Citation Nr: 20052563 Decision Date: 08/07/20 Archive Date: 08/07/20 DOCKET NO. 12-34 697 DATE: August 7, 2020 REMANDED Entitlement to service connection for an undiagnosed illness characterized by fatigue is remanded. Entitlement to service connection for an undiagnosed illness characterized by headaches is remanded. Entitlement to service connection for an undiagnosed illness characterized by digestive problems is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1997 to August 2003. He received the National Defense Service Medal, Army Service Ribbon, and Overseas Service Ribbon. Service Connection for Fatigue The Veteran underwent a VA examination in October 2019 for his claim for service connection for an undiagnosed illness characterized by fatigue. The examiner opined that it is less likely than not that the Veteran’s fatigue is related to his service and based this opinion, in part, on a lack of medical records reflecting fatigue complaints until February 2017. See November 2019 VA Examination, p. 2. However, the Veteran’s medical records document complaints of fatigue prior to February 2017. See March 2013 VA Treatment Records, p. 20. The October 2019 opinion does not fully consider the Veteran’s reported history; accordingly, the claim is remanded for a new opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Service Connection for Headaches The Veteran also underwent an examination for an undiagnosed illness characterized by headaches in October 2019. See November 2019 VA Examination, p. 3. The examiner offered a diagnosis of migraine headaches and opined that such headaches are not related to the Veteran’s active duty service. However, the examiner also indicated that the date of onset of the headaches was in 2000—a year in which the Veteran was on active duty. See November 2019 VA Examination, p. 2. The examiner did not clarify this inconsistency and the opinion is therefore inadequate. Thus, the claim is remanded for a new opinion. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Service Connection for Digestive Problems In October 2019, VA also obtained an opinion on whether the Veteran’s digestive problems are attributed to an undiagnosed or unexplained illness. See November 2019 VA Examination, p. 2. The examiner opined that the Veteran’s gastroesophageal reflux disease and Schatzki ring are less likely than not related to digestive problems in service. However, the Veteran’s digestive problems also include bowel issues and it does not appear that the examiner considered these issues. Accordingly, the claim is remanded for a new opinion that considers the full extent of the Veteran’s digestive issues. See Barr, 21 Vet. App. 303. The matters are REMANDED for the following action: Schedule the Veteran for an examination to ascertain the nature and etiology of his fatigue, headaches and digestive issues, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness as a result of his service in Southwest Asia. All indicated evaluations, studies, and tests deemed necessary should be accomplished, including any diagnostic testing necessary to rule out a diagnosis. The entire claims file, to include a complete copy of this REMAND, should be made available to the examiner designated to provide an opinion. The examiner must elicit a complete history of the Veteran’s conditions and the examination report should include a discussion of the Veteran’s documented medical history as well as his assertions. The examiner should offer comments, an opinion and a supporting rationale that address the following: (a) Describe all signs and symptoms of the Veteran’s fatigue and identify all diagnoses that pertain to his fatigue complaints over the course of the appeal period. In providing this response, the examiner must consider the Veteran’s reports of fatigue dating back to at least 2003. See November 2011 VA Examination, p. 2. (b) For any diagnoses identified in response to (a), is it at least as likely as not (50 percent probability or greater) that such disability was incurred in, aggravated by, or is otherwise etiologically related to the Veteran’s active duty service? The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered in arriving at an opinion. If the examiner rejects the Veteran’s reports, the examiner must provide a reason for doing so. (c) Describe all signs and symptoms of the Veteran’s headaches and identify all diagnoses that pertain to his headache complaints over the course of the appeal period. In providing this response, the examiner must consider the Veteran’s reports of headaches dating back to at least 2000. See November 2019 VA Examination, p. 2. (d) For any diagnoses identified in response to (c), is it at least as likely as not (50 percent probability or greater) that such disability was incurred in, aggravated by, or is otherwise etiologically related to the Veteran’s active duty service, to include his in-service car accident? The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered in arriving at an opinion. If the examiner rejects the Veteran’s reports, the examiner must provide a reason for doing so. (e) Describe all signs and symptoms of the Veteran’s digestive problems, to include bowel issues, and identify all diagnoses that pertain to his digestive complaints over the course of the appeal period. In providing this response, the examiner must consider the Veteran’s reports of digestive problems dating back to at least 2003. See November 2011 VA Examination, p. 2. (f) For any diagnoses identified in response to (e), is it at least as likely as not (50 percent probability or greater) that such disability was incurred in, aggravated by, or is otherwise etiologically related to the Veteran’s active duty service? The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered in arriving at an opinion. If the examiner rejects the Veteran’s reports, the examiner must provide a reason for doing so. (g) If the examiner determines that any of the symptoms associated with the Veteran’s fatigue, headaches, and/or digestive symptoms are not attributable to a diagnosed disorder of conclusive pathophysiology or etiology, the examiner should provide an opinion as to whether it is at least as likely as not that such symptoms, individually or collectively, are attributable to an undiagnosed illness, or to a medically unexplained chronic multisymptom illness defined by a cluster of signs or symptoms. In providing this opinion, the examiner must consider the Veteran’s complaints of fatigue, headaches and digestive problems dating back to at least 2003. See November 2011 VA Examination. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board W.V. Walker, Associate Counsel 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.