Citation Nr: 0005337 Decision Date: 02/29/00 Archive Date: 03/07/00 DOCKET NO. 97-13 043 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUES 1. Entitlement to service connection for headaches due to an undiagnosed illness illness. 2. Entitlement to service connection for chronic fatigue due to an undiagnosed illness. 3. Entitlement to service connection for a sleep disorder due to an undiagnosed illness. 4. Entitlement to service connection for a chronic respiratory disorder including sinusitis due to an undiagnosed illness. 5. Entitlement to service connection for a skin disorder due to an undiagnosed illness. 6. Entitlement to service connection for hair loss due to an undiagnosed illness. 7. Entitlement to service connection for memory loss due to an undiagnosed illness. 8. Entitlement to service connection for blurred vision due to an undiagnosed illness. 9. Entitlement to service connection for lightheadedness due to an undiagnosed illness. 10. Entitlement to service connection for depression due to an undiagnosed illness. 11. Entitlement to an initial rating in excess of 10 percent for an undiagnosed illness manifested by joint pain. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States INTRODUCTION The veteran's active military service from November 1987 to December 1991 that included service in the Southwest Asia theater of operations during the Persian Gulf War has been verified. His final DD Form 214 reports more than four months of prior active service. The veteran brought a timely appeal to the Board of Veterans' Appeals (the Board) from July 1995 and March 1996 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. The issue of entitlement to service connection for chronic fatigue due to an undiagnosed illness is discussed further in the remand portion of this decision. FINDINGS OF FACT 1. The claims of entitlement to service connection for headaches, sleep disorder, respiratory disorder including sinusitis, hair loss, memory loss, blurred vision, lightheadedness and depression are not supported by cognizable evidence showing that the claims are plausible or capable of substantiation as they are either not diagnosed disability or attributed medically to a known diagnosis. 2. It is probable that the veteran has a skin disorder linked to undiagnosed illness, as his skin rash has not been attributed medically to a known diagnosis. 3. Joint pain due to undiagnosed illness is not shown to be manifested by any limitation of motion but there is evidence of involvement of major joints and groups of minor joints with complaints of pain and swelling of variable intensity that approximate incapacitating exacerbations. CONCLUSIONS OF LAW 1. The claims of entitlement to service connection for headaches, sleep disorder, respiratory disorder including sinusitis, hair loss, memory loss, blurred vision, light- headedness and depression are not well grounded as claimed undiagnosed illnesses in a Persian Gulf War veteran. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.303, 3.317 (1999). 2. Compensation may be paid for a skin disorder as an undiagnosed illness in a Persian Gulf War veteran. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.317 (1999). 3. The criteria for an initial rating of 20 percent for an undiagnosed illness manifested by joint pain have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.7, 4.20, 4.21, 4.71a, Diagnostic Code 5003 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Undiagnosed Illness Criteria Service connection may be granted for a disability resulting from personal injury or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 1991). Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. Each disabling condition shown by a veteran's service records, or for which he seeks a service connection must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence. Determinations as to service connection will be based on review of the entire evidence of record, with due consideration to the policy of the Department of Veterans Affairs to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A threshold question to be answered is whether the veteran has presented evidence of a well grounded claim; that is, a claim that is plausible or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Although the claim need not be conclusive, it must be accompanied by supporting evidence. An allegation alone is not sufficient. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Three discrete types of evidence must be present in order for a veteran's claim for benefits to be well grounded: (1) There must be evidence of a current disability, usually shown by a medical diagnosis. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); (2) There must also be competent evidence of incurrence or aggravation of a disease or injury in service. This element may be shown by lay or medical evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991); and (3) There must be competent evidence of a nexus between the in-service injury or disease and the current disability. Such a nexus must be shown by medical evidence. Lathan v. Brown, 7 Vet. App. 359, 365 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In determining whether a claim is well grounded, the Board is required to presume the truthfulness of the evidence. Robinette v. Brown, 8 Vet. App. 69, 77-8 (1995); King v. Brown, 5 Vet. App. 19, 21 (1993). In order for a claim to be well grounded, there must be (1) competent evidence of a current disability (a medical diagnosis); (2) incurrence or aggravation of a disease or injury in service (lay or medical evidence); and (3) a nexus between the in-service disease or injury and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). The Secretary may pay compensation under this subchapter to any Persian Gulf veteran suffering from a chronic disability resulting from an undiagnosed illness (or combination of undiagnosed illnesses) that (1) became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War; or (2) became manifest to a degree of 10 percent or more within the presumptive period prescribed under subsection (b). (b) The Secretary shall prescribe by regulation the period of time following service in the Southwest Asia theater of operations during the Persian Gulf War that the Secretary determines is appropriate for presumption of service connection for purposes of this section. The Secretary's determination of such period of time shall be made following a review of any available credible medical or scientific evidence and the historical treatment afforded disabilities for which manifestation periods have been established and shall take into account other pertinent circumstances regarding the experiences of veterans of the Persian Gulf War. (c)(1) The Secretary shall prescribe regulations to carry out this section. (2) Those regulations shall include the following: (A) A description of the period and geographical area or areas of military service in connection with which compensation under this section may be paid. (B) A description of the illnesses for which compensation under this section may be paid. (C) A description of any relevant medical characteristic (such as a latency period) associated with each such illness. (d) A disability for which compensation under this subchapter is payable shall be considered to be service connected for purposes of all other laws of the United States. (e) For purposes of this section, the term ''Persian Gulf veteran'' means a veteran who served on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War. 38 U.S.C.A. § 1117. Except as provided in paragraph (c) of this section, VA shall pay compensation in accordance with chapter 11 of title 38, United States Code, to a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of this section, provided that such disability: (i) became manifest either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2001; and (ii) by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. (2) For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. (3) For purposes of this section, disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6- month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. (4) A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. (5) A disability referred to in this section shall be considered service connected for purposes of all laws of the United States. For the purposes of paragraph (a)(1) of this section, signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: (1) fatigue, (2) signs or symptoms involving skin, (3) headache, (4) muscle pain, (5) joint pain, (6) neurologic signs or symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the respiratory system (upper or lower), (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss or (13) 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. For purposes of this section: (1) the term "Persian Gulf veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. (2) the Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317. 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, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a clam, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence, the benefit of the doubt doctrine in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Analysis Section 5107 of title 38, United States Code unequivocally places an initial burden upon the claimant to produce evidence that a claim is well grounded; that is, that the 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, except for a skin disorder, the Board finds the claims for service connection not well grounded. The threshold question that must be resolved is whether the veteran has presented evidence of plausible claims. In view of the evidence, the Board finds that the veteran has not met this initial burden and that as a result there is no further duty to assist the veteran. In connection with the development of the claim, the Board observes that the RO has obtained service medical records and VA medical records that include several comprehensive examinations. A diligent effort has been made to provide an adequate record. The records that have been obtained are comprehensive and appear to provide an adequate record for an informed decision. The essential elements of a well-grounded claim are evidence of a current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence depending on the circumstances), and of a nexus between the inservice injury or disease and the current disability (medical evidence). Caluza v. Brown, 7 Vet. App. 498 (1995). Where the determinative issue involves causation or a medical diagnosis, as is the case here, competent medical evidence to the effect that the claim is possible or plausible is required. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The claimant does not meet this burden by merely presenting lay opinion because he is not a medical health professional and does not constitute competent medical authority. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Consequently, the veteran's lay assertions cannot constitute cognizable evidence, and as cognizable evidence is necessary for a well-grounded claim, Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992); his lay assertions on a matter of medical causation or etiology would not be entitled to any favorable presumption in the well-grounded determination. As it is the province of trained health care professionals to enter conclusions, which require medical opinions as to causation, Grivois, the veteran's lay opinion is an insufficient basis to find his claims well grounded. Espiritu. Accordingly, as a well-grounded claim must be supported by competent evidence, not merely allegations, Tirpak, the veteran's claims for service connection as due to an undiagnosed illness, other than a skin disorder, must be denied as not well grounded. He has the required service and he reported for the comprehensive examinations ordered to ascertain a likely etiology for his multiple complaints that include those listed among the signs and symptoms that may be manifestations of an undiagnosed illness. The veteran's service medical records show his vision was 20/20 on examination in August 1987 and in November 1987. He was observed for a cold and productive cough in late 1988. He was seen for headaches initially in April 1989 that reportedly had occurred for three weeks. A skull x-ray was read as normal. The assessment after further evaluation was cephalalgia and probable muscular headache. In June 1989 his complaint of neck pain that reportedly led to headaches was assessed as cervical dysfunction. On another occasion in June 1989 his history of right-sided headache for more than three months was assessed as tension headaches. A medical board evaluation in 1991 was unremarkable except for a back disorder found to have existed prior to service. The service medical records are otherwise pertinently unremarkable. The veteran's initial VA claim was for arthritis and scoliosis in late 1991 which the RO denied and he did not appeal. In early 1993 he asked for service connection for chronic headaches, the right hip, the cervical spine and chronic sinusitis in addition to the thoracic and lumbar spine and stated that all treatment had been at the VA since 1993. The medical records obtained did not refer to any of the disorders. The RO in early 1994 asked him for additional evidence regarding headaches, the cervical spine, chronic sinusitis and the right hip and he responded with military medical board records that reported preexisting scoliosis and mentioned degenerative arthritis of the lumbar spine. Thereafter, in April 1994, the RO denied the claims for the cervical spine, headaches, the right hip and a sinus disorder and notified him of the determination. The next pertinent communication from the veteran was the application in late 1994 for disability based upon Persian Gulf service. Therein he listed hair loss, memory loss, muscle aches, joint pain, lightheadedness, the sinuses, blurred vision, a circulatory problem, sleep disturbance, headaches, a respiratory problem and skin rash. The veteran did not respond to the RO request for information and he was advised of a July 1995 rating decision that found the record was not adequate to rate the claimed Persian Gulf disorders. The veteran provided VA outpatient treatment reports that began in early 1993. Through 1993 and 1994 the recorded complaints regarding the joints predominate. There was a June 1993 reference to severe headaches secondary to stress headaches and normal skin was reported in December 1993. In April 1994 the lungs were clear to auscultation and no lesions were observed. In November 1994 there was an assessment of adjustment disorder with depressed mood with motivational problem and a note for sleep clinic referral for polysonography. On VA psychiatric examination in August 1995 the veteran complained of trouble sleeping and memory loss. The examiner reported adequate long-term memory with some spottiness. The veteran was reported to have had a nearly perfect score on a "mini" mental status evaluation. The examiner opined that the veteran's memory loss did not approach clinical significance in view of his recitation. The diagnosis was adjustment disorder with depressed mood. The examiner stated that the veteran had symptoms of mild depression and mild insomnia. The general medical examination found the veteran complaining of hair loss and nasal discharge in addition to multiple joint pain. The examiner reported hair loss over the top of the head, clear lungs and one erythematous type macular lesion of the upper left arm. The diagnoses included history of symptoms consistent with Persian Gulf syndrome as described in newspapers. In responding to a request from the RO in early 1996 for additional evidence regarding the Persian Gulf illness claims, the veteran stated that all the evidence was in the service records and VA medical records. He complained of weight and hair loss, joint pain and weakness, hand numbness and depression with post-traumatic stress disorder symptoms. The RO in March 1996 granted service connection for undiagnosed illness manifested by joint pain and denied other claims for service connection which the veteran appealed. VA examined the veteran in 1997 for the claimed headaches, sleep disorder, respiratory disorder, skin disorder, hair loss, memory loss, blurred vision and light- headedness. The eye examiner reported 20/20 near and distant visual acuity. The diagnosis was early presbyopia. The psychiatric examiner reported adjustment disorder with depressed mood and polysubstance abuse, alcohol and marijuana. The examiner opined that the veteran's memory changes particularly short term memory an some concentration variability was perhaps likely due to chronic use of marijuana and alcohol which are known to cause some difficulties with concentration, attention and short term memory. On the general medical examination, the veteran reported a three-year history of off and on nonradiating, usually frontal, headaches, with photosensitivity and blurred vision at times. He reported that he was sleeping all right now and the claimed sleep disorder was getting better. As for a respiratory disorder he said that he did not know if it really bothered him any more. He also described skin, hair loss and memory loss problems as well as describing the claimed lightheadedness and blurred vision. The examiner reported a male balding pattern beginning at the front and extending posteriorly. The eyes reacted to light and accommodation and showed intact intraocular movements. Fundoscopic examination found well-marginated discs with vessels in all four quadrants. The nose showed pink mucosa without discharge. The lungs were clear to auscultation and percussion and without rales or wheezes. His oxygen saturation by pulse oximetry was 95%. The skin showed a red petechial-like rash over the anterior thighs and across the top of the shoulders without crusting or drainage. The tentative diagnoses included cephalalgia, resolving respiratory and sleep disorders, skin rash of unknown etiology, hair loss, memory loss, lightheadedness and intermittent blurred vision. Regarding lightheadedness, the examiner reported blood pressure obtained in three positions. As for a respiratory disorder, the examiner noted recent studies showing a radiologically negative chest and pulmonary function tests that appeared to be within normal limits. The examiner reported the following pertinent diagnoses in an addendum to the examination report: Skin rash of unknown etiology, normal male pattern balding, respiratory disorder resolving, cephalalgia with CT scan showing normal examination and negative non-contrast CT of the head. Lightheadedness with postural blood pressures within normal limits, intermittent blurred vision within normal CT scan of the head. The examiner referred to mental hygiene the claimed sleep disorder and memory loss. Concerning a skin disorder, the Board observes that the service medical records do not show complaints of skin disease. There is, however, a recent diagnostic impression of a nonspecific skin condition that when viewed liberally is found as acceptable medical evidence, that is, "signs" of a disorder that cannot be attributed to any known clinical diagnosis. The Board must observe that on the 1997 VA examination there was evidence of a skin disorder on the veteran's thighs and shoulders. The veteran's description of his skin disorder is viewed as "nonmedical indicators" that have been verified medically. On an earlier examination in 1995, the veteran was found to have a singular lesion of the left arm that the examiner did not identify with a diagnosis at the time. In view of this evidence, in particular, the conclusions of the recent examination, the Board is left with the belief that service connection should be granted. The veteran appears to meet the regulatory criteria for chronicity for an undiagnosed illness of the skin and there is skin rash not attributed to a known clinical diagnosis. As to the requirement that the disorder be manifested to a compensable degree, the Board believes that the area involved on the lower extremities and the shoulders sufficient to satisfy the criteria by analogy to eczema. With exfoliation, exudation or itching, if involving an exposed surface or extensive area, a 10 percent rating may be assigned. With slight, if any, exfoliation, exudation or itching, if on an exposed surface or small area, a 0 percent rating is provided. 38 C.F.R. § 4.118, Diagnostic Code 7806. The Board considers the currently observed involvement of the thighs and shoulders an extensive area that need not be exposed. See also VAOPGCPREC 8-98 (O.G.C. Prec. 8-98). Regarding an eye disorder including blurred vision, the Board must observe that the service medical records do not confirm defective visual acuity. The comprehensive VA eye examination found early presbyopia, which is hyperopia, a refractive error, and impairment of vision due to advancing years or old age. . Dorland's Illustrated Medical Dictionary, 797, 1349 (28th ed. 1994). There is no other eye disorder or pathology reported. Therefore, the veteran has defective vision that is attributed to a known clinical diagnosis of presbyopia that in his case cannot reasonably be regarded as other than a refractive error. Intermittent blurred vision was noted without further elaboration indicating a diagnosis of known or unknown disability to account for it. Therefore, as there is no other eye pathology reported, service connection for an eye disorder to include blurred vision, as an undiagnosed illness is not possible on the current record. Regarding headaches the record as it now stands does include competent evidence of cephalalgia. The service medical records do mention headaches before the veteran's Persian Gulf service and headaches were reported several years after service. In any event, the Board finds that an essential element of a well grounded claim, a current diagnosis of headaches is shown, but no nexus is offered to service on a basis unrelated to undiagnosed illness and claim is denied as not well grounded. As for the question of well groundedness under criteria for disability related to an undiagnosed illness, a nonspecific headache has not been reported. Thus, there is currently a clinical diagnosis of a headache disorder to which the headaches are attributable. Therefore consideration may not be given to service connection for headaches on the basis of an undiagnosed illness, as an essential element to well ground the claim on that basis is not met. The Board observes that another element is also missing in that prostrating attacks of headaches, the characteristic of a minimum compensable rating of 10 percent, are not shown. Regarding hair loss, the veteran is found to have male patter baldness, which is a known clinical diagnosis. The disorder is not shown to have been present in service. Since the hair loss is linked to a known clinical diagnosis consideration is not warranted on the basis of an undiagnosed illness. The claim as it now stands is not well grounded. The same reasoning applies to claimed depression, memory loss and insomnia which formal examination found were manifestations of an adjustment disorder. Therefore there is no independent basis for these claimed symptoms. The adjustment disorder is a known clinical diagnosis so consideration as an undiagnosed illness is not possible. The Board observes that no examination has included an opinion of a nexus to service for adjustment disorder. The respiratory complaints have been noted and described as a resolving disorder without any diagnosis of a chronic respiratory disorder linked to service or an undiagnosed illness. What appear to be shown are acute or transitory complaints without pulmonary function or x-ray evidence to substantiate a disabling condition. The Board observes that no sinus disorder was shown on any examination. Therefore the claim based on undiagnosed illness is not well grounded. The same rationale would apply to the claimed lightheadedness. The Board considered and denied the veteran's claim for service connection for disabilities due to an undiagnosed illness other than a skin disorder on different grounds from that of the RO. The appellant has not been prejudiced by the decision as the adjudication by the RO has accorded the appellant greater consideration than his claims in fact warranted under the circumstances. The RO considered and denied the claim for service connection of depression as not well grounded on a basis other than due to an undiagnosed illness although on either basis the claim is not well grounded. Bernard v. Brown, 4 Vet. App. 384 (1993). The Board further finds that the RO has advised the appellant of the evidence necessary to establish a well grounded claim, and the veteran has not indicated the existence of any post service evidence that has not already been obtained that would well ground the claims for service connection. McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). Initial rating for an undiagnosed illness manifested by joint pain Criteria The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. 38 C.F.R. § 4.1. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Although a review of the recorded history of a disability is necessary in order to make an accurate evaluation, see 38 C.F.R. §§ 4.2, 4.41 (1998), the regulations do not give past medical reports precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). Both the use of manifestations not resulting from service- connected disease or injury in establishing the service- connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. 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 disease and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. As regards the joints the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) Less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.). (b) More movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.). (c) Weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.). (d) Excess fatigability. (e) Incoordination, impaired ability to execute skilled movements smoothly. (f) Pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing and weight-bearing are related considerations. For the purpose of rating disability from arthritis, the shoulder, elbow, wrist, hip, knee, and ankle are considered major joints; multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities, the interphalangeal, metatarsal and tarsal joints of the lower extremities, the cervical vertebrae, the dorsal vertebrae, and the lumbar vertebrae, are considered groups of minor joints, ratable on a parity with major joints. The lumbosacral articulation and both sacroiliac joints are considered to be a group of minor joints, ratable on disturbance of lumbar spine functions. 38 C.F.R. § 4.45. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. Arthritis, degenerative (hypertrophic or osteoarthritis): Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, rate as below: With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, 20 percent. With X- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, 10 percent. Note (1): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive. Diagnostic Code 5003. The following diseases listed under diagnostic codes 5013 through 5024, respectively, Osteoporosis, with joint manifestations; Osteomalacia; Bones, new growths of, benign, Osteitis deformans, Gout, Hydrarthrosis, intermittent, Bursitis, Synovitis, Myositis, Periostitis, Myositis ossificans and Tenosynovitis will be rated on limitation of motion of affected parts, as arthritis, degenerative, except gout which will be rated under diagnostic code 5002. In exceptional cases where the schedular evaluations are found to be inadequate, an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities may be approved provided the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalizations as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). When a claimant is awarded service connection for a disability and subsequently appeals the RO's initial assignment of a rating for that disability, the claim continues to be well-grounded as long as the rating schedule provides for a higher rating and the claim remains open. Shipwash v. Brown, 8 Vet. App. 218, 224 (1995). In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that a claim such as the veteran's is properly framed as an appeal from the original rating rather than a claim for increase but that in either case the veteran is presumed to be seeking the maximum benefit allowed by law or regulations. In Fenderson it was held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder and that in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period, classified as "staged ratings". Analysis As a preliminary matter, the Board finds that the veteran's claim for an increased initial disability rating is well grounded. Shipwash v. Brown, 8 Vet. App. 218 (1995); Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is satisfied that all relevant facts have been properly developed to the extent possible and that no further duty to assist exists with respect to the claim. The veteran has been provided comprehensive evaluations in connection with the claim and other records have been obtained. In accordance with 38 C.F.R. §§ 4.1, 4.2 (1998), and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the medical records and other evidence of record pertaining to the history of the veteran's multiple joint pain. The Board has found nothing in the historical record that would lead to a conclusion that the current evidence of record is not adequate for rating purposes. Disability evaluations are based on the comparison of clinical findings to the relevant schedular criteria. 38 U.S.C.A. § 1155. The veteran's joint disorder is rated in accordance with the provisions found at 38 C.F.R. § 4.71a, Diagnostic Code 5003 that provides for ratings based upon joint group involvement or limitation of motion. The Board finds the selected rating scheme appropriate for the veteran's disability in view of the diagnosis and symptomatology. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992); 38 C.F.R. §§ 4.20, 4.21. The Board observes that the RO has assigned a 10 percent evaluation based upon the relevant criteria for pain on motion. The comprehensive examination in 1997 showed an appreciably symptomatic disorder but no limitation of motion. The relevant evidence shows VA outpatient evaluation of multiple joint complaints beginning in 1993 with the complaints referred to the hands, knees, neck, shoulders, elbows and hips primarily with varied intensity. On the VA examination in 1995 he mentioned joint pain in the knees, hips and fingers without swelling. The diagnosis was peripheral arthritis that was an inflammatory arthritis for which the exact mechanism was unknown. On reexamination in 1997 he complained of a worsening condition with more pain and swelling and the involved joints being the wrists, the elbows, the knees and the ankles. The pain varied in intensity. The examiner reported a normal range of motion of the major joints of the upper and lower extremities without joint line tenderness or crepitus. Muscle strength was 5/5 throughout and the veteran appeared neurologically intact. The examiner reported the x-ray findings of the various joints. The diagnosis was arthralgia, multiple joint involvement. Applying this information to the rating schedule criteria leads the Board to conclude that a higher evaluation is warranted. The nature of the symptoms, overall, appear to reflect more nearly what is contemplated in the corresponding 20 percent evaluation under Code 5003. The Board observes that limitation of motion is not per se an essential rating factor, and specific ranges of motion reported by examiner recently have not been reported herein as the examiner stated the ranges of motion were normal for the major joints. The principal factors are joint pain, tenderness, and their temporal presentation. The diagnosis of peripheral arthritis allows for rating under 5003 without the prohibition for a rating based on joint involvement that would apply for other disorders rated under Diagnostic Codes 5013-5024. The rating scheme applied does not require a mechanical application of the schedular criteria. Here, however, applying the rating schedule liberally results in a 20 percent evaluation. The schedular criteria are definitely adequate for rating the disability in view of the manifestations and applicable criteria. That is, extraschedular consideration for an evaluation in excess of 20 percent is not warranted. 38 C.F.R. § 3.321(b)(1) (1999). The evidence of probative value in view of the detailed description of pertinent evaluative criteria, viewed objectively, does not clearly preponderate against the claim for an increased initial rating and in essence establishes entitlement to the highest scheduler evaluation under Diagnostic Code 5003 without limitation of motion. It supports a conclusion that the veteran's disorder with all extremities affected by pain and weakness is nearly continuously present but not reported to be refractory to treatment. Essentially the disorder is accompanied by symptoms characteristic of the level of disability manifested by appreciable objective evidence of joint involvement without residual limitation of motion objectively shown at this time. Since the 20 percent evaluation is the highest rating available for multiple joint involvement without limitation of motion under Diagnostic Code 5003, consideration of a higher evaluation for pain under 38 C.F.R. § 4.40, 4.45 is not warranted. The level of disability does not appear to have been accounted for in the 10 percent evaluation, particularly in view of the objective symptoms shown most recently in light of the history reported to the examiner. The need for medication is noted but it is not reported that the use of medication does not alleviate the pain symptoms. There is no need for staged ratings as the Board finds the disability overall warrants a 20 percent rating for the entire period. ORDER The veteran not having submitted well grounded claims of entitlement to service connection for headaches, sleep disorder, respiratory disorder including sinusitis, hair loss, memory loss, blurred vision, lightheadedness and depression as due to an undiagnosed illness, the appeal is denied. Service connection for a skin rash due to an undiagnosed illness is granted. An increased initial rating of 20 percent for joint pain due to an undiagnosed illness is granted, subject to the regulations governing the payment of monetary awards. REMAND The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. The Board also observes that the veteran's claim of "chronic fatigue" reasonably raises an intertwined issue of service connection for chronic fatigue syndrome as described under 38 C.F.R. § 4.88a. A claimant is not required to precisely articulate all bases for entitlement. Here, however, the variety of symptoms complained of and the veteran's correspondence offer support for this development. Harris v. Derwinski, 1 Vet. App. 180 (1991), Akles v. Derwinski, 1 Vet. App. 118 (1991). If fatigue were attributed to a known clinical diagnosis, the provisions of § 3.317 would by its terms be inapplicable. The Board is of the opinion that any additional records of treatment that may have accumulated during the course of the appeal would materially assist in the adjudication of the intertwined issue. The veteran's due process rights also require that all pertinent laws and regulations be applied, and that he be given an adequate statement of reasons and bases for a decision refusing to fully grant the benefit he is seeking. 38 C.F.R. § 3.103 (1997); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Therefore, to ensure that he is afforded due process, 38 C.F.R. § 3.103(a), the Board is deferring adjudication of the issue of entitlement to compensation for fatigue due to an undiagnosed illness in a Persian Gulf War veteran pending a remand of the case to the RO for further development as follows: 1. The RO should request the veteran to identify the names, addresses, and approximate dates of treatment for all health care providers, VA or non-VA, inpatient or outpatient, who may possess additional records pertinent to his claims for chronic fatigue. After obtaining any necessary authorization or medical releases, the RO should request and associate with the claims file legible copies of the veteran's complete treatment reports from all sources identified which have not previously been secured. Regardless of the veteran's response, the RO should secure all outstanding VA treatment reports. 2. After undertaking any development deemed essential in addition to that specified above, the RO should adjudicate the intertwined issue of service connection for chronic fatigue syndrome to include a determination of whether the claim is well grounded. The RO should also readjudicate the issue of entitlement to service connection for fatigue due to an undiagnosed illness in a Persian Gulf War veteran with consideration of all applicable laws, regulations and VAOPGCPREC 4-99. If the benefit requested on appeal is not granted to the veteran's satisfaction, the RO should issue a Supplemental Statement of the Case. A reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for final appellate review, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. Mark J. Swiatek Acting Member, Board of Veterans' Appeals