Citation Nr: 21076920 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 17-51 818 DATE: December 28, 2021 REMANDED Entitlement to service connection for a respiratory condition manifested by a cough, other than asthma, is remanded. Entitlement to service connection for a gastrointestinal disability is remanded. Entitlement to service connection for a disability characterized by fatigue and lightheadedness is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from October 1986 to October 1992, to include service in Southwest Asia during the Persian Gulf War. These matters are on appeal from September 2014 and June 2015 rating decisions. In December 2019, the Board of Veterans' Appeals (Board) remanded the appeal for additional evidentiary development. 1. Entitlement to service connection for a respiratory condition manifested by a cough, other than asthma, is remanded. 2. Entitlement to service connection for a gastrointestinal disability is remanded. 3. Entitlement to service connection for a disability characterized by fatigue and lightheadedness is remanded. In regard to lightheadedness and fatigue, the Veteran contends that he experienced symptoms while serving in the Gulf War and that these symptoms have been chronic ever since and gradually worsened since his Gulf War service. See October 2017 VA Form 9; July 2015 Notice of Disagreement. He also contends that fatigue and lightheadedness are caused by his uncontrollable coughing episodes and/or his now service-connected headaches. See December 2007 VA Form 9; June 2014 statement. He indicates that his fatigue affects his ability to work and that his lightheadedness causes him to pass out, which is dangerous for him when driving. See June 2014 statement. As for his respiratory condition, he contends that, at times, the coughing causes him to become lightheaded and pass out, which is dangerous when driving, and that the coughing causes muscle pain. Id. With regard to his gastrointestinal disability, the Veteran contends that his digestive problems worsened while he was serving in Southwest Asia and have remained chronic. See October 2017 VA Form 9; July 2014 statement. He reports five bowel movements per day, diarrhea, and stomach aches. See July 2014 statement in support of claim. He contends that his gastrointestinal problems are not in his medical records as he prefers not to speak about them to anyone. See July 2015 Notice of Disagreement. As to the claimed respiratory illness (other than asthma), the Veteran reports at least two to three coughing episodes per day, with as many as ten to fifteen episodes on some days. He states that, at times, the coughing causes him to become lightheaded and pass out, which is dangerous when driving. He also contends that the coughing causes muscle pain. See June 2014 statement. In a February 2010 VA examination and May 2010 addendum opinion, the examiner diagnosed the Veteran's symptoms of cough, shortness of breath, and wheezing as an undiagnosed illness and noted that the problem is associated with asthma. A May 2015 VA examiner diagnosed asthma only. However, the Veteran contends that the asthma medications do not provide relief for his condition, suggesting there is a separate respiratory issue. See June 2014 statement. Thus, the Veteran claims service connection is warranted for symptoms related to fatigue, lightheadedness, a respiratory condition, and a gastrointestinal condition, and that it is unclear whether there are definitive diagnoses associated with these symptoms, or whether they may be symptoms of an undiagnosed illness or a medically unexplained chronic multi-symptom illness (MUCMI). The Veteran is a 'Persian Gulf veteran' as defined by regulation. See 38 C.F.R. § 3.317; DD Form 214. Under 38 C.F.R. § 3.317, 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 not later than December 31, 2021. See 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness (MUMCI); and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117; 38 C.F.R. § 3.117, unlike those for 'direct service connection,' there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. at 8-9. Further, laypersons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see Jandreau v. Nicholson, 19 Vet. App. 470 (2006). A MUCMI is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the VA Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi-symptom illness. A "medically unexplained chronic multi-symptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). 'Objective indications of chronic disability' include both 'signs,' in the medical sense of 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). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). In December 2019, the Board remanded these claims to afford the Veteran VA examinations to thoroughly discuss his symptoms, individually and collectively, to determine whether there are known diagnoses, or whether there is an undiagnosed illness or a MUCMI. In February 2020, the Veteran underwent VA chronic fatigue syndrome and esophageal condition examinations. The Veteran was also afforded a respiratory conditions examination in December 2020. With regard to fatigue, the VA examiner opined that the Veteran's fatigue and lightheadedness were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. She explained that the objective examination was normal and that the Veteran's symptoms were "subjective". There was no objective evidence of chronic fatigue or lightheadedness in the record. There was a diagnosis for Circadian Rhythm Sleep Disorder. A progress note indicated that medication had improved the condition and that this was the cause of the Veteran's fatigue. The VA examiner concluded that that the Veteran's fatigue and lightheadedness were less likely than not related to a specific exposure event from the Veteran's active service. This opinion is inadequate because it provides no rationale as to the etiological relationship between the Veteran's Circadian Rhythm Sleep Disorder and his active service. The Veteran has reported the onset of his fatigue began during active service. A remand is required for an adequate addendum opinion. The VA examiner also diagnosed gastroesophageal reflux disease (GERD) based upon a review of the record. She opined that the Veteran's GERD was less likely than not related to his active service. She elaborated that the Veteran's GERD was diagnosed 17 years after his deployment to Southwest Asia and was highly unlikely to be related to service. The medical literature did not support an association between the Veteran's GERD and his service in Southwest Asia. This opinion is inadequate because it does not address the Veteran's reports of gastrointestinal problems that began during service and were manifested by five bowel movements per day, diarrhea, and stomach aches. A remand is required to obtain an adequate VA addendum opinion. With regard to the claim for a respiratory condition other than asthma, the VA examiner found that the Veteran's persistent cough was less likely than not related to active service. She attributed the cough to the Veteran's GERD. However, the VA examination report includes a diagnosis of a persistent cough since 1993. The evidence of record indicates that the Veteran's GERD was diagnosed later. The Board finds that this opinion is inadequate because it is contradictory. The VA examiner indicated that the persistent cough began during service, but it is also related to GERD. The evidence might also suggest that the Veteran's GERD had its onset during service and was manifested by persistent coughing but was diagnosed later. A remand is required to obtain an addendum opinion. Finally, an opinion has not been provided regarding whether these symptoms are part of an undiagnosed illness or a MUCMI. For the forgoing reasons, a remand is required. The matters are REMANDED for the following actions: 1. Obtain addendum opinions for an appropriate clinician. After reviewing the claims file and interviewing and examining the Veteran, the clinician is asked to address the following: (a) Indicate all diagnoses currently shown manifested by fatigue, Circadian Rhythm Sleep Disorder, lightheadedness, chronic coughing (other than the service-connected asthma), and gastrointestinal symptoms, and all related signs and symptoms. (b) If any disorder/symptom claimed is part of an already service-connected disability, please state so. The Board notes that the Veteran is service connected for posttraumatic stress disorder; asthma, irritant induced with bronchitis; a left elbow disability; and, migraine headaches. (c) For any other known diagnosis manifested by fatigue, Circadian Rhythm Sleep Disorder lightheadedness, chronic coughing (other than the service-connected asthma), and/or gastrointestinal symptoms, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that it had its onset during the Veteran's active service or was otherwise related to his active service, to include his service in the Southwest Asia Theater of Operations. The examiner must acknowledge and consider the Veteran's statement that he experienced fatigue while serving in the Gulf War and his fatigue and lightheadedness have been chronic ever since and gradually worsened since that time. The examiner must also acknowledge and consider the Veteran's statement that his digestive problems worsened while he was serving in the Southwest Asia theater of operations and have remained chronic. If not directly related to service, the examiner should discuss whether any known diagnosis manifested by fatigue, Circadian Rhythm Sleep Disorder, lightheadedness, chronic coughing (other than the service-connected asthma), and/or gastrointestinal symptoms is proximately due to, the result of, or aggravated by any of the Veteran's service-connected disabilities (listed above)? The examiner must acknowledge and consider the Veteran's statement that his condition characterized by fatigue and lightheadedness is caused by his coughing episodes and/or by his service-connected headaches. The examiner must also acknowledge the July 2014 VA examiner's opinion that the Veteran's diagnosis of PTSD contributes to his fatigue. (d) For any fatigue, Circadian Rhythm Sleep Disorder, lightheadedness, chronic coughing (other than the service-connected asthma), and/or gastrointestinal symptoms that cannot be associated with a specific diagnosis, the examiner is asked to discuss whether it is associated with either an undiagnosed illness or a medically unexplained chronic multi-symptom illness that may be associated with the Veteran's Gulf War service. The report should include reasons for any opinion expressed. If the clinician completing the report is unable to provide an opinion without resort to speculation, he or she should state whether the inability is due to the limits of the person's knowledge, the limits of medical knowledge in general, or there is additional evidence that would permit the needed opinion to be provided. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. If the benefits sought are not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R.R. Watkins, 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.