Citation Nr: 21072762 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 19-36 910 DATE: December 6, 2021 ORDER The application to reopen a claim of service connection for respiratory disability/allergic rhinitis is granted. The application to reopen a claim of service connection for disability manifested by fatigue is granted. Entitlement to service connection for fibromyalgia is granted. Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for depressive disorder, secondary to PTSD and chronic sinusitis, on a causation basis, is granted. Entitlement to service connection for sleep apnea is granted. Entitlement to service connection for allergic rhinitis (previously characterized as bronchitis) is granted. REMANDED Entitlement to service connection for disability manifested by fatigue (other than sleep apnea), to include chronic fatigue syndrome, is remanded. Entitlement to service connection for bilateral shoulder disability is remanded. Entitlement to service connection for bilateral knee disability is remanded. Entitlement to service connection for neck disability is remanded. Entitlement to service connection for back disability is remanded. Entitlement to service connection for bilateral elbow disability is remanded. Entitlement to service connection for bilateral hip disability is remanded. Entitlement to service connection for bilateral wrist disability is remanded. Entitlement to an initial compensable rating for irritable bowel syndrome is remanded. FINDINGS OF FACT 1. The Veteran's claims of service connection for respiratory disability (characterized as chronic lung disease, claimed as breathing problems, and allergic rhinitis) and disability manifested by fatigue (characterized as chronic fatigue) were originally denied in a July 1994 rating decision on the basis that the disabilities were not incurred in or caused by service; the Veteran did not appeal this decision within one year of its issuance and new and material evidence was not received within that year. 2. The claims of service connection for respiratory disability (characterized as breathing problems as due to an undiagnosed illness) and disability manifested by fatigue (characterized as fatigue due to an undiagnosed illness) were re-adjudicated on a de novo basis and again denied in April 1995 and July 1997 rating decisions on the basis that the disabilities were not incurred in or caused by service; the Veteran did not appeal either decision within one year of their issuance and new and material evidence was not received within those years. 3. Evidence received since the July 1997 agency of original jurisdiction (AOJ) decision includes information that was not previously considered and which relates to unestablished facts necessary to substantiate the claims of service connection for respiratory disability/allergic rhinitis and disability manifested by fatigue, the absence of which was the basis of the previous denials. 4. The Veteran served in the Southwest Asia theater of operations during the Persian Gulf War. 5. The evidence is at least evenly balanced as to whether the Veteran experiences fibromyalgia which became manifest to a compensable degree in the years since service. 6. The Veteran served in combat, and his PTSD is related to his claimed combat stressors. 7. The Veteran's depressive disorder is caused by his PTSD and chronic sinusitis. 8. The evidence is at least evenly balanced as to whether the Veteran's sleep apnea began during active service. 9. The evidence is at least evenly balanced as to whether the Veteran's allergic rhinitis began during active service. CONCLUSIONS OF LAW 1. The AOJ's July 1994, April 1995, and July 1997 decisions that denied the claims of service connection for respiratory disability/allergic rhinitis and disability manifested by fatigue are final. 38 U.S.C. § 7105 ; 38 C.F.R. §§ 3.104, 3.156(a)-(b), 19.52(a), 20.1103. 2. The evidence received since the July 1997 AOJ decision is new and material and reopening of the claims of service connection for respiratory disability/allergic rhinitis and disability manifested by fatigue is therefore warranted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a). 3. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for fibromyalgia are met. 38 U.S.C. §§ 1110, 1117, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317. 4. The criteria for service connection for PTSD are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(f). 5. The criteria for service connection for depressive disorder, as secondary to PTSD and chronic sinusitis, on a causation basis, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for sleep apnea are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for allergic rhinitis are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1990 to June 1991, which includes service in the Southwest Asia theater of operations. He had additional service with the Marine Corps Reserve, to include a period of active duty for training (ACDUTRA) from March 1987 to July 1987. His awards include the Combat Action Ribbon. These matters come before the Board of Veterans' Appeals (Board) from a March 2017 rating decision. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at an August 2021 hearing and a transcript of the hearing is associated with his claims file. As for characterization of the issues on appeal, claims of service connection for respiratory disability/allergic rhinitis (characterized as chronic lung disease, claimed as breathing problems, and allergic rhinitis) and disability manifested by fatigue (characterized as chronic fatigue) were initially denied by way of a final July 1994 rating decision. Where the claim in question has been finally adjudicated, the Board must initially determine whether new and material evidence has been submitted with regard to the claims of service connection for respiratory disability/allergic rhinitis and disability manifested by fatigue. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Only where the Board concludes that new and material evidence has been received does it have jurisdiction to consider the merits of these claims. Hickson v. West, 11 Vet. App. 374, 377 (1998). Therefore, the Board has included the issues of whether new and material evidence has been received to reopen the claims of service connection for respiratory disability/allergic rhinitis and disability manifested by fatigue. Moreover, in light of the Veteran's reported symptoms and contentions, to encompass all disorders that are reasonably raised by the record, and in light of the fact that the Board is awarding service connection for sleep apnea, the Board has re-characterized the claim of service connection for chronic fatigue syndrome as a claim of service connection for disability manifested by fatigue (other than sleep apnea), to include chronic fatigue syndrome. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (a claim should not be limited to the disorder as characterized by the Veteran but must be characterized based on the reasonable expectations of the non-expert claimant and the evidence in processing the claim). Lastly, the Veteran has specified that his claim of service connection for respiratory disability (characterized by the AOJ as bronchitis) is in reference to allergic rhinitis. Also, he has reported that his claim of service connection for muscle and joint pain involves the shoulders, knees, neck, back, elbows, hips, and wrists. As explained below, the Board is awarding service connection for allergic rhinitis and the respiratory issue has been re-characterized as a claim of service connection for allergic rhinitis (previously characterized as bronchitis). In addition, the Board is awarding service connection for fibromyalgia and has expanded the appeal to include the issues of entitlement to service connection for bilateral shoulder disability, bilateral knee disability, neck disability, back disability, bilateral elbow disability, bilateral hip disability, and bilateral wrist disability. I. Application to Reopen Generally, an AOJ decision denying a claim which has become final may not thereafter be reopened and allowed. 38 U.S.C. § 7105 (d)(3). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. New evidence is defined as existing evidence not previously submitted to VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The newly presented evidence is presumed to be credible for purposes of determining whether it is new and material. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). When evaluating the materiality of newly submitted evidence, the focus must not be solely on whether the evidence remedies the principal reason for denial in the last prior decision; rather the determination of materiality should focus on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). For the purpose of determining whether new and material evidence has been presented to reopen a claim, the evidence for consideration is that which has been presented or secured since the last time the claim was finally disallowed on any basis. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The application to reopen claims of service connection for respiratory disability/allergic rhinitis and disability manifested by fatigue. The Veteran's claims of service connection for respiratory disability/allergic rhinitis (characterized as chronic lung disease, claimed as breathing problems, and allergic rhinitis) and disability manifested by fatigue (characterized as chronic fatigue) were originally denied in a July 1994 rating decision on the basis that the disabilities were not incurred in or caused by service. Specifically, the AOJ explained that there were no complaints, findings, treatment, or diagnoses pertaining to these claimed disabilities in the Veteran's service treatment records and that he reported shortness of breath, a productive cough, sinus drainage, and fatigue more than two years following his discharge from service during an October 1993 VA Persian Gulf examination. Overall, the evidence did not show that the Veteran's claimed disabilities had their onset during service or were otherwise associated with service. The Veteran was notified of the July 1994 decision, he did not appeal the decision within one year of its issuance, and new and material evidence was not received within that year. Therefore, the July 1994 decision became final. See 38 U.S.C. § 7105 (d)(3); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 19.52(a), 20.1103. The claims of service connection for respiratory disability (characterized as breathing problems as due to an undiagnosed illness) and disability manifested by fatigue (characterized as fatigue due to an undiagnosed illness) were re-adjudicated on a de novo basis and again denied in April 1995 and July 1997 rating decisions on the basis that the disabilities were not incurred in or caused by service. The AOJ explained in the April 1995 decision that the Veteran's service treatment records did not show any complaints of or treatment for a breathing problem or fatigue and that the first mention of shortness of breath and fatigue was during the October 1993 VA Persian Gulf examination, which was more than two years after his return from Southwest Asia. Also, in the July 1997 decision, the AOJ explained that the Veteran's breathing problems and fatigue were the result of the known clinical diagnoses of sinus infections and/or bronchitis. The Veteran was notified of the April 1995 and July 1997 decisions, he did not appeal either decision within one year of their issuance, and new and material evidence was not received within those years. Therefore, the April 1995 and July 1997 decisions became final. See 38 U.S.C. § 7105 (d)(3); Bond, 659 F.3d at 1362; 38 C.F.R. §§ 3.104, 3.156(a)-(b), 19.52(a), 20.1103. The pertinent new evidence received since the July 1997 denial of service connection for respiratory disability/allergic rhinitis and disability manifested by fatigue includes a February 2018 examination report from J.W. Ellis, M.D. and the Veteran's testimony during the August 2021 Board hearing. This additional evidence reflects that the Veteran has reported symptoms of allergic rhinitis ever since service and has been diagnosed as having chronic fatigue syndrome due to his service in Southwest Asia. Therefore, the additional evidence pertains to elements of the claims of service connection for respiratory disability/allergic rhinitis and disability manifested by fatigue that were previously found to be lacking and raises a reasonable possibility of substantiating the claims by indicating that the Veteran has current respiratory disability/allergic rhinitis and disability manifested by fatigue that may be related to service. The evidence is, therefore, new and material, and the claims of service connection for respiratory disability/allergic rhinitis and disability manifested by fatigue are reopened. II. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, air, or space service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for fibromyalgia For veterans with service in the Southwest Asia theater of operations during the Persian Gulf War, service connection may be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under this law and regulation, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of "a qualifying chronic disability" that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2026. 38 C.F.R. § 3.317 (a)(1). For purposes of 38 C.F.R. § 3.317, qualifying chronic disabilities include, among other things, a medically unexplained chronic multisymptom illness (including fibromyalgia). 38 C.F.R. § 3.317 (a)(2). 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a),(b). The Veteran contends that he began to experience multiple joint and muscle pain shortly following his service in Southwest Asia during the Persian Gulf War, and that he has continued to experience such symptoms in the years since that time. The Board finds, for the following reasons, that the evidence is at least evenly balanced as to whether the Veteran experiences current fibromyalgia which became manifest to a compensable degree in the years since his service in Southwest Asia. The February 2018 examination report from Dr. Ellis shows the Veteran has a current diagnosis of fibromyalgia. His service personnel records reflect that he participated in Operation Desert Shield and Operation Desert Storm in Southwest Asia from January 1991 to May 1991. Therefore, current fibromyalgia and service in the Southwest Asia theater of operations during the Persian Gulf War has been demonstrated. The Veteran's VA treatment records indicate that he has been prescribed pain medication on various occasions due to joint pain. He reported during the February 2018 examination with Dr. Ellis that six months after he participated in Operation Desert Storm, he began to experience achiness in the back of his shoulders, upper back, and lower back. He also began to experience some migratory joint pains in his shoulders, elbows, wrists, and knees, and by 1995 he had difficulty getting comfortable and there was always a painful sensation in his muscles and in the base of his neck, shoulder girdle area, upper back, lower back, and thoracic area. The pain would also occasionally go around to his anterior chest muscles. His fibromyalgia symptoms severely interfered with his activities of daily living and ability to work. Examination revealed that there were fibromyalgia symptoms in the upper shoulders, thoracic, and lumbar areas. There were areas of tenderness and spasms. The spasms and tenderness were not always identical, and this was consistent with trigger points. Dr. Ellis opined that it was likely ("more likely than not") that the onset and progression of the Veteran's symptoms were consistent with his exposures in Southwest Asia and caused his fibromyalgia. Overall, the impairments and disabilities described in the February 2018 examination report (which include fibromyalgia) were likely ("more likely than not") due to and a consequence of the Veteran's military service. Based on the above, the Board finds that the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War and that the evidence is at least evenly balanced as to whether he has fibromyalgia which became manifest to a compensable degree in the years since service (given his symptoms and the criteria for a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5025). As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for fibromyalgia is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for PTSD and depressive disorder Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f). When there is a current diagnosis of PTSD, the sufficiency of a claimed in-service stressor is presumed. Cohen v. Brown, 10 Vet. App. 128, 144 (1997). Nevertheless, credible evidence that the claimed in-service stressor actually occurred is still required. 38 C.F.R. § 3.304 (f). Credible supporting evidence cannot consist solely of after-the-fact medical evidence containing an opinion as to a causal relationship between PTSD and service. See Moreau v. Brown, 9 Vet. App. 389, 396 (1996). If the evidence establishes that a veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304 (f); see Cohen, 10 Vet. App. at 128; Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). The Veteran contends that he has current psychiatric disability that is related to psychiatric stressors that he experienced during his service in Southwest Asia. The Board finds, for the following reasons, that the Veteran has a current diagnosis of PTSD, that he served in combat, and that his PTSD is related to his claimed combat stressors. Also, he has current depressive disorder which is caused by his PTSD and chronic sinusitis. A January 2018 "Review Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire" (DBQ) completed by H.H. Kamm, Ph.D. indicates that the Veteran has been diagnosed as having PTSD. He contends that his PTSD is related to psychiatric stressors that he experienced during his service in Southwest Asia. For instance, he reported during the examination with Dr. Kamm that he engaged in combat with enemy Iraqi forces when they invaded Kuwait and attempted to invade Saudi Arabia. Also, he witnessed burned bodies while traveling on the "Highway of Death" from Kuwait to Iraq. The Veteran's DD Form 214 and service personnel records confirm that he participated in Operation Desert Shield and Operation Desert Storm in Southwest Asia from January 1991 to May 1991 and that he received the Combat Action Ribbon. Therefore, current PTSD and combat in service has been demonstrated. Also, the January 2018 DBQ from Dr. Kamm establishes a link between the Veteran's PTSD and his combat stressors in service. Dr. Kamm reported that she examined the Veteran and her diagnosis of PTSD was based upon the Veteran's reported stressors in service (including his combat stressors in Southwest Asia). In light of the above evidence, the Board concludes that the Veteran has a current diagnosis of PTSD and that there is competent medical evidence of a nexus between his PTSD and his claimed in-service combat stressors. Moreover, he engaged in combat with the enemy. Therefore, the Veteran's reported combat stressors in service are conceded. In sum, the Veteran has a current diagnosis of PTSD, there is competent medical evidence of a nexus between his PTSD and his claimed in-service stressors, and there is credible evidence that the stressors occurred. Hence, the criteria for service connection for PTSD are met and service connection for this disability is warranted. Moreover, the January 2018 DBQ from Dr. Kamm indicates that the Veteran has been diagnosed as having PTSD "with associated depression" and depressive disorder "due to sinusitis, with depressive features." Although Dr. Kamm did not provide any specific rationale for why the Veteran's depressive disorder is associated with his PTSD and sinusitis, she essentially provided an opinion, based upon her treatment of the Veteran and consideration of his reported history, that his depressive disorder is caused by his now service-connected PTSD and his service-connected sinusitis. This opinion is therefore entitled to some probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). There is no medical opinion that is contrary to a finding that the Veteran's depressive disorder is caused by his PTSD and sinusitis. In sum, the January 2018 diagnosis supports the conclusion that the Veteran's depressive disorder is caused by his now service-connected PTSD and his service-connected sinusitis. There is no medical opinion contrary to this conclusion. Accordingly, service connection for depressive disorder, secondary to PTSD and sinusitis, on a causation basis, is also warranted. 3. Entitlement to service connection for sleep apnea and allergic rhinitis The Veteran contends that he has current sleep apnea and respiratory disability (he has specified that his claimed respiratory disability is in reference to allergic rhinitis) which had their onset in service. The Board finds, for the following reasons, that the Veteran has current diagnoses of sleep apnea and allergic rhinitis, and that the evidence is at least evenly balanced as to whether these disabilities began during active service. The reports of VA sleep apnea and rhinitis examinations dated in October 2016 indicate that the Veteran has been diagnosed as having obstructive sleep apnea and allergic rhinitis. Therefore, current disabilities have been demonstrated. There is also evidence of sleep apnea and rhinitis symptoms during service and evidence of continuous symptoms in the years since service. In this regard, the Veteran has reported that he began to experience snoring (which was witnessed by fellow service members), daytime fatigue, and chronic nasal congestion and drainage in service. As explained above, the Veteran participated in combat while serving in Southwest Asia. Where a veteran engaged in combat, satisfactory lay evidence that an injury or disease was incurred in service will be accepted as sufficient proof of service connection where such evidence is consistent with the circumstances, conditions, or hardships of service. 38 U.S.C. § 1154 (b). The combat rules not only reduce the evidentiary burden for establishing in-service injury but allow a combat veteran to use "satisfactory lay or other evidence" to establish that he incurred the disability itself in service, even in cases where "there is no official record" that such injury or disability occurred. Reeves v. Shinseki, 682 F.3d 988, 998 (Fed. Cir. 2012). In this case, the Veteran's reports of sleep and nasal problems in combat situations in service are satisfactory evidence and the reports are consistent with the circumstances of his service in Southwest Asia. There is no clear and convincing evidence to the contrary. Therefore, the presence of sleep and nasal symptoms in service is established. Moreover, the Veteran's post-service medical records and lay statements indicate that his sleep apnea and rhinitis symptoms have continued in the years since service. The Veteran is competent to report continuous sleep apnea and rhinitis symptoms in the years since service. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Also, there no evidence that explicitly contradicts the Veteran's reports and his reports are generally consistent with the evidence of record. Therefore, the Board concludes that his reports of continuous sleep apnea and rhinitis symptoms in the years since service are credible. In sum, the evidence reflects that the Veteran experienced sleep apnea and rhinitis symptoms in service and that there have been continuous symptoms in the years since service. He has also been diagnosed as having current sleep apnea and allergic rhinitis. There is no medical opinion that is specifically contrary to a conclusion that the current sleep apnea and allergic rhinitis had their onset in service. Thus, the evidence is at least evenly balanced as to whether these disabilities had their onset in service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for sleep apnea and allergic rhinitis is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. See also Buchanan, 451 F.3d at 1335 ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). REASONS FOR REMAND 1. Entitlement to service connection for disability manifested by fatigue (other than sleep apnea), to include chronic fatigue syndrome, is remanded. The Veteran contends that he has current disability manifested by fatigue that began during his service in Southwest Asia and has continued in the years since that time. He was afforded a VA chronic fatigue syndrome examination in October 2016 and the examiner concluded that the Veteran did not meet the diagnostic criteria for chronic fatigue syndrome. Specifically, although he developed chronic fatigue beginning in approximately 1991, he did not have any other accompanying symptoms. In his February 2018 examination report, Dr. Ellis diagnosed the Veteran as having chronic fatigue syndrome. However, the Board points out that for VA purposes, the diagnosis of chronic fatigue syndrome requires that certain criteria must be met. One of these criteria is the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms. See 38 C.F.R. § 4.88A. Dr. Ellis did not provide any specific explanation pertaining to his diagnosis of chronic fatigue syndrome. Also, it is unclear whether the Veteran experiences any disability manifested by fatigue that is separate and distinct from his now service-connected sleep apnea. In light of the above, a remand is necessary to afford the Veteran a new examination to determine the nature of any current disability manifested by fatigue (other than sleep apnea), and to obtain a medical opinion as to whether any such disability is related to service. Also, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the VA Oklahoma City Healthcare System and are dated to October 2019. Any VA treatment records are within VA's constructive possession, and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). See also Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (confirming the holding in Sullivan). A remand is required to allow VA to obtain them. 2. Entitlement to service connection for bilateral shoulder disability, bilateral knee disability, neck disability, back disability, bilateral elbow disability, bilateral hip disability, and bilateral wrist disability are remanded. The Veteran contends that he began to experience pain in multiple joints (identified as the shoulders, knees, neck, back, elbows, hips, and wrists) within months of his separation from service in June 1991 and that such symptoms have continued in the years since that time. With respect to the shoulders and knees, he was afforded VA shoulder and knee examinations in October 2016 and was diagnosed as having bilateral shoulder impingement syndrome and bilateral knee strain. The examiner who conducted the examinations opined that the Veteran's shoulder and knee disabilities were not likely related to specific exposures in Southwest Asia. This opinion is inadequate because the examiner did not discuss more generally whether the Veteran's disabilities had their onset in service or are otherwise related to service. Therefore, the Veteran should be afforded new examinations to determine the nature of his current shoulder and knee disabilities and to obtain medical opinions as to whether such disabilities are related to service. As for the Veteran's claimed neck, back, bilateral elbow, bilateral hip, and bilateral wrist disabilities, there is evidence that he has persistent or recurrent symptoms of such disabilities and that any such disabilities may be related to service, and the record does not contain sufficient information to make a decision on the claims. Therefore, the Veteran should be afforded appropriate examinations upon remand to assess the nature of his claimed neck, back, bilateral elbow, bilateral hip, and bilateral wrist disabilities, and to obtain medical opinions as to whether any such disabilities are related to service. See 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Also, all outstanding VA treatment records should be secured upon remand. 3. Entitlement to an initial compensable rating for irritable bowel syndrome is remanded. The evidence reflects that the Veteran's service-connected irritable bowel syndrome may have worsened since he was last examined by VA in October 2016. Specifically, the October 2016 examination report indicates that his only symptoms of irritable bowel syndrome were daily diarrhea and abdominal pain, and that he was not taking any medications for his disability. However, during the August 2021 Board hearing he reported that he had developed alternating diarrhea and constipation, experienced constant abdominal pressure and pain, and was taking medications for his disability. In light this information and the fact that the issue of entitlement to a higher initial rating for irritable bowel syndrome must otherwise be remanded to obtain outstanding treatment records, the Veteran should be provided an opportunity to report for a new examination to ascertain the current severity and manifestations of his service-connected irritable bowel syndrome. Also, all outstanding VA treatment records should be secured upon remand. In this regard, the Veteran reported during the August 2021 hearing that he had received VA treatment for his irritable bowel syndrome as recently as July 2021. As noted above, the most recent VA treatment records in the claims file are dated to October 2019. The matters are REMANDED for the following action: 1. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for fatigue, shoulder disability, knee disability, neck disability, back disability, elbow disability, hip disability, and wrist disability, to include the dates of any such treatment. Ask the Veteran to complete a VA Form 21-4142 for all records of his treatment for fatigue, shoulder disability, knee disability, neck disability, back disability, elbow disability, hip disability, and wrist disability from any sufficiently identified private treatment provider from whom records have not already been obtained. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran's outstanding VA treatment records from the VA Oklahoma City Healthcare System for the period since October 2019; and all such relevant records from any other sufficiently identified VA facility. 3. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination with an appropriate clinician to determine the nature of any current disability manifested by fatigue other than sleep apnea, and whether any such disability is related to service. The clinician should answer all of the following questions: (a) Has the Veteran experienced chronic fatigue syndrome at any time since approximately June 2016? (b) Is it at least as likely as not that any identifiable disability manifested by fatigue other than sleep apnea experienced by the Veteran since approximately June 2016 (1) began during active service; OR (2) is related to an injury or disease during service? (c) Is it at least as likely as not that any identifiable disability manifested by fatigue other than sleep apnea experienced by the Veteran since approximately June 2016 has at least a partially understood pathophysiology AND etiology? (d) Does any fatigue experienced by the Veteran since approximately June 2016 represent an objective indication of chronic disability resulting from (1) an undiagnosed illness; OR (2) a medically unexplained chronic multisymptom illness without conclusive pathophysiology OR etiology? The clinician must provide reasons for each opinion given. 4. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination with an appropriate clinician to determine the nature of any current shoulder disability, and whether any such disability is related to service. The clinician should answer all of the following questions: (a) Is it at least as likely as not that any identifiable shoulder disability experienced by the Veteran since approximately June 2016 (1) began during active service; (2) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); OR (3) is related to an injury or disease during service? (b) Is it at least as likely as not that any identifiable shoulder disability experienced by the Veteran since approximately June 2016 has at least a partially understood pathophysiology AND etiology? (c) Does any shoulder symptom experienced by the Veteran since approximately June 2016 represent an objective indication of chronic disability resulting from (1) an undiagnosed illness; OR (2) a medically unexplained chronic multisymptom illness without conclusive pathophysiology OR etiology? The clinician must provide reasons for each opinion given. 5. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination with an appropriate clinician to determine the nature of any current knee disability, and whether any such disability is related to service. The clinician should answer all of the following questions: (a) Is it at least as likely as not that any identifiable knee disability experienced by the Veteran since approximately June 2016 (1) began during active service; (2) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); OR (3) is related to an injury or disease during service? (b) Is it at least as likely as not that any identifiable knee disability experienced by the Veteran since approximately June 2016 has at least a partially understood pathophysiology AND etiology? (c) Does any knee symptom experienced by the Veteran since approximately June 2016 represent an objective indication of chronic disability resulting from (1) an undiagnosed illness; OR (2) a medically unexplained chronic multisymptom illness without conclusive pathophysiology OR etiology? The clinician must provide reasons for each opinion given. 6. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination with an appropriate clinician to determine the nature of any current neck disability, and whether any such disability is related to service. The clinician should answer all of the following questions: (a) Is it at least as likely as not that any identifiable neck disability experienced by the Veteran since approximately June 2016 (1) began during active service; (2) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); OR (3) is related to an injury or disease during service? (b) Is it at least as likely as not that any identifiable neck disability experienced by the Veteran since approximately June 2016 has at least a partially understood pathophysiology AND etiology? (c) Does any neck symptom experienced by the Veteran since approximately June 2016 represent an objective indication of chronic disability resulting from (1) an undiagnosed illness; OR (2) a medically unexplained chronic multisymptom illness without conclusive pathophysiology OR etiology? The clinician must provide reasons for each opinion given. 7. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination with an appropriate clinician to determine the nature of any current back disability, and whether any such disability is related to service. The clinician should answer all of the following questions: (a) Is it at least as likely as not that any identifiable back disability experienced by the Veteran since approximately June 2016 (1) began during active service; (2) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); OR (3) is related to an injury or disease during service? (b) Is it at least as likely as not that any identifiable back disability experienced by the Veteran since approximately June 2016 has at least a partially understood pathophysiology AND etiology? (c) Does any back symptom experienced by the Veteran since approximately June 2016 represent an objective indication of chronic disability resulting from (1) an undiagnosed illness; OR (2) a medically unexplained chronic multisymptom illness without conclusive pathophysiology OR etiology? The clinician must provide reasons for each opinion given. 8. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination with an appropriate clinician to determine the nature of any current elbow disability, and whether any such disability is related to service. The clinician should answer all of the following questions: (a) Is it at least as likely as not that any identifiable elbow disability experienced by the Veteran since approximately June 2016 (1) began during active service; (2) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); OR (3) is related to an injury or disease during service? (b) Is it at least as likely as not that any identifiable elbow disability experienced by the Veteran since approximately June 2016 has at least a partially understood pathophysiology AND etiology? (c) Does any elbow symptom experienced by the Veteran since approximately June 2016 represent an objective indication of chronic disability resulting from (1) an undiagnosed illness; OR (2) a medically unexplained chronic multisymptom illness without conclusive pathophysiology OR etiology? The clinician must provide reasons for each opinion given. 9. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination with an appropriate clinician to determine the nature of any current hip disability, and whether any such disability is related to service. The clinician should answer all of the following questions: (a) Is it at least as likely as not that any identifiable hip disability experienced by the Veteran since approximately June 2016 (1) began during active service; (2) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); OR (3) is related to an injury or disease during service? (b) Is it at least as likely as not that any identifiable hip disability experienced by the Veteran since approximately June 2016 has at least a partially understood pathophysiology AND etiology? (c) Does any hip symptom experienced by the Veteran since approximately June 2016 represent an objective indication of chronic disability resulting from (1) an undiagnosed illness; OR (2) a medically unexplained chronic multisymptom illness without conclusive pathophysiology OR etiology? The clinician must provide reasons for each opinion given. 10. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination with an appropriate clinician to determine the nature of any current wrist disability, and whether any such disability is related to service. The clinician should answer all of the following questions: (a) Is it at least as likely as not that any identifiable wrist disability experienced by the Veteran since approximately June 2016 (1) began during active service; (2) manifested within one year after discharge from service (in the case of any currently diagnosed arthritis); OR (3) is related to an injury or disease during service? (b) Is it at least as likely as not that any identifiable wrist disability experienced by the Veteran since approximately June 2016 has at least a partially understood pathophysiology AND etiology? (c) Does any wrist symptom experienced by the Veteran since approximately June 2016 represent an objective indication of chronic disability resulting from (1) an undiagnosed illness; OR (2) a medically unexplained chronic multisymptom illness without conclusive pathophysiology OR etiology? The clinician must provide reasons for each opinion given. 11. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected irritable bowel syndrome. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. (CONTINUED ON NEXT PAGE) The examiner must provide reasons for any opinion given. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Elwood, 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.