Citation Nr: 9934800 Decision Date: 12/14/99 Archive Date: 12/16/99 DOCKET NO. 96-27 372A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for upper back pain, as a chronic disability resulting from an undiagnosed illness. 2. Entitlement to service connection for headaches, as a chronic disability resulting from an undiagnosed illness. 3. Entitlement to service connection for irritability, as a chronic disability resulting from an undiagnosed illness. 4. Entitlement to service connection for joint pain, as a chronic disability resulting from an undiagnosed illness. 5. Entitlement to service connection for muscle pain, as a chronic disability resulting from an undiagnosed illness. 6. Entitlement to service connection for abdominal pain, as a chronic disability resulting from an undiagnosed illness. 7. Entitlement to service connection for fatigue, as a chronic disability resulting from an undiagnosed illness. 8. Entitlement to service connection for dry skin, as a chronic disability resulting from an undiagnosed illness. 9. Entitlement to service connection for a sleep disorder, as a chronic disability resulting from an undiagnosed illness. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Fetty, Associate Counsel INTRODUCTION The veteran's military service includes active duty from February 1991 to October 1991, that encompassed service in Southwest Asia from March to September 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 1996 rating decision by the Department of Veterans Affairs (VA) Regional Office and Insurance Center (RO) in Philadelphia, Pennsylvania, which denied the veteran's claims listed on the first and second of this decision. The veteran timely appealed the determination to the Board. In June 1997, the veteran's claims folder was transferred to the Pittsburgh, Pennsylvania RO. FINDINGS OF FACT 1. The veteran had active duty in the Southwest Asia theater of operations during the Gulf War. 2. The veteran's allegation that she currently has objective manifestations of a chronic disability due to upper back pain, headaches and/or irritability is not supported by any medical evidence that would render the claims in regard to those complaints plausible. 3. The veteran has submitted some evidence that she currently has symptoms of joint pain, muscle pain, abdominal pain, fatigue, a skin condition and a sleep disorder as chronic disabilities which are related to an undiagnosed illness or illnesses; rendering her claims in this regard plausible. CONCLUSIONS OF LAW 1. The veteran has not submitted evidence of a well-grounded claim concerning service connection for upper back pain as a chronic disability resulting from an undiagnosed illness. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99 (May 3, 1999). 2. The veteran has not submitted evidence of a well-grounded claim concerning service connection for headaches as a chronic disability resulting from an undiagnosed illness. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99 (May 3, 1999). 3. The veteran has not submitted evidence of a well-grounded claim concerning service connection for irritability as a chronic disability resulting from an undiagnosed illness. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99 (May 3, 1999). 4. The veteran has submitted evidence of a well-grounded claim concerning service connection for joint pain as a chronic disability resulting from an undiagnosed illness. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99 (May 3, 1999). 5. The veteran has submitted evidence of a well-grounded claim concerning service connection for muscle pain as a chronic disability resulting from an undiagnosed illness. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99 (May 3, 1999). 6. The veteran has submitted evidence of a well-grounded claim concerning service connection for abdominal pain as a chronic disability resulting from an undiagnosed illness. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99 (May 3, 1999). 7. The veteran has submitted evidence of a well-grounded claim concerning service connection for fatigue as a chronic disability resulting from an undiagnosed illness. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99 (May 3, 1999). 8. The veteran has submitted evidence of a well-grounded claim concerning service connection for dry skin as a chronic disability resulting from an undiagnosed illness. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99 (May 3, 1999). 9. The veteran has submitted evidence of a well-grounded claim concerning service connection for a sleep disorder as a chronic disability resulting from an undiagnosed illness. 38 U.S.C.A. § 1117 (West 1991 and Supp. 1999); 38 C.F.R. § 3.317 (1999); VAOPGCPREC 4-99 (May 3, 1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In order to establish service connection for a disability, the evidence must show it resulted from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110, 1137 (West 1991); 38 C.F.R. § 3.303 (1999). A presumption of service connection may be warranted for certain chronic diseases that become manifested to a compensable degree within a prescribed period after separation from service, even though there is no record of the disease in service. The presumption of service connection is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1113, 1137 (West 1991 & Supp. 1999); 38 C.F.R. §§ 3.307, 3.309 (1999). Compensation may be paid 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," provided that such disability was manifest to a degree of 10 percent or more prior to December 21, 2001, and that it cannot, by history, physical examination, and laboratory tests be attributed to any known clinical diagnosis. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period should be considered chronic for purposes of adjudication. 38 U.S.C.A. § 1117 (West 1999); 38 C.F.R. § 3.317 (1999). Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to, neurologic signs or symptoms, neuropsychological signs or symptoms, fatigue, headaches, muscle or joint pain, or sleep disturbances. 38 C.F.R. § 3.317(b). "Objective indications" include both 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). In this regard, VA has stated that non-medical indicators of an illness may include evidence of time lost from work, evidence the veteran has sought medical treatment for his symptoms, and "[l]ay statements from individuals who establish that they are able from personal experience to make their observations or statements." See Compensation for Certain Undiagnosed Illnesses, 60 Fed. Reg. 6660, 6663 (1995). To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317. Claims of service connection for chronic disability resulting from Persian Gulf service (and due to an undiagnosed illness) are subject to the adjudicative procedures set forth in the Veterans Benefits Administration (VBA) Circular 20-92-29 (July 2, 1997). In essence, this publication directs an RO, in receipt of a veteran's claim, to complete all evidentiary development of the claim. With regard to nonmedical (lay) evidence, it is noted that records or reports of time lost from work, changes in physical appearance, changes in physical abilities, and changes in mental and emotional attitude are helpful in support of a Persian Gulf War claim. In addition, VBA All-Stations Letter 98-17 (2/26/98) contains mandatory guidelines for disability examinations of Gulf War veterans outlined in a memorandum dated February 6, 1998. In general, the guidelines require that VA examiners detail all conditions and symptoms that can be elicited from the veteran (including what precipitates and what relieves them). The examiner should then identify all diagnosed conditions arising from the symptoms, and also determine if there are symptoms, abnormal physical findings, or abnormal laboratory test results that are not part of a known clinical diagnosis. In that case, further specialist examinations are required to address these findings. The guidelines also state that symptom-based diagnoses, such as (but not limited to) myalgia, arthralgia, headache and diarrhea, are not considered as diagnosed conditions for compensation purposes The threshold legal question with respect to any claim for service connection is whether the veteran has met her initial burden of submitting evidence to show that the claim is well- grounded, meaning plausible. See 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). In the absence of a well-grounded claim, there is no duty to assist the claimant in developing the facts pertinent to the claim, and the claim must fail. See Slater v. Brown, 9 Vet. App. 240, 243 (1996); Gregory v. Brown, 8 Vet. App. 563, 568 (1996) (en banc); Grivois v. Brown, 6 Vet. App. 136, 140 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The veteran must generally satisfy three elements for each claim for service connection to be well grounded. First, there must be competent evidence of a current disability (a medical diagnosis). Second, there must be evidence of incurrence or aggravation of a disease or injury in service (medical evidence or, in some circumstances, lay evidence). Last, there must be evidence of a nexus or relationship between the in-service injury or disease and the current disorder, as shown by medical evidence. See Epps v. Gober, 126 F.3d 1464, 1468 (1997). The nexus requirement may be satisfied by evidence that a chronic disease subject to presumptive service connection manifested itself to a compensable degree within the prescribed period. See Traut v. Brown, 6 Vet. App. 495, 497 (1994); Goodsell v. Brown, 5 Vet. App. 36, 43 (1993). In the alternative, the chronicity provisions of 38 C.F.R. § 3.303(b) are applicable where the evidence, regardless of its date, shows that a veteran had a chronic condition in service, or during an applicable presumption period, and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded on the basis of 38 C.F.R. § 3.303(b) if the condition is observed during service or during any applicable presumption period, if continuity is demonstrated thereafter, and if competent evidence relates the present condition to that symptomatology. See Savage v. Gober, 10 Vet. App. 488, 498 (1997). The Board notes that special provisions with respect to well- groundedness apply to service connection claims arising from active service in Southwest Asia during the Persian Gulf War period. According to VAOPGCPREC 04-99, a well grounded service connection claim under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 requires some evidence of the following four elements: Active service in Southwest Asia during the Persian Gulf War period; manifestations of one or more signs or symptoms of undiagnosed illness; objective indications of chronic disability of 10 percent of more during the specified period; and lastly, a nexus between the chronic disability and the undiagnosed illness. VAOPGCPREC 04-99 further explains that evidence that the illness is "undiagnosed" may consist of evidence that the illness cannot be attributed to any known diagnosis, or, at a minimum, that the illness has not been attributed to a known diagnosis by physicians providing treatment or examination. The manifestations may be established by lay evidence if the evidence pertains to signs or symptoms ordinarily susceptible to identification by lay persons. The veteran's own testimony may also establish that the illness is chronic. Lay evidence may also be sufficient to establish a nexus between the chronic disability and the undiagnosed illness where that nexus is capable of lay observation. I. Upper Back Pain With regards to the claim for service connection for upper back pain, the Board notes that the veteran first reported upper back pain in June 1992, following some heavy lifting. The examiner found some tenderness and painful motion of the lumbar area, but did not mention the upper back. No diagnosis was given. In November 1992, the veteran was again seen for back pain. In February 1995, the veteran reported upper back pain since Southwest Asia in her claim for VA benefits. In October 1996, two lay witnesses corroborated the veteran's complaints of chronic aches and pains since her return from Southwest Asia. During her August 1997 hearing, she testified that her symptoms appeared after her return from the Persian Gulf War. An October 1997 VA joints examination report notes myalgia and chronic musculoskeletal pain, but does not specifically mention the upper back. Since the veteran submitted her February 1995 claim for service connection for upper back pain, neither she nor the evidence of record specifically mentions any further upper back pain. The Board therefore finds that a necessary element for well groundedness is absent, i.e., the claim lacks specific evidence of a chronic disability of 10 percent or more associated with upper back pain. See VAOPGCPREC 04- 99. Because a well-grounded claim has not been submitted, VA's duty to assist the veteran has not been invoked. Slater, 9 Vet. App. at 243 (1996). II. Headaches The first documented complaint of headaches is shown in the veteran's service medical records (SMR's) during active service in Southwest Asia. A June 1994 gynecology examination report notes complaint of headaches over the previous three years. No further record of headaches exists until the veteran filed her claim in February 1995. A June 1995 VA examination report does not note any complaint of headache. In October 1996, two lay statements concerning the veteran's headache complaints were submitted. The veteran testified that she continued to have headaches that she treated with aspirin. She reported that her private doctor had not rendered any diagnosis concerning the headaches. A VA mental disorders examination was given to determine whether any complaint might have had psychiatric basis. Although the veteran complained of continued headaches during that examination, the VA psychiatrist did not offer a diagnosis. In October 1997, a VA neurologist suggested that the headaches might be migraine, but offered no diagnosis. The Board finds that the claim for service connection for headaches is not well grounded. VAOPGCPREC 04-99. The evidence does not reflect a chronic disability of 10 percent or more. Under 38 C.F.R. § 4.124a, Diagnostic Code 8100, migraine headaches (or any other headache rated under this code) with characteristic prostrating attacks averaging one in two months over the last several months warrants a 10 percent rating. Attacks that are less frequent or less severe do not warrant a compensable rating. Because the veteran's headaches are not shown to cause any impairment equivalent to that required for a minimum compensable rating, the Board finds that the claim for service connection for headaches, claimed as due to undiagnosed illness, is not well grounded. III. Irritability The evidence of record pertinent to the claim for service connection for irritability includes the February 1994 Persian Gulf registry report that notes that the veteran reported irritability, among other symptoms. In her February 1995 claim, she again mentioned irritability, reporting that all symptoms appeared after returning from the Persian Gulf War. The October 1996 lay statements mention irritability. However, an October 1997 VA mental disorders examination report notes that the veteran specifically denied that she had irritability or difficulty controlling her temper. She described herself as a calm person who got along with others. She reported only that the usual frustrations made her irritable. In view of the veteran's recent admission where she denied any symptoms of irritability outside of life's normal frustrations, the Board finds that the claim lacks a necessary element for well groundedness i.e., evidence of a chronic disability of 10 percent or more associated with irritability during the specified period. Simply put, the veteran does not have symptoms of irritability as a chronic disability. Therefore her claim in this regard is considered not well grounded. IV. Joint Pain With regards to the veteran's claim for service connection for joint pain, the Board notes that an August 1994 VA clinical report reflects complaints of low back and neck pain since return from Southwest Asia. The veteran mentioned joint pain in her February 1995 claim for VA benefits. In June 1995, a VA examiner gave a diagnosis of stiff neck and stiffness over the interscapular region. A private medical report in March 1996 notes diffuse joint complaints and right knee pain and crepitus. The examiner, Dr. Guy, offered a diagnosis of patella femoral syndrome for the knee. In October 1996, two lay witnesses reported that the veteran had complaints of joint pain, among others, since her return from Southwest Asia. During her August 1997 hearing, she testified that her joint pain compliant included her shoulders and her back. In October 1997, a VA neurology examiner and a VA joints examiner noted complaint of chronic neck and shoulder stiffness and lower back stiffness. Tenderness in the occipital, trapezius, and lower lumbar spine area were noted in the joints examination report and an assessment of myalgia and chronic musculoskeletal pain was given. In June 1998, Dr. Guy opined that the veteran's symptoms might well be related to active service. Here, the veteran has submitted evidence of active service in Southwest Asia. She has submitted evidence of one or more signs or symptoms of undiagnosed illness. The Board accepts her continued complaint of neck, shoulder, and lower back stiffness as evidence of undiagnosed illness and as an objective indication of a chronic disability of 10 percent of more during the period. (Noting that a diagnosis of stiff neck and stiffness over the interscapular region was made by a VA examiner in June 1995, the Board finds that this is a "symptom based diagnosis" as addressed in VBA All-Stations Letter 98-17. It will therefore not be considered as a diagnosed condition for compensation purposes.) The Board also finds that nexus evidence has been submitted. Dr. Guy reported that the veteran's symptoms may well be related to her Persian Gulf War service and, because VAOPGCPREC 04-99 allows lay evidence of a nexus where that nexus is capable of lay observation, the veteran's own testimony is also accepted as nexus evidence to well ground the claim. Under these circumstances, the Board finds that the claim for service connection for joint pain claimed as due to undiagnosed illness is well grounded. V. Muscle Pain With regards to the claim for service connection for muscle pain, the Board notes that the veteran first mentioned muscle pain in her February 1995 claim for VA benefits. In October 1996, two lay witnesses corroborated the veteran's complaints of chronic aches and pains since her return from Southwest Asia. During her August 1997 hearing, she testified that her symptoms appeared after her return from the Persian Gulf War. An October 1997 VA joints examination report notes myalgia and chronic musculoskeletal pain. In June 1998, Dr. Guy felt that the veteran's complaints of severe fatigue and muscle aches might be related to her exposure to chemicals in Southwest Asia. As in the analysis above, the veteran had active service in Southwest Asia during the Persian Gulf War. The Board also accepts her continued complaints of muscle pain as evidence of undiagnosed illness and as an objective indication of a chronic disability of 10 percent of more during the period. Moreover, Dr. Guy suggested a link between these complaints and the veteran's Gulf War service. Thus, the claim for service connection for muscle pain claimed as due to undiagnosed illness is well grounded. VI. Abdominal Pain A service medical record (SMR) dated in August 1990 indicates abdominal pain associated with menstrual cramps and complaint of stomach pain and stress/nervousness surrounding the death of a friend. Continued complaint of abdominal and menstrual cramps was again noted in the SMR's during 1991 and 1992. A November 1992 VA echogram for possible ovarian cyst was negative and a December 1992 VA report notes an assessment of abdominal pain of questionable etiology. A February 1994 VA Persian Gulf registry examination report was negative for any complain of abdominal pain; however, a June 1994 VA gynecology consultation report notes complaint of dysmenorrhea (painful menstruation, due to various pathologies, Dorland's Illustrated Medical Dictionary 516 (28th ed. 1994)), over the previous three years. The gynecology examination report itself was negative. The veteran next mentioned abdominal pain in her February 1995 claim for VA benefits. During a June 1995 VA general medical examination, she reported sharp abdominal pain and reported that she developed severe cramps around her menstrual period. The examiner offered several diagnoses, including dysmenorrhea. The examiner also reported that the cluster of reported symptoms suggested Persian Gulf symptoms and that a final conclusion [concerning the etiology] could not be made. In June 1995, a VA stomach examination report notes essentially the same findings. In October 1996, two lay witnesses corroborated the veteran's complaints of chronic aches and pains since her return from Southwest Asia. During her August 1997 hearing, the veteran testified that abdominal pain began in June 1992. A November 1997 VA gynecological examination report notes complaint of cramping and abdominal pain. The examiner noted that the right lower quadrant was tender. The diagnoses were dysmenorrhea, right lower abdominal pain, and back pain with no obvious gynecological source. Endometriosis was mentioned as a possible etiology, although it was felt to be unlikely. A January 1997 report notes several weeks of mid epigastric pain felt to represent classic peptic ulcer disease. Prilosec was prescribed and no further peptic ulcer symptoms were noted. The Board finds evidence of a well-grounded claim for service connection for abdominal pain claimed as due to an undiagnosed illness. The veteran has the requisite service, as well as evidence of a chronic undiagnosed illness in this regard. Although some records suggest known clinical entities to account for the veteran's complaints, other records do not. Thus, the claim for service connection for abdominal pain as a chronic disability resulting from an undiagnosed illness is considered well grounded. VII. Fatigue The Board notes that although the veteran underwent several medical evaluations, only one diagnosis related to fatigue was given. That diagnosis consisted of "symptoms suggestive of chronic fatigue syndrome." The Board finds that this is essentially a symptoms based diagnosis, such as mentioned in VBA All Stations Letter 98-17. Moreover, the examiner who provided that diagnosis further expressed a possible direct relationship between active Persian Gulf service and the symptoms. The examiner also reported "Final conclusion cannot be made," which further leads the Board to believe that the examiner did not intend the diagnosis to be dispositive. Other lay statements from the veteran's family indicate that the veteran had multiple health complaints, such as tiredness, upon returning from Southwest Asia. The veteran testified that she noticed that her symptoms appeared shortly after returning from Southwest Asia. An October 1997 VA mental disorders examination report notes that the veteran was being examined to determine whether any of her post Southwest Asia health complaints could be related to any psychiatric illness. During the examination, she complained of fatigue and headaches; however, neither an Axis I diagnosis nor any other etiology was offered. An April 1998 private medical report notes complaint of diffuse fatigue and lethargy and a number of vague complaints. The examiner noted that the veteran's lethargy could be caused by her allergies; however, no diagnosis was given. In June 1998, Dr. Guy reported that he had treated the veteran since January 1995 and noted her complaints of severe fatigue and muscle aches. Dr. Guy expressed his belief that those symptoms "may well be related to exposure to chemical agents in Operation Desert Storm." In August 1998, the veteran's representative reported that the veteran had lost excessive amounts of time from her job because of her undiagnosed fatigue syndrome. Here, the veteran has submitted evidence of active service in Southwest Asia, and evidence of continued complaints of fatigue as evidence of an undiagnosed illness productive of a disability of 10 percent of more. Moreover, a VA doctor and a private doctor have both suggested a nexus between the condition and service in Southwest Asia. Under these circumstances, the Board finds this claim well grounded. VIII. Dry Skin Regarding this claim, the Board notes that the veteran's SMRs contain evidence of treatment for skin conditions prior to deployment to Southwest Asia. Diffuse discrete ulcerated maculopapular lesions over the feet and arms were noted in 1990; however, the assessment was status post insect bites. Thus, this report does not appear to be related to later complaints of dry skin. In June 1992, a painful nodule on the head was found; however, again this does not appear to be related to complaint of dry skin. A March 1994 VA dermatology consultation report notes dry red scaly skin of the arms, felt to be asteatotic eczema; however, no diagnosis was given. In February 1995, the veteran submitted a claim for dry skin, among others and indicated that all symptoms seemed to have begun after returning from Desert Storm. During a June 1995 VA general medical examination, the veteran reported that she had developed skin rashes on both upper and both lower extremities. The examiner reported that the skin lesions resembled chronic folliculitis. They were visible on the upper and lower extremities and on the face. Red sores on the tongue were also noticed. The examiner offered the following diagnosis: generalized skin rashes of both upper and lower extremities. The examiner reported that the symptoms suggested Persian Gulf syndrome, if that existed. The examiner then reported "Final conclusion cannot be made." A June 1995 VA skin examination report contains a diagnosis of chronic folliculitis of both upper extremities, and sore- like lesions on the upper surface of the tongue. An October 1997 VA skin examiner described skin problems on the veteran's arm and foot. This person offered two diagnoses, keratosis pilaris (hyperkeratosis, usually on the thighs and arms, but occurring anywhere, with discrete follicular papules that reform after removal, Dorland's Illustrated Medical Dictionary 880 (28th ed. 1994)) and clavi (from clavicipitales, an order of fungi, Dorland's Illustrated Medical Dictionary 339 (28th ed. 1994)). The examiner noted that the keratosis could be treated with moisturizer and that decreased wearing of boots could prevent the clavi. A June 1997 private examination report notes that the rash on the backs of the arms appeared to be keratosis pilaris. An April 1998 report notes that the examiner prescribed Tetracycline for skin problems, thought to be acne rosacea or perioral dermatitis. In view of the varying diagnoses relating to a skin disorder, but which did include at least a tentative opinion that the condition could be linked to the veteran's Gulf War service, the Board finds this claim well grounded. IX. Sleep Disorder A February 1994 VA Persian Gulf registry preliminary evaluation report indicates that the veteran reported that she required from 30 to 60 minutes to fall asleep. An Axis I diagnostic impression of rule out insomnia disorder was made. The veteran's service connection claim filed in February 1995 mentions sleep disorder. During her June 1995 VA general medical examination, she reported insomnia and the examiner offered a diagnosis of insomnia. Lay witnesses reported the veteran's complaint of trouble falling asleep. The veteran testified that her private physician had given her medication for sleeping. She reported sleep disturbance during her October 1997 VA mental disorders examination; however, no diagnosis was made. In determining well groundedness, the Board notes that the requisite evidence has been submitted. The veteran has submitted evidence of qualifying service in Southwest Asia, lay evidence of symptoms of sleep disorder manifested by trouble falling asleep or insomnia, and lay evidence of use of medication to aid in sleep as evidence of undiagnosed illness. She has also submitted evidence of a chronic disability of 10 percent of more during the period. [Under 38 C.F.R. § 4.130, the general rating formula for mental disorders, a 10 percent rating is warranted for mild or transient symptoms causing a decrease in work efficiency only during periods of significant stress.] The Board therefore finds that the claim for service connection for sleep disorder is well grounded. ORDER 1. Entitlement to service connection for upper back pain as a chronic disability resulting from an undiagnosed illness is denied. 2. Entitlement to service connection for headaches as a chronic disability resulting from an undiagnosed illness is denied. 3. Entitlement to service connection for irritability as a chronic disability resulting from an undiagnosed illness is denied. 4. The claim of entitlement to service connection for joint pain as a chronic disability resulting from an undiagnosed illness is well grounded. To this extent only, the appeal is granted. 5. The claim of entitlement to service connection for muscle pain as a chronic disability resulting from an undiagnosed illness is well grounded. To this extent only, the appeal is granted. 6. The claim of entitlement to service connection for abdominal pain as a chronic disability resulting from an undiagnosed illness is well grounded. To this extent only, the appeal is granted. 7. The claim of entitlement to service connection for fatigue as a chronic disability resulting from an undiagnosed illness is well grounded. To this extent only, the appeal is granted. 8. The claim of entitlement to service connection for dry skin as a chronic disability resulting from an undiagnosed illness is well grounded. To this extent only, the appeal is granted. 9. The claim of entitlement to service connection for a sleep disorder as a chronic disability resulting from an undiagnosed illness is well grounded. To this extent only, the appeal is granted. REMAND Because the claims of entitlement to service connection for symptoms of joint pain, muscle pain, abdominal pain, fatigue, a skin condition and a sleep disorder as chronic disabilities which are related to an undiagnosed illness or illnesses are well grounded, VA has a duty to assist the appellant in developing facts pertinent to the claims. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.159 (1999); Murphy v. Derwinski, 1 Vet. App. 78 (1990). VBA All-Stations Letter 98-17 (2/26/98) contains mandatory guidelines for disability examinations of Gulf War veterans outlined in a memorandum dated February 6, 1998. In general, the guidelines require that VA examiners detail all conditions and symptoms that can be elicited from the veteran (including what precipitates and what relieves them). The examiner should then identify all diagnosed conditions arising from the symptoms, and also determine if there are symptoms, abnormal physical findings, or abnormal laboratory test results that are not part of a known clinical diagnosis. In that case, further specialist examinations are required to address these findings. In this case, the record does not appear to contain an examination report that comports to the guidelines for conducting examinations of Gulf War veterans as set forth above. (Indeed, the VA examinations which took place in the veteran's case, all occurred prior to the issuance of those guidelines.) In view of this, the veteran should be scheduled for another examination to properly evaluate her claims for service connection, as detailed below. Under the circumstances described above, this case is remanded to the RO for the following: 1. The RO should obtain the names and addresses of any medical care providers who have treated the veteran for her joint pain, muscle pain, abdominal pain, fatigue, dry skin and sleep problems since her discharge from service, and which have not already been associated with the claims file. After securing any necessary releases, the RO should obtain these records and permanently associate them with the claims file. 2. Upon completion of the above development, the RO should schedule the veteran for VA examinations that address disabilities relating to the joints, the muscles, the abdomen, the skin, fatigue, and sleep disorders. The veteran and her representative should be notified of the date, time, and place of the examinations in writing. The claims folder must be made available to and be reviewed by the examiners prior to the examinations and any specialist examinations should be conducted if indicated. The physician or physicians conducting these examinations should note and detail all reported symptoms related to joint pain, muscle pain, abdominal pain, fatigue, the skin and sleep problems, as well as information about the onset, frequency, duration and severity of all complaints. He or she should indicate what precipitates these complaints, and what relieves them. The examiner should also indicate whether there are objective medical indications that the veteran is suffering from joint pain, muscle pain, abdominal pain, fatigue, dry skin, and a sleep disorder. Moreover, the specific joints and muscles about which any complaints are made should be identified, as well as the specific location of any skin complaints. Then an opinion should be entered with respect to each joint about which complaints are made, as to whether it is at least as likely as not that it is attributable to a known diagnostic entity. Similarly an opinion should be entered with respect to each muscle about which complaints are made, as to whether it is at least as likely as not that it is attributable to a known diagnostic entity. Likewise, an opinion should be entered as to whether any abdominal pain, fatigue complaints, and sleep disorder is at least as likely as not attributable to a known diagnostic entity, and whether any skin disorder present is at least as likely as not attributable to a known diagnostic entity. All opinions expressed should be supported by reference to pertinent evidence. 3. Upon receipt, the RO should review the examination reports to ensure that they are adequate for rating purposes. If an examination is inadequate for any reason, the RO should return the examination report to the examining physician(s) and request that all questions be answered. 4. Following the completion of the foregoing, the RO should review the issues of entitlement service connection for joint pain as a chronic disability resulting from an undiagnosed illness; muscle pain as a chronic disability resulting from an undiagnosed illness; abdominal pain as a chronic disability resulting from an undiagnosed illness; fatigue as a chronic disability resulting from an undiagnosed illness; dry skin as a chronic disability resulting from an undiagnosed illness; and a sleep disorder as a chronic disability resulting from an undiagnosed illness. If any determination remains unfavorable to the veteran, she and her representative should be provided with a supplemental statement of the case that addresses all evidence added to the record since the last supplemental statement of the case was issued in November 1998. After providing the veteran and her representative the appropriate time in which to respond, the case should then be returned to the Board for further review if otherwise in order. The veteran need take no action until otherwise notified, but she may furnish additional evidence and argument while these issues are in remand status. Kutscherousky v. West, 12 Vet. App. 369 (1999). The purpose of this remand is to ensure due process and fully develop the claims. No inference should be drawn regarding the final disposition of the veteran's claims as a result of this action. 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. MICHAEL E. KILCOYNE Acting Member, Board of Veterans' Appeals