Citation Nr: 0013604 Decision Date: 05/23/00 Archive Date: 05/30/00 DOCKET NO. 98-12 230A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for memory loss/attention problems due to an undiagnosed illness. 2. Entitlement to service connection for a skin disorder due to an undiagnosed illness. 3. Entitlement to service connection for swollen lymph nodes, hair loss, weight/fluid gain/metabolic change, and fatigue due to an undiagnosed illness. 4. Entitlement to service connection for allergic rhinitis, claimed as upper respiratory problems due to an undiagnosed illness. 5. Entitlement to service connection for fibromyalgia/arthritis affecting the shoulders, elbows, wrists, hands, ankles, knees, and back, claimed as muscle/joint pain due to undiagnosed illness. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Valerie E. French, Associate Counsel INTRODUCTION The veteran served on active duty from September 1990 to June 1991. He served in the Persian Gulf in support of Operation Desert Storm. This appeal arises before the Board of Veterans' Appeals (Board) from a July 1997 rating decision of the New Orleans, Louisiana, Regional Office (RO) of the Department of Veterans Affairs (VA). FINDINGS OF FACT 1. The veteran has memory loss and attention problems which are not attributable to a psychological etiology or any known clinical diagnosis. 2. The veteran's skin symptomatology has been variously diagnosed as hemangiomas, lentigines, actinic keratoses, and tinea corporis, and there is no evidence attributing these disorders or the manifestations thereof to an undiagnosed illness. 3. Competent objective indications of a chronic disability associated with the veteran's complaints of swollen lymph nodes, nipple swelling, weight gain, fluid gain, and metabolic change have not been presented. 4. Competent objective indications of a chronic fatigue disability have not been presented. 5. There is no competent evidence attributing hair loss to a disability, disease, or illness. 6. The veteran's allergy and upper respiratory problems have been diagnosed as allergic rhinitis, and there is no evidence attributing allergic rhinitis or the manifestations thereof to an undiagnosed illness. 7. Joint and muscle pain in the arms, hands, shoulders, elbows, knees, and back has been variously diagnosed as arthritis, degenerative joint disease, multiple arthralgias, and fibromyalgia, and there is no evidence attributing joint and muscle pain in these areas to an undiagnosed illness. CONCLUSIONS OF LAW 1. Memory loss/attention problems due to an undiagnosed illness were incurred during the veteran's period of active service. 38 U.S.C.A. §§ 1110, 1117, 5107(a) (West 1991); 38 C.F.R. § 3.317 (1999). 2. The claim for service connection for a skin disorder due to an undiagnosed illness is not well grounded. 38 U.S.C.A. §5107(a) (West 1991); 38 C.F.R. § 3.317 (1999). 3. The claim for service connection for swollen lymph nodes, hair loss, fatigue, weight gain/fluid gain, and metabolic change due to an undiagnosed illness is not well grounded. 38 U.S.C.A. §5107(a) (West 1991); 38 C.F.R. § 3.317 (1999). 4. The claim for service connection for allergic rhinitis, claimed as sinus problems and an upper respiratory disorder due to an undiagnosed illness, is not well grounded. 38 U.S.C.A. §5107(a) (West 1991); 38 C.F.R. § 3.317 (1999). 5. The claim for service connection for fibromyalgia and arthritis of multiple joints, claimed as muscle/joint pain in the ankles, shoulders, elbows, hands, knees, and back due to an undiagnosed illness, is not well grounded. 38 U.S.C.A. §5107(a) (West 1991); 38 C.F.R. § 3.317 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran contends that he has various medical disorders which are related to "Gulf War syndrome." The DD Form 214 shows Persian Gulf service from January 1991 to April 1991. In his initial service connection claim, the veteran claimed benefits for dizziness, vertigo, nausea, headaches, and pressure/ringing in the ear. In January 1995, service connection was granted for residuals of viral labyrinthitis, to include tinnitus in the left ear. The above-noted symptomatology has been considered in conjunction with the assignment of a disability evaluation for residuals of labyrinthitis, and thus, these symptoms have not been considered with regard to the veteran's claim for various disabilities claimed as due to an undiagnosed illness. See 38 C.F.R. § 4.14 (1999). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110 (West 1991). Service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). In making a claim for service connection, the appellant has 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). A well-grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). A well-grounded claim for service connection generally requires medical evidence of a current disability; evidence of incurrence or aggravation of a disease or injury in service as provided by either lay or medical evidence, as the situation dictates; and, a nexus, or link, between the inservice disease or injury and the current disability as provided by competent medical evidence. Caluza v. Brown, 7 Vet. App. 498 (1995); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998). Alternatively, the nexus between service and the current disability can be satisfied by evidence of continuity of symptomatology and medical or, in certain circumstances, lay evidence of a nexus between the present disability and the symptomatology. See Savage v. Gober, 10 Vet. App. 488, 495 (1997). Establishing direct service connection for a disability that was not clearly present in service requires the existence of a current disability and a relationship or connection between that disability and a disease contracted or an injury sustained during service. Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Moreover, establishing a well-grounded claim for service connection for a particular disability requires more than an allegation that the particular disability had its onset in service. It requires evidence relevant to the requirements for service connection cited above and of sufficient weight to make the claim plausible and capable of substantiation. Tirpak v. Derwinski, 2 Vet. App. 609 (1992); see also Murphy, id. at 81. 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 § 3.317 may be service connected, provided that such disability 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 by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (a)(1) (1999). For purposes of § 3.317, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, nonmedical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(2) (1999). For the purposes of Section 3.317, signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurological 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; and (13) menstrual disorders. 38 C.F.R. § 3.317(b) (1999). Disabilities which 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. 38 C.F.R. § 3.317 (a) (3) (1999). A well grounded claim for disability due to an undiagnosed illness suffered by a veteran of the Persian Gulf War under 38 U.S.C.A. § 1117 (a) and 38 C.F.R. § 3.317 generally requires the submission of some evidence of (1) active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; (2) the manifestation of one or more signs or symptoms of undiagnosed illness; (3) objective indications of chronic disability during the relevant period of service or to a degree of disability of 10 percent or more within the specified presumptive period; and (4) a nexus between the chronic disability and the undiagnosed illness. With respect to the second and fourth elements, evidence that the illness is "undiagnosed" may consist of evidence that the illness cannot be attributed to any known diagnosis or, at minimum, evidence that the illness has not been attributed to a known diagnosis by physicians providing treatment or examination. Whether medical or lay evidence is required for these elements depends of the nature of the claim. For purposes of the second and third element, the manifestation of one or more signs or symptoms of undiagnosed illness or objective indications of chronic disability may be established by lay evidence if it is of the type ordinarily susceptible to lay observation. VAOPGCPREC. 4-99 (1999). The Board notes that in December 1998, the RO requested treatment records from the Ochsner Clinic of Baton Rouge, for the period of April 1996 to the present. In addition, the RO scheduled the veteran for rheumatology, dermatology, and neuropsychiatric examinations at the New Orleans RO in December 1998. The record indicates, however, that the veteran called to indicate that he could not come to New Orleans for any examinations and it was explained to him that some examinations had to be completed in New Orleans due to the specialists required. The veteran agreed that he would complete as many of the examinations as he could at the Baton Rouge VA outpatient clinic. Thereafter, the dermatology, rheumatology, and neuropsychiatric examinations were canceled and a subsequent examination was conducted at the Baton Rouge facility. The Board finds that no further evidentiary development is required prior to adjudication of the claims on appeal, and the record shows that the RO informed the veteran of the need for evidence of chronic, current disability with regard to all of the service connection claims based on his Persian Gulf service. See rating decision (July 1997), Statement of the Case (July 1998) and Supplemental Statement of the Case (April 1999). The Board also finds that the RO informed the veteran of the necessary evidence to support his claim in accordance with 38 U.S.C.A. § 5103 (West 1991); 38 C.F.R. § 3.103 (1999). Furthermore, the RO's attempts to obtain additional private treatment records and additional examination findings were unsuccessful. The veteran has not reported that any other pertinent evidence might be available. Evidence The report of a November 1988 Army Reserve medical examination shows that myopic astigmatism was the only noted abnormality. The November 1988 report of medical history shows that medications included topical Rogaine for hair loss. Service medical records include a January 1991 sick slip which shows that due to injury, the veteran was put on profile with no heavy lifting, and no squats, deep knee bends, or running. The nature of the injury is not noted. A February 1991 sick slip shows that the veteran was put on profile with no lifting or use of upper extremities for the next 72 hours. The nature of the injury is not noted. Beginning in March 1991, the veteran was treated for complaints of dizzy spells and loss of equilibrium, and subsequent complaints included ringing in the left ear, extreme fatigue, weakness, weight gain, and headache. Assessments included possible prolonged viral syndrome and labyrinthitis, probably viral origin, causing vertigo. An April 1991 discharge summary shows that the veteran had been evacuated from Saudi for further medical treatment for the diagnosis of viral labyrinthitis. The May 1991 separation examination report shows that with the exception of findings of cerumen in the ears and a notation of his history of labyrinthitis and vertigo, all major systems were clinically evaluated as normal. No defects were noted with regard to the sinuses, skin, spine, or lower extremities. Weight was recorded as 190 pounds. On a Demobilization/Redeployment questionnaire, dated May 1991, the veteran gave a history of fatigue, weight loss, swelling of lymph nodes, and a rash, skin infection, or sores during his Persian Gulf service. On a May 1991 report of medical history, he gave a positive history for swollen or painful joints, frequent or severe headache, dizziness or fainting spells, ear, nose, or throat trouble, hay fever, skin diseases, broken bones, weight gain, and recurrent back pain. He also reported swelling in the chest. The record includes reports of private medical treatment at the Ochsner Clinic in Baton Rouge, for the period of 1992- 1996. In August 1992, findings included a circular erythematous lesion on the right forearm and several hemangiomas and lentigines. In December 1992, an assessment of patellofemoral syndrome was provided after he complained of chronic knee pain. A March 1993 podiatry report shows the following impressions: pes planus foot morphology maybe contributing to chondromalacia patella through a valgus torque creating an increase in the functional genu valgum, and chondromalacia patella, right leg, secondary to stress injury 4-5 years before. A November 1993 treatment note shows impressions which included chondromalacia patella, right leg, aggravated by foot mechanics and muscle atrophy; and low back discomfort. In March 1994, findings included a reddish patch on the right forearm, with assessments of allergic rhinitis and tinea corporis. In May 1994, skin testing was positive for various allergen sensitivities, at which time the veteran began undergoing immunotherapy An August 1994 treatment record shows the impressions of functional equinus with possible talonavicular joint degenerative joint disease, chondromalacia patella, and low back discomfort. On VA examination for Persian Gulf Registry purposes in June 1994, all major systems were clinically evaluated as normal and with the exception of a notation of reddened mucosa with regard to the nose, findings were negative. On VA general medical examination in August 1994, complaints included fatigue and intermittent right knee pain. Skin examination was negative, as was examination of the head, face, and neck. On examination of the lymphatic and hemic systems, there was no adenopathy. Respiratory, digestive, genitourinary, neurological, and endocrine systems were negative. There was full range of motion in the lumbar spine. In the shoulders, there was full range of motion and movements were made with pain. There was no swelling, tenderness, instability, or limitation of motion in the right knee. Diagnoses included injury, right knee; chronic bilateral shoulder pain; and back injury, no complaints at this time. An October 1994 VA medical record shows an impression of lytic lesion, left proximal humerus. Private medical records show in that in October 1994, the veteran wanted to discuss problems he had experienced since returning from the Persian Gulf war. He contended that he was exposed to toxic biological or chemical agents from the destruction of enemy supplies while in the Persian Gulf. With regard to the shoulders, a May 1995 VA treatment record shows that impressions included impingement syndrome, right greater than left, and lytic lesion, left proximal humerus. A January 1996 VA medical record shows complaints of pain in all joints with an assessment of arthritis. In August 1996, assessments of labyrinthitis and arthralgia, multiple "illegible" were provided. On Rheumatology consultation in August 1996, the veteran reported pain in his ankles, elbows, shoulders, back, and finger. Findings included actinic keratoses on the arms. An impression of probable degenerative joint disease is shown. In December 1996, an assessment of arthritis, multiple joints, is shown. A March 1996 private medical record shows that the veteran presented with a 3-4 week history of pruritic rash on the genital area, with an assessment of tinea cruris with possible monilia dermatitis. On VA psychological evaluation in June 1996, the veteran scored below the norms for his age group for immediate memory and delayed recall for verbal and visual material as well as testing scores indicated attentional deficits. His clinical profile suggested that he was experiencing a number of somatic complaints. DSM-IV diagnoses included the following: Axis I, adjustment disorder with anxiety; Axis II, diagnosis deferred, and a Global Assessment of Functioning (GAF) of 68 was assigned. The examiner commented that the multiple somatic symptoms and his problems with memory and attention were not present before the veteran was deployed overseas; that there was no evidence of a psychotic disorder or somatic disorder which might suggest a that these symptoms are a function of emotional distress and have a psychological etiology; and that there was no indication that these symptoms were a reaction to life stressors. It was also noted that these symptoms seemed to fit the constellation of symptoms called the "gulf war syndrome." On VA general medical examination in May 1995, the skin was normal, with no lesions and rashes. The breast had no nipple swelling and no tenderness and there was no gynecomastia. The head, face, and neck were normal, as were the nose, sinuses, mouth, and throat. Respiratory system examination revealed the lungs to be clear. On examination of the musculo-skeletal system, no disease, injuries, or scars were found, and there was no joint swelling or deformity or muscle wasting. A diagnosis of normal physical exam is shown. The record includes lay statements, dated in September 1996, in which several of the veteran's fellow servicemen indicated that they had served with the veteran on active duty. The lay witnesses each stated that it was known that the veteran suffered from various physical problems related to Persian Gulf Service, to include, but not limited to, dizzy spells, vertigo, ringing in the ears, joint pain restricting movement, severe allergic reaction symptoms, and chronic fatigue. All of these lay witnesses indicated that they knew the veteran prior to his service in the Persian Gulf War and from all indications, he was in perfect health at that time. In October 1998, the veteran was afforded a hearing before a local officer at the New Orleans RO. He testified that his memory problems and attention problems began shortly following his Persian Gulf service. In addition, the veteran stated that shortly after returning from Saudi, he began to see spots on his forearms, his neck, and his face, for which a civilian doctor told him to stay out of the sun. The veteran further testified that shortly after his discharge, he began to notice joint pains in the shoulders, elbows, ankles, knees, wrists, and back which had since gotten worse. He described a swollen lymph node under his arm pit when he was in the service, and with no current swelling although the nodes still pained him. The veteran reported that prior to going to Saudi, he was taking medication for hair loss and the hair loss had increased since his return. According to the veteran, during his in-service hospitalization he slept 19 hours a day and he put on a lot of weight (going from approximately 178 to 200 pounds), either as a result of eating or fluid gain, and then he had a terrible time getting the weight off, due to changes in his metabolism. He stated that he was currently slightly overweight at 183. The veteran also indicated that he was hospitalized during service for a diagnosis of viral labyrinthitis, at which time he also had fatigue. During the past year, he had made a little progress with the fatigue which was now a lot better than when he was hospitalized. The veteran reported that prior to going to Saudi Arabia, he had undergone allergy injections for a period of 2 to 3 years for a dust mite allergy. Following that treatment, he had no more problems for approximately four years, until he returned from Saudi. For the past 3 years, he had unsuccessfully undergoing allergy shots. On VA examination in January 1999, the veteran complained of joint pain in areas including his knees, ankles, shoulders, back, and elbows. He appeared to be in moderate chronic distress and at times he was somewhat tremulous. He felt the ophthalmoscope light to be very irritating and otherwise, the cranial nerves were normal. Heel and tandem gait were difficult to perform because of ankle and knee pain. Strength, tone, muscle bulk, coordination, and sensation were normal. Reflexes were symmetric at 2/4 and normal. The examiner provided an impression that the veteran appeared to have symptoms that could be loosely termed as fibromyalgia, as well as additional symptoms of photophobia regarding his skin. Aside from diagnoses of fibromyalgia and labyrinthitis of his ear, no other specific diagnosis was apparent. Memory loss/attention deficit Having reviewed the record, the Board is of the opinion that service connection is warranted for memory loss/attention problems due to an undiagnosed illness. The veteran has reported that he has experienced problems with memory loss and an attention deficit since returning from Persian Gulf service. The veteran is competent to report that on which he has personal knowledge, or what comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Thus, there is evidence of the manifestation of a sign or a symptom of an undiagnosed illness during the applicable presumptive period. In addition, the record includes the report of a VA psychologist, who indicated that the veteran currently has memory and attention problems and there is no evidence of a psychotic disorder or a somatic disorder which might suggest that these symptoms are related to a psychological etiology. As such, the currently manifested memory loss and attention problems are not attributable to a known clinical diagnosis. For these reasons, the Board finds that the preponderance of the evidence weighs in favor of the veteran's claim, and service connection is granted for memory loss and attention problems due to an undiagnosed illness. The Board notes that in its adjudication of the veteran's service connection claims, the RO included the issue of adjustment disorder with anxiety, which was diagnosed at the time of the veteran's 1996 VA examination. There is no evidence that an adjustment disorder with anxiety is related to the veteran's period of active service, either generally or as due to an undiagnosed illness, nor has the veteran claimed that service connection is warranted therefor. Service connection for hemangiomas and lentigines claimed as a skin disorder The veteran has contended that he suffers from skin splotches and skin cancers which are related to his period of active service in the Persian Gulf. Having reviewed the record, the Board is of the opinion that the veteran has failed to present a well grounded claim for service connection for a skin disorder due to an undiagnosed illness. Post-service medical reports show treatment for skin complaints which have been variously diagnosed as hemangiomas, lentigines, actinic keratoses, and tinea corporis. The veteran has not presented any evidence, to include a medical opinion, which suggests that his current skin disorders and the manifestations thereof may be attributed to an undiagnosed illness. As the claimed skin symptomatology, including red splotches, has been attributed to known clinical diagnoses, the veteran's claim for service connection for a skin disorder may not be considered well grounded under 38 C.F.R. § 3.317. Parenthetically, the Board also notes that the service medical records are negative for treatment, complaints, or diagnoses of skin disorders or skin cancer. On his return from the Persian Gulf the veteran gave a history of skin problems, however, service medical records are negative for treatment, diagnosis, or objective findings of a skin disorder. The May 1991 separation examination report shows that the skin was clinically evaluated as normal, and the record does not include a medical opinion which relates the current skin disorders to the period of active service generally. Thus, there is no evidence that service connection would be warranted for a skin disorder on a direct basis under 38 C.F.R. § 3.303 (1999). Although where claims are not well grounded VA does not have a statutory duty to assist a claimant in developing facts pertinent to his claim, the Court has held that VA may be obligated under 38 C.F.R. § 5103(a) (West 1996) to advise the claimant of the evidence required to complete the application. Robinette v. Brown, 8 Vet.App. 69 (1995). The Board finds that the RO fulfilled this obligation in the Statement of the Case. Swollen lymph node, hair loss, weight/fluid gain/metabolic change, fatigue Having reviewed the record, the Board is of the opinion that the veteran has failed to present a well grounded claim for service connection for swollen lymph nodes, hair loss, fatigue, and weight/fluid gain/metabolic change due to an undiagnosed illness. With regard to the veteran's complaints of swollen lymph nodes and weight loss, fluid gain, and metabolic change, the record lacks competent evidence of objective indications of chronic disability either during service or within the presumptive period. The veteran has given a history of a swollen lymph node under his armpit and a swollen nipple during his active service in Southwest Asia, and in 1998 he testified that the nodes under his armpit still pain him somewhat. Service medical records show complaints of weight gain at the time of treatment for labyrinthitis, however, the veteran has testified that his weight is currently 183, approximately 5 pounds more than he weighed on induction into active service. The record does not indicate that a medical professional has attributed this weight change to a disease, injury, or illness which is related to the period of active service. The veteran is competent to report on symptomatology of which he has personal knowledge, such as lymph node swelling, nipple swelling, weight or fluid gain, or metabolic changes. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, while lay evidence may be used to establish manifestation of various signs or symptoms claimed as due to an undiagnosed illness, a well grounded service connection claim also requires evidence of a chronic disability as shown by objective indications. In this case, there is no objective evidence of the manifestation of either a chronic swollen or painful lymph node or a chronic swollen nipple either during active service or in the post-service presumptive period. Furthermore, the veteran's in-service weight gain was not of a sustained or chronic nature (by his own admission), and there is no objective indication of a chronic disability manifested by weight gain, fluid gain, or metabolic change. In the Board's view, therefore, the veteran has failed to present evidence of objective indications of a chronic disability of lymph node swelling, weight or fluid gain, or metabolic change either during the period of service or to a degree of 10 percent or more during the specified presumptive period, and thus, the requirements for a well grounded claim have not been satisfied. The veteran has also claimed that hair loss and chronic fatigue are related to his period of active service in the Persian Gulf. The veteran currently reports that he suffers from chronic fatigue, which he has dated to the period of active service and his treatment for viral labyrinthitis. There is also evidence that the veteran was taking medication as treatment for hair loss prior to his entry into active service and he asserts that the hair loss increased on his return from the Persian Gulf. As noted, the veteran's own testimony is sufficient to establish manifestations of the signs or symptoms of an undiagnosed illness if the sign or symptom is of the type ordinarily susceptible to lay observation, and thus, the veteran's lay testimony constitutes competent evidence of the manifestation of both hair loss and chronic fatigue and the continuity of this symptomatology since the time of service. Although the veteran is competent to report that he currently suffers from chronic fatigue, a well grounded service connection claim also requires evidence of a chronic disability as shown by objective indications. In this case, the record does not include competent evidence of objective indications of a chronic fatigue disability; nor does the evidence confirm that the manifestation of such disability to a degree of 10 percent or more during the presumptive period. As noted, service connection has already been granted for residuals of viral labyrinthitis, the disorder associated with the veteran's in-service complaints of fatigue. There is no evidence of post-service treatment for fatigue, nor does the record include a medical opinion which identifies the manifestation of a chronic fatigue disability or which attributes the current complaints of chronic fatigue to a disease, injury, or illness. For these reasons, the Board finds that the claim for service connection for fatigue claimed as due to an undiagnosed illness is not well grounded under 38 C.F.R. § 3.317 (West 1991 & Supp. 1999). Finally, the Board finds that there is no competent medical evidence indicating that the veteran has a disability manifested by hair loss; nor has a medical professional attributed hair loss to a disease, injury, or illness. As such, the claim for service connection for hair loss may not be considered well grounded. 38 C.F.R. § 3.317 (1999); see also Rabideau v. Derwinski, 2 Vet.App. 141, 144 (1992) (absent "proof of a present disability there can be no valid claim"). The Board notes that the veteran and his lay witnesses have contended that the veteran suffers from chronic fatigue which is related to his Persian Gulf service. However, a layman is not competent to offer opinions on medical causation and, moreover, the Board may not accept unsupported lay speculation with regard to medical issues. See Espiritu v. Derwinski, 2 Vet.App. 482 (1992). Furthermore, lay assertions of medical causation cannot constitute evidence to render a claim well grounded. Grottveitt v. Brown, 5 Vet. App. 91, 93 (1993). Although where claims are not well grounded VA does not have a statutory duty to assist a claimant in developing facts pertinent to his claim, the Court has held that VA may be obligated under 38 C.F.R. § 5103(a) (West 1996) to advise the claimant of the evidence required to complete the application. Robinette v. Brown, 8 Vet.App. 69 (1995). With regard to the claims discussed in this section, the Board finds that the RO fulfilled this obligation in the April 1999 Statement of the Case, in which the veteran was notified that the medical evidence considered did not show a chronic disability, either diagnosed or undiagnosed. Allergic rhinitis The veteran has contended that he suffers from debilitating upper respiratory problems and allergies which are related to his period of service in the Persian Gulf. The respiratory disorder and allergy claims have been considered together in light of the nature of the veteran's symptomatology. Having reviewed the record, the Board is of the opinion that the veteran has failed to submit a well grounded claim for service connection for allergic rhinitis and a respiratory disorder. Specifically, the veteran's upper respiratory symptomatology has been diagnosed and treated as allergic rhinitis, for which he receives immunotherapy. He has not presented any medical evidence, to include a medical opinion, which suggests that he has allergy symptoms or any other respiratory disorders due to an undiagnosed illness. More importantly, his upper respiratory symptomatology has been attributed to a known clinical diagnosis. Thus, the manifestation of one or more signs or symptoms of an undiagnosed illness have not been shown, and as a result, the requirements for a well grounded claim have not been met under 38 C.F.R. § 3.317. Accordingly, the claim for service connection for allergic rhinitis, claimed as allergies and an upper respiratory condition due to an undiagnosed illness, must be denied. The veteran has argued that his current allergy disorder and upper respiratory problems are related to his period of active service in the Persian Gulf. He has noted that he had not experienced any allergy problems for a long period prior to his active service and that his current disorder does not respond to traditional treatment methods. While the veteran is competent to report on the features or symptoms of injury or illness, his contentions may not be relied upon for establishing a medical diagnosis, be that a current diagnosis or one linking a current disability to service. Layno v. Brown, 6 Vet. App. 465. 469-70 (1994). The Board also notes that a history of treatment for a dust mite allergy is shown prior to the veteran's induction into active service in support of Operation Desert Storm. It is noted parenthetically that the veteran has not presented any evidence which suggests a relationship between these problems and the period of active service generally, such that a grant of service connection would be appropriate on a direct basis under 38 C.F.R. § 3.303 (1999). Service medical records are negative for treatment of allergy problems and there is no record of post-service allergy treatment until 1994. The Board notes that in statements on appeal, the veteran and several lay witnesses have contended that the veteran suffers from symptoms of allergic reaction which are related to his Persian Gulf service. However, a layman is not competent to offer opinions on medical causation or diagnosis and, moreover, the Board may not accept unsupported lay speculation with regard to medical issues. See Espiritu v. Derwinski, 2 Vet.App. 482 (1992). Furthermore, lay assertions of medical causation cannot constitute evidence to render a claim well grounded. Grottveitt v. Brown, 5 Vet. App. 91, 93 (1993). For the reasons stated above, the Board finds that the claim for service connection for allergic rhinitis, claimed as an upper respiratory disorder and allergies, is not well grounded. Although where claims are not well grounded VA does not have a statutory duty to assist a claimant in developing facts pertinent to his claim, the Court has held that VA may be obligated under 38 C.F.R. § 5103(a) (West 1996) to advise the claimant of the evidence required to complete the application. Robinette v. Brown, 8 Vet.App. 69 (1995). The Board finds that the RO fulfilled this obligation in the April 1999 Statement of the Case, in which the veteran was informed that the claimed disability was determined to result from a known clinical diagnosis of allergic rhinitis. Fibromyalgia/arthritis Having reviewed the record, the Board has concluded that the veteran has failed to present evidence of a well grounded claim for fibromyalgia/arthritis, affecting the shoulders, elbows, wrists, hands, ankles, knees, and back, claimed as muscle pain and joint pain due to an undiagnosed illness. The post-service medical records show that the veteran has sought treatment for pain in multiple joints; however, this joint pain has been variously diagnosed as arthralgia, probable degenerative joint disease, and arthritis of the multiple joints. The 1999 VA examiner noted that the veteran appeared to have symptoms that could loosely be termed as fibromyalgia. In addition, in August 1994 his complaints of ankle discomfort were attributed to functional equinus with possible talonavicular joint degenerative joint disease. Thus, the veteran's subjective complaints of joint and muscle pain have been attributed to known clinical diagnoses, and he has not presented any evidence, to include a medical opinion, which suggests that he has joint pain or muscle pain resulting from or related to an undiagnosed illness. As such, the claim for service connection for fibromyalgia/arthritis of the multiple joints may not be considered well grounded under 38 C.F.R. § 3.317 (1999). The Board notes that the veteran and his lay witnesses have indicated that the veteran suffers from joint pain as a result of his Persian Gulf service. However, a layman is not competent to offer opinions on medical causation or diagnosis and, moreover, the Board may not accept unsupported lay speculation with regard to medical issues. See Espiritu v. Derwinski, 2 Vet.App. 482 (1992). Furthermore, lay assertions of medical causation cannot constitute evidence to render a claim well grounded. Grottveitt v. Brown, 5 Vet. App. 91, 93 (1993). The Board notes that recent medical records indicate the presence of a lytic lesion in the left proximal humerus, resulting in impingement syndrome in the left shoulder. It is parenthetically noted that there is no evidence which establishes an etiological link, or nexus, between a left shoulder lesion and the period of active service. The 1991 separation examination report indicated that the upper extremities were clinically evaluated as normal, and no shoulder abnormalities were noted. Furthermore, the veteran has not presented any medical evidence suggesting that this current left shoulder pathology is etiologically related to the period of a active service either as a result of an undiagnosed illness or as related to the period of active service generally, and thus, service connection is not warranted for a left shoulder lesion on a direct basis. The Board also notes that the record shows current diagnoses of patellofemoral syndrome and right knee chondromalacia patella, and the veteran has also been diagnosed with low back discomfort. However, in a January 1995 rating decision service connection was denied for residuals of a left shoulder injury, residuals of a right knee injury, and residuals of a back injury. By letter dated January 1995, the veteran was notified of that decision and thereafter, he did not initiate an appeal of that decision by filing a timely notice of disagreement with specific reference to the denials of his claims for a shoulder, knee, and back disability. As such, the January 1995 rating action became final and in order to reopen such direct service connection claims, new and material evidence must be submitted. See 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. §§ 3.156, 20.200, 20.202, 20.302 (1999). Although where claims are not well grounded VA does not have a statutory duty to assist a claimant in developing facts pertinent to his claim, the Court has held that VA may be obligated under 38 C.F.R. § 5103(a) (West 1996) to advise the claimant of the evidence required to complete the application. Robinette v. Brown, 8 Vet.App. 69 (1995). The Board finds that the RO fulfilled this obligation in the Statement of the Case, in which the veteran was notified that the claimed disability was determined to result from a known clinical diagnosis. In denying the above-noted claims for service connection as not well grounded, The Board acknowledges that these issues have been decided on a different legal basis than that utilized by the RO in the original rating. When the Board addresses a question that has not been addressed by the RO, inquiry is required as to whether the claimant has been given adequate notice and opportunity to respond and, if not, whether the claimant will be prejudiced thereby. See Bernard v. Brown, 4 Vet. App. 384 (1993). In this case, the appellant has not been prejudiced by these decisions, as the Board has considered the same law and regulations and merely concludes that the appellant did not meet the initial threshold evidentiary requirements of a well-grounded claim. Therefore, identical results have been reached. ORDER Service connection is granted for memory loss/attention problems due to an undiagnosed illness. Service connection is denied for a skin disorder due to an undiagnosed illness. Service connection is denied for swollen lymph node, hair loss, weight/fluid gain/metabolic change, and fatigue due to an undiagnosed illness. Service connection is denied for allergic rhinitis, claimed as allergies and an upper respiratory condition due to undiagnosed illness. Service connection is denied for fibromyalgia/arthritis of the shoulders, elbows, wrists, hands, ankles, knees, and back, claimed as muscle/joint pain due to an undiagnosed illness. H. N. SCHWARTZ Member, Board of Veterans' Appeals