Citation Nr: 21070971 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 19-04 341 DATE: November 29, 2021 REMANDED Entitlement to service connection for bronchitis is remanded. Entitlement to service connection for a musculoskeletal disorder, to include fibromyalgia, is remanded. Entitlement to service connection for a dermatological disorder of the head, to include sores on top of head, is remanded. Entitlement to service connection for an acquired psychiatric disorder other than PTSD, to include somatic symptom disorder, is remanded. Entitlement to service connection for chronic fatigue syndrome (CFS), also claimed as memory loss, is remanded. REASONS FOR REMAND The Veteran had active military service from July 1990 to May 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2018 rating decision. In July 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. 1. Entitlement to service connection for bronchitis. In April 2018, the Veteran filed a service-connection claim for "bronchitis Gulf War illness." A rating decision of October 2018 denied service connection for bronchitis as due to an undiagnosed illness. The Veteran filed a NOD in November 2018 and VA Form 9 in February 2019. By a rating decision of October 2018, the Veteran is service-connected for sinusitis (with a 50-percent evaluation from April 26, 2018) and for vasomotor rhinitis (with a noncompensable evaluation form April 26, 2018). The Veteran testified before the Board that he first experienced bronchitis symptoms during service and has had recurrent symptoms since that time. He asserts that the symptoms initially occurred once every two or three years and now occur almost yearly. He also suggested that his bronchitis may be caused or aggravated by his service-connected sinusitis. As a layperson, he is not competent to link bronchitis to his other service- connected disabilities. See Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010). The Veteran argued in his hearing testimony that he is entitled to presumed service connection based on his Persian Gulf War service. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A Persian Gulf War veteran is one who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e). The Veteran's DD Form 214 indicates that his decorations and medals include the Southwest Asia Service Medal with three Bronze Stars and the Kuwait Liberation Medal. His military occupational specialty was light wheel mechanic. VA treatment records of December 2010 and March 2017 note an impression of bronchitis. In September 2018, the Veteran underwent a VA examination for respiratory conditions. He was noted to be claiming a disability pattern related to bronchitis under the Gulf War guidelines. Chest x-rays showed mild hyperinflation and blunted posterior costophrenic angle which can represent scarring as well as small pleural effusion. According to the examiner, the Veteran's one episode of acute bronchitis about every other year since 1992 did not represent a chronic respiratory condition and or an unusual frequency of acute bronchitis in the general population. It was noted that the diagnosis had a clear and specific etiology unrelated to any Gulf War exposures. That etiology, however, was not identified. The examiner concluded that, because the Veteran's pulmonary function test (PFT) was normal, the hyperinflation shown by x-rays does not represent a significant respiratory condition and indicated that the Veteran does not have chronic obstructive pulmonary disease (COPD) or asthma. The examiner attributed the scarring seen on the chest x-rays to a previous episode of bronchitis or pneumonia at some time in the Veteran's life. In September 2018, the Veteran underwent a Gulf War general medical examination (including burn pits). The Medical History section of the report noted sinusitis/rhinitis and other conditions of the nose, throat, larynx, and pharynx, and respiratory conditions other than tuberculosis and sleep apnea. It was determined, without explanation, that, from the conditions identified and for which questionnaires were completed, there are no diagnosed illnesses for which no etiology was established. No disability benefit questionnaires were identified in the report. The September 2018 VA examiner for respiratory conditions determined that the Veteran has had recurrent bronchitis about every other year since 1992. The Veteran was in active duty service in 1992. It cannot be determined upon the current record that the Veteran at least as likely as not has a current bronchitis disorder. Service connection requires a current disorder. See Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). In September 2018, the VA examiner for respiratory conditions determined that the Veteran did not have current bronchitis. That finding was based, in part, on the Veteran's report of having had one episode of acute bronchitis about every other year since 1992. The Veteran subsequently testified before the Board that he has had almost yearly bronchitis. A VA examination and nexus opinion must be adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). An adequate nexus opinion must take into account a veteran's competent report as to the onset and history of the claimed disorder. See Miller v. Wilkie, 32 Vet. App. 249, 257 (2020). In this case, the VA examiner for respiratory conditions was not able to consider the Veteran's most recent report before the Board as to the frequency of his alleged bronchitis symptoms. Accordingly, the Board will remand for a new VA examination and nexus opinion that takes into account the full medical record as the onset and history of the claimed disorder, including the Veteran's competent reporting as to his experienced symptoms during and following service. 38 C.F.R. § 19.9(a). 2. Entitlement to service connection for a musculoskeletal disorder, to include fibromyalgia. In April 2018, the Veteran filed a service-connection claim for "major muscle and joint pain Gulf War illness." The scope of the claim includes any disability that may reasonably be encompassed by the description of the claim, reported symptoms, and other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). A rating decision of October 2018 denied service connection for fibromyalgia, claimed as muscle and joint pain as due to an undiagnosed illness. The Veteran filed a NOD in November 2018 and VA Form 9 in February 2019. The Veteran argued in his hearing testimony that he is entitled to presumed service connection based on his Persian Gulf War service. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A Persian Gulf War veteran is one who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e). The Veteran's DD Form 214 indicates that his decorations and medals include the Southwest Asia Service Medal with three Bronze Stars and the Kuwait Liberation Medal. His military occupational specialty was light wheel mechanic. In September 2018, the Veteran underwent a VA examination for fibromyalgia. No response was given in the sections of the report dedicated to "Medical History" and "Findings, Signs, and Symptoms." The examiner found that the Veteran has had diffuse muscle and joint pains for about the past three years, that he has never been diagnosed with fibromyalgia, that he has been doing construction work for the past three years, and that he had earlier done factory work for 22 years. The examiner determined that the diffuse muscle and joint pains have a clear and specific etiology and diagnosis and are less likely than not due to any exposures in the Gulf War. In the examiner's opinion, the diffuse muscle and joint aches and pains are more likely than not due to the Veteran's 25 years of physical labor at work. The Veteran testified before the Board that he had muscle symptoms during active duty service and that it has worsened over the years since service. He also reported having experienced fatigue during service. He has stated that his post- service employment history involves "no real physical labor" or "minimal" physical labor. An August 2021 statement of the Veteran's mother attests to her personal knowledge that the Veteran first complained of muscle pain when he was home on leave from the Persian Gulf and that his pain appeared to have worsened since that time. She reported that the Veteran currently appears to have severe joint and muscle pain. A VA examination and nexus opinion must be adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). An adequate nexus opinion must take into account a veteran's competent report as to the onset and history of the claimed disorder. See Miller v. Wilkie, 32 Vet. App. 249, 257 (2020). In this case, the VA examiner concluded that the Veteran's current disorder is most likely due to post-service employment, but no consideration was given to record evidence, including the Veteran's hearing testimony taken after the examination, that he experienced in- service symptoms of muscle pain with recurrent symptoms to the present and that his post-service employment has not involved demanding physical labor. Accordingly, the Board will remand for a new VA examination and nexus opinion. 38 C.F.R. § 19.9(a). 3. Entitlement to service connection for a dermatological disorder of the head, to include sores on top of head. In April 2018, the Veteran filed a service-connection claim for "sores on top of the head Gulf War illness." The scope of the claim includes any disability that may reasonably be encompassed by the description of the claim, reported symptoms, and other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). A rating decision of October 2018 denied service connection for sores on top of head, as due to an undiagnosed illness. The Veteran filed a NOD in November 2018 and VA Form 9 in February 2019. In September 2018, the Veteran underwent a VA examination for skin diseases. No skin condition was diagnosed. The Veteran reported that he has noticed brown scabs coming off of his scalp for the past 1-2 years when he washes his hair about 3 times per week. Upon examination, there were no scalp sores or lesions and no other pertinent findings, signs, or symptoms. The examiner remarked that, because the Veteran has no diagnosed skin condition and showed no skin lesions upon examination, it could not be determined if he has a skin condition involving sores on the scalp and, if so, whether they represent an undiagnosed illness, a diagnosable chronic multi-symptom illness with a partially explained etiology, a disease with a clear and specific etiology and diagnosis, or a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology. The Veteran alleged in his NOD of November 2018 that his scalp disorder is due to being exposed to environmental elements in the Middle East, to include oil well fires, without proper protection. He argued in his hearing testimony that he is entitled to presumed service connection based on his Persian Gulf War service. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A Persian Gulf War veteran is one who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e). The Veteran's DD Form 214 indicates that his decorations and medals include the Southwest Asia Service Medal with three Bronze Stars and the Kuwait Liberation Medal. His military occupational specialty was light wheel mechanic On the VA Form 9 of February 2019, the Veteran alleged that his symptoms began during military service and increased over the years. He testified before the Board that his scalp sores come and go. In an appellate brief of September 2021, he argued that the intermittent nature of the skin condition explains why the VA examiner did not see any sore on the top of his head. As a layperson, the Veteran is competent to report that he has intermittent sores on his scalp and that the symptoms began during service and have recurred to the present. See Layno v. Brown, 6 Vet. App. 465 (1994). A VA examination and nexus opinion must be adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). An adequate nexus opinion must take into account a claimant's competent report as to the onset and history of the disorder at issue. See Miller v. Wilkie, 32 Vet. App. 249, 257 (2020). In this case, the VA examiner has not considered the Veteran's account of recurrent symptoms since service, and no nexus opinion was offered. In light of the competent lay evidence of recurrent symptoms of a disorder dating from an in-service onset, the Board will remand for a new VA examination that takes into account the Veteran's competent reporting as to the alleged disorder and that offers a nexus opinion. If possible, the examination should be scheduled during a flare-up of the alleged dermatological condition. See Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994). Otherwise, the examiner should record the Veteran's reports of the type and severity of symptoms during a skin flare-up. 4. Entitlement to service connection for an acquired psychiatric disorder other than PTSD, to include somatic symptom disorder. In April 2018, the Veteran filed a service-connection claim that identified "memory loss Gulf War illness" and for posttraumatic stress disorder (PTSD) as claimed disorders. The scope of the claims includes any disability that may reasonably be encompassed by the description of the claims, reported symptoms, and other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). A rating decision of October 2018 denied service connection for PTSD, for chronic fatigue syndrome (CFS) also claimed as memory loss as due to an undiagnosed illness, and for somatic symptom disorder. As to the denial of service connection for somatic disorder and for chronic fatigue syndrome, also claimed as memory loss, the Veteran filed a NOD in November 2018 and VA Form 9 in February 2019. He did not appeal the denial of service connection for PTSD. He has the option to file VA Form 20-0995, Decision Review Request, Supplemental Claim, if he wishes to file a new service- connection claim for PTSD. The appealed issue of entitlement to service connection for chronic fatigue syndrome, also claimed as memory loss, is addressed elsewhere in today's order. The Veteran testified before the Board that he believes his current psychological disorder to be caused by his military service. He stated that he was an eyewitness to the loss of life and/or significant injury. He alleges that he experienced psychological symptoms during his active duty service and that they have become worse over the years. In testifying as to his claimed psychiatric disorder, he stated that he has "made a voluntary attempt to block out a lot of things" and also does not feel at liberty to talk about some events of his service because he was in "Black Ops." The diagnosis of a July 2015 VA treatment record was "depression/adjustment D/O". There also was an assessment of "adjustment disorder with disturbance of conduct/mixed features." The diagnosis of a VA treatment record of April 2016 was depression. A VA neurologist's record of June 2018 noted the Veteran's "psychosocial issues or deep seated anxiety." The neurologist's impression in November 2018 was that the Veteran had "tension type, stress, anxiety, or other psychological problems." The Veteran was noted to be "positive" for depression, anxiety, stress/anxiety, and drug/alcohol issues, although these were not explicitly diagnosed by the neurologist. In September 2018, the Veteran underwent a VA examination for PTSD. The report made no note of in-service psychiatric symptoms. No current mental disorder, including PTSD, was diagnosed. The Veteran again underwent a VA examination for PTSD in October 2018. Depressed mood and chronic sleep impairment, including nightmares, were noted as current symptoms. Somatic symptom disorder was the only diagnosed disorder. The Veteran denied being treated for mental illness during his military service. Although no service treatment record diagnoses traumatic brain injury, the Veteran competently reported to the VA examiner, when asked if he had ever had a head injury, "Explosion. In a hole. Air Force dropped bombs right on top of us." PTSD was ultimately not diagnosed by the October 2018 VA examiner on the basis that all the diagnostic criteria were not met. An alleged stressor was determined by the examiner to be adequate to support a diagnosis of PTSD. The details appear to have involved more than one incident and, as noted in the report, relate to the Veteran's shooting someone, bombs being dropped "on top of us" while the Veteran was in a ditch in 1991 in Saudi Arabia, being encircled by enemy tanks, "met the Republican Guard in the oil field," flames going everywhere, oil coming down, and watching dogs carry away parts of dead bodies. A VA examination and nexus opinion must be adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). An adequate nexus opinion must take into account a claimant's competent report as to the onset and history of the claimed disorder. See Miller v. Wilkie, 32 Vet. App. 249, 257 (2020). An incomplete analysis is not adequate. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The examiner remarked in the report that, because of "multiple inconsistencies comparing [the Veteran's] reported symptoms and experiences as compared to his medical record and his service record," it would be mere speculation to diagnose an adjustment disorder due to the reported military stressors and symptoms. If the likely etiology of an adjustment disorder could be not be identified without speculation, the examiner should have clearly identified precisely which facts cannot be determined, with an explanation as to whether those facts cannot be determined from current medical knowledge or the actual cause cannot be selected from among multiple potential causes. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). There also was not an adequate explanation as to why, if an etiology opinion as to an adjustment order would be mere speculation, the examiner felt confident in opining as to the likely etiology of the Veteran's diagnosed somatic symptom disorder. In the opinion of the VA examiner, the Veteran's somatic symptom disorder was less likely than not incurred in, or caused by, an in-service injury, illness, or event. The stated rationale was that there is "there is no report of mental health issues during the Veteran's service time and no consistent report of ongoing mental health problems since military service until 2013." Because the negative nexus opinion of the VA examiner was offered without consideration of the Veteran's hearing testimony relating to an in-service onset of psychiatric symptoms, the Board must remand for a new VA examination and nexus opinion. 38 C.F.R. § 19.9(a). 5. Entitlement to service connection for chronic fatigue syndrome, also claimed as memory loss. In April 2018, the Veteran filed a service-connection claim that listed, as separately claimed disorders, "chronic fatigue syndrome Gulf War illness" and "memory loss Gulf War illness." A rating decision of October 2018 denied service connection for chronic fatigue syndrome (CFS), also claimed as memory loss as due to an undiagnosed illness. The Veteran filed a NOD in November 2018 and VA Form 9 in February 2019. The Veteran testified before the Board that he experienced fatigue during his active duty service. As a layperson, he is competent to report his experienced symptoms. See Layno v. Brown, 6 Vet. App. 465 (1994). He also argued in his hearing testimony that he is entitled to presumed service connection based on his Persian Gulf War service. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A Persian Gulf War veteran is one who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e). The Veteran's DD Form 214 indicates that the Veteran's decorations and medals include the Southwest Asia Service Medal with three Bronze Stars and the Kuwait Liberation Medal. His military occupational specialty was light wheel mechanic. The Veteran alleges having been exposed to toxic substances during his Persian Gulf service. A Persian Gulf veteran with a qualifying chronic disability that manifests to a degree of 10 percent or more before December 31, 2016, may be entitled to compensation pursuant to 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). VA has defined a medically unexplained chronic multi-symptom illness as 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. 38 C.F.R. § 3.317(a)(2)(ii). Chronic fatigue syndrome is among the listed examples of a medically unexplained, chronic, multi-symptom illness. 38 U.S.C. § 1117(a)(2)(i)(B). In September 2018, the Veteran underwent a Gulf War general medical examination (including burn pits). The Medical History section of the report noted "chronic fatigue syndrome" in the category of infectious disease, immune disorder, or nutritional deficiency, with no indication as to whether the notation referred to a diagnosis, the Veteran's report, or some other source. It was determined, without explanation, that, from the conditions identified and for which questionnaires were completed, there are no diagnosed illnesses for which no etiology was established. No disability benefit questionnaires were identified in the report. In September 2018, the Veteran also underwent a VA examination for chronic fatigue syndrome. No medical history was noted in the relevant section of the report. The examiner noted the following in the Remarks section of the report: that the Veteran has never been diagnosed with chronic fatigue syndrome; that he does not meet the diagnostic criteria for chronic fatigue syndrome; that any chronic fatigue type symptoms have a clear and specific etiology and diagnosis and are not due to any Gulf War exposures; that any such symptoms are more likely than not due to the Veteran's poor sleep hygiene; that the Veteran slept on average only two hours per night for the past three months; and that, prior to that, he had slept either too much (13 to 15 hours per night) or too little (only "a couple of hours of sleep per night"). The Veteran competently testified before the Board that he experienced fatigue during his active duty service. He offered no testimony as to memory loss, and the symptom was not discussed in an appellate brief of September 2021. The Veteran told the September 2018 VA examiner for PTSD that he experienced no memory loss during service. The September 2018 examiner concluded that the Veteran's score on the Montreal Cognitive Assessment (MOCA) indicated possible cognitive impairment, but that it was outside the scope of his expertise to conduct a neuropsychological examination for memory issues and, if present, to determine the etiology of such issues. The October 2018 VA examination report for PTSD made no finding or mention of memory impairment. A VA examination and nexus opinion must be adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). An adequate nexus opinion must take into account a claimant's competent report as to the onset and history of the claimed disorder. See Miller v. Wilkie, 32 Vet. App. 249, 257 (2020). An incomplete analysis is not adequate. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board will remand for a new VA examination and nexus opinion, because the October 2018 was unable to consider the Veteran's subsequent testimony before the Board that he experienced fatigue during his active military service. Furthermore, the sections of the examination report dedicated to medical history, diagnostic testing, and findings, signs, and symptoms were left completely blank. Because the agency of original jurisdiction (AOJ) has considered the Veteran's claim of entitlement to service connection for memory loss in the context of chronic fatigue syndrome and not the claimed psychiatric disorder, the issue of entitlement to service connection for "chronic fatigue syndrome, also claimed as memory loss" is inextricably intertwined with the remanded claim relating to service connection for an acquired psychiatric disorder and, therefore, must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Undertake appropriate development to associate with the record any outstanding, identified, private medical records pertinent to the remanded issues and any outstanding VA treatment records. All efforts to obtain such records should be documented in the electronic claims folder. 3. Specifically notify the Veteran that he may submit digital photographs of his claimed skin disorder of the head when it is symptomatic. 4. Schedule the Veteran for an examination with an appropriate clinician regarding the nature and etiology of any bronchitis disorder. The examiner must opine as to whether any such disorder of the Veteran at any time since his service-connection claim was filed in April 2018, even if now resolved, at least as likely as not: a. Is caused by an in-service injury, disease, or event, to include the Veteran's report of in- service symptoms and exposure to environmental hazards during his Gulf War service; b. Had its inception during active duty service; c. Is a manifestation of an infectious disease, an undiagnosed illness, or a medically unexplained, chronic multi- symptom illness; or d. Is proximately due to, or aggravated beyond its natural progression by a service- connected disability, to include sinusitis or vasomotor rhinitis, or by any other disorder. Notify the examiner that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it would be as medically sound to find in favor of such a conclusion as to find against it. Notify the examiner that laypersons such as the Veteran are competent to attest to matters of first-hand knowledge gained through the senses, including observable symptoms. Notify the examiner that the rationale given for the nexus opinion must address the Veteran's report before the Board that he has had bronchitis symptoms almost on a yearly basis. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall explain why an opinion cannot be offered. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. 5. Schedule the Veteran for an examination with an appropriate clinician regarding the nature and etiology of any recurrent muscle/musculoskeletal impairment or pain, to include as a symptom of fibromyalgia. The examiner must opine as to whether any such disorder of the Veteran at any time since his service-connection claim was filed in April 2018, even if now resolved, at least as likely as not: a. Is caused by any in-service injury, disease, or event, to include the Veteran's report of in-service muscle symptoms and exposure to environmental hazards during his Gulf War service; b. Had its inception during active duty service; c. Manifested during active service or within one year after discharge from service back injury and back symptoms during service; d. Was noted during service such that the condition was not shown to be chronic at that time or a diagnosis of chronicity could be legitimately questioned, and there was a continuity of the same symptomatology since service; e. Is a manifestation of an infectious disease, an undiagnosed illness, or a medically unexplained, chronic multi- symptom illness; or f. Is proximately due to, or aggravated beyond its natural progression by, a service- connected disability or by any other disorder. Notify the examiner that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it would be as medically sound to find in favor of such a conclusion as to find against it. Notify the examiner that laypersons such as the Veteran are competent to attest to matters of first-hand knowledge gained through the senses, including observable symptoms. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall explain why an opinion cannot be offered. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. 6. Schedule the Veteran for an examination with an appropriate clinician regarding the nature and etiology of any dermatological disorder of the head, to include sores on top of the head. Undertake appropriate steps, to the extent possible, to schedule the examination during a flare-up of the alleged dermatological condition. The examiner must opine as to whether any such disorder of the Veteran at any time since his service-connection claim was filed in April 2018, even if now resolved, at least as likely as not: a. Is caused by any in-service injury, disease, or event, to include the Veteran's report of in-service skin symptoms and exposure to environmental hazards during his Gulf War service; b. Had its inception during active duty service; c. Is a manifestation of an infectious disease, an undiagnosed illness, or a medically unexplained, chronic multi- symptom illness; or d. Is proximately due to, or aggravated beyond its natural progression by, a service- connected disability or by any other disorder. Notify the examiner that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it would be as medically sound to find in favor of such a conclusion as to find against it. Notify the examiner that laypersons such as the Veteran are competent to attest to matters of first-hand knowledge gained through the senses, including observable symptoms. The examiner must record the Veteran's report as to the frequency, type, and severity of symptoms for the active phase of the claimed skin disorder as experienced by the Veteran. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall explain why an opinion cannot be offered. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. 7. Schedule the Veteran for an examination with an appropriate clinician regarding the nature and etiology of any acquired psychiatric disorder other than PTSD, to include cognitive impairment, depression, anxiety, and somatic symptom disorder. The examiner must opine as to whether any such disorder of the Veteran at any time since his service- connection claim was filed in April 2018, even if now resolved, at least as likely as not: a. Is caused by an in-service injury, disease, or event, to include the in-service stressors as reported by the Veteran in his hearing testimony before the Board and upon VA examination for PTSD in October 2018, and to include exposure to environmental hazards during his Gulf War service; b. Had its inception during active duty service; c. Is a manifestation of an infectious disease, an undiagnosed illness, or a medically unexplained, chronic multi- symptom illness; or d. Is proximately due to, or aggravated beyond its natural progression by, a service- connected disability or by any other disorder. If the Veteran's medical history indicates that the diagnosis relating to a psychiatric disorder has changed, the examiner must discuss the prior diagnosis or diagnoses of record and offer an opinion as to whether any later finding represents the progression of a prior diagnosis, a correction of an error in the prior diagnosis, or the development of a new and separate disorder. Notify the examiner that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it would be as medically sound to find in favor of such a conclusion as to find against it. Notify the examiner that laypersons such as the Veteran are competent to attest to matters of first-hand knowledge gained through the senses, including observable symptoms. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall explain why an opinion cannot be offered. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. 8. Schedule the Veteran for an examination with an appropriate clinician regarding the nature and etiology of any recurrent symptoms of fatigue, to include cognitive impairment, memory loss, and chronic fatigue syndrome. The examiner must opine as to whether any such disorder of the Veteran at any time since his service-connection claim was filed in April 2018, even if now resolved, at least as likely as not: a. Is caused by any in-service injury, disease, or event, to include the Veteran's report of in-service fatigue and exposure to environmental hazards during his Gulf War service; b. Had its inception during active duty service; c. Manifested during active service or within one year after discharge from service back injury and back symptoms during service; d. Was noted during service such that the condition was not shown to be chronic at that time or a diagnosis of chronicity could be legitimately questioned, and there was a continuity of the same symptomatology since service; e. Is a manifestation of an infectious disease, an undiagnosed illness, or a medically unexplained, chronic multi- symptom illness; or f. Is proximately due to, or aggravated beyond its natural progression by, a service- connected disability or by any other disorder. Notify the examiner that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it would be as medically sound to find in favor of such a conclusion as to find against it. Notify the examiner that laypersons such as the Veteran are competent to attest to matters of first-hand knowledge gained through the senses, including observable symptoms. (Continued on the next page) If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall explain why an opinion cannot be offered. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A rationale is required for all opinions in the report. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Steven D. Najarian, 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.