Citation Nr: 1009840 Decision Date: 03/15/10 Archive Date: 03/24/10 DOCKET NO. 99-14 996 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for respiratory problems, including sinusitis and/or rhinitis), to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C. § 1117. 3. Entitlement to service connection for right elbow disability, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117. 4. Entitlement to service connection for body aches and joint pain, including low back, hip, neck and bilateral knee pain, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117. 5. Entitlement to service connection for sleep impairment, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117. 6. Entitlement to service connection for fatigue, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117. 7. Entitlement to service connection for night sweats, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117. 8. Entitlement to service connection for memory loss, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117. 9. Entitlement to service connection for headaches, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117. 10. Entitlement to service connection for skin rash, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117. ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran had active military service from November 1980 to March 1981, from November 1990 to June 1991, and from December 2003 to March 2005. Service personnel records also reflect that the Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War from January to May 1991. Additionally, the Veteran served in the Army National Guard. This appeal arises from a March 1999 rating decision that denied the Veteran's claims for service connection for migraine headaches, allergic rhinitis, tinea versicolor, right elbow pain and numbness, body aches and joint pain, each on a direct basis and as due to chronic disability resulting from undiagnosed illness (associated with Persian Gulf service). The RO also denied service connection for PTSD (claimed as a sleep disorder, fatigue, night sweats, and memory loss). The Veteran filed a notice of disagreement (NOD) in April 1999 and the RO issued a statement of the case (SOC) in May 1999. The Veteran filed a substantive appeal (via a VA Form 9 Appeal to the Board of Veterans' Appeals) in May 1999. In November 2000, the Board remanded these matters to the RO for further evidentiary development. In the remand, the Board characterized the claims for service connection for sleep impairment, fatigue, night sweats, and memory loss as individual claims separate and distinct from the claim for service connection for PTSD. The RO followed suit in a November 2002 supplemental SOC (SSOC), which reflects the RO's continued denial of the claims. In March 2003, the Board undertook additional development of the claims on appeal pursuant to the provisions of 38 C.F.R. § 19.9 (2002) and Board procedures then in effect. The Veteran was notified of that development by letter of April 2003. In August 2003, the Board remanded the matters of service connection for headaches, respiratory problems (claimed as sinusitis and/or rhinitis), skin rash, right elbow pain and numbness, body aches and joint pain, sleep impairment, fatigue, night sweats, memory loss and PTSD to the RO via the Appeals Management Center (AMC) for completion of the actions requested. At that time, it was noted that the provisions of 38 C.F.R. § 19.9 essentially conferring upon the Board jurisdiction to adjudicate claims on the basis of evidence developed by the Board, but not reviewed by the RO, had been held to be invalid. See Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). In an August 2006 rating decision, the RO granted service connection for allergic rhinitis (based only on the Veteran's final period of service, from December 2003 to March 2005, PTSD (based on the Veteran's final period of service only), degenerative joint disease of the bilateral knees (based on the Veteran's final period of service only), lumbosacral strain (based on the Veteran's final period of service), right shoulder strain and left shoulder strain. The RO also denied service connection for sinusitis based on the Veteran's final period of service only. As determined by the RO and as reflected on the title page, because the August 2006 rating decision only addressed the issues of whether service connection for allergic rhinitis, sinusitis, joint disability (i.e. degenerative joint disease of the bilateral knees and the low back) and PTSD was warranted for the Veteran's final period of service, the claims for service connection for these disabilities remain on appeal based on the Veteran's earlier periods of service. In this regard, the Board notes that the Veteran is primarily alleging that these disabilities were incurred during his second period of service. Thereafter, in a January 2007 SSOC, the AMC continued the denial of the claims for service connection for headaches, respiratory problems (claimed as sinusitis and/or rhinitis), skin rash, right elbow pain, body aches and joint pain, sleep impairment, fatigue, night sweats, and memory loss. The AMC then returned the matters to the Board for further appellate consideration. Specifically regarding the Veteran's remaining claim for PTSD, the Board notes that in the August 2003 Remand, the Board instructed the RO to make further attempts to corroborate the Veteran's reported stressors of SCUD missile alerts and witnessing carnage related to the ground war, to specifically include seeking verification of the stressors from the U.S. Army and Joint Services Environmental Support Group (USACRUR), as the Board had instructed in the November 2000 remand. The RO did subsequently seek such verification from USACRUR and in December 2006, USACRUR, by then renamed as the U.S. Armed Services Center for Unit Records Research (CURR), provided a report concerning the activities of the Veteran's unit during Operation Desert Storm/Desert Shield. However, the RO did not include the issue of entitlement to service connection for PTSD (based on the Veteran's second period of service) in the subsequent January 2007 SSOC and did not otherwise readjudicate this claim. In May 2007, the Board again remanded the case for further development, including association with the claims file of the service treatment records for the Veteran's final period of service and of reports of VA examinations from June 2006, July 2006 and August 2006. Unfortunately, however, the Board did not recognize that the Veteran's claim for service connection for PTSD based on the Veteran's second period of service was still on appeal. Given this state of the record, this claim would normally have to be remanded for issuance of an SSOC. However, as explained in the analysis below, as there is sufficient evidence of record for the Board to grant the claim, a Remand is unnecessary. The Board's decision on the claim for entitlement to service connection for PTSD, and entitlement to service connection for respiratory problems (claimed as sinusitis and/or rhinitis), right elbow pain and numbness, body aches and joint pain, sleep impairment, fatigue, night sweats and memory loss, all to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117, are set forth below. The claims for service connection for headaches and skin rash are addressed in the remand following the order; these matters are remanded to the RO, via the AMC. VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim herein decided have been accomplished. 2. The Veteran's current PTSD results in part from a corroborated stressor event during his second period of active service from November 1990 to June 1991, exposure to alerts associated with SCUD missile attacks. 3. The Veteran's respiratory problems, to include allergic rhinitis and sinusitis, are reasonably shown to have been incurred during his second period of active service from November 1990 to June 1991. 4. The Veteran's right elbow disability, diagnosed as cubital tunnel syndrome, is reasonably shown to have been incurred in service. 5. Aside from his right elbow disability, the Veteran's body aches and joint pain are limited to pain in the neck, bilateral knees and back; the Veteran is not shown to have a neck disability, and was not shown to have a bilateral knee disability prior to his final period of service. 6. The Veteran's low back disability, diagnosed as degenerative joint disease, and more recently diagnosed as lumbosacral strain, is not shown to be related to service. 6. The Veteran's sleep problems and night sweats are shown to be symptoms of his PTSD and are not shown to be independent disabilities. 7. The Veteran's fatigue is not shown to be disabling and is shown to be related to his problems sleeping, which is a symptom of the service-connected PTSD, and does not constitute a separately diagnosed disability. 8. The Veteran is not shown to have a memory loss disability. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are met. 8 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125(a) (2009). 2. The criteria for service connection for respiratory problems to include sinusitis and rhinitis, are met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2009). 3. The criteria for service connection for right elbow disability, claimed as right elbow pain and numbness, are met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2009). 4. The criteria for service connection for body aches and joint pain, including pain in the back, neck, hip and bilateral knees, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C. § 1117, are not met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2009). 5. The criteria for service connection for sleep impairment, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117, are not met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2009). 6. The criteria for service connection for night sweats, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117, are not met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2009). 7. The criteria for service connection for fatigue, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117, are not met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2009). 8. The criteria for service connection for memory loss, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117, are not met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2009)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2009). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353- 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: Veteran status, existence of a disability, a connection between a Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, in a March 2005 post-rating letter, the RO provided notice to the Veteran regarding what information and evidence was needed to substantiate the Veteran's claims for service connection, to include those associated with service in Southwest Asia during the Gulf War, as well as what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. The letter also specifically informed the Veteran to submit any evidence in his possession pertinent to the claims on appeal (consistent with Pelegrini and the version of 38 C.F.R. § 3.159 then in effect). A subsequent May 2007 letter provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. After issuance of the May 2007 letter, and opportunity for the Veteran to respond, the December 2009 SSOC reflects readjudication of the claims. Hence, the Veteran is not shown to be prejudiced by the timing of the post-rating notices. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). Regarding to the Veteran's claim for service connection for PTSD, given the favorable outcome detailed below, an assessment of VA's duties under the VCAA is not necessary. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters herein decided. Pertinent medical evidence associated with the claims file consists of the service treatment records for the Veteran's first two periods of active duty and for his National Guard service, and the reports of numerous VA examinations. Also of record and considered in connection with the appeal are various written statements provided by the Veteran. The Board notes that in the May 2007, the Board instructed the RO to attempt to associate the service treatment records pertaining to the Veteran's final period of active service. In response the RO attempted to obtain the records from the National Personnel Records Center (NPRC) and then, after receiving a negative response, made five separate attempts to obtain the records from the Veteran's U.S. Army Reserve unit. However, all of these attempts were unsuccessful. The RO then made a formal finding of unavailability of the records in November 20, 2009. Although, it does not appear that the RO actually received a negative response from the Veteran's reserve unit pertaining to the availability of the records, given that they attempted to obtain the records on five separate occasions, the Board finds that the RO substantially complied with the Board's remand request (See Dyment v. West¸ 13 Vet. App. 141, 146-47 (1999) -remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with) and that a further remand to attempt to obtain the records would impose unnecessary additional burdens on adjudication resources, with no benefit flowing to the Veteran, and is, thus, unnecessary. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). The Board notes that no further RO action, prior to appellate consideration of any of these claims, are required. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO, the Veteran has been notified and made aware of the evidence needed to substantiate the claim(s), the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim(s). Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter(s) herein decided, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO, the Veteran has been notified and made aware of the evidence needed to substantiate the claim(s), the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim(s). Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter(s) herein decided, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Such a determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) [i.e., a diagnosis under DSM-IV]; a link, established by medical evidence, between current symptoms and a stressor event in service; and credible supporting evidence that the claimed stressor event in service occurred. 38 C.F.R. § 3.304(f). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2005). If, however, VA determines either that the Veteran did not engage in combat with the enemy or that he or she did engage in combat, but that the alleged stressor is not combat related, then his or her lay testimony, in and of itself, is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain service records or other evidence that corroborate his or her testimony or statements. See Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). See also Cohen, 10 Vet. App. 128, 142 (1997). A Persian Gulf Veteran is defined as a Veteran who served on active duty in the Armed Forces in the Southwest Asia Theater of operations during the Persian Gulf War. See 38 U.S.C.A. § 1117(f); 38 C.F.R. § 3.317(d). The Board notes that, during the pendency of this appeal, Congress revised 38 U.S.C.A. § 1117, effective March 1, 2002. In the revised statute, the term "chronic disability" was changed to "qualifying chronic disability," and the definition of "qualifying chronic disability" was expanded to include (a) undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. Effective June 10, 2003, VA promulgated revised regulations to, in part, implement these statutory changes. See 38 C.F.R. § 3.317(a)(2). The Board notes that the Veteran was provided notice of the revised legal authority via the July 2006 SSOC. Under 38 U.S.C. § 1117(a)(1), compensation is warranted for a Persian Gulf Veteran who exhibits objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. Effective December 18, 2006, VA extended the presumptive period in 38 C.F.R. § 3.317(a)(1)(i) through December 31, 2011 (for qualifying chronic disabilities that become manifest to a degree of 10 percent or more after active duty in the Southwest Asia theater of operations). See 71 Fed. Reg. 75669 (2006). Furthermore, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a), (b). The term "objective indications of a qualifying chronic disability" include both "signs," in a medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. See 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or a chronic multi-symptom illness include the following: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. See 38 U.S.C.A. § 1117(g). The Veteran in the instant case served in the Southwest Asia Theater of operations during the Persian Gulf War. Hence, for purposes of the pertinent statute and regulation, he is a Persian Gulf Veteran. However, as indicated below, to give the Veteran every consideration in connection with each claim for service connection where an allegation of undiagnosed illness has been raised, the Board has (as the RO has done) considered not only 38 C.F.R. § 1117, but other legal authority governing claims for service connection under alternative theories of entitlement. A. PTSD Service treatment records do not reveal any findings of psychiatric pathology during service or that the Veteran received any mental health treatment. On his June 1996 periodic report of medical history the Veteran did report that he had been seen for "trouble sleeping" 1 to 2 times per week. He also reported that he was not taking any prescription medications. On January 1999 VA psychiatric examination, the Veteran reported difficulties associated with his time in the Gulf War. His mood was such that he did not feel like being around other people. He indicated that he had a rough time in the Gulf, living in the desert. He was worried about scorpions, and this disturbed his sleep greatly. In addition, after getting into the country, he found that he would take a shower and then get fully dressed afterwards because he was always afraid of SCUD missile alerts and it was very difficult for him to relax. He was not involved in combat but remembers as a truck driver driving through the ground war area where tanks were still smoking and seeing the carnage on the ground. At times he felt like shadows were following him and he was very jumpy to loud noises and would be bothered by taps on his shoulder. He was not particularly disturbed by violence and his wife described him as having a temper. At times he felt depressed. Mental status examination showed an o.k. mood with a slightly depressed affect. Speech was slow and soft. Memory was fair for immediate, recent and remote events. The Veteran was able to concentrate well enough to spell backwards and interpret a proverb. The examiner diagnosed the Veteran with PTSD. He noted that the Veteran was exhibiting mild signs of PTSD, which was shown in his sleep disturbance, exaggerated startle response, isolation and some avoidance behavior. The stressor was somewhat difficult to determine but seemed to be associated with his lack of sleep and inability to relax and frequently being on edge during his service in the Gulf War, to the point of fearing for his safety. On April 2002 VA psychiatric examination, the examiner indicated that the Veteran denied that he had a mental condition but did report that he had sleep problems. Regarding potential stressors in service, the Veteran indicated that while he was in Saudi Arabia, he lived in a high rise apartment and did not get sleep because SCUD missile attack alerts were occurring and he would have to run down the stairs when the building was on alert. The Veteran indicated that the SCUD missiles did not actually hit anywhere closer than 100 miles away. The Veteran also indicated that in late January or early February of 1991 he was on a bus in Saudi Arabia and a Patriot missile intercepted a SCUD somewhere in the air above the bus and everyone went on a MOPP 4 alert and had to put on their chemical suits. Additionally, in March or April 1991, the Veteran was close by when a truck caught fire and exploded because it was carrying ammunition. Some shrapnel was thrown down into the compound, which injured two people who had to be sent home. The examiner found that there was no evidence of PTSD but that the Veteran did report some sleep problems, which seemed to be stressful to him at times. The examiner estimated the Veteran's level of disability to be slight due to his sleep difficulties but he did not appear to have a complete Axis I diagnosis. In a December 2006 report, the Center for Unit Records Research (CURR), found that the Veteran's unit, the 1052nd Transportation Company, arrived in Southwest Asia on January 20, 1991 at the King Fahd International Airport and moved to the Al Khobar Towers in Damman. The unit remained at this location providing port clearance throughout its deployment to Southwest Asia. On February 3rd and 4th, 82 personnel of the 158 assigned moved forward and colocated with the 286th Supply and Service Battalion at Tactical Assembly Area Roosevelt, leaving a cell at port to receive the unit's equipment that was still due in port. The port cell continued to provide port clearance as the forward group gave support to the 1174th Quartermaster Company. On February 17, 1991 the forward group moved to Junction City and became operationally controlled by the 87th Maintenance Battalion and prepared to move north. On February 20, 1991, the port cell was reduced to 15 persons and the majority of the unit was located at Junction City. After a nine day mission supplying the allied advance with ammunition carried on trucks and trailers, beginning on February 22, 1991, this cell moved to a location 20 miles north of the Kuwait Airport where it remained until April 20, 1991, assisting the 3rd Armored Division pulling out of Kuwait following the cease fire. CURR also reviewed an information paper regarding the SCUD missiles fired during the 1990 to 1991 Gulf War. See http://www.gulfling.osd.mil/scud_info_ii/. The paper indicates that there were seven SCUD missile attacks in the general Damman/Dhahran/Al Khobar area during the time period the unit was base camped there, including five attacks in January (while all members of the unit were still based at Al Khobar). An attack on Dharan on January 20, 1991 was specifically noted to have resulted in a 6 or 7 hour MOPP IV level (i.e. full chemical protection) alert. On July 2006 VA psychological evaluation, the Veteran reported sleep difficulty, wanting to be by himself too much, nightmares, night sweats and intrusive thoughts. He also reported avoidance of crowds, hypervigilance, problems with anger control, emotional blunting, loss of interest in activities and feeling tense and keyed up most of the time. He avoided programs about the war and did not watch the news from Iraq. The examiner commented that the Veteran was presenting with symptoms of PTSD, which was related to his experiences during Operation Iraqi Freedom and to a lesser extent to his experience in Desert Storm. At the outset, the Board notes, as mentioned above, service connection for PTSD has already been granted for the Veteran's final period of service so the instant appeal is limited to determining whether service connection is warranted for PTSD based on the Veteran's second period of active service (the Veteran has not alleged any stressor events relating to his first period of active service, nor has he alleged any stressor events during any Active Duty for Training (ACDUTRA) or Inactive Duty for Training (INACDUTRA) that he may have completed while a member of the Army National Guard). The evidence reasonably establishes a PTSD diagnosis, based on the findings of the January 1999 VA examination and confirmed by the findings of the July 2006 VA psychological evaluation. In this regard, although the April 2002 VA examination did not produce a diagnosis of PTSD, the Board finds that this finding is outweighed by the January 1999 and July 2006 VA examination findings, given their agreement that the Veteran met the relevant PTSD diagnostic criteria. The evidence also reasonably establishes a link between the Veteran's symptoms and a stressor event in service. In this regard, the January 1999 examiner found that the stressor leading to his PTSD symptoms seemed to be associated with his lack of sleep and frequently being on edge, to the point of fearing for his safety while stationed in the Gulf. Also, the July 2006 VA examiner more generally found that the Veteran's PTSD, while primarily related to his experiences during Operation Iraqi Freedom, was to a lesser extent related to his experiences in Desert Storm. Additionally, the Board finds that there is credible supporting evidence that one of the Veteran's claimed stressor events during his second period of service actually occurred. Notably, corroboration of every detail of a stressor event, including the Veteran's personal participation, is not required; rather, there only needs only to be independent evidence of a stressful event that is sufficient to imply the Veteran's personal exposure. Suozzi v. Brown, 10 Vet. App. 307 (1997). See also Pentecost v. Principi, 16 Vet. App. 124 (2002). In the instant case, the Veteran reported that a primary reason that he was on edge and fearful for his life during his Desert Storm service, was his fear of SCUD missile attacks. The presence of such SCUD missile attacks in the general area where the Veteran was stationed (i.e. Damman/Al Khobar/Dharan) is corroborated by the information paper reviewed by CURR, which references five SCUD attacks in this area in January 1991, including five an attack on Dharan on January 20, 1991 which resulted in a 6 or 7 hour MOPP IV level (i.e. full chemical protection) alert. Even though this report does not specifically show that the Veteran was put on alert at any specific time, the Board finds that it provides reasonable corroboration that the Veteran would have been subject to SCUD missile alerts while stationed at Al Khobar. Accordingly, resolving all reasonable doubt in the Veteran's favor, the Board finds that the record contains credible supporting evidence that the claimed stressor event in service occurred. 38 C.F.R. § 3.304(f), See also 38 C.F.R. § 3.102 ( It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant). In summary, given that the evidence reasonably establishes a diagnosis of PTSD, a link between current symptoms and a stressor event in service and credible evidence that the claimed stressor event in service actually occurred, service connection for PTSD based on the Veteran's second period of active service, from November 1990 to June 1991, is warranted. B. Respiratory problems Considering the pertinent evidence in light of the controlling legal authority, the Board finds that service connection for respiratory problems is warranted. Service treatment records do not reflect any objective findings or complaints of respiratory problems, including sinusitis or rhinitis. On April 1991 separation examination, the nose, sinuses, mouth and throat were all found to be normal. At that time the Veteran reported that he did not have a cough or sinus infection and that he had not had ear, nose or throat trouble. A subsequent April 1993 letter from a private physician, Dr. Graham, indicates that that the Veteran presented complaining of cold and flu symptoms. He was diagnosed with flu and bronchitis and treated with antibiotics. On a June 1, 1996 report of medical history, the Veteran reported that he had not had any ear, nose and throat trouble. On a June 6, 1996 annual medical certificate for dental purposes the Veteran reported that he currently had the flu. On January 1999 VA otolaryngological examination, the Veteran reported problems beginning in 1991 with occasional sore throat. It was noted that he smoked about half a pack of cigarettes per day. It was also noted that the Veteran had been told by his medical provider that he had allergic rhinitis. A CT scan done just prior to examination revealed that the left maxillary sinus showed marked mucosal thickening with inferior opacification. There was some minimal mucosal thickening in some of the ethmoid sinuses and the other sinuses were essentially clear. The internal mucosa may have been slightly pale. The diagnostic impression was mild allergic rhinitis, changes of tobacco usage in the nose and muscosal thickening with inferior opacification of the left maxillary antrum with mild ethmoid changes. On April 2002 VA otalaryngological examination, performed by the same physician who performed the January 1999 VA examination, the Veteran continued to complain of nasal congestion which began in 1991 during the time he was in Desert Storm. He has been using a cortisone nose spray as well as an antihistamine with some help. He was told he had a sinus infection a few times in the past. He was last treated for a sinus infection a couple of years prior. He was still smoking 1/2 pack of cigarettes per day. His problems were particularly bad during the spring and fall. A CT scan done prior to the examination showed the same polypoid changes in the maxillary antra as described in the previous examination in 1999. He still had some changes in the ethmoids though it was minimal. Interestingly, the frontal sinuses, particularly the left, showed mucosal membrane thickening and polypoid change in that area. The diagnostic impression was probable allergic rhinitis with polypoid changes in the maxillary, ethmoid and frontal sinuses, likely on the basis of allergy. The examiner found that it was as likely as not that the problem began in the desert when the Veteran was on active duty. The examiner found no reason to refute the Veteran's history in this regard. It was as likely as not that the Veteran's exposure to material at that time had begun the allergies from which he was still suffering, with changes intranasally as well as intrasinus, though his continued smoking was certainly contributing to his current problems. During the April 2002 VA general medical examination, the Veteran reported allergic rhinitis again upon returning from Desert Storm, controlled with Flonase. Physical examination was unremarkable. The pertinent diagnostic assessment was allergic rhinitis. On June 2006 VA general medical examination, it was noted that the Veteran reported chronic sinus problems, which seemed to irritate him almost on a daily basis, since returning from Desert Storm. He used multiple nasal sprays and medications to help correct this. Physical examination revealed that the nasopharynx was clear. On August 2006 VA otolaryngological examination performed by the same physician who performed the January 1999 and April 2002 VA examinations, the Veteran indicated that he began having problems with his nose and sinuses in about 1991. He was primarily complaining of nasal stuffiness and congestion. He apparently had been treated in 1998 for a sinus infection with antibiotics. He was still smoking half a pack a day of cigarettes and was currently taking Flonase and chlorpheniramine daily with some improvement. A CT scan done prior to the examination showed mucous membrane thickening in the interior portions of the maxillary sinuses. There was also some ethmoid congestion noted. Examination of the nose, the external nose, was normal. The vestibule was normal. The turbinates were somewhat pale and boggy. The internal nasal mucosa showed changes of tobacco smoking as well as some apparent allergic changes. The diagnostic impression was allergic rhinitis with secondary changes of mucous membrane thickening in the maxillary, particularly on the left, no current evidence of acute infectious process in the sinuses or the nose, no current evidence of acute or chronic nose or sinus disease otherwise. On December 2006 VA Gulf War guideline examination, the Veteran reported that his respiratory symptom was nasal congestion. He had been diagnosed with allergic rhinitis and was still taking Flonase and chropheniramine. The problem had had its onset in 1990 or 1991. Physical examination revealed that the throat was clear. The examiner noted that the sinus CT scan from June 2006 showed a left maxillary sinus cyst and polyps and that an MRI of brain in January 1999 had been normal other than sinus disease. The pertinent diagnosis was respiratory problems, which were due to allergic rhinitis and left maxillary sinus disease. The above-cited medical evidence reflects that the Veteran's respiratory problems have been attributed to allergic rhinitis and sinusitis. Thus, the evidence establishes that the Veteran's respiratory problems are entirely attributable to known clinical diagnoses, not to undiagnosed illness or other medically unexplained chronic multi-symptom illness. Under these circumstances, service connection pursuant to the provisions of 38 U.S.C. § 1117 is precluded. However, the record does present a basis for a grant of service connection for the Veteran's underlying respiratory disability. See 38 U.S.C.A. § 1113(b) (nothing in 38 U.S.C. § 1117 prevents the grant of service connection on a direct incurrence basis); 38 C.F.R. § 3.303. Notably, the April 2002 VA otalaryngological examiner specifically diagnosed the Veteran with probable allergic rhinitis, along with sinusitis, and found that it was as likely as not that the allergies began as a result of exposure to material during the Veteran's active duty in the Persian Gulf (from 1990 to 1991) and had then resulted in intranasal as well as intrasinus changes (though his smoking contributed to his problems). As the April 2002 examiner's opinion relating the Veteran's allergic rhinitis and sinusitis to his second period of active service, is not contradicted by any other medical opinion of record, the Board finds that it is reasonably established that the Veteran's allergic rhinitis and sinusitis was incurred in service. Accordingly, service connection for respiratory disability to include sinusitis and rhinitis is warranted based on the Veteran's second period of service. C. Right Elbow Pain and Numbness Considering the pertinent evidence in light of the controlling legal authority, the Board finds that service connection for right elbow pain and numbness is warranted. On April 1991 separation examination, no abnormalities of the upper extremities were noted and on his April 1991 report of medical history the Veteran reported that he had not had any problems with swollen or painful joints, painful or trick shoulder or elbow or arthritis, rheumatism or bursitis. On December 1998 VA joints examination, the Veteran complained of right elbow and hand pain. He stated that he had noticed progressively worsening right hand numbness and weakness originating at the elbow and shooting down his left hand. This had been of gradual onset since the early 80s. The Veteran indicated that he had sought treatment and that his management had included activity modification as well as aspirin in the form of Goody powder. The aspirin helped but even so, he had noticed subjectively worsening numbness into his finger and hands. He denied any history of pain or tightness in his neck or shoulder and denied any history of weakness in the right shoulder. Examination revealed a palpable ulnar nerve subluxation at the cubital tunnel with elbow flexion. The Veteran demonstrated elicita pull paresthesias overlying the right cubital tunnel and tapping overlying this area reproduced the symptoms. The diagnosis was cubital tunnel syndrome of the right elbow. EMG and nerve conduction studies of the right forearm were recommended to electrically confirm the diagnosis as well as to localize the specific area of pathology. On April 2002 VA right elbow examination, performed by a different VA physician, the Veteran once again reported progressively worsening right hand numbness and weakness originally at the elbow and shooting down into his right hand, with gradual onset since the 1980s. Physical examination revealed tenderness over the cubital tunnel and a palpable ulnar nerve subluxation with elbow flexion. The Veteran also demonstrated elicitable paresthesias by tapping the ulnar nerve as it went through the cubital tunnel into the small and ring fingers. He had 4/5 grip strength and had decreased sensation in the small and ring finger compared with the contralateral side. The diagnostic impression was cubital tunnel syndrome, right elbow with impingement of the ulnar nerve causing paresthesias and incoordination of the right hand as well as mild to moderate elbow pain. The examiner commented that the Veteran's symptoms appeared to coincide with his time during the service so that it was at least as likely as not that his disability had it's onset in service. On April 2002 VA general medical examination, the Veteran reported the presence of carpal tunnel syndrome in the right upper extremity that started while in Desert Storm. The pertinent diagnostic assessment was carpal tunnel syndrome in the right upper extremity. During the December 2006 VA Gulf War guideline examination, the Veteran reported that in 1991 while in the Persian Gulf, just prior to his return, he had hit his elbow. He pointed to the oleacranon as the area of his pain. Physical examination showed some tenderness over the right olecranon process but no swelling. Both elbows ranged normally without pain and the range of motion did not change with repetitive use. The pertinent diagnosis was right elbow pain and numbness due to right oleacranon bursitis. The above-cited medical evidence reflects that the Veteran's elbow problems have been attributed to cubital tunnel syndrome and more recently to oleacranon bursitis. Thus, the evidence establishes that the elbow problems are entirely attributable to known clinical diagnoses, not to undiagnosed illness or other medically unexplained chronic multi-symptom illness. Under these circumstances, service connection pursuant to the provisions of 38 U.S.C. § 1117 is precluded. However, the record does present a basis for a grant of service connection for the Veteran's right elbow disability on a direct basis. See 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303. Notably, the April 2002 VA examiner diagnosed the Veteran with cubital tunnel syndrome and found that it was at least as likely as not that the disability had it's onset in service. Also, although the December 2006 VA examiner did not diagnose this disability, instead finding that the Veteran had right olecranon bursitis, the Board notes that the April 2002 VA examination was conducted to extensively evaluate the Veteran's right elbow disability whereas the December 2006 VA examination was more general and briefly evaluated a number of the Veteran's disabilities. Additionally, the earlier December 1998 VA right elbow examination also found that the Veteran had right elbow cubital tunnel syndrome. Consequently, the Board finds the findings of the April 2002 VA examination more persuasive. Accordingly, given that the examiner found that the Veteran's right cubital tunnel syndrome was at least as likely as not related to service, and given that this finding concerning the nexus of the right elbow disability is not contradicted by any other medical opinion of record, the Board finds that it is reasonably established that the Veteran's right elbow disability, diagnosed as cubital tunnel syndrome, had its onset in service. In this regard, although the service treatment records do not show treatment or complaints of right elbow pathology during service, the Veteran is competent to report that he had elbow problems in service and the Board does not find a sufficient basis in the record to make an affirmative finding that the Veteran's report is not credible. Accordingly, given the opinion of the April 2002 VA examiner, service connection for right elbow disability, diagnosed as cubital tunnel syndrome, is warranted. D. Body aches and joint pain Considering the pertinent evidence in light of the controlling legal authority, the Board finds that service connection for body aches and joint pain is not warranted. Service treatment records do not reflect any objective findings or complaints of knee problems or joint complaints. On April 1991 separation examination the lower extremities were found to be normal and on April 1991 report of medical history, the Veteran reported that he had not had any trouble with a trick or locked knee or arthritis, rheumatism or bursitis. On a June 1996 National Guard periodic-report of medical history, the Veteran did report cramps in the legs as well as trick or locked knee. The physician's notes accompanying the history indicate that although the Veteran reported right knee trouble and that he had been seen by a physician for 'swollen knee', examination had not revealed any current limitations. During a December 1998 VA general medical examination, the Veteran reported arthritis in his knees and back. He noted the typical symptoms of cold intolerance with aggravation of his joint pain and decreased mobility in the morning hours. The examiner entered a diagnosis of chronic bilateral knee pain and lower back arthritis. During the April 2002 VA general medical examination, the Veteran reported bilateral knee pain and occasional neck pain, which started while on Desert Storm. The bilateral knee pain was controlled with Tylenol. The examining physician did not provide the Veteran with any diagnosis related to his reported knee or neck pain. During the June 2006 VA general medical examination, the Veteran reported bilateral knee and foot pain, on and off since 2004 when he returned from his most recent tour of duty in Iraq. Physical examination revealed that the joints in the extremities ranged normally bilaterally. In the August 2006 rating decision, the RO granted service connection for left knee degenerative joint disease apparently based on the Veteran having been treated for left knee pain due to a possible meniscus injury during his final period of service. Service connection for right knee degenerative joint disease was granted on a presumptive basis, apparently on the basis that the disease was first manifest within a year from separation from his final period of service. Service connection for lumbosacral strain was granted on the basis that the Veteran was treated for back problems during his final period of service. During the December 2006 VA gulf war guideline examination, the Veteran reported that his body/joint aches were pain in both knees with their onset in 1990 or 1991. He stated that the knees swelled in the Persian Gulf and that they now ached. He took diclofenac for them and that seemed to help. Physical examination of the knees was normal. At the outset the Board notes that the joint pain or body aches reported by the Veteran, which he has attributed to his active duty service (aside from his elbow pain with associated hand pain and numbness), are pain in the bilateral knees, back, hip and neck. As noted above, a bilateral knee disability and a low back disability are already subject to service connection based on the Veteran's final period of service from December 2003 to March 2005. Accordingly, the instant analysis is limited to whether service connection is warranted for disability of the knees and back based on the Veteran's first and second periods of service and whether service connection is warranted for disability of the neck or hip for all periods of the Veteran's service. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. § 1131; see also 38 C.F.R. § 3.310. In the instant case, the evidence of record does not establish that the Veteran had any disability of the bilateral knees prior to his final period of active duty from December 2003 to March 2005. The Veteran was found to have degenerative joint disease of the bilateral knees after his final period of service (as noted by the August 2006 rating decision). Also, the Veteran did earlier report that he had arthritis in the knees during the December 1998 examination and also reported bilateral knee pain on a number of occasions beginning with his report of medical history from June 1996. However, there are no objective findings in the record that degenerative joint disease was actually present in either knee prior to December 2003. In this regard, a medical examination in 1996 did not find any limitations of the knee and the only objective limitation noted by the medical examinations thereafter was pain. Similarly, although the Veteran has also complained of neck pain during the April 2002 examination and noted hip pain on his April 1999 NOD, there is no indication from the record that he has had any other pathology of the neck or hip aside from pain. The Board notes that pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). Consequently, given that there is no objective evidence of any bilateral knee pathology or neck pathology other than pain prior to December 2003, the Board does not have a basis for awarding service connection for joint or body aches, to include bilateral knee disability or neck disability, based on the Veteran's first two periods of service. See Gilpin v. West, 155 F. 3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (In the absence of proof of current disability, there can be no valid claim of service connection). This finding is applicable not only to the question of whether the Veteran could be awarded direct service connection under 38 U.S.C.A. § 1110 but also to the question of whether the Veteran could be awarded service connection on the basis of undiagnosed illness under 38 U.S.C.A. § 1117. In both cases, the threshold requirement is the presence of a current disability. 38 U.S.C.A. §§ 1110, 1117. Regarding the Veteran's reports of low back pain, this pain was attributed to a clinical diagnosis, degenerative joint disease of the lumbar spine, by the December 1998 general medical examiner. Accordingly, service connection under 38 U.S.C.A. § 1117 is precluded. Also, there is no evidence that the degenerative joint disease noted in December 1998 is related to the Veteran's first or second period of service, or any intervening periods of ACDUTRA or INACDUTRA he may have had. In this regard, no problems with the spine were found on April 1991 release from active duty examination or on the June 1996 periodic medical examination and the Veteran did not report any problems with the low back on his reports of medical history accompanying these examinations. Additionally, there is no medical opinion of record indicating any relationship between the Veteran's service prior to his final period of active duty and degenerative joint disease of the lumbar spine. Consequently, service connection for low back disability based on the Veteran's service prior to his final period of active duty is not warranted. In summary, given the absence of a finding of a current disability manifested by joint pain or body aches, to include bilateral knee disability, neck disability and/or hip disability prior to December 2003, service connection for such disability is not warranted. Also, given that it is not shown that the Veteran's back disability, noted on the December 1998 examination is related to service, other than his final period of active duty, service connection for low back disability is not warranted for the time frame prior to this final period of active service. E. Sleep impairment, fatigue, night sweats and memory loss Considering the pertinent evidence in light of the controlling legal authority, the Board finds that service connection for sleep impairment, fatigue, night sweats and memory loss is not warranted. At the outset, the Board notes that the RO scheduled a stress disorder examination as part of the December 2006 medical examination, which was presumably going to include assessment of the Veteran's claimed sleep impairment, fatigue, night sweats and memory loss. However, the Veteran failed to report for this component of the examination, as noted by the December 2006 medical examiner. Consequently, these claims will be decided based on the evidence of record. See 38 C.F.R. § 3.655 (2009). Service treatment records do not reveal any findings of sleep problems, fatigue, night sweats or memory loss during active duty. On an April 1991 chronological report of medical care, the Veteran specifically indicated that he had not had nightmares, trouble sleeping or recurring Desert Storm thoughts. On a June 1996 periodic report of medical history, the Veteran did report frequent trouble sleeping. He indicated that he had been seen by a physician for 'trouble sleeping' 1 to 2 times per week. He was not currently taking and prescription medication. A June 1996 periodic physical examination produced normal findings. During the January 1999 VA psychiatric examination, the Veteran reported ongoing difficulty with his sleep since returning from the Persian Gulf . He would go to bed at 8 or 9 o'clock and then wake up between 1 or 2 AM. If he went to bed later he still woke up at the same time. He found himself listening for noises, waking up to see where he was. He was somewhat disoriented and could not go back to sleep until a couple of hours later. At that point it was usually time for him to get up and go to work. At times he would wake up in sweats. In the daytime he was usually tired. He reported that he had a rough time in the Gulf and was worried about scorpions and that this disturbed his sleep greatly. As noted above, the examiner found that the Veteran was exhibiting mild signs of PTSD, which would be indicative of his sleep disturbance, exaggerated startle response, isolation and some avoidance behavior. During the April 2002 VA psychiatric examination, the examiner noted that the Veteran reported some sleep problems which seemed to be stressful to him at times. The Veteran reported that he slept anywhere from 4 1/2 to 6 hours per night. Three or four days a week he would get 6 hours sleep and three or four days he would get 4 1/2 to 5 1/2 hours. When he awoke at night he could be a bit hypervigilant and would go and check the house sometimes when he awakened. He indicated that his energy level varied. Sometimes, he felt tired, especially when he did not get enough sleep. He did wake up sweating about two to three times a week but he attributed this to the fact that he could be rather hot natured. His ability to maintain employment, perform job duties in a reliable, flexible and efficient manner appeared to be mildly impaired, possibly related to his sleep difficulties. The examiner found that the Veteran's memory was intact for immediate, recent and remote events. The examiner estimated the Veteran's level of disability to be slight because of his sleep problems but it did not appear that he had a complete Axis I psychiatric diagnosis. During the April 2002 VA general medical examination, the Veteran reported severe fatigue and night sweats, which were occasional and severe but were improved. Physical examination was unremarkable. The pertinent diagnostic assessments fatigue, weakness and night sweats. During the July 2006 VA psychological evaluation Veteran reported sleeping problems as part of his emotional problems (along with just liking to be by himself too much). He had difficulty maintaining sleep and got three to four hours of sleep per night. He had nightmares two to three times per week about combat. When he woke up he was anxious and also disoriented. He did have night sweats and thrashed around in his sleep. Immediate, recent and remote memories were all found to be within normal limits. The diagnostic impression was PTSD, moderate. During the December 2006 general medical examination, the Veteran reported that the onset of his sleeping problems was since the first explosion in the desert during the First Gulf War. He had difficulty falling asleep because his mind was active and often times when he would get up to check and see if the doors were locked. He did snore but apparently did not have sleep apnea. He stated that he only slept 3 hours per night. He believed that he was fatigued because he did not sleep well. He would get up in the morning and was tired but the would drink coffee and was ready to go. By 5 pm, however, he was getting quite fatigued. The Veteran would also awaken during the night with night sweats. It was during these times that his mind went back to the war. It appeared that he had some nightmares. The Veteran drove a truck and since returning from the Persian Gulf he had had episodes where he drove past where he was supposed to turn in. This had not been a particularly progressive problem. The examiner found that the Veteran could recall 2 out of 4 unrelated words after several minutes. The examiner did not find any objective indicators of a non-psychiatric condition causing sleep impairment, fatigue, night sweats or memory loss. The evidence of record reasonably establishes that the Veteran's sleep impairment is a symptom of his PTSD. In this regard, the January 1999 VA examiner specifically attributed his sleep problems to his PTSD and the Veteran specifically reported during the July 2006 VA psychological evaluation that his sleep problems were part of his emotional problems, which were attributed to PTSD by the examining psychologist. Additionally, although the April 2002 VA examiner did not diagnose the Veteran with PTSD but suggested that the Veteran had slight disability due to his sleep problems (which the examiner did not attribute to a specific diagnosis), as noted above, the Board attaches more evidentiary weight to the combined opinions of the January 1999 and July 2006 VA examiners. The Board also notes that during the December 2006 VA medical examination, the Veteran reported sleep problems due to hypervigilance, thoughts of the war and apparent nightmares, all of which may be symptoms of PTSD. See Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM- IV). Thus, the evidence establishes that the sleep problems are attributable to a known clinical diagnosis, not to undiagnosed illness or other medically unexplained chronic multi-symptom illness. Under these circumstances, service connection pursuant to the provisions of 38 U.S.C. § 1117 is precluded. Additionally, as the weight of the evidence establishes that the sleep problems are a symptom of the Veteran's already service-connected PTSD, and do not represent a separate disability, they may not be subject to service connection on a direct or secondary basis 38 C.F.R. § 3.303, 3.310. Similarly, the Veteran's night sweats were also specifically attributed to the Veteran's PTSD by both the January 1999 and July 2006 VA examiners. Additionally, during the December 2006 VA medical examination, the Veteran attributed his night sweats to thoughts about the war, once again a symptom of PTSD. Accordingly, as the weight of the evidence establishes that the night sweats are simply a symptom of the Veteran's already service-connected PTSD, and do not represent a separate disability, they may not be subject to service connection on a direct or secondary basis. 38 C.F.R. § 3.303, 3.310. Regarding fatigue, during the December 2006 VA examination, the Veteran specifically attributed this problem to his sleep problems, which in turn have been attributed to his PTSD. Thus, although the Veteran was earlier given an unexplained diagnosis of fatigue during the April 2002 VA general medical examination, given the Veteran's more recent explanation, and the lack of any indication in the record for any other reason that the Veteran might feel fatigued, the Board finds that the fatigue may be indirectly attributed to his PTSD. Because the medical evidence of record demonstrates that the Veteran's fatigue is essentially a symptom of the already service- connected PTSD and is not a "stand alone" disability, the Veteran's service connection claim must be denied. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) [service connection cannot be granted if the claimed disability does not exist]. Similarly, the Veteran is also not shown to have a disability manifested by memory loss. Notably, the April 2002 VA examiner found that the Veteran's memory was intact for immediate, recent and remote events and the July 2006 VA examiner found that immediate, recent and remote memories were all found to be within normal limits. The Veteran did report during the December 2006 examination that since returning from the Persian Gulf, there are times that he has driven past where he was supposed to turn in. Also, the December 2006 examiner did note that the Veteran could recall two out of 4 unrelated words after several minutes. However, the examiner did not indicate that the Veteran's recall of the words was abnormal, nor did he find that the Veteran had any objective indicators of a non-psychiatric condition causing memory loss. Thus, in the absence of a showing of actual memory loss, there is no valid claim for service connection. 38 U.S.C.A. §§ 1110, 1117; Brammer, 3 Vet. App. 223, 225 (1992). ORDER Service connection for PTSD is granted. Service connection for respiratory problems, including sinusitis and rhinitis is granted. Service connection for right elbow disability, diagnosed as cubital tunnel syndrome, is granted. Service connection for body aches and joint pain, including bilateral knee pain and neck pain, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117, is denied. Service connection for sleep impairment, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117 is denied. Service connection for fatigue, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117 is denied. Service connection for night sweats, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117 is denied. Service connection for memory loss, to include as due to undiagnosed illness or other qualifying disability, pursuant to 38 U.S.C.§ 1117 is denied. REMAND The Board's review of the claims file reveals that further RO action on the Veteran's claims for service connection for headaches and for skin rash is warranted. Regarding the Veteran's headaches, the evidence of record reveals conflicting medical opinions as to their nature and etiology. On December 1998 VA general medical examination, the examiner entered a diagnosis of history of migraine headaches. On December 1998 VA neurological examination the Veteran's headaches were noted to have some characteristics of tension-type headaches but that they may have also been migraine headaches without an aura. On April 2002 VA neurological examination, the pertinent diagnostic impression was headaches, quite possibly related to sinus headache with no evidence of migraine. On December 2006 VA general medical examination, the diagnosis was headaches which sounded like common migraines. These medical opinions do generally attribute the Veteran's headaches to known clinical diagnoses (i.e. migraine headaches, tension headaches or sinus headaches). However, it is unclear from the current medical evidence whether the Veteran's headaches may be attributed to the Veteran's military service. In this regard, the Board notes that although no specific treatment is shown for headaches by the available service treatment records, the notes accompanying the Veteran's periodic report of medical history from June 1996 indicate a history of headaches since 1991. Also, the April 2002 VA examination finding that the Veteran's headaches were quite possibly related to his sinus problems raises the possibility that the headaches are a symptom of the Veteran's sinusitis, which is now service connected. Accordingly, the Board finds that a VA medical examination and opinion in connection with the claim for service connection for headaches would be helpful in resolving this matter. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2009); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Regarding the Veteran's claim for service connection for skin rash, the Board notes that the rash, when present, was attributed to a known clinical diagnosis, tinea versicolor by the December 1998 general medical examiner. However, the record does not contain a medical opinion as to whether the rash was related to the second period of active duty (as he has alleged) or to his initial period of active duty (during which the Veteran was noted in June 1981 to have a probable heat rash). Accordingly, the Board finds that a VA skin examination is necessary to determine the likely etiology of the Veteran's skin rash. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2009); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board also notes that although there are no objective findings of record of skin rash after December 1998, the Veteran may be entitled to service connection for a disability existing at the time he files his claim for service connection (in this case November 1998) or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (citing Gilpin v. West, 155 F.3d 1353 (F.3d 1998); Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997)). Further, to ensure that all due process requirements are met, and that the record before the examiner is complete, the RO should also give the appellant another opportunity to present information and/or evidence pertinent to the claims on appeal, notifying him that he has a full one-year period for response. See 38 U.S.C.A § 5103(b)(1) (West 2002); but see 38 U.S.C.A. § 5103(b)(3) (West Supp. 2009) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). After providing the notice letter, the RO should attempt to obtain any additional evidence for which the Veteran provides sufficient information and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159 (2009). The actions identified herein are consistent with the duties imposed by the Veterans Claim Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2008). However, identification of specific actions requested on remand does not relieve the RO of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the RO should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claims on appeal. Accordingly, these matters are hereby REMANDED to the RO, via the AMC, for the following action: 1. The RO should send to the Veteran a letter requesting that he provide information and, if necessary, authorization, to enable it to obtain any additional evidence pertinent to the claims on appeal. If the Veteran responds, the RO should assist him in obtaining any additional evidence identified. If any records sought are not obtained, the RO should notify the Veteran and his representative of the records that were not obtained, 2. After all available records and/or responses from each contacted entity are associated with the claims file, the RO should arrange for the Veteran to undergo VA headache and skin examinations by appropriate physicians at a VA medical facility. The entire claims file, to include a complete copy of this REMAND, must be made available to the physicians designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented medical history and assertions. All indicated tests and studies should be accomplished (with all results made available to the requesting physician prior to the completion of his or her report), and all clinical findings should be reported in detail. A. Regarding the examination for headaches, the examining physician should particularly review the service treatment records and the reports of the December 1998 VA general medical examination, the December 1998 VA neurological examination, the April 2002 VA neurological examination and the December 2006 VA neurological examination. Then, after examination, the examiner should comment on the nature and etiology of the Veteran's headaches. In particular, the examiner should provide an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., whether there is a 50 percent or greater probability) that the headaches had their onset in or are medically related to service or to a service connected disability, including sinusitis/rhinitis and/or PTSD. The examiner should explain the rationale for the opinion given. B. Regarding the skin examination, the examining physician should particularly review the service treatment records (to specifically include the notation of heat rash from June 1981) and the reports of the December 1998 general medical examination, the April 2002 VA general medical examination and the December 2006 VA general medical examination. Then, after examination, the examiner should comment on the nature and etiology of the Veteran's skin disorder. In particular, the examiner should provide an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., whether there is a 50 percent or greater probability) that current skin disorder had its onset in or is medically related to service. The examiner should explain the rationale for the opinion given. 3. After the completion of the examinations and any additional notification and development deemed warranted, the RO should readjudicate the claims in light of all pertinent evidence. If the benefits sought remain denied, the RO must furnish to the Veteran an appropriate SSOC that includes clear reasons and bases for all determinations, and afford him the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process; it is not the Board's intent to imply whether the benefit requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This REMAND must be afforded expeditious treatment. The law requires that all claims remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ K. J. ALIBRANDO Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs