Citation Nr: 1306754 Decision Date: 02/27/13 Archive Date: 03/01/13 DOCKET NO. 98-07 029 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for multiple joint arthritis, including rheumatoid arthritis, to include as due to an undiagnosed illness. 2. Entitlement to service connection for a lung disease, to include as due to an undiagnosed illness. 3. Entitlement to service connection for a disability manifested by chronic fatigue, to include as due to an undiagnosed illness. REPRESENTATION Appellant represented by: Katrina J. Eagle, Esquire WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD B. Elwood, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1985 to July 1991. He served in Southwest Asia from December 1990 to May 1991. These matters initially came before the Board of Veterans' Appeals (Board) from March 1997, May 2004, and February 2005 rating decisions of the Department of Veterans Affairs (VA) Regional Offices (ROs) in Nashville, Tennessee and Atlanta, Georgia. In the March 1997 decision, the RO denied entitlement to service connection for rheumatoid arthritis, a respiratory/lung disease, and chronic fatigue. In the May 2004 decision, the RO denied entitlement to service connection for headaches. In the February 2005 decision, the RO readjudicated (pursuant to the Veterans Claims Assistance Act of 2000 (VCAA)) and again denied entitlement to service connection for rheumatoid arthritis. The RO in Montgomery, Alabama currently has jurisdiction over the Veteran's claims. In November 1997, the Veteran testified at a hearing before a local hearing officer at the RO and a transcript of that hearing has been associated with his claims folder. In May 1999, the Board, among other things, denied the claim of service connection for a lung disease and remanded the claim of service connection for a disability manifested by chronic fatigue for further development. The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (Court). In August 2000, the Court set aside the Board's May 1999 decision, in part, and remanded the case for readjudication in compliance with directives specified in an August 2000 Joint Motion filed by counsel for the Veteran and VA. In May 2001, the Board remanded the claim of service connection for a lung disease for further development in compliance with the Joint Motion. In June 2008 decisions, the Board denied all claims currently on appeal. However, in October 2008 the Board vacated the June 2008 decisions and remanded all issues currently on appeal to allow the Veteran and his representative to submit additional evidence and for issuance of a supplemental statement of the case. In February 2012, the Board denied the claims of service connection for multiple joint arthritis, a lung disease, and a disability manifested by chronic fatigue. The Board also remanded the claim of service connection for a headache disability for further development. The development has not been completed and that matter is not currently before the Board. In October 2012, the Court set aside the Board's February 2012 decision, in part, and remanded the case for readjudication in compliance with directives specified in an October 2012 Joint Motion filed by counsel for the Veteran and VA. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claims. The documents in this file have been reviewed and are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. The Veteran's rheumatoid arthritis did not have its clinical onset in service, was not exhibited within the first post service year, and is not otherwise related to active duty. 2. The Veteran's current lung disease did not have its clinical onset in service, is not otherwise related to active duty, and has been attributed to a known clinical diagnosis of non service-connected rheumatoid arthritis. 3. The Veteran's chronic fatigue is not due to chronic fatigue syndrome and has been attributed to known clinical diagnoses of non service-connected rheumatoid arthritis and a service-connected psychiatric disability. CONCLUSIONS OF LAW 1. Multiple joint arthritis, including rheumatoid arthritis was not incurred or aggravated in service and may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113(b), 1117, 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307(a), 3.309(a), 3.317 (2012). 2. A current lung disease is not the result of an undiagnosed illness and was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1113(b), 1117, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310, 3.317 (2012). 3. A disability manifested by chronic fatigue is not the result of an undiagnosed illness or a chronic multi symptom illness and was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 1113(b), 1117, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The 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, 5126 (West 2002 & Supp. 2012) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Under the VCAA, 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; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a July 2004 letter, the RO notified the Veteran of the evidence needed to substantiate his claims of service connection for multiple joint arthritis, a lung disease, and a disability manifested by chronic fatigue. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The claimant's Veteran status has been substantiated. He was notified of all other elements of the Dingess notice, including the disability-rating and effective-date elements of his claims, in a March 2006 letter. There was a timing deficiency in that the July 2004 and March 2006 letters were sent after the initial adjudication of the claims currently on appeal. This timing deficiency was cured by readjudication of the claims in supplemental statements of the case dated in May 2006 and March 2007. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The Court has held that the provisions of 38 C.F.R. § 3.103(c)(2) (2012) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the Veteran's November 1997 hearing, the hearing officer identified the issues on appeal (including entitlement to service connection for multiple joint arthritis, a lung disease, and a disability manifested by chronic fatigue) and asked the Veteran about the treatment received for his claimed disabilities to ensure that all relevant records were obtained. Further, the Veteran provided testimony as to the symptoms and history of his claimed disabilities and the treatment received for these disabilities. Also, he has submitted additional relevant evidence during the course of the appeal. Thus, he has demonstrated actual knowledge of the ability to identify and submit additional relevant evidence. The duties imposed by Bryant were thereby met. VA obtained the Veteran's service treatment records, pertinent service personnel records, and all of the identified relevant post-service VA treatment records and private medical records. In addition, the Veteran was afforded VA examinations to assess the nature and etiology of his current multiple joint arthritis, lung disease, and chronic fatigue and opinions have been obtained concerning the etiology of these problems. In its May 1999, May 2001, and October 2008 remands, the Board instructed the agency of original jurisdiction (AOJ) to, among other things: ask the Veteran to identify any VA or private medical treatment for a lung disease, obtain any additional identified relevant VA treatment records, attempt to obtain any sufficiently identified private treatment records for which appropriate release forms had been submitted, afford the Veteran VA examinations to obtain opinions as to the nature and etiology of his claimed lung disease and disability manifested by chronic fatigue, and issue supplemental statements of the case. In a May 2001 letter, the Veteran was asked to identify any VA or private medical treatment for his claimed lung disease and was asked to complete the appropriate release forms so as to allow VA to obtain any identified private treatment records. As explained above, all relevant identified VA treatment records and private medical records have been obtained and associated with the claims file. He was afforded VA examinations in June 1999 and April 2005 and opinions were obtained concerning the nature and etiology of his claimed lung disease and disability manifested by chronic fatigue. Also, supplemental statements of the case were issued in January and August 2010. Thus, the AOJ substantially complied with all of the Board's relevant May 1999, May 2001, and October 2008 remand instructions and VA has no further duty to attempt to obtain any additional records or conduct additional examinations with respect to the claims being decided at this time. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Analysis Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Service connection is also provided for a disability which is proximately due to, the result of, or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. VA has amended 38 C.F.R. § 3.310 to reflect that it will not concede aggravation unless certain additional conditions are met. 38 C.F.R. § 3.310(b). As explained below, the Board finds that there is no competent evidence that a service-connected disability caused or aggravated any claimed separate and distinct non service-connected disability. Hence, it is not necessary to determine which version of 38 C.F.R. § 3.310 is applicable in this case. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In relevant part, 38 U.S.C.A. § 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For veterans with service in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. Under this law and regulation, service connection may 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, 2016. 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 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). Medically unexplained chronic multi symptom illnesses are defined by a cluster of signs or symptoms and include, but are not limited to, chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(i), (ii). To obtain service connection for an undiagnosed illness or combination of undiagnosed illnesses, a veteran needs to show (1) that he or she is a Persian Gulf veteran; (2) who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) that have become manifest either during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016 and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a). "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 an undiagnosed illness or a medically unexplained chronic multisymptom 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 38 C.F.R. § 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). Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis, are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). Notwithstanding the foregoing presumptions, a claimant is not precluded from establishing service connection with proof of direct causation. 38 U.S.C.A. § 1113(b); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Multiple Joint Arthritis In this case, medical records reflect that the Veteran has been diagnosed as having multiple joint arthritis. For example, a November 2005 VA examination report includes a diagnosis of inflammatory polyarthritis. Thus, a current disability has been demonstrated. The Veteran has essentially claimed that he began to experience multiple joint pains around the time of his separation from service and that such symptoms have persisted ever since that time. For example, he reported during a January 2008 VA examination that after returning to Germany in approximately May 2001, he began to experience joint aches. Joint problems have continued in the years since service. In the alternative, he contends that his current multiple joint arthritis is related to exposure to various toxins in service while serving in the Gulf War. The Veteran is competent to report symptoms of multiple joint arthritis, such as pain, as well as a continuity of symptomatology. However, his reports must be weighed against the objective evidence and their credibility must be assessed. See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. There is no evidence of any complaints of or treatment for arthritis, symptoms associated with arthritis, or any other multiple joint problems in the Veteran's service treatment records. Moreover, his June 1991 separation examination was normal other than for acne. If a chronic disease, such as arthritis, is shown in service and at any time thereafter, service connection will be conceded. 38 C.F.R. § 3.303(b). There must, however, be sufficient observations in service to identify the disease entity. Id. As discussed above, there is no evidence showing any diagnosed arthritis in service. Hence, service connection cannot be granted on this basis here. The objective evidence otherwise indicates that the Veteran's current multiple joint arthritis did not manifest until more than a year after his separation from service. The first post-service clinical evidence of possible multiple joint arthritis is a September 1993 VA medical certificate which includes a report of joint pain and cracking. The Veteran reported that 6 weeks prior to the evaluation his ankles, foot joints, and elbows began to "make noise." He was diagnosed as having crepitus of the joints. There is no clinical evidence of any earlier multiple joint symptoms following service. Additionally, the first report of joint problems following service is the Veteran's April 1995 claim (VA Form 21-526) on which he reported chronic joint aches. During the November 1997 hearing he reported that he had submitted a claim in November 1991 which had allegedly included a claim of service connection for joint problems. While the Veteran is competent to make such a statement, the objective evidence reflects that his November 1991 claim only referred to a fractured right wrist, a skin rash, and right wrist numbness. There is no evidence of any other claim submitted in November 1991. Hence, his report of a November 1991 claim of service connection for multiple joint problems is not credible. Furthermore, the Veteran has provided varying statements as to the history of his multiple joint problems. For example, he contended during the January 2008 VA examination that he began to experience joint aches in service in approximately May 1991. However, he indicated on a June 1991 report of medical history for purposes of separation of service that he was neither experiencing nor had he ever experienced any "swollen or painful joints," "arthritis, rheumatism, or bursitis," or "bone, joint, or other deformity." In an August 1996 statement he reported that he began to experience unexplained problems with his health in August 1991, including pain in the muscles and joints of his hands, shoulders, and knees. He reported during VA evaluations dated in July 1995 and May 1997 that he had experienced arthritis for 2 and 5 years, respectively (i.e. since 1993 and 1992, respectively). Additionally, he reported during the November 1997 hearing that he had begun to experience joint stiffness in approximately September or October 1991. In light of the absence of any objective evidence of complaints of or treatment for multiple joint/arthritis problems during service, the fact that the Veteran's June 1991 separation examination was normal other than for acne, and his inconsistent and contradictory statements concerning the history of his joint symptoms, the Board concludes that his reports concerning the history of his joint symptoms, including those of a continuity of symptomatology since service, are not credible. Thus, neither the clinical record nor the lay statements of record establish a continuity of symptomatology in this case, precluding an award of service connection on this basis. There is conflicting medical evidence as to the onset and etiology of the Veteran's multiple joint arthritis. The Board, therefore, must weigh the credibility and probative value of this evidence, and in so doing, may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). The Board must account for the evidence it finds persuasive or unpersuasive and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 29-40 (1994). The Veteran's medical records contain numerous reports that specifically state or allude to the conclusion that multiple joint arthritis had been present since 1991. However, many of these reports are not accompanied by any specified explanation or reasoning. A November 2000 examination report from Douglas Satcher, M.D. includes a diagnosis of a rheumatologic disorder which was "possibly" related to exposure to Gulf War agents. There was no further explanation or reasoning for this opinion. The November 2005 VA examination report includes an opinion that it was not likely ("less likely as not") that the Veteran's inflammatory arthritis was caused by or related to military service. The physician who provided this opinion explained that the Veteran's service treatment records did not contain any documentation to support a conclusion that the inflammatory arthritis had its onset or incurrence during service. In an October 2007 letter, Lasongia Morton, M.D. opined that the Veteran had symptoms consistent with Gulf War Syndrome, including joint pain. She explained that the Veteran had reported exposure to the nerve agent sarin while serving in the Gulf War. In a March 2009 letter, Dr. Satcher opined that the Veteran had clearly suffered from rheumatoid arthritis since 1995, but most likely since 1991. Dr. Satcher reasoned that the Veteran had first presented with complaints of polyarthritis and arthralgia in Germany in 1991. The history of autoimmune disease is such that many patients have a variable illness which waxes and wanes over the years. This type of clinical course would be consistent with the onset of vague symptoms in 1991. The Veteran then presented with full-blown obvious joint pain and swelling after a relatively benign course. Moreover, a review of literature regarding the effects of stress, war, and other major life events on the onset of rheumatoid arthritis showed a clear association between such stressors and the onset of autoimmune disease. There were also cases documenting a relationship between anthrax vaccinations and the onset of rheumatoid arthritis. Overall, based on the time of onset of the Veteran's illness and the associated events related to his military service, the preponderance of the evidence was in favor of a conclusion that his rheumatoid arthritis was related to service. In March 2011, the Board sought to obtain an expert medical opinion through the Veterans Health Administration (VHA opinion) in accordance with the provisions of 38 C.F.R. § 20.901(a) (2012). In May 2011, a VA rheumatologist reviewed the Veteran's claims file and opined that his multiple joint arthritis, diagnosed as seronegative rheumatoid arthritis, had its onset around 1994. The physician reasoned that in 1995 the Veteran reported that he had experienced muscle and joint pains since November 1991. In 2008, he reported the onset of fatigue and joint and muscle aches in May 1991. There were no available records from May 1991 and the available records relating to arthritic complaints were mainly dated since 1994. The physician also explained that the etiology of rheumatoid arthritis and most other autoimmune conditions was unknown, with a presumption that genetic, environmental, and possibly infectious etiologies could all play a part in some individuals. It was also unknown how much time was needed to elapse between any exposure to an environmental or infectious agent before signs and symptoms of an autoimmune disease appeared. It was well recognized that a person could have autoantibodies (such as rheumatoid factor or ANA) for years before developing a clinical autoimmune disease, and it was likely that many, if not most, persons with such autoantibodies never developed an autoimmune disease. Additionally, the physician reasoned that in retrospect the Veteran first reported musculoskeletal symptoms approximately 2 months after possible exposures in Iraq, and then came to more consistent medical attention approximately 3 years after his service in Iraq. Since the cause of rheumatoid arthritis (or inflammatory arthritis) was unknown and the development of this disease after an exposure was purely theoretical, there was no medical evidence that would lead a rheumatologist to state that the Veteran's service history was causally related to the development of rheumatoid arthritis. However, if musculoskeletal symptoms were in fact reported in May 1991, it could be said that it was possible that such symptoms were early symptoms of rheumatoid arthritis. However, there was no documentation of joint inflammation (e.g. swelling and redness, and not just pain) at that moment. Rheumatoid arthritis could begin with flares that improved and worsened over days and weeks before the disease was finally present every day. With respect to the Veteran in this case, however, the available records instead suggested that the true arthritis had its onset around 1994. Moreover, the physician opined that it was likely ("more likely than not") that the onset of the Veteran's rheumatoid/inflammatory arthritis was not related to exposure to various toxins and other substances in service, including sarin, cyclosarin, burning oil wells, and the anthrax vaccine. This opinion was based on the fact that the etiology of rheumatoid/inflammatory arthritis was unknown. There was no medical literature that connected exposure to sarin, cyclosarin, or burning oil wells to the onset of rheumatoid arthritis. The anthrax vaccine had been found to occasionally be associated with antibodies to the adjuvant found in the vaccine, and there were 5 case reports that had been found which showed inflammatory arthritis beginning in the days to weeks after the immunization. However, these reports did not prove causation. Also, the timeframe with respect to the Veteran in this case was longer than that which was reported in the available case reports. Gulf War syndrome was also under study for an association with symptoms such as joint pains, fatigue, poor sleep, and depressive symptoms. Nevertheless, there was a lack of medical literature on the subject of Gulf War syndrome and rheumatoid or inflammatory arthritis. Thus, this did not support a statement that rheumatoid arthritis was likely ("at least as likely as not") a result of Gulf War syndrome. In sum, rheumatoid arthritis was of unknown etiology and there was extremely little scientific evidence to connect exposure to sarin, cyclosarin, burning oil wells, or the anthrax vaccine to the onset of rheumatoid arthritis. Thus, it was likely "(more likely than not") that the onset of the Veteran's rheumatoid/inflammatory arthritis was not due to any of these specific causes. The numerous reports in the Veteran's medical records of multiple joint arthritis having its onset in 1991 are of minimal, if any, probative value because they appear to be mere transcriptions of the lay history provided by the Veteran. As explained above, the Veteran's reports as to the onset and history of his arthritis are not credible. Thus, these various reports do not constitute competent medical evidence as to the onset of the Veteran's arthritis. Moreover, these various reports are not accompanied by any specific explanation or reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). Dr. Satcher's November 2000 opinion that the Veteran's rheumatologic disorder was "possibly" related to exposure to Gulf War agents is also of minimal probative value because it is speculative and equivocal. See Hood v. Shinseki, 23 Vet. App. 295, 296 (2009); Perman v. Brown, 5 Vet. App. 237, 241 (1993) (speculative or equivocal medical opinions may be considered "non-evidence" and have no probative value); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim). The November 2005 opinion is minimally probative because it was based on a lack of clinical evidence of treatment for arthritis in the Veteran's service treatment records and it does not reflect consideration of the Veteran's reports of joint symptoms in the years since service. A medical opinion based solely on the absence of documentation in the record is inadequate and a medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). The March 2009 opinion by Dr. Satcher is largely based on the Veteran's reports of arthritis symptoms having their onset in 1991. As the Board has determined that such reports are not credible, Dr. Satcher's March 2009 opinion is based upon an inaccurate history and is also of little probative value. See Nieves-Rodriguez, 22 Vet. App. at 304; Boggs v. West, 11 Vet. App. 334, 345 (1998); Kightly v. Brown, 6 Vet. App. 200, 205-06 (1994); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). The March 2011 opinion, however, was based upon a review of the Veteran's medical records and reported history (including the lay evidence of arthritis symptoms since 1991) and is accompanied by a detailed rationale that is not inconsistent with the evidence of record. Thus, this opinion is adequate and entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The Veteran has contended that his claim of service connection for multiple joint pain should be evaluated as a disability that is the result of an undiagnosed illness that he developed during service in the Southwest Asia Theater of operations during the Persian Gulf War. He has also expressed his belief that his current multiple joint pains are related to exposure to various toxins in service. However, as a lay person, he can only comment as to symptoms and immediately-observable relationships. He lacks the expertise in this case, not involving such an immediately observable cause-and-effect relationship, to conclude that his current disability manifested by multiple joint pain is related to any specific toxin or substance in service or an undiagnosed illness, as opposed to some other cause. Rather, it would require medical expertise to evaluate the disability, consider all the potential causes, and determine that one was a more likely cause than another. Hence, the Veteran's opinion on this question is not competent evidence. 38 C.F.R. § 3.159(a)(1), (2) (2012). Although Dr. Morton opined in her October 2007 letter that the Veteran's symptoms, including joint pain, were consistent with "Gulf War Syndrome," such symptoms have consistently been attributed on numerous occasions to a known diagnosis, namely multiple joint arthritis. This precludes entitlement to service connection on the basis of an undiagnosed illness. Moreover, the most probative medical opinion of record (i.e. the March 2011 opinion) reflects that no relationship exists between the Veteran's current multiple joint arthritis and service. Additionally, the Board acknowledges that there are several medical opinions of record which attribute the Veteran's claimed lung problems and fatigue to his diagnosed multiple joint arthritis. The Veteran has reported on several occasions that such lung problems and fatigue have persisted since the time of his separation from service. Thus, as there are reports that symptoms attributed to the diagnosed multiple joint arthritis have reportedly existed since the time of the Veteran's separation from service, the evidence would appear to suggest that the multiple joint arthritis also had its onset around the time of his separation from service. However, as will be explained below, the Veteran's reports concerning the history of his lung symptoms and fatigue are not credible. Rather, the weight of the evidence reflects that such problems had their onset more than a year following the Veteran's separation from service. Hence, the Veteran's reports of lung problems and fatigue in the years since his separation from service do not support a conclusion that his multiple joint arthritis had its onset in service or in the year immediately following service. The October 2012 Joint Motion was premised on the Board's failure to adequately address the inconsistency between a conclusion that the Veteran's arthritis did not have its onset until years after service and the reports of arthritis related symptoms (such as fatigue) having their onset around the time of his separation from service. There is no other evidence of a relationship between the Veteran's multiple joint arthritis and service, and neither the Veteran nor his representative have alluded to the existence of any such evidence. Also, as discussed above, the record fails to demonstrate any credible evidence of a continuity of symptomatology. Thus, the preponderance of the evidence is against a finding that the Veteran's current multiple joint arthritis is related to service, manifested in service, or manifested within a year after his July 1991 separation from service. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim. The benefit-of-the-doubt doctrine is therefore not for application in this case and the claim of service connection for multiple joint arthritis must be denied. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57. Lung Disease Medical records reveal that the Veteran has been diagnosed as having various lung problems. For example, a March 2005 VA chest X-ray report includes a diagnosis of interstitial lung disease. Thus, a current lung disease has been demonstrated. The Veteran has claimed on several occasions that he began to experience lung problems (including shortness of breath) in service following his return from Iraq and that such symptoms have continued in the years since that time. He also contends that his current lung disease is related to his exposure to toxins in service or an undiagnosed illness due to participation in the Gulf War. He is competent to report symptoms of a lung disease, as well as a continuity of symptomatology. However, such reports must be weighed against the objective evidence and their credibility must be assessed. See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. There is no evidence of any complaints of or treatment for a lung disease or any symptoms associated with a lung disease in the Veteran's service treatment records and there were no respiratory abnormalities documented during his June 1991 separation examination. The objective medical evidence otherwise indicates that his current lung disease did not manifest until after service. The first post-service clinical evidence of possible lung disease is a May 1995 VA chest X-ray report which revealed accentuated peribronchial pulmonary interstitial markings in the basal segments of the right lower lobe. Such findings required medical professionals to rule out underlying interstitial pneumonia. The chest was otherwise within normal limits. There is no clinical evidence of any earlier respiratory symptoms following service. The first report of lung problems following service is the Veteran's April 1995 VA Form 21-526 on which he reported respiratory and lung problems. As explained above, his report of a November 1991 claim of service connection for lung problems is not credible in light of the fact that the only November 1991 claim in the claims file refers only to a fractured right wrist, a skin rash, and right wrist numbness. Moreover, the Veteran has provided varying statements as to the history of his lung problems. For example, he reported during the November 1997 hearing and an April 2005 VA examination that he began to experience shortness of breath in service while running. Such symptoms had reportedly continued in the years since that time. However, he reported on the June 1991 report of medical history for purposes of separation from service that he was not experiencing and had never experienced any asthma, shortness of breath, or chronic cough. He reported in his August 1996 statement that he began to experience difficulty breathing subsequent to service in August 1991. Furthermore, he reported during a December 2004 VA examination that he had experienced dyspnea on exertion for approximately 12 years (i.e. since approximately 1992). In light of the absence of any objective evidence of complaints of or treatment for lung problems during service or for several years after service and the Veteran's inconsistent and contradictory statements concerning the history of his respiratory symptoms, his reports concerning the history of his respiratory symptoms, including those of a continuity of symptomatology since service, are found to be not credible. Thus, neither the objective evidence nor the lay statements of record establish a continuity of symptomatology, precluding an award of service connection on this basis for the currently diagnosed lung disease. Additionally, the only medical opinion of record reflects that the Veteran's current lung disease is not related to service, but is related to his non service-connected multiple joint arthritis. The physician who conducted the December 2004 VA examination opined that the Veteran did not have a respiratory system abnormality that could be explained by service in the Gulf War. Rather, it was much more likely that his current lung disease, diagnosed as lung fibrosis and impairment, was related to his non service-connected rheumatoid arthritis. This opinion was based upon his examination of the Veteran and a review of his medical records. Specifically, such records reflected that the Veteran denied having any pulmonary problems prior to service, that he smoked approximately 1 pack per day for approximately 5 years while in service, and that there was no clinical evidence of respiratory complaints in service. A chest X-ray conducted in service in June 1990 was within normal limits. Despite the Veteran's reports of exposure to various toxins in service (including depleted uranium, burning oil wells, pesticides, and possible sarin), a review of medical literature did not indicate any references that specifically linked exposures in the Gulf War to lung fibrosis. Also, there were no obvious pulmonary risk exposures following service. For example, he was a student and worked as a car salesman and postal employee after service. The examiner further explained that although the Veteran had reported a 12 year history of dyspnea on exertion, there were no claims of dyspnea dating that far back in the record. The first clinical evidence of a lung problem in the record was from a chest film dated in October 1996 which revealed lung infiltrates. Respiratory symptoms were first emphasized in approximately 1999 when he received treatment at the VA Medical Center in Atlanta, Georgia for lung problems. The fibrosis pattern shown in several chest X-rays was most consistent with long-standing rheumatoid arthritis that commonly affects the lungs. Such lung disease begins as an inflammatory process that eventually develops into an irreversible fibrotic pattern. Pulmonary function tests conducted since 1999 were consistent with the Veteran's clinical presentation and lung fibrosis in that they showed a mild restrictive impairment that had been stable over time. Diffusing capacity of the lung had been at the low end of normal to just below normal. This was not unexpected in fibrotic lung processes due to collagen-vascular diseases like rheumatoid arthritis. There was no indication of airflow limitation or obstruction suggestive of reactive airways (e.g. asthma) or chronic fixed airways (e.g. pulmonary emphysema). In sum, the December 2004 examiner concluded that the Veteran had developed rheumatoid arthritis sometime around 1990. Radiological evidence of lung involvement was noted in 1996 with documented respiratory symptoms occurring between 1996 and 1999. At that time, evidence of a restrictive impairment was noted by pulmonary function testing. The time, course, and pattern of events was most consistent with a pulmonary impairment secondary to lung involvement in rheumatoid arthritis. This was much more likely than an explanation implicating any exposures during the Gulf War. While the date of onset of rheumatoid arthritis in 1990 is inaccurate, this does not materially undermine the gist of the opinion, i.e., pulmonary disability was related to nonservice-connected rheumatoid arthritis. The Board recognizes that the December 2004 examiner stated that the first clinical evidence of a lung problem was from a chest film dated in October 1996. However, the first post-service clinical evidence of a possible lung disease is the May 1995 VA chest X-ray report. Nevertheless, the fact remains that there is no credible evidence of any lung problems in service or for several years after service. The December 2004 opinion was based upon an examination of the Veteran and a review of his medical records and reported history, and it is accompanied by an extensive rationale that is not otherwise inconsistent with the evidence of record. Thus, this opinion is adequate and entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The Veteran claims that his current lung disease is either the result of an undiagnosed illness that he developed during the Persian Gulf War or exposure to various toxins in service. However, as his claim does not involve an immediately observable cause-and-effect relationship, he lacks the necessary medical expertise to conclude that his current lung disease is related to an undiagnosed illness or exposure to toxins in service, as opposed to some other cause. Thus, his opinion concerning the etiology of his current lung disease is not competent evidence. 38 C.F.R. § 3.159(a)(1), (2). Although the Veteran has received treatment from medical professionals for his lung disease, none have attributed this disability to any undiagnosed illness or toxic exposure in service. His lung symptoms have consistently been attributed to a known diagnosis of interstitial lung disease, which itself has been attributed to a known diagnosis of rheumatoid arthritis. Thus, entitlement to service connection on the basis of an undiagnosed illness is precluded. Also, the only medical opinion of record indicates that no relationship exists between the Veteran's current lung disease and service. There is no other evidence of a relationship between the Veteran's current lung disease and service, and neither the Veteran nor his representative have identified any such evidence. Also, there is no credible evidence of a continuity of symptomatology. Thus, the weight of the evidence reflects that the Veteran's current lung disease is not related to service and did not manifest in service. Rather, the disease is related to his diagnosed rheumatoid arthritis. As the Board is denying the claim of service connection for multiple joint arthritis, including rheumatoid arthritis, service connection for a current lung disease as secondary to the diagnosed rheumatoid arthritis under 38 C.F.R. § 3.310 is not warranted. Hence, the claim of service connection for a lung disease is denied. 38 U.S.C.A. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310. Disability Manifested by Chronic Fatigue The Veteran claims that he experiences a disability manifested by chronic fatigue and he contends that this symptom is also due to an undiagnosed illness or exposure to various toxins in service. He has reported on several occasions that he began to experience fatigue in service and that there has been a continuity of symptomatology since service. While he is competent to report fatigue and a continuity of symptomatology, his reports must be compared to the objective evidence of record and a determination must be made as to their credibility. See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. There is no evidence of any complaints of or treatment for fatigue in the Veteran's service treatment records and there were no problems related to fatigue reported during his June 1991 separation examination. The first post-service clinical evidence of fatigue is the September 1993 VA medical certificate which reveals that the Veteran reported that he lacked energy and was chronically tired. There is no earlier clinical evidence of fatigue following service. Further, the first credible report of fatigue following service is the Veteran's April 1995 VA Form 21-526. The Veteran has also provided varying statements as to the history of his fatigue. He reported during VA examinations dated in June 1999 and January 2008 that he first experienced fatigue in service in May 1991 after returning to Germany from the Gulf War. However, in his August 1996 statement he reported that chronic fatigue began following service in August 1991. Due to the absence of any objective evidence of complaints of or treatment for fatigue during service or for several years after service and the Veteran's inconsistent and contradictory statements concerning the history of his fatigue, the Board concludes that his reports concerning the history of his fatigue, including those of a continuity of symptomatology since service, are not credible. Thus, there is no credible clinical or lay evidence of record to establish a continuity of symptomatology in this case with respect to the claimed fatigue. There are conflicting medical opinions concerning the etiology of the Veteran's fatigue. The physician who conducted the June 1999 VA examination diagnosed the Veteran as having chronic fatigue due to undiagnosed illness. He explained that based on a review of a July 1997 letter from the Office of the Secretary of Defense to the Veteran concerning possible exposure to nerve agents (such as sarin and cyclosarin) and a review of the findings in the Board's May 1999 decision, he was unable to connect the Veteran's chronic fatigue to anything except the possible exposure to low levels of sarin and cyclosarin gases. Exposure to such gases had not been proven to cause chronic fatigue syndrome, and the examiner suggested that the Veteran be allowed to enroll in the Department of Defense Comprehensive Clinical Evaluation Program which was listed in the July 1997 letter. Also, he suggested that the services of an expert in the field of nerve gases be enlisted. The examiner further explained that although the Veteran reported the onset of fatigue as being in May 1991, there was no clinical evidence of any fatigue until August 1995, at which time he was evaluated by a VA rheumatologist and reported fatigue. He was eventually found to have a positive RNP antibody, an elevated SED rate, and positive ANA. The conclusion was that he had polyarthritis. Overall, the examiner opined that the Veteran's progressive fatigue had a causative relationship to his diagnosed rheumatoid arthritis. As service connection for rheumatoid arthritis had been denied, the examiner was unable to "make a well rounded claim for service connected chronic fatigue syndrome." However, he reiterated that an expert in exposure to nerve gas (specifically sarin and cyclosarin) should be consulted for an opinion on this conclusion, if such an expert existed. The April 2005 VA examination includes an opinion that there was insufficient evidence to support a diagnosis of chronic fatigue syndrome. This opinion was based on the fact that the Veteran did not meet six or more of the ten criteria sufficient for a diagnosis of chronic fatigue syndrome. Specifically, he did report generalized muscle aches and weakness. Also, he reported fatigue lasting 24 hours or longer after exercise. However, he also reported that he did not exercise, so it was unclear how this complaint could be judged related to exercise. He experienced a vague history of headaches, but could not specify their severity, pattern, or other details. He reported pharyngitis, palpable lymph nodes, and low grade fevers. However, no such symptoms were evidenced during the April 2005 examination. Additionally, he reported neuropsychologic symptoms and his VA problem list included a diagnosis of recurrent major depression. A November 2005 VA psychiatric examination report includes an opinion that the Veteran's fatigue was likely ("at least as likely as not") caused by his diagnosed depression. However, he also had multiple other conditions, to include his arthralgias, which may have contributed significantly to his fatigue. The examiner could not resolve the question of which factor was the major contributor to his symptoms of fatigue without resorting to mere speculation. The rheumatologist who conducted the November 2005 VA examination opined that the Veteran's fatigue was caused by his underlying inflammatory arthritis. She reasoned that he had experienced persistent fatigue throughout the course of his arthritis and that fatigue, and other systemic symptoms, were often a major part of inflammatory arthritis. In her October 2007 letter, Dr. Morton opined that the Veteran had symptoms consistent with Gulf War Syndrome, including fatigue. She explained that the Veteran had reported exposure to the nerve agent sarin while serving in the Gulf War. The physician who conducted the January 2008 VA examination opined that the evidence did not support a conclusion that the Veteran's fatigue had its onset in service. She reasoned that records dated since 1995 included reports of fatigue and joint complaints. The diagnosis had fallen under the category of inflammatory arthritis, possibly seronegative RO or ANA mediated mixed connective tissue disease. His complaints of fatigue since 1995 had been attributed to his inflammatory arthritis. The January 2008 examiner also opined that while the Veteran endorsed many of the criteria for chronic fatigue syndrome, his diagnosed inflammatory polyarthritis was the diagnosis likely responsible for his fatigue. She reasoned that his laboratory findings showed a pattern of ANA 1:320 that was speckled. Such findings were rarely associated with lupus and were often associated with scleroderma, "sjogren's," and mixed connective tissue disease. He was evaluated by neuropsychology in 2005 and his memory problems were felt most likely to be related to depression and/or posttraumatic stress disorder (PTSD). Either of these diagnoses could affect sleep quality and quantity. Polyarthritis and insufficient sleep could influence physical endurance. Thus, the Veteran did not meet the criteria for a diagnosis of chronic fatigue syndrome. The June 1999 opinion is of somewhat limited probative value due to the fact that it is contradictory. Specifically, the examiner diagnosed the Veteran as having chronic fatigue due to undiagnosed illness. However, the examiner subsequently opined that the fatigue was due to diagnosed rheumatoid arthritis. The April and November 2005 and January 2008 opinions, however, were based upon examinations of the Veteran and a review of his medical records and reported history, and they are all accompanied by rationales that are not inconsistent with the evidence of record. Thus, these opinions are entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Although the Veteran has contended that his current fatigue is the result of an undiagnosed illness, he again lacks the necessary medical expertise to make such a conclusion. Thus, his opinion concerning the etiology of his current fatigue is not competent evidence. 38 C.F.R. § 3.159(a)(1), (2). Although Dr. Morton opined in her October 2007 letter that the Veteran's fatigue was consistent with Gulf War Syndrome, the preponderance of the evidence indicates that his fatigue is attributed to known diagnoses, including rheumatoid arthritis, depression, and PTSD. Also, the medical opinions of record reflect that he does not have chronic fatigue syndrome. Thus, entitlement to service connection on the basis of an undiagnosed illness or a chronic multi symptom illness (such as chronic fatigue syndrome) is precluded in this case. There is no other evidence of any current disability manifested by chronic fatigue that is separate and distinct from the Veteran's diagnosed rheumatoid arthritis and psychiatric disability, and neither the Veteran nor his representative have alluded to the existence of any such evidence. Also, there is no credible evidence of a continuity of symptomatology. In sum, the preponderance of the evidence supports a conclusion that the Veteran does not have chronic fatigue syndrome and that his reported fatigue is not due to an undiagnosed illness. Rather, the fatigue is related to his diagnosed rheumatoid arthritis and psychiatric disability. As explained above, the Board is denying the claim of service connection for multiple joint arthritis, including rheumatoid arthritis. Additionally, service connection has already been granted for dysthymia, major depressive disorder, and PTSD. In reaching its decision in this appeal, the Board has resolved reasonable doubt in the Veteran's favor, where applicable. The record does not show that the evidence is so evenly balanced as to warrant service connection for a separately diagnosed disability manifested by chronic fatigue. Hence, the appeal is denied. 38 U.S.C.A. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.310. ORDER Service connection for multiple joint arthritis is denied. Service connection for a lung disease is denied. Service connection for a disability manifested by chronic fatigue is denied. ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs