Citation Nr: 0003022	
Decision Date: 02/07/00    Archive Date: 02/10/00

DOCKET NO.  96-05 313A	)	DATE
	)
	)

On appeal from the Department of Veterans Affairs (VA) 
Regional Office (RO) in Winston-Salem, North Carolina


THE ISSUES

Entitlement to service connection for a sinus condition, a 
skin rash, loose stools/diarrhea, shoulder pain, hip pain, 
and fatigue, as due to an undiagnosed illness.


REPRESENTATION

Appellant represented by:	The American Legion


WITNESS AT HEARING ON APPEAL

Appellant


ATTORNEY FOR THE BOARD

Kimberly E. Harrison Osborne, Counsel


INTRODUCTION

The veteran had active military service from September 1983 
to June 1992.  This matter comes before the Board of 
Veterans' Appeals (Board) on appeal from a November 1995 
rating decision which denied service connection for a sinus 
condition, a skin rash, loose stools/diarrhea, shoulder pain, 
hip pain, and fatigue, claimed as due to an undiagnosed 
illness from Persian Gulf War service.


FINDINGS OF FACT

1.  The veteran had active duty in Southwest Asia during the 
Persian Gulf War.

2.  The veteran has not presented competent evidence of 
plausible claims for service connection for a sinus disorder, 
a skin rash, loose stools/diarrhea, shoulder pain, hip pain, 
and fatigue, as due to an undiagnosed illness.


CONCLUSION OF LAW

The claims for service connection for a sinus condition, a 
skin rash, loose stools/diarrhea, shoulder pain, hip pain, 
and fatigue, claimed as due to undiagnosed illness, are not 
well grounded.  38 U.S.C.A. § 5107(a) (West 1991).



REASONS AND BASES FOR FINDINGS AND CONCLUSION

I.  Factual Background

The veteran had active military service in the Army from 
September 1983 to June 1992, including a period in Southwest 
Asia from August 1990 to March 1991 during the Persian Gulf 
War.  His February 1983 service enlistment examination 
reveals he had a rash behind both knees which he said 
recently developed after swinging on gym bars; the assessment 
was dermatitis of the popliteal areas.  Service medical 
records show that in August 1987 the veteran requested 
treatment for acne, and in October 1988 he was treated for 
acne vulgaris.  On a November 1988 retention examination, he 
was noted to have cystic acne vulgaris which involved the 
facial area.  Examination of other pertinent systems was 
normal.  An August 1990 general medical examination revealed 
no pertinent abnormalities.  In February 1992, he underwent a 
Desert Storm examination.  He denied having any rashes or 
diarrhea.  He made no complaints regarding joint pain, sinus 
problems, or fatigue.  A February 1992 service separation 
examination revealed the veteran had normal skin, sinuses, 
gastrointestinal system, and musculoskeletal system.  He did 
not report any pertinent complaints.

An August 1992 VA general examination revealed the veteran 
had normal sinuses, skin, and digestive system.  Examination 
of the musculoskeletal system showed he complained of back 
and knee pain.  (Service connection is in effect for a low 
back condition).  He did not make any complaints regarding 
the shoulder or hip.  In addition, the report is negative for 
any complaints of fatigue.

Private medical records from July 1994 show treatment for a 
low back condition.  A whole body bone scan was normal. 

During an August 1994 VA Persian Gulf examination, the 
veteran indicated he was exposed to smoke and oil when 
stationed in the Persian Gulf.  He stated he had a sinus 
condition that worsened after his return from the Persian 
Gulf.  He stated he developed fatigue after his return from 
the Persian Gulf.  He stated his fatigue would last for 
several days and that he felt like he had no energy.  He 
complained of having a rash which started about 6 to 8 months 
after his return from the Persian Gulf.  He stated the rash 
affected his left leg and left arm.  He stated he had hip and 
shoulder pain for the past year.  He related his stools 
seemed softer than usual.  Examination of his four 
extremities revealed he had a full range of motion and had 
equal strength and grip.  Abdominal examination was normal.  
Examination of the skin revealed a pruritic rash to the upper 
left arm and the left calf medially.  The rash was red with 
maculopapular dry patches and scaling next to the skin.  The 
examiner's impression was that the veteran was generally 
healthy and well developed and in no acute distress.

In September 1994, the veteran filed a claim of service 
connection for a sinus condition, fatigue syndrome, rash, hip 
and shoulder pain, and loose stools/diarrhea due to service 
in the Persian Gulf.  He stated that he had had these 
problems since returning from the Persian Gulf.  

When treated in February 1995, the veteran complained of 
having a chronic sinus condition which worsen after returning 
from the Persian Gulf.  He also complained of chronic 
fatigue.  He stated he was tired upon awakening and that he 
tired easily after one to two hours.  The diagnoses were 
chronic rhinitis and or rhinosinusitis.  March 1995 X-ray 
studies of the sinuses revealed inflammatory changes in the 
frontal sinus.  A March 1995 dermatology consultation 
revealed a diagnosis of nummular dermatitis with lichen 
simplex chronicus.

In May 1995, the veteran was treated in the ear, nose and 
throat clinic due to complaints of nasal drainage.  In June 
1995, he was diagnosed as having chronic sinusitis.

In July and August 1995, the veteran reported to the 
dermatology clinic and was assessed as having lichen simplex 
chronicus of the extremities; such skin condition was treated 
and noted to be resolving.

In an August 1995 letter, David N. Olson, M.D., primarily 
discussed the veteran's service-connected low back and 
hearing loss disorders.  It was also noted that the veteran 
had sinusitis and reported that such arose after exposure to 
oil fires when stationed in the Persian Gulf.

Medical records from August 1995 show the veteran underwent 
surgery for chronic sinusitis.  The operation consisted of a 
bilateral endoscopic maxillary enterostomy and bilateral 
anterior ethmoidectomy.  A related pathology report notes the 
mucosa showed changes consistent with allergic rhinitis with 
focal polypoid changes.

In August 1995, the veteran presented to a VA clinic wanting 
to be evaluated for complaints of fatigue, joint pain, and 
loose stools.  He claimed he was tired all the time and that 
his condition did not improve with rest.  He stated he had 
had loose stools for the past three years.  The diagnoses 
were rule out chronic fatigue syndrome, eosinophilic 
fasciitis, and chronic diarrhea.  Laboratory and X-ray 
studies were recommended.

A November 1995 outpatient treatment report shows that the 
veteran was referred for evaluation of his joint pain and 
fatigue.  The report noted the veteran had chronic sinusitis 
and was status post endoscopic sinus surgery in August 1995.  
The veteran related a two year history of joint pain.  He 
complained of being fatigued and of having a rash affecting 
the left upper arm and left lower leg.  Physical examination 
revealed no rash.  He had a full range of motion of his 
extremities.  There was no swelling or warmth of any of the 
joints and his strength was 5/5 throughout.  He had no joint 
or muscle tenderness and no active synovitis.  X-ray studies 
of the shoulder joint were normal.  In November 1995, his 
sinus condition had improved.

In a January 1996 substantive appeal, the veteran stated he 
developed a sinus condition after discharge from service.  He 
claimed, in essence, that doctors told him his sinus problems 
were due to exposure to toxins or irritants while in 
Southwest Asia.  He complained of fatigue and indicated he 
had shoulder and hip pain.  He stated he developed a skin 
rash 6 to 8 months following discharge from service.  He 
claimed all of his conditions developed after deployment from 
Southwest Asia.

In March 1996, there was a question as to whether the veteran 
was diabetic.  He complained of being fatigued.  When seen in 
April 1996, he continued to complain of fatigue and of 
symptoms compatible with sinusitis.

During a June 1996 RO hearing, the veteran testified that the 
first symptoms of sinus problems were in the winter months of 
1993.  He stated his sinus condition worsened and that in 
1995 he had sinus surgery.  He stated he was diagnosed as 
having chronic sinusitis.  He testified that diarrhea was a 
problem he encountered right after he was discharged.  He 
stated he took over-the-counter medication.  He claimed he 
currently had loose stools daily.  However, he later reported 
he had bowel movements every other day.  With respect to hip 
and shoulder pain, the veteran testified that approximately 
12 months after discharge he began having pain in the 
shoulder and hip joints.  He stated that the weather was a 
precipitating factor with respect to his joint pain.  He 
reported he saw a rheumatologist and that no cause could be 
given for his complaints.  He related he began having fatigue 
in the winter of 1993.  He claimed he felt exhausted and that 
he had a lack of energy.  He also claimed he required 12 
hours of sleep a night.  He stated he had a reoccurring skin 
condition in the fall and winter months.  He related he had 
vesicles which would pop and scab and that his skin itched.  
He stated he was treated with creams. 

In a letter dated in August 1996, a fellow serviceman of the 
veteran stated he had known the veteran for 10 years and that 
they were both assigned to the 4th Battalion 325 Airborne 
Infantry Regiment during the Persian Gulf War.  He stated the 
veteran was exposed to chemicals while in the Persian Gulf.  
He stated he noticed that in the winter of 1993, the veteran 
developed respiratory problems.  He reported that one of the 
VA doctors who treated the veteran stated the veteran had to 
have sinus surgery due to exposure to chemicals.  He stated 
the veteran was only exposed to chemicals in the Persian 
Gulf.  He reported that in the winter months of 1993, the 
veteran seemed tired all the time and that he needed rest 
periods.  He stated he would sleep 8 hours at night and 
within 2 hours he would be back to sleep again.  He reported 
that the veteran told him that he had numerous tests 
performed but physicians could not determined what was 
causing him to be fatigued.  He also related that the veteran 
had hip and shoulder pain since the winter of 1993.  He 
reported the veteran had seen several physicians but no one 
could find the underlying cause of his pain.

In a letter dated in September 1996, the veteran's wife 
indicated she had known the veteran for the past 15 years and 
had been married to him for the past 12 years.  She reported 
that after the veteran's return from Southwest Asia, he 
developed medical problems.  She stated in the winter months 
of 1993 the veteran began having problems breathing through 
his nose.  She related that around this time he started 
having bilateral hip and shoulder pain.  She reported he 
underwent numerous examinations and tests but that no one 
could determine the cause of his pain.  She stated the 
veteran started to have a rashes on his body around this 
time.  She stated the rashes were located on his left arm and 
left leg.  She reported that after numerous trips to the VA 
and numerous medications, the doctors could not determine the 
cause of the rashes.  She reported that in the summer of 1993 
she noticed the veteran slept a lot and was easily fatigued.  
She reported the veteran's doctor performed several test but 
could not determine the cause of his fatigue.  She reported 
the veteran worked at a local hospital and that doctors would 
write out prescriptions for his conditions and as a result 
there were no formal records for some of his treatment.  She 
related the veteran still suffered from the aforementioned 
problems.

Additional letters dated in September 1996 from the veteran's 
parents were submitted in support of the veteran's assertions 
with respect to his claimed symptoms/disabilities.

Private medical records show treatment in September and 
October 1997 (including surgery in October 1997) for chronic 
sinusitis, nasal polyposis, and a nasal septal deformity.

In April 1998, the veteran underwent a VA general 
examination.  Examination of the skin revealed acne lesions 
on the back and on the face.  The veteran stated that during 
the Gulf War, he noted an eruption over the right lateral 
calf and the left medial calf which itched.  He described the 
eruption as involving small vesicles and a few areas of 
excoriation with some destruction of the hair follicles.  The 
examiner noted the veteran had a long history of allergic 
rhinitis/sinusitis with nasal congestion, facial pain, and 
headaches. 

At the VA examination, the veteran gave a history of a change 
in bowel movements since returning from the Persian Gulf.  He 
said he had soft stools which were not watery, and that he 
had a stool at least once a day.  The examiner noted that the 
veteran referred to his condition as diarrhea, although the 
description of the condition did not fit that for diarrheal 
stools.  Examination of the abdomen was essentially normal, 
with slight increase in bowel sounds.

During the examination, the veteran gave a history of 
multiple bilateral joint pains, including the shoulders, 
hips, knees and lumbosacral spine.  He stated the symptoms 
were essentially the same in all four joints and occurred 
with the same frequency, approximately 10 to 15 days per 
month.  He stated that upon rising in the morning he had 
stiffness across both shoulders, hips, knees and lumbosacral 
spine.  There was a feeling of difficulty in bending like he 
had some kind of lead pipe in the joint.  He tried to bend 
and this caused pain.  He had the feeling that the joints 
were stiff.  He was not sure if his joints actually became 
swollen.  He related that as the day warmed up, he was able 
to perform his normal business.  He stated that he did not 
have discomfort on dry and hot days or in dry or hot weather.  
He stated that his condition was not affected by exercise but 
if he exercised a lot, the symptoms worsened.  He stated he 
could not run because of pain but that he was able to walk 
approximately two miles.  Examination of the shoulders, hips, 
and knees was completely normal.  There was no redness, 
swelling, or tenderness.  There was a full range of motion of 
each of the joints.

During the VA examination, the veteran complained of chronic 
fatigue.  He stated that since returning from the Persian 
Gulf he had noted that he now slept eight to ten hours each 
night.  He stated he slept very soundly.  He claimed that 
when he got up in the morning he felt very tired.  He stated 
he was able to get himself ready for the day and eat 
breakfast.  He related he was also able to get his children 
dressed for school.  He reported that after such activities 
he had to lie down for approximately two hours.  He stated 
that from 11 a.m. until 5 or 6 p.m. he was normal.  He stated 
he could cut his grass and do his activities of daily living.  
He stated he had to sleep 1/2 hour after supper.  He reported 
he was able to stay awake during the evening hours.  He 
related he went to bed at 10 p.m.  

The diagnoses at the April 1998 VA examination included a 
skin rash of undetermined etiology; allergic 
rhinitis/sinusitis, status post septoplasty with residual 
symptomatology; arthralgias of the shoulders, hips, knees, 
and lumbosacral spine with normal examination; fatigue with 
no obvious disease process found; and soft stools with no 
disease process found.  The examiner later reviewed the 
claims file and confirmed the diagnoses.

On April 1998 VA neurological examination, the veteran 
reported that for the past 3 to 4 years he had been tired 
during the day.  He stated he had fatigue and that he had 
some falling asleep during the day.  He related he worked as 
a nurse in a surgical intensive care unit.  He stated he 
worked three twelve hour shifts a week.  He reported he did 
not have a problem keeping up with that pace.  The examiner 
diagnosed fatigue, not due to psychiatric illness.  The 
examiner later reviewed the claims file and confirmed the 
diagnosis.

II.  Analysis

The veteran served in the Southwest Asia theater of 
operations from August 1990 to March 1991, during the Persian 
Gulf War.  He claims he has a sinus condition, skin rash, 
loose stools/diarrhea, shoulder pain, hip pain, and fatigue, 
and that such are due to undiagnosed illnesses from his 
Persian Gulf War service.  He alleges that all of his 
symptoms developed after his discharge from service.

Service connection may be granted for a disability due to a 
disease or injury which was incurred in or aggravated by 
active military service.  38 U.S.C.A. §§ 1110, 1131; 
38 C.F.R. § 3.303.

Subject to various conditions, service connection may be 
granted for a disability due to undiagnosed illness of a 
veteran who served in the Southwest Asia theater of operation 
during the Persian Gulf War.  Among the requirements are that 
there are objective indications of a chronic disability 
resulting from an illness or combination of illnesses 
manifested by one or more signs or symptoms such as fatigue, 
neuropsychological signs or symptoms, sleep disturbances, 
gastrointestinal signs or symptoms, etc; the illness must 
become manifest during either active service in the Southwest 
Asia theater of operations during the Persian Gulf War or to 
a degree of 10 percent or more, under the appropriate 
diagnostic code of 38 C.F.R. Part 4, not later than December 
31, 2001; by history, physical examination, and laboratory 
tests, the disability cannot be attributed to any known 
clinical diagnosis; there must be objective signs that are 
perceptible to an examining physician and other non-medical 
indicators that are capable of independent verification; a 
minimum of a 6 month period of chronicity; and no affirmative 
evidence which relates the undiagnosed illness to a cause 
other than being in the Southwest Asia theater of operations 
during the Persian Gulf War.  38 U.S.C.A. § 1117; 38 C.F.R. § 
3.317.

A well-grounded claim for compensation under 38 U.S.C.A. 
§ 1117 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) 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 disability of 10 percent or more within the 
specified presumptive period; and (4) a nexus between the 
chronic disability and the undiagnosed illness.  Medical 
evidence will suffice to satisfy the last three of these 
elements; lay evidence may also suffice, depending on the 
nature and circumstances of the individual claim (generally 
lay evidence is sufficient in circumstances in which the 
condition is observable to a layman and does not require 
medical expertise).  VAOPGCPREC 4-99.  If signs and symptoms 
have been medically attributed to a diagnosed (rather than 
undiagnosed) illness, the Persian Gulf War presumption of 
service connection does not apply.  VAOPGCPREC 8-98.

The veteran's claims for service connection for a skin rash 
and for a sinus condition as undiagnosed illnesses fail as 
such conditions have been attributed to diagnosed disorders.  
The specific skin condition the veteran refers to is a rash 
of his extremities.  Such is first shown in 1995, after 
service, and has been diagnosed as nummular dermatitis with 
lichen simplex chronicus.  There is no medical evidence to 
link this condition to service.  Acne of the face is shown in 
service in 1987 and 1988 (before the veteran went to the 
Persian Gulf) but not later during active duty which ended in 
1992.  The only post-service evidence of acne is a 1998 VA 
examination, and there is no medical evidence to link this 
acne with the acute acne episodes in service (and it does not 
appear the veteran is actually claiming service connection 
for acne).  A sinus disorder is not shown during the 
veteran's service, and diagnosed sinusitis was first noted 
after service and has since been subject to treatment 
including two operations.  There is no medical evidence 
linking the postservice sinus disorder with service.  Since 
the veteran's claimed sinus and skin conditions have been 
medically attributed to diagnosed conditions, rather than 
undiagnosed illnesses, the Persian Gulf War provisions do not 
apply, and the claims for service connection on this theory 
must be denied as not well grounded.  38 U.S.C.A. § 5107(a); 
VAOPGCPREC 4-99; VAOPGCPREC 8-98.  Moreover, claims for 
direct service connection for the diagnosed sinus and skin 
conditions also must be denied as not well grounded, as there 
is no medical evidence to link the conditions, which were 
first shown after service, with the veteran's active duty.  
38 U.S.C.A. § 5107(a); Caluza v. Brown, 7 Vet.App. 498 
(1995).  Lay statements on causality, which the veteran has 
submitted, do not constitute competent medical evidence and 
do not serve to make the claims well grounded.  Grottveit v. 
Brown, 5 Vet.App. 91 (1993).  

Turning to the veteran's claim of service connection for 
loose stools/diarrhea, the Board notes that service medical 
records from his 1983-1992 active duty (including from the 
period of Southwest Asia service) are negative for any 
complaints or findings referable to this condition.  He 
alleges he first developed loose stools/diarrhea after 
discharge from service.  The first complaint of any problems 
concerning his stools was on a 1994 VA Persian Gulf 
examination.  During the examination, he reported that his 
stools seemed softer than usual.  At a 1996 RO hearing, he 
testified he had loose stools daily, but he also reported 
that he had bowel movements every other day.  At a 1998 VA 
examination, the veteran said he had at least one bowel 
movement a day and that his stools were soft; the examiner 
noted that the veteran called this diarrhea although it 
actually was not; and the diagnosis was soft stools with no 
disease found.

Assuming the veteran's minor complaint of loose stools (which 
he refers to as diarrhea) is an undiagnosed illness, there is 
no evidence that the condition is disabling to a degree of at 
least 10 percent.  The veteran's complaint of loose 
stools/diarrhea is to be rated by analogy under Code 7319, 
irritable colon syndrome.  Under this code, he would be 
assigned a noncompensable rating, as his condition is no more 
that mild with disturbance of bowel function with occasional 
episodes of abdominal distress.  See 38 C.F.R. § 4.114, Code 
7319.  Since the veteran's loose stool/diarrhea complaint 
began after service and there is no evidence that it is at 
least 10 percent disabling, the claim for service connection 
must be denied as not well grounded.  38 U.S.C.A. § 5107(a); 
VAOPGCPREC 4-99.

With respect to the claim of service connection for hip and 
shoulder pain due to undiagnosed illness, the Board notes 
that service medical records are negative for any complaints 
or findings regarding hip and/or shoulder pain.  His 
musculoskeletal system was normal on a 1992 service 
separation examination.  The veteran alleges that his joint 
pain developed after service discharge.  Postservice physical 
examination in 1994 revealed he had a full range of motion of 
the joints.  He also had equal strength and grip.  When 
examined in 1995, he had full range of motion of all 
extremities.  He had no swelling or warmth of any of the 
joints and his strength was 5/5 throughout.  He had no joint 
or muscle tenderness and no active synovitis.  In 1998, 
examination of the shoulders and hips was normal.  There was 
no redness, swelling, or tenderness.  He had full range of 
motion of all joints.

The Board observes that, even if the current complaints of 
hip and shoulder pain are due to an undiagnosed illness, 
there is no evidence that the claimed joint conditions are 
least 10 percent disabling.  Given normal findings on 
examinations, the shoulder and hip joint symptoms would be 
rated noncompensable under the relevant analogous rating 
criteria.  See 38 C.F.R. § 4.71a, Code 5201 (shoulder range 
of motion) and Codes 5251, 5252, and 5253 (hip range of 
motion).  Since the veteran's hip and shoulder complaints 
began after service and there is no evidence that they are at 
least 10 percent disabling, the claims for service connection 
must be denied as not well grounded.  38 U.S.C.A. § 5107(a); 
VAOPGCPREC 4-99.
 
Likewise, the claim of service connection for fatigue as due 
to undiagnosed illness is not well grounded.  Service medical 
records are negative for any complaints of fatigue.  The 
veteran asserts that his symptom of fatigue developed after 
service discharge.  His symptom of fatigue is to be rated by 
analogy under 38 C.F.R. § 4.88b, Code 6354, chronic fatigue 
syndrome.  This code provides a 10 percent rating for chronic 
fatigue syndrome when there is debilitating fatigue, 
cognitive impairment (such as inability to concentrate, 
forgetfulness, confusion), or a combination of other signs 
and symptoms, which wax and wane but result in periods of 
incapacitations of at least one but less than two weeks total 
duration per year, or symptoms controlled with continuous 
medication.  The note to the code provides that for the 
purpose of evaluating this disability, the condition will be 
considered incapacitating only while it requires bed rest and 
treatment by a physician.  Statements from the veteran and 
his acquaintances include vague descriptions that he feels 
tired at times.  Yet the record demonstrates he is able to 
work full-time, able to care for his children, cut his grass, 
and perform other activities of daily living.  His general 
complaint of tiredness does not rise to the level of 
impairment described in the code for a 10 percent rating.  
There is no evidence of incapacitating episodes as defined in 
the regulation, nor is the condition treated with medication.  
Since the veteran's fatigue complaints began after service 
and there is no evidence that they are at least 10 percent 
disabling, the claims for service connection must be denied 
as not well grounded.  38 U.S.C.A. § 5107(a); VAOPGCPREC 4-
99.  




ORDER

Service connection for a sinus condition, a skin rash, loose 
stools/diarrhea, shoulder pain, hip pain, and fatigue, 
claimed as due to an undiagnosed illness, is denied.



		
	L. W. TOBIN
	Member, Board of Veterans' Appeals