Citation Nr: 22058280 Decision Date: 10/18/22 Archive Date: 10/18/22 DOCKET NO. 15-27 473A DATE: October 18, 2022 ORDER Entitlement to a rating more than 10 percent for hypertension is denied. Entitlement to service connection for Gulf War unexplained illness (chronic multi-symptom illness) (to include symptoms of fatigue, respiratory problems, headaches and dizziness) as due to an undiagnosed illness is denied. FINDINGS OF FACT 1. During the appeal period, the Veteran's hypertension did not manifest in diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. 2. The Veteran had active service in Southwest Asia. 3. The evidence of record persuasively weighs against finding that the Veteran has had Gulf War unexplained illness (chronic multi-symptom illness) (to include symptoms of fatigue, respiratory problems, headaches and dizziness) as due to an undiagnosed illness at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for a disability rating more than 10 percent for hypertension are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.104, Diagnostic Code 7101. 2. The criteria for service connection for Gulf War unexplained illness to include symptoms of fatigue, respiratory problems, headaches and dizziness as due to an undiagnosed illness, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1989 to January 1993, which included service in the Southwest Asia Theater of operations during the Persian Gulf War. These matters are before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in July 2018. A transcript of the hearing is associated with the electronic file. The issues were previously before the Board, most recently in October 2021. The Veteran raised the issue of entitlement to service connection for sleep apnea and a neurological disorder with headache and dizziness symptoms. The Board refers these claims to the RO for appropriate action. 38 C.F.R. § 20.904(b). 1. Entitlement to a rating more than 10 percent for hypertension is denied. The Veteran contends entitlement to a rating higher than 10 percent for hypertension. Hypertension is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code (DC) 7101, for hypertensive vascular disease (hypertension and isolated systolic hypertension). Under DC 7101, a 10 percent rating is warranted for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; it is the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted for diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. Diagnostic Code 7101, Note (1) requires multiple blood pressure readings to be taken over multiple days to confirm the existence of hypertension. That requirement is not applicable to increased rating claims. Gill v. Shinseki, 26 Vet. App. 386, 391 (2013). In rating hypertension under DC 7101, the Board may consider blood pressure readings taken while a veteran is using medication. McCarroll v. McDonald, 28 Vet. App. 267, 271 (2016) (holding that DC 7101 contemplates the effects of medication and therefore Jones v. Shinseki, 26 Vet. App. 56 (2012), does not apply. The term "predominant" is not defined in the rating criteria. Merriam-Webster defines predominant to mean "being most frequent or common." See, e.g., "predominant," Merriam-Webster.com Online Dictionary, https://www.merriam-webster.com/dictionary/predominant. In May 2014, VA received the Veteran's claim for an increased rating of hypertension. The medical evidence of record documents that from June 2013 to December 2021, the Veteran's hypertension has manifested in systolic pressure predominantly 160 but less than 200, corresponding to the criteria for a 10 percent rating under DC 7101. June 2013 to July 2014 VA records show that the Veteran's highest systolic blood pressure reading was 156 and the highest diastolic blood pressure reading was 86. Private records show that, in June, September, and December 2013, the Veteran's systolic/diastolic blood pressure readings were 164/76, 152/80, and 125/80, respectively. In March, June, and September 2014, the Veteran's systolic/diastolic blood pressure readings were 145/83, 149/81, and 153/81, respectively. In September 2014, the Veteran underwent a VA examination. The Veteran reported that blood pressure "fluctuates but has leveled out." The Veteran denied any heart or kidney problems. The Veteran reported taking hypertension medications: atenolol, lisinopril, amlodipine, and losartan. The Veteran's systolic/diastolic blood pressure readings were 159/92, 152/84, and 134/68. The VA examiner found no functional impact on the ability to work. Between October 2014 and June 2015, VA records showed that the Veteran's diastolic blood pressure readings were 160 or above twice, in December 2014 (164) and April 2015 (160). The Veteran's systolic blood pressure readings did not rise to 100 or above during this period. In a July 2015 letter, a VA primary care physician wrote that the Veteran has had difficulty controlling high blood pressure and was on three medications: lisinopril, atenolol, and losartan. The VA physician wrote that the Veteran's blood pressure readings fluctuated from "normal to greater than 180/100." Between August 2015 and June 2018, VA records showed that the Veteran's diastolic blood pressure readings were 160 or above one to four times a year, in August 2015 (166), September 2015 (168), January 2016 (166), February 2016 (160), June 2016 (160), October 2016 (160), May 2017 (170), July 2017 (164), August 2017 (160), September 2017 (180), and June 2018 (160). The Veteran's systolic blood pressure readings rose to 100 or above only once during this period, in June 2016 (102). In July 2018, the Veteran appeared a Board hearing. The Veteran testified to recent systolic/diastolic blood pressure readings were 156/76 and 160/80. The Veteran testified to feeling a pounding heart and annoyed at taking all the medications all the time. The Veteran's representative noted five different medications. Between September 2018 and February 2020, VA records showed that the Veteran's diastolic blood pressure readings were 160 or above four times, in September 2018 (166), December 2018 (186), and November 2019 (168, 167). The Veteran's systolic blood pressure readings did not rise to 100 or above during this period. Between October 2019 and April 2020, VA records show that the Veteran's average systolic/diastolic blood pressure readings were 157/77, with highs of 183/86. Between April and October 2020, the Veteran's average systolic/diastolic blood pressure readings were 153/75, with highs of 178/85. In October 2020, the Veteran underwent a VA examination. The Veteran reported taking hypertension medications: Amlodipine, Metoprolol, and Lisinopril. The Veteran denied any change in symptoms. The Veteran's systolic/diastolic blood pressure readings were 156/90, 166/91, and 152/76. The VA examiner found that the Veteran's essential hypertension had progressed but did not affect work. In November 2020, the Veteran's systolic/diastolic blood pressure readings was 140/70. The Veteran's VA cardiologist assessed that the Veteran's blood pressure control was "improving." In March and May 2021, the Veteran's systolic/diastolic blood pressure readings were 136/80 and 148/82, respectively. In an August 2021 statement, the Veteran asserted, though an authorized representative, that the hypertension disability had increased in severity since the Veteran was last examined by VA in October 2020. In December 2021, the Veteran underwent another VA examination. The Veteran reported lightheadedness and taking hypertension medications: amlodipine besylate, furosemide, lisinopril, losartan, and metoprolol tartrate. The Veteran's systolic/diastolic blood pressure readings were 158/92, 164/96, and 168/94. The VA examiner found that there was a worsening of the Veteran's symptoms, but no change of diagnosis or any new diagnoses. The VA examiner also found no functional impact on the ability to work. The Veteran, through a letter from a Member of Congress, contended that the VA has not acknowledged that the Veteran is on multiple medications to control blood pressure and any assertion that the Veteran is not at hypertensive risk is contradicted by the notion that, if the Veteran were to come off medications, the Veteran would be at high risk for a heart attack or stroke. The Board acknowledges that the Veteran' requires continuous medication for control and is at hypertensive risk otherwise. In rating hypertension under DC 7101, however, the Board may consider blood pressure readings taken while a veteran is using medication because the diagnostic code expressly contemplates the effects of medication. Accordingly, during the appeal period, the Veteran's hypertension has manifested in systolic pressure predominantly 160 or more but less than 200, corresponding to the criteria for a 10 percent rating under DC 7101. A higher 20 percent rating under DC 7101 is not warranted unless diastolic pressure is predominantly 110 or more, or systolic pressure is predominantly 200 or more. There was no evidence in the record of any diastolic or systolic blood pressure readings this high. Thus, during the appeal period, the Veteran's hypertension did not manifest in diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. Accordingly, the Veteran's hypertension does not more nearly approximate the criteria corresponding to a 20 percent rating. A higher 20 percent rating is not warranted. The claim for an increased rating is denied. 2. Entitlement to service connection for Gulf War unexplained illness (chronic multi-symptom illness) (to include symptoms of fatigue) as due to an undiagnosed illness is denied. The Veteran alleges chronic fatigue syndrome related to service in Southwest Asia. The service connection claim was received in May 2014. The Board notes the Veteran is already service connected for an unspecified muscle condition with pain which was linked to environmental exposures in South West Asia. In June 2022, the Veteran, through a Member of Congress, alleged that with respect to his Gulf War Illness claim, VA had cast doubt on the Veteran's symptoms because the Veteran was "well-groomed" for one of the VA examinations. The Veteran contends that this fails to acknowledge that the Veteran's spouse helped the Veteran get dressed for the exam and ignores the fact that the Veteran was so tired after the examination that the Veteran slept for four hours after returning home. The Veteran contends that VA has not fully accounted for the fact that the Veteran requires assistance with most activities of daily living and needs to take frequent breaks. The Veteran's Member of Congress contended that the VA has not adequately accounted for the Veteran's sleep problems, which are severe enough to warrant a continuous positive airway pressure (CPAP) machine. The Veteran's Member of Congress alleged that the VA has asserted that the Veteran did not have muscle weakness or aches even though the Veteran frequently mentioned these symptoms to medical providers, and frequently must take breaks during and after any activity due to being tired or sore. The Veteran's Member of Congress contended that it was not at all clear that the VA had properly accounted for the symptoms of fatigue, indigestion, respiratory problems, muscle pain, headaches, insomnia, memory issues, diarrhea, and dizziness. The Veteran's Member of Congress expressed concern that this was evidence that VA examiners rushed through examinations without paying the requisite attention to detail. At the July 2018 Board hearing, the Veteran's representative similarly contended that VA examinations did not take into an account all the Veteran's symptoms. Finally, the Veteran's Member of Congress also expressed concerns about the qualifications of VA examiners. Service connection generally requires a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted on a presumptive basis if the evidence shows: (1) that the Veteran is a Persian Gulf veteran; (2) with a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms; such as chronic fatigue syndrome; or an undiagnosed illness (3) which became manifest either 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, 2021; and (4) that is a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping signs and symptoms, and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317. For purposes of 38 C.F.R. § 3.317, 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. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a). In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). Further, lay persons are competent to report objective signs of illness. The level of training, education, and experience of the person conducting the exam can be a factor considered in assigning weight to the report. Cox v. Nicholson, 20 Vet. App. 563, 568-69 (2007). During service, the Veteran did not complain of and was not treated for fatigue. An October 1992 Report of Medical Examination for enlistment noted a pilonidal cyst, but no other issues. The Veteran reported no other issues. The Veteran denied a history of dizziness in January 1989, February 1990, May 1991, and January 1993. In July 1989, the Veteran denied asbestos exposure. In April 1991, the Veteran was treated for a sore throat, cough, and ear pain. In February 1992, the Veteran was treated for a common cold and, in November 1992, for a viral syndrome. An October 1992 Report of Medical Examination for discharge noted elevated triglycerides, dermatitis, skin rash, and a pilonidal cyst, but no other issues. The Veteran denied frequent or severe headaches; dizziness or fainting spells; ear, nose, or throat trouble, or any other trouble other than inconsistently high blood pressure and recurrent back discomfort. In November 1992, the Veteran was treated for a viral upper respiratory infection. In May 1993, the Veteran denied a history of chronic obstructive pulmonary disease (COPD) or pleurisy. In October 1996, the Veteran was treated privately for acute tonsilitis and laryngitis with postnasal drip. In October 1998, the Veteran denied headaches, dizziness, and shortness of breath during a VA visit. In January 2001, the Veteran was treated by VA for bronchitis. During an October 2002 VA primary care visit, the Veteran denied any headaches, trauma, seizures, vertigo, dizziness, numbness, or gait problems. In September 2004, the Veteran reported a history of nasal congestion to a private provider. In October 2004, the Veteran became fatigue during an exercise stress test. In November 2004 and December 2007, a private provider noted possible sleep apnea. In May 2007, the Veteran denied headaches, vertigo, or cough. In September 2007, the Veteran denied headaches a VA rheumatology visit. In May 2008, the Veteran was treated privately for acute sinusitis. In June 2008, the Veteran denied shortness of breath, and headaches. In March, June, September, and December 2009, and again in February 2010, the Veteran was treated privately for upper respiratory symptoms. The Veteran denied headaches or vertigo. In June 2010, a private otolaryngologist found that the Veteran was "probably on the margin of having sleep apnea," noting the Veteran's reflux, obesity, arthritis, psoriasis, and a temporomandibular joint issue but no symptoms of sinusitis, "excellent" airways, and "normal" ears. In September 2010, the Veteran denied shortness of breath. In October 2010, the Veteran reported fatigue and that psoriasis interfered with sleep from time to time. During VA examinations in November 2010, the Veteran denied dizziness, fatigue, and dyspnea. The VA examiner noted that the side effects of the Veteran's liver medication included respiratory infections and headaches. The VA examiner affirmed that the Veteran had a history of headaches related to hypertension. In March 2011 and January 2013, the Veteran denied shortness of breath. In May 2011, the Veteran's VA dermatologist noted possible side effects of skin medications included infection, headache, and fatigue. In February, May, and July 2012, the Veteran reported to a private doctor about chronic nasal and sinus symptoms, fatigue, memory changes, and dizziness. In June and August 2013, the Veteran reported asbestos exposure, but could not quantify it. In August and November 2013, a private doctor noted a diagnosis of severe obstructive sleep apnea. In October 2013, a VA nurse practitioner assessed that the Veteran had symptoms of dizziness and lethargy, noting that the Veteran reported that "doing too much" resulted in tiredness, a sore body, and periodic dizziness. The Veteran had a neuropsychological examination done in March 2014 with the following results: "Across 5 learning trials of a 16-word list, he immediately recalled 7, 10, 12, 11 and 12 words, respectively. This was overall an average rate of recall. After a brief interference delay, he was able to recall 7 of these words, which was low average. After an approximate 20-minute delay he was able to recall 8 words, which was low average. Showed good use of semantic clustering." The neuropsychologist assessed "mild" cognitive problems which were "most likely" secondary to medical issues involving advance metabolic syndrome, liver dysfunction, and a history of hypo-apnea from uncontrolled sleep apnea. The neuropsychologist also found stress was also "likely labile" here. In May 2014, a private doctor noted severe obstructive sleep apnea and restrictive lung disease. In September 2014, the Veteran reported to a VA examiner about experiencing psoriatic arthritis "attacks" that began with headaches. The Veteran had gone to the emergency room three times in the prior year for these attacks. Symptoms during the attacks included joint swelling, pain, headaches, and muscle spasms. The duration of the attacks was usually one week, during which the Veteran was unable to work. The Veteran reported he missed about 45 days due to psoriatic arthritis. The VA examiner remarked that the Veteran had never been diagnosed with chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome. The Veteran reported problems with fatigue. The Veteran stated this has been going on for the last several years. The VA examiner noted that the Veteran had a diagnosis of severe sleep apnea. Since starting the CPAP, the symptoms had improved. The Veteran still occasionally woke up tired and experienced daytime hypersomnolence. The Veteran also reported occasional headaches and needing to lay down. The Veteran had not been diagnosed with migraines. The VA examiner noted that the headaches occurred around psoriatic arthritis attacks. The VA examiner opined that the Veteran's headaches were "most likely secondary to his psoriatic arthritis." The Veteran also reported occasional problems falling or staying asleep. The Veteran reported having a hard time turning off the mind. The Veteran was taking amitriptyline for this. The Veteran stated that the CPAP machine has helped some. There Veteran denied problems with dizziness. The Veteran also complained of problems with frequent episodes of bronchitis or sinus infections. The Veteran had about four to six infections per year. The Veteran was on antibiotics now for sinus infection. The VA examiner opined that this was not secondary to Gulf War Syndrome. The Veteran also reported memory problems beginning about five years prior. The Veteran stated that this has progressively become worse. The VA examiner opined that this condition was not Gulf War related. The VA examiner noted that the Veteran's processing speed on a visuomotor number search task was "borderline impaired." The Veteran's processing speed on a visuomotor letter and number-set shifting task was "average." The Veteran was presently showing mild cognitive problems which were "likely secondary to complex interplay of advanced metabolic syndrome, liver dysfunction, history of hypopnea from prior uncontrolled sleep apnea. Also, pain disorder and stress are also likely causing some attentional disruption." The Veteran denied post-traumatic stress disorder, a history of head injury and drug or alcohol use. The Veteran reported being in a combat zone but not active combat. The VA examiner opined that the Veteran's overall disability pattern was "a disease with clear and specific etiology and diagnosis." In September 2014, the Veteran was treated privately for an upper respiratory infection. In October 2014, the Veteran denied shortness of breath. In October and December 2014 and January and April 2015, the Veteran reported fatigue to a VA psychiatrist. In an April 2015 rating decision, the RO found that the Veteran had active service in the Southwest Asia. During July 2015 VA arthritis examination, the Veteran reported weekly "arthritic attacks" of diffuse pain with increased activity. The Veteran had gone to the emergency room three times in 2014 for severe pain. Symptoms during the "arthritis attacks" included severe pain, joint swelling, headaches, and muscle spasms. The duration of the "arthritis attacks" were usually one week. The Veteran was unable to work during these times. The Veteran reported being out of work since March 2015. The VA examiner opined that pain, weakness, fatigability, or incoordination significantly limited the Veteran's functional ability during a flare-up or if the joint is used repeatedly over time. The VA examiner found that the Veteran had episodes of flareups that severely limited functional ability secondary to pain. The VA examiner opined that service-connected psoriatic arthritis would cause increased absenteeism and other physical limitations. In July 2015, the Veteran reported worsening symptoms of severe recalcitrant psoriatic arthritis, sleep apnea, chronic fatigue, and depression directly resulting from medical illness and impaired functioning. Later in July 2015, a VA doctor wrote a letter including about the Veteran's chronic fatigue and weakness. The VA doctor wrote that this was "likely multifactorial and related to depression sleep apnea, chronic inflammatory joint disease, and medications. This has also led to severe impairments of function. He has also demonstrated mild cognitive dysfunction believed related to his sleep apnea stress possible PTSD and depression. There has been a question if his multisystem complaints including chronic fatigue and memory issues maybe [sic] related to undiagnosed Gulf War Syndrome." The doctor also noted obstructive sleep apnea treated with a CPAP machine. In December 2015, a VA nurse practitioner treated the Veteran for acute sinusitis. In February 2016, the Veteran consulted a VA pulmonologist for persistent dyspnea. The Veteran denied having respiratory symptoms until three years prior when the Veteran developed intermittent episodes of dyspnea and cough not associated with exertion. The pulmonologist noted the Veteran's medical history including diagnostic imaging showing restriction, but no obstruction; inhalers and steroids; immunosuppressives, and obstructive sleep apnea. The Veteran also reported smoking during high school and working for a state prison with asbestos exposure for at least six years. The VA pulmonologist ruled out COPD and found heart disease unlikely but found that the restrictive defect could have been secondary to interstitial lung disease (drug induced) and obesity. In April 2016, a VA nurse practitioner treated the Veteran for a flu. In September 2016, it was noted that the Veteran was 72 percent compliant with sleep apnea therapy. In October 2016, a VA nurse practitioner assessed the Veteran with dizziness and lethargy. The Veteran had reported that doing too much made the body sore, tired, and periodically dizzy. In March 2017, the nurse practitioner treated the Veteran for an upper respiratory infection. In May 2017, the Veteran reported to the VA nurse practitioner about two more episodes of shortness of breath and chest tightness. The Veteran reported to a VA speech pathologist about persistent episodes of dizziness, headaches, anxiety, and frustration with medical condition such that it has begun to impact interpersonal relationships. In September 2017, the Veteran reported feeling fatigue during a primary care visit for cellulitis and abcess. In December 2017 and January 2018, the VA nurse practitioner treated the Veteran for an acute upper respiratory infection. In June and September 2018, the Veteran reported to a VA nurse practitioner about general fatigue, shortness of breath, and cough. The VA nurse practitioner assessed that obesity and metabolic syndrome was having a negative impact on many health issues such as blood pressure, diabetes, shortness of breath, lack of energy, and sleep apnea. In June 2018, private computerized tomography imaging showed "complete right and subtotal left maxillary sinus opacification." In July 2018, the Veteran appeared before the undersigned Veterans Law Judge. The Veteran testified to symptoms of fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disorder, and memory problems. The Veteran testified that the symptoms began nine years prior and have progressed since then. The Board notes that the Veteran is already service connected for psoriatic arthritis, including symptoms of joint pain; chronic diarrhea, including gastroesophageal reflux disease and indigestion; unspecified depressive disorder, including symptoms a wake-sleep disorder and memory problems; and an unspecified muscle condition with pain. The Veteran's service connection claim for sleep apnea, a respiratory disorder, is being referred. In October 2018, the Veteran reported to a VA psychiatrist and a VA endocrinologist about dizziness after beginning a new medication. The Veteran was 95 percent compliant with therapy for obstructive sleep apnea. In February 2019, the Veteran was treated for a sinus infection. In March and May 2019, the Veteran reported to a VA cardiologist and a VA psychologist about fatigue and dizziness. In May 2019, the Veteran was treated for recurrent upper respiratory infections. The Veteran's nurse practitioner noted an upcoming sinus surgery. A September 2019 mental disorders VA examination noted unspecified depressive disorder symptoms of depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; and disturbances of motivation and mood. In October 2019, the Veteran underwent a VA examination for chronic fatigue syndrome. The Veteran reported treatment for "all conditions at some point by his pcp or/and while in the service except for menstrual symptoms." The VA examiner noted that the Veteran has not been diagnosed with "chronic fatigue," but "fatigue." The Veteran also reported, during active service, getting an anthrax shot in 1991, having skin problems, and cough, colds, and exposure to burn pits, sandstorms, and fuel. The VA examiner found that the fatigue did not have a functional impact on the ability to work. The Veteran also underwent a VA examination of ear conditions. The VA examiner diagnosed "myotomy tubes placed in 1967, chronic drainage (2017)." The Veteran reported, "when he becomes dizzy he cannot walk straight and needs to hold onto things. Feels that things are distorted and not 'right' and this makes him uncertain of his footing and makes him apprehensive about being social or working and driving." The VA examiner found no vestibular conditions. The Veteran also underwent a VA examination for intestinal conditions. The VA examiner diagnosed chronic diarrhea. The Veteran endorsed symptoms of alternating diarrhea and constipation and intermittent nausea. The Veteran also underwent a VA examination for respiratory conditions. The VA examiner diagnosed COPD and chronic bronchitis based on diagnostic imaging and the Veteran's report about seeking respiratory treatment nine times over the prior year. The Veteran also underwent a VA examination for mental disorders. The VA examiner diagnosed Unspecified Depressive Disorder, Anxiety Disorder Due to a General Medical Condition, Unspecified Sleep-Wake Disorder, Sleep Apnea, Psychophysiologic insomnia, morbid obesity, arthritis, psoriasis. The Veteran endorsed symptoms of depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks; difficulty in understanding complex commands; and disturbances of motivation and mood. The Veteran denied any current headaches and the VA examiner offered no headache diagnosis. Diagnostic imaging showed no acute lung pathology. An October 2019 VA examiner opined it was "less likely than not" that the Veteran had a diagnosable or diagnosable disorders related to chronic fatigue syndrome (CFS) because "he does not have CFS, he has fatigue." An October 2019 VA examiner opined it was "at least at likely as not (50 percent probability) or greater" that the Veteran's reported symptoms of dizziness constitute a diagnosable disorder or "agnosable" disorders. The VA examiner explained that the Veteran had "many reasons as to why he has dizziness," ranging from cardiac, psychiatric, daily habits, and obesity. The VA examiner explained that the Veteran complained of dizziness intermittently throughout the years and had a history of tubes in ears as a baby, vitamins B12 and D deficiency, dizziness with position changes, and "a multitude of other things." The VA examiner opined that it was "less likely than not that" this dizziness is caused by an unexplained illness or chronic disability caused by a medically unexplained illness as there are multiple reasons as to why he could be having dizziness. The VA examiner explained that the reasons for dizziness are many including Vitamin D and B12 deficiency, GERD, psoriatic arthritis, or cardiac conditions, such as when his heart starts racing. The VA examiner explained that, as an otolaryngologist said during a consult, it may be an element of postnasal drip or having the excess drainage in ears from having tubes as a kid, that caused some unbalance issues as well. The VA examiner concluded that there were many reasons, including medical and psychiatric, could be playing a role in the dizziness. The October 2019 VA examiner did not offer an opinion about any possible cognitive disorder. The VA examiner noted that the Veteran had exhibited "mild" cognitive problems in certain areas in 2014, but that "this can change over time." The VA examiner found that current formal testing was required to render a diagnosis of a current cognitive disorder. At a later October 2019 VA examination for heart conditions, the Veteran reported fatiguing quickly, which affected production and work performance and often caused missing work as well. The Veteran also reported that depression, anxiety, or stress exacerbates the fatigue. The VA examiner diagnosed essential hypertension and chronic heart failure but with "normal" ejection fraction. Interview-based testing showed dyspnea, fatigue, and dizziness greater than three but less than five metabolic equivalents. In November 2019, the Veteran denied dizziness, increased shortness of breath, or increased fatigue at the time of the visit with a VA nurse. The Veteran reported headaches, pain in the head when swallowing, and sinus pressures to a VA emergency department nurse. The Veteran was assessed with an upper respiratory infection and sinus headache by a VA physician assistant. In December 2019, the Veteran denied headache or shortness of breath on a phone call to a VA nurse. In January 2020, the Veteran's VA primary care physician linked headaches to chronic sinusitis and assessed that shortness of breath was "stable" without the regular use of inhalers. A February 2020 computerized tomography scan showed no acute disease of the brain, "mild" cortical frontal atrophy, and chronic sinusitis with near complete opacification of left maxillary sinus. In April and August 2020 and March and June 2021, the Veteran denied headaches, shortness of breath, dizziness, or vertigo. In April 2020, the Veteran reported a history of chronic headaches and current fatigue and sleep apnea to a VA psychologist. The Veteran denied headaches to a VA primary care physician. In June 2020, the Veteran reported lightheadedness or dizziness during the prior week to a VA nurse. In September 2020, the Veteran consult a respiratory therapist about a prescribed CPAP machine. In October 2020, a VA examiner opined that, since there was no pathology to render a diagnosis of "dizziness," it was less likely than not that the Veteran had a dizziness condition that was incurred, caused, or aggravated by active military service to include exposure to environmental hazards. The VA examiner explained that the October 1987 enlistment physical examination documented the absence of complaints of "hay fever," "sinusitis," "asthma," or "chronic of frequent colds" upon entrance to the service and a history of tonsillectomy at age 5. The VA examiner noted an October 2019 VA examination report that documented findings of a "normal" Dix Hallpike test, a Romberg test noted as "abnormal or positive for unsteadiness," and a finger to nose test noted as "abnormal, describe: pass pointing on both sides with finger to nose, no double or blurry vision." The VA examiner explained that Romberg and finger to nose tests are tests of cerebellar function and proprioception and not tests for "dizziness." The Dix Hallpike test is a test for peripheral vestibular dysfunction and was normal. In March 2021, the Veteran reported to a VA physical therapist about wanting a rolling walking to improve his ability to walk without becoming overly fatigued. The Veteran denied a history of a respiratory condition to a VA dentist. In May 2021, the Veteran denied shortness of breath, fatigue, or headaches during a phone call with a VA nurse and at a visit with a VA cardiologist. In March and June 2021, the Veteran denied headaches, shortness of breath, dizziness, or vertigo. In May 2021, the VA examiner found that records show that the Veteran was seen and evaluated multiple times for headaches. The VA examiner found that headaches were sinus related. The Board notes that the Veteran is service connected for allergies. In December 2021, the Veteran underwent a VA examination for chronic fatigue syndrome. The VA examiner found that the Veteran did not currently have chronic fatigue syndrome. The Veteran reported that, since 2015, getting tired without any reason and doctors could not figure out what the problem was so the Veteran is just dealing with the tiredness. The Veteran reported that symptoms of fatigue and forgetfulness, including daily chores, had progressed, or worsened. Physical examination was "normal." The VA examiner noted that the Veteran was diagnosed with sleep apnea and using a continuous positive airway pressure (CPAP) machine. The Board notes that, in October 2019, the RO granted service connected for an unspecified depressive disorder, including symptoms of forgetting names, mild memory loss, forgetting recent events, chronic sleep impairment, and forgetting directions. The VA examiner opined that that Veteran's fatigue symptoms were not at least likely as not (50 percent probability or greater) due to an undiagnosed illness or a chronic disability caused by a medically unexplained illness. The VA examiner explained that there were no laboratory results showing that Veteran was in any distress or other health conditions causing fatigue. The VA examiner explained that the Veteran can perform greater than 60-75 percent of daily chores. The VA examiner explained that were no chronic headaches, no sleep problems, no muscle weakness or arches, and no fatigue lasting longer than 24 hours noted in the records. The VA examiner explained that there was no objective evidence available to warrant a diagnosis of chronic fatigue syndrome. The VA examiner explained that at a September 2014 VA examination, the Veteran did not report any fatigue, diarrhea, or constipation. During the examination, the Veteran denied problems with dizziness. The Veteran did report headaches around psoriatic arthritis. The VA examiner explained that at an October 2019 VA examination and a separation examination noted indigestion, respiratory, muscle pain, headaches, insomnia, memory problems, and chronic diarrhea. The VA examiner concluded that the Veteran did not meet the diagnostic criteria for chronic fatigue syndrome. In December 2021, the Veteran also reported lightheadedness at a VA examination for hypertension. Another VA examiner diagnosed seasonal allergies with no mention of related headaches. At a VA examination for esophageal conditions, the Veteran reported frequently waking up at night due to heart burn that caused sleepiness and making it hard to concentrate during the day. In January 2022, the VA examiner opined that the Veteran's alleged chronic fatigue syndrome was not related to the Veteran's Gulf War service because there was no diagnosis or new onset of chronic fatigue syndrome reported in the Veteran's medical record. The VA examiner explained that, during physical examination, the Veteran looked "well-groomed with no signs of any acute illness or tiredness noted." The VA examiner explained that sleep apnea was not evaluated in December 2021, therefore the VA examiner offered no medical opinion regarding a medically unexplained chronic multi-symptom illness. Review of the record does not establish a diagnosis of chronic fatigue syndrome or evidence of an undiagnosed illness as required for presumptive service connection under 38 C.F.R. § 3.317. The Veteran underwent VA examinations in December 2019 and December 2021. The examiner noted that chronic fatigue syndrome is not identified by history, record review or current examination and reported that the Veteran did not have nor ever has been diagnosed with chronic fatigue syndrome. The examiner did not identify a chronic disability pattern and concluded that the Veteran's reports of fatigue are at least partly due to sleep apnea. This is consistent with the medical evidence of record, which also attributes fatigue to the Veteran's sleep apnea and service-connected hypertension, unspecified muscle condition with pain, allergies, and unspecified depressive disorder with anxiety disorder and sleep-wake disorder associated with psoriasis with psoriatic arthritis. As the Veteran's fatigue is linked to diagnosed conditions, the Board finds that presumptive service connection under 38 C.F.R. § 3.317 is not warranted. The Board has also considered direct service connection. However, review of the record does not provide a diagnosed condition for which service connection is warranted. Fatigue is a symptom of the Veteran's service-connected hypertension, unspecified muscle condition with pain, allergies, and unspecified depressive disorder with anxiety disorder and sleep-wake disorder associated with psoriasis with psoriatic arthritis, and of the Veteran's non-service-connected condition of sleep apnea. Fatigue is not a separate diagnosis for VA purposes. Therefore, the Board concludes that the evidence does not establish the presence of a current disability; thus, service connection is not warranted. See Brammer v. Derwinski, 3 Vet. App. 223, 255 (1992). The claim is denied. Regarding the Veteran's contention about the need for assistance with activities of daily living, including grooming, the Board notes that the Veteran is already receiving special monthly compensation based on the need for regular aid and attendance. Regarding the Veteran's subjective symptoms of muscle weakness and pain, the Board notes that the Veteran is already service connected for an unspecified muscle condition with pain. Regarding the Veteran's subjective symptoms of indigestion and diarrhea, the Board notes that the Veteran is already service connected for chronic diarrhea to include gastroesophageal reflux disease (GERD). Regarding the Veteran's subjective symptoms of respiratory problems, the Board notes that the Veteran is already service connected for allergies. Regarding the Veteran's subjective symptoms of insomnia and memory issues, the Board notes that the Veteran is already service connected for an unspecified depressive disorder with anxiety disorder and sleep-wake disorder associated with psoriasis with psoriatic arthritis. As noted by the RO in October 2019, the symptoms of this disability include forgetting names, mild memory loss, occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, forgetting recent events, chronic sleep impairment, and forgetting directions. Regarding the Veteran's representative contentions at the July 2018 hearing, the Board notes that most of the remaining testimony from the Veteran and spouse was about skin and arthritic pain symptoms of the already service-connected psoriasis, psoriatic arthritis, and hypertension. Regarding the Veteran's concerns about the qualifications of VA examiners, the Board finds this nonspecific and unfounded. The qualifications of the VA examiners are of record. For example, the profile of the VA examiner that performed the December 2021 VA examination is on page three of a letter from Veterans Evaluation Services dated November 2011. The profile provides the VA examiner's name, specialty, license number, state, board certifications, experience, and training. The letter from the Veteran's Member of Congress has failed to specify what it is about these qualifications that could be of concern. The Board notes that VA examinations do not have to be conducted by physicians or specialists. Exceptions include psychiatric, ear, and eye disabilities, all of which do require a specialist but none of which apply here. Other VA examinations can be, and commonly are, conducted by a wide range of medical professionals. As such, the Board does not find any of the Veteran's examiners incompetent to provide medical opinions based on their education or degree. Regarding the Veteran's use of a CPAP machine and the subjective symptoms of tiredness or fatigue that may not be related to a chronic fatigue syndrome, the Board refers the issue of entitlement to service connection for sleep apnea to the RO. Regarding the Veteran's subjective symptoms of headaches, the Board notes that the Veteran is already service connected for allergies and psoriatic arthritis. A review of the records shows that most of the Veteran's headaches occurred within the context of sinus infections (such as in January 2001, January 2020, and May 2021) or a during psoriatic arthritis "attack," such as reported during VA examinations September 2014 and July 2015. Headaches was also listed as a side effect of a liver medication at a November 2010 VA examination. Regarding the Veteran's subjective symptoms of dizziness, the Board notes that, prior to October 2013, the Veteran consistently denied dizziness during VA treatment and examinations. In October 2018, a treating VA psychiatrist noted that the dizziness may be related to the Veteran's nerve pain medication that might resolve. In October 2019, the Veteran related the dizziness to now service-connected unspecified depressive disorder with anxiety disorder and sleep-wake disorder associated with psoriasis with psoriatic arthritis or non-service-connected sleep apnea, traumatic brain injury, or another memory or cognitive impairment. In October 2019, a VA examiner related dizziness to a Vitamin D deficiency, GERD, psoriatic arthritis, hypertension, or a childhood otolaryngological disorder (the Veteran had tubes as a child). To the extent that Veteran may wish to file a service connection claim for a headache, dizziness, or any another cognitive issue, the Board refers this matter to the RO. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James Hekel 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.