Citation Nr: A25035345 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 240219-419508 DATE: April 16, 2025 ORDER The claim of entitlement to service connection for anemia is denied. The claim of entitlement to weight gain (obesity) is denied. The claim of entitlement to service connection for depression is denied. The claim of entitlement to an initial rating higher than 10 percent for left knee strain is denied. A 70 percent for PTSD effective May 20, 2022, is granted. REMANDED The claim of entitlement to service connection for a lung disability (claimed as a respiratory disability) is remanded. The claim of entitlement to service connection for a left foot disability is remanded. The claim of entitlement to service connection for a deviated septum is remanded. The claim of entitlement to service connection for sleep apnea is remanded. The claim of entitlement to an initial rating higher than 10 percent for sinusitis is remanded. The claim of entitlement to an initial compensable rating for rhinitis is remanded. The claim of entitlement to a compensable rating for bilateral hearing loss is remanded. The claim of entitlement to a rating higher than 10 percent for tinnitus is remanded. FINDINGS OF FACT 1. The record on review does not show that the Veteran has anemia. 2. Obesity is not a disability for Department of Veterans Affairs (VA) purposes. 3. The Veteran's depression has not been attributed to her service, but the symptoms of her depression cannot be differentiated from the symptoms of her service-connected PTSD, which means that the symptoms of her depression are compensated as a part of PTSD. A separate rating for depression would result in duplicate compensation for the same symptoms, which is prohibited. 4. The Veteran's left knee manifests with painful flexion functionally limited to 130 degrees. 5. The Veteran's PTSD has manifested with social and occupational impairment with deficiencies in most areas since May 20, 2022, the date of a VA examination conducted in the year preceding receipt of her January 15, 2023, fully developed claim for an increased rating. CONCLUSIONS OF LAW 1. The criteria for service connection for anemia have not been met. 38 U.S.C. §§?1110, 5107(b); 38?C.F.R. §§?3.159, 3.303. 2. The criteria for entitlement to service connection for obesity, to include as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 3. The criteria for entitlement to service connection for depression have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 4. The criteria for an initial rating higher than 10 percent for left knee strain have not been met. 38?U.S.C. §§?1155, 5107; 38?C.F.R. §§?3.105, 3.344, 4.71a, DC 5260. 5. The criteria for a 70 percent rating for PTSD effective May 20, 2022, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1992 to November 2000. This appeal is from February 2024, October 2023, April 2023, and March 2023 rating decisions. The Veteran timely appealed to the Board, asking for placement on the direct review docket. Under the docket review selection, the record closed with respect to each claim on the date of notification of the decision on that issue. The period on review will be more specifically discussed with each issue below. With respect to the claims decided herein, the Veteran is advised that if she has possession or knowledge of any evidence that she wishes to be considered, then she should file it along with a supplemental claim within a year of this decision. Service Connection Service connection is granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for a disease diagnosed after discharge, where all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing: (1) the existence of a current 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 1. The claim of entitlement to service connection for anemia is denied. The Veteran has appealed the denial of service connection for anemia. The claim for service connection for anemia was received February 1, 2023, and denied in the February 2023 rating decision, which had a notification date of March 3, 2023. This means that the record closed on March 3, 2023, and the Board's consideration of the evidence is restricted to that which was of record March 3, 2023. The first inquiry in a service connection claim is whether there is a current disability, which means whether there is evidence of disability present during the period from receipt of the claim to notification of the decision. The record on review does not show a diagnosis for anemia for the period from February 1, 2023, to March 3, 2023. Indeed, her VA treatment records show a February 2023 letter to the Veteran reporting the results of her bloodwork show that she was not anemic. There is no other evidence, apart from her report, that she has anemia. The Board acknowledges that a claimant can be considered competent to repeat a diagnosis that had been made, but there must also be evidence that shows that it was made. Here, the evidence from the period on review and of record on the date of notification of the decision shows that she did not have a current diagnosis of anemia. Based on this evidence, the Board finds that service connection for anemia is not warranted. The Board finds this claim has been appropriately developed by the AOJ. The Veteran reported that she had VA treatment, and those records were obtained. She was not given a VA examination because of the evidence showing that she did not have a current diagnosis, nor did she report any symptoms suggesting she had anemia or any other blood disorder. The Board finds that an examination was not required given the evidence of record. 38 C.F.R. § 3.159. Accordingly, as service connection for anemia is not warranted, the claim is denied. 2. The claim of entitlement to weight gain (obesity) is denied. The Veteran has appealed the denial of service connection for weight gain. The claim for service connection was received February 16, 2023, and was addressed in the February 2023 rating decision, which had a notification date of March 3, 2023. This means that the record closed on March 3, 2023, and the Board's consideration of the evidence is restricted to that which was of record March 3, 2023. Here, however, the decision is based on the law and is not dependent upon the facts. Under current legal authority, obesity is not a disability for VA compensation purposes. Marcelino v. Shulkin, 29 Vet. App. 155 (2018); see also VAOGCPREC 1-2017. Although obesity may be considered as an intermediate step in secondary service connection, obesity itself is not considered a disease or injury for which direct or secondary service connection may be granted. See VAOGCPREC 1-2017. Accordingly, as obesity is not a disability for which service connection can be granted, the claim cannot be granted as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). Thus, service connection for obesity is denied. 3. The claim of entitlement to service connection for depression is denied. The Veteran has appealed the denial of service connection for depression. The claim for service connection for depression was received February 16, 2023, and was addressed in the February 2023 rating decision, which had a notification date of March 3, 2023. This means that the record closed on March 3, 2023, and the Board's consideration of the evidence is restricted to that which was of record March 3, 2023. The record shows that depression was diagnosed at the February 2023 VA examination. The VA examiner opined that depression was related to the Veteran's current living situation and family dynamics, and not related to the Veteran's service or to service-connected PTSD. She noted that depression and PTSD are highly co-morbid. The Veteran was noted to have depressed mood as a symptom, and the examiner indicated that, though the diagnoses were separate, there was no way to differentiate the symptoms of each, they overlapped. Depression was not diagnosed at the December 2023 VA examination but depressed mood was identified as a symptom of PTSD. Because the symptoms overlap and cannot be differentiated from each other, all of her symptoms are considered to be a part of her service-connected PTSD. Mittleider v. West, 11 Vet. App. 181 (1998). Thus, even though separate service connection continues to be denied, all of her mental health symptoms are compensated for under her service-connected PTSD. Further, because their symptoms overlap and cannot be separated or differentiated from each other, a separate rating for depression would result in duplicate compensation for the same symptoms. This is called "pyramiding," and it is not permitted under the regulations. 38 C.F.R. § 4.14. Accordingly, as depression has not been shown to have distinct symptoms apart from PTSD, and has not been shown to be related to service or to service-connected PTSD, this claim must be denied. The Board finds that the development undertaken for this claim was adequate, and that any further development would not avail the Veteran of any additional benefit because, again, all symptoms of an acquired psychiatric disability are being compensated for under her rating for PTSD. Increased Ratings Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate diagnostic codes (DCs) identify the various disabilities. See generally 38 C.F.R. Part 4. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. 4. The claim of entitlement to an initial rating higher than 10 percent for left knee strain is denied. The Veteran has appealed for an increased initial rating for the left knee. The Veteran's claim for service connection was granted in a February 2024 rating decision, which had a notification date of February 6, 2024. This means that the record closed on February 6, 2024, and the Board's consideration of the evidence is restricted to that which was of record February 6, 2024. The record on review, then, is from the effective date of service connection, April 23, 2023, up to the date of notification of the rating decision on appeal. Her left knee strain is rated 10 percent under DC 5260, which pertains to limited flexion. 38 C.F.R. § 4.71a. Limited flexion is rated under DC 5260, which assigns a 0 percent rating when flexion is limited to 60 degrees; a 10 percent rating when limited to 45 degrees; a 20 percent rating when limited to 30 degrees; and a 30 percent rating when limited to 15 degrees. 38 C.F.R. §?4.71a, DC 5260. Normal range of motion of the knee is from 0 (fully extended) to 140 degrees (fully flexed). Id., Plate II. When evaluating disabilities on the basis of limited motion, it is necessary to consider both the schedular criteria and any functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8?Vet. App.?202 (1995). Pain on movement, swelling, deformity,?or atrophy of disuse are relevant factors in regard to joint disability. 38?C.F.R. §?4.45. Painful, unstable, or malaligned joints, due to a healed injury, are entitled to at least the minimal compensable rating for the joint. 38?C.F.R. §?4.59. Pursuant?to 38?C.F.R. §?4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13?Vet. App.?31, 34 (1999); Hicks v. Brown, 8?Vet. App.?417, 421 (1995). Turning to the evidence, the record shows her left knee flexion was normal at the January 2024 VA examination. This is the only range of motion test of flexion during the appeal period. She had pain on flexion and extension. This corresponds to her 10 percent rating for limited flexion that is already assigned. 38 C.F.R. §§ 4.59, 4.71a, DC 5260. The Board considered whether her functional loss warranted a higher rating at any time during the period on review. She reported having flares during the examination and that she had functional loss, including pain and the inability to pick things up off the floor. The VA examiner did opine that the Veteran would have loss of flexion after repetitive use over time and during flares, but only to 130 degrees, which well exceeds the criteria for even a 10 percent rating. The record on review does not show that her left knee flexion was ever reduced to 30 degrees or less, or to that level of loss, which is required for the next higher rating to be assigned. Deluca, supra. The Veteran has not alleged having this level of loss. Accordingly, for left knee limited flexion, the Board continues the 10 percent rating. The record does not show any symptoms that would support a separate rating for the left knee. The Board acknowledges that she has painful extension but does not find a separate rating for limited extension of the knee is warranted. She has full extension, and already has the minimum rating for the joint based on painful motion. 38 C.F.R. §§ 4.59, 4.71a, DC 5261. A separate rating is not warranted under these circumstances. The record does not show that a separate rating is warranted for ankylosis, recurrent subluxation or lateral instability, patellar instability, symptoms of the meniscus, impairment of the tibia and fibula, or genu recurvatum of the left or right knee. Id., DCs 5256, 5257, 5258, 5259, 5262, and 5263. The Board finds that this claim has been appropriately developed. The Veteran's claim indicated VA treatment, which was obtained. In September 2023, she filed a VA form 21-4142 authorizing VA to obtain private records, which was completed in November 2023. She was given a VA examination in January 2024, which the Board finds is adequate for adjudication. It conforms with the requirements of Correia v. McDonald, 28 Vet. App. 158 (2017), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). Accordingly, a higher initial rating for the left knee is not warranted, and this claim must be denied. The Veteran is advised, that if she has knowledge or possession of evidence showing an increase in severity in her left knee, she is advised to file it along with a supplemental claim within a year of this decision in order to preserve the effective dates associated with this appeal stream. 5. A 70 percent for PTSD effective May 20, 2022, is granted. The Veteran's PTSD is currently rated 50 percent disabling prior to April 23, 2023, and 70 percent starting from then. She has appealed for a higher rating. The Veteran filed a fully developed claim on January 15, 2023, for an increased rating for PTSD. This was addressed in a March 2023 rating decision. The Veteran then filed a supplemental claim in April 2023, which was addressed in an October 2023 rating decision. She was given another VA examination in December 2023, and the decision on appeal was issued in February 2024. It had a notification date of February 6, 2024. The period on review, then, is from January 15, 2023, up to February 6, 2024, because she has continuously pursued this claim since the January 15, 2023, claim. Further, the Board notes that, because service connection for PTSD was already in effect, the effective date of any increased rating may be assigned in the year preceding receipt of the claim, if the evidence shows that the increase occurred within that year. 38 C.F.R. § 3.400(o). The criteria for evaluating PTSD are found at 38 C.F.R. § 4.130, DC 9411. A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands, impairment of short and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and, difficultly in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and, memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed above serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and are not intended to constitute an exhaustive list. See Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). After review of the record, the Board finds that it is factually ascertainable that the Veteran's PTSD was causing social and occupational impairment with deficiencies in most areas since a May 20, 2022, VA examination. During that examination, the VA examiner noted the Veteran's symptoms had increased in severity since the previous VA examination in October 2020. The report noted she had a persistent negative emotional state, markedly diminished interest in participating in significant activities, and feelings of detachment from others. She has irritable behavior and angry outbursts, she reported she has no patience, which her job has accommodated by allowing her to work from home. She has problems with concentration and chronic sleep impairment. She has a depressed mood, anxiety, and suspiciousness. She was noted to have a disturbance in motivation and mood. She had an anxious affect and fair judgment and insight. During the January 2023 VA examination, she was noted to have difficulty adapting to stress and an inability to establish effective relationships. The Board finds this evidence shows deficiencies in most areas. Her persistent negative emotional state and diminished interest in activities would negatively impact her social life and her relationship with her family. Her symptoms impacted her ability to work with other people, and she was allowed to work from home part of the time. Her judgment and insight were only assessed as fair, and she was noted to have irritable or angry outbursts. Finally, she has consistently had depressed mood and a persistent negative emotional state. This evidence more closely corresponds to a 70 percent rating. The Veteran does not have total impairment and a 100 percent rating is not warranted. She is married and has been for 15 years, as of December 2023. She reported having some friends. She works full-time as of December 2023. She had been unemployed in January 2023, but that was due to her contract ending. She was actively looking for work and found it. This evidence does not show total impairment or correspond to a 100 percent rating. Considering all the evidence, as summarized above, the Board finds that the Veteran retains some level of occupational and social functionality. On this basis, the Board finds that the impairment is not total. The Board finds that this claim has been adequately developed. The AOJ obtained VA treatment records and attempted to obtain private treatment records. The VA examinations are adequate for adjudication. The Veteran has not raised any issue with the examination report. In sum, a 70 percent rating is granted from May 20, 2022, but a rating higher than 70 percent for PTSD is denied. REASONS FOR REMAND VA has a duty to assist in the development of claims. 38 C.F.R. § 3.159. The Board only has the authority to remand issues back to the AOJ in limited circumstances: (1) to correct errors in fulfilling the duty to assist committed by the AOJ prior to the issuance of the decision on appeal; and (2) to correct other errors in fulfilling statutory or regulatory duties if correction would have a reasonable possibility of substantiating the claim. 38 C.F.R. § 20.802(a). 6. The claim of entitlement to service connection for a lung disability (claimed as a respiratory disability) is remanded. The Veteran's claim for service connection for a respiratory disability was denied in an April 2023 rating decision, which had a notification date of April 28, 2023. The record closed on that date, which means the Board's consideration of the evidence is restricted to that which was of record on April 28, 2023. The Veteran claimed service connection for a general respiratory disability, along with claims for sinusitis, rhinitis, and sleep apnea, which are not addressed as part of this specific claim. The Board has recharacterized the claim to be one for a lung disability, based on the results of the March 2023 VA examination. During the VA examination, the Veteran was not diagnosed with any respiratory disabilities apart from service-connected sinusitis and rhinitis. She was diagnosed with a pulmonary disability, an inactive bacterial lung infection. A claim for a respiratory disability reasonably encompasses a claim for a lung disability. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran reported that her respiratory symptoms began during her service in Kuwait, which the Board finds reasonably raises the issue of whether the bacterial lung infection is related to exposures while serving there. When a claim involves toxic exposure risk activities (TERA), as here, and there is evidence of a disability that may be related, VA must obtain a medical opinion addressing the possibility of a nexus between the claimed disability and the TERA. 38 U.S.C. §1168(a)(1). It is unclear what the basis is for the diagnosis or whether it causes any symptoms, and the examiner also did not provide a medical nexus opinion regarding whether it is related to service. VA has a duty to assist in developing claims, including providing VA examinations. If an examination is provided, it must be adequate. Here, the examination and opinion are both inadequate for the reasons noted above; that is, they are not adequate to determine whether bacterial lung infection causes or has caused functional loss during the period on review, or whether there is a relationship to service. On remand, an updated examination and opinion shall be obtained. 7. The claim of entitlement to service connection for a left foot disability is remanded. The Veteran's claim for service connection for a left foot was denied in a February 2023 rating decision, which had a notification date of March 3, 2023. The record closed on that date, which means the Board's consideration of the evidence is restricted to that which was of record on March 3, 2023. The Veteran was not provided a VA examination for the foot because the record does not show a current diagnosis. However, the Veteran is competent to report the presence of physical symptoms, which, while not specifically described, the Board finds likely to be present based upon her claim for left foot "sprain, pain, and misalignment." Further, the Board notes that she has been found to meet the definition of a Persian Gulf Veteran under 38 U.S.C. § 1117. Veterans who meet this definition may be compensated for "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 U.S.C. § 1117; 38 C.F.R. § 3.317. There are three types of "qualifying chronic disabilities:" (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). An "undiagnosed illness" is defined as a condition that, by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). A "medically unexplained chronic multi-symptom illness" is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome and fibromyalgia as well as functional gastrointestinal disorders. A medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2). The AOJ committed error in failing to schedule a VA examination and obtaining an opinion in this case. The Board notes that the Veteran's claim for service connection suggests that she believes that a left foot disability is related to her now-service-connected left knee. However, as that disability was not yet service connected when the left foot was denied, the AOJ did not commit a duty to assist error in failing to obtain a medical opinion on a relationship, and the Board may not direct the AOJ to develop this issue. If the Veteran has any evidence showing or suggesting a relationship between the left knee and the left foot, she is advised to file it as soon as possible so that it may be considered in conjunction with this appeal. 8. The claim of entitlement to service connection for a deviated septum is remanded. 9. The claim of entitlement to service connection for sleep apnea is remanded. 10. The claim of entitlement to an initial rating higher than 10 percent for sinusitis is remanded. 11. The claim of entitlement to an initial compensable rating for rhinitis is remanded. 12. The claim of entitlement to a compensable rating for bilateral hearing loss is remanded. 13. The claim of entitlement to a rating higher than 10 percent for tinnitus is remanded. The claims for service connection for a deviated septum and sleep apnea, and for higher ratings for sinusitis, rhinitis, hearing loss, and tinnitus were addressed in an October 2023 rating decision, which had a notification date of October 23, 2023. The record closed on that date, which means the Board's consideration of the evidence is restricted to that which was of record on October 23, 2023. VA has a duty to assist claimants in obtaining evidence, including records from private treatment providers. Here, in September 2023, prior to the issuance of the October 2023 rating decision, the AOJ received a VA 21-4142 authorizing VA to obtain records from a private treatment provider. The process to obtain these records had not been completed upon issuance of the October 2023 rating decision. It was error to have issued that rating decision before receiving a response to that records request. On remand, the Veteran shall be asked to provide another authorization so that another attempt can be made to obtain the records of private treatment reported by the Veteran. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate examination for a report on whether the inactive bacterial lung infection diagnosed at the March 2023 VA examination causes functional loss and if so, whether the lung infection is approximately as likely as not related to her service, including exposure TERA. The Veteran asserts she developed respiratory symptoms while serving in Kuwait, and she is presumed to have toxic exposures. Her STRs also show multiple respiratory infections. The examiner is asked to elicit from the Veteran a detailed history of her respiratory symptoms, and to provide an opinion on whether the Veteran's bacterial lung infection, if it continues to be present, causes functional loss. If it causes any symptoms, the examiner should so note what they are. Following review of the file and the examination, the examiner is asked to provide opinions on whether it is approximately as likely as not that any lung disability is related to (a) respiratory infections during service or to (b) TERA activities and presumed exposures while serving in Southwest Asia (Kuwait). In forming the TERA opinion, the examiner is asked to consider (i) the total potential exposures through all applicable military deployments and (ii) the synergistic combined effect of all toxic exposure risk activities. The examiner should consult with relevant medical literature prior to opining. All opinions should be accompanied by explanation. 2. Schedule the Veteran for an appropriate examination of the left foot for an opinion on whether any reported symptoms, including pain, are attributable to a known diagnosis, or if not, whether these symptoms represent an undiagnosed illness or MUCMI. The examiner is asked to review the record and the relevant literature prior to opining. The examiner is asked to elicit from the Veteran a detailed history of her left foot symptoms. If the Veteran does not have any diagnoses that the symptoms are related to, the examiner is asked to provide an opinion as to whether these symptoms cause functional impairment. The examiner is asked to conduct any necessary diagnostic tests. If there is no diagnosis to attribute functional loss to, the examiner should state as much. If the Veteran does have diagnosis or diagnoses manifesting with the left foot symptoms, the examiner is asked whether they represent a MUCMI, which 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. The examiner is asked to address whether the etiology and/or the pathophysiology of any rendered diagnosis is inconclusive. The examiner is advised that consideration of pathophysiology and etiology is a veteran-specific inquiry, as opposed to an inquiry regarding the general knowledge of the medical community. The examiner is also asked whether the Veteran's diagnoses are characterized by overlapping signs and symptoms, with features such as fatigue, pain, disability, out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. All opinions must be supported with explanation. 3. Ask the Veteran to provide authorization for private treatment records at Palomar Health, and, if provided by the Veteran, try to obtain them. Nathaniel J. Doan Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gibson, Amanda 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.