Citation Nr: 22005263 Decision Date: 02/01/22 Archive Date: 02/01/22 DOCKET NO. 18-28 397 DATE: February 1, 2022 REMANDED 1. Entitlement to service connection for anemia, including as due to a qualifying chronic disability to include as an undiagnosed illness, is remanded. 2. Entitlement to service connection for a skin disability, to include dermatitis, including as due to a qualifying chronic disability to include as an undiagnosed illness, is remanded. 3. Entitlement to service connection for hypoglycemia, including as due to a qualifying chronic disability to include as an undiagnosed illness, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 2005 to November 2006, December 2005 to November 2006, and from December 2007 to March 2008, with additional reserve service. In September 2021, the Veteran provided testimony in a virtual Board hearing before undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the claims file. 1. Entitlement to service connection for anemia is remanded. 2. Entitlement to service connection for a skin disability, to include dermatitis, is remanded. 3. Entitlement to service connection for hypoglycemia is remanded. The Board finds that remand is warranted to fully assist the Veteran with the development of her claims. VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, and there is insufficient medical evidence of record to decide the claim. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon, 20 Vet. App. at 79. When VA undertakes to obtain an examination, it must ensure that the examination and opinion therein is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran was provided VA examinations for her claimed skin disability, anemia, and hypoglycemia in August 2014; however, no opinions were provided as to whether these claimed disabilities were caused by or otherwise related to service. Moreover, the Veteran had qualifying service in the Southwest Asia during the Persian Gulf War, as service personnel records provide evidence of deployment to Iraq from March 2006 to October 2006. The Board has broadened the appeals to include the theory of presumptive service connection as due to a qualifying chronic disability (see 38 U.S.C. § 1117; 38 C.F.R. § 3.317). A "qualifying chronic disability" means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) a medically unexplained chronic multi-symptom illnesses that is defined by a cluster of signs or symptoms. 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. Significantly, the Veteran has not been provided with a VA examination that addresses her service in the Southwest Asian Theatre of operations during the Persian Gulf War and any nexus between the claimed disabilities and to exposure to environmental hazards during that time. The Veteran reiterated during the September 2021 Board hearing that she was also claiming hypoglycemia and anemia as due to an undiagnosed illness and that she was exposed to burn pits in Iraq. Specifically, for the claimed skin disability, during the September 2021 Board hearing, the Veteran testified that she frequently broke out with rashes on multiple parts of her body, including both sides of her hips, ankles, back, neck, and scalp. She reported that she had the rash on the inside of her thighs the week prior and at the time had it on the back of her scalp. The Veteran explained that she believed it was related to being in the Gulf and that while it may have started after service, she was not entirely sure if she had misdiagnosed chicken pox during service that was possibly the first rash. The Veteran indicated that she was exposed to burn pits in Iraq and that she contracted chicken pox from one of the detainees. As such, remand is necessary in order to provide the Veteran with a new VA examination and to obtain VA opinions regarding any nexus between the claimed disabilities and service. Additionally, the Board notes that there are outstanding medical records that are potentially relevant to the issues on appeal. For example, in an October 2013 statement, the Veteran indicated that she was diagnosed with hypoglycemia and anemia in the summer or fall of 2007 by a private physician, Dr. James Wieferich, in Barlow, Ohio. There a eight pages of medical records from Dr. Wieferich submitted by the Veteran, which indicates that the Veteran's initial visit was in March 2008 and in May 2008 she complained of episodes of nearly passing out which usually occurred when she was standing in formation with her Marine Reserve Unit. The Veteran questioned whether she had a blood sugar problem or that she might be anemic. A four-hour glucose tolerance test was performed, and CBC was checked. The latest records from Dr. Wieferich are from June 2010. There are also 16 pages of records from Dr. Teri Cook, in Belpre, Ohio, with the latest records from July 2013. December 2013 VA medical records document that the Veteran saw her non-VA primary care provider regularly and had received B-12 shots monthly. In a March 2014 VA medical record, the Veteran requested to see a non-VA provider close to her home for endocrinology. An April 2014 VA medical record indicates that the Veteran was going to try to get a glucometer to get a better handle over her hypoglycemic attacks and hyperthyroidism and was going to be visiting the endocrinologist on May 21, 2014. However, these private medical records were not submitted by the Veteran or otherwise associated with the claims file. The most recent VA medical records are from August 2014. Thus, as the Board finds that these records may be potentially relevant to the Veteran's claim, an effort must be made assist the Veteran to locate and associate any outstanding private medical records with the claims file and updated VA medical records should also be obtained. The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private medical records relevant to the claimed disabilities on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records, related to treatment of the claimed disabilities on appeal should be obtained; to include but are not limited to records from the following medical professionals: Dr. James Wieferich at Marietta Memorial Hospital Department of Primary Care Barlow, in Vincent, Ohio; Dr. Teri Cook at Marietta Memorial Hospital Department of Internal Medicine Belpre, in Belpre, Ohio; any other non-VA primary care provider ; a non-VA endocrinologist since March 2014; and any other private medical professional whose records would be relevant to the issues on appeal. Any negative response should be in writing and associated with the claims file. The Veteran may submit these records herself. 2. Obtain all outstanding VA treatment records, particularly since August 2014, and associate them with the claims file. 3. Schedule a VA Gulf War examination to assist in determining the nature and etiology of the claimed anemia, skin disability, and hypoglycemia. The Veteran's claims file should be made available to the examiner who must review the claims file. All appropriate tests, studies, and consultations should be accomplished, and all clinical findings should be reported in detail, to include current symptomatology. Examinations have been previously performed in July 2014 for each of the claimed disabilities on appeal. The agency of original jurisdiction is asked to provide a copy of the below facts to the examiner. The VA examiner's attention is drawn to the following facts with citations to the record, when applicable: The Veteran served on active duty from June 2005 to November 2006, December 2005 to November 2006, and from December 2007 to March 2008; with additional reserve service. The Veteran's Certificate of Release or Discharge from Active Duty (DD-214) indicates that her military occupational specialty (MOS) was a warehouse clerk. In an October 2013 statement, the Veteran claimed that she first began having issues with hypoglycemia and anemia while in Iraq in 2006, when she was passing out during formation. She indicated that her corpsman initially thought it was due to dehydration and was later diagnosed in the summer/fall of 2007 by a private physician. The Veteran indicated that she had dermatitis on her scalp and bilateral hips which began in 2007 but was undiagnosed until 2011 by her private primary care provider. See VBMS entry with document type, "VA Form 21-4138 Statement In Support of Claim," receipt date 03/31/2014. The Veteran testified during a September 2021 Board hearing that she believed that her skin disability was related to being in the Gulf and that while it may have started after service, she was not entirely sure if she had been misdiagnosed as having chicken pox during service that was possibly the first rash. The Veteran reported that she was exposed to burn pits in Iraq and that she contracted chicken pox from one of the detainees. See VBMS entry with document type, "Hearing Transcript," receipt date 09/17/2021, on pages 12 15, generally. The Veteran explained that she was also claiming hypoglycemia and anemia as due to an undiagnosed illness and that she was exposed to burn pits. See id. on pages 3-4, generally. The Veteran stated that the first time she passed out was when she was at an Angel Flight ceremony on standby due to brownout condition. She indicated that one of the medics from Charlie medical wanted to take her into the facility to have her tested but the medical chief did not want her to go back to the unit and told her that she was dehydrated and forced her to chug water but no testing was performed to show that she was actually dehydrated. Id. at 5, generally. In an Adult Preventive and Chronic Care Flowsheet, DD Form 2766, first dated December 2005 and last dated May 2011, under chronic illness, "hypoglycemia reported by self" and "anemia reported by self" are documented. See VBMS entry with document type, "STR - Medical," receipt date 02/26/2013, with "#1" in the subject field, on page 1. July 2006 service treatment records reflect "suspected varicella resolving" and a "viral exanthem" that resembled "atypical chickenpox." See VBMS entry with document type, "STR - Medical," receipt date 02/26/2013, with "#1" in the subject field, on pages 71-76. In May 2008 private medical records, the Veteran complained of episodes of nearly passing out, which usually occurred when she was standing in formation with her Marine Reserve Unit. The Veteran questioned whether she had a blood sugar problem or that she might be anemic. A 4-hour glucose tolerance test was performed and CBC was checked. The physician noted that the description "really sounds more like a vasovagal reaction," and the Veteran was advised to maintain adequate hydration. See VBMS entry with document type, "Medical Treatment Record - Non-Government Facility," receipt date 03/31/2014, with "#2" in the subject field, on page 6. In a Dental Health Questionnaire, signed by the Veteran in October 2007, August 2007, October 2008, and February 2009, she denied a history of anemia. See VBMS entry with document type, "STR - Medical," receipt date 02/26/2013, with "#2" in the subject field, on page 80. In a July 2009 post-partum examination, the physician's impression included anemia. See VBMS entry with document type, "STR - Medical," receipt date 02/26/2013, with "#1" in the subject field, on page 54. In October 2009 and January 2010 Adult Screening and Immunization Documentation Forms, the Veteran answered "no" when asked if she had a chronic health problem, to include anemia. See VBMS entry with document type, "STR - Medical," receipt date 02/26/2013, with "#1" in the subject field, on pages 30-31. In a Dental Health Questionnaire, signed by the Veteran in January 2010 and January 2011, she documented that she had a positive history of anemia. See VBMS entry with document type, "STR - Medical," receipt date 02/26/2013, with "#2" in the subject field, on page 79. A November 2012 private medical record includes an assessment of contact dermatitis. See VBMS entry with document type, "Medical Treatment Record - Non-Government Facility," receipt date 03/31/2014, with "#2" in the subject field, on page 17. A December 2013 VA treatment record indicates that the Veteran saw her non-VA primary care physician regularly and got B12 shots monthly. See VBMS entry with document type, "CAPRI," receipt date 04/18/2018, on pages 179-181. A January 2014 VA treatment record shows the Veteran reported fatigue, low energy, and excessive sleep. She attributed these symptoms to her B12 deficiency. See VBMS entry with document type, "CAPRI," receipt date 04/18/2018, on pages 160-161. A March 2014 VA medical record reflects an episode of "hypoglycemia." The Veteran stated that she had times when she had dizziness and lightheaded. The Veteran failed a 6-hour glucose tolerance test when she was pregnant. See VBMS entry with document type, "CAPRI," receipt date 04/18/2018, on page 129. March 2014 VA medical records show the Veteran reported that she started to get sick while deployed to Iraq, passed out for the first time there and continued to have symptoms since she returned home. She noted that her commander ordered her to drink water because they thought she was only dehydrated. The medical professional noted that the Veteran understood that those symptoms fell under Gulf War syndrome. See VBMS entry with document type, "CAPRI," receipt date 04/18/2018, on pages 126-128. March 2014 VA laboratory results show some results were abnormal with the Veteran being instructed to keep her endocrinology appointment for the recurrent hypoglycemia episodes. See VBMS entry with document type, "CAPRI," receipt date 04/18/2018, on pages 130-131. An April 2014 VA medical record includes the Veteran's report that she was diagnosed with hypoglycemia in 2007 and that she had been modifying her diet to try to make the hypoglycemic spells less in number. She also stated that she had been diagnosed with hyperthyroidism, which has similar and overlapping symptoms, and was diagnosed with a B12 deficiency that apparently has normalized. See VBMS entry with document type, "CAPRI," receipt date 04/18/2018, on pages 117-118. A June 2014 VA medical record shows the Veteran stated that she did have hypoglycemic episodes and symptoms of hyperthyroidism, but apparently the endocrinologist said that both of these situations were fairly stable. The Veteran was confused as to where she stands in that respect, but she had some of the symptoms and was feeling better with Paxil. See VBMS entry with document type, "CAPRI," receipt date 04/18/2018, on page 93. A July 2014 VA examination for hematologic and lymphatic conditions shows the examiner noted a diagnosis of B-12 deficiency anemia. See VBMS entry with document type, "C&P Exam," receipt date 08/07/2014, with "#3" in the subject field, on pages 1-4. A July 2014 VA examination for skin diseases shows the examiner noted diagnoses of dermatitis and eczema. See VBMS entry with document type, "C&P Exam," receipt date 08/07/2014, with "#3" in the subject field, on pages 5-12. A July 2014 VA examination for diabetes mellitus shows the examiner noted a diagnosis of hypoglycemia. See VBMS entry with document type, "C&P Exam," receipt date 08/07/2014, with "#3" in the subject field, on pages 13-17. An April 2017 private medical record indicates patches of scaley skin on the anterior bilateral ankles for a month. The Veteran was noted to wear boots at her job with the Forest Service and had symptoms previously intermittent but "it moves around," and had been on her bilateral hips, back and neck. The Veteran indicated that the rash was once on her ankle and spread up her leg. See VBMS entry with document type, "Medical Evidence from Private Provider," receipt date 05/17/2018, on page 3, generally. VA is in the process of obtaining additional private treatment records that the Veteran identified and updated VA medical records. Thus, they may have been added to the file after January 2022. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. The VA examiner should note all reported symptoms, and specifically state whether any of the Veteran's complaints are attributable to a known diagnosis. If there are known diagnoses to which the Veteran's complaints are attributable, based upon a review of the record (including service treatment records, post-service treatment records, lay statements, history of the Veteran, and clinical findings), the examiner should offer the following opinions with supporting rationale with respect to each disorder (anemia, skin disability, and hypoglycemia): a) Please list the any confirmed diagnoses for the claimed: 1. anemia, 2. skin disability, and 3. hypoglycemia. b) For each diagnosis identified (1. anemia, 2. skin disability, and 3. hypoglycemia), did such disability have its onset during a period of active duty or is otherwise related to a period of active duty, which periods are from June 2005 to November 2006, December 2005 to November 2006, and from December 2007 to March 2008? Please state upon what facts, medical principles, and/or medical literature you base the opinion. Specifically, for the claimed skin disability, the examiner should address the July 10, 2006, service treatment record, which reflects a "viral exanthem" that resembled "atypical chickenpox" and the Veteran's reported exposure to "burn pits." (Location in VBMS file laid out above). c) If no diagnosis is identified, does the Veteran have a disability due to symptoms of or similar to (1) anemia; (2) a skin disorder; or (3) hypoglycemia? If so, did such disability have its onset in during a period of active duty or is otherwise related to a period of active duty, which periods are from June 2005 to November 2006, December 2005 to November 2006, and from December 2007 to March 2008? Please state upon what facts, medical principles, and/or medical literature the opinion is based. d) Notwithstanding any diagnosis or functional impairment identified, is the disorder(s) 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. Please state upon what facts, medical principles, and/or medical literature the opinion is based. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. After all available evidence has been associated with the record, review the evidence, and determine if further development is warranted. The AOJ should take any additional development as deemed necessary. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Cheng, 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.