Citation Nr: 0815174 Decision Date: 05/08/08 Archive Date: 05/14/08 DOCKET NO. 04-28 679 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for a brain disorder with memory loss, to include as a qualifying chronic disability resulting from an undiagnosed illness. 2. Entitlement to service connection for a hiatal hernia. 3. Entitlement to service connection for a disability manifested by joint pain, to include as a qualifying chronic disability resulting from an undiagnosed illness. 4. Entitlement to service connection for allergies. 5. Entitlement to service connection for a right shoulder disability. 6. Entitlement to service connection for a disability manifested by stomach problems, nausea, sweating, and lightheadedness, to include as a qualifying chronic disability resulting from an undiagnosed illness. 7. Entitlement to service connection for non-alcoholic steatohepatitis. 8. Entitlement to an initial evaluation in excess of 10 percent for hypertension. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R. Kessel, Associate Counsel INTRODUCTION The veteran had active military service from September 1973 to September 1977 and from October 1990 to July 1991. He also had periods of National Guard service from September 1981 to May 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. (The decision below addresses the veteran's claims of service connection for hiatal hernia, allergies, and a disability manifested by stomach problems, nausea, sweating, and lightheadedness, as well as his appeal for a higher initial rating for hypertension. The claims of service connection for a brain disorder with memory loss, a disability manifested by joint pain, a right shoulder disability, and non-alcoholic steatohepatitis are addressed in the remand that follows the Board's decision.) FINDINGS OF FACT 1. The veteran served in the Southwest Asia theater of operations during the Persian Gulf War. 2. The veteran does not have a hiatal hernia. 3. The veteran has seasonal allergies that are not attributable to his active military service. 4. The veteran does not exhibit chronic objective indications of nausea, sweating, and lightheadedness. 5. The veteran's irritable bowel syndrome is a medically unexplained chronic multisymptom illness that became manifest to a degree of at least 10 percent. 6. Since the award of service connection, the veteran's hypertension has not been manifested by readings of diastolic blood pressure of predominantly 110 or more, or systolic blood pressure of predominantly 200 or more. CONCLUSIONS OF LAW 1. The veteran does not have a hiatal hernia that is the result of disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2007). 2. The veteran does not have allergies that are the result of disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.380 (2007). 3. The veteran does not have a disability manifested by nausea, sweating, and lightheadedness that is the result of disease or injury incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2007). 4. The veteran's irritable bowel syndrome is a qualifying chronic disability for which service connection is warranted. 38 U.S.C.A. § 1117 (West 2002 & Supp. 2007); 38 C.F.R. § 3.317 (2007). 5. The criteria for an initial rating in excess of 10 percent for service-connected hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.104, Diagnostic Code 7101 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000, during the pendency of the claims. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2007). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2007). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The Board finds that all notification and development action needed to render a decision as to the claims of service connection for hiatal hernia, allergies, and a disability manifested by stomach problems, nausea, sweating, and lightheadedness, as well as the appeal for a higher initial rating for hypertension, has been accomplished. Through January 2001 and May 2002 notice letters, the RO notified the veteran and his representative of the information and evidence needed to substantiate his service connection claims, including under the provisions for undiagnosed illnesses. While the notice did not refer to criteria for assigning disability ratings or effective dates, see Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), neither of these questions is now before the Board for those claims. Consequently, a remand of those service connection claims for further notification is not necessary. The Board also finds that the January 2001 and May 2002 notice letters satisfy the statutory and regulatory requirement that VA notify a claimant which evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)). In those letters, the RO notified the veteran that VA would obtain VA treatment records and that the RO would make reasonable efforts to obtain relevant records held by other Federal agencies and records from private treatment providers and employers. Additionally, the notice letters requested the veteran to submit medical evidence, opinions, treatment records, and non-medical evidence regarding his claimed disabilities. The veteran was also told that it was still his responsibility to make sure those types of records were received by VA. Consequently, the Board finds that the veteran has been put on notice to submit any pertinent evidence that he may possess. Regarding the hypertension appeal, the veteran is challenging the initial evaluation assigned following the grant of service connection. Once the veteran disagrees with an initial determination, other provisions apply to the remainder of the adjudication process, particularly those pertaining to the duty to assist and issuances of rating decisions and statements of the case. See 38 U.S.C.A. §§ 5103A, 5104(a), 7105(d) (West 2002); 38 C.F.R. §§ 3.103(b)(1), 3.159(c), 19.29 (2007); Dingess, 19 Vet. App. at 490-91; see also Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007). Thus, VA's duty to notify has been satisfied for that claim. There is no indication that any additional action is needed to comply with the duty to assist in connection with the claims of service connection for hiatal hernia, allergies, and a disability manifested by stomach problems, nausea, sweating, and lightheadedness, as well as the appeal for a higher initial rating for hypertension. The veteran's service medical and personnel records have been obtained and associated with the claims file, including those from both periods of active military service and from the National Guard. Treatment records have been obtained from the VA Medical Center (VAMC) in Lexington, Kentucky. Private treatment records from R.J.L., M.D., and C.C.A., Ph.D., have also been obtained. Significantly, the veteran has not otherwise alleged that there are any outstanding medical records probative of his claims that need to be obtained. In July 2002 and July 2004, the veteran was provided VA examinations in connection with his claims, the reports of which are of record. An examination was not specifically provided for the claim regarding allergies. Because the information and evidence did not establish an in-service event, injury, or disease, and did not indicate that the veteran's allergies may be associated with military service, an examination was not required for that claim. II. Analysis A. Service Connection Service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2007). In addition, certain chronic diseases, such as arthritis, may be presumed to have been incurred during service if the disease becomes manifest to a compensable degree within one year of separation from qualifying military service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.307, 3.309 (2007). Service connection may also be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest 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, 2011. 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317 (2007). Persian Gulf veteran means a veteran who, during the Persian Gulf War, served on active military, naval, or air service in the Southwest Asia theater of operations, which includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d). For purposes of section 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Further, lay persons are competent to report objective signs of illness. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). A medically unexplained chronic multi-symptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. A medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2). There are currently no diagnosed illnesses that have been determined by the Secretary to warrant a presumption of service connection under 38 C.F.R. § 3.317(a)(2)(C). 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. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-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. 38 C.F.R. § 3.317(a)(4). Lastly, compensation shall not be paid under section 3.317 if there is affirmative evidence that an undiagnosed illness was not incurred during active military service in the Southwest Asia theater of operations during the Persian Gulf War; 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 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. 38 C.F.R. § 3.317(c). The veteran's personnel records document that he served in the Southwest Asia theater of operations during the Persian Gulf War. From November 11, 1990, to June 2, 1991, the veteran served in the area in support of Operation Desert Shield and Operation Desert Storm. He was awarded the Southwest Asia Service Medal. Thus, in general, the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 apply to the veteran. Hiatal hernia A review of the veteran's service medical records from both periods of active service is negative for treatment for or a diagnosis of a hiatal hernia. Both separation examinations were normal regarding the abdomen and hernias. Additionally, the veteran's National Guard records do not contain any information or evidence pertaining to a hiatal hernia and the periodic examinations were normal. Post-service medical records do not indicate that the veteran has, or has ever had, a hiatal hernia. In a January 1992 VA examination report, it was specifically noted that the veteran did not have a hernia. In December 1993, a "Persian Gulf" examination was administered. The examiner noted that no hernia was found. In July 2002, the veteran underwent VA examination in connection with the claim. The examiner did not find a hernia on examination. The veteran underwent further VA examination in July 2004. A hernia was not listed as a diagnosis and the veteran reported that he had no knowledge of having been told that he had a hiatal hernia. The Board notes that Congress has specifically limited entitlement to service connection to instances where disease or injury has resulted in a disability. See 38 U.S.C.A. § 1110. The evidence reflects that the veteran does not have a hiatal hernia. It also suggests that he has never had a hiatal hernia. In the absence of proof of disability, the claim of service connection may not be granted. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, service connection for a hiatal hernia is not warranted. Allergies Diseases of allergic etiology, including bronchial asthma and urticaria, may not be disposed of routinely for compensation purposes as constitutional or developmental abnormalities. Service connection must be determined on the evidence as to existence prior to enlistment and, if so existent, a comparative study must be made of its severity at enlistment and subsequently. Increase in the degree of disability during service may not be disposed of routinely as natural progress or as due to the inherent nature of the disease. Seasonal and other acute allergic manifestations subsiding on the absence of or removal of the allergen are generally to be regarded as acute diseases, healing without residuals. The determination as to service incurrence or aggravation must be on the whole evidentiary showing. 38 C.F.R. § 3.380 (2007). The veteran's service medical records from both periods of active service are negative for complaints of or treatment for allergies. Both separation examinations were normal and the veteran noted no history of sinusitis or hay fever. Additionally, the veteran's National Guard records do not contain any information or evidence pertaining to the existence of allergies and the periodic examinations were normal. In a March 1985 periodic examination report, it was noted that the veteran had no allergies. The first documented complaint of symptoms potentially related to allergies was during the December 1993 "Persian Gulf" examination. The veteran reported a history of sinus congestion since September 1993, although he also mentioned that he had problems prior to service in the Persian Gulf. On examination, the veteran's sinuses were clear and nontender. He was diagnosed with possible sinusitis at that time, but the diagnosis was never confirmed. Records from Dr. R.J.L. show treatment for allergies beginning in August 1998. Dr. R.J.L. treated the veteran through November 1999 until the veteran sought treatment for allergies through the Lexington VAMC in March 2000. Thereafter, he was treated for seasonal allergies on a biannual or annual basis. He carried a diagnosis of allergic rhinitis. Although there is medical evidence that the veteran has seasonal allergies, no medical practitioner, including Dr. R.J.L. and the treatment providers at the Lexington VAMC, has related the allergies to his active military service. Additionally, the veteran has not identified any event, injury, or disease that he suffered during his active military service that may have led to the onset of allergies. Moreover, the service medical records, including the records from the National Guard, do not suggest that allergies existed during active military service. In fact, examinations were normal regarding allergies. The Board notes that allergies that are seasonal, such as the veteran's allergies, are generally to be regarded as acute diseases, healing without residuals. See 38 C.F.R. § 3.380. Although this type of disability may not be denied solely as a constitutional or developmental abnormality, even with consideration of the evidence as a whole, service connection is not warranted for this claim because only current disability is shown. Further VA examination is not necessary to adjudicate the claim. Because an in-service event, injury, or disease is not established and there is no indication that the veteran's allergies are related to active military service, a VA examination specific to this claim is not required. Additionally, because the veteran's symptoms are attributable to a known clinical diagnosis, the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 are not applicable. Stomach problems, nausea, sweating, and lightheadedness The veteran's representative submitted a claim of service connection for stomach problems, lightheadedness, nausea, and sweating as due to an undiagnosed illness resulting from military service during the Persian Gulf War. Stomach problems, nausea, sweating, and lightheadedness can be objective indications of a chronic disability, which may also be a manifestation of an undiagnosed illness. See 38 C.F.R. § 3.317(b). In the veteran's case, nausea, sweating, and lightheadedness have not been chronically documented in the medical evidence. Such symptoms were also not indicated by the service medical records. Additionally, the veteran has not stated that he has experienced these types of symptoms. In July 2004, the veteran underwent VA examination in connection with this claim. Notably, he denied that he had, then or essentially ever, any significant problems with nausea, sweating, or lightheadedness. Although the veteran is a Persian Gulf veteran, without evidence of objective indications of a qualifying chronic disability, service connection is not warranted for nausea, sweating, or lightheadedness under the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. Additionally, because there is no evidence of a related current disability or an in-service event, injury, or disease, service connection is not warranted for a disability manifested by nausea, sweating, and lightheadedness on a direct basis. The veteran's primary complaint in this regard pertains to stomach problems. Service medical records document two stomach complaints during examinations conducted in May 1991. Although no diagnosis was provided, the notations are evidence that a qualifying chronic stomach disability may have become manifest during service in the Persian Gulf War. Subsequent to his separation from his second period of active military service, the veteran underwent VA examination in January 1992. At that time, the veteran had positive bowel sounds and his digestive system was normal. However, during the December 1993"Persian Gulf" examination, the veteran complained of frequent diarrhea once per week. He was diagnosed with intermittent diarrhea. Thereafter, beginning in January 1994, the veteran sought treatment for diarrhea at the Lexington VAMC. At that time, the veteran reported that his problems did not start until after service in Saudi Arabia. In June 1994, an assessment of probable irritable bowel syndrome (IBS) was provided. A confirmed diagnosis of IBS was given in July 1994. The veteran received regular treatment for diarrhea and IBS through the Lexington VAMC. At times, it was noted that the veteran was asymptomatic, but he continued to carry a diagnosis of IBS. In July 2003 and November 2004, the veteran's treating VA physician provided opinions that attributed the veteran's IBS to his military service in the Persian Gulf. This was so even though the physician stated that the veteran's symptoms did not have their onset until after the Gulf War and he could not assign a known etiology. The physician based his opinion on the assessment and experiences of other Persian Gulf War veterans. Unlike service connection on a direct basis, the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 do not require competent medical nexus of a link between the qualifying chronic disability and military service. Service connection is presumed unless there is affirmative evidence to the contrary. See 38 C.F.R. § 3.317(c); Gutierrez, 19 Vet. App. at 1. Here, the evidence confirms that the veteran has IBS. According to 38 C.F.R. § 3.317(a)(2), IBS is a medically unexplained chronic multi-symptom illness. Thus, IBS is considered a qualifying chronic disability under the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. The veteran's IBS may have become manifest during active military service in the Southwest Asia theater of operations during the Persian Gulf War as evidenced by his stomach complaints. Nonetheless, the veteran's IBS became manifest to a degree of at least 10 percent after his Persian Gulf service. The treatment records document that he had at least moderate IBS with frequent episodes of bowel disturbance with abdominal distress. See 38 C.F.R. § 4.114 (Diagnostic Code 7319) (2007) (rating criteria for irritable colon syndrome). Consequently, the criteria for service connection under the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 are met. Service connection for IBS is warranted. B. Higher Initial Rating Disability evaluations are determined by comparing a veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2007). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2007). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2007). The veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1 (2007); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Since the award of service connection, the veteran's hypertension has been evaluated under Diagnostic Code 7101 for hypertensive vascular disease (hypertension and isolated systolic hypertension). That diagnostic code provides for a 10 percent rating for diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more, or where an individual with a history of diastolic pressure predominantly 100 or more requires continuous medication for control. A 20 percent rating is assigned for diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent rating is assigned for diastolic pressure predominantly 120 or more. Lastly, a 60 percent rating is assigned for diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104 (Diagnostic Code 7101) (2007). (During the pendency of the appeal, the diagnostic code regarding hypertension was amended. 71 Fed. Reg. 52457-60 (Sept. 6, 2006). Effective October 6, 2006, a note was added after the rating criteria of Diagnostic Code 7101 concerning separate evaluations of hypertension and other heart diseases. Because the veteran is not service connected for any other heart disease, the change to the regulation is inapplicable to the appeal at hand.) A review of the medical records since the effective date of the award of service connection reveals that the veteran has been diagnosed with hypertension and the disability has required continuous medication for control. In July 2002, the veteran was afforded a VA examination in connection with the claim. During the examination, the veteran's blood pressure was 138/80, 122/80, and 120/78. A rating of 20 percent or higher is not warranted based on the results of the examination. Diastolic pressure was not measured at 110 or more; nor was systolic pressure measured at 200 or more. See 38 C.F.R. § 4.104 (Diagnostic Code 7101). Additionally, the pertinent treatment records do not provide a basis for assigning a higher initial rating during any period since the award of service connection. Records from the Lexington VAMC and Dr. R.J.L. document nearly forty blood pressure readings. During the relevant period, the highest diastolic pressure was noted as 98 by Dr. R.J.L. in January 2000. The highest systolic pressure was noted as 168 at the Lexington VAMC in October 2003. Without evidence of the higher blood pressure readings set forth in the criteria for a 20 percent rating, an initial rating in excess of 10 percent is not warranted for hypertension at any time since the award of service connection. The above determination is based upon consideration of applicable rating provisions. Additionally, there is no showing that the veteran's hypertension reflects so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluation on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2007). In this case, there is no evidence showing that the disability results in marked interference with employment (i.e., beyond that contemplated in the evaluation assigned), or frequent periods of hospitalization, or evidence showing that the disability otherwise renders impractical the application of the regular schedular standards. In fact, his disability is accurately reflected by the schedular criteria. In the absence of evidence of such factors as those outlined above, the criteria for invoking the procedural actions outlined in 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 157, 158-59 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). C. Conclusion For all the foregoing reasons, the Board finds that the claims of service connection for hiatal hernia, allergies, and a disability manifested by nausea, sweating, and lightheadedness must be denied. Additionally, the appeal for a higher initial rating for hypertension must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against those claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). For the reasons identified above, service connection for IBS is warranted. ORDER Service connection for a hiatal hernia is denied. Service connection for allergies is denied. Service connection for a disability manifested by nausea, sweating, and lightheadedness is denied. Service connection for irritable bowel syndrome is granted. An initial evaluation in excess of 10 percent for hypertension is denied. REMAND The Board finds that further development is necessary regarding the claims of service connection for a brain disorder with memory loss, a disability manifested by joint pain, a right shoulder disability, and non-alcoholic steatohepatitis. Concerning the brain disorder claim, further VA examination is warranted. The veteran's service medical records are negative for treatment for or a diagnosis of a brain disorder. However, he apparently suffered a head injury when he was involved in a motor vehicle accident in January 1975. Residual injury was not noted at the time, but the veteran reported a history of a head injury on several subsequent examinations conducted during his National Guard service and second period of active service. Potential problems with the brain were first documented in April 2000. The veteran underwent a brain scan at the Lexington VAMC that revealed mild abnormalities of the brain. A follow-up MRI later that month was negative. The veteran first reported short-term memory loss in October 2000. Another brain scan was interpreted as abnormal in May 2001 and organic brain syndrome was added to the veteran's problem list at the Lexington VAMC by October 2001. The veteran submitted a neuropsychological report from Dr. C.C.A., dated in September 2001. The veteran reported a decrease in memory and concentration. Although the veteran's cognitive skill was within normal limits, Dr. C.C.A. found that he had impaired auditory attention and significant neuropsychological deficits. Dr. C.C.A. noted that the origins of the findings were unclear, but they may well have been related to the veteran's service in the Gulf War. An October 2001 note from the VA memory disorders clinic reflected an impression of mild cognitive impairment. At that time, a psychiatrist noted that the veteran had memory complaints typical of those seen in other Gulf War veterans. In March 2003, another brain scan was administered. A progression and worsening of the abnormalities was noted. Dr. C.C.A. issued a supplemental report in May 2003 wherein he stated that the veteran's condition was worsening. In July 2003, the veteran's treating VA physician, J.C.S., M.D., noted that the veteran had an organic brain syndrome that was confirmed by neuropsychological testing and nuclear medicine brain scan. Dr. J.C.S. stated that the veteran's condition had its onset after the Gulf War and his cognitive deficits had worsened. Dr. J.C.S. gave the opinion that the condition more likely than not had its origin as a result of exposures that occurred during the Gulf War. No further rationale was provided and the "exposures" were not identified. In July 2004, the veteran underwent VA examination in connection with the claim. The veteran reported his memory loss and belief that it may relate back to the Gulf War. The examiner found that the veteran was basically intact from a cognitive standpoint with no overt signs of memory impairment. Fairly mild attention deficits were noted. At first, the examiner stated that there was no convincing evidence that the veteran's minor memory disturbances were directly related to Gulf War service. Interestingly, the examiner stated that it was equally likely that the condition might be related to the documented in-service head injury and the veteran's report that he was unconscious at that time. After the examiner reviewed Dr. C.C.A.'s May 2003 report, he issued an addendum. In the addendum, the examiner stated that he thought it would be less likely that the additional deficits might be related to the documented head injury, but it would be as likely as not related to the veteran's Gulf War service. In August 2004, the veteran underwent further VA examination. The veteran was examined by a psychiatrist, J.M.F., and the accompanying report was cosigned by the Chief of Mental Health at the Lexington VAMC. The veteran reported his history of short-term memory loss since returning from the Persian Gulf. Dr. J.M.F. provided a diagnosis of adjustment disorder with mixed anxiety and depression. Despite the findings in previous reports, Dr. J.M.F. gave the opinion that there was no clearly evident organic brain disorder or short-term memory loss. Dr. J.M.F. questioned the prior reliance on the brain scans. He stated that those types of scans provide information about blood flow, but do not measure the brain structure. Dr. J.M.F., citing to medical literature, stated that MRI scans are more appropriate for the evaluation of people with memory problems. In this case, the April 2000 MRI scan was normal. Dr. J.M.F. did note that any future development of dementia could be related to the veteran's head injury that resulted from the in-service motor vehicle accident. He concluded that the veteran's memory complaints were not likely due to Gulf War service and that the veteran did not appear to have a dementia or organic brain syndrome. Despite Dr. J.M.F.'s findings, the veteran continued to seek treatment for organic brain syndrome at the Lexington VAMC. In October 2004, Dr. J.C.S. noted that the veteran should be reassessed in light of recent VA examination findings. In November 2004, Dr. J.C.S. reaffirmed the diagnosis of organic brain syndrome. He found that it was reasonable to assume that the condition was related to Gulf War exposures. Given the state of the evidence, the veteran should be scheduled for a VA examination with a specialist in disorders of the brain. Another VA examination is necessary in order to determine if the veteran in fact has a brain disorder, to include organic brain syndrome. A medical opinion should be requested to determine if any diagnosed brain disorder is attributable to either of the veteran's periods of active military service. It is also necessary in order to determine if the veteran suffers from memory loss. Memory loss can be a neuropsychological sign or symptom that may be a manifestation of an undiagnosed illness as contemplated by the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. Thus, the requested opinion should address whether the veteran has memory loss that cannot be attributed to any known clinical diagnosis. With respect to the joint pain claim, further VA examination is warranted. The veteran asserts that he has joint pain that is not limited to any specific joint. He was first diagnosed with polyarthralgia in the December 1993 "Persian Gulf" examination report. Since October 2000, the veteran has been treated at the Lexington VAMC for joint pain and has carried a diagnosis of polyarthralgia. Of note, the veteran has already been awarded service connection for several disabilities that affect the joints. He is already being compensated for his complaints of joint pain regarding the left shoulder, left elbow, left wrist, and left ankle. The associated disabilities were found to be as a result of a January 1975 in-service motor vehicle accident. During active duty service examinations and National Guard periodic examinations, the veteran regularly reported a history of painful joints and broken bones. He referred to the injuries from the motor vehicle accident as the cause of the painful joints and broken bones. In July 2004, the veteran underwent VA examination in connection with the claim. However, the Board finds that examination to be inadequate, because the focus of the examination was on the joints and musculoskeletal areas that have already been service connected. Thus, the veteran should be scheduled for a VA examination that addresses his complaints of system-wide joint pain. The examination is necessary to determine whether the veteran has joint pain in areas other than for which service connection has already been awarded. A medical opinion should also be requested to determine whether the veteran has any disability manifested by joint pain that is attributable to his active military service. Under the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317, joint pain is a sign or symptom that may be a manifestation of an undiagnosed illness. Thus, the requested opinion should address whether the veteran has joint pain that cannot be attributed to any known clinical diagnosis. A review of the record indicates that an examination was not provided in connection with the veteran's claim of service connection for a right shoulder disability. However, the Board finds that an examination is necessary to adjudicate the claim. As noted above, the veteran has been treated for polyarthralgia at the Lexington VAMC. However, the specific painful joints have not been identified. Notably, the veteran's right shoulder was x-rayed in October 2001. The findings were interpreted as mild degenerative arthritis of the right shoulder. The veteran's service medical records pertaining to his two periods of active military service are negative for any right shoulder injury. However, his records from the National Guard document an injury to the right shoulder that occurred on March 25, 1995. A Statement of Medical Examination and Duty Status, dated in April 1995, found that the veteran was on inactive duty training from March 24, 1995, to March 26, 1995. It was note that the veteran fell down some steps of the barracks at Fort Knox, Kentucky on March 25, 1995. He fell approximately five feet and landed in a graveled area. The veteran was treated for injuries to his right shoulder, neck, and face. The injury was found to have been incurred in the line of duty. For the purposes of service connection, active military service includes any period of inactive duty training during which the individual concerned was disabled from an injury incurred or aggravated in line of duty. 38 U.S.C.A. § 101(24) (West 2002); 38 C.F.R. § 3.6(a) (2007). Here, there is evidence of an injury to the right shoulder during inactive duty training and evidence of a current right shoulder disability. Additionally, the veteran submitted an undated statement from a fellow Guardsman, W.D.R., who attested to the right shoulder injury. W.D.R. also stated that he knew the veteran had considerable difficulty with the shoulder during drills in the years that followed. Given the evidence, the veteran should be scheduled for a VA examination in order to determine whether he has a right shoulder disability that is the result of active military service, including the injury during inactive duty training. The right shoulder claim must also be remanded to comply with the notification provisions of the VCAA. The January 2001 and May 2002 VCAA letter did not reference the right shoulder claim. The veteran was not sent a VCAA letter regarding the right shoulder claim until May 2007. Although post- adjudicatory notice is acceptable if the claim is re- adjudicated thereafter, see Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006), this claim was not re-adjudicated after the May 2007 letter was issued. Thus, a supplemental statement of the case is necessary. The same holds true for the claim of service connection for non-alcoholic steatohepatitis. The veteran was not sent a VCAA letter prior to the May 2007 letter for this claim. Neither of the previous VCAA letters referenced the veteran's claim concerning non-alcoholic steatohepatitis or a liver disorder in general. Thus, a supplemental statement of the case must be issued for this claim as well. See Prickett, 20 Vet. App. at 376-77. It appears that the veteran continues to receive regular treatment at the Lexington VAMC. Updated treatment records should be obtained in light of the remand. Accordingly, these issues are REMANDED for the following actions: 1. Obtain the veteran's updated treatment records from the Lexington VAMC and associate the records with the claims folder. 2. Schedule the veteran for examinations with appropriate specialists to determine the nature and etiology of any disability with respect to his claims of service connection for a brain disorder with memory loss, joint pain, and a right shoulder disability. The entire claims file, to include a complete copy of this remand, should be made available to, and reviewed by, the examiners designated to examine the veteran. A complete history should be taken and all necessary tests and studies should be conducted, to include x-rays of the right shoulder and other painful joints. All opinions should be set forth in detail and explained in the context of the record. With respect to the brain disorder claim, the examiner should determine whether the veteran has a brain disorder, to include organic brain syndrome. To the extent possible, the examiner should reconcile the prior findings in the record. If a brain disorder is identified, based on a review of all medical documentation and history on file, including the service medical records, the examiner should provide a well-reasoned opinion consistent with sound medical judgment, as to the medical probabilities that the veteran has a brain disorder that is related to his active military service (the veteran has periods of service from September 1973 to September 1977 and from October 1990 to July 1991). The examiner should also address whether the veteran experiences memory loss. If memory loss is found, the examiner should determine if the memory loss is attributable to a known clinical diagnosis or if it is the result of an undiagnosed illness. With respect to the joint pain claim, the examiner should ascertain which joints are painful. For each painful joint for which the veteran has not already been awarded service connection, the examiner should determine if the painful joint is attributable to a known clinical diagnosis or if it is the result of an undiagnosed illness. If a diagnosed disability is found, the examiner should provide an opinion as to the medical probabilities that the disability is related to the veteran's active military service. Regarding the right shoulder claim, the examiner should determine the current diagnosis, if any, of a disability of the right shoulder. Based on a thorough review of the evidence of record, the examiner should provide an opinion as to the medical probabilities that the veteran has such a current disability that is related to his military service, particularly the March 25, 1995 injury where he fell down some stairs at Fort Knox, Kentucky. After the requested examinations have been completed, the reports should be reviewed to ensure that they are in complete compliance with the directives of this remand. If a report is deficient in any manner, it should be returned to the examiner. (The veteran should be advised that failure to appear for an examination as requested, and without good cause, could adversely affect his claim. See 38 C.F.R. § 3.655 (2007).) 3. After undertaking any other development deemed appropriate, re- adjudicate the claims remaining on appeal. If any benefit sought is not granted, furnish the veteran and his representative with a supplemental statement of the case (SSOC) and afford them an opportunity to respond before the record is returned to the Board for further review. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by VA. The veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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. 2007). ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs