Citation Nr: 21073104 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 17-42 993 DATE: December 7, 2021 REMANDED Entitlement to service connection for an undiagnosed illness is remanded. Entitlement to service connection for folliculitis is remanded. Entitlement to service connection for Grave's disease is remanded. Entitlement to service connection for tonsillectomy is remanded. Entitlement to service connection for a bilateral foot condition other than pes planus is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 2000 to June 2004. She testified before the undersigned Veterans Law Judge at a Board of Veterans' Appeals (Board) hearing in February 2021. The transcript is of record. The statement of the case included the additional issues of service connection for tubal ligation (claimed as tubes tied), lock jaw, and temporomandibular articulation. The Veteran did not appeal these issues in her VA Form 9 and accordingly they are not before the Board. 1. Entitlement to service connection for an undiagnosed illness is remanded. The Veteran had claims for immune system deficiency, chronic fatigue syndrome, and fibromyalgia that stemmed from her time in the Persian Gulf. The VA medical examination found that the Veteran did not have one of the named conditions but did have undiagnosed fatigue and gastrointestinal problems. The Board will accordingly recharacterize these claims as a single claim for undiagnosed illness. Unfortunately, the Veteran's Gulf War Examination is inconsistent, and a new examination is necessary. In one section, the examiner opined that the Veteran did not have any signs or symptoms that may represent an undiagnosed illness. In other sections, however, the examiner wrote that the Veteran had fatigue and GI symptoms of "unclear etiology." Fatigue and GI symptoms are two of the enumerated signs or symptoms of 38 U.S.C. § 3.317(b). The Veteran has also endorsed symptoms of respiratory problems and sleep disturbances in service. These should be considered in a new examination. 2. Entitlement to service connection for folliculitis is remanded. VA has not conducted an examination for folliculitis. Remand is warranted for one to be conducted. Service treatment records from December 2003 indicated that the Veteran had been seen for unknown rash and bumps. The note included possible folliculitis. An examination is necessary to determine if the Veteran's condition was incurred in service. 3. Entitlement to service connection for Grave's disease is remanded. VA examined the Veteran's thyroid in June 2014. The examiner identified current symptoms of constipation, sleepiness, and cold intolerance. The Veteran endorsed these symptoms as having occurred during service and an opinion is necessary to determine if the Veteran had an undiagnosed thyroid problem in service. In particular, the Veteran's claim for frost bite of the toes during service has not been confirmed as frost bite and could be cold intolerance. Fatigue and constipation were also described in service treatment records. 4. Entitlement to service connection for tonsillectomy is remanded. Although the Veteran's tonsillectomy occurred after service, she testified that she had symptoms starting while in service. No examination has yet occurred, and an opinion is necessary to determine if those symptoms support an earlier incurrence of disability. 5. Entitlement to service connection for a bilateral foot condition other than pes planus is remanded. VA examined the Veteran's feet and an addendum opinion in November 2012 stated that the Veteran "other foot conditions" could contribute to her current symptoms which is unrelated to her claim of frost bite. The examiner did not opine on whether these other foot conditions could be related to service. The Veteran is not required to diagnose herself precisely and VA is obligated to consider whether these other problems are related to her report in service. An addendum opinion is necessary. The Veteran is already service connected for pes planus, so the Board interprets this claim as for conditions other than pes planus. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate examination to determine the nature and etiology of her condition. The examiner must review the entire claims file, including a copy of this remand. The examiner should conduct all appropriate diagnostic testing. The examiner should then record all noted signs and reported symptoms, document all clinical findings, and provide a diagnosis if possible. The examiner is asked to provide responses to the following: A) Identify the Veteran's objective indications of a disability. "Objective indications" of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Non-medical indicators include evidence such as time lost form work, the veteran having sought treatment for his symptoms, and change in the veteran's appearance, physical abilities, and mental or emotional attitude. 60 Fed. Reg. 6661, 6663 (Feb. 3, 1995). B) By history, physical examination, or laboratory testing, can the Veteran's objective indications of a disability be attributed to a known clinical diagnosis? If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should so indicate. There is no requirement that the examiner provide a diagnosis of undiagnosed illness. C) If the Veteran's objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran's departure from service during the Persian Gulf War? The examiner should note that a positive response to this question requires affirmative evidence. The mere absence of evidence is not sufficient. D) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the etiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the etiology of the disease or disability population as a whole. E) If the Veteran's objective indications can be attributed to a known clinical diagnosis, is the pathophysiology of the Veteran's condition (1) inconclusive, (2) partially understood, or (3) fully understood? This determination as to each must be based on the Veteran's specific case and cannot be based on the pathophysiology of the disease or disability population as a whole. F) If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran's diagnosed condition was incurred in, or is otherwise related to, her active service? A complete rationale must be provided for all opinions expressed. 2. Schedule the Veteran for a VA examination for her claimed folliculitis. The examiner must review the claims file. Attention must be given to the report in service of a rash and potential folliculitis from December 2003. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion below. The examiner is asked to provide a response to the following: Is the disability at least as likely as not related to service, including being incurred in service? Provide a rationale to support the opinion. In providing the requested opinion, consider the Veteran's description of her in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's thyroid disorder was at least as likely as not incurred in service, including whether the Veteran's symptoms described in service at least as likely as not indicate an undiagnosed thyroid disorder during service. 4. Schedule the Veteran for a VA examination for her claimed tonsil disability. The examiner must review the claims file. Attention must be given to the Veteran's testimony that symptoms began during service. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion below. The examiner is asked to provide a response to the following: Is the disability at least as likely as not related to service, including being incurred in service? Provide a rationale to support the opinion. In providing the requested opinion, consider the Veteran's description of her in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of her current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 5. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's foot disorders other than pes planus. An additional examination may be conducted if necessary. After identifying the Veteran's disorders, state whether they are at least as likely as not related to the reported incident in the service treatment records recorded as too small boots. In the alternative, state whether the disorders are secondarily caused or aggravated by the Veteran's service-connected pes planus. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Saindon, 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.