Citation Nr: 0003783 Decision Date: 02/14/00 Archive Date: 02/15/00 DOCKET NO. 98-03 925 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, including post-traumatic stress disorder. 2. Entitlement to service connection for a disorder characterized by fatigue, including fatigue due to an undiagnosed illness. 3. Entitlement to service connection for a skin disorder, including a skin rash due to an undiagnosed illness. 4. Entitlement to service connection for a disorder characterized by muscle and joint pains, including muscle and joint pains due to an undiagnosed illness. 5. Entitlement to service connection for headaches, including headaches due to an undiagnosed illness. 6. Entitlement to service connection for memory loss, including memory loss due to an undiagnosed illness. 7. Entitlement to service connection for a respiratory disorder, including respiratory symptoms associated with an undiagnosed illness. 8. Entitlement to service connection for a gastrointestinal disorder associated with diarrhea and hematochezia, including gastrointestinal symptoms associated with an undiagnosed illness. 9. Entitlement to service connection for a disorder associated with pain of the back and neck, including pain due to an undiagnosed illness. 10. Entitlement to service connection for impotence, including impotence due to an undiagnosed illness. 11. Entitlement to service connection for arteriosclerosis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Ralph G. Stiehm, Counsel INTRODUCTION The veteran had active service from October 1980 to October 1993. This case comes before the Board of Veterans' Appeals (Board) on appeal from a January 1998 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Saint Louis, Missouri. Although the veteran initially included in his claim the issues of service connection for nicotine dependence and alcohol dependence, both due to undiagnosed illness, he specifically noted the disorders he was appealing in his substantive appeal dated in March 1998, and they did not include either nicotine dependence or alcohol dependence. FINDINGS OF FACT 1. A claim of entitlement to service connection for a psychiatric disorder is plausible. 2. Claims of entitlement to service connection for an undiagnosed illness or illnesses characterized by fatigue, a skin rash, muscle and joint pains, headaches, memory loss, respiratory symptoms consisting of shortness of breath and a cough, gastrointestinal symptoms consisting of diarrhea and hematochezia, back and neck pain, and impotence are plausible. 3. There is no medical evidence linking arteriosclerosis to service. CONCLUSIONS OF LAW 1. Entitlement to service connection for a psychiatric disorder, including post-traumatic stress disorder, is well grounded. 38 U.S.C.A. § 5107 (West 1991). 2. Entitlement to service connection for a disorder characterized by fatigue, including fatigue due to an undiagnosed illness, is well grounded. 38 U.S.C.A. § 5107 (West 1991). 3. Entitlement to service connection for a skin disorder, including a skin rash due to an undiagnosed illness, is well grounded. 38 U.S.C.A. § 5107 (West 1991). 4. Entitlement to service connection for a disorder characterized by muscle and joint pains, including muscle and joint pains due to an undiagnosed illness, is well grounded. 38 U.S.C.A. § 5107 (West 1991). 5. Entitlement to service connection for headaches, including headaches due to an undiagnosed illness, is well grounded. 38 U.S.C.A. § 5107 (West 1991). 6. Entitlement to service connection for memory loss, including memory loss due to an undiagnosed illness, is well grounded. 38 U.S.C.A. § 5107 (West 1991). 7. Entitlement to service connection for a respiratory disorder, including respiratory symptoms associated with an undiagnosed illness, is well grounded. 38 U.S.C.A. § 5107 (West 1991). 8. Entitlement to service connection for a gastrointestinal disorder associated with diarrhea and hematochezia, including gastrointestinal symptoms associated with an undiagnosed illness, is well grounded. 38 U.S.C.A. § 5107 (West 1991). 9. Entitlement to service connection for a disorder associated with pain of the back and neck, including pain due to an undiagnosed illness, is well grounded. 38 U.S.C.A. § 5107 (West 1991). 10. Entitlement to service connection for impotence, including impotence due to an undiagnosed illness, is well grounded. 38 U.S.C.A. § 5107 (West 1991). 11. Entitlement to service connection for arteriosclerosis disease is not well grounded. 38 U.S.C.A. § 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be granted for a disorder that was incurred in or aggravated during the veteran's active duty service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Certain diseases, including cardiovascular diseases, are presumed to have been incurred in service if manifested within a year of separation from service to a degree of 10 percent or more. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Moreover, a disease which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The initial inquiry in reviewing any claim before the Board is whether the appellant has presented evidence of a well- grounded claim; that is, one that is plausible or capable of substantiation. The appellant carries the burden of submitting evidence "sufficient to justify a belief by a fair and impartial individual that the claim is well grounded." 38 U.S.C.A. § 5107(a); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). If the appellant has not presented a well-grounded claim, that appeal must fail. While the claim need not be conclusive, it must be accompanied by supporting evidence; a mere allegation is not sufficient. Tirpak v. Derwinski, 2 Vet. App. 609 (1992). In cases which the determinative issue is one involving medical causation, competent medical evidence is required to establish a well- grounded claim. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). A well-grounded claim for service connection, moreover, requires that three elements be satisfied. First, there must be competent evidence of a current disability, as established by a medical diagnosis; second, there must be evidence of an incurrence or aggravation of a disease or injury in service, as established by lay or medical evidence, as appropriate; third, there must be competent evidence of a nexus or relationship between the in-service injury or disease and the current disorder, as established by medical evidence or a medical opinion. See generally Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Alternatively, a claim may be well grounded based upon application of the rule for chronicity and continuity of symptomatology, set forth in 38 C.F.R. § 3.303(b). See Savage v. Gober, 10 Vet. App. 488 (1997). The chronicity provision applies where there is evidence, regardless of its date, which shows that a veteran had a chronic condition either in service or during an applicable presumption period and that the veteran still has such a condition. That evidence must be medical, unless is relates to a condition that may be attested to by lay observation. If the chronicity provision does not apply, a claim may still be well grounded "if the condition is observed during service or any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology." Savage, 10 Vet. App. at 498. I. Psychiatric Disorder A well grounded claim for post-traumatic stress disorder is one where the appellant has submitted medical evidence of a current disability; lay evidence (presumed credible for these purposes) of an in-service stressor; and medical evidence of a nexus between service and the current post-traumatic stress disorder disability. Falk v. West, 12 Vet. App. 402, 404 (1999); Cohen v. Brown, 10 Vet. App. 128, 137 (1997). The veteran asserts that he suffers from post-traumatic stress disorder as a result of stressful incidents experienced in service, including being the subject of incoming mortar attacks. Evidence associated with the claims file includes a June 1998 entry in outpatient treatment records that documents that the veteran articulated psychiatric complaints associated with combat and that further documents diagnoses of depression and post-traumatic stress disorder at that time. This evidence is sufficient to render the veteran's claim for a psychiatric disorder well grounded. II. Multiple Complaints Compensation is available to Persian Gulf veterans for any chronic disability resulting from an undiagnosed illness manifested by one or more of a number of signs or symptoms. These signs or symptoms must become manifest to a degree of 10 percent no later than December 31, 2001, and must have existed for at least six months or have manifested episodes or improvement or worsening over a six-month period in order to be considered chronic. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. See also VAOGCPREC 8-98. 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 and undiagnosed illness generally requires evidence of (1) active service in Southwest Asia during the Persian Gulf War, (2) manifestation of one or more signs or symptoms, (3) objective indications of chronic disability during the relevant period of service or to a degree of 10 percent or more within the specified presumptive period, and (4) a nexus between the chronic disability and the undiagnosed. See VAOGCPREC 4-99. The veteran has articulated numerous complaints, which he attributes to service in the Persian Gulf. These consist of fatigue, a skin rash, generalized muscle and joint pain, chronic back and neck pain, headaches, memory problems, shortness of breath associated with a cough, diarrhea, as well as hematochezia, and impotence. During a VA examination in December 1997, examination revealed numerous diagnoses. These included status post service in the Persian Gulf War with multiple symptoms. They also included arthralgia of multiple joints, etiology not diagnosed by clinical radiographic examination; myalgia, etiology not diagnosed by clinical or laboratory examination; shortness of breath, etiology not diagnosed; status post service in the Persian Gulf War with exposure to oil fire smoke; chronic arthralgia of the cervical spine and lumbar spine, and impotence. Although not necessarily dispositive, this medical evidence raises some questions as to whether the veteran does not, in fact, suffer from a medical condition that eludes diagnosis. Although diagnoses also included irritable bowel syndrome, a known disorder, additional treatment records reference complaints of hematochezia, but contain no reference to functional bowel disorder and reflect that colonoscopies, including a colonoscopy in February 1998, were within normal limits. In addition, treatment records reveal that the veteran revealed complaints similar to those raised in December 1997 at later points in time, including March and August 1998. An August 1998 entry reflects a medical condition characterized as dyssomnia secondary to a medical condition, without further elaboration of the medical condition other than a parenthetical reference to pain. Additional entries from August 1998 reflect that the veteran did not meet the criteria for fibromyalgia reference mixed anxiety and depression disorder. The body of evidence before the Board raises unresolved questions concerning the etiology of the veteran's various complaints, including whether the veteran's complaints may be attributed to a known diagnosis. Therefore, the veteran's claims for service connection for disorders associated, with these various complaints, which includes claims for service connection based upon service in the Persian Gulf, are at least plausible and, as such, are well grounded. III. Arteriosclerosis Service medical records, other than an entrance examination, are not associated with the claims file. A review of the claims file reveals that the RO made every effort to secure the veteran's service medical records. It would appear that either there are no other service records to obtain or that any other records are unavailable. A December 1997 x-ray examination revealed evidence of arteriosclerosis. Arteriosclerosis is a known disease and, therefore, is not subject to service connection as a unknown illness related to Persian Gulf service. There is no evidence that arteriosclerosis was present within a year of the veteran's separation from service, and there is no medical evidence otherwise linking arteriosclerosis to service. The veteran furthermore, has not claimed that arteriosclerosis was diagnosed during service. As such there is no basis for attempting to corroborate such a claim by examining morning reports. Because there is no medical evidence linking arteriosclerosis to service, the veteran's claim for service connection for arteriosclerosis is not well grounded. ORDER Entitlement to service connection for a psychiatric disorder, including post-traumatic stress disorder, is well grounded. Entitlement to service connection for a disorder characterized by fatigue, including fatigue due to an undiagnosed illness, is well grounded. Entitlement to service connection for a skin disorder, including a skin rash due to an undiagnosed illness, is well grounded. Entitlement to service connection for a disorder characterized by muscle and joint pains, including muscle and joint pains due to an undiagnosed illness, is well grounded. Entitlement to service connection for headaches, including headaches due to an undiagnosed illness, is well grounded. Entitlement to service connection for memory loss, including memory loss due to an undiagnosed illness, is well grounded. Entitlement to service connection for a respiratory disorder, including respiratory symptoms associated with an undiagnosed illness, is well grounded. Entitlement to service connection for a gastrointestinal disorder associated with diarrhea and hematochezia, including gastrointestinal symptoms associated with an undiagnosed illness, is well grounded. Entitlement to service connection for a disorder associated with pain of the back and neck, including pain due to an undiagnosed illness, is well grounded. Entitlement to service connection for impotence, including impotence due to an undiagnosed illness, is well grounded. Entitlement to service connection for arteriosclerosis is denied. REMAND Although the veteran has presented a well grounded claim for service connection for post-traumatic stress disorder, the RO has not requested a stressor statement from the veteran or attempted further development of the veteran's stressors. Such development is required. See Falk, supra; M-21, Part III, 5.14. In addition, although evidence associated with the claims file raises some questions concerning the etiology of many of the veteran's complaints which he attributes to service in the Persian Gulf, it is not clear from a review of the evidence whether the veteran's symptoms elude diagnosis and whether the veteran's multiple complaints are manifested by objectively verifiable signs. An examination for the purpose of ascertaining the nature and etiology of the veteran's numerous complaints would be beneficial in resolving the veteran's claims in this respect. Therefore, the claims file is REMANDED for the following development: 1. The RO should request from the veteran a comprehensive statement containing as much detail as possible regarding the alleged in-service stressors. The veteran should be asked to provide specific details of the claimed stressful events during service, such as the dates, locations, detailed descriptions of events, units involved, and identifying information concerning any other individuals involved in the events, including their names, ranks, units of assignment, or any other identifying details. The veteran is advised that this information is vitally necessary to obtain supportive evidence of the stressful events and that he must be as specific as possible because without such details an adequate search for verifying information cannot be conducted. 2. With this information, the RO should review the file and prepare a summary of all the claimed stressors. This summary must be prepared whether or not the veteran provides an additional statement, as requested above. The RO's attention is directed to the veteran's claims of having been exposed to incoming fire and have assisted with wounded soldiers, as set forth in the veteran's June 1997 statement and his September 1999 testimony. This summary and a copy of the veteran's DD 214 and all associated service documents should be sent to the U.S. Armed Services Center for Research of Unit Records (USASCRUR), 7798 Cissna Road, Suite 101, Springfield, Virginia 22150-3197. USASCRUR should be provided with a copy of any information obtained above, and should be requested to provide any additional information, including any available unit histories, that might corroborate the veteran's alleged stressors. 3. Following the receipt of a response from USASCRUR, the RO must prepare a report detailing the nature of any stressor which it has determined is established by the record. If no stressor has been verified, the RO should so state in its report. This report is then to be added to the claims folder. 4. After completing the above actions, if any stressors are corroborated, the veteran should be afforded a VA psychiatric examination to determine the diagnosis of any and all psychiatric disorders which may be present. All indicated studies, tests and evaluations deemed necessary should be performed. The RO must provide the examiner the summary of any stressors described above, and the examiner must be instructed that only these events may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in the current psychiatric symptoms. The examiner must determine whether the diagnostic criteria to support the diagnosis of post-traumatic stress disorder have been satisfied. If the diagnostic criteria for post- traumatic stress disorder are not satisfied, the examiner should so indicate. If a diagnosis of post- traumatic stress disorder is deemed appropriate, the examiner should comment upon the link between the current symptomatology and one or more of the in- service stressors found to be established by the RO. The report of examination should include a complete rationale for all opinions expressed. Since it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1, the claims file, must be made available to the examiner for review. 5. The veteran should be afforded an examination to ascertain the nature and etiology of any disorder associated with the veteran's complaints of fatigue, a skin rash, muscle and joint pains, headaches, memory loss, respiratory symptoms consisting of shortness of breath and a cough, gastrointestinal symptoms consisting of diarrhea and hematochezia, back and neck pain, and impotence. After reviewing the claims file, including the report of a December 1997 VA examination, the examiner should explicitly indicate whether there is objective evidence of clinically significant findings associated with each of the veteran's complaints. If there is such evidence, the examiner should indicate whether it is possible to attribute the findings in question to a known diagnosis. If so, that diagnosis should be identified. If there is no objective evidence of clinically significant findings, or if such findings elude diagnosis, the examiner should so indicate. All necessary tests, studies, or examinations should be performed. The claims file must be made available to the examiner for review. When the development requested has been completed, the case should again be reviewed by the RO on the basis of all the evidence. If the benefit sought is not granted, the appellant should be furnished a supplemental statement of the case, and be afforded the appropriate time period to respond before the record is returned to the Board for further review. The purpose of this REMAND is to obtain additional development. The Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. No action is required of the appellant unless he is notified. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). BRUCE KANNEE Member, Board of Veterans' Appeals