Citation Nr: 0000945 Decision Date: 01/12/00 Archive Date: 01/27/00 DOCKET NO. 98-07 949 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUES 1. Entitlement to an increased rating for bronchial asthma currently evaluated 10 percent disabling. 2. Entitlement to an increased rating for headache disorder currently assigned a non-compensable evaluation. 3. Entitlement to service connection for hypothyroidism. 4. Entitlement to service connection for irritable colon syndrome. 5. Entitlement to service connection for rash due to an undiagnosed illness. 6. Entitlement to service connection for joint and bone pain due to an undiagnosed illness. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Maureen A. Young, Associate Counsel INTRODUCTION The veteran had active military service from October 1987 to June 1991. His service included active duty in the Southwest Asia theater of operations during the Persian Gulf War from January 1991 to May 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 1998 rating decision by the Department of Veterans' Affairs (VA) Regional Office (RO) in Boise, Idaho. FINDINGS OF FACT 1. The veteran's service-connected bronchial asthma is currently manifested by pulmonary function test results of Forced Expiratory Volume in one second (FEV-1) 95 percent and FEV-1/Forced Vital Capacity (FVC) 96 percent, controlled by inhalational therapy. 2. The veteran's headache disorder is not characteristic of prostrating attacks averaging one in two months over several months. 3. The claims of entitlement to service connection for hypothyroidism and irritable colon syndrome are not supported by cognizable evidence showing that the claims are plausible or capable of substantiation. 4. There are no objective indications of a rash and joint and bone pain as due to an undiagnosed illness. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for bronchial asthma have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.97 Diagnostic Code 6602 (1999). 2. The criteria for a compensable evaluation for headache disorder have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.124(a), Diagnostic Code 8100 (1999). 3. The claims of entitlement to service connection for hypothyroidism and irritable colon syndrome are not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. Compensation may not be paid for a rash and joint and bone pain as an undiagnosed illness in a Persian Gulf War veteran. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background Bronchial Asthma Service medical records at enlistment show that the veteran had no abnormalities of his respiratory system. The veteran's medical history at enlistment indicated he had never had asthma, pain or pressure in the chest, or a chronic cough. The examination report showed normal lungs, chest and sinuses. From February 1988 to May 1990 the veteran was intermittently diagnosed with viral upper respiratory infection, viral syndrome or mild bronchitis upon complaints, of coughing, sore throat and headaches. In-service chest x-rays in April and June 1990 showed the lung fields were clear with no evidence of active inflammatory disease. VA examination in August 1997 showed the veteran's lungs were clear. There were no rales, rhonchi or rubs. The examiner noted that the veteran has a history of bronchial asthma and he occasionally uses inhalers. The diagnosis was mild asthma. It was noted in the VA mental disorder examination report of August 1997 that inhalers were helping the veteran's asthmatic condition in that he was having fewer asthmatic attacks. A pulmonary function test was conducted and it revealed the veteran's FVC was 99 percent, his FEV-1 was 95 percent and his FEV-1/FVC was 96 percent. In his notice of disagreement filed in March 1998 the veteran stated that his bronchial asthma condition is more than 10 percent disabling. He also stated that he is suffering from a condition where his lungs only absorb 60 percent oxygen. Headache disorder Service medical records show that the veteran had complaints of headaches intermittently from March 1988 to March 1990. During this period, however, there was no diagnosis of a headache disorder. The diagnoses were viral upper respiratory infection, viral syndrome or mild bronchitis and the headaches were associated with these diagnoses. Service medical records of April 1990 and November 1990 show a diagnosis of headache. On April 3, 1990 the veteran complained of having a bitemporal migraine headache since the previous night and the diagnosis was tension headache versus common migraine. He was prescribed Midrin. On April 5, 1990 he complained of having headache, dry cough and congestion for one month. His previous medications were continued, including Midrin. In November he complained of bitemporal migraine headache which he stated was extremely bad the night before. He reported vomiting; and, it was noted that he had a history of headaches while stationed in Germany. At his VA examination in August 1997 the veteran complained of having headaches once or twice a week. Upon examination of the head, there was no headache disorder noted. In pertinent part, the diagnosis was Persian Gulf Syndrome such as skin rashes, fatigue, headaches, joint and bone pain and weight loss. The veteran contends in his notice of disagreement that his headaches are more severe than was indicated on the rating decision. He stated that he suffers several severe headaches a month to a point that he loses his eyesight, his arms tingle and they put him in a "prostrating condition." Hypothyroidism and Irritable Colon Syndrome Service medical records at enlistment show no evidence of hypothyroidism or irritable colon syndrome. Service medical records of March 1989 reveal that the veteran was seen at the hospital emergency room with complaints that he had nausea and vomiting for five hours. He reported intermittent lower abdominal pain, chills and a headache. On examination the abdomen was soft, non-tender and there was no mass or organomegaly. He was diagnosed with gastroenteritis. In March 1990 the veteran complained, inter alia, of having diarrhea for three days. He was diagnosed with upper respiratory infection. The August 1997 VA examination revealed that the veteran had a history of hypothyroidism. The examiner noted that he has the easy fatigability and gastrointestinal symptoms of very soft stool. He has a decreased levothyroxine thyroxine (T4) and an increased thyroid-stimulating hormone (TSH). His mental assessment was within normal limits. The examiner further noted that he does not have nervous or cardiovascular symptoms. He does not show any myxedema. He is on continuous medications. The veteran contends that his exposure to depleted uranium in the Persian Gulf caused his hypothyroidism. Further, he stated that he experienced numerous x-rays as a result of his lung condition and, according to the veteran, VA Medical Center (MC) doctors, have said that this leads to things like fatigue and hypothyroidism. The veteran further contends that he continues to have several colon problems such as bleeding and frequent loose stools. He stated that he has been through numerous tests at VA for his colon problems and has not been diagnosed. Upon VA examination of his digestive system in August 1997, the veteran denied any problems with nausea, vomiting, diarrhea or constipation. The examiner noted that the veteran's stools were very soft and almost diarrhea-like. The veteran reported that he notices blood in his stool daily. Examination further revealed no hemorrhoid problems with the exception of a history of hematemesis or melena. The abdomen was soft, non-tender and there was no organomegaly. The diagnosis was irritable bowel syndrome as evidenced by the endoscopy and soft, almost diarrhea-like stool with occasional blood. Rash, Joint Pain and Bone Pain Service medical records at enlistment indicated that the veteran was allergic to some detergents which cause a skin rash. All other references to the veteran's skin at enlistment revealed no abnormalities or disease. In January 1990 the veteran complained of a rash on his forehead. He reported that the rash was present for 10 days with itching. The physician noted that the veteran had mildly irritated skin of the forehead and no distinct lesions. He prescribed hydrocortisone 1 percent as needed. The VA medical examiner noted in August 1997 that the veteran has had rashes since 1991 that come and go. There were no rashes present at the time of the examination, but the veteran described the appearance of the rash which he stated occurs mostly on his arms. He described the rash as tiny blisters with clear fluid, itchy with dry skin around it. The examiner also noted that there were no problems at the time of the examination. However, the veteran contends that he continues to have a rash problem with no diagnosis. The veteran further contends that he continues to have severe bone and joint pain that has not been diagnosed. Service medical records at enlistment show no musculoskeletal abnormalities. Service medical records subsequent to enlistment reveal several musculoskeletal injuries. April 1988 medical treatment records show that the veteran was diagnosed with a right ankle strain. There was soft tissue swelling overlying the lateral malleolus. There was no fracture or dislocation. In June 1988 the veteran complained of pain, swelling and discoloration in his left ankle when he twisted it while walking down the steps. X-ray revealed no fracture. He was diagnosed with left ankle sprain. He received follow-up treatment for the left ankle sprain in July and August 1988. In April 1989 the veteran complained of waking up with pain to the left sternocleidomastoid. He had no spasm or tenderness. He was diagnosed with left supraclavicular muscle strain. In November 1989 he had a hyperextension injury of his distal interphalangeal while in a football game. He complained of persistent pain and swelling and intermittent numbness of distal volar aspect. He was diagnosed with grade I sprain of the 3rd right distal interphalangeal. X-ray revealed a small linear separation at the base of the distal phalanx, right digit, volar aspect, indicating the presence of a small avulsion-type of fracture. In December 1989 the veteran reported injury to his left knee while skiing. He complained of sharp pain while walking or bending the knee. On examination there was tender resolving ecchymosis of the medial knee and calf. There was no laxity, deformity or internal derangement. The diagnosis was left knee contusion. In March 1990 the veteran slipped on glass which became imbedded in his left heel. The glass was pulled out and the left heel was negative on x- ray. During the VA examination in August 1997 the veteran complained of knee pain, elbow joint pains and bone-type pain in the arms. Examination revealed he had good range of motion throughout all of the joints with no difficulties at all. The examiner noted that the examination was within normal limits. In pertinent part, the diagnosis was Persian Gulf Syndrome such as joint and bone pain. A VA mental disorder examination was also conducted in August 1997. Examination revealed that the veteran appeared alert, had good hygiene and grooming, was well developed and nourished, and was in no apparent acute physical distress. He communicated fairly well verbally; his conversation was coherent, relevant and goal directed. His affect was broad ranged with euthymic mood appropriate to his thought content. His insight, judgment and impulse control were all intact. It was noted that after military discharge, the veteran started college, and he was married in 1992. He quit school and started working full-time in sales and had continued to work. He had had no problems in school or at work. He had a past and present Global Assessment of Functioning (GAF) score of 75. Criteria Increased Rating for Bronchial Asthma and Headache Disorder Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (1999). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.1 (1999). In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. §4.2 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20 (1999). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14 (1999). The United States Court of Appeals for Veterans Claims (Court) has held that an appellant may not be compensated twice for the same symptomatology as "such a result would overcompensate the appellant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph, an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (1999). Under the criteria for evaluating bronchial asthma, a 10 percent rating is warranted when there is a FEV-1 of 71- to 80-percent of predicted, or; when the ratio of FEV-1/FVC is 71 to 80 percent, or; when intermittent inhalational or oral bronchodilator is required. A 30 percent rating is warranted when the FEV-1 is 56- to 70-percent of predicted; or, the FEV-1/FVC is 56 to 70 percent; or, daily inhalational or oral bronchodilator therapy is required; or, inhalational anti- inflammatory medication is required. A 60 percent rating is warranted when the FEV-1 is 40- to 55-percent of predicted; or, the FEV-1/FVC is 40 to 55 percent; or, at least monthly visits to a physician are required for the care of exacerbations; or, when intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids are required. A 100 percent rating is required when the FEV-1 is less than 40-percent of predicted; or, the FEV-1/FVC is less than 40 percent; or, when there is more than one attack per week with episodes of respiratory failure; or, when daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications is required. 38 C.F.R. § 4.97, Diagnostic Code 6602 (1999). As above, in the absence of clinical findings of asthma at time of examination, a verified history of asthmatic attacks must be of record. 38 C.F.R. § 4.97, Diagnostic Code 6602. Migraine headaches are evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8100. That code provides that very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability warrant assignment of a 50 percent evaluation. Where there are characteristic prostrating attacks occurring on an average of once a month over several months, a 30 percent evaluation is warranted. Where there are characteristic prostrating attacks averaging one in two months over several months, a 10 percent evaluation is warranted. Where attacks are less frequent, a zero percent evaluation is warranted. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (1999). Examination reports must be interpreted in light of the whole-recorded history of the disabling condition. Various reports should be reconciled into a consistent picture so that the current rating may accurately reflect the elements of disability present. Each disability must be considered from the point of view of the veteran working or seeking work. If a diagnosis is not supported by the findings on the examination report or if the report does not contain sufficient detail the report must be returned as inadequate for evaluation purposes. 38 C.F.R. § 4.2 (1999). Service Connection for Hypothyroidism and Irritable Colon Syndrome Pursuant to 38 U.S.C.A. § 5107(a), a person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. The Court has held that a well- grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of § [5107(a)]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Although a claim need not be conclusive, it must be accompanied by evidence. The VA benefits system requires more than just an allegation; the claimant must submit supporting evidence and the evidence must justify a belief by a fair and impartial individual that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609, 610 (1992). Where the issue presented in an application for service- connection disability is factual in nature, that is, whether an incident or injury occurred in service, competent lay testimony, including a veteran's solitary testimony, may constitute sufficient evidence to establish a well-grounded claim under 38 U.S.C.A. § 5107(a). See Cartright v. Derwinski, 2 Vet. App. 24 (1991). However, the Court has held that "where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is 'plausible' or 'possible' is required." Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993) (citing Murphy, at 81). In determining whether a claim is well grounded, the claimant's evidentiary assertions are presumed true unless inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown 5 Vet. App. 19, 21 (1993). The Court has held that a well grounded claim requires competent evidence of current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). See Epps v. Brown, 9 Vet. App. 341, 343-44 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). In order to establish service connection for a claimed disability the facts must demonstrate that a disease or injury resulting in current disability was incurred in the active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. §§ 1110, 1131(West 1991); 38 C.F.R. § 3.303 (1999). Service connection for certain chronic conditions may be established where the condition was not diagnosed during service, but became manifest to a compensable degree within one year of the veteran's discharge from service. 38 C.F.R. §§ 3.307, 3.309 (1999). Notwithstanding the foregoing, service connection may be granted for disease which is diagnosed after discharge from military service, when all the evidence establishes that such disease was incurred in service. 38 C.F.R. § 3.303(d) (1999); Cosman v. Principi, 3 Vet. App. 303,305 (1992). Service connection may also be granted for disability which is proximately due to a service-connected disease or granted for disability which is proximately due to a service- connected disease or injury. 38 C.F.R. § 3.310 (1999); Harder v. Brown 5 Vet. App. 183, 187 (1993). Service Connection for Rash and Joint and Bone Pain 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, which has persisted for a period of six months or more, 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 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 by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117 (West 1991 & Supp. 1999); 38 C.F.R. § 3.317 (1999); Public Law 103-446 (November 2, 1994). "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. 38 C.F.R. § 3.317(a)(2). A disability referred to in this section shall be considered service connected for purposes of all laws of the United States. Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss or menstrual disorders. 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. 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, 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). In a precedent opinion, dated May 3, 1999, the VA General Counsel concluded that a well grounded claim for compensation under 38 U.S.C.A. § 1117(a) and 38 C.F.R. § 3.317 for disability due to undiagnosed illness generally requires the submission of some evidence of: (1) active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) 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 disability of 10 percent within the specified presumptive period; and (4) a nexus between the chronic disability and the undiagnosed illness. VAOPGCPREC 4-99. The Board is bound by such interpretations. 38 U.S.C.A. § 7104(c) (West 1991). When all the evidence is assembled, the Secretary, is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Analysis Increased Rating for Bronchial Asthma and Headache Disorder As a preliminary matter, the Board finds that the veteran's claims for an increased rating for bronchial asthma and headache disorder are well grounded within the meaning of 38 U.S.C.A. § 5107(a). When a veteran submits a well-grounded claim, VA must assist him in developing facts pertinent to that claim. 38 U.S.C.A. § 5107(a). In this case, the veteran's service medical records have been obtained and he has been afforded VA examinations. The veteran has not informed VA of the existence of any additional medical evidence to support his claims. The Board, therefore, is satisfied that all available relevant evidence that may be obtained has been obtained regarding the claims and that no further assistance to the veteran is required to comply with 38 U.S.C.A. § 5107(a). In accordance with 38 C.F.R. §§ 4.1, 4.2, and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the veteran's service-connected disabilities. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. The veteran's bronchial asthma has been rated as 10 percent disabling under Diagnostic Code 6602 because the objective medical evidence shows that he occasionally uses an inhaler. The Board notes that the veteran's FVC and FEV-1/FVC levels are not within the compensable level under an evaluation of 10 percent for the cited pulmonary study guidelines. The next highest rating of 30 percent under Diagnostic Code 6602 is not warranted because there is no competent medical evidence reflecting that the veteran's FEV-1 or FEV-1/FVC is ever less than 78 percent of predicted or better. Furthermore, there is no competent medical evidence reflecting that the veteran uses daily inhalational or oral bronchodilator therapy or inhalational anti- inflammatory medication. The competent medical evidence reflects that the veteran has been diagnosed with mild asthma. He has been placed on inhalers that he uses occasionally. It was noted in the August 1997 VA mental disorder examination that he has fewer asthmatic attacks because he uses the inhaler. Therefore, a preponderance of the evidence supports a finding that the symptoms associated with the veteran's service-connected bronchial asthma more nearly approximate those of a 10 percent evaluation where intermittent inhalational or oral bronchodilator therapy is required. Therefore, the 10 percent evaluation is appropriate and, based on the above analysis, a preponderance of the evidence is against a higher evaluation. Moreover, the veteran maintains that his bronchial asthma condition is more than 10 percent disabling due to other residuals involved with his lungs. There is, however, no objective medical evidence of record to support his contention. In this regard, lay statements are considered to be competent evidence when describing symptoms of a disease or disability or an event. However, symptoms must be viewed in conjunction with the objective medical evidence of record. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Since the evidence does not demonstrate the presence of symptomatology resulting from the veteran's service-connected bronchial asthma as required for an evaluation of 30 percent, the Board reiterates its finding that an increased evaluation is not warranted. Headache Disorder The veteran is currently assigned a non-compensable evaluation for his service-connected headache disorder. A non-compensable or zero percent evaluation is assigned when characteristic prostrating attacks of migraine are less frequent than an average of one in two months over the last several months. See 38 C.F.R. § 4.124a, Diagnostic Code 8100. A review of the evidence of record reveals that the veteran's disability picture more nearly approximates the criteria required for a non-compensable evaluation. 38 C.F.R. § 4.7 (1999). Service medical records show two occasions where the veteran was diagnosed with headache, that is, April and November 1990. Prior to April 1990 the veteran complained of headaches but resultant diagnoses indicated a condition or conditions other than a headache disorder. The Board has closely evaluated the medical records containing the veteran's intermittent complaints of headache during service and note that there was no independent treatment for a headache disorder until the diagnosis in April 1990. Prior treatment was in direct response to the respective diagnoses. The regulations require both characteristic prostrating attacks and a frequency of an average of one attack in two months over the last several months. In the instant case, the evidence does not show that the veteran's treatment of headache in April and November 1990 was manifested by characteristic prostrating attacks. The examiner did not render a finding or opinion that the veteran's headaches were prostrating, nor do the records contain findings upon which the Board could infer that such attacks were of such severity to support a conclusion that the attacks were prostrating. The veteran reported in his notice of disagreement that he has had headaches sufficient to cause him to lose his eyesight and make his arms tingle. He indicated that he suffers several severe headaches a month. He also reported that the headaches put him in a prostrating condition. As noted above, symptoms must be viewed in conjunction with the objective medical evidence of record. See Espiritu, supra. Here, the medical evidence does not support the veteran's contentions. Furthermore, there is no indication in the file of medical treatment of a headache disorder since in-service treatment in November 1990. VA examination of the head revealed no symptoms in connection with the veteran's service-connected headache disorder to warrant a compensable evaluation. Accordingly, the Board finds that the veteran's disability picture more nearly approximates the criteria of characteristic prostrating attacks less frequent than an average of one in two months averaging over last several months for a non-compensable evaluation. 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Code 8100 (1999). Based upon the above findings with regard to the veteran's service-connected bronchial asthma and headache disorder, and following a full review of the record, the Board finds that the evidence is not so evenly balanced as to require application of the benefit of the doubt in favor of the veteran's claims. Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). The Board is required to address the issue of entitlement to an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in cases where the issue is expressly raised by the claimant or the record before the Board contains evidence of "exceptional or unusual" circumstances indicating that the rating schedule may be inadequate to compensate for the average impairment of earning capacity due to the disability. See VAOPGCPREC 6-96. In this case, consideration of an extraschedular rating has not been expressly raised. Furthermore, the record before the Board does not contain evidence of "exceptional or unusual" circumstances that would preclude the use of the regular rating schedule. Service Connection for Hypothyroidism and Irritable Colon Syndrome Section 5107 of Title 38, United States Code unequivocally places an initial burden upon the veteran to produce evidence that his claim is well grounded; that is, that his claim is plausible. Grivois v. Brown, 6 Vet. App. 136, 139 (1994); Grottveit v. Brown, 5 Vet. App. 91, 92 (1993). Because the veteran has failed to meet this burden, the Board finds that his claims of entitlement to service connection for hypothyroidism and irritable colon syndrome must be denied as not well grounded. The Board reiterates the three requirements for a well grounded claim: (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in- service incurrence or aggravation of a disease or injury; and, (3) medical evidence of a nexus between the claimed in- service injury or disease and a current disability. See Caluza, supra. The record shows no in-service treatment for or diagnosis of hypothyroidism or irritable colon syndrome. The record does show that while in-service the veteran had complaints of nausea, vomiting, diarrhea and reported intermittent lower abdominal pain, but he was not treated for or diagnosed with hypothyroidism or irritable colon syndrome. In one instance he was diagnosed with gastroenteritis and in another the diagnosis was upper respiratory infection. Furthermore, there is no evidence of post-service treatment or diagnosis of hypothyroidism or irritable colon syndrome within any applicable presumptive period. Consequently, there is no competent medical evidence of a nexus between any current thyroid or colon disability and service. Because the veteran has failed to provide competent evidence of a nexus between his current diagnoses of hypothyroidism and irritable colon syndrome and military service, the Board finds that his claims of entitlement to service connection for such conditions must be denied as not well grounded. The veteran has proffered no objective medical evidence to support his contention that numerous x-rays of his lungs and exposure to depleted uranium has led to his hypothyroidism condition. The veteran's own opinions and statements will not suffice to well ground his claim. While a lay person is competent to provide evidence on the occurrence of observable symptoms during and following service, such a lay person is not competent to make a medical diagnosis or render a medical opinion, which relates a medical disorder to a specific cause. Espiritu, supra at 494-495. Moreover, the veteran contends that his colon problems have not been diagnosed. His contention has no probative value as the file contains an August 1997 VA examination that provides a diagnosis of irritable bowel syndrome, as evidenced by the endoscopy and soft, almost diarrhea-like stool with occasional blood. The Board further finds that the RO has advised the veteran of the evidence necessary to establish his claims as well grounded and the veteran has not indicated the existence of any evidence that has not already been obtained that would well ground his claims. 38 U.S.C.A. § 5103(a) (West 1991); McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Brown, 9 Vet. App. 341, 344 (1996), aff'd sub nom. Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). It is noted that the RO did not specifically deny the veteran's claim on the basis of it not being well grounded. When the Board addresses in its decision a question that has not been addressed by the RO, such as whether the veteran's claim is well grounded, it must consider whether the veteran has been given adequate notice to respond and, if not, whether the veteran has been prejudiced thereby. In light of the veteran's failure to meet the initial burden of the adjudication process, the Board concludes that he has not been prejudiced by the decision herein. This is because in assuming that the claims were well grounded, the RO accorded him greater consideration than his claims in fact warranted under the circumstances. See Meyer v. Brown, 9 Vet. App. 425, 432 (1996);. Bernard v. Brown, 4 Vet. App. 384 (1993). As the veteran's claims for service connection for hypothyroidism and irritable colon syndrome are not well grounded, the doctrine of reasonable doubt has no application to his claims. Service Connection for Rash, Joint and Bone Pain The Board reiterates the four requirements of a well grounded claim for compensation under 38 U.S.C.A. § 1117(a) and 38 C.F.R. § 3.317 for disability due to undiagnosed illness: (1) active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) 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 disability of 10 percent within the specified presumptive period; and (4) a nexus between the chronic disability and the undiagnosed illness. See VAOPGCPREC 4-99. In the instant case, there is clear evidence that the veteran served in the Southwest Asia theater of operations during the Persian Gulf war. There is also evidence of signs or symptoms of an undiagnosed illness. This is based upon the veteran's statements to the effect that he continues to have a rash problem and severe bone and joint pain. 38 C.F.R. § 3.317 allows consideration of non-medical indicators that can be independently observed or verified. Lay statements from the veteran that he is able from personal experience to make an observation are considered as evidence in determining whether he is suffering from an undiagnosed illness. In Espiritu, supra the Court held that although lay persons are not qualified to render opinions as to a medical diagnosis or causation, they may testify to manifestations of symptoms that are capable of observation. Thus, in this instance, the first two requirements of a well-grounded claim have been satisfied. See 38 C.F.R. § 3.317 and VAOPGCPREC 4- 99. 38 C.F.R. § 3.317 requires that there must be some objective indication or showing of the disability, which is observable by a person other than the veteran or for which medical treatment has been sought; this requirement is not met in the instant case. Objective indications of a chronic disability during the relevant period of service or to the degree of disability of 10 percent within the specified presumptive period is not shown in the record. Service medical records show that the veteran had a mildly irritated skin condition of his forehead with no distinct lesions. This condition was manifested in January 1990 prior to the veteran's tour of duty in the Persian Gulf. Such condition was not shown to be chronic or disabling. There is no evidence in the record of treatment for a rash or any other skin disorder since service. Furthermore, there was no rash present at the VA examination in August 1997. Consequently there is no objective medical indication of a rash to any degree of disability during or after service. In addition, a person other than the veteran has not observed joint and bone pain indicated by the veteran nor has he sought medical treatment for the alleged joint and bone pain. Service medical records show that veteran sustained injury to his ankles, left supraclavicular, 3rd distal interphalangeal, knee and heel prior to his tour in the Persian Gulf. His current complaints of joint pain are described as being of the knee, elbow, bone, and arms. There is no evidence in the record of treatment for joint and bone pain since service. Furthermore, the VA examination in August 1997 revealed good range of motion of all joints with no difficulty. Consequently there is no objective medical indication of joint and bone pain to any degree of disability during or after service. Since there are no objective indications of a chronic disability, specifically, rash and joint and bone pain, the fourth requirement necessary to establish a well grounded claim cannot be met. The law limits entitlement for service-related diseases and injuries to cases where the underlying in-service incident has resulted in a disability. In the absence of proof of a present disability, there is no valid claim presented. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). "Disability" is defined as any impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439 (1995). Here, the veteran has proffered no evidence that the alleged rash and joint and bone pain conditions are disabling. He reported that he currently works in sales and has no problems with work. Based upon the foregoing, the Board finds that the veteran has not provided the necessary evidentiary requirements to establish a well-grounded claim for compensation under 38 U.S.C.A. § 1117(a) and 38 C.F.R. § 3.317 for disability due to undiagnosed illness. Consequently the veteran's claims for service connection for rash and joint and bone pain is not well grounded. It is again noted that the RO did not specifically deny the veteran's claim on the basis of it not being well grounded. When the Board addresses in its decision a question that has not been addressed by the RO, such as whether the veteran's claim is well grounded, it must consider whether the veteran has been given adequate notice to respond and, if not, whether the veteran has been prejudiced thereby. In light of the veteran's failure to meet the initial burden of the adjudication process, the Board concludes that he has not been prejudiced by the decision herein. This is because in assuming that the claims were well grounded, the RO accorded him greater consideration than his claims in fact warranted under the circumstances. See Meyer, supra; Bernard, supra. Fatigue In his July 1997 application the veteran raised a claim for service connection for fatigue. In his notice of disagreement and appeal to the Board, he stated that the issue of fatigue had not been rated or addressed. However, the RO addressed the issue of fatigue in the March 1998 Statement of the Case. The RO noted that symptoms of fatigue are an aspect of the veteran's hypothyroidism disorder and therefore cannot be considered as a separate disability entity under Public Law 103-446. In this case, even assuming arguendo that the veteran has shown that fatigue is an undiagnosed condition resulting from Persian Gulf Service, there has been no showing the claimed fatigue has resulted in a disability within the meaning of applicable law. The Board notes in this regard that there has been no suggestion, either by medical or lay evidence that the veteran's claimed fatigue is severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months. See 38 C.F.R. § 4.88 (1999). ORDER Entitlement to a rating excess of 10 percent for bronchial asthma is denied. Entitlement to an increased (compensable) rating for a headache disorder is denied. The veteran not having submitted well grounded claims of entitlement to service connection for hypothyroidism and irritable colon syndrome, the appeal is denied. The veteran not having submitted well grounded claims of entitlement to service connection for rash and joint and bone pain due to an undiagnosed illness, the appeal is denied. RONALD R. BOSCH Member, Board of Veterans' Appeals