Citation Nr: 0001802 Decision Date: 01/21/00 Archive Date: 01/28/00 DOCKET NO. 98-19 637 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a disability manifested by headaches, claimed in the alternative as disability due to undiagnosed illness. 2. Entitlement to service connection for a disability manifested by diarrhea, claimed in the alternative as disability due to undiagnosed illness. 3. Entitlement to service connection for a disability manifested by insomnia, claimed in the alternative as disability due to undiagnosed illness. 4. Entitlement to a compensable disability rating for rash on arms of undetermined etiology, on appeal from the initial grant of service connection. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD M. L. Kane, Associate Counsel INTRODUCTION The veteran had active military service from October 1984 to May 1992. He served in the Southwest Asia theater of operations during the Persian Gulf War from September 1990 to July 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 1997 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which, in pertinent part, denied the above claims for service connection and granted service connection for a skin rash on the arms, with assignment of a zero percent disability rating. The veteran's claims for undiagnosed illness and for higher evaluation are the subjects of the REMAND herein. FINDINGS OF FACT 1. There is no medical evidence showing that the veteran currently has diagnosed medical disorder(s) accounting for his complaints of headaches, diarrhea, and insomnia, and his claims for service connection on a direct basis are not plausible. 2. The veteran had active military service in the Southwest Asia theater of operations during the Persian Gulf War. 3. There is non-medical objective evidence capable of independent verification that the veteran has a chronic disability manifested by headaches, insomnia, and diarrhea. 4. There is non-medical objective evidence showing that the veteran's chronic disability manifested by complaints of headaches, insomnia, and diarrhea, has become manifest to a degree of 10 percent or more since his service in the Southwest Asia theater of operations. 5. The medical evidence shows diagnosis of undiagnosed illness from service in Southwest Asia manifested by tension- like headaches, diarrhea, and insomnia. 6. The veteran's claims for service connection for undiagnosed illness manifested by headaches, diarrhea, and insomnia are plausible, but the RO has not obtained sufficient evidence for a fair disposition of these claims. CONCLUSIONS OF LAW 1. The claims for direct service connection for disabilities manifested by headaches, diarrhea, and insomnia are not well grounded, and there is no statutory duty to assist the veteran in developing facts pertinent to these claims. 38 U.S.C.A. § 5107 (West 1991). 2. The claims of entitlement to service connection for headaches, diarrhea, and insomnia due to an undiagnosed illness are well grounded, and VA has not satisfied its statutory duty to assist the veteran in developing facts pertinent to these claims. 38 U.S.C.A. §§ 1117(a), 5107(a) (West 1991 & Supp. 1999); 38 C.F.R. § 3.317 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background In December 1996, the veteran filed claims for service connection for headaches, diarrhea, and chronic fatigue, which he indicated began in 1992. He also indicated that he was exposed to environmental hazards during his service in the Persian Gulf, in the form of burning oil fields. Prior to his Persian Gulf service, the veteran complained of diarrhea in December 1985, and he was provided Kaopectate. He complained of an upset stomach and diarrhea in November 1987, with diagnosis of rule-out gastroenteritis. During his service in the Persian Gulf, he complained of loose stools and fatigue in February 1991, with diagnoses of viral syndrome and hepatitis. He complained of "cold" symptoms in April 1991, which included headache, and diagnoses were upper respiratory infection and rule-out strep throat. On dental health questionnaires completed in September 1991 and January 1992, he denied having any symptoms pertinent to these claims. On a Report of Medical History completed in February 1992 in conjunction with his separation examination, the veteran denied having stomach trouble, rectal illness, frequent trouble sleeping, or frequent/severe headaches. Physical examination showed no pertinent abnormalities. The RO obtained the veteran's VA outpatient records dated from November 1996 to January 1997. In November 1996, he underwent a Persian Gulf examination. He stated that he had onset of insomnia in 1991 and that this occurred nearly every night. He stated that he had trouble falling asleep and fatigue upon awakening. In a January 1997 statement, the veteran stated that his health was not the same as prior to serving in the Persian Gulf. He stated that he had diarrhea at least once per week, as well as headaches. His physical strength was not the same, and he got tired easily. He stated that he needed more sleep than he used to. He also indicated that he had insomnia from "time to time." The veteran submitted a statement from his mother in January 1997. She indicated that she had noticed a drastic change in him upon his return from the Persian Gulf. He was always tired and complained of headaches. He also submitted a statement from his wife, which indicated that his health had changed after his service in the Persian Gulf. He had a lot of diarrhea and headaches and was always tired. He also had insomnia at times. In July 1997, the veteran underwent VA examinations. He stated that in May 1992 he developed headaches, diarrhea, extreme tiredness, and fatigue. The headaches were frontal in nature. The diarrhea occurred twice per week, with no blood in the stool. He indicated that the chronic fatigue and tiredness were like a hangover. He got tired easily, but his supervisor helped him carry out his duties at work. He stated that he did not have the same energy as previously. Physical examination showed no pertinent abnormalities. Diagnoses included undiagnosed illness from service in Southwest Asia with manifestations of tension-like headaches, chronic fatigue, diarrhea, and insomnia. The veteran also underwent a VA psychiatric examination, with no diagnosis of a psychiatric disorder. In his substantive appeal, the veteran argued that his disabilities were linked to his Persian Gulf service. He stated that since leaving the service in 1992, he had had headaches, diarrhea, and insomnia. The veteran submitted additional lay statements in September 1998. His wife indicated that his health was "terrible." She stated that he had headaches every week, and he was tired all the time. He also had difficulty sleeping and a lot of diarrhea. His mother indicated that he lived with her between May and October 1992, and she observed him having bouts of diarrhea that seemed to have no relationship to food intake. She stated that he still had diarrhea 3-4 times per week. She stated that after he returned from the Persian Gulf, but while he was still in the military, the veteran constantly complained on the telephone that he had terrible headaches. Upon his return home, she noticed him putting the newspaper down or turning off the television because of headaches. He had purchased new eyeglasses, with no change in his headaches. She stated that the headaches continued an average of four times per week, and someone could visually see when he had a terrible headache. The veteran's mother also indicated that he used to have unlimited energy, but he now complained of being tired and never seemed to get enough sleep. He did not join in family activities due to fatigue. The veteran's stepfather indicated that the veteran was extremely active, full of energy, and had a tremendous ability for instant recall and memory prior to his service in the Persian Gulf. He now no longer had this "ability," and his energy level was that of someone much older. It was stated that "something" was not right with him. A statement from a co-worker of the veteran's indicated that he sometimes had difficulty performing his duties at work. He was limited due to headaches and fatigue. The veteran also submitted a statement in September 1998. He indicated that he continued to have headaches several times per week that were not affected by medication. He had tried altering his diet, but still had diarrhea several times per week. He indicated that he had been unable to get to sleep "at a decent hour" for years, and he was always tired. He stated that sometimes he had to have someone cover for him at work so he could use the bathroom due to diarrhea, and he had called in sick because of his headaches. II. Legal Analysis A. Entitlement to service connection on a direct basis Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. §§ 1110 and 1131 (West 1991); 38 C.F.R. § 3.303(a) (1999). It is the responsibility of a person seeking entitlement to service connection to present a well-grounded claim. 38 U.S.C.A. § 5107 (West 1991). Generally, a well-grounded claim is a "plausible claim, one which is meritorious on its own or capable of substantiation." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). In order to be well grounded, a claim for service connection must be accompanied by supporting evidence that the particular disease, injury, or disability was incurred in or aggravated by active service; mere allegations are insufficient. Tirpak v. Derwinski, 2 Vet. App. 609, 610-611 (1992); Murphy, 1 Vet. App. at 81. In general, the veteran's evidentiary assertions are accepted as true for the purpose of determining whether a well-grounded claim has been submitted. King v. Brown, 5 Vet. App. 19, 21 (1993). A claim for direct service connection requires three elements to be well grounded. It requires competent (medical) evidence of a current disability; competent (lay or medical) evidence of incurrence or aggravation of disease or injury in service; and competent (medical) evidence of a nexus between the in-service injury or disease and the current disability. Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997); denied, sub nom. Epps v. West, 118 S. Ct. 2348 (1998); Caluza v. Brown, 7 Vet. App. 498, 504 (1995); aff'd 78 F.3d 604 (Fed. Cir. 1996) (table). The second and third Caluza elements can also be satisfied under 38 C.F.R. § 3.303(b) by (a) evidence that a condition was "noted" during service or during an applicable presumption period; (b) evidence showing post-service continuity of symptomatology; and (c) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Brewer v. West, 11 Vet. App. 228, 231 (1998); see also Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease. Brewer, 11 Vet. App. at 231. Section 3.303(b) provides an alternative method of demonstrating entitlement to service connection. Rose v. West, 11 Vet. App. 169, 171- 172 (citing Savage, 10 Vet. App. at 495-6 (section 3.303(b) is provision that veteran "may utilize" because it provides "a substitute way" of proving service connection)). In this case, the veteran has failed to satisfy the first element of a well-grounded claim for direct service connection under regulations pertaining generally, i.e., other than claimed as undiagnosed illness. The medical evidence does not show that the veteran has any disability manifested by headaches, diarrhea, and/or insomnia. As discussed above, the VA examiner attributed the veteran's complaints to an undiagnosed illness. There is no ascertainable, diagnosed medical disorder to account for any of his complaints. The veteran's complaints of headaches, diarrhea, and insomnia are symptoms only, and no diagnosis is shown in the current medical evidence to account for any of those symptoms. The VA examination in 1997 was completely normal. Since the medical evidence does not show a current disability due to headaches, diarrhea, and/or insomnia, the veteran's claims for direct service connection are not well grounded. There must be a current, ascertainable medical disorder in order to warrant service connection. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. §§ 1110 and 1131 (West 1991); see Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that Secretary's and Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Caluza, 7 Vet. App. at 505; Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v Derwinski, 2 Vet. App. 141, 143 (1992). The veteran is certainly competent to state what his symptoms are. However, even accepting his statements as true, he cannot meet his initial burden under 38 U.S.C.A. § 5107(a) by simply presenting his own opinion. He does not have the medical expertise to render a probative opinion as to medical causation. See Edenfield v. Brown, 8 Vet. App. 384, 388 (1995); Robinette v. Brown, 8 Vet. App. 69, 74 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Consequently, his statements are insufficient to well ground his claims for service connection for headaches, diarrhea, and insomnia on a direct basis. Moreover, even accepting his complaints as representative of continuity of symptomatology, there is no competent medical opinion of record showing that he currently has a diagnosed disorder accounting for those complaints. Cf. Savage, 10 Vet. App. at 497. Therefore, the Board concludes that the veteran's claims for service connection for headaches, diarrhea, and insomnia on a direct basis are not well grounded. Until he establishes a well-grounded claim, VA has no duty to assist him in developing facts pertinent to the claim, including providing him a medical examination at VA expense. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.326(a) (1999) (VA examination will be authorized where there is a well-grounded claim for compensation); see Morton v. West, 12 Vet. App. 477 (1999) (VA cannot assist a claimant in developing a claim that is not well grounded). When a claimant refers to a specific source of evidence that could make his claim plausible, VA has a duty to inform him of the necessity to submit that evidence to complete his application for benefits. See Epps v. Brown, 9 Vet. App. 341, 344-45 (1996), aff'd Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). VA has no outstanding duty in this case to inform the veteran of the necessity to submit certain evidence to complete his application for VA benefits. See 38 U.S.C.A. § 5103(a) (West 1991). There is no indication of any medical records that might well ground any of these claims. The veteran has not alleged that he has received medical treatment for any ascertainable medical disorder based on his symptoms of headaches, diarrhea, and/or insomnia. The presentation of a well-grounded claim is a threshold issue. Therefore, since the veteran has failed to present competent medical evidence that his claims are plausible, the claims for service connection on a direct basis must be denied as not well grounded. Dean v. Brown, 8 Vet. App. 449 (1995); Boeck v. Brown, 6 Vet. App. 14, 17 (1993). There is no duty to assist further in the development of these claims, because such additional development would be futile. See Murphy, 1 Vet. App. 78. B. Entitlement to service connection under 38 C.F.R. § 3.317 For servicemembers who served in the Southwest Asia theater of operations during the Persian Gulf War who exhibit objective indications of chronic disability manifested by one or more specific signs or symptoms, such disability may be service connected provided that it became manifest during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2001; and provided that the disability cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117 (West Supp. 1999); 38 C.F.R. § 3.317(a)(1)(i) and (ii) (1999). Signs and symptoms that may be manifestations of undiagnosed illness include headaches, gastrointestinal signs or symptoms, fatigue, and sleep disturbances. 38 C.F.R. § 3.317(b)(7) (1999). This list is not inclusive. "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) (1999). 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. 38 C.F.R. § 3.317(a)(3) (1999). The threshold question in any claim for service connection is whether the claim is well grounded. 38 U.S.C.A. § 5107 (West 1991). VA's General Counsel addressed the issue of what constitutes a well-grounded claim under the provisions of 38 U.S.C.A. § 1117 in VAOPGCPREC 4-99. A well-grounded claim for compensation under 38 U.S.C. § 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 service in the Southwest Asian 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. VAOPGCPREC 4-99. With respect to the second and fourth elements, 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. Id. The type of evidence necessary to establish a well-grounded claim as to each of those elements may depend upon the nature and circumstances of the particular claim. For purposes of the second and third elements, 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. Id. If the claimed signs or symptoms of undiagnosed illness or the claimed indications of chronic disability are of a type that 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. Id. 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. Id. The veteran's claims for service connection for headaches, diarrhea, and insomnia as due to an undiagnosed illness are plausible, in that he has met all four elements of a well- grounded claim for an undiagnosed illness, as discussed above. He had active military service in the Southwest Asia theater of operations during the Persian Gulf War. His complaints of headaches, diarrhea, and insomnia are signs or symptoms of a possible undiagnosed illness according to 38 C.F.R. § 3.317. Objective indications of chronic disability are described as either objective medical evidence perceptible to a physician or other, non-medical indicators that are capable of independent verification. He has submitted lay statements and his own statements to the effect that he experiences chronic headaches, diarrhea, and insomnia. Lay witnesses "are perfectly competent to testify as to their first-hand observations of [a veteran's] visible symptoms." Doran v. Brown, 6 Vet. App. 283, 288 (1994). Also, the veteran's subjective report of experiencing headaches, diarrhea, and insomnia is considered competent evidence. See Savage v. Gober, 10 Vet. App. 88 (1997). The VA examiner in 1997 concluded that the veteran had an undiagnosed illness as a result of his service in the Persian Gulf that was manifested, in part, by headaches, diarrhea, and insomnia. The examiner's statement provides a link between the chronic disabilities and an undiagnosed illness. The evidence fails to document objective proof of chronic disability due to headaches, diarrhea, or insomnia during the veteran's period of active duty in the Southwest Asia theater of operations. The treatment records from that time period do not show chronic complaints of such symptoms. There is no record of any complaints of headaches, diarrhea, or insomnia in the ten months between his return to the United States and his separation from service. Moreover, he denied ever experiencing any such symptoms upon his separation examination in February 1992. Therefore, in order to be well grounded, there must be evidence that would support assigning a 10 percent disability evaluation for any of these symptoms. The presumptive period has not yet expired, so the Board has considered all the post-service evidence of record. As discussed above, a finding that the veteran's signs or symptoms of undiagnosed illness are manifested to a degree of 10 percent or more may be established by (a) lay evidence if the claimed signs or symptoms are of a type which would ordinarily be susceptible to identification by lay persons, or (b) a veteran's own testimony if it relates to non-medical indicators of disability within the veteran's competence and the indicators are capable of verification from objective sources. In this case, the veteran has submitted lay evidence, including his own statements, showing that his headaches, diarrhea, and insomnia are manifested to a degree of 10 percent or more. The veteran complains of chronic headaches several times per week, and he has stated that he has to lie down to relieve his headaches. He has also submitted lay statements indicating that it is visually apparent when he has a terrible headache and that his headaches interfere with his ability to work. Under Diagnostic Code 8100, a 10 percent disability rating requires prostrating attacks characteristic of migraine headaches that average one in two months over the last several months. 38 C.F.R. § 4.124a (1999). Interpreting the veteran's statements liberally, it can be said that he has complained of prostrating attacks of headaches that are unrelieved by medication and that interfere with functioning. The veteran complains that he has diarrhea several times per week, despite altering his diet. Diarrhea is not identified in 38 C.F.R., Part IV, as a recognized medical disorder. When an unlisted condition is encountered, it will be rated under a closely related disease in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (1999). The RO chose Diagnostic Code 7319 for irritable colon syndrome as analogous to the veteran's symptom of diarrhea. Under Diagnostic Code 7319, a 10 percent disability rating requires moderate irritable colon syndrome (spastic colitis, mucous colitis, etc.) with frequent episodes of bowel disturbance with abdominal distress. 38 C.F.R. § 4.114 (1999). The veteran has complained of "frequent" episodes of bowel disturbance that interfere with normal functioning. The veteran complains of insomnia with resulting chronic fatigue. Insomnia is not identified in 38 C.F.R., Part IV, as a recognized medical disorder and will be rated under a closely related disease. 38 C.F.R. § 4.20 (1999). The RO chose Diagnostic Code 9400 for generalized anxiety disorder as analogous to the veteran's symptom of insomnia. Under Diagnostic Code 9400, a 10 percent disability rating is warranted where there is occupational and social impairment due to mild or transient symptoms that decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or, if the symptoms are controlled by continuous medication. 38 C.F.R. § 4.130 (1999). The veteran's statements and the lay statements he has submitted indicate that his insomnia affects his social functioning, in that he does not participate in family events, and affects his occupational functioning, in that he works in a diminished capacity. The veteran has submitted lay evidence describing the debilitating effects of the reported headaches, diarrhea, and insomnia, which suggest that these symptoms are present to a degree warranting a 10 percent disability rating. Assuming the credibility of this evidence, the claims must be said to be plausible, and therefore well grounded. The veteran having stated well-grounded claims, the Department has a duty to assist in the development of facts relating to these claims. 38 U.S.C.A. § 5107(a) (West 1991). The Board concludes that VA has not satisfied its duty to assist the veteran in the development of these claims. The record does not contain sufficient evidence to decide these claims fairly, as discussed more fully below. Accordingly, further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. §§ 5103 and 5107(a), and these claims are REMANDED for the development discussed below. ORDER The claims of entitlement to direct service connection for disabilities manifested by headaches, diarrhea, and insomnia are not well grounded and are therefore denied. The claims of entitlement to service connection for headaches, diarrhea, and insomnia claimed as undiagnosed illness are well grounded, and, to that extent, the appeal is granted. REMAND Additional evidentiary development is needed prior to further disposition of the veteran's claims. A. Claims for service connection due to undiagnosed illness As discussed above, the veteran underwent a VA physical examination in 1997, and the examiner concluded that the veteran has an undiagnosed illness due to his service in the Persian Gulf that is manifested by headaches, diarrhea, and insomnia. Since that examination, the Under Secretary for Benefits/Under Secretary for Health has issued guidelines for disability examinations for Gulf War veterans. See Memorandum dated January 6, 1998. In light of the veteran's complaints, in conjunction with the fact that a definitive diagnosis has not yet been rendered, an additional VA physical examination that conforms to the new guidelines is appropriate. The Board does not have sufficient medical information to adjudicate the veteran's claims. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991); Santiago v. Brown, 5 Vet. App. 288, 292 (1993). The veteran has submitted competent lay statements as to the manifestations of his headaches, diarrhea, and insomnia. Although this evidence is sufficient to establish plausible claims, there must be some verification of that evidence in order to warrant an award of benefits. VAOPGCPREC 4-99. Therefore, the veteran should be informed of the need to submit evidence verifying the lay statements he has submitted (i.e., work records showing time lost due to the claimed disabilities, evidence affirming changes in his appearance or behavior, evidence that he has sought medical treatment for the claimed symptoms, etc.). Id. B. Claim for higher rating for skin disorder It is necessary to provide the veteran an opportunity to undergo further examination, preferably by a dermatologist. The report of the VA examination conducted in 1997 is inadequate to evaluate his service-connected disability. There are no findings regarding the severity of the rash on the veteran's arms. The Board does not currently have sufficient medical evidence upon which to base a decision. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991); Santiago v. Brown, 5 Vet. App. 288, 292 (1993). An additional examination is also needed because the veteran has submitted statements indicating that the skin rash has worsened since the 1997 examination. The appearance of his skin disorder during flare-ups must be addressed. See Ardison v. Brown, 6 Vet. App. 405, 407 (1994). With a disorder such as the veteran's, where the service-connected disease is cyclical in the manifestations of its symptoms, the duty to assist includes conducting an examination during the active stage of the disease. Id. at 408. Accordingly, this case is REMANDED for the following: 1. Ask the veteran to identify the names and complete addresses of any medical providers who have treated him for headaches, diarrhea, insomnia, and/or skin rash on the arms since his separation from active service in 1992. After securing any necessary releases, request records of any treatment identified by the veteran, and associate all records received with the claims file. If any request for private medical records is unsuccessful, advise the veteran that his actual treatment records are important to his claims, and that it is his responsibility to submit them. See 38 C.F.R. § 3.159(c) (1999). Allow him an appropriate period of time within which to respond. 2. Inform the veteran that it is his responsibility to submit objective evidence verifying that he has the claimed symptoms of headaches, diarrhea, and insomnia, such as work records showing time lost due to the claimed disabilities, evidence affirming changes in his appearance or behavior, evidence that he has sought medical treatment for the claimed symptoms, etc. Allow him an appropriate period of time within which to respond. 3. After obtaining as many of the veteran's referenced medical records as possible or allowing him an opportunity to submit such records, schedule him for a comprehensive VA physical examination. It is very important that the examiner be provided an opportunity to review the claims folder and a copy of this remand prior to the examination. The examiner should indicate in the report that the claims file was reviewed, including the service medical records, the report of the 1997 VA examination, and the lay statements submitted by the veteran. The examination must conform to the guidelines for disability examinations in Gulf War veterans. See Under Secretary for Benefits/Under Secretary for Health Memorandum dated January 6, 1998. All necessary testing is to be done to determine the nature, etiology, and extent of any disability. In particular, the examiner is asked to determine the onset, frequency, duration, and severity of the veteran's complaints of headaches, diarrhea, and insomnia. The examiner is asked to note specifically all objective signs of chronic disabilities manifested by headaches, diarrhea, or insomnia, if any. The examiner is asked to express an opinion whether the veteran's complaints are due to a specific, diagnosed illness, or whether there is no diagnosis to account for these symptoms. The examiner must provide a comprehensive report including complete rationales for all conclusions reached. 4. Send a letter to the veteran explaining to him that he needs to report to a VA Medical Center for examination of his service-connected skin disorder when his skin disability becomes active or flares-up, so that documentation can be obtained as to the symptoms he experiences during such periods of heightened activity. The RO should make the necessary arrangements for the veteran to report to a VA facility for examination by a dermatologist while he is symptomatic. The examining physician should discuss the extent of any exfoliation, exudation, itching, or lesions associated with the veteran's service-connected rash on the arms. The areas affected by this disorder should be described in terms of location and extent of involvement. Unretouched color photographs of the areas affected by the service-connected disorder should be obtained. 5. Allow the veteran's case to remain in remand status for an appropriate period of time so that he can seek examination of his skin disorder while it is symptomatic. Following completion of the above, review the claims folder and ensure that the examination reports include fully detailed descriptions and the opinion requested. If any report does not, it must be returned to the examiner for corrective action. 38 C.F.R. § 4.2 (1999). 6. After completion of the above evidentiary development, readjudicate the veteran's claims for service connection for headaches, diarrhea, and insomnia as due to undiagnosed illness under the provisions of 38 C.F.R. § 3.317 and his claim for a higher rating for the rash on his arms, with consideration of the additional evidence developed upon remand. The RO should review the evidence of record at the time of the September 1997 rating decision that was considered in assigning the original disability rating for the veteran's rash on the arms, then consider all the evidence of record to determine whether the facts show that he was entitled to a higher disability rating for this condition at any period of time since his original claim. See Fenderson v. West, 12 Vet. App. 119 (1999). If any benefit sought on appeal remains denied, provide the veteran and his representative a supplemental statement of the case. The SSOC must correctly identify the arm rash issue as on appeal from the initial grant of service connection. Allow an appropriate period for response. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran has the right to submit additional evidence and argument on the matters that the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). The purpose of this REMAND is to obtain additional information. No inference should be drawn regarding the final disposition of these claims as a result of this action. These claims 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 (Historical and Statutory Notes) (West Supp. 1999). 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. J. SHERMAN ROBERTS Member, Board of Veterans' Appeals