence of a current disability, a November 2019 VA examination report shows that the Veteran was diagnosed with eczema. Therefore, the Veteran meets the first element of a service-connection claim. As to evidence of an in-service disease or injury, the service treatment records do not show that the Veteran’s eczema had its onset in service. The Veteran asserts that she was diagnosed with eczema in 2009, during service. See November 2019 VA examination report. However, throughout her service treatment records, physicians have opined that she was negative for eczema. See STRs. While the Veteran is competent to report her diagnosis of eczema, medical notes written by physicians from during her service noted that she was negative for eczema. As the question of diagnosis requires medical expertise, the Board finds the Veteran’s physicians in service more probative than her recollection of onset. Thus, the Veteran did not have eczema while in service. However, service treatment records note that the Veteran had a skin rash in May 2009. See STRs. The Veteran believed it to be a reaction to some cream. Id. She was told to use over-the-counter medication and return within 10 days if no improvement. Id. No further visit was noted. Thus, the Veteran meets the second element of a service-connection claim. The Board notes that service treatment records also note several allergies in which a rash is reported as an effect. As to evidence of a nexus between the current disability and service, the Board finds that the preponderance of the evidence is against a nexus. The Veteran was provided a VA examination in November 2019. After a review of the Veteran’s contentions, service records, and medical records, the examiner opined that the Veteran’s eczema is less likely than not incurred in or caused by service. See November 2019 VA examination report. Indeed, the Veteran’s separation examination showed that her skin was absent of any abnormalities. See STRs. Her Medical Board reassessment also showed that her skin was absent of any abnormalities. The Board finds the in-service examining physicians and their opinions highly probative. Because the November 2019 VA medical opinion was based on a review of the record and an examination of the Veteran, the Board accords the opinion high probative value. Thus, the Veteran does not meet the third element of a service-connection claim. The Board also notes that the evidence does not indicate, nor does the Veteran argue, that this diagnosed condition has any overlapping symptoms or signs. Thus, the Board finds that the preponderance of the evidence is against finding that the Veteran’s eczema is a MUCMI for the purposes of § 3.317. While the Veteran is competent to report symptoms that she has experienced in service and since service, the Board does not find that there is evidence of eczema in service. Thus, to the extent that the Veteran attempts link the post-service diagnosis of eczema to service, she is not competent provide this opinion, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. At the present time, there is no competent evidence to weigh against the negative VA opinion. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the claim for service connection for eczema is denied. 4. Entitlement to service connection for a gastrointestinal disability. The Veteran contends that she has a stomach disability that she generally asserts is related to service. See July 2017 VA Form 21-526EZ; April 2018 notice of disagreement; July 2018 VA Form 9. Her service treatment records and VA treatment records show symptoms and diagnoses, such as gallstones. To afford the Veteran the broadest review, the Board will expand her claim to an entitlement to service connection for a gastrointestinal disability. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim of service connection for a gastrointestinal disability, to include chronic diarrhea. Specifically, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s chronic diarrhea had its onset in service or is otherwise related to service. The reasons follow. The Board will first address the (A) applicability of § 3.317, then the entitlements to direct (B) service connection as to the Veteran’s chronic diarrhea. A. Applicability of 38 C.F.R. § 3.317 As noted above, the Veteran is a Persian Gulf Veteran for the purposes of § 3.317. Thus, she is entitled to a presumption of service connection for certain qualifying chronic diseases. First, the Board finds that the preponderance of the evidence is against finding that the Veteran has an undiagnosed illness. The Veteran was afforded a stomach and duodenal VA examination in November 2017. The November 2017 examiner opined that the Veteran did not have a stomach disability and that her reported, recurring episodes of stomach symptoms, to include abdominal pain, weight loss, nausea, and vomiting, “are not believed to be related” to a stomach condition and have an unknown etiology. See November 2017 VA examination report. The examiner added that these findings were outside the scope of the current exam. Id. The Board notes that the examiner conducted the examination without reviewing the Veteran’s claim’s file or medical records. Id. In July 2019, the Board remanded this claim for development as an undiagnosed illness. The Veteran was afforded a general, Gulf War VA examination in November 2019. The examiner reviewed the Veteran’s claim’s file and medical records and opined that the Veteran did not have any disability for which an etiology was not established. See November 2019 VA examination report. The examiner further opined that the Veteran did not have any additional signs and/or symptoms that may represent an undiagnosed illness or MUCMI. Id. The Board finds that the November 2019 examiner is more probative than the November 2017 examiner. Notably, the November 2019 examiner reviewed the Veteran’s claim’s file and medical record. More precisely, the November 2019 examiner reviewed each of the Veteran’s systems rather than just stomach and duodenal conditions as the November 2017 examiner had. Thus, the Veteran does not have an undiagnosed illness. Second, the Veteran does not have a MUCMI. In addition to the November 2019 examiner’s opinion that the Veteran has no additional signs and/or symptoms that may represent a MUCMI, the examiner determined that the Veteran’s symptoms reflect one disability, her only current disability, more fully discussed below. Thus, the Board finds that the preponderance of the evidence is against finding that the Veteran’s chronic diarrhea is a MUCMI for the purposes of § 3.317. Therefore, § 3.317 is not applicable to the Veteran’s asserted entitlement to service connection for a gastrointestinal disability. B. Chronic Diarrhea The Veteran has not asserted any particular contentions as to her chronic diarrhea, its onset, or any associated injury or disease. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim of service connection for a gastrointestinal disability. Specifically, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s chronic diarrhea had its onset in or is otherwise related to service. The reasons follow. As to evidence of a current disability, a November 2019 VA examination report shows that the Veteran was diagnosed with chronic diarrhea, to include abdominal pain relieved by bowel movements. Therefore, the Veteran meets the first element of a service-connection claim. The Board notes that the November 2019 examiner thoroughly reviewed the Veteran’s service treatment records and VA treatment records. See November 2019, January 2020, and March 2020 VA examination reports. The examiner noted that the Veteran had abdominal pain, treatment for GERD, and treatment for esophagitis in service. Id. The examiner noted these manifestations resulted in diagnoses of gallstones, cholecystitis, prepyloric gastritis, and monilial esophagitis shortly after separation from service. Id. The examiner acknowledged that the Veteran was treated for these conditions and her symptoms related to these conditions had resolved. Id. The Board observes that service treatment records note several instances of diarrhea in relation to the Veteran’s prepyloric gastritis. See STRs. However, the examiner’s diagnoses of a chronic diarrhea was based on a new onset of symptoms. See November 2019, January 2020, and March 2020 VA examination reports. The Board finds the examiner’s opinion that the Veteran’s gastrointestinal disabilities, other than chronic diarrhea, and their associated symptoms have resolved is highly probative. The Veteran’s last complaint prior to 2015 of a gastrointestinal disability was in 2012. See January 2020, August 2019, and September 2017 VA treatment records; see also January 2020 private medical records. In 2012, the Veteran underwent cholecystectomy to treat her gastrointestinal disabilities. Id.; see also STRs. The Veteran underwent a Medical Board reassessment in August 2013. See STRs. The physician found that the Veteran’s gastrointestinal system had no abnormalities outside of asserted residuals that the Veteran stated were being evaluated. Id. No residuals from the surgery have been documented in the Veteran’s records, nor has the Veteran contended that her asserted stomach disability is a residual of the cholecystectomy. Indeed, the November 2019 examiner specifically found that all symptoms had resolved. Thus, the only current disability eligible for service connection is the Veteran’s chronic diarrhea. The Board also notes that the Veteran has recently contended that she has irritable bowel syndrome. See January 2020 VA Form 21-526EZ; January 2020 VA treatment records. Partial private medical records, submitted in the form of a photo taken of a portion of a page 2 in a report, indicate that biopsies were taken of her colon. See January 2020 private medical records. A note states that “[a]ssuming the biopsies are unremarkable, your symptoms are irritable bowel syndrome. You should follow up at the VA for further treatment. Treating stress and PTSD will help with your GI complaints.” Id. The author of the statements, conditions of analysis, and medical expertise utilized are unknown. Id. However, the Veteran’s gastrointestinal system was examined by a November 2019 examiner, who did not diagnose the Veteran with a current irritable bowel syndrome. See November 2019 and March 2020 VA examination reports. The examiner concluded that the note quoted above was not a conclusive diagnosis. Id. The Board agrees. The statement is conditional on the return of results from biopsies. These results are not available, and the condition remains pending. Even if the biopsies did return normal, the statement itself does not seem one of diagnosis, but one of differential or one needing to be ruled-out. The only evidence of record supporting a conclusive diagnosis are the Veteran’s statement. While the Veteran is competent to report symptoms that she has experienced in service and since service, she is not competent to diagnose irritable bowel syndrome, as medical expertise is required. In this regard, the question of diagnosis involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of diagnosis in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. Thus, the Board finds that the preponderance of evidence is against finding that the Veteran has been diagnosed with irritable bowel syndrome. As more fully explained below, her symptoms are associated with another diagnosed disability. As to evidence of an in-service disease or injury, the Board reiterates that the Veteran had several disabilities and symptoms in service and shortly after service as noted above. See STRs. Thus, the Veteran meets the second element of a service-connection claim. As to evidence of a nexus between the current disability and service, the Board finds that the preponderance of the evidence is against a nexus. For example, the Veteran’s August 2013 Medical Board assessment did not note any abnormalities of her gastrointestinal system. See STRs. Additionally, the Veteran’s disabilities and symptoms in service were completely resolved prior to her new diagnosis of chronic diarrhea. See November 2019 VA examination report. The November 2019 VA examiner reviewed the Veteran’s contentions, medical history, and service history to opine that the Veteran’s chronic diarrhea is not related to any disability in service. The Board finds the examiner’s opinion highly probative. Thus, the Veteran does not meet the third element of a service-connection claim. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the claim for service connection for chronic diarrhea is denied. 5. Entitlement to service connection for abnormal weight loss is denied. The Veteran contends that she has had abnormal weight loss. See July 2017 VA Form 21-526EZ; April 2018 notice of disagreement; July 2018 VA Form 9. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for abnormal weight loss. Specifically, the Board finds that the preponderance of the evidence is against a finding that the Veteran has had abnormal weight loss. The reasons follow. The Board finds that the Veteran has not had a current disability for the purposes of the contended abnormal weight loss at any time during the pendency of the claim or recent to the filing of the claim that causes functional impairment of earning capacity. Thus, the initial requirement for service connection for abnormal weight loss is not met. Degmetich, 104 F.3d at 1332; McClain, 21 Vet. App.at 322-23. The Veteran’s medical records in service and thereafter are absent of any complaints of abnormal weight loss or any functional impairment in earning capacity as a result of abnormal weight loss. At the time of separation, the Veteran weighed 161 pounds. See STRs. During her Medical Board reassessment, the Veteran weighed 125 pounds and told the physician she intentionally lost weight through exercise. See STRs. Further, the November 2019 VA examiner opined that her use of oral steroids to treat her asthma most likely resulted in the Veteran’s weight gain in service and any weight loss thereafter would be appropriate. See November 2019 VA examination report. Indeed, the Veteran had told the physician at the Medical Board assessment that she had discontinued all prescribed medication. See STRs. The Veteran currently weighs “within 5 pounds of her usual weight” and “there is no evidence that the Veteran has unexplained weight loss.” See November 2019 VA examination report. Thus, the preponderance of the evidence is against finding that the Veteran has a current disability, asserted as abnormal weight loss. It follows that without abnormal weight loss as a sign or symptom at any point in the Veteran’s medical records, there is not an undiagnosed illness or MUCMI manifested by abnormal weight loss. The Board notes that VA has not provided the Veteran with an examination or opinion in connection with the claim for service connection for abnormal weight loss, though an opinion had been provided. VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the evidence does not show competent evidence of a current disability or persistent or recurrent symptoms of a disability. For a VA examination to be warranted, all the McLendon criteria have to be met, and at least one of the criteria is not met. Therefore, entitlement to a VA examination is not warranted for this service-connection claim. While the Veteran is competent to report symptoms like weight loss that she has experienced in service and since service, she is not competent to explain whether such weight loss is medically abnormal, as medical expertise is required. In this regard, the determination of whether weight loss is abnormal involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of whether the Veteran’s weight loss was abnormal may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the claim for service connection for abnormal weight loss is denied. 6. Entitlement to service connection for a psychiatric disorder, to include PTSD and adjustment disorder with anxiety. The Veteran contends that she has PTSD. See July 2017 VA Form 21-526EZ; April 2018 notice of disagreement; July 2018 VA Form 9. The Veteran was afforded a VA examination in November 2019. The examiner diagnosed the Veteran with adjustment disorder with anxiety. See November 2019 VA examination report. To afford the Veteran the broadest review, the Board will expand her claim to an entitlement to service connection for a psychiatric disorder, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim of service connection for a psychiatric disorder, to include PTSD and adjustment disorder with anxiety. Specifically, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s adjustment disorder with anxiety had its onset in service or is otherwise related to service. The reasons follow. First, the Board notes that the Veteran does not have a diagnosis of PTSD. See November 2019 VA examination report. Service connection for PTSD requires medical evidence diagnosing the disability in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the in-service stressor occurred. 38 C.F.R. § 3.304(f). The diagnosis of PTSD must comply with the criteria set forth in the American Psychiatric Association Diagnostic and Statistical manual of Mental Disorders, 5th edition, of the American Psychiatric Association (DSM-5). See 38 C.F.R. § 4.125(a), 4.130. There is no diagnosis of PTSD in the evidentiary record. Indeed, the Veteran has screened negative for PTSD in 2015. See September 2017 VA treatment records. Thus, the Veteran does not meet the criteria for service connection for PTSD. As to evidence of a current disability, a November 2019 VA examination report shows that the Veteran was diagnosed with adjustment disorder with anxiety. Therefore, the Veteran meets the first element of a service-connection claim. As to evidence of an in-service disease or injury, the service treatment records are silent for any complaints of psychiatric illness, trouble sleeping, depression, or nervous trouble. See STRs; see also November 2019 VA examination report. During her Medical Board evaluation, the Veteran denied anxiety. See STRs. During her separation exam, the Veteran denied anxiety and depression. Id. Thus, the Veteran does not meet the second element of a service-connection claim. Moreover, the November 2019 VA examiner opined that the Veteran’s adjustment disorder with anxiety is not related to her service, citing the reasons described above. See November 2019 VA examination report. The examiner’s opinion is based on a review of the Veteran’s service record, treatment records, and contentions. Id. The Board finds the examiner’s opinion highly probative. Thus, the Veteran does not meet the third element of a service-connection claim. While the Veteran is competent to report symptoms that she has experienced in service and since service, she is not competent provide a nexus between her current psychiatric disorder and service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. At the present time, there is no competent evidence to weigh against the negative VA opinion. The Board has considered the applicability of the benefit-of-the-doubt doctrine. However, it is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the claim for service connection for a psychiatric disorder, to include PTSD and adjustment disorder with anxiety, is denied. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Strickland The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.