Citation Nr: 0322330 Decision Date: 09/02/03 Archive Date: 09/08/03 DOCKET NO. 97-10 271A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection for a respiratory condition. 3. Entitlement to service connection for a headache disorder. 4. Entitlement to service connection for a right leg condition. 5. Entitlement to service connection for residuals of a fractured pelvis 6. Entitlement to service connection for a skin condition. 7. Entitlement to service connection for peptic ulcer disease. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Frank L. Christian, Counsel INTRODUCTION The veteran served on active duty in the United States Army from November 1966 to May 1974, including service in the Republic of Vietnam from August 1968 to August 1969, from July 1970 to June 1971, and from June 1972 to June 1973. The claimant also served with the West Virginia Army National Guard from September 1977 to September 10, 1989, and with the Army National Guard of the District of Columbia from August 31, 1989, to April 23, 1991, including service in the Southwest Asia theater of operations from November 1990 to April 1991 during Desert Storm/Desert Shield. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of October 1996 and April 2002 from the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The rating decision of October 1996 denied service connection for a back condition, a respiratory condition, a headache disorder, a right leg condition, residuals of a fractured pelvis, a hernia, a skin condition and ulcers, finding those claims not well grounded. The record shows that the RO has issued Supplemental Statements of the Case addressing those issues on the merits. The rating decision of April 2002 denied service connection for post-traumatic stress disorder (PTSD) and for schizophrenia. In May 2002, the claimant submitted a Notice of Disagreement with the denial of his claims for service connection for PTSD and for schizophrenia. With that document, he enclosed a copy of a Technical Information Bulletin from the State of Louisiana, dated September 21, 1999, together with an incomplete VA PTSD Stressor Questionnaire. A Statement of the Case was provided the claimant and his representative in January 2003. No Substantive Appeal (VA Form 9) has been received from the claimant addressing the issue of service connection for PTSD or schizophrenia as of the date of this decision. Those issues are not properly before the Board, and the Board limits its consideration herein to the issues set forth on the title page of this decision. The case was previously before the Board in June 1999, and was Remanded to the RO to afford the claimant a requested hearing before a traveling Veterans Law Judge of the Board of Veterans' Appeals. That hearing has been held, and the transcript is a part of this record. The case was previously before the Board in January 2000, and was Remanded to the RO to obtain verification of all periods of service, and to obtain service medical records of the claimant for all periods of active service. That development has been completed to the greatest extent possible, and the case is now before the Board for further appellate consideration. During the pendency of this appeal, a rating decision of May 2002 granted service connection for a postoperative right inguinal hernia scar, rated as noncompensably disabling, effective January 23, 1996. The claimant and his representative were notified of that action and of his right to appeal by RO letter of June 4, 2002. That decision constitutes a full grant of the issue on appeal, and the claimant has not taken issue with any component of that decision. There has been a significant change in the law with the enactment of the Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, § 3(a), 114 Stat. 2096, 2097-98 (2000) [codified as amended at 38 U.S.C.A. §§ 5102, 5103, 5103A, and 5107 (West 2000)]. This law eliminates the concept of a well-grounded claim, redefines the obligations of VA with respect to the duty to assist, and supersedes the decision of the United States Court of Appeals for Veterans Claims (the Court) in Morton v. West, 12 Vet. App. 477 (1999), withdrawn sub nom. Morton v. Gober, No. 96-1517 (U.S. Vet. App. Nov. 6, 2000) (per curiam order) (holding that VA cannot assist in the development of a claim that is not well grounded). The VCAA is applicable to all claims filed on or after the date of enactment, November 9, 2000, or filed before the date of enactment and not yet final as of that date. See Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). In Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991), the Court held that where a statute or regulation changes during the appellate process, the version more favorable to the claimant shall apply. VA's General Counsel has determined, in a precedential opinion that the Board is bound to follow, that the VCAA is more favorable to claimants than the law in effect prior to its enactment. See VAOPGCPREC 11-00; Janssen v. Principi, 15 Vet. App. 123 (2001) (per curiam). Final regulations to effectuate the VCAA were published on August 29, 2001 with the same effective date of the VCAA, November 9, 2000. Except for the amendment to 38 CFR § 3.156(a), the second sentence of 38 CFR § 3.159(c), and 38 CFR § 3.159(c)(4)(iii), effective August 29, 2001, governing reopening of previously and finally denied claims, the provisions of this final rule apply to any claim for benefits received by VA on or after November 9, 2000, as well as to any claim filed before that date but not decided by VA as of that date. As the instant appeal does not address a reopened claim, the revised regulations pertaining to reopened claims are inapplicable to this appeal. The record shows that the claimant and his representative were notified of the provisions of the VCAA by RO letter of November 1, 2001, and by Board letter of March 24, 2003, both of which informed them of VA's duty to notify them of the information and evidence necessary to substantiate the claims and to assist them in obtaining all such evidence. That letter also informed the claimant and his representative which part of that evidence would be obtained by the RO and which part of that evidence would be obtained by the claimant, pursuant to Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (requiring VA to notify the claimant of what evidence he or she was required to provide and what evidence the VA would attempt to obtain). The claimant and his representative were also provided a Statement of the Case on January 7, 2003, and a Supplemental Statement of the Case on May 30, 2002, which informed them of the issues on appeal, the evidence considered, the adjudicative actions taken, the pertinent law and regulations pertaining to direct and presumptive service connection, the decisions reached, and the reasons and bases for those decisions. That Statement of the Case and Supplemental Statement of the Case also notified the claimant and his representative of VA's duty to assist them by obtaining all evidence in the custody of military authorities or maintained by any other federal, State or local government agency, as well as any medical, employment, or other non-government records which are pertinent or specific to that claim; and which the claimant identified and provided record release authorizations permitting VA to obtain those records. Further, that Supplemental Statement of the Case informed the claimant and his representative that should efforts to obtain records identified by the claimant prove unsuccessful for any reason which the claimant could remedy, the VA would notify the claimant and advise him that the ultimate responsibility for furnishing such evidence lay with the claimant. In addition, by letter of March 24, 2003, the Board notified the claimant and his representative of the pertinent law and regulations pertaining to presumptive service connection for undiagnosed illness due to Persian Gulf War service. The Board finds that all relevant evidence necessary for an equitable disposition of the instant appeal has been obtained by the RO, and that VA's duty of notification to the claimant and his representative of required information and evidence and of its duty to assist them in obtaining all evidence necessary to substantiate the issue on appeal have been fully met. The RO has obtained all available service medical and personnel records of the claimant, as well as all private or VA medical evidence identified by the claimant. The RO has further afforded the claimant a videoconference hearing in October 1999 before the undersigned Veterans Law Judge of the Board of Veterans' Appeals. Neither the appellant nor his representative have argued a notice or duty to assist violation under the VCAA, and the Board finds that there is no question that the appellant and his representative were fully notified and aware of the type of evidence required to substantiate the claims. In view of the extensive factual development in the case, as demonstrated by the Board's June 1999 and January 2000 remands and the record on appeal, the Board finds that there is no reasonable possibility that further assistance would aid in substantiating this appeal. For those reasons, further development is not necessary for compliance with the provisions of 38 U.S.C.A. §§ 5103 and 5103A (West 2000). FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the instant appeal has been obtained by the RO, and VA's duty of notification to the claimant of required information and evidence and of its duty to assist him in obtaining all evidence necessary to substantiate his claims have been fully met. 2. The claimant's service entrance examination is not available, and he is presumed to have been without defects at the time of service entry. 3. A chronic back disability was not clinically manifest during active duty, on service separation examination, during any applicable presumptive period, or at any time prior to an October 1992 on-the-job injury; traumatic back sprain,with early degenerative arthritis and residuals of a back injury sustained in an October 1992 on-the-job injury are not undiagnosed illnesses; and a back injury has not been linked or related to active service by competent medical evidence or opinion, but has been specifically attributed to his October 1992 on-the-job injury. 4. A chronic respiratory condition was not shown during active duty, on service separation examination, or during any applicable presumptive period, VA examination in March 1997 revealed normal chest X-rays and spirometry, and a chronic respiratory condition has not been clinically demonstrated or diagnosed; upper respiratory infections, with nasal congestion and draining sinuses are not undiagnosed illnesses. 5. A chronic headache disorder was not shown during active duty, on service separation examination, or during any applicable presumptive period; and recurrent tension headaches and post-traumatic headaches have been specifically attributed by competent medical evidence to his October 1992 on-the-job injury and are not undiagnosed illnesses. 6. A right leg injury was not shown during active duty, but the claimant has reported sustaining a right lower leg injury on an engineer's stake, and his service separation examination in April 1974 showed a scar of the right lower leg. 7. Residuals of a fractured pelvis were not shown during active duty, on service separation examination, during any applicable presumptive period, or on VA examination in March 1997, when X-rays were negative for evidence of a pelvic fracture; it is neither contended nor established that any pelvic disorder had its onset during the Persian Gulf War. 8. A chronic skin condition was not shown during active duty, on service separation examination, during any applicable presumptive period, or on VA examinations in May 1997; jock itch (tinea cruris), folliclitis, militaria ribra, and pruritis are not undiagnosed illnesses. 9. Peptic ulcer disease was not clinically demonstrated or diagnosed during active duty, on service separation examination, during any applicable presumptive period, or on VA examination in March 1997; gastritis from taking Motrin is not an undiagnosed illness. CONCLUSIONS OF LAW 1. Service connection for a back disability is not warranted. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A (West 2000); 38 C.F.R. §§ 3.102, 3.303(a), 3.317, Part 4, Diagnostic Codes 5003-5295 (2002). 2. Service connection for a respiratory condition is not warranted. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A (West 2000); 38 C.F.R. §§ 3.102, 3.303(a), 3.317, Part 4, Diagnostic Code 6599 (2002). 3. Service connection for a headache disorder is not warranted. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A (West 2000); 38 C.F.R. §§ 3.102, 3.303(a), 3.317, Part 4, Diagnostic Code 8100 (2002). 4. The grant of service connection for a scar of the right lower leg is warranted. 38 U.S.C.A. §§ 1110, 1117, 5103, 5103A (West 2000); 38 C.F.R. §§ 3.102, 3.303(a), 3.317, Part 4, Diagnostic Code 5299 (2002). 5. Service connection for residuals of a fractured pelvis is not warranted. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A (West 2000); 38 C.F.R. §§ 3.102, 3.303(a), 3.317, Part 4, Diagnostic Code 5299 (2002). 6. Service connection for a skin condition is not warranted. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A (West 2000); 38 C.F.R. §§ 3.102, 3.303(a), 3.317, Part 4, Diagnostic Code 7899 (2002). 7. Service connection for peptic ulcer disease is not warranted. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A (West 2000); 38 C.F.R. §§ 3.102, 3.303(a), 3.317, Part 4, Diagnostic Code 7346 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Evidence As noted, the veteran served on active duty in the United States Army from November 1966 to May 1974, including service in the Republic of Vietnam from August 1968 to August 1969, from July 1970 to June 1971, and from June 1972 to June 1973. The claimant also served with the West Virginia Army National Guard from September 1977 to September 10, 1989, and with the Army National Guard of the District of Columbia from August 31, 1989, to April 23, 1991, including service in the Southwest Asia theater of operations from November 1990 to April 1991 during Desert Storm/Desert Shield. The record shows that the RO has made repeated efforts to obtain all service medical records of the claimant from each period of his active service, including his service during the Persian Gulf War, and all records of his Army National Guard service, from all recognized repositories or sources for those records. Following the Board's remand order of January 5, 2000, the RO renewed its efforts to obtain the requested records, again to no avail. In January 1996, the claimant sought service connection for a back condition, a right upper leg condition, a right lower leg injury, residuals of a fractured pelvis, postoperative residuals of a hernia, a respiratory disorder, a skin disorder, and frequent headaches. He reported no postservice treatment for those conditions, and requested a Persian Gulf War examination. By RO letter of March 21, 1996, the claimant was notified that additional evidence was needed in support of his claims, and he was asked to submit any medical evidence he had since beginning active duty in the Persian Gulf War area, including service medical records showing medical treatment while in the Persian Gulf area; to submit any medical evidence from the time he left the Persian Gulf area, including doctor's statements, hospital records, or laboratory reports; and medical statements showing dates of examination or treatment, finding, and diagnoses of disabilities, and their symptoms and duration. He was further informed that he could submit lay statements from persons who knew him during service or during the Persian Gulf War. Similar information was solicited by RO letters of June and July 1996. The claimant's available service medical records showed that he was seen in September 1972 for complaints of a cough and nasal congestion, and was treated with Dimetapp and cough syrup. In November 1972, the claimant was noted to have been involved in an automobile accident, with a soft tissue injury to the medial right knee, with swelling just medial to the tibial tuberosity,and a small abrasion, as well as middle and low back paraspinal tenderness, without muscle spasm, and with multiple abrasions. He was given Valium and Darvon. The following day, the claimant was seen for a syncopal episode shortly after taking prescribed Valium on an empty stomach. Physical examination was negative, his neck was supple, his throat was not inflamed, and his chest was normal, and his extremities and central nervous system were normal. The impression was neurogenic syncope, and no treatment was provided. In December 1972, the claimant was seen for complaints of a chest cold with cough, sore throat and headache. Examination was negative, and he was given Dimetapp and cough syrup. The service medical records show that in January 1973, the claimant was seen for a head cold, his throat and ears were clear, and the impression was upper respiratory infection. In April 1973, the claimant was seen for complaints of jock itch and pubic lice, and given Kwell cream. Also in April 1973, the claimant was seen for complaints of chest pain and shortness of breath of 2 hours duration. He further complained of epigastric burning in the mornings. Examination revealed that his abdomen was negative, blood pressure was 120/80, his lungs were clear, and cardiac examination was normal, with no friction, rubs, gallops or murmurs. He was given Maalox and Donnatal, and there was no diagnosis provided. In October 1993, the claimant was seen for complaints of a lump in the chest, with chest pain on coughing and sometimes on swallowing. Examination disclosed that his neck was supple, his lungs were clear to auscultation and percussion, chest X-ray was negative, and a slight anterior chest tenderness was noted. The impression was upper respiratory infection, and he was given chloraceptic. That same day, he was seen in the podiatry clinic for plantar warts. In November 1973, the claimant was seen in the Emergency Room after attempting suicide by lacerating his wrists. He was ambulatory, and his blood pressure was 130/90. He was seen in the orthopedic clinic 60 days later, and noted to have anesthesia along the palmar cutaneous branch of the median nerve. A report of medical history completed by the claimant at the time of service separation examination shows that he complained of frequent colds, sinusitis, and hay fever, leg cramps, a fracture of his left wrist 10-12 years previously, and recurrent low back pain. He further related that he injured his back in January 1967 and in 1972, while in Vietnam, with occasional lumbar pain. He denied any hospitalizations, denied treatment for frequent or severe headaches, dizziness or fainting spells, skin diseases, shortness of breath, chronic cough, or stomach, liver or intestinal trouble, and denied treatment by physicians or clinics within the past 5 years for other than minor illnesses. His service separation examination, conducted in April 1974, disclosed that his nose, throat, sinuses, throat, chest and lungs were normal, a chest X-ray was negative, and his spine, musculoskeletal system, neurological system and lower extremities were normal. A scar of the left knee and right lower leg were noted. The claimant was notified by RO letter of March 21, 1996, that he should submit both medical and nonmedical evidence from the time he began active duty in the Persian Gulf area; medical and nonmedical evidence from the time he left the Persian Gulf area, lay statements from any individuals who knew him during or after his military service, medical records which show the date of any examination or treatment, findings and diagnoses, as well as pertinent data about any disabilities noted. The claimant subsequently failed to report for scheduled VA examinations in August 1996, and his claims were denied as not well-grounded by rating decision of October 1996. The claimant was notified of those adverse determinations and of his right to appeal by RO letter of October 28, 1996. In December 1996, the claimant submitted a hospital summary from Plateau Medical Center (Dr. A.U.), a private medical facility in Oak Hill, West Virginia, showing that the veteran complained of chest pain, shortness of breath, back pain, epigastric discomfort, and a history of peptic ulcer disease, and was admitted in November 1995 to rule out possible unstable angina or myocardial infarction, an upper respiratory infection, pleuritis, duodenal ulcer, or low back strain. On examination, the claimant had a slight cold, with nasal congestion and a normal throat, a chest X-ray was normal, and a few rales were noted on the right side, not very clear, a regular cardiac rate and rhythm was noted, and he had some "vague complaints" of chest and back pain. The abdomen was soft, with mild epigastric tenderness, and the liver and spleen were not palpable. Tenderness was found over the lumbar spine, with some limitation of lumbar motion, but no limitation of motion of the extremities, bilaterally. Laboratory tests were normal, and he was noted to maintain low blood pressure throughout his hospitalization. He was discharged after three days with the following diagnoses: unstable angina or myocardial infarction ruled out; upper respiratory infection; back strain, and peptic ulcer disease. The hospital summary was silent for any clinical findings of peptic ulcer disease or a chronic respiratory disease. The claimant filed a Notice of Disagreement with the denial of his claims for service connection for a back condition, a right upper leg condition, a right lower leg injury, residuals of a fractured pelvis, postoperative residuals of a hernia, a respiratory disorder, a skin disorder, and a headache disorder. A Statement of the Case was issued in February 1997 addressing those issues. VA outpatient treatment records from the VAMC, Beckley, dated in October 1991, show that the claimant was seen for complaints of a cough and sinus drainage. His chest and abdomen were normal. The impression was probable hay fever with postnasal drainage. In February 1992, he was seen for complaints of itching in the genital area. His chest was clear, and his abdomen was nontender. The diagnosis was rule out fungal genitourinary infection. In March 1992, theveteran complained of coughing, chest tightness, and sinus trouble, while in October 1992, he was seen for complaints of tingling in his feet, severe low back pain, and no sensation from the mid-chest down. In April 1993, the claimant was seen for bumps in the right thigh area, thought to be possible folliculitis, while in May 1993, he was seen for complaints of something in his throat and burning in the stomach after taking Motrin. The impression was gastritis secondary to Motrin. In May 1993, he was also seen for complaints of recurrent neck spasms, leg weakness and anxiety. A VA hospital summary and treatment records from the VAMC, Beckley, dated from October 1992 to February 1993, shows that the claimant was transferred to the VAMC, Charleston, after a fall from a building in October 1992; that he underwent a CT scan of the head, cervical spine and upper dorsal spine at the VAMC, Huntington, with normal findings; and that he was subsequently returned to the VAMC, Beckley for further evaluation, management and recovery from his multiple contusions of the body and headaches. The claimant related that he had umbilical surgery in 1980, right inguinal surgery in 1989; and that he has been healthy otherwise. He reported that he had no allergies, but has a recurrent cough, and an intermittent sinus condition, but denied any psychiatric abnormalities. Examination upon his return showed that the claimant wore a back brace and cervical collar, and complained of overall body pain. His chest was clear to auscultation and percussion, his abdomen was unremarkable; there was a slight tenderness to palpation over the lumbar, thoracic and cervicle spine, and a full range of motion was demonstrated, and some mild paresthesias was noted to the left 4th and 5th fingers. The claimant complained of headaches, sometimes relieved by Vistaril, as well as neck pain and a burning sensation in the left thigh. An orthopedic consultation in December 1992 yielded an opinion that the claimant's complaints were musculoskeletal in nature and were associated with his contusions. A neurological examination in January 1993 showed that the claimant's complaints of headaches were post-traumatic in nature, and considered an associated anxiety reaction. At the time of hospital discharge, it was noted that the use of a cervical collar was unnecessary. The diagnoses at hospital discharge were multiple contusions to the spine and body; and recurrent headaches secondary to diagnosis #1. VA outpatient treatment records, dated in February 1993, show that the claimant was seen for complaints of residual headaches, neck and back pain following a fall from a building in October 1992. It was noted that a CT scan of his head, neck and spine were normal in November 1992. A report of neurological consultation in February 1993 noted that the claimant was being followed for headaches, neck pain and back discomfort associated with an injury in October 1992, but had not been in therapy since hospital discharge. In March 1993, the claimant was seen for follow-up of back pain, radiating into the left leg, and headaches, at which time no neurological deficits were found other than a slight paresthesias of the 4th and 5th fingers of the left hand. In April 1993, the claimant was again found to have no signficant neurological deficits, and it was noted that he had an MRI of the lumboscaral spine which was normal, and an MRI of the cervical spine which disclosed mild disc protrusion at the C5-C6 level, but no cord compression, impingement on the thecal sac, or nerve root compromise, and surgery was not indicated. The claimant was noted to have a full range of motion, with some pain at the extremes of motion, and had good motor function with no sensory deficit. Some paravertebral muscle spasm was noted, while dorsiflexion was to 40-45 degrees, and he had good heel and toe walk with no sciatic notch tenderness. The claimant was noted to continue the use of a lumbosacral corset. VA outpatient treatment records, dated in May 1993, show that the claimant was noted to have fallen off a building in October 1992, with multiple contusions and residual joint pain as a result of that injury. It was noted that the claimant also complained of visual disturbances, headaches, tingling and weakness in his legs, and tenderness across his shoulders. It was suggested that the claimant return to work, as he was capable of doing sedentary type work, and he was placed on light work status. The claimant was seen four days later in a wheelchair, complaining of neck stiffness, weakness, fatigue, dizziness, and dry throat, and alleging inability to return to work. Examination revealed some limitation of neck motion due to discomfort, but was otherwise complete. There were no physical findings to support the veteran's complaints, and when confronted with that fact, he indicated that he could not work because of the discomfort, and that he needed to lie down and rest in order to relieve his pain. When it was recommended that he go home and rest, and report for duty in the morning, the veteran asserted that if he returned to work, he might get dizzy and fall off the stool, and that he would sue it that occurred. The examiner stated that he explained to the veteran that they had not found a specialist who has examined him who had found any reason why he would be unable to work at this time. A VA hospital summary and treatment records from the VAMC, Beckley, dated in June 1993, shows that the claimant was admitted with complaints of low back and right flank pain, and underwent an intravenous pyelogram which revealed no abnormalities. The claimant was noted to have fallen about 18 feet from a ladder in October 1992 while working at the VAMC, Beckley, alleging that he lost consciousness and was unable to move his arms and legs. However, there was no evidence of fracture. Examination on admission revealed that his chest and lungs were normal, and his abdomen was soft, non-tender, and without masses. A chest X-ray was negative. The claimant became asymptomatic and was released. The diagnoses were right renal colic, cause undetermined; and past history of spinal contusion from fall. VA outpatient treatment records from the VAMC, Beckley, dated in July 1993, cited the veteran's complaints of inability to work due to chronic low back pain, dizziness,and headaches, and insisted that he was not safe on the jobsite where he could potentially be injured. It was noted that the claimant had been referred to multiple different physicians, without resolution of his problems. In August 1993, it was noted that the claimant continued to complain of chronic neck and back pain; and that CT scans and X-rays of the cervical and lumbar spine, chest and pelvis were unremarkable; and that further MRI scans of the cervical and lumbosacral spine at the VAMC, Richmond disclosed no significant findings. The diagnosis was status post spinal contusion, and muscuskeletal back and neck pain. Later in August 1993, the claimant complained of constant low back pain, recurrent dizzy spells and headaches. VA outpatient treatment records from the VAMC, Beckley, dated in January 1997, show that the claimant complained of low back pain and sinus problems, relating that he sustained a back injury in a fall while working construction. Examination showed that his chest was symmetrical and his lungs were clear, while his abdomen was soft and nontender, and there was no edema of the extremities. The impression was post-traumatic arthritis. In March 1997, it was noted that the claimant was suspected of narcotics excess, and his file was marked to not give narcotics to the claimant. His skin was noted to be warm and dry, and his respirations were regular and non-labored. A VA dermatological examination, conducted at the VAMC, Beckley, in March 1997, cited the veteran's complaints of rash and generalized itching since Vietnam. Examination revealed a few papules on his trunk and extremities. The diagnosis was pruritis, etiology undetermined. The examiner noted that there was no evidence of an underlying illness to cause itching; that such might be a component of neurodermatitis secondary to his chronic anxiety tension state; and recommended symptomatic treatment with nupercainal cream and generic lidex cream. A VA scars examination, conducted in March 1997, cited the veteran's complaints of falling on an engineer's stake while in Vietnam in 1968, causing a small laceration of his right leg; and that the wound was sutured at an aid station and healed okay. He further cited an injury to his left knee in a childhood biking accident. Examination disclosed a 2 x 3 cm. flat scar of the left [sic] leg, moveable and nontender, and a very faint, 3 x 0.5 cm. transverse scar was seen over the anterior part of the left patella, identified as a childhood injury, and the scar was noted to be movable and nontender. There were no findings of a scar of the right leg. The diagnoses were scar, left leg, healed, nondisfiguring, asymptomatic; and childhood scar, left knee, asymptomatic. A VA orthopedic examination, conducted in March 1997, cited the veteran's complaints of right thigh symptoms, without knee or joint complaints. The claimant alleged that he injured his thigh in about 1966 while running hurdles at a track meet in Germany; that when he woke up in a hospital, where he remained two days; and that he was then discharged. He related that he had experienced aching in the right thigh since that event; that he saw a private physician in Washington, DC, who gave him pills, but no diagnosis; and that the pain in his thigh has gotten worse. Examination of the right thigh was negative, and it was thought that his complaints might be referred pain from his back. The diagnosis was painful right thigh, probably secondary to referred pain from the lumbar spine. A VA bones and joints examination, conducted in March 1997, cited the veteran's complaints of injuring his pelvis while in the National Guard in 1983, when a jeep in which he was riding hit a bump and he fell over the seat back. He claimed to have sustained a hairline fracture of the pelvis in that accident, relating that he was taken to a VA medical facility in Virginia, where he remained three days before being discharged to home on crutches. He further related that he had recovered from the alleged fracture and was asymptomatic regarding that injury. Examination disclosed no objective clinical evidence of the claimed pelvic fracture, and X-rays of the pelvis disclosed no evidence of an old fracture, while some minimal osteoarthritis of the left sacroiliac joint was noted. The diagnosis was history of hairline fracture of pelvis, healed, asymptomatic. A VA spine examination, conducted in March 1997, cited the veteran's complaints of constant low back pain since a 20- foot fall while working on remodeling the examining VA medical facility in 1992. He related that he was a patient in that VA medical facility for four months, and was unable to walk for two months, and received physical therapy for six months. He further related that he had X-rays and computerized axial tomography (CT) scans of his back while being treated, and that the X-rays showed no evidence of fracture. The VA examiner noted that there were no records of a CT scan of the claimant's back at that hospital. The claimant further related that he injured his back in in Germany and again in Vietnam when a jeep turned over, and that those injuries were not severe and he recovered. He further asserted that he had been a construction worker prior to his 1992 accident while working on the VA medical facility, but had not worked since that accident. He related that he did not see a doctor regularly, but saw a private physician (Dr. A.U.) at Oak Hill [Plateau Medical Center] six months previously. He further related that he had been wearing a TENS unit since 1992, as well as a back brace given him by the State Compensation Agency. He related that his back pain was worsened by prolonged standing or sitting, but relieved by lying on his left side. Examination disclosed that the claimant walked slowly, with a cane in his right hand, stating that he used the cane because of back pain and right leg pain. He was also noted to be wearing a back brace with steel stays extending from the scapula to the sacrum, and a TENS unit with electrodes located over the thoracic and lumbar spines. Examination further showed that the claimant stands leaning slightly to the left; that there was no fixed deformity; that there were spasms of the paraspinal muscles; that forward flexion was accomplished to 30 degrees, extension to zero degrees, left lateral flexion to 25 degrees, with pain on all motions, and right lateral flexion was not attempted due to complaints of pain. Rotation to either side was claimed as painful. The diagnoses were traumatic low back strain with right sciatica; and early degenerative arthritis of the lumbosacral spine and of the left sacroiliac joint. A VA neurologic examination, conducted in March 1997, cited the veteran's complaints of recurrent posterior neck and low back pain and headaches since 1992, when he sustained neck and back injuries falling from a roof about 15-20 feet high. He related that he was first seen at the Emergency Room at the VAMC, Beckley; then transferred to the VAMC, Charleston, for about a week before being returned to the VAMC, Beckley, where he remained for another 4 or 5 months. He related that he had been using a cane since hospital discharge, and complained of residual neck and back pain, as well as headaches. He related that he had experienced headaches sine the 1960's but they had become worse since his accident. He complained of intermittent weakness in his hands, and neck pain on movement of his head, with pain radiating from his low back into his lower extremities, with a burning sensation, worse on the right. He complained of inability to walk long distances, or to lift heavy weights, and stated that coughing or sneezing caused increased neck and back pain. He complained of sleep impairment and memory impairment since his 1992 accident. The claimant further offered a history of undergoing a right inguinal herniorrhaphy and umbilical herniorrhaphy, and of having chronic obstructive pulmonary disease (COPD), but denied any history of heart trouble, hypertension, or diabetes mellitus. Examination disclosed no neck rigidity, but he complained of back pain on flexion to 45 degrees and extension to 30 degrees, as well as neck pain on rotation to 45 degrees, bilaterally. Finger-to-nose testing was normal, and strength was 4/5 in the upper extremities on extension and abduction of the arms. He declined to grip with his hands, declined to dorsiflex his wrists against resistance, and would moan and groan when asked to move his upper extremities against resistance and on muscle testing of the lower extremities. He could flex and extend his legs slowly, and dorsiflex his ankles slowly, while strength was 4/5 and he declined to exert effort against resistance during muscle testing of the lower extremities, although it was noted that he could flex his legs spontaneously. Sensory examination was intact over the lower extremities, and deep tendon reflexes showed 1+ biceps and triceps jerks, but no knee jerks and no Babinski's sign. He was able to ambulate alone, using a cane, but would drag his legs while walking, worse on the right. He was unable to walk on tiptoes or heels. Moderate tenderness was found on percussion over the lower lumbar spine region, and straight leg raising was positive, bilaterally, at 45 degrees. No muscle atrophy was seen in the intrinsic muscles of the hands, and no rigidity of the wrists was found. The impression was chronic low back strain with lumbar radiculopathy, worse on the right; chronic cervical strain; chronic tension headaches; and generalized anxiety disorder with depression. The VA neurological examiner noted that the claimant did not exert full effort on movements of his lower extremities, especially on dorsiflexion of his ankles against resistance; that he did not grip fully with his hands during examination, which might be due to pain but probably is due to functional overlay. It was noted that MRI testing might rule out nerve root impingement or disc herniation, and that the claimant would have a difficult time gaining work because of his persistent pain. A report of VA respiratory examination, conducted in March 1997, noted that the claimant offered a history of dyspnea, etiology unknown; chronic low back strain with lumbar radiculopathy; chronic cervical strain; chronic tension headaches; generalized anxiety disorder with depression; status post right herniorraphy times 2 in 1988 and in 1991; status post umbilical hernia in 1983; childhood injury to right wrist; chronic right lower chest pain since Vietnam; and duodenal ulcers for the past 10 years (i.e., since 1987). The veteran complained of shortness of breath, with a dry cough productive of whitish phlegm since returning from Vietnam, worsening since returning from the Persian Gulf. He further complained of right lower chest pain, difficulty in breathing through his nose, and a choking sensation in his throat. VA respiratory examination revealed that the claimant was well-developed and well-nourished; that lymph nodes revealed no lymphadenopathy; that the lips were noncyanotic; that the chest was symmetrical, nontender, and unrestricted in expansion; and that the lungs were clear to percussion and auscultation, without rales or wheezing. The VA respiratory examiner stated that there were no findings of cor pulmonale, no history of asthma, no clubbing or cyanosis of the fingertips, and no evidence of infectious disease, while blood chemistry tests and urinalysis were within normal limits, no active skin lesions were present, a chest X-ray was negative, and an electrocardiogram (EKG) disclosed no abnormalities. Pulmonary function tests (PFT's) revealed that forced vital capacity was normal, as was the FEV-1/FVC ratio. The FEV-1 value was 3.1 liters, while the mid- inspiratory flow were normal, and the maximal voluntary ventilation was 98 liters/minute, which was 82 percent of predicted. The diffusion capacity for carbon monoxide was 73 percent, and arterial blood gases were on room air showed a pH of 7.37, PCO2 of 43.4, PO2 of 74.1, while carboxyhemoglobin of 2.4 percent. The inspiratory and expiratory portions of the flow volume were both normal, and the volume time curve was incomplete due to poor effort. The impression was normal spirometry, history of duodenal ulcer, chronic low back strain with lumbar radiculopathy, chronic cervical strain, chronic tension headache, and generalized anxiety disorder with depression. A report of VA digestive system examination, conducted in March 1997, cited a history offered by the claimant of duodenal ulcer for the last 10 years, status post umbilical surgery in 1983; status post right herniorrhaphy times 2 in 1989 and in 1991; chronic low back strain with lumbar radiculopathy, right more than left; chronic cervical strain; chronic tension headaches; and generalized anxiety disorder with depression. The veteran complained of frequent heartburn, indigestion, nausea without vomiting, abdominal pains, especially in the epigastric region, without radiation and without diarrhea. He complained of epigastric pain three or four times per week. Examination revealed that the claimant was well-developed and well-nourished, weighed 135 pounds, and was in no distress. There was no evidence of anemia, hematemesis, or melena. The abdomen was soft and nontender, bowel sounds were audible, there were no masses or organomegaly, and there was no rebound tenderness. A postoperative scar was noted at the umbilical region and right inguinal region. Rectal examination revealed no evidence of active bleeding, and there were no hemorrhoidal tags. The diagnoses were duodenal ulcer for the last 10 years; status post umbilical surgery for umbilical hernia; status post right herniorrhaphy times 2; chronic low back strain with lumbar radiculopathy, right more than left; chronic cervical strain; chronic tension headaches; and generalized anxiety disorder with depression. A VA hospital summary and treatment records from the VAMC, Beckley, dated in March 1997, show that the claimant was admitted with complaints of dizziness, nausea and low back pain. Examination disclosed no abnormalities, and it was noted that there was no evidence of vertigo or of a neurological deficit. The diagnoses at hospital discharge were dizziness and chronic back pain. A VA hospital summary and treatment records from the VAMC, Beckley, dated in March and April 1997, show that the claimant was admitted with complaints of generalized weakness of unknown etiology, and chronic back pain. After one day of observation, the claimant asserted that he was unable to get up. It was noted that the claimant had a history of back injury about 5 years ago, and that he was trying to get compensation for that. Examination revealed that his neck was supple, without stiffness; that his lungs were clear; that his abdomen was normal; and that there was no evidence of muscle weakness or atrophy in any of the extremities, neurological examination was unremarkable, and deep tendon reflexes were normal, bilaterally. A CT scan of the head was negative. The claimant was observed by a physician over the weekend and was seen to ambulate on his own and to be relatively free of any medical problems, and it was suggested that he seek psychological evaluation to determine why he wanted to be sick. The diagnoses at hospital discharge were dizziness and low back pain. VA outpatient treatment records from the VAMC, Beckley, dated in April 1997, show that the claimant continued to complain of neck and back pain and numbness related to a fall while doing construction work in 1992. In August 1997, the impression was rule out cervical radiculopathy, and status post generalized trauma in 1992 fall. A report of VA neurological examination in October 1997 cited the veteran's complaints of headache and chronic low back and neck pain since a fall while at work in October 1992. It was noted that the claimant was admitted to the VAMC, Beckley , in March 1997 with complaints of being unable to get up because of dizziness and leg weakness; that he underwent an evaluation for generalized weakness, neuromuscular disease, motor neuron disease and stroke, as well as a CT scan which was negative; that the claimant was observed by the attending physician to ambulate without assistance and without difficulty when not aware that he was being observed; that the following day, the claimant again claimed that he was unable to stand unassisted; and that he was discharged with the recommendation that he seek follow-up in the mental health clinic. With regard to the claimant's initial injury, it was noted that X-rays from 1992 revealed diffuse osteoporosis of the cervical spine with mild cervical spondylosis and degenerative changes, most marked at C5-C6; a mild anterior wedging compression fracture in the upper middle thoracic spine; and marginal bone spurring at L3, without evidence of acute bone trauma. The claimant appeared for neurological evaluation in a wheelchair. Neurological examination disclosed no evidence of muscle atrophy or skin atrophy, while the deep tendon reflexes were brisk and symmetrical, bilaterally, and plantar responses were downgoing, bilaterally. Muscle strength could not be reliably tested as the claimant claimed an inordinate amount of pain, and when assisted to the standing position, he tended to buckle his knees. No sensory loss to light touch, pinprick or proprioception was found, and there was no sensory hypesthesias. Palpation of the low back revealed left lumbar muscle tightness, however, the examiner noted that such might be due to the claimant's distorted posture. The VA neurological examiner stated that the veteran had a fixed complaint of entire neuroaxis pain, which might or might not have any anatomical basis; that based upon his examination, he was unable to pinpoint any anatomical source for this pain; that he should undergo another cervical, thoracic and lumbar MRI and, if a treatable condition was found, that he undergo an inpatient pain management program. VA outpatient treatment records from the VAMC, Beckley, dated in April 1997, show that the claimant had a pain disorder of unknown etiology, and that he had been referred to that clinic by his primary care physician for a psychological evaluation. It was noted that the claimant had been admitted in March 1997 for dizziness, weakness, and back pain; that no positive findings were arrived at through that hospitalization; that a CT scan was negative; and that the attending physician had observed the claimant moving well one day, while the following day, he had stated that he was unable to rise from his bed. The claimant presented in a wheelchair, and stated that he was unemployed because of a back injury in a 1992 fall. He made poor eye contact, and indicated that he had discontinued physical therapy when it didn't make the pain go away. He was not receptive to suggestions that he be more active, thus strengthening his muscles. He appeared to exaggerate the difficulty of responding to questions, with a great deal of grimacing, crushing his eyelids shut, and in general conveying a sense of terrific difficulty and emotional pain involved in trying to answer questions. He alleged that his appetite had been poor; that he had lost 25 pounds in the last 4 to 6 months, alleging that he doesn't eat at all; that he cannot walk and cannot interact with people; and that he only sleeps 3 to 4 hours per night, and does not nap. The VA psychiatric examiner expressed the opinion that such an amount of sleep would result in virtual psychosis. It was noted that the claimant had not taken psychoactive medications in the past and had no history of psychosis or depression, and no history of psychiatric hospitalization or treatment. Mental status examination revealed that the claimant presented as a flat, nonspontaneous individual who answered questions with a great deal of drama; that he stated that he did not feel like interacting or answering the examiner's questions; that he further stated that his memory was so poor that he cannot remember things day to day; and that he was no longer able to read and write. There was no evidence of psychosis; and the claimant answered questions quickly, with a sense of drama, and insight and judgment were poor. The examiner noted that this presented a difficult case to evaluate because of the inconsistencies in the claimant's presentation and response to various questions, both historical and mental statuswise. There were also inconsistencies about the pain dysfunction itself, with the claimant asserting that it never lets up and never leaves, which the examiner noted was inconsistent with real pain, which is always a fluctuating problem and is virtually never absolutely nonstop. Secondly, the claimant stated that nothing helps, while true pain does respond at least partially to some interventions. In addition, the claimant asserted that he has multiple pains, all of which express themselves at the same time, while the examiner noted that psychologically, one pain will always predominate. Further, when asked about what his understanding of pain is or what might have been explained to him about medical understanding of the pain and it's diagnosis, the claimant responded that he "can't remember." The examining VA psychiatrist expressed the opinion that the issue of a pain disorder has to do with the multiplicity of pain sites, the impairment of function, and the fact that it cannot be accounted for by some other illness, such as depression, and that there is no specific physical finding to encompass the multiple pains. Depression was noted to be one possible cause of this and while the examiner did not think the claimant was depressed, she would give him the benefit of the doubt and treat him with Sertaline as if he had depression. VA outpatient treatment records from the mental health clinic, dated in April 1997, show that the claimant was seen walking with the help of a cane, stating that he had started physical therapy. He would grimace often when answering questions and continued to present in a depressed way, but was more talkative and receptive. He denied suicidal or homicidal ideation, and continued to report pain on a continual basis. In May 1997, the claimant presented in a wheelchair, and verbalized no suicidal or homicidal ideation. While he presented in a wheelchair, he indicated that he drove from his wife's place of business. Later in May 1997, a VA psychiatrist reported that the claimant again presented in a grimacing and dramatic fashion, speaking in a near whisper most of the time with the theme of his discussion involving how downcast he feels about being nonproductive, and that his compensation issues are still pending, The examiner stated that this was one of those cases that would not resolve until the compensation issues were completely out of the way. Toward the end of the discussion , the claimant voiced some vague suicidal ideation, asserting that he had discussed such at an earlier interview, but the notes of that previous interview showed no such discussion. The examiner further noted that the claimant can push his wheelchair with one foot without any evidence of pain, although he asserted that he cannot stand or ambulate well. The examiner stated that he believed that this is a pain disorder with psychological features, and that such was extremely difficult to treat. In June 1997, a VA mental health technician noted that the claimant had missed his appointment, but indicated that he had seen the claimant in the crossroads mall, and that he was ambulatory without a cane or wheelchair, and did not appear to be in significant physical distress. The claimant contacted him by telephone the following day, stating that he missed the appointment because of stress and depression. Also in June 1997, the VA psychiatric examiner stated that the Axis I diagnosis was a differential between malingering and a pain disorder; that the degree and intensity of the inconsistencies and what appeared to be dramatizations, coupled with the claimant's preoccupation with legal and compensation issues, made him deeply concerned that this may be a malingered process. Other diagnoses were said to include a pain disorder with psychological features, which was also considered a strong possibility. In July 1997, the psychiatric diagnosis was again malingering versus a pain disorder. VA outpatient treatment records from the VAMC, Beckley, dated in July 1997, show that the claimant sought medication other than Motrin for leg, hip, back and neck pain. In September 1997, the claimant was seen for symptoms of an upper respiratory infection, with post-nasal drip, and multiple somatic pain complaints. He presented in a wheelchair, alleging that he was unable to walk, but had been seen walking in town and at the hospital with a cane, and there were significant other indications that the claimant could ambulate. It was noted that the claimant's file documented that he was not to be given class II or III narcotics. Examination showed that his chest was clear, and his abdomen was benign. The impression was upper respiratory infection with post-nasal drip. In November 1997, the claimant alleged that he was not eating well because of depression and chronic pain. It was noted that a n MRI scan of his cervical, thoracic and lumbar spine had been recommended to rule out any anatomical cause for the chronic pain the claimant is experiencing secondary to injuries he sustained in a 1992 fall, and that if an anatomical abnormality is identified, to refer him to the neurosurgical service. In November and December 1997, it was noted that a CT scan was negative, that the neurology clinic was unable to find much wrong with the claimant; and that a VA psychiatrist had affirmed a differential diagnosis between malingering and a pain disorder. The Axis I diagnosis in November and December 1997 was depressive disorder, nonspecific, with vague psychotic features, rule out major depression, recurrent; rule out malingering; rule out pain disorder associated with psychological and physical problems related to the accident of 1992; rule out personality disorder. By RO letter of February 1998, the claimant was asked to submit medical record release authorizations (VA Form s 21- 4142) for any medical evidence showing treatment during active service, or by private physicians or medical facilities after May 1974, or at any VA medical facility other than the VAMC, Beckley. A Supplemental Statement of the Case was provided the claimant and his representative on November 17, 1998, continuing the denial of his claims as not well grounded. He submitted a Substantive Appeal (VA Form 9) addressing all issues in January 1999. In January 1999, the claimant appointed a private attorney as his representative, revoking the previous appointment of The American Legion as such representative. He further requested a hearing before a traveling Veterans Law Judge of the Board of Veterans' Appeals. The case was before the Board in June 1999, and was Remanded to the RO for the claimant's requested hearing before a traveling Veterans Law Judge of the Board of Veterans' Appeals. A videoconference hearing was held at the RO in October 1999 before the undersigned Veterans Law Judge of the Board of Veterans' Appeals. During that hearing, the issues on appeal were identified. The claimant testified that he first hurt his back when he was pinned between two vehicles while stationed in Germany; that he was hospitalized for 2 or 3 days; that he subsequently hurt his back on two occasions while serving in Vietnam when jeeps turned over on him; that after the first such incident he was hospitalized for about a day; and that the last incident was asserted to have occurred while in combat. He related that he was currently receiving treatment, including medication, for his back problems; that he stopped working after he fell and hurt his lower back and neck in 1992. The claimant further reported treatment at the VAMC, Beckley, for a skin fungus and respiratory problem, as well as treatment at the VAMC, Washington, for headaches. He testified that he sustained a fracture of his pelvis in about 1983 when the jeep in which he was riding went over a bump while at summer camp with the Army Reserve; that he was hospitalized 3 to 5 days for the pelvic fracture; that he sustained no injury to his back during his Army Reserve service, but was seen by a doctor because his back symptoms. He further stated that he was not on active duty of serving with the Army National Guard when he was seen at Plateau Medical Center in November 1995. He testified that he injured his right leg running track while stationed in Germany when he hit one of the hurdles, and the next thing he knew, he woke up in the hospital because "he had passed out for 3 days"; that he remained in the hospital for about 3 weeks or more; and that while both his legs tingle, his right leg gives out on him a lot. The claimant further stated that while in Vietnam in 1968, an engineer's stake went through his right lateral lower leg, about 6-8 inches up from his ankle; that he had no therapy for that leg injury; and that his right leg. his right leg tingles worse than the left. He further stated that the injury running hurdles in 1968 was about 5 months before injuring his leg on an engineer's stake while in the Republic of Vietnam. He testified that since his 1992 accident, his right leg had gone numb on him. He testified that his pelvic fracture causes pain to his whole right side "all the time;" that the combination of his injuries to his legs, pelvis and back are the source of his inability to walk; and that a wheelchair was prescribed because of his back and legs. He testified that his skin disorder started in 1968 while he was in the Republic of Vietnam; that it currently involves his back and leg area; that he had not received any treatment for private physicians for his skin disorder and that he is not currently receiving any treatment for that condition. The claimant further testified that he developed ulcers in about 1968 when he was stationed in Vietnam; that he was given some kind of pill; that he subsequently received medications for VA doctors which coated his stomach and made him feel better; and that he currently uses about 3-4 bottles of Mylanta per week. He testified that he incurred a hernia while he was out of the Army; then suffered a recurrence of that hernia while in the Persian Gulf area; that he was sent to Germany before being sent to Walter Reed Army Hospital for surgery; and that his testicles hurt all the time because of that hernia. He testified that he had breathing and sinus problems while in Vietnam; that those symptoms became worse while in the Persian Gulf area; that he is currently using a Theo-Dur inhaler 3-4 times daily; and that his doctors have not told him the diagnosis of his respiratory problem. He asserted that he began to have headaches when he first went into service and was in basic training, and that the headaches have never resolved; that he takes 12-14 Tylenol daily for headaches; that he has never seen a private physician for his headache complaints; and that he described his complaints at the time of service separation. The claimant further complained that his service medical records were not complete. A transcript of the testimony is of record. Following the hearing, the case was again Remanded to the RO to obtain verification of the claimant's service in the Army National Guard during the Persian Gulf War, to obtain medical records of his treatment at Walter Reed Army Hospital; and to readjudicate his claims in light of the additional evidence obtained. In June 2000, the claimant appointed a veteran's service organization to represent him, thereby revoking all prior appointments for that purpose. While the case was thus in Remand status, the claimant submitted a Statement in Support of Claim (VA Form 21-4138), received in October 2001, in which he sought service connection for post-traumatic stress disorder (PTSD) and for schizophrenia. He asked that his claims file be transferred to the VARO Huntington. The claimant was provided a VA PTSD stressor questionnaire, but returned that document to the RO without completion, stating in the area provided for stressful events, that he heard screaming and bombing while at home, telling his grandmother to "get down", and fighting with his cousins. He provided no information as to dates, places, stressors, events, casualties, or units of assignment. In January 2001, the RO received notice from the National Personnel Records Center (NPRC) that no additional service medical records of the claimant were available; that all such records had previously been provided VA; and that no additional records were available at code 13. The RO subsequently received a copy of the claimant's DD Form 214 showing the claimant's service with the Army National Guard from September 23, 1990, to March 18, 1991, showing his service overseas for a period of 3 months, 27 days, and an Army separation report showing that he served in Desert Storm/Desert Shield. Multiple RO requests for the claimant's service medical records from his period of Army National Guard service from ARPCEN and from the headquarters of his unit was unavailing. A rating decision of April 2002 denied service connection for PTSD and schizophrenia. The claimant and his representative were notified of that action and of his right to appeal by RO letter of April 28, 2002. The claimant subsequently submitted additional service medical and personnel records. Those records show that while in Saudi Arabia in January 1991, the claimant sustained pain and numbness in the left thigh and groin area after lifting heavy equipment; that he was noted to be status post a right inguinal hernia repair; that the etiology of his injury was unknown, probably neuralgia parasitica; that he was given a physical profile in March 1991 prohibiting lifting over 25 pounds or performing lower extremity exercises because of status post right inguinal exploration; that he was treated at Kenner Army Community Hospital, Fort Lee, Virginia; and was sent to Walter Reed Army Hospital for follow-up treatment. A report of medical examination for service separation, conducted in March 1991, shows that the claimant underwent a right inguinal hernia repair; that he complained of chronic numbness and pain in the left thigh area, beginning in December 1991, not associated with trauma; and that range of motion and muscle strength were normal. There was no complaint or finding of any abnormalities of the head, neck, nose, sinuses, throat, lungs or chest, no abnormalities of the abdomen, stomach or viscera except for the noted hernia, and no abnormalities of the skin, back, lower extremities, or musculoskeletal system except for the noted postoperative pain and numbness in the left thigh area. A rating decision of May 2002 granted service connection for a postoperative right inguinal hernia scar, rated as noncompensably disabling, effective January 23, 1996. The claimant and his representative were notified of that action and of his right to appeal by RO letter of June 4, 2002. A Supplemental Statement of the Case was provided the claimant and his representative on May 30, 2002, addressing the issues of service connection for a back disability, a right leg disability, residuals of a fractured pelvis, a skin disorder, peptic ulcer disease, a respiratory disability, and headaches. In May 2002, the claimant submitted a Notice of Disagreement with the denial of his claims for service connection for PTSD and for schizophrenia. With that document, he enclosed a copy of a Technical Information Bulletin from the State of Louisiana, dated September 21, 1999, and another VA PTSD stressor questionnaire, which provided no useful information, but noted the deaths of individuals whom he could not name. A Statement of the Case was provided the claimant and his representative in January 2003. No Substantive Appeal (VA Form 9) has been received from the claimant addressing the issue of service connection for PTSD or schizophrenia as of the date of this decision. II. Analysis In order to establish service connection for claimed disability, the facts, as shown by evidence, must demonstrate that a particular disease or injury resulting in current disability was incurred during active service or, if preexisting active service, was aggravated therein. 38 U.S.C.A. §§ 1110, 1131 (West 2000); 38 C.F.R. § 3.303(a) (2002). Service connection may also be granted on a presumptive basis for certain chronic disabilities, including organic diseases of the central nervous system, arthritis, and peptic ulcer disease, when manifested to a compensable degree within the initial post service year. 38 C.F.R. §§ 3.307, 3.309(b) (2002). A veteran who served during a period of war or during peacetime service after December 31, 1946, is presumed in sound condition except for defects noted when examined and accepted for service. 38 U.S.C.A. § 1111, 1137 (West 2000). Clear and unmistakable evidence that the disability existed prior to service will rebut this presumption. 38 U.S.C.A. § 1111 (West 2000); 38 C.F.R. § 3.304(b) (2002). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated while performing active duty for training (ACDUTRA) or for injury incurred or aggravated while performing inactive duty for training (INACDUTRA). Active service is defined as including any period of inactive duty training during which the claimant is disabled or died from an injury incurred or aggravated in line of duty or from a covered disease which occurred during such training. For purposes of this section, the term "covered disease" is limited to (1) an acute myocardial infarction, (2) a cardiac arrest, or(3) a cerebrovascular accident. 38 U.S.C.A. §§ 101(24), 1110, 1131 (West 2000); 38 C.F.R. § 3.6 (2002). Prior to November 1, 2000, nontraumatic recurrence or aggravation of a disease process during a period of inactive duty for training was not defined as an injury. For example, manifestations of cardiovascular disease, such as a myocardial infarction of nontraumatic origin, were not to be considered an "injury" to meet the requirements of 38 C.F.R. § 3.6. Where service medical records are absent, the Court has held that the Board had a heightened duty to provide reasons and bases for its findings and conclusions. See O'Hare v. Derwinski, 1 Vet. App. 365 (1991). The general rule is that where evidence to prove a fact is peculiarly within the knowledge and competence of one of the parties, fairness requires that party to bear the burden of coming forward. By conducting both induction and physical examinations, the government is in the best position to have reliable medical evidence about any changes in a preexisting or other medical condition. If it does not, it cannot penalize the veteran, in whose favor all doubts are to be resolved. Jensen v. Brown, 19 F.3d. 1413 (Fed. Cir. 1994). The record shows that the only service medical records which are reasonably complete are those from January 1972 to the claimant's service separation examination in April 1974, and the claimant's service separation examination in March 1991. As the claimant's service entrance examination is not available, the claimant is entitled to the presumption of soundness at service entry. Service connection generally requires: (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. See Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); Caluza v. Brown, 7 Vet. App. 498 (1995); see also Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Savage v. Gober, 10 Vet. App. 488, 497 (1997). Where the determinative issue involves medical etiology or a medical diagnosis, competent medical evidence is required to support this issue. See Epps, supra.; Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). This burden may not be met merely by presenting lay testimony, because lay persons are not competent to offer medical opinions. See Epps, supra; Grottveit, supra; Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). In addition, a claim may be established under the provisions of 38 C.F.R. § 3.303(b) when 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 a condition. Such evidence must be medical unless it relates to a condition as to which, under the case law of the United States Court of Appeals for Veterans Claims (Court), lay observation is competent. If the chronicity provision is not applicable, a claim may still be established or reopened on the basis of § 3.303(b) if the condition observed during service or any applicable presumption period still exists, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488, 498 (1997). Chronic manifestations of any of the disabilities at issue were not clinically demonstrated or diagnosed during active service, and continuity of symptomatology has not been demonstrated. In determining whether an appellant is entitled to service connection for a disease or disability, VA must determine 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 the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(b) (West 2000); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The United States Court of Appeals for Veterans Claims (the Court) has held, in pertinent part, that the term "disability" as used in 38 U.S.C.A. § 1110 (West 2000) refers to impairment of earning capacity, and that such definition mandates that any additional impairment resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, shall be compensated (emphasis in original). Thus, pursuant to 38 U.S.C.A. § 1110 (West 2000) and 38 C.F.R. § 3.310(a) (2002), when aggravation of a veteran's nonservice-connected condition is proximately due to or the result of a service- connected condition, such veteran shall be compensated for the degree (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439,448 (1995). The claimant's service- connected disabilities have not been implicated in any other disability alleged by the claimant. Evidence of the veteran's current condition is not generally relevant to the issue of service connection, absent some competent linkage to military service. See, e.g., Morton v. Principi, 3 Vet. App. 508, 509 (1992); Mingo v. Derwinski, 2 Vet. App. 51, 53 (1992). The duty to assist is not a one-way street. If a veteran wishes help in developing a claim, he or she cannot passively wait for it in those circumstances where he or she may or should have evidence that is essential in obtaining putative evidence. Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996); Wood v. Derwinski, 1 Vet. App. 190, 192 (1991); reconsidered, 1 Vet. App. 406 (1991). Again, the Federal Circuit Court has held that the general rule is that where evidence to prove a fact is peculiarly within the knowledge and competence of one of the parties, fairness requires that party to bear the burden of coming forward. Jensen v. Brown, 19 F.3d.1413 (Fed. Cir. 1994). The record in this case shows that the claimant was informed by RO letters of March, June, and July 1996 of the need to submit medical or nonmedical evidence in support of his claims, but failed to submit any such evidence apart from the November 1995 hospital summary from Plateau Medical Center. The Court has held that a lay person, such as the claimant, is not competent to offer evidence that requires medical knowledge, such as the diagnosis or cause of a disability. See Ramey v. Brown, 9 Vet. App. 40 (1996); Cromley v. Brown, 7 Vet. App. 376, 379 (1995); Holland v. Brown, 6 Vet. App. 443 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). If such evidence is not competent, it cannot be probative. As causative factors of a disease amount to a medical question; only a physician's opinion would be competent evidence. Gowen v. Derwinski, 3 Vet. App. 286, 288 (1992). A claimant's statements as to nexus are entitled to no probative weight. Layno v. Brown, 6 Vet. App. 465 (1994). The Court has held, however, that a veteran's statements are competent as to the onset and continuity of symptomatology, including pain. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 405 (1995). It is the Board's responsibility to evaluate the credibility and probative value of proffered evidence in relation to the record in its whole. See, e.g., Owens v. Brown, 7 Vet. App. 429, 433 (1995); Guimond v. Brown, 6 Vet. App. 69, 72 (1993); Hensley v. Brown, 5 Vet. App. 155, 161 (1993). The Board must account for the evidence that it finds persuasive or unpersuasive and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). This is critically important in a claim for service connection as frequently there is medical evidence in the form of a nexus opinion both for and against the claim. And it is not error for the Board to favor one competent medical expert over another when the Board gives an adequate statement of reasons and bases. Owens v. Brown, 7 Vet. App. 429, 432-3 (1995). In assessing such evidence, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). In some cases, the physician's special qualifications or expertise in the relevant medical specialty or lack thereof may be a factor. In every case, the Board must support its conclusion with an adequate statement of its reasoning of why it found one medical opinion more probative than the other. Self interest may effect the credibility of testimony, although not the competency to testify. Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) An appellant's sworn statement, then, unless specifically found incredible or sufficiently rebutted, may serve to place the evidence in equipoise. The VA may not ignore the appellant's sworn testimony simply because he is an interested party. Smith, id., at 147, 148; Cartwright, id., at 24, 25. Credibility is a factual determination going to the probative value of the evidence, and is made after the evidence is admitted. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). With the enactment of the Persian Gulf War Veterans' Benefits Act, Title I of Public Law No. 103-446 (Nov. 2, 1994), a new section 1117 was added to Title 38, United States Code. To implement the Persian Gulf War Veterans' Benefits Act, VA issued a new regulation, entitled "Compensation for certain disabilities due to undiagnosed illnesses," which provides as follows: (a)(1) 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, 2006; 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. (b) 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 and symptoms involving skin (3) Headache (4) Muscle pain (5) Joint pain (6) Neurologic signs and symptoms (7) Neurophysiological 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 (c) Compensation may 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. (d) 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. On July 6, 2001, the Secretary of Veterans Affairs, under the relevant statutory authorities, determined that at that time there was no basis for establishing a presumption of service connection for any illness suffered by Gulf War veterans based on exposure to depleted uranium, sarin, pyridostigmine bromide, and certain vaccines. See 66 Fed. Reg. 35702-35710 (July 6, 2000), and 66 Fed. Reg. 58784-58785 (Nov. 23, 2001). As a preliminary matter, the Board must determine whether the appellant, who served on active duty with the United States Army in the Southwest Asia theater of operations from November 1990 to April 1991 during the Persian Gulf War submitted objective indications of chronic disability which result from one or more signs or symptoms which became manifest either during active service in the Southwest Asia theater of operations during the Gulf War, or to a degree of 10 percent not later than December 31, 2006, and by history, physical examination, and laboratory tests it cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. §§ 1117 (West 2000); 38 C.F.R. §§ 3.317 (2002). Service Connection for a Back Disability The record in this case shows that the claimant has alleged that he sustained back injury in jeep accidents in 1967 and in 1972. However, the available medical records show no notation of a 1967 jeep accident The service medical records dated in November 1972 show that the claimant asserted that he was in an automobile accident, with no reference to a jeep turning over; and that he was shown to be ambulatory, with complaints which included paraspinous tenderness over the mid- and low back. No treatment was provided, and no further complaint, treatment, findings or diagnosis of back symptoms were noted during the claimant's remaining period of active service. At the time of his service separation examination in April 1974, the claimant complained of recurrent back pain, while his service separation examination revealed no abnormalities of the spine, lower extremities, or musculoskeletal or neurological system. In March 1991, his spine, musculoskeletal amd neurological system, and lower extremities were normal. While the claimant was informed by RO letters of March, June and July 1996 of the necessity for submitting medical evidence in support of his claims, the only evidence forthcoming was a November 1995 hospital summary from Plateau Medical Center which cited a history of back pain, without objective clinical findings other than subjective tenderness over the lumbar spine, with normal movement of the extremities, and a diagnosis of low back strain was offered by history, without any association to active service. Further, VA outpatient treatment records from the VAMC, Beckley, are silent for complaint, treatment, findings or diagnosis of back symptoms at any time prior to the claimant's October 1992 on-the-job injury, which is the only claimed back injury which has any evidentiary support in the medical record. Based upon the foregoing, the Board finds that a chronic back disability was not clinically manifest during active duty, on service separation examination, during any applicable presumptive period, or at any time prior to an October 1992 on-the-job injury. The RO examination conducted in March 1997, diagnosed traumatic back sprain with radiculopathy, and X-ray evidence of early degenerative arthritis, which were associated with the October 1992 on-the-job injury. Such findings and diagnoses are not undiagnosed illnesses; and a back injury has not been linked or related to active service by competent medical evidence or opinion, but has been specifically attributed to his October 1992 on-the-job injury. Based upon the foregoing, and for the reasons and bases stated, the Board finds that the record does not support a finding that any current back disability of the claimant was incurred during active service. Rather, the Board concludes that such is the result of an October 1992 on-the-job injury, and is unrelated to any incident during active service. Accordingly, service connection for a back disability on a direct or presumptive basis, or as an undiagnosed illness due to Persian Gulf War service, must be denied. Service Connection for a Chronic Respiratory Condition The record in this case shows that a chronic respiratory condition was not clinically demonstrated or diagnosed during active duty, on service separation examination, or during any applicable presumptive period. At the time of service separation in April 1974, the claimant himself described his symptoms as frequent colds, sinusitis, and hay fever. The claimant's service separation examinations in April 1974 and in March 1991 disclosed no abnormalities of the nose, sinuses, throat, lungs or chest, and a chest X-ray was negative, while the VA respiratory examination in March 1997 revealed normal chest X-rays and spirometry. An upper respiratory infection, with nasal congestion and draining sinuses, shown briefly during active service and subsequently, are not undiagnosed illnesses, but appear to be residuals of a common cold. Further, the record in this case does not demonstrate continuity of symptomatology with respect to the claimant's claimed respiratory disorder. Based upon the foregoing, and for the reasons and bases stated, the Board finds that the record does not support a finding that any current respiratory condition of the claimant was incurred during active service, or during any applicable presumptive period, or that such is an undiagnosed illness due to Persian Gulf War service. Accordingly, service connection for a chronic respiratory condition on a direct or presumptive basis, or as an undiagnosed illness due to Persian Gulf War service, must be denied. Service Connection for a Chronic Headache Disorder A chronic headache disorder was not shown during active duty, on service separation examination, or during any applicable presumptive period, and the available service medical records show a single complaint of headache in December 1972. The record shows that recurrent tension headaches and post- traumatic headaches have been specifically attributed by competent medical evidence to his October 1992 on-the-job injury and are not undiagnosed illnesses. The claimant has offered sworn testimony that his complaints of headaches originated in boot camp. However, his service separation examinations in April 1974 and March 1991 disclosed that his head and sinuses were normal, and there were no findings of a neurological disorder. Further, the record in this case does not demonstrate continuity of symptomatology with respect to the claimant's claimed chronic headache disorder. The contemporaneous documents are more reliable than the veteran's recollections of events spanning more than twenty- five years. Thus, a clear preponderance of the evidence supports findings that the headaches the veteran had in boot camp resolved without resulting in a lasting disability, and that the current headaches are the result of an injury that was unrelated to service. Based upon the foregoing, and for the reasons and bases stated, the Board finds that the record does not support a finding that any current headache disorder of the claimant was incurred during active service, or during any applicable presumptive period, or that such is an undiagnosed illness due to Persian Gulf War service. Accordingly, service connection for a chronic headache disorder condition on a direct or presumptive basis, or as an undiagnosed illness due to Persian Gulf War service, must be denied. Service Connection for a Scar as Residual to a Right Leg Injury While a right leg injury was not shown during active service, the claimant has reported sustaining a right lower leg injury on an engineer's stake, and his service separation examination in April 1974 showed a scar of the right lower leg. As previously noted, in the absence of a service entrance examination, the claimant is entitled to the presumption of soundness at entry. Based upon the foregoing, and with consideration of the clinical findings of a scar of the right lower leg on service separation examination, service connection for a scar of the right leg as residual to an inservice right lower leg injury is granted. Service Connection for Residuals of a Fractured Pelvis The claimant has asserted that he sustained a fractured pelvis when a jeep in which he was riding went over a bump. However, the record on this case is devoid of any medical evidence of such injury, none was shown on service separation examination in March 1991, while on VA examination in March 1997, X-rays were negative for evidence of a pelvic fracture. The Board notes that the claimant has asserted that he sustained a pelvic fracture in 1983, and that it is neither contended nor established that any pelvic disorder had its onset during the Persian Gulf War. As noted, a service connection claim must be accompanied by evidence which establishes that the claimant currently has the claimed disability. See Caluza v. Brown, 7 Vet. App. 498 (1995), affirmed per curiam, 78 F.3d 604 (Fed. Cir. 1996); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). In the instant appeal, the medical evidence includes no clinical or radiographic findings, or competent medical diagnosis of a fractured pelvis in the claimant, and he does not meet the minimum requirements for an allowance of service connection for such disability on a direct or secondary basis, or as an undiagnosed illness due to Persian Gulf War service in the absence of such diagnosis. Based upon the foregoing, and for the reasons and bases stated, the Board finds that the claim for service connection for residuals of a fractured pelvis must be denied. Service Connection for a Chronic Skin Condition The medical evidence of record does no demonstrate a chronic skin condition during active duty, on service separation examinations, during any applicable presumptive period, or on VA examinations in March 1997. The claimant has testified that he has not received any treatment from private physicians for his skin condition, and that he is not currently under treatment for such. The Board further notes that jock itch (tinea cruris), folliculitis, militaria ribra, and pruritis are not undiagnosed illnesses. Based upon the foregoing, and for the reasons and bases stated, the Board finds that the record does not support a finding that any current skin condition of the claimant was incurred during active service, or during any applicable presumptive period, or that such is an undiagnosed illness due to Persian Gulf War service. Accordingly, service connection for a chronic skin condition on a direct or presumptive basis, or as an undiagnosed illness due to Persian Gulf War service, must be denied. Service Connection for Peptic Ulcer Disease The record shows that peptic ulcer disease was not clinically demonstrated or diagnosed during active duty, on service separation examination, during any applicable presumptive period, or on VA examination in March 1997. Gastritis from taking Motrin is not an undiagnosed illness. The record shows that the claimant was repeatedly informed of the necessity of submitting medical or nonmedical evidence of the disabilities claimed, and that he had not submitted any medical evidence showing a diagnosis of peptic ulcer disease during active duty, on service separation examination, during any applicable presumptive period, or on VA examination in March 1997. In addition, evidence showing that the claimant currently has peptic ulcer disease would not establish, or tend to make more likely, that such was present during active service or within any applicable presumptive period. In the absence of clinical evidence of peptic ulcer disease during active service or within any applicable presumptive period, a medical opinion as to whether any current peptic ulcer disease is related to active service would lack any factual predicate. 38 U.S.C.A. § 5103A (West 2000). Based upon the foregoing, and for the reasons and bases stated, the Board finds that the record does not support a finding that the claimant has peptic ulcer disease which was incurred during active service, or during any applicable presumptive period, or that such is an undiagnosed illness due to Persian Gulf War service. Accordingly, service connection for peptic ulcer disease on a direct or presumptive basis, or as an undiagnosed illness due to Persian Gulf War service, must be denied. In reaching its decisions, the Board has considered the doctrine of reasonable doubt, however, as the evidence is not in equipoise, or evenly balanced, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a back disability is denied. Service connection for a respiratory condition is denied. Service connection for a headache disorder is denied. Service connection for a scar of the right lower leg condition is granted. Service connection for residuals of a fractured pelvis is denied Service connection for a skin condition is denied. Service connection for peptic ulcer disease is denied. ____________________________________________ G. H. Shufelt Veterans Law Judge, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.