Citation Nr: 21011124 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 16-04 010 DATE: March 1, 2021 REMANDED Entitlement to service connection for a right elbow disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. Entitlement to service connection for a left elbow disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. Entitlement to service connection for a right hip disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. Entitlement to service connection for a left hip disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. Entitlement to service connection for a low back disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. Entitlement to service connection for a right knee disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. Entitlement to service connection for a left knee disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. Entitlement to service connection for a skin disorder (previously claimed as skin irritation/rash of the back, chest and shoulders), including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. Entitlement to service connection for constipation and diarrhea, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. Entitlement to service connection for gastritis, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. Entitlement to service connection for nerve twitching of the chest, back, and legs, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. Entitlement to service connection for an acquired psychiatric disorder (previously claimed as insomnia, anxiety, and night sweats), including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. REASONS FOR REMAND The Veteran had active duty service from August 1985 to May 1992, including service in the Southwest Asia theater of operations. In June 2019, the Veteran appeared at a Board videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. 1. Entitlement to service connection for a right elbow disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. 2. Entitlement to service connection for a left elbow disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. 3. Entitlement to service connection for a right hip disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. 4. Entitlement to service connection for a left hip disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. 5. Entitlement to service connection for a low back disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. 6. Entitlement to service connection for a right knee disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. 7. Entitlement to service connection for a left knee disorder, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. 8. Entitlement to service connection for a skin disorder (previously claimed as skin irritation/rash of the back, chest and shoulders), including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. 9. Entitlement to service connection for constipation and diarrhea, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. 10. Entitlement to service connection for gastritis, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. 11. Entitlement to service connection for nerve twitching of the chest, back, and legs, including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. 12. Entitlement to service connection for an acquired psychiatric disorder (previously claimed as insomnia, anxiety, and night sweats), including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia is remanded. The Veteran seeks entitlement to the above conditions. For Persian Gulf War veterans (as is the case here), service connection for chronic, undiagnosed illnesses (or a medically unexplained chronic multi-symptom illness such as fibromyalgia, chronic fatigue syndrome, or functional gastrointestinal disorders) arising from service in Southwest Asia during the Persian Gulf War may be established under 38 U.S.C. § 1117 (2012) and 38 C.F.R. § 3.317 (2019). Under those provisions, service connection may be established for objective indications of a chronic disability resulting from an undiagnosed illness or illnesses, provided that such disability (1) became manifest in service on active duty in the Armed Forces 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, 2021; and (2) by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. To fulfill the requirement of chronicity, the illness must have persisted for six months. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317(b). Initially, the Board notes that the Veteran’s service records are mostly silent for any complaints of or treatment for the above conditions. However, there is some treatment for low back pain, which appears to have resolved upon separation from service. The Veteran also sought treatment for nightmares and sleep difficulty as well as several skin conditions, which may also have resolved. These records also contain treatment for intermittent diarrhea and vomiting, with an impression of acute gastroenteritis. The Board further notes that the Veteran has received some VA and private treatment for multiple conditions, including complaints of joint pain/fibromyalgia, digestive problems, and dermatological flare-ups. He has also received some mental health therapy and treatment. The Veteran underwent a VA Gulf War General Medical examination in July 2012, wherein he was noted to suffer from a skin disorder, intestinal disorder, various joint pain, and a mental disorder. With respect to the skin disorder, he was diagnosed with dermatitis or eczema that had since resolved. The examiner stated that since no diagnosis was found and the skin examination was normal, an opinion was not necessary. The examiner then found that the Veteran’s intestinal disorder is due to over the counter or prescribed medications and illicit drug use. There were no further remarks. With respect to the back disorder, the examiner stated that the Veteran first complained of back pain in 1997 around the time of a motor vehicle accident. The examiner found that the back disorder is less likely than not attributable to service. Upon psychiatric examination, the examiner provided an Axis I diagnosis of polysubstance dependence and alcohol abuse and stated that the Veteran’s night sweats, anxiety and insomnia are a part of his polysubstance abuse. The examiner further noted several inconsistencies were identified on exam and a maladaptive pattern of alcohol abuse and problems related to using mushrooms, ecstasy, Xanax, cannabis and Percocet were reported. The examiner also stated that the Veteran’s complaints of nerve twitching are related to his claimed mental health symptoms and substance abuse. The Board observes that the VA Gulf War general medical examination did not yield diagnoses of fibromyalgia or chronic fatigue syndrome, so etiological opinions with respect to the remaining joints were not provided. The Veteran later received another VA stomach examination in October 2013, wherein he was diagnosed with irritable bowel syndrome (IBS). The examiner stated that the condition is less likely than not attributable to service, including the in-service treatment for gastroenteritis. The examiner reasoned that according to medical literature: Gastroenteritis is a temporary and self-limiting condition caused by pathogenic organism. However, the veteran’s documented IBS is an organic condition which is not related to a pathogen. The Veteran claims he has gulf war syndrome, and if he falls into that category, his IBS is one of the presumptive gulf war syndromes. During the July 2019 Board hearing, the Veteran and his representative challenged the adequacy of the previous VA opinions, reasoning that there is insufficient rationale and conflicting information. It is also alleged that the prior VA examiners did not acknowledge the Veteran’s subjective complaints of injuries sustained during service. Given the Veteran’s statements and the significant time period since the Veteran’s previous VA examinations and opinions, the Board finds that new VA examinations would be of considerable assistance in determining his claim. Finally, there may be outstanding or pertinent treatments available for review. The Board finds that it would be prudent for an attempt to obtain any outstanding treatment records be made. The matters are REMANDED for the following action: 1. With the assistance of the Veteran as necessary, identify and obtain any outstanding, relevant treatment records, and associate them with the Veteran’s electronic claims file. If the Agency of Original Jurisdiction (AOJ) cannot locate or obtain such records, it must specifically document the attempts that were made to locate or obtain them, and explain in writing why further attempts to locate or obtain any government records would be futile. The AOJ must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. All attempts to obtain records should be documented in the Veteran’s electronic claims file. 2. Thereafter, but whether or not additional treatment records are obtained, schedule the Veteran for VA examinations with an examiner(s) of appropriate expertise to determine the nature and etiology of his claimed 1) bilateral elbow disorder; 2) bilateral hip disorder; 3) low back disorder; 4) bilateral knee disorder; 5) skin disorder; 6) constipation and diarrhea; 7) gastritis; and 8) nerve twitching of the chest, back, and legs, all claimed to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia The claims file must be made available to and reviewed by any examiner. The examiner(s) is/are asked to make the following determinations: a) Provide a current diagnosis for the Veteran’s claimed 1) bilateral elbow disorder; 2) bilateral hip disorder; 3) low back disorder; 4) bilateral knee disorder; 5) skin disorder; 6) constipation and diarrhea; 7) gastritis; and 8) nerve twitching of the chest, back, and legs. b) Is the Veteran’s disability pattern for each identified disorder consistent with: (1) a diagnosable but medically unexplained chronic multi symptom illness of unknown etiology, (2) a diagnosable chronic multi symptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? c) If the Veteran’s disability pattern for each identified disorder is either a diagnosable chronic multi-symptom illness with a partially explained etiology, or a disease with a clear and specific etiology and diagnosis, is it related to presumed environmental exposures experienced by the Veteran during service in the Persian Gulf? d) Is it at least as likely as not (50 percent or greater probability) that any currently diagnosed 1) bilateral elbow disorder; 2) bilateral hip disorder; 3) low back disorder; 4) bilateral knee disorder; 5) skin disorder; 6) constipation and diarrhea; 7) gastritis; and 8) nerve twitching of the chest, back, and legs began in-service, was caused by service, or is otherwise related to service, including presumed environmental exposures during service in the Persian Gulf? The examiner should address the Veteran’s continuity of symptoms since separation from service. The examiner should specifically address the Veteran’s documented in-service treatment for several conditions, as well as relevant VA and private. The reviewer should set forth the medical reasons for accepting or rejecting the statements of continuity of symptoms since service. A complete rationale must be provided for any opinion. All prior reports should be reconciled, as needed. 3. Additionally, schedule the Veteran for a VA examination with a VA examiner of appropriate expertise to determine the nature and etiology of his claimed acquired psychiatric disorder (previously claimed as insomnia, anxiety, and night sweats), including as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness as a result of exposure to environmental contaminants in Southwest Asia. The examiner is to be provided access to the Veteran’s electronic claims file and must specify in the report that these records have been reviewed. (a) After the review of the electronic claims file and examination of the Veteran, the examiner should identify and state all acquired psychiatric disorders found. An explanation for any opinions expressed must be provided, and if the requested information cannot be provided without resort to speculation, the examiner should so state and explain why. It should be noted that polysubstance dependence and alcohol abuse is not considered by the VA as disability for which compensation may be granted. (b) If the examiner does not find any acquired psychiatric disorder(s) or finds that a diagnosis of such is not appropriate, the examiner should give specific reasoning for that conclusion. If no disorder is found the examiner must express whether the disorder existed earlier in the appeal period and the examiner should clearly explain why the noted evidence does not establish a chronic diagnosis. (c) If and only if the examiner finds that any acquired psychiatric disorder(s) is/are present, or was/were present at any time during the appeal period though it has since resolved, the examiner should then opine whether the Veteran’s identified disorder(s) at least as likely as not (50 percent or greater probability) began in or is otherwise the result of military service. The examiner should specifically address the Veteran’s contentions and his lay statements regarding onset of symptomatology and any continuity of symptomatology since discharge from service or since onset of symptomatology. The examiner should also address and reconcile any previous examination reports, as well as any other pertinent evidence of record, as necessary. The examiner must provide a complete rationale for any opinions expressed, based on the examiner’s clinical experience, medical expertise, and established medical principles. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 4. After the development requested has been completed, the AOJ should review any report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures at once. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Miller, 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.