Citation Nr: 0005450 Decision Date: 02/29/00 Archive Date: 03/07/00 DOCKET NO. 989-16 860 ) DATE ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for asthma and reactive bronchitis. 2. Entitlement to service connection for respiratory symptoms including persistent cough, chest congestion, respiratory infections, and shortness of breath as manifestations of an undiagnosed illness. 3. Entitlement to psychiatric symptoms, including fatigue, lack of energy, irritability, social isolation and sleep problems, as manifestations of an undiagnosed illness. 4. Entitlement to service connection for headaches as manifestations of an undiagnosed illness. 5. Entitlement to service connection for memory loss as a manifestation of an undiagnosed illness. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD R. L. Shaw, Counsel INTRODUCTION The veteran had active military service from February 25, 1988, through July 2, 1988, and from November 17, 1990, through July 24, 1991. She served in the Southwest Asia Theatre of Operations from January 6, 1991, through June 28, 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 26, 1998, rating decision by the Pittsburgh, Pennsylvania, Regional Office (RO) of the Department of Veterans Affairs (VA) which denied service connection for various disorders claimed as manifestations of an undiagnosed illness. The veteran testified at a hearing before the Board at the RO on May 28, 1999, in connection with her appeal. As developed as certified for appeal by the RO, the issues before the Board have been characterized as claims of service connection for disability due to undiagnosed illness pursuant to 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. With respect to respiratory pathology, however, it appears from the record that while the veteran desires that service connection be granted for various symptoms claimed to be due to undiagnosed illness, she also seeks to establish service connection for specific disorders, asthma and reactive bronchitis, on the basis of provisions of law pertaining to direct service incurrence. See, e.g., 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309. The Board is obligated to seek out all issues that are reasonably raised from a liberal reading of documents or testimony of record and to identify all potential theories of entitlement to a benefit under the applicable laws and regulations. Floyd v. Brown, 9 Vet.App. 88 (1996). Douglas v. Derwinski, 2 Vet.App. 103 (1992) aff'd in part and vacated in part on reconsideration en banc, 2 Vet.App. 435 (1992). Under the circumstances, therefore, the Board will consider the claim of service connection for asthma and reactive bronchitis on a direct basis as well as on the basis of disability due to undiagnosed illness. FINDINGS OF FACT 1. The record contains competent evidence of respiratory disability due to manifestations of undiagnosed illness during the presumptive period since service. 2. The veteran has current psychiatric symptoms which have been attributed by physicians to a known diagnosis. 3. The record does not contain competent evidence of objective indications of current disability due to loss of headaches ratable at 10 percent or more under VA rating criteria. 4. The record does not contain competent evidence of objective indications of current disability due to memory loss ratable at 10 percent or more under VA rating criteria. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for respiratory symptoms, including persistent cough, chest congestion, respiratory infections, and shortness of breath as manifestations of undiagnosed illness is well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107, 7104 (West 1991 & Supp. 1997); 38 C.F.R. §§ 3.307, 3.309 (1999). 2. Psychiatric symptoms, including fatigue, lack of energy, irritability, social isolation and sleep problems, as manifestations of undiagnosed illness, were not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5107, 7104 (West 1991 & Supp. 1997); 38 C.F.R. §§ 3.307, 3.309 (1999). 3. The claim of entitlement to service connection for headaches as manifestations of an undiagnosed illness is not well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107, 7104 (West 1991 & Supp. 1997); 38 C.F.R. §§ 3.307, 3.309 (1999). 4. The claim of entitlement to service connection for memory loss as a manifestation of undiagnosed illness is not well grounded. 38 U.S.C.A. §§ 1110, 1131, 5107, 7104 (West 1991 & Supp. 1997); 38 C.F.R. §§ 3.307, 3.309 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background No complaints or abnormal findings pertinent to the issues on appeal were reported on an examination for enlistment performed in October 1987. Service department medical records dated before the veteran's deployment to Southwestern Asia show that an upper respiratory infection and sinus congestion were reported in March 1988 and that she was treated for a flu in December 1990. The veteran was examined for redeployment in May 1991. No pertinent complaints or defects were noted. In a chronological record of medical care signed by the veteran in connection with this examination, she reported having been exposed to large amounts of dust and smoke for 15 days during her service in Southwest Asia. She indicated "no" in response to a question as to whether she had reason to believe that she or members of her unit were exposed to chemical or germ warfare. She denied having a cough or sinus infection. Records from the Good Samaritan Hospital show that in August 1992 the veteran was treated for a two-day illness characterized by productive cough, low grade fever, nasal congestion and sore throat. The clinical impression was respiratory infection. Medication was prescribed. A quadrennial service department examination was performed in October 1992. In a medical history questionnaire, the veteran checked yes in response to questions as to whether she had or had ever had chronic or frequent colds, shortness of breath, pain or pressure in chest, frequent trouble sleeping, and depression or excessive worry. The reviewing physician noted that she had had two episodes of "febrile illness/bronchitis" with a productive cough, fever and weakness. The symptoms had resolved with therapy. She reported shortness of breath/dizziness, noting that there had been occasional shortness of breath since the first infection with no progression. On examination, the lungs and chest were clear to auscultation. No pertinent defects were reported. The veteran's original claim for VA compensation based on service in Southwest Asia was received in December 1996. In support of her claim, she submitted a January 1997 statement from her husband, who related that he had known the veteran since November 1990 and had been deployed with her to Saudi Arabia. He related that she was suffering from a chronic cough which had gotten much worse in the past two years. He stated that she had respiratory infections and bronchitis, that physical activity left her short of breath and wheezing, and that medication had no long term affect. He further related that the veteran had problems sleeping and often seemed to be depressed and tired. He claimed that her health had drastically declined since her return from the Persian Gulf. The veteran underwent a VA examination in February 1997 for "systemic conditions." She stated that before going to the Persian Gulf her health was excellent but that upon returning to the United States she developed a number of medical complaints, including chronic coughing, nose and chest congestion, frequent respiratory tract infections, shortness of breath, fatigue, short-term memory loss, inability to sleep, and depression. On examination the veteran was in no acute distress. The lungs were clear bilaterally with no wheezing. There were no neurologic deficits. The examiner reported under the heading of " mental changes" that the veteran was "much better than she was." She still had slight depression and slight insomnia but did not have full blown symptoms of post-traumatic stress disorder. Pulmonary function tests showed that her FEV-1 was 80 percent of that predicted. Chest X-ray was normal. Under the diagnosis heading, the examiner stated that "the veteran has unexplained illness of Persian Gulf War syndrome which manifests by the symptoms that she described above." The veteran underwent a VA psychiatric examination in September 1997. She related that after returning from Desert Storm, she reenrolled at Ohio State University in a mechanical engineering program but withdrew due to difficulty readjusting to school. She had worked for 2 1/2 years as an auditor for a hotel. After her marriage she had relocated and obtained another job as a hotel auditor but had left that job in 1995 and had become a secretary at a veterans' center. She reported good relations with her husband and son. With respect to her symptoms, the veteran related that after returning from Desert Storm she had become short tempered and irritable, especially with her family, and tended to avoid other people because of this. She had been isolating herself from others, had few friends, and avoided crowds. She had had a depressed mood in Saudi Arabia which had improved somewhat since her return. She reported a several year history of difficulty with sleep initiation and maintenance. She found that she did not trust other people and was somewhat paranoid regarding their intentions and motives. She described difficulty with the citizens of Saudi Arabia and felt anger toward members of her unit who she felt were disrespectful. On examination, the veteran was alert and oriented. She described her mood as good, and her affect was normal. She reported mild anxiety attacks two or three times per month which did not appear to significantly interfere with her functioning. A Mississippi scale test for combat related post-traumatic stress disorder showed a score below the cut-off for clinically significant PTSD. The diagnosis was anxiety disorder, not otherwise specified. The veteran underwent a VA general medical examination in September 1997. Her major complaint was of shortness of breath and of a chronic hacking dry cough. She stated that she had been seen by a private physician who had given her Allegra which had not been effective until she was given a bronchodilator which had improved her breathing. She stated that she had been diagnosed with asthma and reactive bronchitis by her private physician. On review of systems she denied a history of headache. She expressed the belief that her recurrent shortness of breath occurred when she was exposed to something she was allergic to. She reported wheezing also. She was able to climb stairs with no problems but could not perform strenuous exercises such as running, especially in cold weather. On examination, there was equal expansion of the chest. The lungs were clear. There were no rales. The chest was hyperresonant. No neurological or psychiatric abnormalities were found. The diagnoses included chronic cough with shortness of breath of unknown etiology; and chronic sinusitis. The veteran underwent a VA respiratory examination in September 1997. The complaints and findings were essentially the same as those reported on the general medical examination. The pertinent diagnosis was chronic cough, etiology unknown. The veteran underwent a neurological examination in September 1997. The examiner commented that she did not really have any specific neurological problems. The veteran claimed that one time she had had a nonspecific aching headache which was not of the throbbing variety, which was resolved by taking Tylenol or aspirin. It did not really interfere with her functioning. On examination there were negative findings. The diagnosis was essentially normal neurological examination. A record from the St. Clairesville branch of the Wheeling Clinic shows that the veteran was seen in November 1996 for complaints of a productive morning cough and shortness of breath when lying down of one week's duration. There was no current dyspnea and she was feeling better on the day she was seen. The diagnosis was upper respiratory infection. Follow up was suggested if new symptoms developed. Medication was prescribed. The veteran testified at a Travel Board hearing at the RO on May 28, 1999. With respect to respiratory pathology, she stated that asthma had first been diagnosed in about October or November 1997. Before that she had had shortness of breath. She related that in October or November 1997 she had had an episode of severe breathing problems which last several days and had gone to a specialist in asthma, Dr. Urval, who prescribed inhalers which she had used ever since then. She claimed that before the diagnosis of asthma was made, she thought she had colds and took over-the-counter medications. She described exposure to respiratory irritants during the Gulf War as a result of oil fires. She indicated that she was currently seeing the asthma specialist and was taking inhaler medications. With respect to psychiatric symptoms, the veteran testified that her biggest problem was that she could not sleep, claiming that it took her two hours to fall asleep and that she would then wake up at least once, sometimes three or four times, during the night. She described constant irritability, lack of patience, dislike of crowds, and a preference for being by herself. She denied flashbacks but indicated that she did not like to discuss the Gulf War or watch television programs about it. She had not received any treatment for anxiety. She denied having had problems with anxiety before her Gulf War service. With respect to headaches, the veteran testified that she currently experienced headaches about once per week and took Ibuprofen for them. She normally needed to take her medication and lie down for a few minutes to get some relief. She described headaches associated with bright lights. She related that she had not had frequent headaches before service but began to have them persistently during the Persian Gulf War when exposed to smoke in the air or when they used kerosene heaters in their tents. She complained that the headaches had gotten worse since a period of active duty for training in 1993 after her return from the Gulf War. She had not received regular medical attention for them. With respect to memory loss, the veteran testified that she would go into her office and forget what she was going there for. She stated that she had to lay things on the table or write down what she was going to take. This had been going on consistently since the Gulf War. II. Legal Criteria Service connection may be established for disability that is shown to have been incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110 (wartime), 1131 (peacetime) (West 1991 & Supp. 1998). If the disability is not shown to have been chronic in service, continuity of symptomatology after separation is required to support the claim. 38 C.F.R. § 3.303(b) (1999). VA regulations also provide that service connection may be granted for any disease diagnosed after discharge 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) (1999). On November 2, 1994, Congress enacted the "Persian Gulf War Veterans' Act " (Title I of the "Veterans' Benefits Improvements Act of 1994," Public Law 103-446). That statute added a new section 1117 to Title 38, United States Code, authorizing VA to compensate any Persian Gulf veteran suffering from a chronic disability resulting from an undiagnosed illness or combination of undiagnosed illnesses which became manifest either during active duty in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more within a presumptive period following service in the Southwest Asian theater of operations during the Persian Gulf War. To implement the Act, the VA added a new regulation, 38 C.F.R. § 3.117, which provides as follows: (a)(1) Except as provided in paragraph (c) of this section, VA shall pay compensation in accordance with chapter 11 of title 38, United States Code, to a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of this section, provided that such disability: (i) 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, 2001; and (ii)by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. (2) For purposes of this section, "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. (3) For purposes of this section, disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-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. (4) A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. (5) A disability referred to in this section shall be considered service- connected for purposes of all laws of the United States. (b) For the purposes of paragraph (a)(1) of this section, signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: (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 (13) menstrual disorders. (c) Compensation shall not be paid under this section: (1) if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or (2) if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or (3) if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. (d) For purposes of this section: (1) the term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. (2) the Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (1999). (Note: As originally constituted, the presumptive period continued no later than two years after the date on which the veteran last performed active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. Effective November 2, 1994, the period within which such disabilities must become manifest to a compensable degree in order for entitlement for compensation to be established was expanded to extend to December 31, 2001.) The preliminary requirement for establishing entitlement to any VA benefit is that the applicant submit a claim which is sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991). The United States Court of Veterans Appeals (renamed on March 1, 1999, as the United States Court of Appeals for Veterans Claims) (Court) has defined a well- grounded claim as "a plausible claim, one which is meritorious on its own or capable of substantiation." Such a claim need not be conclusive, but only plausible, to satisfy the initial burden of § 5107. Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). In Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that, under 38 U.S.C. § 5107(a), the VA has a duty to assist only those claimants who have established well grounded (i.e., plausible) claims. More recently, the Court issued a decision holding that the VA cannot assist a claimant in developing a claim which is not well grounded. Morton v. West, 12 Vet. App. 477 (July 14, 1999), req. for en banc consideration by a judge denied, No. 96-1517 (U.S. Vet. App. July 28, 1999) (per curiam). The Court has held that, in general, a claim for service connection is well grounded when three elements are satisfied with competent evidence. Caluza v. Brown, 7 Vet. App. 498 (1995); see also Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997) quoting Epps v. Brown, 9 Vet. App. 341, 343-344 (1996). First, there must be competent medical evidence of a current disability (a medical diagnosis). Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) Second, there must be evidence of an occurrence or aggravation of a disease or injury incurred in service (lay or medical evidence). Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991); Layno v. Brown, 6 Vet. App. 465 (1994). Third, there must be a nexus between the in-service injury or disease and the current disability (medical evidence or the legal presumption that certain disabilities manifest within certain periods are related to service). Grottveit v. Brown, 5 Vet. App. 91, 93; Lathan v. Brown, 7 Vet. App. 359 (1995). For the purpose of determining whether a claim is well grounded, the credibility of the evidence is presumed. See Robinette v. Brown, 8 Vet. App. 69, 75 (1995). Where the claim involves a question of medical diagnosis or medical causation, competent medical evidence to the effect that the claim is plausible or possible is required to establish a well-grounded claim. Grottveit, Id. Lay assertions of medical causation or diagnosis cannot constitute evidence to render a claim well grounded under 38 U.S.C.A. § 5107(a) (West 1991); if no cognizable evidence is submitted to support a claim, the claim cannot be well grounded. Grottveit, Id.; see also, Tirpak v. Derwinski, 2 Vet. App 609 (1992) (To be well-grounded, a claim must be supported by evidence that suggests more than a purely speculative basis for an award of benefits; medical evidence is required, not just allegations). With respect to undiagnosed illness claims specifically, the VA General Counsel has held that a well-grounded claim for compensation under 38 U.S.C.A. § 1117(a) and 38 C.F.R. § 3.317 generally requires the submission of some evidence of: (1) Active military, naval, or air service in the Southwest Asia Theatre of Operations during the Persian Gulf War; (2) The manifestation of one or more signs or symptoms of undiagnosed illness; (3) objective indications of chronic disability during the relevant period of service or to a degree of 10 percent or more within the specified presumptive period; (4) a nexus between the chronic disability and the undiagnosed illness. VAOPGCPREC 4-99 (May 3, 1999). With respect to the second and fourth elements of a well- grounded claim, VAOPGCPREC 4-99 indicates that evidence that the illness is "undiagnosed" may consist of evidence that the illness cannot be attributed to any known diagnosis or, at minimum, evidence that the illness has not been attributed to a known diagnosis by physicians providing treatment or examination. The type of evidence necessary to establish a well-grounded claim as to each of these elements may depend upon the nature and circumstances of the particular claim. Medical evidence would ordinarily be required to satisfy the fourth element, although lay evidence may be sufficient in cases where the nexus between the chronic disability and the undiagnosed illness is capable of lay observation. For purposes of the second and third elements, VAOPGCPREC 4- 99 indicates that the manifestation of one or more signs or symptoms of undiagnosed illness or objective indications of chronic disability may be established by lay evidence if the claimed signs or symptoms, or the claimed indications, respectively, are of a type which would ordinarily be susceptible to identification by lay persons. If the claimed signs or symptoms of undiagnosed illness or the claimed indications of chronic disability are of a type which would ordinarily require the exercise of medical expertise for their identification, then medical evidence would be required to establish a well-grounded claim. With respect to the third element, a veteran's own testimony may be considered sufficient evidence of objective indications of chronic disability, for purposes of a well-grounded claim, if the testimony relates to non-medical indicators of disability within the veteran's competence and the indicators are capable of verification from objective sources. III. Respiratory symptoms claimed to be manifestations of undiagnosed illness. In the present case, the veteran had well documented active military, naval, or air service in the Southwest Asia Theatre of Operations during the Persian Gulf War and thus satisfies the first element of a well-grounded claim. At VA examinations performed in February and September 1997, she complained of various respiratory symptoms which include a persistent cough, chest congestion, respiratory infections, wheezing, and shortness of breath of post service onset. Not all of the symptom have been clinically documented, but the court has held that a lay person is competent to proffer testimony as to the existence of a chronic disability as to those matters that are susceptible of non-medical interpretation. In this category would be the veteran's subjective report of having the symptoms that she claims. See Savage v. Gober, 10 Vet. App. 88 (1997). For the limited purpose of ascertaining whether the claim is well grounded, her evidentiary assertions as to the existence of respiratory symptoms are presumed credible. King, Id.; Savage, Id. The manifestations reported by the veteran through statements that are presumed to be credible were interpreted by a VA examiner in February 1997 to represent an "unexplained illness of Persian Gulf War syndrome," and a VA respiratory examiner concluded in September 1997 that the veteran has a cough of undetermined etiology. These medical findings are sufficient to satisfy the second element to of a well-grounded claim. These manifestations are not claimed or shown to have been present during the veteran's military service, but they became manifest during the period established by Congress for presumptive service connection, a period which continues to remain open through the end of the year 2001, and the presumed-credible evidence suggests the likelihood of a degree of disability of 10 percent or more under various VA diagnostic codes pertaining to respiratory illnesses. The symptoms have been present for more than 6 months and are thus "chronic" under the undiagnosed illness regulation. The third element of a well-grounded claim is thus satisfied. The opinions of the VA examiners attributing the veteran's respiratory symptoms to undiagnosed illness is sufficient to satisfy element four. The veteran's claim for service connection for respiratory symptoms as manifestations of an undiagnosed illness is therefore well grounded. VAOPGCPREC 4-99 (May 3, 199). The finding of a well-grounded claim is not the equivalent of a finding of entitlement to service connection. A review of the merits of the service connection claim as to this disability will be undertaken following completion of the additional evidentiary development discussed in the remand portion of this decision below. IV. Psychiatric Symptoms as Manifestations of Undiagnosed Illness The veteran claims that she has experienced various psychiatric problems since her service in the Persian Gulf, especially anxiety, irritability, withdrawal from social contacts and feelings of depression. She is plainly competent to testify regarding these symptoms and her reports are presumed credible for the purpose of ascertaining the plausibility of the claim. See Savage, Id., King, Id. The veteran reported certain psychiatric symptoms, including depression and insomnia, at the VA examination of February 1997 and they are to that extent included within the examiner's broad conclusion that the manifestations reported were part of an undiagnosed illness due to the Persian Gulf service. The conclusion by that examiner is sufficient to establish a well-grounded claim under the criteria in the VA General Counsel in Opinion 4-99. The February 1997 VA examination report is sufficient to establish a well-grounded claim, but a determination of the veteran's claim for entitlement to service connection must be based on consideration of whether a preponderance of all the evidence of record, positive and negative, supports the granting of service connection, and the Board is obligated to ascertain the credibility and probative value to be assigned to each item of evidence. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the February 1997 examination was followed several months later by a separate psychiatric examination which produced a different diagnosis, finding that the veteran's symptomatology was due to an anxiety disorder. If this diagnosis is accepted, the veteran's claim for service connection based on psychiatric symptoms due to an undiagnosed illness must fail since an anxiety disorder is not an "undiagnosed illness" within the meaning of the applicable law. The September 1997 examination report containing the diagnosis of anxiety disorder is clearly the more persuasive of the two reports. It is more detailed and specific and sets forth a complete statement of reasons for the diagnosis recorded. The thorough review of the record undertaken in September 1997 gives the diagnosis reported by that examiner a greater degree of plausibility and weight than that resulting from the rather superficial and unsupported diagnosis given in February 1997. The preponderance of the relevant evidence of record is against the claim for service connection for psychiatric symptoms as manifestations of undiagnosed illness. Since the positive and negative evidence is not in relative equipoise, the benefit of the doubt rule is not applicable. 38 U.S.C.A. § 5107(b) (West 1991). V. Headaches as Manifestations of an Undiagnosed Illness The veteran claims that after her service in the Persian Gulf, she began to experience headaches of greater degree than those she had had previously and that the pain has eventually become even worse. At a neurological examination in September 1997, she indicated that the headaches had responded to over-the-counter medications. She indicated at her hearing that she has received no medical attention for treatment of headaches. The diagnosis recorded at the February 1997 VA examination satisfies element two of the requirements for a well-grounded claim for service connection (manifestation of one or more signs or symptoms of undiagnosed illness). However, to satisfy the third element, there must be objective indications of chronic disability during service or current disability of 10 percent or more within the presumptive period. To satisfy element three of a well-grounded claim, the record must show that the headache disability was present during service or to a degree of 10 percent within the presumptive period. Objective indications of chronic headaches were not recorded during service, and none have been recorded in a clinical setting at any time since separation. In addition, to warrant a 10 percent rating under the VA Rating Schedule, 38 C.F.R. § 4.124(a), Diagnostic Code 8100, for headaches (specifically, migraine), it would be necessary to demonstrate by medical evidence that the veteran's headaches result in characteristic prostrating attacks averaging one in two months over a period of several months. Even if the veteran's lay evidence is accepted and presumed to be true pursuant to Savage and King, the headaches are not shown to be characteristically prostrating in nature. This element of a well-grounded claim is therefore not satisfied. The claim for service connection for headaches based on manifestations of an undiagnosed illness is not well grounded under the criteria established by the VA General Counsel in its Precedent Opinion 4-99. In addition, even if a well-grounded claim were conceded, it is relevant that at a subsequent neurological examination performed in September 1997, the findings were normal. In no event may service connection be granted for a disability which has been attributed to a known diagnosis. In the absence of a well-grounded claim, service connection for headaches as manifestations of an undiagnosed illness must be denied. Edenfield v. Brown, 8 Vet. App. 384 (1995). VI. Memory Loss as a Manifestation of Undiagnosed Illness The veteran complains of disability due to memory loss but such a condition has not been identified in a clinical setting. Nevertheless, the veteran is competent as a lay person to proffer testimony as to matters that are susceptible of non-medical interpretation, including a subjective report of memory problems. Savage, Id. For the limited purpose of ascertaining of whether the claim is well grounded, her evidentiary assertions regarding the presence of memory loss are presumed to be credible. King, Id. In addition, the report of the February 1997 VA examination attributing various symptoms that included memory loss to undiagnosed illness is sufficient to satisfy element two of the criteria for a well-grounded claim. However, since memory loss was not documented during service or clinically described after separation, the veteran may satisfy the current disability requirement by showing disability due to memory loss ratable at 10 percent or more within the presumptive period. Since memory loss was not clinically documented during service, the veteran may benefit from the undiagnosed illness presumption only by establishing by objective evidence that the disorder is manifest at the present time and that it results in disability ratable at 10 percent or more. In considering the claim under the presumption, it is relevant that memory loss is not identified as a clinical entity in 38 C.F.R. Part IV, the VA Schedule for Rating Disabilities; however, when an unlisted condition is encountered, it may be rated as a closely-related disease or injury in which the functions affected and the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (1999). Under 38 C.F.R. § 4.124(a), neurological conditions and convulsive disorders are evaluated "in proportion to the impairment of motor, sensory or mental function." The record contains no suggestion that the recorded memory loss results in impairment of motor or sensory function. Under 38 C.F.R. § 4.130, mental disorders are evaluated on the basis of occupational and social impairment. The record does not demonstrate social and industrial impairment due to memory loss. The veteran describes a form of mild forgetfulness that requires her to write things down, but memory lapses of the kind she describes are not shown to result in any objective interference with her work or social relationships. There is no evidence to corroborate the allegation that memory problems were a factor in the discontinuance of her college education. In the absence of objective indications of a current disability due to loss of memory, the claim for service connection for memory loss as a manifestation of an undiagnosed illness is not well grounded and must be denied. Edenfield, Id. With respect to the claims involving headaches and memory loss, the veteran is advised that when a claim is not well grounded, there is no VA duty under the law to assist a claimant in developing the facts pertinent to the claim, though the VA may be obligated to advice a claimant of the evidence needed to complete the application, depending on the particular facts of the case and the extent to which the RO has advised claimant of the evidence necessary in connection with a claim for benefits. See Robinette v. Brown, 8 Vet. App. 69 (1995). In this case, the RO sent a letter to the veteran on January 23, 1997, which explained the prerequisites for payment of benefits based on an undiagnosed illness and itemized the type of evidence necessary to support her particular claims. Further explanations concerning the sufficiency of the evidence of record and the nature of the evidence needed to support her claim has been provided in various statements of the case, supplemental statements of the case, and the present decision of the Board. These explanations are sufficient to satisfy any VA obligation under Robinette. ORDER The claim of entitlement to service connection for respiratory symptoms, including persistent cough, chest congestion, respiratory infections, and shortness of breath as manifestations of undiagnosed illness, is well grounded. To this extent only, the appeal is granted. Service connection for psychiatric symptoms, including fatigue, lack of energy, irritability, social isolation and sleep problems, as manifestations of undiagnosed illness, is denied. Service connection for headaches as manifestations of an undiagnosed illness is denied as not well grounded. Service connection for memory loss as a manifestation of undiagnosed illness is denied as not well grounded. REMAND The law requires full compliance with all orders in this remand. Stegall v. West, 11 Vet.App. 268 (1998). Although the instructions below should be carried out in a logical chronological sequence, no instruction in this remand may be given a lower order of priority in terms of the necessity of its being carried out completely. Because the claim of entitlement to service connection for respiratory symptoms as manifestations of undiagnosed illness is well grounded, the VA has a duty to assist the veteran in developing the facts pertinent to the claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.159 (1999); Murphy v. Derwinski, 1 Vet. App. 78 (1990). Although the record contains VA medical evidence sufficient to well ground the claim for service connection for respiratory symptoms as manifestations of an undiagnosed illness, a determination as to whether this evidence is sufficient to support an award of benefits must be deferred until completion of development of the record. In this regard, it is relevant that the veteran has reported a history of treatment for asthma and reactive bronchitis, apparently beginning in 1997. She reports that she is currently receiving treatment from a specialist in respiratory diseases who has prescribed inhalant medication for asthma, and she submitted at her hearing a January 1998 payment receipt from K. R. Urval, M.D., of the Ohio Valley Allergy Institute, Inc., showing treatment for allergic rhinitis and asthma. Complete documentation describing the clinical findings and diagnoses reported by this physician and any others who have seen the veteran for respiratory pathology are not of record but are highly relevant to the present claim. An attempt must be made to obtain this evidence, and upon its receipt, a further VA examination should be conducted to establish the correct diagnosis, or lack of a diagnosis, for the veteran's respiratory pathology. The issues on appeal also include the question of entitlement to service connection for asthma and reactive bronchitis on the basis of direct service incurrence or aggravation, as noted above. The evidentiary development requested in this remand may well produce evidence germane to that issue. Therefore, the Board will defer adjudication of that matter pending completion of the development outlined below. Where the record before the Board is inadequate, a remand is required. Green v. Derwinski, 1 Vet. App. 121 (1991). Accordingly, the issue of entitlement to service connection for respiratory symptoms as manifestations of undiagnosed illness is REMANDED for the following actions: 1. The RO and any physician to whom this case is assigned for an examination and/or a statement of medical opinion must read the entire remand, including the explanatory paragraphs above the numbered instructions. 2. The veteran should be given an opportunity to identify all medical providers, both VA and private, including both physicians and institutions (hospitals or clinics), from which she has received examination or treatment for any respiratory symptomatology since military service. Upon receipt of proper authorization, the RO should attempt to obtain all available documentation from the providers identified by the veteran. In particular, an effort should be made to obtain the complete record of examination and treatment from K. R. Urval, M.D., of the Ohio Valley Allergy Institute, Inc. 3. Regardless of the success or failure of the foregoing requests in procuring additional medical documentation, the RO should then schedule the veteran for a VA examination by a specialist in respiratory disorders. The claims folder and a copy of this remand must be provided to the examiner for use in connection with the examination, and the examiner should be asked to state the extent to which the file was reviewed. All indicated tests and studies should be conducted, and all clinical findings must be reported in detail. On the basis of current examination findings, the medical evidence already of record, and any additional information received from the veteran, the examiner should address the following: a. The examiner should individually itemize every symptom of upper or lower respiratory pathology manifested by the veteran. b. The examiner should itemize each respiratory diagnosis supported by the evidence of record. For each diagnosis listed, the examiner must itemize in detail each and every symptom associated with such diagnosis. c. The examiner should itemize each and every symptom or manifestation that is not accounted for by the diagnosis or diagnoses listed above. For each such symptom or manifestation, the examiner should state a conclusion as to whether it is as likely as not, more likely than not, or less likely than not that such symptom is the result of an undiagnosed illness associated with service in the Persian Gulf War. d. The basis for the findings and conclusions stated in response to questions a, b and c should be set forth fully and in detail. 4. The RO should review the examination report received to ensure that it is adequate to satisfy the purposes of this remand as stated above. If not, the RO should return the report to the examiner for a complete response. All other follow-up actions necessary to comply with the Board's remand instructions should be undertaken. See 38 C.F.R. § 4.2 (1999). 5. The RO should then review the issue of entitlement to service connection for asthma and reactive bronchitis and the issue of entitlement to service connection for respiratory symptoms as manifestations of an undiagnosed illness. If either determination is adverse to the veteran, a supplemental statement of the case should be prepared and the veteran and his representative should be given a reasonable period of time for reply. Thereafter, the claim should be returned to the Board for further review on appeal, if in order. No action is required of the veteran until he receives further notice. The purpose of this remand is to obtain additional information. The Board does not intimate any factual or legal conclusions as to the outcome ultimately warranted in this appeal. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. G. H. SHUFELT Member, Board of Veterans' Appeals Error! Not a valid link.