Citation Nr: 1008147 Decision Date: 03/04/10 Archive Date: 03/11/10 DOCKET NO. 01-01 086 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for anxiety, depression, fatigue, and memory loss, to include as due to an undiagnosed illness. 3. Entitlement to service connection for a heart disorder, to include as due to an undiagnosed illness. 4. Entitlement to service connection for a skin disorder, to include as due to an undiagnosed illness. 5. Entitlement to an increased rating for chronic low back pain with degenerative disc disease, currently rated as 20 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Veteran ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from June 13, 1979 to September 7, 1979; May 1981 to May 1984; and December 27, 1990 to July 11, 1991, including approximately 12 years of inactive service with the United States Army Reserves. He served in Southwest Asia from February 1991 to June 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Montgomery, Alabama, Department of Veterans Affairs (VA) Regional Office (RO). In April 2000, the RO granted an increased rating of 20 percent for chronic low back pain with degenerative disc disease and denied service connection for fatigue, anxiety, and loss of memory due to an undiagnosed illness. In August 2001, a video-conference hearing was held before Mark D. Hindin, Veterans' Law Judge. In November 2001, the Board remanded this case. In a January 2003 rating decision, the RO denied service connection for heart and skin conditions as due to an undiagnosed illness. In July 2003, the Board again remanded this case. In a February 2008 rating decision, service connection for PTSD was denied. In December 2009, the Veteran testified at a video-conference hearing before P.M. DiLorenzo, Veterans Law Judge. In February 2009, the Veteran submitted claims for service connection for headaches and gastrointestinal signs and symptoms as due to undiagnosed illness. These matters are referred to the RO for appropriate action. The Board notes that in the April 2000 rating decision, the RO also denied service connection for hearing loss. The Veteran submitted a notice of disagreement in January 2001. See 38 C.F.R. § 20.201. The November 2001 Board remand instructed that the Veteran be provided a statement of the case as to this issue. A statement of the case was issued in December 2001. The Veteran did not submit a substantive appeal. See 38 C.F.R. §§ 20.200, 20.202, 20.302. Accordingly, the Board does not have jurisdiction over this claim. The issue of entitlement to an increased rating for chronic low back pain with degenerative disc disease is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. PTSD is attributable to service. 2. Anxiety, depression, fatigue, and memory loss are attributable to a diagnosed disability - PTSD. 3. The Veteran's complaints of chest pain and shortness of breath, claimed as a heart disorder, are attributable to diagnosed disabilities - hypertension, costochondritis, and PTSD. 4. The Veteran's tinea cruris, tinea pedis, dermatophytosis, dyshidrosis, and dermatitis are attributable to service. CONCLUSIONS OF LAW 1. PTSD with associated anxiety, depression, fatigue, and memory loss, was incurred in active service. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2009); 38 C.F.R. § 3.304(f) (2009). 2. The criteria for service connection for anxiety, depression, fatigue, and memory loss (as separate conditions unassociated with PTSD), to include as due to an undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1110, 1117 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.317 (2009). 3. The criteria for service connection for a heart disorder, to include as due to an undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1110, 1112, 1117 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.307, 3.317 (2009). 4. A skin disorder diagnosed as tinea cruris, tinea pedis, dermatophytosis, dyshidrosis, and dermatitis was incurred in active service. 38 U.S.C.A. §§ 1110, 1117 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.317 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, that will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. In this decision, the Board grants service connection for PTSD and a skin disorder. Thus, a discussion of VA's duties to notify and assist is not necessary with respect to those claims. With respect to the claim for service connection for a heart disorder and anxiety, depression, fatigue, and memory loss, to include as due to an undiagnosed illness, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Letters from the RO dated in May 2003 and January 2004 (heart disorder), March 2006 (Dingess criteria), and December 2008 (anxiety, depression, fatigue, and memory loss) fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Although the notification letters were not sent prior to the initial adjudication of the claims, this was not prejudicial to the Veteran since the claims were readjudicated and additional supplemental statements of the case (SSOC) were provided in May and June 2009. See 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 an SOC or SSOC, is sufficient to cure a timing defect). VA has a duty to assist the appellant in the development of the claim. This duty includes assisting the appellant in the procurement of any pertinent treatment records and obtaining a medical opinion when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's available service treatment records, VA medical treatment records, and identified private medical records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication in the record that any additional evidence, relevant to the issue decided herein, is available and not part of the claims file. The Veteran was also afforded appropriate VA psychiatric and general medical examinations, as set forth below. See 38 C.F.R. § 3.159(c)(4). An additional VA examination/opinion is not warranted as to the heart claim, as the Veteran does not contend that this condition was present during service or that he has had continuity of symptomatology since service. Rather, he argues that he has heart symptoms as due to undiagnosed illness. See 38 C.F.R. § 3.317. The medical evidence of record is sufficient to decide this claim, as he has undergone numerous diagnostic heart studies. The duty to assist has therefore been satisfied and there is no reasonable possibility that further assistance to the Veteran by VA would be capable of substantiating his claims. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating the appeal. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110; 1131; 38 C.F.R. §§ 3.303, 3.304. Further, VA regulation provides that, with chronic disease shown as such in service (or within an applicable presumptive period under section 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of an evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection, the evidence must show: (1) the existence of a present disability; (2) inservice incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during the service." Shedden v. Principi, 381 F. 3d 1163, 1166-67 (Fed. Cir. 2004). There must be competent evidence of a current disability; proof as to incurrence or aggravation of a disease or injury in service, as provided by either lay or medical evidence, as the situation dictates; and competent evidence as to a nexus between the inservice injury or disease and the current disability. Cohen v. Brown, 10 Vet. App. 128, 137 (1997); Layno v. Brown, 6 Vet. App. 465 (1994). The Court has consistently held that, under the law cited above, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). This principle has been repeatedly reaffirmed by the U.S. Court of Appeals for the Federal Circuit (Federal Circuit), which has stated, "a veteran seeking disability benefits must establish . . . the existence of a disability [and] a connection between the veteran's service and the disability." Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Service connection may be presumed for cardiovascular disease if manifested to a compensable degree (10 percent) within a one year after discharge from service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2009). Subject to various conditions, service connection may be granted for a disability due to undiagnosed illness of a veteran who served in the Southwest Asia Theater of Operations during the Persian Gulf War. Among the requirements are that there are objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as fatigue, signs or symptoms involving the skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper and lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. The illness must become manifest during either active service in the Southwest Asia theater of Operations during the Persian Gulf War or to a degree of 10 percent or more, under the appropriate diagnostic code of 38 C.F.R. Part 4, not later than December 31, 2011. See 71 Fed. Reg. 75,669 (Dec. 18, 2006). By history, physical examination, and laboratory tests, the disability cannot be attributed to any known clinical diagnosis. There must be objective signs that are perceptible to an examining physician and other non-medical indicators that are capable of independent verification. There must be a minimum of a six-month period of chronicity. There must be no affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia Theater of Operations during the Persian Gulf War. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98 (Aug. 3, 1998) (cited at 63 Fed. Reg. 56,703 (Oct. 22, 1998). For purposes of this section, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). For purposes of this section, the term medically unexplained chronic multisymptom 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 multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). For purposes of this section, 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). To qualify for compensation under above-indicated provisions, "Persian Gulf veteran" is defined as "a veteran who served on active military, naval or air service in the Southwest Asia Theater of Operations during the Persian Gulf War." 38 C.F.R. § 3.317 (d)(1). "Southwest Asia Theater of Operations" includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (d)(2). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To do so, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). PTSD, Anxiety, Depression, Fatigue, and Memory Loss In witting correspondence and at his hearings, the Veteran asserted that he developed PTSD as a result of stressors experienced during active service. These stressors included being near a housing unit for Reserve soldiers that was blown up and being in the general vicinity of scud missile attacks/bombing. He also stated that he saw people dying. Service connection for PTSD requires medical evidence establishing a diagnosis of the disorder, credible supporting evidence that the claimed in-service stressor(s) actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). To establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD will vary depending upon whether the veteran engaged in "combat with the enemy." See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(f); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Participation in combat, a determination that is to be made on a case by case basis, requires that the veteran have personally participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality. See VAOPGCPREC 12-99 (October 18, 1999). In determining whether the veteran participated in combat, the veteran's oral and written testimony will be weighed together with the other evidence of record. Cohen v. Brown, 10 Vet. App. 128, 146 (1997). If VA determines the veteran engaged in combat with the enemy and his alleged stressor is combat-related, then his lay testimony or statement is accepted as conclusive evidence of the stressor's occurrence and no further development or corroborative evidence is required - provided that such testimony is found to be "satisfactory," i.e., credible and "consistent with circumstances, conditions or hardships of service." See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(f); Zarycki, 6 Vet. App. at 98. If, however, VA determines either that the veteran did not engage in combat with the enemy or that he did engage in combat, but that the alleged stressor is not combat related, then his lay testimony, in and of itself, is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain evidence that corroborate his testimony or statements. See Zarycki, 6 Vet. App. at 98. Where a determination is made that a veteran did not "engage in combat with the enemy," or that the claimed stressor is not related to combat, a veteran's lay testimony alone will not be enough to establish the occurrence of the alleged stressor. In such cases, the record must contain service records or other corroborative evidence which substantiates or verifies the veteran's testimony or statements as to the occurrence of the claimed stressor. See West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki, 6 Vet. App. at 98 (1993). In Doran v. Brown, 6 Vet. App. 283, 290-91 (1994), the Court stated that "the absence of corroboration in the service records, when there is nothing in the available records that is inconsistent with other evidence, does not relieve the Board of its obligations to assess the credibility and probative value of the other evidence." As noted, in a precedent opinion, VA's General Counsel held that the ordinary meaning of the phrase "engaged in combat with the enemy," as used in 38 U.S.C.A. § 1154(b), requires that a veteran "have participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality." VAOPGCPREC 12-99. The General Counsel also indicated that the determination of whether a veteran engaged in combat with the enemy necessarily must be made on a case-by-case basis, and that absence from a veteran's service records of any ordinary indicators of combat service may, in appropriate cases, support a reasonable inference that the veteran did not engage in combat; such absence may properly be considered "negative evidence" even though it does not affirmatively show that the veteran did not engage in combat. Id. In this case, there is no evidence currently in the claims file that establishes the Veteran's participation in combat. Therefore, his allegations with regard to stressors alone are not enough to establish the occurrence of a stressor. Rather, the record must contain service records or other corroborative evidence that substantiates or verifies the Veteran's testimony or statements as to the occurrence of the claimed stressor. As noted, in Doran, the Court stated that "the absence of corroboration in the service records, when there is nothing in the available records that is inconsistent with other evidence, does not relieve the Board of its obligations to assess the credibility and probative value of the other evidence." In the three previously noted cases, the Court cited a provision of the VA ADJUDICATION PROCEDURE MANUAL M21-1 (MANUAL 21-1), which has now been revised as to "Evidence of Stressors in Service" to read, in part, ... "[C]orroborating evidence of a stressor is not restricted to service records, but may be obtained from other sources." Since the MANUAL 21-1 October 1995 revision, the Court has held that the requirement in 38 C.F.R. § 3.304(f) for "credible supporting evidence " means that the "appellant's testimony, by itself, cannot establish the occurrence of a noncombat stressor." See Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Information in the claims file indicates that a Reserves barracks was blown up, but that the Veteran's unit was located several miles from where the other military unit was housed. There is no verification of specific scud missile attack since the Veteran did not provide more than general information in that regard. It was also indicated that there were no chemicals or oil smoke from Kuwait where the Veteran was stationed. However, the information does generally confirm the barracks incident even if the Veteran was located a few miles away. The Board notes that corroboration of every detail of a claimed stressor, including personal participation, is not required; independent evidence that the incident occurred is sufficient. The Court has held that the fact that a veteran was stationed with a unit that sustained attacks strongly suggests that the veteran was, in fact, exposed to these attacks. See Pentecost v. Principi, 16 Vet. App. 124 (2002). In addition, while the Veteran was not in the immediate vicinity of the barracks incident, it caused him to be fearful. He is competent to report what he felt. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Thus, the alleged stressors of being in the area of enemy fire and being fearful after the barracks incident, are generally corroborated by credible supporting evidence. VA and private records diagnosed the Veteran as having PTSD. The current regulation requires that a diagnosis of PTSD conform to the criteria of the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FOURTH ED, American Psychiatric Association (1994) (DSM-IV). The record raises the question of a current valid diagnosis. The Veteran has been treated by a private psychologist, Joan L. Kogelschatz, Ph.D., who has submitted several supporting letters regarding the Veteran's claim. In pertinent part, in March 2004 and May 2006 letters, she indicated that the Veteran was exposed to bombing and chemical fallout during his 5 months serving in Desert Storm. In addition, she indicated that the Veteran was near a barracks which was blown up and soldiers were killed. She stated that the Veteran's current presenting problems were acute anxiety, depression, overwhelming fatigue, insomnia, concentration, loss of appetite, weight loss, heart palpitations, shortness of breath, intermittent chest pain, high blood pressure, and skin rashes. The diagnosis was PTSD. VA outpatient records have diagnosed PTSD due to his Desert Storm service. See for example, February 26, 2008 VA outpatient record. However, VA examinations have variously diagnosed PTSD as well as other psychiatric disorders. On a March 2000 VA examination, the Veteran reported inservice scud missile attacks. The examiner indicated that the Veteran had a cognitive disorder, not otherwise specified, as well as a Major Depressive Disorder. The examiner also stated that the Veteran's impaired memory was related to his cognitive disorder. An opinion regarding the etiology of diagnosed psychiatric disabilities was not provided. On a December 2001 VA examination, the Veteran was diagnosed as having PTSD with anxiety, depression, and loss of memory. In June 2007, a VA examiner indicated that he was not a psychiatrist, so could not provide an opinion as to whether the Veteran met the criteria for PTSD; however, the examiner stated that it was the examiner's opinion that the Veteran's anxiety, depression, fatigue, and memory loss were not due to undiagnosed illness, but were due to the diagnosis provided by the psychiatrist in December 2001 (PTSD). In May 2009, the Veteran was afforded another VA examination. The examiner indicated that the Veteran had a depressive disorder, not otherwise specified, but did not meet the criteria for PTSD or Major Depressive Disorder. The examiner felt that the symptoms of being tired and fatigued were related to the depressive disorder. In sum, all of the medical opinions are competent as they were rendered by medical professionals. The examiners each provided opinions based on a generally accurate history and performed mental status examinations of the Veteran. As such, they are all probative. While the examiners disagree over the current diagnosis, they all concluded that the Veteran has psychiatric impairment, which includes symptoms of anxiety, depression, fatigue, and memory loss. The private psychologist also referenced heart palpitations, shortness of breath, and intermittent chest pain. The Veteran reported his in-service experiences to the examiners, and most diagnoses were made based on those reports, which, as noted, are mainly supported by the record. The Board notes that while PTSD was clearly attributed by the medical professionals to service, the VA examiners who opined that the Veteran has other psychiatric diagnoses, did not provide opinions regarding the etiology of those diagnoses. The Board has also taken into consideration the circumstances of service in Desert Storm as due consideration shall be given to the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which he served, his military records, and all pertinent medical and lay evidence. See 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). The Board finds that the medical evidence of record is in relative equipoise as to the matter of whether the Veteran has PTSD, attributable to service. As noted, there are contradictory opinions, but the Board finds that they are of equally probative value as they were provided by specialists and were based on mostly accurate medical histories. The evidence in this case is so evenly balanced so as to allow application of the benefit-of- the-doubt rule as required by law and VA regulations. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Since PTSD has been attributed to corroborated stressors, service connection for PTSD is warranted. Finally, anxiety, depression, fatigue, and memory loss, are part and parcel of the PTSD, but are not subject to separate service connection because they are attributable to a known clinical diagnosis. See 38 C.F.R. § 3.317. Heart Disorder As noted, the private psychologist referenced heart palpitations, shortness of breath, and intermittent chest pain, as being symptoms of the Veteran's PTSD. In December 2000, the Veteran was seen at First Med of Dothan, P.A., as well as Athens Regional Medical Center for complaints of chest pain, diagnosed as costochondritis, after electrocardiogram (EKG), and pericarditis. The chest x-ray was negative for acute cardiopulmonary disease. In a December 2000 letter, Nelson S. Gwinn, III, M.D., indicated that the Veteran's EKG showed most repolarization and no evidence of any acute pericarditis. The physician felt that his chest pain was the result of a viral syndrome. The Veteran was thereafter treated at Southeast Cardiology Clinic, Inc., in January 2001. At that time, he had a negative Bruce protocol stress echo. The Veteran was seen by VA in March 2001. He complained of chest pain and reported a history of possible Gulf War Syndrome. The assessment was borderline hypertension and nonspecific chest pain. In December 2001, the Veteran underwent a VA examination. It was noted that pericarditis was suspected in December 2000, but his Bruce protocol test as well as echocardiogram were negative. In October 2003, the Veteran was treated at Southeast Cardiology Clinic, Inc. At that time, his EKG was normal. The Veteran had gone to the emergency room the night before, but the workup was normal. The current Bruce protocol was also negative. The physician indicated that the Veteran had diastolic hypertension and the best approach was to place him on different hypertension medication. It was noted that he was not taking his medication on a regular basis. In December 2008, the Veteran was seen for chest pain with hypertension. His Bruce protocol was negative. In sum, the Veteran has been diagnosed as having costochondritis, pericarditis, and hypertension. It appears that the Veteran's private physician resolved that he does not have pericarditis. However, he has had a diagnosis of hypertension for years, but has not consistently been compliant with his medication. In addition, his chest pain and shortness of breath complaints have also been associated with costochondritis, a viral syndrome (since resolved), as well as his PTSD. Since the claimed disability/symptoms has associated diagnoses - costochondritis, hypertension, and PTSD - it is not considered an undiagnosed illness. The medical records are competent and probative in that regard. See generally Prejean v. West, 13 Vet. App. 444, 448-9 (2000); see also Cohen. The Veteran does not contend and the evidence do not show that that any heart condition was present during service or that he has had continuity of symptomatology since service. Rather, he argues that he has heart symptoms as due to undiagnosed illness. The service treatment records are negative for any complaints or findings of a heart or cardiovascular disorder. The Veteran's complaints were first noted many years after service, and there is no competent evidence relating any current disability to his active service. Therefore, service connection is not warranted. See 38 U.S.C.A. §§ 1110, 1112; 38 C.F.R. §§ 3.303, 3.307. The evidence in this case is so evenly balanced so as to allow application of the benefit-of- the-doubt rule as required by law and VA regulations. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is not warranted for a heart disorder, to include as due to an undiagnosed illness. Skin Disorder The service treatment records show that in April 1981, the Veteran was diagnosed as having Athlete's foot. In September 1983, he was treated for dishydrosis of the hands. In January 1991, there was a notation of xerotic skin of the feet and legs. After the Veteran's separation from active service, a July 1992 Reserve record shows that he was using Lotrimin cream to treat his Athlete's foot. The post-service medical evidence also shows that in January 1997, the Veteran was treated for a fungal rash of the groin and dyshidrosis of the feet. In June 1998, he was treated for recurrent groin and feet rash. In November 2001, the Veteran complained of "jock itch." The assessment was recurrent yeast infection and a lesion on the right arm. He was afforded a VA examination in December 2001. He reported having a skin rash since coming back from Saudi Arabia, mainly in the groin area and also in different parts of the body at different times. The diagnosis was chronic dermatophytosis of the feet. The Veteran was treated for tinea cruris in April 2003. In July 2004, he was treated for tinea cruris (located in the groin area), tinea pedis, and dyshidrosis of the feet. In July 2005, he complained of recurring dermatitis of the legs, groin, and arm. He was noted to have dermatitis of the lower extremities. He was also seen for a rash of the groin and foot with a notation of tinea cruris. At his hearing before the Board in December 2009, the Veteran testified that his skin problems started when he got back from Desert Storm and that it had been continuous. He stated that it seemed like there was a rash somewhere all the time. Since the claimed disability, a skin disorder, has associated diagnoses, tinea cruris, tinea pedis, dermatophytosis, dyshidrosis, and dermatitis, it is not considered an undiagnosed illness. See 38 C.F.R. § 3.317. The service treatment record show that the Veteran was treated for Athlete's foot, dishydrosis of the hands, and xerotic skin of the feet and legs. He has also reported having a groin rash in service, though it was not reflected in the service treatment records. The Veteran has stated that has had a skin rash since coming back from Saudi Arabia, mainly in the groin area and also in different parts of the body at different times. He is competent to report his observations of his skin symptomatology, and the Board finds him to be credible in this regard. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Post-service medical records show diagnoses of tinea cruris (groin rash), tinea pedis (Athlete's foot), dermatophytosis, dyshidrosis, and dermatitis. As there is competent medical evidence of a current skin disorder, in-service treatment for skin problems, and competent and credible evidence of a continuity of symptomatology, the Board finds that service connection for a skin disorder is warranted. Accordingly, service connection is granted for tinea cruris, tinea pedis, dermatophytosis, dyshidrosis, and dermatitis. ORDER Service connection for PTSD with anxiety, depression, fatigue, and memory loss is granted. Service connection for anxiety, depression, fatigue, and memory loss (as separate conditions unassociated with PTSD), to include as due to an undiagnosed illness, is denied. Service connection for a heart disorder, to include as due to an undiagnosed illness, is denied. Service connection for tinea cruris, tinea pedis, dermatophytosis, dyshidrosis, and dermatitis is granted. REMAND Increased rating for chronic low back pain with degenerative disc disease Unfortunately, a remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that the Veteran is afforded every possible consideration. At his recent Board hearing, the Veteran indicated that he receives treatment for his low back disorder from several facilities: Southern Bone and Joint in Dothan, Alabama; the Dothan VA; and First Med of Dothan. A review of the claims file reflects that although some records have been obtained from the first two facilities, the records from Southern Bone and Joint in Dothan, Alabama have not been obtained. When reference is made to pertinent medical records, especially records in VA's possession, VA is on notice of their existence and has a duty to assist the veteran to attempt to obtain them. See Ivey v. Derwinski, 2 Vet. App. 320, 323 (1992); see also Jolley v. Derwinski, 1, Vet. App. 37 (1990). These records should be obtained in compliance with VA's duty to assist. In addition, the Board finds that the Veteran should be afforded a VA examination in light of the symptoms he described at his recent hearing. His representative indicated that his back disorder has deteriorated and requested a new back evaluation. He should be afforded a new examination in compliance with VA's duty to assist. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). On remand, the Veteran should also be provided notice in compliance with the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2009). Accordingly, this matter is REMANDED for the following actions: 1. Inform the Veteran about (1) the information and evidence not of record that is necessary to substantiate his claim for an increased rating for chronic low back pain with degenerative disc disease; (2) the information and evidence that VA will seek to obtain on his behalf; and (3) the information or evidence that he is expected to provide. 2. Obtain and associate with the claims file copies of all clinical records related to the Veteran's back from the Dothan VA clinic, dated from July 2008 forward. 3. After securing the appropriate medical releases, obtain and associate with the claims file copies of all clinical records, which are not already in the claims file, of the Veteran's treatment at the First Med of Dothan, P.A. and at Southern Bone and Joint in Dothan, Alabama. 4. Thereafter, schedule the veteran for a VA examination of his lumbar spine. The claims file and a copy of this remand must be made available to and reviewed by the examiner. All necessary tests, including x-rays if indicated, should be conducted. The examiner should identify and describe in detail all residuals attributable to the Veteran's service-connected chronic low back pain with degenerative disc disease. The examiner should identify any orthopedic and neurological findings related to the service-connected disability and fully describe the extent and severity of those symptoms. The examiner should conduct range of motion testing of the lumbar spine. Whether there is any pain, weakened movement, excess fatigability or incoordination on movement should be noted, and whether there is likely to be additional range of motion loss due to any of the following should be addressed: (1) pain on use, including during flare- ups; (2) weakened movement; (3) excess fatigability; or (4) incoordination. The examiner is asked to describe whether pain significantly limits functional ability during flare-ups or when the lumbar spine is used repeatedly. All limitation of function must be identified. If there is no pain, no limitation of motion and/or no limitation of function, such facts must be noted in the report. With regard to any neurological disability resulting from the service- connected disability, the specific nerve(s) affected should be specified, together with the degree of paralysis caused by service-connected disability. The examiner should document the number of weeks, if any, during the past 12 months, that the Veteran has had "incapacitating episodes," defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician." With respect to the low back strain, the examiner should determine if the Veteran has listing of the whole spine to the opposite side; positive Goldthwaite's sign, marked limitation of forward bending in a standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. The examiner should determine whether the service-connected low back strain has resulted in intervertebral disc syndrome. Are there persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief? Are there recurring attacks, with intermittent relief? A rationale for any opinion expressed should be provided. 5. Finally, readjudicate the claim with consideration of the rating criteria of Diagnostic Code 5293 in effect prior to September 23, 2002 and on and subsequent to that date. If the claim remains denied, the Veteran should be provided with a supplemental statement of the case as to the issue on appeal, and afforded a reasonable period of time within which to respond thereto. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2009). MARK D. HINDIN K. OSBORNE Veterans Law Judge Veterans Law Judge Board of Veterans' Appeals Board of Veterans' Appeals ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs