Here is a sample medical statement that might be found in the Remarks section of a documentation protocol.

Remarks:
Summary of Diagnosis: This Veteran’s disability pattern falls under the categories indicated below:

An undiagnosed illness (category 1)

1. Generalized muscle ache
2. Loss of appetite
3. Tiredness

A disease with a clear and specific etiology and diagnosis (category 4)

1. Asthma
2. Degenerative disc disease (DDD) of cervical spine

Since asthma and DDD are in category (4), disease with a clear and specific etiology and diagnosis, you are required to provide a medical opinion with supporting rationale as to whether either condition was related to a specific exposure event experienced by the Veteran during his service in Southwest Asia.

For example, in this case asthma may have been caused by specific exposure to particulate matter or hazardous gases if the Veteran was stationed or worked near burn pits, oil fires, or dust storms. On the other hand, if the Veteran’s service treatment records (STRs) were positive for record of an injury or incident involving the neck, the required opinion and rationale would explain that Veteran’s DDD of the cervical spine was not caused by any specific exposure event due to his service in Southwest Asia.