Citation Nr: 21027457 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 14-25 574 DATE: May 5, 2021 REMANDED 1. Service connection for a respiratory disorder. 2. Service connection for a lung disorder. 3. Service connection for high blood pressure. 4. Service connection for a joint disorder. 5. Service connection for colon polyps. 6. Service connection for a urinary disorder. 7. Service connection for a skin disorder. 8. Service connection for a menstrual disorder. 9. Service connection for anemia. REASONS FOR REMAND The Veteran served on active duty from September 1990 to August 1991 with additional Reserve service. The case is on appeal from July 2012 and November 2013 rating decisions. In November 2015, the Veteran testified at a Board hearing. Most recently, in May 2020, the Board remanded the claims of appeal for additional development. 1. Service connection for a respiratory disorder. 2. Service connection for a lung disorder. 3. Service connection for high blood pressure. 4. Service connection for a joint disorder. 5. Service connection for colon polyps. 6. Service connection for a urinary disorder. 7. Service connection for a skin disorder. 8. Service connection for a menstrual disorder. 9. Service connection for anemia. The Veteran contends that she has respiratory, lung, blood pressure, joint, urinary, menstrual, and skin disorders, as well as colon polyps and anemia, due to Gulf War service in Saudi Arabia. During the November 2015 Board hearing, she reported being exposed to vehicle exhaust, sand, mold, and smoke and soot from burning oil wells while serving in Dhahran, Saudi Arabia. She also reported experiencing sinus and upper respiratory symptoms, high blood pressure, weakness, urinary incontinence, menstrual problems, and itching on her back during such service. She further reported being diagnosed with bursitis and colon polyps in 2012, but denied being diagnosed with fibromyalgia. In an August 2016 correspondence, the Veteran reported taking Pyridostigmine Bromide pills and being exposed to pesticides, missile launches, and burning garbage and human waste while serving in Saudi Arabia. She also reported experiencing the onset of fatigue, joint pain, respiratory symptoms, hypertension, and skin rash not long after returning from Saudi Arabia. In an April 2017 correspondence, the Veteran reported that high blood pressure causes swelling in her bilateral upper and bilateral lower extremity joints. In a February 2018 correspondence, she reported that she has several skin conditions that are due to Gulf War service. The Veteran's service personnel records (SPRs) show that she served in Southwest Asia during the Gulf War from November 1990 to July 1991. Her file also includes STRs from December 1990 indicating treatment for a sinus condition that was assessed as probable sinusitis. In June 1993, the Veteran was treated for sinus and chest congestion. The treatment provider assessed her with upper respiratory congestion. However, most of the Veteran's SPRs and STRs are unavailable. The Veteran's post-service VA treatment records note conditions including Raynaud phenomenon, foot and ankle conditions, allergic rhinitis, and carpal tunnel syndrome. Pursuant to a May 2016 Board remand, the Veteran was afforded examinations in regard to these claims in July 2017 and January 2018. The examiners reported diagnoses of allergic rhinitis in 2010, asthma in 2011, peroneal nerve neuropathy in 2014, Raynaud's syndrome in 2015, bilateral upper extremity carpal tunnel syndrome in 2016, right ankle tendonitis in 2013, hypertension in 2011, colon polyps as early as 2004, anemia in 2010, urinary incontinence in 2015, and uterine fibroids in 2013. However, the examiners found that these conditions are not due to the Veteran's service or in-service environmental exposures. In addition, in August 2018, a skin disorder opinion was obtained from a VA examiner. The examiner reported diagnoses of atopic dermatitis, eczematoid dermatitis, and pruritus of the back that are not related to service. Pursuant to the May 2020 Board remand, the Veteran was again afforded examinations in regard to these claims in October 2020. During the urinary incontinence examination, the Veteran reported receiving private treatment for the condition in October 2020 at the University of Texas Southwestern Medical Center. During the anemia examination, the examiner noted that the Veteran was found to have iron deficiency anemia possibly due to menorrhagia in 2014. The examiner also diagnosed the Veteran with a right knee strain and left knee meniscal condition. An examination in regard to the diagnosed allergic rhinitis was not performed. Thereafter, in January 2021, addendum opinions were obtained for these claims. However, the opinions did not adequately address whether the diagnosed conditions have unknown, partially explained, or known pathophysiologies and etiologies. Therefore, a remand is required to obtain additional examinations and opinions in regard to the claimed disorders. See Stewart v. Wilkie, 30 Vet. App. 383 (2018). In addition, on remand, the RO should attempt to associate treatment records from the University of Texas Southwestern Medical Center with the claims file. These claims are REMANDED for the following actions: 1. Afford the Veteran an opportunity to submit or identify any outstanding relevant treatment records, to include from the University of Texas Southwestern Medical Center. Obtain any identified records with the use of the Veteran's authorization as necessary. If such records are unavailable, the file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. After completing the records development indicated above, schedule the Veteran for an examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) by an appropriate clinician to determine the nature and etiology of the respiratory and lung conditions. The examiner is asked to address each of the following: (a.) List all respiratory and lung conditions present during the claims period, to specifically include allergic rhinitis and asthma. (b.) Provide a medical opinion explaining whether each condition, whether singly or in combination, is: i. an undiagnosed illness; ii. a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI) of unknown etiology or pathophysiology; iii. a diagnosable chronic multi-symptom illness with a partially explained etiology or pathophysiology, or; iv. a disease with a clear and specific etiology and diagnosis. (c.) For each condition found consistent with options (iii) or (iv) above, the examiner should explain the condition's pathophysiology as well as the etiology of the Veteran's condition. (d.) For each condition found consistent with options (iii) or (iv) above, the examiner should provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to the Veteran's service or is otherwise causally related to any event or circumstance of service, to include taking Pyridostigmine Bromide pills or environmental exposures including vehicle and missile exhaust, sand, mold, and smoke and soot from burning oil wells, garbage, and human waste. A rationale should be provided for opinions expressed. 3. Also, schedule the Veteran for an examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) by an appropriate clinician to determine the nature and etiology of the high blood pressure. The examiner is asked to address each of the following: (a.) List all the blood pressure conditions present during the claims period, to specifically include hypertension. (b.) Provide a medical opinion explaining whether each condition, whether singly or in combination, is: i. an undiagnosed illness; ii. a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI) of unknown etiology or pathophysiology; iii. a diagnosable chronic multi-symptom illness with a partially explained etiology or pathophysiology, or; iv. a disease with a clear and specific etiology and diagnosis. (c.) For each condition found consistent with options (iii) or (iv) above, the examiner should explain the condition's pathophysiology as well as the etiology of the Veteran's condition. (d.) For each condition found consistent with options (iii) or (iv) above, the examiner should provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to the Veteran's service or is otherwise causally related to any event or circumstance of service, to include taking Pyridostigmine Bromide pills or environmental exposures including vehicle and missile exhaust, sand, mold, and smoke and soot from burning oil wells, garbage, and human waste. (e.) The examiner should state whether hypertension had its onset within one year of discharge from service. A rationale should be provided for opinions expressed. 4. Also, schedule the Veteran for an examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) by an appropriate clinician to determine the nature and etiology of the joint conditions. The examiner is asked to address each of the following: (a.) List all the joint conditions present during the claims period, to specifically include bilateral upper extremity and bilateral lower extremity conditions including peroneal nerve neuropathy, Raynaud's disease, carpal tunnel syndrome, right ankle tendonitis, right knee strain, left knee meniscal condition. (b.) Provide a medical opinion explaining whether each condition, whether singly or in combination, is: i. an undiagnosed illness; ii. a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI) of unknown etiology or pathophysiology; iii. a diagnosable chronic multi-symptom illness with a partially explained etiology or pathophysiology, or; iv. a disease with a clear and specific etiology and diagnosis. (c.) For each condition found consistent with options (iii) or (iv) above, the examiner should explain the condition's pathophysiology as well as the etiology of the Veteran's condition. (d.) For each condition found consistent with options (iii) or (iv) above, the examiner should provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to the Veteran's service or is otherwise causally related to any event or circumstance of service, to include taking Pyridostigmine Bromide pills or environmental exposures including vehicle and missile exhaust, sand, mold, and smoke and soot from burning oil wells, garbage, and human waste. (e.) The examiner should state whether any diagnosed arthritis had its onset within one year of discharge from service. (f.) The examiner should also provide a medical opinion as to whether it is at least as likely as not that each diagnosed condition is caused or aggravated by high blood pressure or hypertension. Aggravation means an increase in severity beyond the natural progress of the disease. A rationale should be provided for opinions expressed. 5. Also, schedule the Veteran for an examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) by an appropriate clinician to determine the nature and etiology of the colon polyps. The examiner is asked to address each of the following: (a.) Provide a medical opinion explaining whether the colon polyps are: i. an undiagnosed illness; ii. a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI) of unknown etiology or pathophysiology; iii. a diagnosable chronic multi-symptom illness with a partially explained etiology or pathophysiology, or; iv. a disease with a clear and specific etiology and diagnosis. (b.) For each condition found consistent with options (iii) or (iv) above, the examiner should explain the condition's pathophysiology as well as the etiology of the Veteran's condition. (c.) For each condition found consistent with options (iii) or (iv) above, the examiner should provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to the Veteran's service or is otherwise causally related to any event or circumstance of service, to include taking Pyridostigmine Bromide pills or environmental exposures including vehicle and missile exhaust, sand, mold, and smoke and soot from burning oil wells, garbage, and human waste. A rationale should be provided for opinions expressed. 6. Also, schedule the Veteran for an examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) by an appropriate clinician to determine the nature and etiology of the urinary conditions. The examiner is asked to address each of the following: (a.) List all the urinary conditions present during the claims period, to specifically include urinary incontinence. (b.) Provide a medical opinion explaining whether the urinary incontinence, whether singly or in combination with other conditions, is: i. an undiagnosed illness; ii. a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI) of unknown etiology or pathophysiology; iii. a diagnosable chronic multi-symptom illness with a partially explained etiology or pathophysiology, or; iv. a disease with a clear and specific etiology and diagnosis. (c.) For each condition found consistent with options (iii) or (iv) above, the examiner should explain the condition's pathophysiology as well as the etiology of the Veteran's condition. (d.) For each condition found consistent with options (iii) or (iv) above, the examiner should provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to the Veteran's service or is otherwise causally related to any event or circumstance of service, to include taking Pyridostigmine Bromide pills or environmental exposures including vehicle and missile exhaust, sand, mold, and smoke and soot from burning oil wells, garbage, and human waste. A rationale should be provided for opinions expressed. 7. Also, schedule the Veteran for an examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) by an appropriate clinician to determine the nature and etiology of the skin conditions. The examiner is asked to address each of the following: (a.) List all skin conditions present during the claims period, to specifically include atopic dermatitis, eczematoid dermatitis, and pruritis. (b.) Provide a medical opinion explaining whether each condition, whether singly or in combination, is: i. an undiagnosed illness; ii. a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI) of unknown etiology or pathophysiology; iii. a diagnosable chronic multi-symptom illness with a partially explained etiology or pathophysiology, or; iv. a disease with a clear and specific etiology and diagnosis. (c.) For each condition found consistent with options (iii) or (iv) above, the examiner should explain the condition's pathophysiology as well as the etiology of the Veteran's condition. (d.) For each condition found consistent with options (iii) or (iv) above, the examiner should provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to the Veteran's service or is otherwise causally related to any event or circumstance of service, to include taking Pyridostigmine Bromide pills or environmental exposures including vehicle and missile exhaust, sand, mold, and smoke and soot from burning oil wells, garbage, and human waste. A rationale should be provided for opinions expressed. 8. Also, schedule the Veteran for an examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) by an appropriate clinician to determine the nature and etiology of the menstrual conditions. The examiner is asked to address each of the following: (a.) List all menstrual conditions present during the claims period, to specifically include uterine fibroids, menorrhagia, and leiomyoma. (b.) Provide a medical opinion explaining whether each condition, whether singly or in combination, is: i. an undiagnosed illness; ii. a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI) of unknown etiology or pathophysiology; iii. a diagnosable chronic multi-symptom illness with a partially explained etiology or pathophysiology, or; iv. a disease with a clear and specific etiology and diagnosis. (c.) For each condition found consistent with options (iii) or (iv) above, the examiner should explain the condition's pathophysiology as well as the etiology of the Veteran's condition. (d.) For each condition found consistent with options (iii) or (iv) above, the examiner should provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to the Veteran's service or is otherwise causally related to any event or circumstance of service, to include taking Pyridostigmine Bromide pills or environmental exposures including vehicle and missile exhaust, sand, mold, and smoke and soot from burning oil wells, garbage, and human waste. A rationale should be provided for opinions expressed. 9. Also, schedule the Veteran for an examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) by an appropriate clinician to determine the nature and etiology of the anemia. The examiner is asked to address each of the following: (a.) Provide a medical opinion explaining whether the anemia is: i. an undiagnosed illness; ii. a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI) of unknown etiology or pathophysiology; iii. a diagnosable chronic multi-symptom illness with a partially explained etiology or pathophysiology, or; iv. a disease with a clear and specific etiology and diagnosis. (b.) For each condition found consistent with options (iii) or (iv) above, the examiner should explain the condition's pathophysiology as well as the etiology of the Veteran's condition. (c.) For each condition found consistent with options (iii) or (iv) above, the examiner should provide a medical opinion as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to the Veteran's service or is otherwise causally related to any event or circumstance of service, to include taking Pyridostigmine Bromide pills or environmental exposures including vehicle and missile exhaust, sand, mold, and smoke and soot from burning oil wells, garbage, and human waste. (d.) The examiner should also provide a medical opinion as to whether it is at least as likely as not that the anemia is caused or aggravated by a menstrual condition. Aggravation means an increase in severity beyond the natural progress of the disease. A rationale should be provided for opinions expressed. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Jimerfield 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.