Citation Nr: 21000200 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 16-14 013 DATE: January 4, 2021 ORDER As new and material evidence has been received, the claim of entitlement to service connection for Chronic Fatigue Syndrome (CFS) is reopened; the appeal is granted to this extent only. As new and material evidence has been received, the claim of entitlement to service connection for memory loss is reopened; the appeal is granted to this extent only. Entitlement to service connection for Chronic Fatigue Syndrome (CFS), to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317, is denied. Entitlement to service connection for a cardiovascular disorder, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317, is denied. Entitlement to service connection for fibromyalgia, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317, is denied. Entitlement to service connection for a headache disorder, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317, is granted. Entitlement to service connection for a respiratory disorder, including chronic obstructive pulmonary disease (COPD), to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317, is denied. REMANDED Entitlement to service connection for memory loss, including Alzheimer’s Disease, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317, is remanded. Entitlement to service connection for neurological symptoms manifested by tingling and numbness in both legs and feet, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317, is remanded. Entitlement to an initial rating in excess of 50 percent prior to July 10, 2012, and a rating in excess of 70 percent thereafter, for posttraumatic stress disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities prior to July 17, 2015 is remanded. FINDINGS OF FACT 1. A previous rating decision denied service connection for CFS and memory loss; however, a copy of the rating decision and all evidentiary record considered as part of that decision are unavailable. 2. Affording the Veteran the benefit of the doubt, evidence added to the record provides a reasonable possibility of substantiating the claim for CFS and memory loss. 3. The Veteran served in the Southwest Asia theater of operations during the Persian Gulf War. 4. The Veteran is not shown to have CFS or other undiagnosed or multisymptom illness manifested by fatigue. 5. The Veteran is not shown to have an undiagnosed or multisymptom illness manifested by cardiovascular symptoms; rather, the most probative evidence establishes that his cardiovascular symptoms are symptoms of coronary artery disease (CAD) and tricuspid regurgitation. 6. The Veteran’s CAD and tricuspid regurgitation was not incurred in, caused by, or otherwise etiologically related to a period of active service; nor was it caused or aggravated by a service-connected disability. 7. The Veteran is not shown to have fibromyalgia or other undiagnosed or multisymptom illness manifested by muscle pain; rather, the most probative evidence establishes that his muscle and joint pain is symptoms of structural musculoskeletal changes. 8. The Veteran’s structural musculoskeletal changes were not incurred in, caused by, or otherwise etiologically related to a period of active service. 9. Affording the Veteran the benefit of the doubt, his headache disorder is etiologically related to his military service. 10. The Veteran is not shown to have an undiagnosed or multisymptom illness manifested by respiratory symptoms; rather, the most probative evidence establishes that his breathing problem is a symptom of his chronic obstructive pulmonary disease (COPD). 11. The Veteran’s COPD was not incurred in, caused by, or otherwise etiologically related to a period of active service. CONCLUSIONS OF LAW 1. New and material evidence has been received sufficient to reopen the claim of entitlement to service connection for CFS. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. 2. New and material evidence has been received sufficient to reopen the claim of entitlement to service connection for memory loss. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. 3. The criteria for entitlement to service connection for fatigue, to include on an undiagnosed illness basis, have not been met. 38 U.S.C. §§ 1110, 1117, 1118, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 4. The criteria for entitlement to service connection for a cardiovascular disorder, to include on an undiagnosed illness basis, have not been met. 38 U.S.C. §§ 1110, 1117, 1118, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317. 5. The criteria for entitlement to service connection for fibromyalgia, to include on an undiagnosed illness basis, have not been met. 38 U.S.C. §§ 1110, 1117, 1118, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 6. The criteria for service connection for headaches have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310(a). 7. The criteria for entitlement to service connection for respiratory symptoms, to include on an undiagnosed illness basis, have not been met. 38 U.S.C. §§ 1110, 1117, 1118, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty April 1952 to June 1952; from February 1954 to January 1956; and from December 1990 to May 1991, including service in Southwest Asia during the Persian Gulf War. These matters come before the Board of Veterans’ Appeals (Board) on appeal from December 2013 and February 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The appeal was before the Board in October 2017 when it was remanded for further development. Specifically, the Board indicated that the Veteran’s record was largely incomplete, missing service treatment records (STRs) and pertinent prior rating decisions. Additionally, the July 2012 VA opinions of record were inadequate for purposes of deciding the Veteran’s service connection claims and the Veteran claimed that his service-connected PTSD had worsened since his last examination. Therefore, the Board found that a remand to obtain the additional records, VA examinations, and medical opinions was necessary. The Board also remanded the issue of entitlement to a TDIU as inextricably intertwined with the issues being remanded. Following a request for STRs and military personnel records (MPRS), a July 2019 correspondence from National Personnel Records Center (NPRC) indicates that all available records were shipped to the contracted scan vendor. Shortly, thereafter, additional MPRS were added to the Veteran’s claims file; additionally, two pages suggesting that they may have been part of the Veteran’s February 1954 to January 1956 healthcare record were associated with the claims file, although these pages note only the Veteran’s duty stations between 1954 and 1956. Other uploaded records include a service department records envelope and a medical records folder, without any accompanying medical documents. Additionally, attempts were made to obtain the requested prior rating decisions; however, it was determined that these rating decisions are unavailable, and any further attempts to locate them would be futile. The requested VA examinations and opinions were obtained in December 2017, and in March 2020, the VA provided a formal finding of unavailability of his STRs, and notice was given to the Veteran to submit any records in his possession. The claims were subsequently readjudicated, and a SSOC was issued in July 2020. The Board notes that the Veteran’s claims file has been rebuilt, so the record before the Board unfortunately remains incomplete. However, the Board finds that VA has made all reasonable efforts to identify and obtain relevant records in support of the Veteran’s claims, including STRs and prior rating decisions. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the Board will base its decision on the evidence of record. See 38 C.F.R. § 3.159 (c) and (e). Additionally, the Board notes that the Veteran was afforded new VA examinations for PTSD, central nervous system disorders, heart conditions, fibromyalgia, headaches, gastrointestinal disorders, and respiratory disorders. Thus, the Board finds that there has been substantial compliance with regard to the Veteran’s claims for PTSD, memory loss, a cardiovascular disorder, fibromyalgia, headaches, a gastrointestinal disorder, and a respiratory disorder. However, none of the examinations discussed the Veteran’s claim for service connection for neurological disorder manifested by numbness and tingling in the bilateral lower extremities. Thus, the Board finds there has been substantial compliance with the Board’s October 2017 remand directives with respect to each of these issues except entitlement to service connection for a neurological disorder manifested by numbness and tingling in the bilateral lower extremities. Stegall v. West, 11 Vet. App. 268 (1998). Additionally, as will be addressed below, the Board finds that further development is still necessary with regard to the Veteran’s claim for memory loss. Additionally, and as a result of the requested development, in a July 2020 rating decision, the RO increased the Veteran’s PTSD rating from 50 percent to 70 percent, effective July 17, 2015; the rating decision also awarded service connection for irritable bowel syndrome (IBS); and granted entitlement to a TDIU, effective July 17, 2015. With regard to PTSD, the Board notes that higher ratings are available; therefore, this issue remains in appellate status. See A.B. v. Brown, 6 Vet. App. 35, 38 (1993). Regarding IBS, the RO’s grant of service connection constitutes a full award of benefits sought on appeal. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). Thus, this matter is no longer in appellate status. Id. Finally, with regard to the TDIU, given that the Veteran’s claim for a TDIU stems from his increased rating claim for his PTSD, the issue remains in appellate status. Harper v. Wilkie, 30 Vet. App. 356, 360-61 (reflecting that a partial grant of TDIU does not bifurcate an appeal for TDIU). This appeal has been advanced on the Board’s docket pursuant to 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.900(c). New and Material Evidence The Veteran seeks to reopen his claims of entitlement to service connection for CFS and memory loss. The Veteran’s paper claims file was rebuilt and subsequently scanned as an electronic file. As a result, and as noted above, the current claims file does not include pertinent documents. Specifically, most of the Veteran’s STRs, including entrance and separation examinations; a copy of the April 2008 rating decision that initially denied service connection for CFS and memory loss and any related procedural or evidentiary records; and the December 2011 claim that led to the December 2013 rating decision on appeal are missing from the record. When records in the possession of the government are lost or destroyed, such as in this case, VA has a heightened obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365 (1991). The available records include the December 2013 rating decision on appeal, which indicates only that service connection for CFS and memory loss were denied because the Veteran did not have CFS and memory loss was not incurred in or aggravated by military service. However, there is no indication in this decision as to why these claims were denied in April 2008. Nevertheless, the Board notes that new evidence was received in the form of December 2013 VA examinations, which note that the Veteran’s spouse reported that, since returning from Iraq, the Veteran has been constantly fatigued and irritable and has had short term memory loss. Additionally, military personnel records and medical treatment records, indicating ongoing treatment for fatigue and memory loss, were received. Given the loss of most of the pertinent evidence, considering this new evidence and affording the Veteran the benefit of the doubt, the Board concludes that new and material evidence has been submitted and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156; Shade v. Shinseki, 24 Vet. App. 110 (2010). Service Connection Establishing service connection generally requires (1) evidence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307, and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For Persian Gulf Veterans, service connection is warranted pursuant to 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 if a Veteran presents evidence (1) that he or she is a Persian Gulf Veteran; (2) who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either 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 during the presumptive period prescribed by the Secretary; and, (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As an initial matter, and as noted above, the rebuilt claims file does not contain complete copies of his STRs. The Board is aware that in this circumstance it has a heightened obligation to explain its findings and conclusions and carefully consider applying the benefit-of-the-doubt rule. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board must also point out, however, that the O’Hare precedent does not raise a presumption that the missing medical records, if available for consideration, necessarily would support the claim. That is to say, missing STRs do not lower the threshold for an allowance of a claim; there is no reverse presumption for granting a claim. The legal standard for proving a claim is not lowered; rather, the Board’s obligation to discuss and evaluate evidence is heightened. See Russo v. Brown, 9 Vet. App. 46 (1996). The case law does not establish a heightened “benefit of the doubt,” only a heightened duty of the Board to consider the applicability of the benefit-of-the-doubt doctrine, to assist the claimant in developing the claim, and to explain its decision when a claimant’s medical records have been lost or destroyed. See Ussery v. Brown, 8 Vet. App. 64 (1995). Thus, missing STRs, alone, while indeed unfortunate, do not obviate the need for the Veteran to still have competent and credible evidence supporting his claim for service connection by suggesting a correlation between his claimed condition and his military service. See Milostan v. Brown, 4 Vet. App. 250, 252 (1993) (citing Moore, 1 Vet. App. at 406 and O’Hare, 1 Vet. App. at 367). 1. Entitlement to service connection for CFS, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness, is denied. The Veteran contends that he has chronic fatigue syndrome due to his military service, to include his service during the Persian Gulf War. None of the available service records indicate any treatment or diagnosis for CFS or the presence of any fatigue symptoms. A September 2011 private treatment record notes that the Veteran was seen for an initial visit for fatigue symptoms. He endorsed trouble sleeping at night and fatigue all day. A diagnosis of insomnia was noted, and the record indicates that the Veteran should continue with his medications for his chronic fatigue and sleep disturbances. Subsequent medical treatment records reflect that the Veteran reported sleep disturbances, fatigue, and changes in his sleep pattern, generally reporting sleep impairment due to nightmares and flashbacks in the context of his mental health treatment. A July 2012 VA Gulf War examination notes that the Veteran reported that his fatigue began after his service in Iraq. His wife, who attended the examination, reported that he “came back a different man;” he had panic attacks and nightmares, and he was “constantly fatigued and irritable” since that time. The examiner opined that, from the conditions identified and for which Disability Benefits Questionnaires (DBQs) were completed, there was no diagnosed illnesses for which no etiology was established; nor was there additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections. However, the examiner indicated that, due to multiple comorbidities, the unavailability of Veteran’s private sector medical records (where the majority of his medical care was obtained), and the unavailability of the Veteran’s multiple diagnostics, definitive diagnoses and medical opinions could not be ascertained at this time. An associated July 2012 CFS examination indicated that the Veteran did not and had not received a diagnosis of CFS. The examination indicates that the Veteran endorsed symptoms of debilitating fatigue, generalized muscle aches or weakness, fatigue lasting 24 hours or longer after exercise, headaches, migratory joint pains, neuropsychological symptoms, and sleep disturbances, all of which had been near constant since his return from Desert Storm. The Veteran reported that his activities of daily living were unaffected by fatigue; they were more affected by depression. However, chores, such as mowing grass, were restricted to doing just a little bit at a time. Although the examiner found that the Veteran did not have CFS, no medical opinion was provided for the Veteran’s claimed fatigue symptoms. Additional medical treatment records were received after the July 2012 VA examination; consequently, the file was returned to the examiner who conducted the July 2012 VA examination for review and a medical opinion. In July 2013, the examiner indicated that, after a review of the newly obtained medical records, there is no evidence of Chronic Fatigue Syndrome. The Veteran does not meet the diagnostic criteria for Chronic Fatigue Syndrome. While he may experience chronic fatigue, this is a symptom rather than a separate diagnosis, which is most likely secondary to his multiple comorbidities, including specifically chronic pain and his mental health condition. Moreover, there was no evidence that the Veteran suffered from chronic fatigue during his active duty service. Therefore, the examiner opined that it was less likely than not that his claimed fatigue was incurred in or caused by active service. However, as noted above, the Board previously found these opinions to be inadequate for purposes of deciding the Veteran’s claim. A December 2017 VA examination notes that there is no objective medical indication that the Veteran is suffering from an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by fatigue. Specifically, the examiner indicated that the Veteran’s fatigue is a symptom of sleep disturbances due to PTSD and chronic pain; fatigue is not a separate condition. The examiner indicated that the Veteran’s fatigue is not an undiagnosed illness or medically unexplained chronic multisymptom illness. After a review of the evidence, the Board concludes that the Veteran is not shown to have an undiagnosed illness manifested by fatigue, nor are there objective signs or symptoms which may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome). Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board finds that the December 2017 VA examination, which indicates that the Veteran did not have a diagnosis of CFS, to be the most probative evidence of record. Moreover, there is no indication in the available service records and post-service treatment records that the Veteran received a diagnosis of CFS at any time during the period on appeal. Thus, the competent evidence of record does not establish that the Veteran currently has a diagnosis of CFS. There is no medical opinion to the contrary. Indeed, the post-service medical treatment records generally describe symptoms of insomnia or sleep impairment as related to his mental health disorder, and the Veteran’s spouse, a registered nurse, also suggested such a relationship, describing his fatigue in the context of his panic attacks and nightmares. Moreover, the December 2017 VA examination specifically opined that the Veteran’s fatigue was a symptom, rather than a separate diagnosis, due to PTSD and chronic pain. The Board notes that, while the Veteran is competent to report observable symptoms, such as tiredness, he is not shown to possess the medical training necessary to establish a current disability or render competent opinions about the etiology of a disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Although fatigue is a symptom readily observable to a layperson, attributing the fatigue to chronic fatigue syndrome is beyond the capabilities of a layperson. This is particularly true here, where the VA examination notes that there are specific criteria to be met before a diagnosis of chronic fatigue syndrome is appropriate, and where there are other etiologic factors present that may account for the fatigue symptoms. Even if the Veteran were competent to diagnose chronic fatigue syndrome, the Board finds that the probative value of his opinion is outweighed by that of the VA examiner, who clearly has the training, education and experience to diagnose fatigue disorders. Moreover, the Board acknowledges that the Veteran’s spouse has medical experience as a registered nurse; however, she has not provided any separate diagnosis with regard to the Veteran’s symptoms of fatigue. Therefore, to the extent that the Veteran attempts to establish the presence of a current disability, namely CFS, manifested by symptoms of fatigue, these statements are outweighed by the medical evidence of record. As noted above, under 38 C.F.R. § 3.317, service connection may be granted for signs and symptoms that are objective indications of qualifying chronic disability. Chronic fatigue syndrome is specifically listed as a manifestation of an undiagnosed or medically unexplained chronic multisymptom illness for which service connection may be granted based on Gulf War service. Thus, such symptoms are considered precipitating factors rather than a real clinical diagnosis within the meaning of VA regulations. If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98. Thus, the lack of a chronic disability precludes the consideration of an undiagnosed or medically unexplained chronic multi-symptom illness because the findings here are explained. In other words, while the Veteran has articulated subjective complaints of fatigue as evidence of an objective indication of chronic disability, the Board cannot ignore the medical evidence indicating that his mental health disorder and/or chronic pain account for this symptom. As such, the requirements for entitlement to service connection for an undiagnosed illness under 38 C.F.R. § 3.317 have not been met. Furthermore, the Board finds that service connection for fatigue on a direct basis is not warranted. In this regard, the Board finds that the December 2017 VA examination provides the most probative evidence, which noted no separate, underlying diagnosis for his fatigue symptoms. Rather, the Veteran’s subjective symptoms were associated with his service-connected PTSD, which is supported by the remaining medical evidence of record, and chronic pain. As there is no disability that can be related to active service, the Veteran’s claim for service connection for fatigue must be denied. 38 U.S.C. § 1110; Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Based on the foregoing, the Board finds that the preponderance of the competent and credible evidence is against finding that the Veteran has had CFS at any time during the period on appeal. As there is no disability that can be related to active service, the benefit-of-the-doubt rule does not apply, and the claim is denied. See 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102; 4.3; Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for a cardiovascular disorder, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317, is denied. The Veteran contends that he has a cardiovascular disorder, manifested by shortness of breath and chest pain, that is due to his active service, including his service during the Persian Gulf War. An April 1985 military personnel record notes that the Veteran reported severe chest pain when walking upstairs in his barracks on March 9, 1985. He indicated that he was examined, transported to the hospital, and underwent a series of tests, including x-rays and a stress test. All of these tests were negative. The records note that the Veteran was informed by the physician that his chest pains may have been the result of a stomach disorder. The Veteran indicated that since this time, he had returned to work and had not experienced any discomfort since. A May 1985 Report of Investigation indicates that the Veteran had chest pains of possible cardiac origin while ascending stairs in the barracks in March 1985, during a period of inactive duty for training. It was determined that this injury was not incurred in the line of duty and not due to his own misconduct. A July 1985 military personnel record notes that described the Veteran’s activities the day before and the day of his reported chest pain, and indicates that he was generally involved in his normal activities within the scope of his employment and normal social activities; the Veteran reported that he had no prior history of GI track problems. VA and private treatment records from June 2008 through October 2013 are silent for any complaints, treatment, or diagnosis for a cardiovascular disorder or related symptoms; however, VA records indicate that the Veteran received hypertension education in January 2013, and essential hypertension is noted in his active VA problem list. More recent medical treatment records reflect diagnoses of coronary artery disease (CAD) and tricuspid valvular regurgitation and additionally note a probable abnormal myocardial perfusion scan with a small reversible perfusion defect in the inferoapical wall may represent a small region of stress-induced ischemia. These records consistently note that the Veteran did not have a gallop or murmur. A July 2012 VA examination notes that the Veteran’s wife reports that he had intermittent exertional shortness of breath, which they attributed to his lungs or heart. He has had intermittent chest pain and has undergone cardiac workup, which according to his wife, has been negative in the past. She reported that the Veteran had been told this is secondary to his GERD. The examiner opined that, from the conditions identified and for which DBQs were completed, there was no diagnosed illnesses for which no etiology was established; nor was there additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections. However, the examiner indicated that, due to multiple comorbidities, the unavailability of Veteran’s private sector medical records (where the majority of his medical care was obtained), and the unavailability of the Veteran’s multiple diagnostics, definitive diagnoses and medical opinions could not be ascertained at this time. An associated July 2012 VA examination for heart conditions notes that the Veteran did not and had not been diagnosed with a heart condition. The examination notes that the Veteran had atypical chest pain of uncertain etiology “due to the lack of diagnostic records.” Physical examination was normal and the Veteran’s blood pressure reading was 136/84. An interview-based METs test revealed that the Veteran reported symptoms of dyspnea, fatigue, angina, and dizziness with METs greater than three to 5, consistent with activities such as light yard work, mowing the lawn, and brisk walking. The examiner indicated, however, that these METs results were not due solely to a heart condition; rather, the limitation in METs level was due to multiple factors, and it was not possible to accurately estimate this percentage. Following receipt of additional medical treatment records, the file was returned to the examiner who conducted the July 2012 VA examination for review and a medical opinion. In July 2013, the examiner indicated that, after a review of the newly obtained medical records, there was still no evidence that the Veteran has been treated for a heart disability, other than essential hypertension. The examiner indicated that hypertension is a disease with a clear and specific etiology and is a diagnosis which is not presumptively related to service in Southwest Asia at this time. There is no known “specific” exposure event experienced by the Veteran during service in Southwest Asia. The examiner additionally indicated that the Veteran’s January 1956 separation examination noted “grade 2 apical systolic murmur without abnormal rhythm or heart size. Stated to be present prior to service. No history of RF.” Therefore, the examiner opined that the Veteran’s heart murmur pre-existed his service. However, as previously indicated, the Board has found these opinions to be inadequate for purposes of deciding the Veteran’s claim. Moreover, the Board points out that this referenced STR is not currently available for review. A December 2017 VA examination notes that the Veteran had received diagnoses of coronary artery disease (CAD) and valvular heart disease. The Veteran denied experiencing any heart problems, including chest pain, pressure, or tightness. He did indicate, however, that he had testing and treatment for his heart. The examination notes that the Veteran was not taking any heart medications. The examiner indicated that the Veteran’s heart disability did not qualify within the generally accepted medical definition of ischemic heart disease (IHD). Prior to rendering the requested opinions, the December 2017 examiner noted that there were records reviewed in the July 2013 report that were not available for review currently, and it was additionally incredibly difficult to obtain a history from the Veteran due to his Alzheimer’s, and the history that he did provide had numerous discrepancies and inconsistencies. Notwithstanding the foregoing, the examiner referenced medical treatment records that were available for review, including an October 2011 record, which notes a past medical history of hypertension, and records noting diagnoses of CAD and tricuspid regurgitation. Based on this evidence, the examiner opined that there is no objective medical indication that the Veteran is suffering from an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by cardiovascular signs or symptoms. Rather, the Veteran had two diagnosed heart disorders: minimal CAD or mild tricuspid regurgitation; both are structural cardiac changes and are not caused by environmental exposures. The examiner further opined that neither of which was in anyway caused by military service. Rather, minimal CAD was secondary to smoking, aging, diabetes, hyperlipidemia; and mild tricuspid regurgitation was secondary to the aging process. After a review of the evidence, the Board finds that the Veteran is not shown to have an undiagnosed illness manifested by cardiovascular signs or symptoms. The December 2017 examiner opined that there is no objective medical indication that the Veteran is suffering from an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by cardiovascular signs or symptoms. Indeed, the examiner indicated that the Veteran’s cardiovascular symptoms were due to CAD and tricuspid regurgitation. These disorders are not conditions for which the Secretary has determined a presumption of service connection is warranted under 38 C.F.R. § 3.317(c). Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for cardiovascular symptoms due to an undiagnosed illness under 38 C.F.R. § 3.317. To the extent that the Veteran contends that his cardiovascular symptoms constitute an undiagnosed or medically unexplained chronic multisymptom illness, the Board finds that these statements are outweighed by the opinion of the VA examiner. Moreover, although the Board acknowledges that the Veteran’s spouse has medical training, she has not provided any medical opinion indicating that the Veteran’s cardiovascular symptoms constitute an undiagnosed or medically unexplained chronic multisymptom illness; indeed, she merely indicated that his shortness of breath was attributed to his heart or lungs and relayed that the Veteran was told that his chest pain was due to a stomach disorder. As such, the Board finds that the requirements for entitlement to service connection for an undiagnosed illness under 38 C.F.R. § 3.317 have not been met. Turning to the issue of direct service connection, the Board initially acknowledges that the record reflects that the Veteran reported chest pain in March 1985 and recognizes that none of the VA examinations of record addressed this report of chest pain in March 1985. The Board is mindful of Barr v. Nicholson, 21 Vet. App. 303 (2007), but as addressed below, the Board finds that this single occurrence of chest pain did not occur in the line of duty during his period of INACDUTRA, and neither the evidence reflects, nor has the Veteran alleged, that a preexisting heart disability was aggravated by a period of active service. Therefore, the Board finds that a remand for a medical opinion specifically addressing this March 1985 report of chest pain would have no evidentiary basis. Although the Board recognizes that the medical records associated with this March 1985 report of chest pain are not of record, the Board notes that service records note that it was determined that his injury was not sustained in the line of duty during a period of inactive duty for training (INACDUTRA). When a claim is based on a period of Reserve or National Guard service, it must be shown that the individual concerned became disabled (or died) as a result of a disease or injury incurred or aggravated in the line of duty (on Reserve ACDUTRA/INACDUTRA or during Federalized National Guard service). Otherwise, the period would not qualify as “active military, naval, or air service” and the claimant would not achieve “veteran status” for purposes of that claim. See 38 U.S.C. § 101 (2)-(24). INACDUTRA is not defined as “active” service unless the individual concerned was disabled or died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a). Here, the evidence does not reflect, nor does the Veteran contend, that his disease or injury occurred in the line of duty or that he suffered from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident during his period of INACDUTRA. Moreover, there is no evidence of record, nor does the Veteran contend, that he had a preexisting heart disability upon entrance into a subsequent period of active service that was aggravated by a period of active service. Indeed, the Board notes that, in an April 1985 record, the Veteran indicated that his cardiac tests results were negative, and he had not experienced any chest discomfort since; additionally, available post-service medical treatment records are silent for any cardiac complaints or treatment for approximately two decades after discharge from his last period of active service, and in July 2012, the Veteran’s spouse reported that the Veteran had undergone cardiac workup, which had been negative in the past. For all of these reasons, the Board finds that a remand for a medical opinion specifically addressing this March 1985 report of chest pain is not warranted. After a review of the available records, the Board finds that entitlement to service connection for CAD and tricuspid regurgitation on a direct basis is not warranted in this case. Although the records reflect that the Veteran’s spouse reported that the Veteran suffered from exertional shortness of breath and chest pain, neither the Veteran nor his spouse has reported that he suffered from a cardiovascular disability or related symptoms during active service or since his discharge from active service. As noted above, the earliest evidence of record indicating the presence of any heart disability or treatment for cardiovascular related problems, after the one instance in March 1985, is approximately 25 years later and approximately 20 years after his most recent period of active service. Thus, the Board finds the first indication of the presence of any heart disability was many years after his separation from active service. Additionally, there is no probative medical opinion of record indicating that the Veteran’s heart disorders were incurred in or otherwise related to his active service. In this regard, the December 2017 VA examination provided a negative nexus opinion for his CAD and tricuspid regurgitation, indicating that CAD was secondary to smoking, aging, diabetes, hyperlipidemia; and tricuspid regurgitation was secondary to the aging process. There is no medical opinion to the contrary and neither the Veteran nor his spouse has provided any evidence that otherwise suggests a relationship between his heart disorders and his active service. The Board notes that, while the Veteran is competent to report observable symptoms, he is not shown to possess the medical training necessary to establish a current disability or render competent opinions about the etiology of a disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). The Board acknowledges that the Veteran’s spouse has medical experience as a registered nurse; however, she has not provided any medical opinion linking the Veteran’s heart disorders to his active service. Therefore, to the extent that the Veteran attempts to establish that a heart disability is related to a period of active service, these statements are afforded no probative value. Additionally, to the extent that the Veteran contends that his heart disability is related to a stomach disorder, including his service-connected IBS, the Board finds the VA examiner’s opinion indicating that his heart disabilities were due to his nonservice-connected smoking, aging, diabetes, hyperlipidemia to be the most probative evidence of record, as the examiner thoroughly reviewed the available medical treatment records, conducted an in-person examination, and, to the extent possible, elected lay reports of the Veteran regarding his symptoms. Moreover, the July 2012 statement from the Veteran’s spouse merely relayed information that the Veteran was told that his chest pain was due to a stomach disorder; she did not render such an opinion in her capacity as a registered nurse, and there is otherwise no medical evidence of record suggesting a relationship between a heart disorder and a service connected disability. Therefore, the Board finds that entitlement to service connection for a heart disability on a secondary basis is not warranted. 38 C.F.R. § 3.310. In summary, the Board finds that the preponderance of does not establish that the Veteran has an undiagnosed or medically unexplained chronic multisymptom illness manifested by cardiovascular symptoms, and entitlement to service connection is not warranted on a direct basis for CAD and tricuspid regurgitation. Thus, as the preponderance of the competent and credible evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the Veteran’s claims of entitlement to service connection for cardiovascular symptoms on an undiagnosed illness basis and entitlement to service connection for CAD and tricuspid regurgitation on a direct and secondary basis is denied. See 38 U.S.C. § 5107. 3. Entitlement to service connection for fibromyalgia, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317, is denied. The Veteran contends that he is entitled to service connection for fibromyalgia due to his active service during the Gulf War. The available service records are silent for any complaints, treatment, or diagnosis related to fibromyalgia. Post-service medical treatment records note complaints of right shoulder pain as early as 2002, osteoarthritis of the shoulder as early as June 2011; back pain as early as June 2011, and degeneration of intervertebral disc as early as May 2012. A January 2014 VA treatment record notes that the Veteran had a history of chronic pain and was receiving spinal injections and hydrocode from a private provider. These records are silent for any diagnosis or treatment for fibromyalgia or polymyalgia. A July 2012 VA examination notes that the Veteran reported generalized, migratory joint and muscle pain over his entire body, adding that he believed that it was due to old age. He indicated, however, that these symptoms began a short time after returning from Desert Storm. The examiner opined that, from the conditions identified and for which DBQs were completed, there was no diagnosed illnesses for which no etiology was established; nor was there additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections. However, the examiner indicated that, due to multiple comorbidities, the unavailability of Veteran’s private sector medical records (where the majority of his medical care was obtained), and the unavailability of the Veteran’s multiple diagnostics, definitive diagnoses and medical opinions could not be ascertained at this time. Nevertheless, in an associated July 2012 fibromyalgia VA examination, examiner indicated that, although the Veteran was taking pain medication for muscle aches and pains, he has not received a diagnosis of fibromyalgia. Following receipt of additional medical treatment records, the file was returned to the examiner who conducted the July 2012 VA examination for review and a medical opinion. In July 2013, the examiner indicated that, after a review of the newly obtained medical records, the Veteran did not have a diagnosis of fibromyalgia; however, the Veteran has been diagnosed with Polymyalgia Rheumatica (PMR). Polymyalgia Rheumatica is a diagnosable chronic multi-symptom illness with a partially explained etiology. The examiner indicated that according to current medical literature, the cause of PMR is not known. It is thought, however, that it may be secondary to “an environmental exposure.” However, the examiner indicated that the Veteran has no documented specified exposures while in service and there is no evidence that the Veteran suffered from PMR during an active service period. However, as previously indicated, the Board has found these medical opinions inadequate for purposes of deciding the Veteran’s claim. At his December 2017 VA examination, the Veteran indicated that he did not remember if he had fibromyalgia; however, he reported that he had pain in his lower back that radiated down his legs. He reported that his back is treated with shots and pain medications. He additionally noted that he had arthritis in his shoulders. Upon examination, the examiner indicated that the trigger point examination was negative; the examiner found that the Veteran did not have fibromyalgia. After a review of the available evidence of record, the examiner indicated that there were no objective medical indications that the Veteran is suffering from an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by muscle pain or joint pain. The examiner indicated that the Veteran has well documented degenerative changes in his lumbar spine with radiculopathy and cervical spondylitis; additionally, VA medical treatment records note a past medical history of a knee surgery, but these records are not available for review. The examiner indicated that these conditions represent structural musculoskeletal changes and are conditions with a clear and specific etiology and diagnosis. Moreover, review of medical literature reveals no evidence of a link between environmental exposures and the development of orthopedic/ musculoskeletal conditions. Therefore, there is insufficient/inadequate evidence of an association between deployment to the Gulf War and musculoskeletal system diseases. After a review of the evidence, the Board concludes that the Veteran does not have a current diagnosis for fibromyalgia and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). None of the VA examiners found that the Veteran had a diagnosis of fibromyalgia, and fibromyalgia is not noted in any of the Veteran’s medical treatment records. Indeed, neither the Veteran nor his spouse has specifically claimed that the Veteran had fibromyalgia or had ever received a diagnosis of fibromyalgia. Thus, the Board finds that the evidence of record does not establish that the Veteran currently has a diagnosis of fibromyalgia. Post-service medical treatment records generally describe symptoms of muscle and joint pain as related to degenerative changes in his back and shoulder. Moreover, the December 2017 VA examination specifically opined that there were no objective medical indications that the Veteran is suffering from an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by muscle pain or joint pain. The examiner indicated that the Veteran has well documented degenerative changes in his lumbar spine with radiculopathy and cervical spondylitis and a past medical history of knee surgery. The examiner indicated that these conditions represent structural musculoskeletal changes and are conditions with a clear and specific etiology and diagnosis. The Board finds that the December 2017 VA opinion is the most probative evidence of record. Specifically, the examiner reviewed the Veteran’s available medical treatment records, conducted an in person examination with trigger point testing, elicited lay statements from the Veteran to the extent possible, and rendered a medical opinion regarding the Veteran’s symptoms of muscle and joint pain which is supported by the medical evidence of record. There is no medical evidence to the contrary. While the Veteran has articulated subjective complaints of muscle and joint pain as evidence of an objective indication of a chronic disability, the Board cannot ignore the medical evidence indicating that his structural musculoskeletal changes account for these symptom and finds this medical evidence highly probative. Thus, to the extent that the Veteran contends that his muscle and joint pains constitutes an undiagnosed or medically unexplained chronic multisymptom illness, the Board finds that these statements are outweighed by the opinion of the VA examiner. Moreover, although the Board acknowledges that the Veteran’s spouse has medical training, she has not provided any medical opinion regarding his muscle or joint pain. As such, the Board finds that the requirements for entitlement to service connection for an undiagnosed illness under 38 C.F.R. § 3.317 have not been met. Accordingly, the Board finds that the preponderance of the competent and credible evidence is against finding that the Veteran has had fibromyalgia at any time during the period on appeal. As there is no disability that can be related to active service, the Veteran’s claim for service connection for fibromyalgia must be denied. 38 U.S.C. § 1110; Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Turning to direct service connection, initially, although the Board points out that it had previously found the July 2013 VA opinion inadequate, the Board nonetheless has considered the July 2013 VA examiner’s diagnosis of polymyalgia; however, the Board finds that the July 2013 VA examiner’s findings are not probative evidence of a current diagnosis of polymyalgia. Specifically, the examiner was asked to review the Veteran’s records and provide a diagnosis and opinion with regard to the Veteran’s reported muscle and joint complaints, without the Veteran returning for another examination. The examiner noted a review of the Veteran’s records, and notably, none of the documented medical records reviewed indicated a diagnosis of polymyalgia. Indeed, the only documented record even mentioning polymyalgia or “PMR” is an April 2011 medical record which notes “Diagnosis: 1. High clinical suspicion for inflammatory arthritis (??PMR)”. The April 2011 record does not include a confirmed diagnosis of polymyalgia, and a review of the Veteran’s medical treatment records reveals no confirmed clinical diagnosis of polymyalgia or further mention of polymyalgia or PMR. Thus, given that the examiner did not provide a diagnosis of polymyalgia in the previous 2012 in-person examination, the 2013 opinion was not based on an in-person examination with appropriate testing, the examiner did not provide an explanation for the diagnosis, and the lack of documentation of a polymyalgia diagnosis in the Veteran’s available medical treatment records, the Board finds that the VA examiner’s diagnosis of polymyalgia is afforded no probative weight and outweighed by the remaining medical evidence of record. Thus, the Board finds that, to the extent that the December 2017 VA examination did not address the July 2013 examiner’s diagnosis of polymyalgia, the Board finds that remand addressing this particular diagnosis is not necessary. The Board finds that entitlement to service connection for structural musculoskeletal changes, including back and shoulder pain, on a direct basis is not warranted in this case. The earliest medical evidence of record indicating treatment for any structural musculoskeletal changes is many years after separation from active service. The Board notes that, although not a dispositive factor, the passage of time between the Veteran’s discharge and an initial diagnosis for the claimed disorder is one factor that weighs against the Veteran’s claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board has considered the statements noting the onset and continuity of his muscle and joint pain symptoms. Specifically, although the Veteran indicated that he developed muscle and joint pain “a short time” after returning home from the Gulf War, none of the statements suggest the symptoms or a diagnosis was present within one year of his active service. Therefore, to the extent that these statements purport to establish the onset or continuity of the Veteran’s symptoms, the Board affords these statements no probative weight. Additionally, there is no probative medical opinion of record indicating that the Veteran’s structural musculoskeletal changes or related symptoms were incurred in or otherwise related to his active service. In this regard, the December 2017 VA examination provided a negative nexus opinion for his structural musculoskeletal changes, indicating that there was no evidence of a link between environmental exposures and the development of orthopedic/musculoskeletal conditions. There is no medical opinion to the contrary and the Veteran has not submitted any evidence, lay or medical, suggesting a relationship between his structural musculoskeletal changes and a period of active service. The Board notes that, while the Veteran is competent to report observable symptoms, such as muscle and joint pain, he is not shown to possess the medical training necessary to establish a current disability or render competent opinions about the etiology of a disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). The Board acknowledges that the Veteran’s spouse has medical experience as a registered nurse; however, she has not provided any medical opinion with regard to the Veteran’s symptoms of structural musculoskeletal changes, including muscle and joint pain. Therefore, to the extent that the Veteran attempts to establish that structural musculoskeletal changes are related to a period of active service, these statements are afforded no probative value. In summary, the Board finds that the preponderance of does not establish that the Veteran has an undiagnosed or medically unexplained chronic multisymptom illness manifested by muscle and joint pain, and entitlement to service connection is not warranted on a direct basis for structural musculoskeletal changes. Thus, as the preponderance of the competent and credible evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the Veteran’s claim of entitlement to service connection for muscle and joint pain on an undiagnosed illness basis and structural musculoskeletal changes on a direct service connection basis is denied. See 38 U.S.C. § 5107. 4. Entitlement to service connection for persistent headaches, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317, is granted. The Veteran contends that he is entitled to service connection for headaches as related to his active service, to include his service in the Gulf War. Service records do not contain any complaints, treatment, or diagnosis related to headaches. Similarly, post-service medical treatment records are silent for any complaints, treatment, or diagnosis for headaches until a February 2020 medical treatment record, indicating that the Veteran had head, neck, and back pain; his active problem list indicated that he had cervicalgia and headache syndrome. A July 2012 VA examination notes that the Veteran reported that he developed headaches as soon as he returned home from Iraq, and he has had the headaches since. He reported that “stress really brings them out.” The examiner opined that, from the conditions identified and for which DBQs were completed, there was no diagnosed illnesses for which no etiology was established; nor was there additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections. However, the examiner indicated that, due to multiple comorbidities, the unavailability of Veteran’s private sector medical records (where the majority of his medical care was obtained), and the unavailability of the Veteran’s multiple diagnostics, definitive diagnoses and medical opinions could not be ascertained at this time. An associated July 2012 VA headache examination notes that the Veteran has not and had not received a diagnosis for a headache disorder. The Veteran reported that he took over the counter pain medication for treatment of headaches. He described his symptoms as pulsating or throbbing head pain located on both sides of the head, which worsened with physical activity, stress, or getting “overheated”. The headaches lasted less than one day and were not prostrating. The examination notes that the Veteran had a head CT following a motor vehicle accident; however, the records were unavailable for review. The Veteran reported that he did not let his headaches get him down, although he did report decreased concentration with his headaches. Additional medical treatment records were received after the July 2012 VA examination; consequently, the file was returned to the examiner who conducted the July 2012 VA examination for review and a medical opinion. In July 2013, the examiner indicated that, after a review of the newly obtained medical records, there was no evidence indicating that the Veteran was treated for chronic headaches or has a diagnosed condition related to headaches. The examiner additionally noted that there was no evidence that the Veteran suffered from headaches during an active duty period. Therefore, the examiner opined that it was less likely than not that the Veteran’s claimed headaches were incurred in or caused by active service. However, the Board reiterates that it previously found that these opinions are inadequate for purposes of deciding the Veteran’s claim. A December 2017 VA examination notes that the Veteran did not have a headache disorder. The Veteran reported that he began getting headaches “about a couple months ago.” He reported that he had no problems with headaches prior to a couple months ago. The examiner asked about the onset of headaches several times, specifically pointing out that his service connection claim had been pending for a few years, and the Veteran continued to respond that headaches were present for “a couple of months.” The Veteran later indicated “when I was over in Desert Storm, I got sun poisoning and I think that is what caused the headaches. I never had no trouble with headaches before I went over there.” The examination notes that the Veteran’s Alzheimer’s was most likely playing a role in obtaining the history. The examiner indicated that a considerable amount of time was spent trying to elicit a history of the Veteran’s headaches, and the examiner completed the examinations “to the best of my ability with the history I was able to obtain” from the Veteran. The Veteran attended the examination alone, as his wife was unable to attend. The examiner indicated that the Veteran was unable to provide sufficient history for the examiner to determine if there is a diagnosable headache disorder. On review of the available records, it is noted that the veteran has denied having problems with headaches on numerous occasions. After carefully reviewing and weighing the competent evidence of record, the Board is satisfied that the evidence is at least in approximate balance as to whether the Veteran’s headache disorder is related to active service. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Although the Board acknowledges that none of the VA examinations of record provided a diagnosis of a headache disorder, a February 2020 private medical record indicates a such a diagnosis. Moreover, given the nature of headaches, the Veteran is uniquely situated to competently identify and report on its onset and duration. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Here, despite his consistent reports of headache symptoms in his most recent VA examination, the Board finds his assertion that the headaches began “as soon as” he returned from Iraq, noted during his earlier July 2012 examination, is both competent and credible, and thus is positive evidence that supports a finding of nexus in this case. This supporting evidence places the pertinent record in relative equipoise. As the Board finds that the grant of service connection is warranted for the Veteran’s headache disorder on a direct basis, further analysis addressing whether the Veteran’s headache disorder constitutes undiagnosed illness or medically unexplained chronic multi symptom illness is not necessary. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). For these reasons, the Board resolves reasonable doubt in favor of the Veteran and grants service connection for a headache disorder. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 5. Entitlement to service connection for a respiratory disorder, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317, is denied. The Veteran contends that his respiratory symptoms, to include COPD, coughing, bronchitis, and asthma, are due to his military service, to include his service during the Persian Gulf War. Available service records are silent for any respiratory disorders or symptoms. A September 2011 private treatment record notes that the Veteran was seen for an initial visit for shortness of breath. He indicated that he currently smoked one pack of tobacco per day. A diagnosis of COPD was noted. A March 2012 private treatment record notes that the Veteran denied any respiratory symptoms; he reported that he continued to smoke. The record indicates that the Veteran was treated for COPD and chronic bronchitis. A July 2012 VA examination notes that the Veteran and his wife denied any history of asthma or bronchitis. The Veteran reported that he “might have a little COPD” but nothing that required regular treatment; he did not require any breathing medication. The Veteran reported some exertional shortness of breath at times. The examination notes that the Veteran has been a smoker for more than 50 years, starting during service. The Veteran reported that he had a PFT within the last six months, but these records were not available for review. The examiner opined that, from the conditions identified and for which DBQs were completed, there was no diagnosed illnesses for which no etiology was established; nor was there additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections. However, the examiner indicated that, due to multiple comorbidities, the unavailability of Veteran’s private sector medical records (where the majority of his medical care was obtained), and the unavailability of the Veteran’s multiple diagnostics, definitive diagnoses and medical opinions could not be ascertained at this time. An associated VA respiratory examination notes that the Veteran had not received a diagnosis of a respiratory disorder. Following receipt of additional medical treatment records, the file was returned to the examiner who conducted the July 2012 VA examination for review and a medical opinion. In July 2013, the examiner indicated that, after a review of the newly obtained medical records, the Veteran was treated for COPD. COPD is a disease with a clear and specific etiology, and diagnosis for which is not presumptively related to service in Southwest Asia at this time. There is no known “specific” exposure event experienced by the Veteran during service in Southwest Asia, and there was no evidence that the Veteran suffered from a respiratory condition or COPD during an active duty period. The examiner noted that the Veteran has a 50+ year smoking history which is the cause of his COPD. Therefore, the examiner opined that it was less likely than not that the Veteran’s COPD was incurred in or caused by active service. As noted above, the Board has found that this opinion is inadequate for purposes of deciding the Veteran’s claim on appeal. A December 2017 VA examination notes a diagnosis of COPD. The Veteran reported that he had problems breathing for “quite a while.” The Veteran reported that he had been smoking for 60 years; he used to smoke one pack per day, but he currently smoked less. The Veteran additionally indicated that he had been treated for bronchitis. The examiner indicated that, after a review of the medical records, including those noting treatment for bronchitis, the Veteran did not have multiple respiratory conditions. The examiner indicated that there are no objective medical indications that the Veteran is suffering from an undiagnosed illness or medically unexplained chronic multisymptom illness manifested by respiratory symptoms. The Veteran has no respiratory complaints at the time of the examination. However, he does have COPD, which is not an undiagnosed illness or medically unexplained chronic multisymptom illness; COPD is a disease with a clear and specific etiology and diagnosis. The examination also notes that the Veteran had shortness of breath with minimal to moderate exertion, which is due to a combination of COPD and deconditioning/aging. After a review of the Veteran’s available records, an in-person examination, and medical literature, the examiner opined that the Veteran’s COPD was secondary to his longstanding smoking history. The examiner indicated that the earliest available evidence of COPD was dated in April 2009; there was no evidence that COPD had its onset during service or that service caused his COPD. The examiner cited medical literature that indicated, in pertinent part, that the most significant risk factor for COPD is long-term cigarette smoking; the more years one smokes and the more packs one smokes, the greater the risk. Based on the foregoing, the examiner indicated that it was less likely than not that the Veteran’s COPD was incurred in or caused by the claimed in-service injury, event or illness. Initially, the Veteran is not shown to have an undiagnosed illness manifested by respiratory symptoms, nor did VA examiners find objective signs or symptoms which may be manifestations of an undiagnosed illness or medically unexplained chronic multisymptom illness. Rather, the Veteran’s respiratory symptoms have been specifically attributed to a known diagnosis, namely COPD, which is not a condition for which the Secretary has determined a presumption of service connection is warranted under 38 C.F.R. § 3.317(c), service connection for that condition as a result of an undiagnosed illness is not warranted. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for respiratory symptoms, to include COPD, due to an undiagnosed illness under 38 C.F.R. § 3.317. Turning to direct service connection, the Board initially notes that the evidence does not reflect, nor does the Veteran contend, that he has asthma or has had asthma at any time during the period on appeal. Additionally, the Board acknowledges that the Veteran has received treatment for chronic bronchitis; however, the Board finds that the weight of the competent and credible evidence does not support a finding that the Veteran has a current bronchitis disability. In this regard, the Board finds the December 2017 VA examination to be the most probative evidence of record. The examiner reviewed the available medical treatment records, including the Veteran’s reports of treatment for bronchitis and the medical record noting such treatment, and found that the only current respiratory disorder was COPD. Therefore, to the extent that the Veteran was treated for bronchitis and chronic bronchitis is noted in the Veteran’s medical treatment records, the Board finds this evidence is outweighed by the VA examiner’s determination that the Veteran only had COPD. As the evidence of record does not demonstrate that the Veteran does in fact have the claimed disabilities of asthma or bronchitis, the first element of service connection has not been met, and no further analysis is necessary with regard to these issues. 38 U.S.C. § 1110; Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223 (1992). As noted above, however, the Veteran has received a diagnosis of COPD. After a review of the evidence, the Board finds that entitlement to service connection for COPD on a direct basis is not warranted in this case. The Veteran does not claim, nor does the record reflect, that he had any symptoms related to COPD during, or on an ongoing basis since, service. The earliest medical evidence of record indicating treatment for COPD is many years after separation from service. The Board notes that, although not a dispositive factor, the passage of time between the Veteran’s discharge and an initial diagnosis for the claimed disorder is one factor that weighs against the Veteran’s claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Additionally, there is also no probative medical opinion of record indicating that the Veteran’s COPD was incurred in or otherwise related to his active service. The VA examinations of record indicate that the Veteran’s COPD more likely than not related to his longstanding smoking history. The Board affords these opinions great probative weight because the examiners reviewed the available medical records; conducted in-person interviews, eliciting lay responses from the Veteran and his spouse regarding his symptoms; and considered this evidence along with an evaluation of the disabilities in rendering the opinions. Additionally, the supporting rationale for these opinions is supported by the medical treatment records. There is no medical opinion to the contrary, to include from the Veteran’s spouse in her capacity as a registered nurse. The Board has additionally considered the statements noting the onset his respiratory symptoms. Specifically, although the Veteran indicated that he had breathing problems for “quite a while”, none of the statements suggest the symptoms or a diagnosis were present within one year of his active service. Therefore, to the extent that these statements purport to establish the onset or continuity of the Veteran’s symptoms, the Board affords these statements no probative weight. Further, the Board finds that the probative value of the VA examiner’s opinion outweighs that of the Veteran, given the absence of any actual indication of respiratory problems until many years after service, and as the examiner has more education, experience and training in determining the etiology of respiratory disorders. Thus, the Board finds that service connection is not warranted for an undiagnosed or medically unexplained chronic multisymptom illness manifested by respiratory symptoms or for COPD. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the Veteran’s claim is denied. See 38 U.S.C. § 5107. REASONS FOR REMAND 6. Entitlement to service connection for memory loss, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness, is remanded. The Veteran contends that he has memory loss due to his military service, to include his service during the Persian Gulf War. The available service records are silent for any complaints, treatment, or diagnosis related to memory loss. Available post-service medical treatment records reflect ongoing treatment for memory loss, dementia, and Alzheimer’s Disease. A July 2012 VA examination notes that the Veteran’s wife reported that his memory loss began upon his return from Iraq. She indicated that it had progressively worsened since that time; he started Aricept approximately 10 years ago, but it had not helped. He had difficulty concentrating and focusing, starting a task, then getting sidetracked and forgetting what he had started. The examiner opined that, from the conditions identified and for which DBQs were completed, there was no diagnosed illnesses for which no etiology was established; nor was there additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections. However, the examiner indicated that, due to multiple comorbidities, the unavailability of Veteran’s private sector medical records (where the majority of his medical care was obtained), and the unavailability of the Veteran’s multiple diagnostics, definitive diagnoses and medical opinions could not be ascertained at this time. Following receipt of additional medical treatment records, the file was returned to the examiner who conducted the July 2012 VA examination for review and a medical opinion. In July 2013, the examiner indicated that, after a review of the newly obtained medical records, the Veteran had received a diagnosis of Alzheimer’s dementia. Alzheimer’s Disease is a disease with a clear and specific etiology and diagnosis which is not presumptively related to service in Southwest Asia at this time. There is no known “specific” exposure event experienced by the Veteran during service in Southwest Asia. Additionally, there was no evidence that the Veteran suffered from memory loss during a period of active service. Therefore, the examiner opined that it was less likely than not that the Veteran’s claimed memory loss was incurred in or caused by the claimed in-service injury, event, or illness. However, as previously indicated, the Board previously found these opinions to be inadequate for purposes of deciding the Veteran’s claim. A December 2017 VA examination for the central nervous system indicates that the Veteran reported problems with his memory, and he indicated that he received a diagnosis of Alzheimer’s prior to serving in Desert Storm. The Veteran indicated that he primarily had problems with his short-term memory, indicating that his past haunts him and he has nightmares. The examiner found that the Veteran did not have a central nervous system disorder; nor did the Veteran have any neurological signs or symptoms. However, the examiner indicated that the Veteran does have Alzheimer’s, which is not an undiagnosed illness or medically unexplained chronic multisymptom illness. The examiner indicated that although the non-VA records are incomplete, the earliest evidence of Alzheimer’s is in June 2010, and he was already taking medication for it at that time, so it was clearly diagnosed prior to June 2010. However, the examiner noted that, given the lack of records, any attempt to provide further information regarding when the condition developed or was diagnosed would require resorting to mere speculation. Unfortunately, after a review of the evidence, the Board finds that another remand is necessary regarding the Veteran’s service connection claim for memory loss. Specifically, although the examiner has indicated that the Veteran’s memory loss was due to Alzheimer’s Disease, the examiner failed to provide a direct service connection for Alzheimer’s Disease, merely indicating that a determination as to the onset of the Veteran’s Alzheimer’s Disease would amount to resorting to mere speculation due to the missing medical records. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Moreover, the examiner seemingly failed to address the competent and credible reports of the Veteran’s spouse during the July 2012 VA examination that the Veteran’s memory loss began upon his return from Iraq. Additionally, a December 2017 VA mental health examination notes diagnoses of PTSD and major neurocognitive disorder, unspecified. The examiner indicated that it was possible to differentiate the symptoms between each, although studies have shown that there is an association between PTSD and neurocognitive disorders (dementia), such that individuals with PTSD appear twice as likely to develop dementia than those in the general population. Clinically, it has also been suggested that individuals with PTSD who develop dementia may have an increase in PTSD symptoms as their cognitive functioning declines. Thus, in light of the December 2017 VA mental health examiner’s suggestion that the Veteran’s dementia may be secondary to his service-connected PTSD, the Board finds that, upon remand, a medical opinion should be obtained addressing this alternative theory of entitlement. In light of the deficiencies of the December 2017 central nervous system VA examination and the December 2017 mental health examination’s indication that neurocognitive disorders, such as dementia, may be caused by PTSD, the Board finds that an addendum opinion addressing the nature and etiology of the Veteran’s memory loss is necessary before a decision can be made on this issue. 7. Entitlement to service connection for neurological symptoms manifested by tingling and numbness in both legs and feet, to include as due to an undiagnosed illness or medically unexplained chronic multisymptom illness under 38 C.F.R. § 3.317, is remanded. The Veteran contends that service connection for neurological symptoms, described as tingling and numbness in the bilateral lower extremities, is warranted as due to his active service, to include service during the Gulf War. Pursuant to the Board’s October 2017 remand, a medical examination was requested to determine the current nature and etiology of any neurological disorder manifested by numbness and tingling in the bilateral legs and feet. However, an examination addressing these claimed symptoms has not been obtained. Although a December 2017 VA examination for fibromyalgia notes that the Veteran was treated for his lumbar spine with radiculopathy and cervical spondylitis, no medical opinion was provided with regard to the etiology of the Veteran’s claimed neurological disorder manifested by numbness and tingling. Therefore, the Board finds that remand for an examination and opinion regarding the nature and etiology of his claimed neurological symptoms, including numbness and tingling in the bilateral lower extremities, is necessary. Stegall v. West, 11 Vet. App. 268 (1998). 8. Entitlement to an initial rating in excess of 50 percent prior to July 10, 2012, and a rating in excess of 70 percent thereafter, for posttraumatic stress disorder is remanded. The Board finds that the Veteran’s claim for an increased evaluation for PTSD is inextricably intertwined with the issue of entitlement to service connection for memory loss, which is being remanded for further development. An allowance of this claim could change the outcome of the rating assigned for the Veteran’s psychiatric disorder. As such, the Veteran’s claim of entitlement to an increased evaluation for PTSD is inextricably intertwined such that it should not be reviewed while the pending claim remains unresolved. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 9. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities prior to July 17, 2015 is remanded. The Veteran contends that he is unable to work as a result of his service-connected disabilities. As there are unresolved issues that bear on entitlement to TDIU, the Board finds that the Veteran’s claim of entitlement to TDIU is inextricably intertwined with the issues being remanded. Therefore, the Board finds that remanding the claim for TDIU for contemporaneous consideration is also warranted. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate examiner to ascertain the current nature and etiology of the Veteran’s memory loss. A complete rationale for any opinions must be provided. The examiner should review the claims file and note that review in the report. (a.) Whether it is at least as likely as not that the Veteran’s memory loss, to include Alzheimer’s Disease/dementia, was incurred during a period of active service, to include as a result of his exposure to environmental hazards while serving in Southwest Asia during the Persian Gulf War. (b.) The examiner should additionally opine as to whether Alzheimer’s Disease/dementia is at least as likely as not (1) proximately due to a service-connected disability, to include PTSD, or (2) aggravated beyond its natural progression by a service-connected disability, to include PTSD. In rendering these opinions, the examiner is asked to consider the statement by the Veteran’s spouse, who has medical experience as a registered nurse, that the Veteran’s memory loss began upon his return from Iraq. 2. Obtain an addendum opinion from an appropriate examiner to ascertain the current nature and etiology of the Veteran’s claimed neurological symptoms manifested by tingling and numbness in both legs and feet. A complete rationale for any opinions must be provided. The examiner should review the claims file and note that review in the report. (a.) The examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s claimed neurological symptoms manifested by tingling and numbness in both legs and feet is due to a (1) a diagnosable chronic multisymptom illness with a partially explained etiology, or (2) a disease with a clear and specific diagnosis. If it is the latter, the examiner must provide the diagnosis of the disability(ies). (b.) If the Veteran’s disability pattern is either a diagnosable chronic multisymptom illness with a partially explained etiology or a disease with a clear and specific etiology and diagnosis, then the examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s current disability was incurred during a period of active service, to include as a result of his exposure to environmental hazards while serving in Southwest Asia during the Persian Gulf War. (c.) If the examiner determines that the Veteran’s disability pattern is neither a diagnosable chronic multisymptom illness with a partially explained etiology nor a disease with a clear and specific etiology and diagnosis, then the examiner should opine whether the Veteran’s claimed disability is due to objective indications of a qualifying chronic disability to include (1) an undiagnosed illness, or (2) medically unexplained chronic multisystem illness. If no disability, undiagnosed illness, or medically unexplained chronic multisymptom is identified, an explanation should be provided. A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. Thereafter, the AOJ should readjudicate the issues related to memory loss, a neurological disorder, and PTSD; implement the award of service connection for a headache disorder and assign a disability rating for the disability; and then readjudicate the claim for entitlement to a TDIU. Kelli A. Kordich Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Hite, 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.