Citation Nr: 21068420 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 15-30 005 DATE: November 10, 2021 ORDER Service connection for a respiratory disability as an undiagnosed illness is granted. REMANDED Service connection for a left elbow disability (other than joint stiffness and arthralgias) is remanded. Service connection for a right elbow disability (other than joint stiffness and arthralgias) is remanded. Service connection for a left hand disability (other than joint stiffness or arthralgias) is remanded. Service connection for a right hand disability (other than joint stiffness or arthralgias) is remanded. Service connection for a knee disability (other than joint stiffness or arthralgias) is remanded. Service connection for a left ankle disability (other than joint stiffness or arthralgias) is remanded. Service connection for obstructive sleep apnea (OSA), to include as due to particulate matter exposure or secondary to psychiatric disability is remanded. Service connection for a low back disability, to include as secondary to right ankle disability is remanded. Service connection for hypertension, to include as due to particulate matter exposure or as secondary to psychiatric disability is remanded. Service connection for a disability manifested by symptoms such as joint stiffness and arthralgias of the hands, elbows, or knees, muscle pains, to include as an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) is remanded. A compensable initial rating for service-connected generalized fatigue (currently rated as noncompensable and combined with the PTSD rating) is remanded. Higher initial ratings for service-connected posttraumatic stress disorder with generalized fatigue (psychiatric disability), now rated 10 percent prior to May 6, 2020 and 30 percent thereafter is remanded. More than a 10 percent initial rating for service-connected right ankle degenerative joint disease (DJD) and impingement is remanded. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDING OF FACT The evidence is at least in relative equipoise as to whether the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War and has since developed restrictive lung disease that, despite repeated clinical evaluation, cannot be attributed to any known clinical diagnosis and has an unknown etiology. CONCLUSION OF LAW The criteria for presumptive service connection for a respiratory disability are met. 38 U.S.C. §§ 1110, 1113, 1117, 5107(b) (2018); 38 C.F.R. §§ 3.102, 3.303(b), 3.317 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from September 1989 to January 1990 and September 1990 to September 1994 with subsequent periods of active and inactive duty for training during Reserve service. These matters are before the Board of Veterans' Appeals (Board) on appeal from March 2012, September 2014, November 2015, and March 2017 rating decisions. The Board previously remanded these claims in September 2018. For reasons discussed further in the remand portion, the Board has recharacterized the issues on appeal involving joint complaints to consider both conditions that are specific to the elbows, hands, and knees and varied complaints of stiffness and arthralgias in those joints along with concurrent reports of fatigue and muscle pain in the record as possible signs of an undiagnosed illness or MUCMI. Although the prior remand characterized the Veteran's fatigue as part of the PTSD rating, a review of the record shows the Veteran was formally granted service connection for generalized fatigue and assigned an effective date and functionally noncompensable rating itself (by combining it with his PTSD rating). The subsequent appeal of that initial rating effectively seeks a separate compensable rating for his service-connected fatigue and the Board has recharacterized the issue accordingly. TDIU has been raised by multiple correspondences during the pendency of the multiple initial rating appeals before the Board and, therefore, is part and parcel of this appeal under Rice v. Shinseki, 22 Vet. App. 447, 455 (2009). 1. Service connection for a respiratory disability as an undiagnosed illness The Veteran contends that he has a respiratory disability related to verified service in the Southwest Asia theater of operations during the Persian Gulf War. A December 2014 private chest X-ray showed "[n]onspecific (abnormal) findings on radiological and other examination of lung field" that was curiously described as "normal given history of military Iraq duty." A May 2015 VA examination report diagnosed nonspecific restrictive lung disease that the examiner ultimately concluded was "an undiagnosed [respiratory] illness with an unknown etiology." A subsequent July 2020 VA examination again described his restrictive lung disease as an "unknown" specific type. A medical opinion at the time found no direct relationship to service but did not consider environmental exposures or address the nonspecific nature of the diagnosis or the prior findings regarding undiagnosed illness or unknown etiology. In summary, private and VA medical records confirm the presence of a nonspecific lung condition, the only negative opinion of record is inadequate and not probative, and the evidence medical opinion addressing the uncertain nature and etiology of this condition explicitly points to an undiagnosed illness with unknown etiology. Resolving reasonable doubt in the Veteran's favor, the Board finds presumptive service connection for an undiagnosed respiratory illness with unknown etiology is warranted under 38 U.S.C. § 1117. REASONS FOR REMAND At the outset, the Board notes that a review of the record shows the Veteran alleged along with his original claims that he was exposed to unspecified nerve agents from rockets during military service, but it does not appear that any development was taken to further probe that assertion, or that it was substantively part of any medical inquiries regarding the disabilities on appeal. In addition, VA medical evidence of record suggests the Veteran has been getting private treatment from a Dr. Dada at CHI Health Immanuel in Omaha, Nebraska for some time, but there are only sporadic records from that facility in the record. Therefore, additional development is needed. 1. Service connection for a left elbow disability (other than joint stiffness and arthralgias) is remanded. 2. Service connection for a right elbow disability (other than joint stiffness and arthralgias) is remanded. As noted above, no medical opinion of record has considered whether the Veteran's various left and right elbow conditions, to include both primary elbow diagnoses and bilateral ulnar neuropathy, might be related to the alleged nerve agent exposure during service. Moreover, the Veteran also previously alleged that all his claimed conditions might be related to environmental hazards (i.e., burn pits or particulate matter) during Southwest Asia service. More concretely, there is also no opinion of record considering the significance of a November 1989 service treatment record (STR) noting he fell on his elbows while playing basketball and complaints of shooting pain up the arm(s). Therefore, a remand is needed. 3. Service connection for a left hand disability (other than joint stiffness or arthralgias) is remanded. 4. Service connection for a right hand disability (other than joint stiffness or arthralgias) is remanded. It does not appear the Veteran ever had a full, formal VA hand examination. An October 2011 VA examination report covering multiple conditions indicates a normal left hand while simultaneously noting "diffuse arthralgias of the small joints of the hands." X-rays at the time also noted surgical fixation pins in the right scaphoid that might extend into the lunate as well, but did not discuss these findings further. A March 2012 VA opinion found no relationship between current hand complaints and service based on the examiner's observation that the Veteran only received treatment for left middle finger problems in service (as opposed to the entire left hand or any part of the right hand). There is no further explanation as to why that left middle finger treatment was deemed irrelevant to his current claim. Moreover, no opinion or evidence of record addresses the significance of the aforementioned November 1989 STR which does make a specific note regarding movement of the hands (though it is unclear what this specifically meant). Consequently, additional medical clarification is needed. 5. Service connection for a knee disability (other than joint stiffness or arthralgias) is remanded. No pertinent medical opinions of record adequately consider or discuss the Veteran's lay reports regarding onset of symptoms which consistently place onset in service and relate them to jumping off of tanks, an event that is documented in his STRs. Moreover, in the most recent July 2020 VA examination report, the Veteran specifically says that knee symptoms have only "progressed/worsened" since onset, which is at least suggestive of continuity. Consequently, additional clarification is needed. 6. Service connection for a left ankle disability (other than joint stiffness or arthralgias) is remanded. There is no adequate medical nexus opinion of record for the left ankle. The only relevant opinion is from a November 2012 VA examiner who improperly provided an opinion on whether an ankle disability pre-existed service and was aggravated therein. While STRs do show the Veteran reported a history of ankle injuries at enlistment, the actual enlistment examination report found no abnormalities and the physician's notes on the report of medical history explicitly state that he had no residual problems from prior injuries. Therefore, he is presumed sound upon entry to service. Consequently, medical clarification is needed. 7. Service connection for obstructive sleep apnea (OSA), to include as due to particulate matter exposure or secondary to psychiatric disability is remanded. No VA examination report of record adequately addresses all the Veteran's theories of entitlement here. In fact, the only medical opinions of record are either conclusory because they simply found (without any discernible explanation) no evidence of Southwest Asia exposures that would trigger the physical mechanisms involved with OSA or simply fail to address the full breadth of the Veteran's allegations. There is nothing of record which adequately explaining why particulate matter exposure would or would not cause OSA or otherwise considers a secondary theory of entitlement or the relevant medical literature he's submitted. Additional development is therefore needed. 8. Service connection for a low back disability, to include as secondary to right ankle disability is remanded. Despite medical evidence confirming post-service treatment for back pain, November 1989 STRs noting back and joint pain after a basketball injury, and allegations that back pain may be secondary to his right ankle disability, there has not yet been a VA examination scheduled in this claim. Corrective action is needed. 9. Service connection for hypertension, to include as due to particulate matter exposure or as secondary to psychiatric disability is remanded. There is no adequate medical opinion of record. The only pertinent opinion here is an October 2011 negative VA opinion that includes no supporting rationale and does not consider a secondary theory of entitlement or medical literature submitted in support of that theory. Additional development is needed. 10. Service connection for a disability manifested by symptoms such as diffuse joint stiffness and arthralgias of the hands, elbows, or knees, muscle pains, to include as an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) is remanded. 11. A compensable initial rating for service-connected generalized fatigue (currently rated as noncompensable and combined with the PTSD rating) is remanded. Although the Veteran's original claims specifically allege joint stiffness in multiple locations (e.g., knees, hands, arms, and elbows) and he later also filed a claim for chronic fatigue syndrome (CFS) that included allegations of nonspecific muscle pain, the Agency of Original Jurisdiction (AOJ) does not appear to have ever considered the possibility that these symptoms could be part of a single MUCMI or undiagnosed illness. Rather, they adjudicated them as separate claims for elbow, hand, or knee disability and only granted service connection for "generalized fatigue" as part of PTSD. Clarifying this medical question is crucial to an accurate adjudication of these service connection and initial rating appeals. 12. Higher initial ratings for service-connected posttraumatic stress disorder with generalized fatigue (psychiatric disability), now rated 10 percent prior to May 6, 2020 and 30 percent thereafter is remanded. VA and private treatment records suggest psychiatric diagnoses outside of PTSD (including anxiety, adjustment disorder, and unspecified depressive disorder), but no psychiatric VA examiner has adequately addressed these in the context of his initial rating appeal. The only opinion that acknowledges non-PTSD diagnoses simply concludes, without explanation, that unspecified depressive disorder is not service-connected. Moreover, records from the prior few years suggests the Veteran has been receiving specifically psychiatric treatment from a private provider, including a thrice daily medication of unknown type. Records of such treatment are likely to be relevant to this claim and may be critical to an accurate adjudication thereof. Consequently, additional development is still needed. 13. More than a 10 percent initial rating for service-connected right ankle degenerative joint disease (DJD) and impingement is remanded. The prior remand specifically directed that any examination obtained on remand include range of motion testing active and passive motion, weight-bearing, and non-weight-bearing to comply with Correia v. McDonald, 28 Vet. App. 158, 168 (2016) (holding that "the final sentence of [38 C.F.R.] § 4.59 creates a requirement that...range of motion testing be conducted whenever possible" on both active and passive motion, in weight-bearing and non-weight-bearing, and, if possible, in the opposite, undamaged joint). However, the July 2020 VA examination report obtained on remand only discusses active and passive range of motion. Moreover, a June 2021 addendum that indicates the Veteran had no additional limitation of motion with flare-ups or repeated use over time is based solely on a lack of range of motion data during such periods, and is in violation of Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) (holding that the Board can "accept an examiner's statement that he or she cannot offer an opinion without resorting to speculation, but only after determining that this is not based on the absence of procurable information or on a particular examiner's shortcomings or general aversion to offering an opinion on issues not directly observed"). It is unclear whether the June 2021 addendum providera different provider than the July 2020 VA examinerreviewed or otherwise had access to notes from the July 2020 examiner outside what was available in the formal examination report that would have allowed them to consider more detailed lay descriptions of functioning under such conditions (particularly given the lack of directly relevant clinical data), as the responses to those portions of the July 2020 examination report are not particularly detailed. Further remand is required. 14. A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. This matter is inextricably intertwined with the other being remanded and therefore cannot be adjudicated at this time. Moreover, as other matters are being remanded, it would be appropriate to send the Veteran a formal TDIU application to be completed and returned so the Board may obtain crucial information relevant to this claim. The matters are REMANDED for the following action: 1. Obtain all updated records (i.e., those not already of record) of VA and adequately identified private treatment the Veteran has received for the disabilities remaining on appeal (including, but not limited to, records from CHI Health Immanuel in Omaha, Nebraska). 2. Conduct exhaustive development to verify or corroborate the Veteran's allegations of nerve agent exposure from rocket fire during active duty, to include obtaining any and all records relevant to this inquiry and forward the file to the Joint Services Records Research Center (JSRRC). 3. Send the Veteran a formal application for TDIU to be completed and returned. 4. Schedule the Veteran for an in-person or telehealth (whichever is appropriate) examination by an orthopedist or other appropriate physician to determine the nature and cause of any right or left elbow condition. Based on a review of the record, examination of the Veteran (INCLUDING A DETAILED SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that any of the Veteran's documented elbow diagnoses (i.e., bilateral elbow strain, left elbow old trauma to the medial epicondyle, small ossicle left elbow likely from old trauma, or bilateral ulnar neuropathy) are related to his military service, TO SPECIFICALLY INCLUDE BUT NOT LIMITED TO: i. any verified nerve agent exposure; ii. presumed particulate matter exposure during Southwest Asia service; OR iii. November 1989 STRs showing he fell on his elbows and knees playing basketball and later complained of shooting pains in the arm(s). All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 5. Schedule the Veteran for an in-person or telehealth (whichever is appropriate) examination by an orthopedist or other appropriate physician to determine the nature and cause of any left and right hand disabilities. Based on a review of the record, examination of the Veteran (INCLUDING A DETAILED SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Please diagnose all FINGER AND HAND disability entities found. All diagnostic findings (or lack thereof) must be reconciled with conflicting evidence in the record (including, but not limited to, October 2011 diagnoses for diffuse arthralgias of the small joints of the hands and surgical fixation pins in the right scaphoid). If any previously documented diagnoses are no longer or otherwise not felt to apply, the examiner must explain why, citing to the pertinent diagnostic criteria. (b.) For each disability diagnosed, please opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is related to the Veteran's military service, INCLUDING BUT NOT LIMITED TO: i. November 1993 records indicating left third finger radial collateral ligament strain; ii. any verified nerve agent exposure; and iii. presumed burn pit (particulate matter) exposure. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 6. Schedule the Veteran for an in-person or telehealth (whichever is appropriate) examination by an orthopedist or other appropriate physician to determine the nature and cause of any knee disabilities found. Based on a review of the record, examination of the Veteran (INCLUDING A DETAILED SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Please diagnose all left and right knee disability entities found. All diagnostic findings (or lack thereof) must be reconciled with conflicting evidence in the record (including but not limited to left knee ligament strain, left moderate quadriceps insertional tendinosis, left interstitial tear, bilateral chondromalacia, possible degenerative changes of the right knee, small right knee ossicle or dystrophic calcification, bilateral knee strains, or bilateral patellofemoral pain syndrome). If any previously documented diagnoses are no longer or otherwise not felt to apply, the examiner must explain why, citing to the pertinent diagnostic criteria. (b.) For each disability identified, please opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is related to the Veteran's military service, TO INCLUDE BUT NOT LIMITED TO: i. November 1989 STRs indicating he fell on his knees; ii. August 1991 STRs showing bilateral knee pain after jumping off a tank eight months prior; iii. June 1992 STRs diagnosing retropatellar pain syndrome (RPPS); iv. any verified nerve agent exposure on active duty; OR v. presumed particulate matter (burn pit) exposure in Southwest Asia; The examiner MUST CONSIDER AND DISCUSS the significance of the Veteran's competent lay reports describing onset, course, and progression of left and right knee symptoms, as well as the significance of any intervening post-service injuries or events, particularly when evaluating the related post- and in-service diagnoses of patellofemoral pain syndrome and retropatellar pain syndrome. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 7. Schedule the Veteran for an in-person or telehealth (whichever is appropriate) examination by an orthopedist or other appropriate physician to determine the nature and cause of any left ankle disability and the current severity of the Veteran's right ankle disability. Based on a review of the record, examination of the Veteran (INCLUDING A DETAILED SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Please diagnose all left ankle disability entities found. All diagnostic findings (or lack thereof) must be reconciled with conflicting evidence in the record. If any previously documented diagnoses are no longer or otherwise not felt to apply, the examiner must explain why, citing to the pertinent diagnostic criteria. (b.) For each disability diagnosed, please opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is related to the Veteran's military service, TO INCLUDE BUT NOT LIMITED TO: i. a November 1989 STR noting a basketball injury that also references movement of the ankles (though it is unclear what that note means precisely); ii. any verified nerve agent exposure during active duty; OR iii. presumed burn pit (particulate matter) exposure in Southwest Asia The examiner MUST CONSIDER AND DISCUSS the significance of competent lay reports describing the onset, course, and progression of observable left ankle symptoms (e.g., pain, weakness, etc.) The examiner MUST ALSO ask the Veteran for a DETAILED ACCOUNT DESCRIBING HOW FUNCTIONING AND MOTION VARY WITH FLARE-UPS OR REPEATED USE OVER A PERIOD OF TIME, before describing all pathology, symptoms (frequency and severity), and functional impairment associated with the Veteran's right ankle disability in enough detail to allow for application of the pertinent rating criteria. Range of motion test results MUST BE REPORTED in ACTIVE MOTION, PASSIVE MOTION, WEIGHT-BEARING, and NON-WEIGHT-BEARING, including in the opposite, undamaged joint (if applicable). If it is not feasible to perform range of motion testing in any of these circumstances, the examiner MUST EXPLAIN WHY. If range of motion data is identical across any of those circumstances, the examiner MUST CLEARLY SAY SO. The examiner should also note any further functional limitations due to pain, weakness, fatigue, incoordination, or any other such factors. The examiner MUST ALSO comment on or describe, to the extent possible, the functional impact of his right ankle disability during flare-ups or with repeated use over a period of time. In doing so, the examiner MUST CONSIDER lay reports along with all other pertinent evidence. If the examiner is still unable to provide such an opinion, they MUST explain why that is so in specificity. The examiner should note that the inability to directly observe functioning under such conditions IS NOT a valid reason to avoid providing an opinion in this matter per se. Finally, the examiner should comment on the expected occupational impact of right ankle disability, to include identifying the types of activities or tasks that the disability would preclude and those that would remain feasible. All opinions must include a detailed rationale. Providing an opinion without one will delay processing of the claim and may require clarification. 8. Schedule the Veteran for an in-person or telehealth (whichever is appropriate) examination by a sleep or respiratory specialist to determine the likely cause of the Veteran's confirmed OSA. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the Veteran's OSA is related to military service, TO INCLUDE BUT NOT LIMITED TO: i. any verified nerve agent exposure; OR ii. presumed particulate matter (burn pit) exposure? The examiner MUST CONSIDER AND DISCUSS the significance of competent lay reports regarding onset, course, and progression of observable OSA symptoms (e.g., snoring, difficulty breathing at night, etc.). (b.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the Veteran's OSA is CAUSED BY OR PROXIMATELY DUE TO his service-connected psychiatric disability? (c.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the Veteran's OSA is or has ever been WORSENED BEYOND ITS NATURAL PROGRESSION TO ANY DEGREE AND FOR ANY AMOUNT OF TIME BY his service-connected psychiatric disability? In answering (b.) and (c.), the examiner MUST REVIEW, CONSIDER, AND DISCUSS the significance of the medical literature the Veteran has submitted in support of a relationship between PTSD and OSA, TO INCLUDE literature suggesting PTSD is related to OBESITY, which itself is a risk factor for OSA. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 9. Schedule the Veteran for an in-person or telehealth (whichever is appropriate) examination by an orthopedist or other appropriate physician to determine the nature and cause of any back disability. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Please diagnose all low back disability entities found. All diagnostic findings (or lack thereof) must be reconciled with conflicting evidence in the record. If any previously documented diagnoses are no longer or otherwise not felt to apply, the examiner must explain why, citing to the pertinent diagnostic criteria. (b.) For each disability diagnosed, please opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such disability is related to the Veteran's military service, TO INCLUDE BUT NOT LIMITED TO: i. any verified nerve agent exposure; ii. presumed particulate matter (burn pit) exposure; OR iii. November 1989 STRs indicating back and joint pain after a basketball injury. The examiner MUST CONSIDER AND DISCUSS the significance of any competent lay reports describing onset, progression, and course of low back symptoms. (c.) For each back disability diagnosed, please also opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such is CAUSED BY OR PROXIMATELY DUE TO his service-connected right ankle disability. (d.) For each back disability diagnosed, please also opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that such is WORSENED BEYOND ITS NATURAL PROGRESSION TO ANY DEGREE AND FOR ANY AMOUNT OF TIME BY his service-connected right ankle disability. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 10. Schedule the Veteran for an in-person or telehealth (whichever is appropriate) examination by a cardiologist or other appropriate physician to determine the likely cause of his confirmed hypertension. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his hypertension is related to military service, TO INCLUDE BUT NOT LIMITED TO: i. any verified nerve agent exposure; OR ii. presumed particulate matter (burn pit) exposure? (b.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his hypertension is CAUSED BY OR PROXIMATELY DUE TO his service-connected psychiatric disability? (c.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that his hypertension is WORSENED BEYOND ITS NATURAL PROGRESSION TO ANY DEGREE AND FOR ANY AMOUNT OF TIME BY his service-connected psychiatric disability? In answering (b.) and (c.), the examiner MUST REVIEW, CONSIDER, AND DISCUSS the significance of medical literature the Veteran has submitted in support of a relationship between PTSD and hypertension, TO INCLUDE literature suggesting a link between PTSD and OBESITY, which itself is a risk factor for hypertension. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 11. Schedule the Veteran for an in-person or telehealth examination by a psychiatrist, psychologist, licensed social worker, or other appropriate clinician to determine the current severity of his service-connected psychiatric disability. Based on an examination (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF SYMPTOMS), review of the record, and any tests or studies deemed necessary, the examiner should describe all pathology, symptoms (frequency and severity), and functional impairment associated with such disabilities in enough detail to allow for application of the pertinent rating criteria. SPECIFICALLY, the examiner should identify the degree of occupational and social impairment caused by the Veteran's psychiatric pathology The examiner MUST ALSO identify, by diagnosis, ALL CURRENT PSYCHIATRIC DISABILITY ENTITIES FOUND ON EXAMINATION OR BASED ON A REVIEW OF MEDICAL RECORDS. All diagnostic findings (or lack thereof) MUST BE RECONCILED with conflicting evidence in the record and, if any documented diagnoses are either not or no longer felt to apply, the examiner must explain why, citing to the pertinent diagnostic criteria. If the Veteran is found to have other psychiatric diagnoses IN ADDITION TO THOSE EXPLICITLY SERVICE-CONNECTED (e.g., unspecified depressive disorder, adjustment disorder, or anxiety), the examiner must indicate whether there is clear evidence allowing for differentiation of the symptoms, pathology, or impairment attributable to service-connected and nonservice-connected diagnoses, and explain why. IF SO, the examiner must clearly identify all symptoms and impairment found and attribute them to their appropriate underlying diagnoses. IF NOT, the examiner should bear in mind that indistinguishable diagnoses and symptoms MAY NOT BE EXCLUDED when evaluating the severity of the Veteran's condition. All opinions must include a detailed rationale. Providing an opinion without one will delay processing of the claim and may require clarification 12. Schedule the Veteran for an in-person or telehealth (whichever is appropriate) examination by an appropriate physician to determine the nature and cause of any disability manifested by symptoms including (but not limited to) joint stiffness and arthralgias, muscle pain, fatigue, nonspecific abdominal pain, or other unexplained symptoms. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF SYMPTOMS), and any tests or studies deemed necessary, the examiner must respond to the following: (a.) Is it at as least as likely as not that the Veteran's complaints are an undiagnosed illness (i.e., they cannot be attributed to a known clinical diagnosis by history, physical examination, or laboratory testing)? (b.) Is it AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the Veteran has symptoms or complaints consistent with chronic fatigue syndrome OR SOME OTHER MEDICALLY UNEXPLAINED CHRONIC MULTISYMPTOM ILLNESS? If the examiner finds there is an undiagnosed illness or chronic multisymptom illness at play, they should be specific as to what symptoms specifically are involved with such conditions. The examiner should keep in mind that "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Yuan, 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.