Citation Nr: 22014576 Decision Date: 03/14/22 Archive Date: 03/14/22 DOCKET NO. 16-58 375A DATE: March 14, 2022 ORDER Entitlement to service connection for irritable bowel syndrome (IBS) is granted. Entitlement to service connection for a disorder manifested by indigestion and/or acid reflux/heartburn, diagnosed as dyspepsia, Barrett's esophagus without dysplasia, and esophageal reflux, is granted. Entitlement to service connection for a headache disorder, diagnosed as tension headaches, is granted. Entitlement to service connection for dermatopolymyositis is granted. Entitlement to service connection for fibromyalgia as secondary to service-connected dermatopolymyositis is granted. Entitlement to service connection for chronic fatigue syndrome as secondary to service-connected dermatopolymyositis is granted. FINDINGS OF FACT 1. The Veteran has been diagnosed with IBS, a medically unexplained chronic multisymptom illness (MUCMI), which has manifested to a degree of 10 percent or more and existed for 6 months or more, and he served in the Southwest Asia theater of operations. 2. The Veteran's disorder manifested by indigestion and/or acid reflux/heartburn, diagnosed as dyspepsia, Barrett's esophagus without dysplasia, and esophageal reflux, is at least as likely as not related to his active duty service. 3. The Veteran's headache disorder, diagnosed as tension headaches, is at least as likely as not related to his active duty service. 4. The Veteran's dermatopolymyositis is at least as likely as not related to his active duty service. 5. The Veteran's fibromyalgia is attributable to his service-connected dermatopolymyositis. 6. The Veteran's chronic fatigue syndrome is attributable to his service-connected dermatopolymyositis. CONCLUSIONS OF LAW 1. The criteria to establish entitlement to service connection for IBS have been met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. The criteria to establish entitlement to service connection for a disorder manifested by indigestion and/or acid reflux/heartburn, diagnosed as dyspepsia, Barrett's esophagus without dysplasia, and esophageal reflux, have been met. 38 U.S.C. §§ 1101, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303. 3. The criteria to establish entitlement to service connection for a headache disorder, diagnosed as tension headaches, have been met. 38 U.S.C. §§ 1101, 1154, 5103, 5103A, 5107; 38 C.F.R. § 3.303. 4. The criteria to establish entitlement to service connection for dermatopolymyositis have been met. 38 U.S.C. §§ 1101, 1154, 5103, 5103A, 5107; 38 C.F.R. § 3.303. 5. The criteria to establish entitlement to service connection for fibromyalgia as proximately due to, or the result of, the Veteran's service-connected dermatopolymyositis have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria to establish entitlement to service connection for chronic fatigue syndrome as proximately due to, or the result of, the Veteran's service-connected dermatopolymyositis have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the United States Army from March 1981 to February 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in July 2021. A transcript from that proceeding is associated with the claims file. The Board notes that the agency of original jurisdiction (AOJ) characterized one of the service connection claims on appeal as a service connection claim for acid reflux/heartburn. However, the Veteran's statements during the appeal period reflect that he also intended this claim to encompass symptoms of indigestion. See, e.g., July 2021 Statement. Consequently, the Board has recharacterized the issue as a service connection claim for a disorder manifested by indigestion and/or acid reflux/heartburn. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Service Connection 1. Entitlement to service connection for a bowel disorder, to include as due to an undiagnosed illness or MUCMI. 2. Entitlement to service connection for a disorder manifested by indigestion and/or acid reflux/heartburn, to include as due to an undiagnosed illness or MUCMI. 3. Entitlement to service connection for a headache disorder, to include as due to an undiagnosed illness or MUCMI. 4. Entitlement to service connection for a disorder manifested by muscle and joint pain, to include as due to an undiagnosed illness or MUCMI. 5. Entitlement to service connection for a disorder manifested by chronic fatigue, to include as due to an undiagnosed illness or MUCMI. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For veterans with service in the Southwest Asia theater of operations during the Persian Gulf War, service connection may be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under this law and regulation, 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 December 31, 2026. 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, qualifying chronic disabilities include, among other things, an undiagnosed illness and a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2). A MUCMI is 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 multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 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. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. 38 C.F.R. § 3.317. Signs or symptoms which may be manifestations of undiagnosed illness or MUCMI include, but are not limited to, fatigue, signs or symptoms involving skin, headaches, muscle pain, joint pain, neurological 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). Although entitlement to service connection on any of the presumptive bases noted above may not be established, a veteran is not precluded from establishing service connection on a direct basis. See 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis). An illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive and the determination of whether an illness is "medically unexplained" is particular to the claimant in each case. Stewart v. Wilkie, 30 Vet. App. 383, 389 (2018). Service connection may also be granted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 48 (1995) (en banc). In this case, the record has raised the theories that the Veteran has a bowel disorder, a disorder manifested by indigestion and/or acid reflux/heartburn, a headache disorder, a disorder manifested by muscle and joint pain, and a disorder manifested by chronic fatigue that are related to his active duty service and/or due to an undiagnosed illness or MUCMI as a result of his active duty service in the Southwest Asia theater of operations during the Persian Gulf War. The Board notes that as the Veteran's DD 214 for his period of active duty documents that he had service in Southwest Asia from January 3, 1991 to May 3, 1991, and service in Kuwait/Iraq from February 21, 2003 to July 1, 2003, the Veteran is considered a Persian Gulf veteran under 38 C.F.R. § 3.317(e). A review of the Veteran's STRs shows that all categories of the clinical evaluation were marked as normal in the February 1981 enlistment examination, and no history of any relevant complaints was indicated in the February 1981 Report of Medical History. Subsequent service examinations dated in March 1982, April 1987, August 1991, and April 1992 did not document any pertinent abnormalities. An August 1992 Report of Medical History also did not include reports for any relevant problems. A March 23, 1995 Report of Medical History was completed for the noted purpose of "Gulf physical." Under the statement of present health, the Veteran reported good, but he added that he felt tired all the time and had an upset stomach. He also marked that he had a history of dizziness or fainting spells; frequent indigestion; and stomach, liver, or intestinal trouble. He did not report having frequent or severe headaches or any other relevant problem. A March 23, 1995, service examination related to Desert Storm healthcare noted that the clinical evaluation of the Veteran's anus and rectum as well as his genitourinary system was deferred. No other relevant problem was noted. Under the summary of defects and diagnoses, the report stated that the Veteran had a normal physical examination. An upset stomach was noted, and the record indicated that gastroesophageal reflux disorder (GERD) and occult cholelithiasis needed to be ruled out. Fatigue was also noted. A subsequent March 30, 1995, STR related to the Veteran's Report of Medical History noted that the Veteran felt lightheaded when he rose from a chair. He also felt somewhat nauseated with greasy good. He did not experience vomiting, diarrhea, or abdominal pain. The record stated that he also complained of fatigue. While the Veteran reported feeling tired all the time, he did not feel as though this symptom limited him physically. The record indicated that the Veteran's thyroid function test was normal. On March 30, 1995, a radiologic consultation request/report indicated that imaging was requested in relation to the Veteran's symptom of nausea with greasy foods. An associated April 17, 1995, upper gastrointestinal radiologic report noted under the impression that it was a normal air contrast upper gastrointestinal series. As the study did not explain the Veteran's complaints, he was scheduled for an abdominal ultrasound examination in the next few days. A subsequent April 28, 1995, abdominal ultrasound that appeared to be related to this record noted an impression of normal abdominal ultrasound. A May 3, 1995, Comprehensive Clinical Evaluation Program (CCEP) Patient Questionnaire noted the Veteran's responses that while in the Gulf, he was exposed to smoke from oil fires and fumes of tent heaters as well as cigarette smoke (passive) from other smokers. The Veteran also reported exposure to diesel and/or other petrochemical fuel. In the CCEP Provider-Administered Symptom Questionnaire, the Veteran's chief current complaint was identified as fatigue with the date of onset noted to be June 1993. The record indicated that this symptom was always present. The Veteran's current complaints also included an upset stomach which he reported began in January 1992. In a May 3, 1995, STR labeled as Phase I CCEP Diagnosis Form, the primary diagnosis was fatigue, functional not otherwise specified (NOS). The secondary diagnoses "(ranked downward in importance)" were non ulcer dyspepsia, compression fracture T11, frequent upper respiratory infections, and orthostatic lightheadedness. A separate May 3, 1995, STR noted that the Veteran felt well with no recent problems with nausea and no abdominal pain. The record also appeared to reference the April 1995 upper gastrointestinal x-ray and gallbladder sonogram, noting that these tests were normal. The record stated that the Veteran did not feel his symptoms warranted further evaluation, and the provider stated that he would follow the Veteran in the clinic and arrange further workup if indicated. No abnormalities related to the Veteran's claims were noted in a subsequent January 1997 service examination. In the January 1997 Report of Medical History, however, the Veteran reported having frequent indigestion. The report explained that the Veteran experienced indigestion with certain foods, and he did not treat this complaint. A February 13, 2003, Pre-Deployment Health Assessment for a deployment to Southwest Asia, specifically Kuwait, noted the Veteran's report that his health in general was fair. The Veteran reported having current medical problems that he identified as back problems and side pains. He denied currently being on a profile, light duty, or undergoing a medical board. The provider found that no referral was indicated and the final medical disposition noted that the Veteran was deployable. A June 26, 2003, Post-Deployment Health Assessment was completed for the Veteran's deployment to Kuwait from February 24, 2003, to April 27, 2003; and to Iraq from April 28, 2003, to June 30, 2003. The Veteran reported that his health worsened during this deployment, and he had current symptoms that included weakness; muscle aches; dizziness, fainting, or lightheadedness; still feeling tired after sleeping; diarrhea; and frequent indigestion. The Veteran did respond to the category to indicate whether headaches were present. The Veteran also reported environmental exposures that included DEET insect repellant applied to skin and sand/dust. In terms of medical problems that developed during the deployment, the Post-Deployment Health Care Provider Review, Interview, and Assessment identified chest pain, chronic cough, inguinal pain, and back pain. A referral was also indicated in relation to the Veteran's fatigue, malaise, multisystem complaint. A July 8, 2003, Medical Record - Post Deployment Health Assessment later noted the Veteran's report that he had a history of frequent indigestion or heartburn; persistent diarrhea or constipation; and weakness or fatigue. The Veteran denied having frequent or severe headaches. He did not provide an answer regarding painful joints, tendons, or ligaments. A July 3, 2008, Report of Medical Assessment noted the Veteran's report that when compared to his last medical assessment/physical examination, his health was worse. He reported coughing more with difficulty breathing and having worse back pain in addition to knee pain/swelling. A July 14, 2003, STR noted that the Veteran's current problems included feeling tired all the time and indicated that this complaint had been present for 4 to 5 years. An October 9, 2003, retirement examination did not note any specific problems relevant to the Veteran's claims. Although the spine/other musculoskeletal was marked as abnormal, the record indicated that this finding was related to lumbar spine aches. No general muscle aches were indicated. In the associated October 3, 2009, Report of Medical History, the Veteran reported having a painful shoulder, elbow, or wrist; arthritis, rheumatism, or bursitis; recurrent back pain or any back problem; and swollen, stiff, or painful joints. The Veteran separately attributed these complaints to specific joints, including his shoulder, back, knees, feet, and left hand. The Veteran additionally reported frequent indigestion or heartburn; and the Veteran separately explained that he had experienced this issue after eating certain foods for about 12 years. The Veteran also denied currently being in good health, and he separately explained that this report related to the fact that he always seemed to feel tired and "give out." He currently had to make himself do anything whereas he previously had all kinds of energy. He denied having stomach, liver, intestinal trouble, or ulcer, or a history of frequent or severe headache. In an October 9, 2003, Report of Medical Assessment, the Veteran similarly stated that his health was worse when compared to his last assessment partly due to his decreased energy levels and always feeling tired. The Veteran also noted under a section related to other questions or concerns regarding his health that he had chronic fatigue. An October 9, 2003, VA compensation and pension examination noted that the Veteran's STRs were reviewed. The examiner noted that the Veteran served in the Persian Gulf War and was listed in the Department of Defense Persian Gulf War Registry. He also served in Operation Iraqi Freedom. The Veteran had developed numerous medical complaints since enlistment, which the Veteran described as left knee pain, low back pain, bilateral foot and hand pain, history of bilateral orchalgia, bilateral foot pain, left hand pain, nasal fracture, basal cell carcinoma, and difficulty with shortness of breath and cough. The diagnoses were chronic groin pain secondary to varicocele, degenerative joint disease of the left knee, status post basal cell carcinoma excision from the back, mechanical low back pain; chronic sinusitis, Dupuytren's disease of the left hand with old left fifth metacarpal fracture, nasal septal deviation with airway obstruction, and degenerative joint disease of the first metacarpophalangeal joints of the feet bilaterally. A subsequent STR signed on January 12, 2004, stated that the Veteran was qualified for retirement. Regarding the Veteran's post-service treatment records relevant to his service connections claims for a headache disorder, a disorder manifested by muscle and joint pain, and a disorder manifested by chronic fatigue, a June 2006 Blanchfield Army Community Hospital (ACH) record stated that the Veteran was transferred from the emergency room at that facility to a private medical center to the care and service of Dr. V.A., with a headache; the worst he had ever had. The CT scan showed a subarachnoid hemorrhage. The record also includes a June 2006 head CT scan that was obtained in relation to the Veteran's history of subarachnoid hemorrhage. The impression was subarachnoid and intraventricular hemorrhage with mild ventricular prominence; and a possible 2 millimeter aneurysm of the right carotid ziphon was noted. A June 29, 2006, chest x-ray was also obtained in relation to the Veteran's history of a headache. The impression noted that the study was within normal limits. A November 8, 2006, private treatment record from Dr. V.A. with a neurological surgeon's practice, stated that the Veteran had experienced a subarachnoid hemorrhage. They had worked him up extensively and found no source for this. The Veteran came and was neurologically intact, and the provider noted that the Veteran would be discharged from his care. In January 2007, a VA treatment record noted under the Veteran's past medical history that the Veteran was status post subarachnoid hemorrhage in June 2006. He was privately hospitalized, and there was no sequalae. The Veteran had been released to full work without restrictions. In December 2007, a Blanchfield ACH record noted that the Veteran's chief complaint was headaches. He had a history of a subarachnoid hemorrhage last year. He complained of headaches 4 to 5 times a week that lasted up to 3 hours. There was no history of headaches prior to the subarachnoid hemorrhage. The Veteran was admitted to the private medical center for a stroke for 15 days in June 2006. Since that time, the Veteran had experienced almost daily headaches. He was last seen by neurology in 2006. The assessment included headache syndromes, and the record stated next to this assessment that the Veteran had a history of sinus problems. The assessment also noted muscle spasm, cervicalgia, muscle weakness, and subarachnoid hemorrhage. In March 2008, a private treatment record from a neurology and neuromuscular center stated that the Veteran returned for a followup of recurrent headaches associated with mild neck pain. The onset of this condition was associated with a subarachnoid hemorrhage in 2006. The Veteran described having intermittent recurrence of pain since his recovery from that event. He denied having preexisting headaches, and in relation to the history of his 2006 subarachnoid hemorrhage, he reported feeling "like his head was being shot off" when he leaned over one day. He was life-flighted to the private medical center where he was treated for the hemorrhage, but investigations apparently showed no aneurysm; and he underwent no invasive intervention. Although there was improvement with the use of physical therapy, the headaches recurred as soon as he stopped treatment. The Veteran underwent an MRI of the brain that was normal apart from the presence of pansinusitis. The magnetic resonance angiography (MRA) demonstrated no aneurysm or abnormalities apart from a mild irregularity of the basilar artery. The assessment was subarachnoid hemorrhage, headache, neck pain, mixed hyperlipidemia, chronic maxillary sinusitis, chronic frontal sinusitis, and chronic ethmoidal sinusitis. Under the plan, the provider noted that it was suspected that the symptoms were in keeping with his pansinusitis, and the Veteran was instructed to follow up with his primary care provider. The provider explained that sinusitis could contribute to chronic headaches and dizziness. In May 2008, a private treatment record stated that the Veteran had a past medical history of tension headaches in addition to frequent sinusitis. In October 2008, a Blanchfield ACH record noted an assessment sinusitis as well as a separate assessment of headache. A June 4, 2009, record from Blanchfield ACH noted that the Veteran had been having a lot of headaches, and he was feeling fatigued. His headaches were worse with bending over and quick movements. The record noted an assessment of feeling tired or poorly and acute sinusitis. A plan was made to recheck the Veteran's liver and other labs that could contribute to tiredness. On August 7, 2009, the Veteran's problem list included muscle weakness and feeling tired or poorly. In April 2012, a VA treatment record noted that the Veteran was there with his wife for a follow up visit for fatigue and joint and back pain. He complained of persistent pains, and his labs showed elevated creatine phosphokinase (CPK). The record also noted under the past medical history that the Veteran was status post subarachnoid hemorrhage in June 2006 with no sequala. The assessment was fatigue and elevated CPK, and the record indicated that the Veteran planned to follow up with a private provider. In an October 23, 2012, private treatment record, Dr. A., MD, noted that the Veteran presented for an evaluation of myalgias and elevated CPKs. The Veteran reported that in 2000, he began to notice pain and soreness in his muscles all over his body; and the symptoms had been progressing since then. He also experienced weakness and tiredness. The Veteran was started on Vytorin in 2007 after having an episode of stroke, and his CPKs started to rise. He also had mild osteoarthritis. The assessment was myalgia and myositis NOS. The plan noted that the Veteran had some myalgias and weakness that appeared to be generalized. In consideration of this complaint and the Veteran's elevated CPKs, Dr. A. planned to do some serologies and arrange a muscle biopsy "to get to the bottom of this." On November 8, 2012, the Veteran presented for follow up for myalgia and muscle weakness. The assessment was unchanged, and Dr. A. indicated under the plan that they were awaiting a muscle biopsy. On September 5, 2014, a Blanchfield ACH consultation report stated that the Veteran had been experiencing worsening proximal muscle weakness of the bilateral upper and lower extremities for approximately two years with elevated CPK. He reported aching muscles and atrophy as well as fatigue and headaches. The review of systems was also significant for GERD. The Veteran had seen a rheumatologist and neurologist, but he had not undergone an electromyography (EMG). He was requiring a muscle biopsy for further diagnosis. The Veteran's past medical history also included a cerebral vascular accident (CVA) in 2006 secondary to an aneurysm. The record added that no surgery was required, and the Veteran had no neurologic sequalae secondary to this event. The assessment was myalgia and myositis, and generalized muscle weakness. On October 7, 2014, a Blanchfield ACH record noted that the Veteran presented with longstanding proximal muscle weakness of the bilateral upper and lower extremities. He had seen a rheumatologist and neurologist, and he needed an open muscle biopsy to obtain a diagnosis. The record included the findings from an associated September 2014 biopsy report for the left thigh muscle, which noted a diagnosis of myopathic process. The comments stated that in summary, it was an abnormal muscle with degenerating and regenerating fibers indicative of myopathy. On October 14, 2014, Dr. A. noted that the Veteran was returning after two years for a follow up for myalgias and myopathy. The record indicated that he underwent a muscle biopsy in September 2014. The assessment was still myalgia and myositis NOS. The plan noted that the biopsy showed degenerative and regenerative fibers without inflammation or vasculitis. An October 27, 2014 Blanchfield ACH record stated that the muscle biopsy confirmed degenerative and regenerative muscle fibers suggestive of myopathy. There was no inflammation or cellulitis. The assessment was myopathies. The Veteran's active problem list from Blanchfield ACH also reflects that chronic fatigue syndrome was added to the list by provider W.B., on June 2, 2015. In a subsequent November 2015 private treatment record, Dr. A. noted a diagnosis of dermatopolymyositis. Regarding the Veteran's post-service treatment records relevant to his service connections claims for a bowel disorder and a disorder manifested by indigestion and/or acid reflux/heartburn, the record includes a July 2007 colonoscopy operation report from Blanchfield ACH that noted a postoperative diagnosis of normal colonoscopy. On June 24, 2014, a Blanchfield ACH record from the gastroenterology clinic noted that the Veteran was referred for a single episode of blood in his stool. The Veteran indicated that real changes in his bowel habits had been going on for a while with current symptoms of 3 to 4 stools a day associated with tremendous urgency to the point of near incontinence. He also had regular dyspeptic symptoms several days a week. The assessment was red blood in bowel movement (hematochezia), and a plan was made to obtain a colonoscopy. The record stated that this issue may or may not be associated with fecal urgency. The record added that inflammatory bowel disease (IBD) was also a consideration in addition to neoplasia or insignificant functional disease with hemorrhoidal bleeding. The assessment also noted dyspepsia and the provider planned to have the Veteran undergo an esophagogastroduodenoscopy (EGD) regarding his dyspeptic symptoms, including his frequent nocturnal dyspeptic symptoms. The July 23, 2014, colonoscopy procedure report noted that the indications for the procedure were hematochezia and change in bowel habits. Also on July 23, 2014, a Blanchfield ACH consultation report authored by Dr. D., MD, indicated that the Veteran had a gastroenterology consultation related to an EGD/colonoscopy. Under the reason for the consultation, the record stated that the Veteran had bowel urgency with loose brown stools 3 to 5 times a day. and he also reported episodic red blood in stool that had been present for a few weeks. His last colonoscopy was in 2004. The provisional diagnosis was bowel urgency/hematochezia. The assessment from the consultation report was red blood in bowel movement (hematochezia), and the record noted that the Veteran had two small colon polyps and small hemorrhoids; indicating that the hemorrhoids were the source of the hematochezia. The record indicated that the colonoscopy was within normal limits. The Veteran was also assessed to have dyspepsia, and the record added next to this assessment that he had an "eccentric Z" versus a short segment Barrett's. A subsequent April 16, 2015, Blanchfield ACH record noted that the Veteran was seen in the clinic for follow up regarding blood in stool. The record indicated that he had a history of inflammatory bowel syndrome (IBS) and loose bowels. The record also observed that a colonoscopy a year ago and stool studies were negative for celiac. The assessment on this date included bowel urgency as well as a separate assessment of internal hemorrhoids. A summary of the Veteran's active problem list from Blanchfield ACH received in July 2019 reflects that IBS was subsequently added to his active problem on May 15, 2015, by a provider at the gastroenterology clinic. The Board also notes that to the extent that it was unclear from Dr. D.'s assessment in the July 23, 2014, record whether the Veteran received a diagnosis for Barrett's esophagus, this record also reflects that Dr. D. from the gastroenterology clinic later added Barrett's esophagus short segment to the problem list on July 28, 2014. Rather than removing this disorder during subsequent encounters, the record shows that his problem list was instead updated by a provider during the subsequent May 15, 2015, encounter at the gastroenterology clinic to show Barrett's esophagus without dysplasia. The provider also documented esophageal reflux in relation to the May 15, 2015, appointment at the gastroenterology clinic. In connection with the service connection claims on appeal, the Veteran attended a June 2012 VA Gulf War General Medical Examination. The examiner indicated that he completed Disability Benefits Questionnaires (DBQs) for hearing loss and tinnitus as well as the lumbar spine. The associated June 2012 DBQ for the lumbar spine noted a diagnosis of lower back pain. In this regard, the Board notes that the Veteran is already service-connected for bilateral hearing loss, tinnitus, and a mechanical low back pain with T-11 compression fracture. The June 2012 examiner stated that for the conditions identified and for which questionnaires were completed, there was no diagnosed illness for which no etiology was established. The examiner also stated that the Veteran did not report any additional signs and/or symptoms not addressed through the completion of the identified DBQs. The examiner additionally noted that the Veteran's physical examination was normal. The examiner opined that the Veteran's disability pattern was a disease with a clear and specific etiology and diagnosis; adding that the disability pattern was not at least as likely as not related to a specific exposure event experienced by the Veteran in Southwest Asia. In the rationale, the examiner noted the Veteran's report that his doctors attributed the Veteran's muscle pain to his use of statin drugs that had been stopped. In addition, the Veteran's fatigue could be attributed to his chronic sinusitis. The examiner indicated that the sinusitis was demonstrated upon CT scan of his sinuses noted in his claims file in March 2008 and December 2007. Following this examination, in an August 2021 letter from the office of Dr. A., A.H., PA-C, confirmed that the Veteran had been a patient in their office; and he had been diagnosed with fibromyalgia, chronic fatigue, and dermatopolymyositis. A.H. stated that fibromyalgia is a medical condition characterized by widespread pain and heightened pain in response to pressure; and A.H. opined that the fibromyalgia was at least as likely as not related to exposure events from Southwest Asia. In a September 2021 letter, W.B., ARNP, indicated that she was writing a letter on the Veteran's behalf as his medical provider. W.B. noted that the Veteran had been a patient at the Gold Medal Medical Home at Blanchfield ACH for 8 to 10 years. He served in the military between March 1981 and February 2004, and he had two deployments to Southwest Asia. W.B. noted that the deployments occurred during Desert Storm in 1991 and Iraqi Freedom in 2003 where there were known, documented illness in addition to undiagnosed illnesses due to the underdeveloped countries, unsanitary conditions, contaminants in the air, and exposures to environmental hazards not typical in the United States. The Board finds that the W.B.'s understanding of the Veteran's dates of service and periods of deployment is generally consistent with the information noted in his DD 214. W.B. stated that the Veteran was evaluated with multiple complaints while in service, including fatigue, irritable bowel symptoms, chronic sinusitis, headaches that were mostly of the tension type, and muscle aches and joint pain. He self-reported having daily headaches that he treated with Tylenol and Motrin while in service as well as when he left service until 2006. The headaches eventually led to a spontaneous subarachnoid hemorrhage in 2006 that brought the Veteran to the emergency room (ER) with "the worst headache of his life" with a well-documented hospital stay. The Veteran suffered a slight stroke from the headaches. W.B. opined that the Veteran's headaches led to his spontaneous subarachnoid hemorrhage which was more likely than not due to his time in service and deployments in Southwest Asia. W.B. reported that the Veteran's health continued to decline as he was evaluated from 2011 to 2014, and he later developed proximal muscle weakness in his upper arms and thighs; an onset of elevated serum CPK; and atypical rashes on his fingers, documented as gottron/papule and hand dermatitis. The Veteran was referred by the neurologist, Dr. C., to Dr. A., a rheumatologist; as well as Dr. H., a general surgeon, in 2014. Dr. H. performed the confirmatory muscle biopsy, and the Veteran was diagnosed with dermatopolymyositis by Dr. A. He was also diagnosed by Dr. A. with secondary illnesses such as fibromyalgia and chronic fatigue syndrome due to his autoimmune illness. W.B. explained that dermatopolymyositis is a condition where the immune system continues to attack itself, and the cause was unknown; but not limited to infection, chemicals, and toxins in one's environment. The autoimmune disease had no cure, and the prognosis was usually poor. Once a person was exposed to chemicals and toxins in their environment, it could take months to years for the disease to manifest itself. In W.B.'s medical opinion, the Veteran's dermatopolymyositis with secondary illnesses were all more likely than not acquired from his military deployments to Southwest Asia. The Board will first address the Veteran's service connection claims for a bowel disorder and a disorder manifested by indigestion and/or acid reflux/heartburn. As noted above, the record has documented that the Veteran received a diagnosis for dyspepsia in July 2014 relation to his complaints of indigestion. The Veteran has also asserted that he received diagnoses from providers at the Blanchfield ACH for IBS, Barrett's esophagus without dysplasia, and esophageal reflux at the times that these disorders were added to his active problem list. See July 2021 Statements. The Board notes that the Veteran is competent to relay what a medical provider has told him. See Layno v. Brown, 6 Vet. App. 465 (1994). The Board also finds that the Veteran's reports are credible as they are consistent with the information documented on his active problem list. Resolving all doubt in favor of the Veteran, the Board finds that he has received diagnoses for these disorders during the appeal period. Turning to the Veteran's service connection claim for a bowel disorder, diagnosed as IBS, the Board finds that entitlement to service connection for IBS as a chronic qualifying disability is warranted. The evidence reflects that the Veteran served in the Southwest Asia theater of operations, and the Veteran's July 2021 Board hearing testimony and a July 2021 statement reflect that he has suffered from observable symptoms of IBS with gastrointestinal signs or symptoms since service. 38 C.F.R. § 3.317(b)(10). W.B.'s September 2021 opinion also supports the conclusion that the Veteran's in-service symptoms were consistent with irritable bowel symptoms. The Board notes that the Veteran is competent to report his history of observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board also finds the Veteran's reports to be credible in light of the STRs documenting his reports of an upset stomach in 1995 and diarrhea in 2003. In the July 2021 statement, the Veteran appeared to highlight the May 1995 CCEP Patient Questionnaire as evidence to indicate he has experienced complaints of an upset stomach since 1992. Thus, the evidence of record reflects that his gastrointestinal signs and symptoms have persisted for more than six months. Furthermore, the criterion of manifesting to a compensable rating has been met. The Veteran's IBS is rated by analogy under 38 C.F.R. § 4.114, Diagnostic Code 7319 for irritable colon syndrome. Under this code, a 10 percent rating is provided for a moderate symptoms including frequent episodes of bowel disturbance with abdominal distress. The Veteran submitted a July 2021 statement in which he described experiencing abdominal pain, uncontrollable bowel urgency, and needing to use the restroom 5 to 6 times a day in relation to his IBS symptoms. The Board finds that the Veteran's reported IBS symptomatology more nearly approximates the criteria associated with a compensable rating. Based on the foregoing, the Veteran has met the criteria for service connection for IBS under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, as he has a MUCMI that has manifested to a compensable degree with symptoms for more than six months and served in the Southwest Asia theater of operations. In addition, there is no affirmative evidence to specifically weigh against this finding. Entitlement to service connection for IBS is therefore warranted. Regarding the Veteran's service connection claim for a disorder manifested by indigestion and/or acid reflux/heartburn, the Board finds that the fact that Dr. D.'s reference to Barrett's esophagus next to the assessment of dyspepsia in July 2014 reflects that the Veteran's dyspepsia diagnosis also encompasses the diagnosed Barrett's esophagus without dysplasias. As indicated above, the evidence supports that the Veteran's has also been diagnosed with esophageal reflux in relation to this claim. During the July 2021 Board hearing, the Veteran indicated that he did not experience heartburn or any other symptoms relevant to this claim prior to his active duty service. The Veteran indicated that he first began to experience relevant symptoms in conjunction with his first deployment to Southwest Asia which led to his diagnosis of dyspepsia in 1995. The Veteran indicated that he continued to experience relevant symptoms, including heartburn, after his 2004 discharge that had persisted since that time. As noted above, the Veteran is competent to report this medical history of observable symptoms of a disorder manifested by indigestion and/or acid reflux/heartburn that have continued to be present since they began during service. In addition, the Board finds the Veteran's reports to be credible as they are consistent with the numerous STRs documenting his complaints of indigestion and heartburn. The Board also notes that the June 2012 VA examiner did not specifically address the Veteran's complaints of indigestion or heartburn/acid reflux in the rationale, and there is no medical opinion that clearly addresses the question of whether the disorders that have been diagnosed in connection with this claim are directly related to service. After considering the Veteran's competent and credible reported history related to this claim, the Board finds that the most probative evidence establishes a nexus between active duty service and the Veteran's current disorder manifested by indigestion and/or acid reflux/heartburn, diagnosed as dyspepsia, Barrett's esophagus without dysplasia, and esophageal reflux. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection is granted for a disorder manifested by indigestion and/or acid reflux/heartburn, diagnosed as dyspepsia, Barrett's esophagus without dysplasia, and esophageal reflux. See 38 C.F.R. § 3.303(a) (service connection must be considered on the basis of the places, types, and circumstances of his service as shown by his service records, the official history of each organization in which he served, his medical records, and all pertinent medical and lay evidence); see also Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006) ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). Regarding the Veteran's service connection claim for a headache disorder, W.B.'s September 2021 opinion reflects that the Veteran has been found to have tension headaches. The Board also notes that the Veteran is separately service connected for maxillary sinusitis. To the extent that the March 2008 private treatment record suggested that the Veteran's headaches are a manifestation of his sinusitis disability, the Board finds that W.B.'s September 2021 characterization of his headaches as tension-type headaches supports the conclusion that he has a separately diagnosable headache disorder that is distinct from this disability. Although the Board has also considered the medical history noted in the December 2007 and March 2008 treatment records indicating that the Veteran did not experience headaches before his June 2006 subarachnoid hemorrhage, the Veteran later clarified during the Board hearing that he first began to experience headache disorder symptoms during his second deployment to Southwest Asia that included service in Iraq. Although the Veteran acknowledged experiencing isolated incidents of headaches prior to this point, his testimony suggests that he did not have symptoms of a headache disorder until his second deployment as the Veteran stated that he "[h]ardly ever had headaches" before then. The Veteran also indicated that the symptoms had continued and progressively worsened since that time with the Veteran really beginning to notice the headaches in 2004 or 2005. This history is also consistent with the history noted in W.B.'s September 2021 opinion indicating that he has experienced persistent tension headaches since service. W.B. also provided an explanation for the lack of evidence of headaches in the STRs as she indicated that the Veteran self-treated his headaches with the over-the-counter medications of Tylenol and Motrin. The Veteran is competent to report his history of observable headache symptoms, and affording the Veteran the benefit of the doubt, the Board also finds him credible. The Board also finds that W.B.'s September 2021 opinion provides probative evidence to support the finding that the Veteran's current tension headaches are related to his in-service Gulf War military environmental exposures. W.B. referenced the Veteran's environmental exposures during his deployments to Southwest Asia, and she indicated that the Veteran's current headaches are a continuation of the headaches he experienced during service. W.B's opinion that the Veteran's headaches led to his spontaneous subarachnoid hemorrhage which was more likely than not due to his time in service and deployments in Southwest Asia also appears to relate his claimed headache disorder to his deployments to Southwest Asia that included military environmental exposures. The Board finds that W.B's conclusion provides probative value when it is considered as a whole and in the context of the record as it addresses the medical issues in this case and was based on an analysis of the evidence and current medical understanding. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (providing that an examination is not rendered inadequate where the rationale provided by an examiner did not explicitly lay out the examiner's journey from facts to a conclusion,"); see also Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (stating that medical reports must be read as a whole in the context of the evidence of record). As noted above, the Veteran's STRs include his May 1995 report of exposure to smoke from oil fires and fumes of tent heaters in relation to his first deployment to Southwest Asia; and his June 2003 report of exposure DEET insect repellant applied to skin and sand/dust in relation to his second deployment to Southwest Asia. The Board consequently concedes the Veteran's military environmental exposures during his Gulf War service as consistent with the circumstances of his service. 38 U.S.C. § 1154(a). The Board also notes that the June 2012 VA examiner did not specifically address the Veteran's claimed headache disorder in the opinion, and there is no negative opinion to directly weigh against W.B.'s conclusion. After considering W.B.'s opinion with the Veteran's competent and credible reports of continued headache complaints since active service, the Board finds that the weight of the evidence supports the conclusion that the Veteran's current headache disorder is related to his active duty service. Accordingly, entitlement to service connection for a headache disorder, diagnosed as tension headaches, is granted. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. Regarding the Veteran's remaining service connection claims for a disorder manifested by muscle and joint pain and a disorder manifested by chronic fatigue, the record supports the conclusion that he has received diagnoses for dermatopolymyositis, fibromyalgia, and chronic fatigue syndrome in relation to these clams. Although A.H. only stated in the August 2021 letter that the Veteran had been diagnosed with chronic fatigue, W.B. reported in the August 2021 opinion that the Veteran had chronic fatigue syndrome, and this report is also consistent with his active problem list from the Blanchfield ACH. As the Board is granting the Veteran's dermatopolymyositis and fibromyalgia under different theories of entitlement, the Board finds that it is appropriate to bifurcate the service connection claim for a disorder manifested by muscle and joint pain to adjudicate these diagnosed disorders separately. See Locklear v. Shinseki, 24 Vet. App. 311, 315 (2011) ("[b]ifurcation of a claim is generally within the Secretary's discretion"); see also Tyrues v. Shinseki, 732 F.3d 1351 (Fed. Cir. 2013); Roebuck v. Nicholson, 20 Vet. App. 307, 315 (2006) (acknowledging that the Board can bifurcate a claim and address different theories or arguments in separate decisions). The Board finds that W.B.'s September 2021 opinion constitutes probative evidence of a nexus between the Veteran's dermatopolymyositis and his conceded in-service Gulf War environmental exposures. The opinion also provides probative evidence of an association between the Veteran's dermatopolymyositis and his diagnosed fibromyalgia and chronic fatigue syndrome. W.B. opined that the Veteran's dermatopolymyositis was acquired from his deployments to Southwest Asia, and she separately noted that these deployments included miliary environmental exposures and indicated that while the cause of the disorder was unknown, toxins in one's environment are nevertheless a relevant consideration. W.B. also explained that the Veteran's fibromyalgia and chronic fatigue syndrome were secondary illnesses that were due to his dermatopolymyositis. These opinions are probative when considered with the other evidence of record as the opinions address the relevant medical questions at issue, and they were based on W.B.'s understanding of the Veteran's relevant history as well as W.B.'s medical expertise. See Monzingo, 26 Vet. App. at 106; see also Acevedo, 25 Vet. App. at 294. Although the Board has considered the June 2012 VA examiner's opinion indicating that the Veteran's muscle pain was attributable to his use of statin drugs, and his fatigue could be attributed to his chronic sinusitis; the Board finds that this opinion has minimal probative value as the examiner was unable to consider the Veteran's subsequently diagnosed dermatopolymyositis, fibromyalgia, and chronic fatigue syndrome that W.B. indicated in the September 2021 opinion were the appropriate diagnoses in relation to these complaints. The most probative evidence therefore supports the finding that the Veteran's dermatopolymyositis is related to his Gulf War military environmental exposures during his active duty service. Entitlement to service connection for dermatopolymyositis is therefore granted. 38 U.S.C. § 5107(b). The weight of the evidence additionally supports finding that the Veteran's diagnosed fibromyalgia and chronic fatigue syndrome are respectively attributable to, or the result of, his now service-connected dermatopolymyositis. Consequently, service connection for fibromyalgia and chronic fatigue syndrome is granted as secondary to service-connected dermatopolymyositis. 38 C.F.R. § 3.310. In light of the Board's grants of service connection on the bases explained above, it is unnecessary to address any other theory of entitlement that has been advanced in relation to these claims. Although the Board notes that there have been various diagnoses provided in relation to the Veteran's claims during the appeal period, the benefit sought on appeal for these claims is granted in a manner consistent with the fact that the most probative evidence shows that the proper diagnoses for the Veteran's relevant complaints during the appeal period are those that have been identified by the Board in its grant of these claims. Thus, the Board concludes that service connection for these specific disorders is granted. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.C. Spragins, 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.