Citation Nr: 1318501 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 99-08 420A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to service connection for a disability manifested by dizziness, to include as due to an undiagnosed illness. 2. Entitlement to service connection for a disability manifested by joint pain, to include as due to an undiagnosed illness. 3. Entitlement to service connection for a skin disability, to include as due to an undiagnosed illness. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from November 1977 to May 1983 and from December 1990 to August 1991, including in the southwest Asia theater of operations during the Persian Gulf War. He also had additional U.S. Army National Guard (ANG) service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 1998 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York, which denied, in pertinent part, the Veteran's claims of service connection for a disability manifested by dizziness (which was characterized as dizziness), a disability manifested by joint pain (which was characterized as joint aches), and for a skin disability (which was characterized as a skin rash), each to include as due to an undiagnosed illness. Having reviewed the record evidence, the Board finds that the issues are characterized more appropriately as stated on the title page of this decision. Although the Veteran requested a Travel Board hearing when he perfected a timely appeal on these claims in May 1999, he failed to report for this hearing when it was scheduled at the RO in May 2005. Thus, his Board hearing request is deemed withdrawn. See 38 C.F.R. § 20.704 (2012). In September 2005, October 2009, and September 2011, the Board remanded these matters to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. The issues of entitlement to a disability rating greater than 50 percent for PTSD, entitlement to a total disability rating based on individual unemployability (TDIU), and entitlement to service connection for asthma have been raised by the record but have not been adjudicated by the Agency of Original Jurisdiction (AOJ) (in this case, the RO). The Board has referred back all of these claims to the RO previously in its October 2009 and September 2011 remands. To date, however, it appears that the RO has not adjudicated any of these claims. Because the Board still does not have jurisdiction over these issues, they are referred back to the RO for the third time since October 2009 for adjudication. It also is not clear from a review of the Veteran's claims file whether he is being compensated appropriately for his 3 dependents (his wife and 2 children). The Veteran filed a VA Form 21-686c in January 2006 claiming all 3 dependents and asking to have them added to his VA disability compensation award. The Veteran's service representative also submitted correspondence to the RO in October 2008 asking for an update on the status of the Veteran's request to add all 3 of his dependents to his VA disability compensation award. It is not clear from a review of the claims file whether he is being compensated appropriately for all 3 of his dependents. The cover letter to the most recent rating decision issued by the RO in November 2012 indicates that he only is being paid for 1 dependent (his wife). The Board does not have jurisdiction over this dependency issue. Accordingly, on remand, the RO must determine whether the Veteran is being compensated appropriately for all 3 of his dependents and, if not, take appropriate action to correct any underpayment of VA disability compensation. FINDINGS OF FACT 1. The Veteran's service personnel records confirm that he served in the southwest Asia theater of operations during the Persian Gulf War. 2. The evidence of record indicates that the Veteran may have been exposed to nerve gas while on active service in the southwest Asia theater of operations during the Persian Gulf War. 3. The evidence of record shows that the Veteran's complaints of dizziness, which first manifested several years after his service separation, have been attributed to a known clinical diagnosis of anemia. 4. The evidence of record shows that the Veteran's current dizziness is not the result of a disease or injury incurred in active service or any incident of service, to include as due to an undiagnosed illness. 5. The evidence of record indicates that the Veteran does not experience any current disability due to joint pain which could be attributed to active service or any incident of service. 6. The evidence of record indicates that the Veteran's complaints of a skin disability, which first manifested several years after his service separation, have been attributed to known clinical diagnoses of mild intertrigo and tinea cruris. 7. The evidence of record shows that the Veteran's current mild intertrigo and tinea cruris are not the result of a disease or injury incurred in active service or any incident of service, including his acknowledged in-service nerve gas exposure, or as due to an undiagnosed illness. CONCLUSIONS OF LAW 1. A disability manifested by dizziness was not incurred in or aggravated by active service, to include as due to an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1117, 1118, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2012). 2. A disability manifested by joint pain (claimed as joint aches) was not incurred in or aggravated by active service, to include as due to an undiagnosed illness, nor may arthritis of the joints be presumed to have been caused or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1117, 1118, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.317 (2012). 3. A skin disability (claimed as a skin rash) was not incurred in or aggravated by active service, to include as due to an undiagnosed illness. 38 U.S.C.A. §§ 1110, 1117, 1118, 1131, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. In letters issued in December 2005, October 2008, and in March and July 2010, VA notified the Veteran of the information and evidence needed to substantiate and complete his claims, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). This letter informed the Veteran to submit medical evidence relating the claimed disabilities to active service and noted other types of evidence the Veteran could submit in support of his claim. The Veteran also was informed of when and where to send the evidence. After consideration of the contents of these letters, the Board finds that VA has substantially satisfied the requirement that the Veteran be advised to submit any additional information in support of his claims. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Additional notice of the five elements of a service-connection claim was provided in the March and July 2010 VCAA notice letters, as is now required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As will be explained below in greater detail, the evidence does not support granting service connection for a disability manifested by dizziness, a disability manifested by joint pain, or for a skin disability, each to include as due to an undiagnosed illness. Because the Veteran was fully informed of the evidence needed to substantiate these claims, any failure of the RO to notify the Veteran under the VCAA cannot be considered prejudicial. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The Veteran also has had the opportunity to submit additional argument and evidence and to participate meaningfully in the adjudication process. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). With respect to the timing of the notice, the Board points out that the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a Veteran before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Although the Veteran was not provided with pre-adjudication VCAA notice in this case, the Board finds that this was not prejudicial, as the currently appealed rating decision was issued in January 1999 prior to the VCAA's enactment. Because all of the Veteran's claims are being denied in this decision, any question as to the appropriate disability rating or effective date is moot. See Dingess, 19 Vet. App. at 473. Additionally, any defect in the timing or content of the notice provided to the Veteran and his service representative has not affected the fairness of the adjudication. See Mayfield, 444 F.3d at 1328. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the RO and the Board. As noted above, the Veteran failed to report for his Travel Board hearing when it was scheduled in May 2005. It appears that all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Veteran's Virtual VA claims file has been reviewed. The Veteran's complete Social Security Administration (SSA) records also have been obtained and associated with the claims file. In May 1997, the National Personnel Records Center in St. Louis, Missouri (NPRC), notified VA that the Veteran's service treatment records for 1990-1991 could not be located. In cases where the Veteran's service treatment records (or other pertinent records, for that matter) are unavailable through no fault of the claimant, there is a heightened obligation to assist the claimant in the development of his or her case. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). VA also must provide an explanation to the Veteran regarding VA's inability to obtain his or her service treatment records. Dixon v. Derwinski, 3 Vet. App. 261 (1992). The Court also has held that VA's efforts to obtain service department records shall continue until the records are obtained or unless it is reasonably certain that such records do not exist or that further efforts to obtain those records would be futile. Hayre v. West, 188 F.3d 1327 (Fed. Cir. 1999); see also McCormick v. Gober, 14 Vet. App. 39 (2000). It appears, however, that all of the Veteran's available service treatment records from his service in the southwest Asia theater of operations in 1990-1991 have been obtained and associated with his claims file. Having reviewed the record, the Board finds that it is reasonably certain that the Veteran's available service treatment records from 1990-1991 have been obtained, and it is reasonably certain that further efforts to obtain these records would be futile. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the Veteran shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. An examination or opinion shall be treated as being necessary to make a decision on the claim if the evidence of record, taking into consideration all information and lay or medical evidence (including statements of the claimant), contains competent evidence that the Veteran has a current disability, or persistent or recurring symptoms of disability; and indicates that the disability or symptoms may be associated with the Veteran's active service; but does not contain sufficient medical evidence for VA to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) ; McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran has been provided with VA examinations which address the contended causal relationship between the claimed disabilities and active service. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claims adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. Additionally, a review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed the RO/AMC to obtain the Veteran's updated VA and private treatment records. These records subsequently were associated with the claims file and with the Veteran's Virtual VA claims file. The Board also directed the RO/AMC to obtain the Veteran's Social Security Administration (SSA) records. These records were associated with the Veteran's claims file in July 2006. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. Service Connection Claims The Veteran contends that he incurred a disability manifested by dizziness, a disability manifested by joint pain, and a skin disability during active service. He alternatively contends that his dizziness, joint pain, and skin disability all are due to an undiagnosed illness incurred while he was on active service in the southwest Asia theater of operations during the Persian Gulf War. He contends further that in-service exposure to nerve gas while on active service in Khamisayah, Iraq, during the Persian Gulf War caused or contributed to these disabilities. Law and Regulations Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease 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). Certain chronic diseases, including arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Establishing service connection generally requires (1) medical evidence of a presently existing 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 claim in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)); Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be established for a Persian Gulf Veteran who exhibits objective indications of chronic disability which cannot be attributed to any known clinical diagnosis, but which instead results from an undiagnosed illness that became manifest either during active 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)(i) (2011). See also 76 Fed. Reg. 81834 (Dec. 29, 2011). A "Persian Gulf Veteran" is one who served in the Southwest Asia theater of operations during the Persian Gulf War. Id. Objective indications of a 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. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(2)-(5). Effective March 1, 2002, the law affecting compensation for disabilities occurring in Persian Gulf War Veterans was amended. 38 U.S.C.A. §§ 1117, 1118. Essentially, these changes revised the term "chronic disability" to "qualifying chronic disability," and involved an expanded definition of "qualifying chronic disability" to include: (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2)(B); 38 C.F.R. § 3.317. 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). With claims based on undiagnosed illness, the Veteran is not required to provide competent evidence linking a current disability to an event during service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). Signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multi-symptom illness include: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C.A. § 1117(g); 38 C.F.R. § 3.317(b). Section 1117(a) of Title 38 of the United States Code authorizes service connection on a presumptive basis only for disability arising in Persian Gulf Veterans due to "undiagnosed illness" and may not be construed to authorize presumptive service connection for any diagnosed illness, regardless of whether the diagnosis may be characterized as poorly defined. VAOPGCPREC 8-98 (Aug. 3, 1998). Compensation may be paid under 38 C.F.R. § 3.317 for disability which cannot, based on the facts of the particular Veteran's case, be attributed to any known clinical diagnosis. The fact that the signs or symptoms exhibited by the Veteran could conceivably be attributed to a known clinical diagnosis under other circumstances not presented in the particular Veteran's case does not preclude compensation under § 3.317. Id. If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). 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. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. In Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit recently overruled Savage and limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); see also 38 C.F.R. § 3.309(a). Because a disability manifested by dizziness and a skin disability are not explicitly recognized as "chronic" disabilities in 38 C.F.R. § 3.309(a), the Board finds that Savage and the theory of continuity of symptomatology in service connection claims is inapplicable to the Veteran's service connection claims for a disability manifested by dizziness and for a skin disability, each to include as due to an undiagnosed illness. By contrast, because arthritis is considered a "chronic" disability under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology remains valid in adjudicating the Veteran's service connection claim for a disability manifested by joint pain, to include as due to an undiagnosed illness. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. Factual Background The Veteran's service personnel records confirm that he served in the southwest Asia theater of operations during the Persian Gulf War. The Veteran's service treatment records from his first period of active service show that, at his enlistment physical examination in October 1977, he denied all relevant pre-service medical history. Clinical evaluation was normal except for an asymptomatic left varicocele. The Veteran's medical history and clinical evaluation were unchanged on periodic physical examination in October 1978. On outpatient treatment in January 1982, the Veteran's complaints included dizziness which had lasted for 2 days. A "Medical Clearance for CONUS Returnees" form dated in March 1983 indicates that the Veteran was medically clear for retirement from service following his return from overseas. In April 1983, the Veteran stated that he wanted a separation physical examination. It appears, however, that a copy of the Veteran's 1983 separation physical examination was not included in his service treatment records. On VA examination in July 1983, approximately 2 months after the Veteran's service separation in May 1983, the Veteran's complaints included low back and bilateral knee pain. He denied any other joint problems. Physical examination showed "no back orthosis," alleged tenderness "over upper sacrum only, no lumbar muscle spasm," no bilateral knee effusion, and a full range of motion in both knees with no crepitus, lateral instability, or patellar subluxation. X-rays of the lumbosacral spine were normal. The diagnoses were no orthopedic condition found and no specific conditions found. The Veteran's service treatment records from his ANG service show that, on periodic physical examination in December 1986, he denied all relevant medical history. Clinical evaluation showed a small papule on the right scapula. On periodic physical examination in August 1990, clinical evaluation of the Veteran showed a nevus on the right scapula. The Veteran denied all relevant medical history on a "Medical History Report" form completed in October 1990, just prior to his second period of active service. It was noted on this form that the Veteran had undergone a complete physical in August 1990 and was fit for mobilization. The Veteran's service treatment records from his second period of active service show that, on outpatient treatment in December 1990, the Veteran complained of pain in the back of the head due to a growth on the scalp. Objective examination showed large hypertropic scar on the lower neck (back of the head) and patched areas of small papules at the scalp. The assessment was acne keloidalis nuchae. At his separation physical examination in July 1991, just prior to the end of his second period of active service, the Veteran denied all relevant medical history. Clinical evaluation was normal. A "Southwest Asia Demobilization/Redeployment Medical Evaluation" completed in July 1991 indicated that the Veteran denied experiencing any fatigue, rash, skin infection, or sores, or any exposure to chemical warfare or germ warfare during his recent deployment to southwest Asia. On VA outpatient treatment in May 1994, the Veteran's complaints included dizziness which had lasted for 5 months. The Veteran stated that he felt "light [and] unsteady only when standing." The impressions included dizziness. In December 1994, the Veteran's complaints included pain in the knees, arms, and lower back. He denied any in-service exposure to chemicals or radiation during active service, including while he was overseas during the Persian Gulf War. He reported that his joint pain had begun 4-5 months after he had returned from the Persian Gulf. He noted that his joint pain occurred in the shoulders, hips, low back, and knees. Objective examination of the Veteran's joints showed anterior superior thickening and edema and some cracking in the right knee with a full range of motion. The assessment included joint pain. In February 1995, no complaints were noted. The assessment included joint pain. On ANG periodic physical examination in August 1995, clinical evaluation of the Veteran was normal. On VA outpatient treatment later in August 1995, the Veteran complained of "brown spots" on the abdomen and back and itching lesions on the left arm. Physical examination showed irregular uniformly colored medium brown macules on the back and abdomen approximately 2 centimeters, wristband erythematous papules on the left arm 2 centimeters, and 2 blanching plaques. The assessment was probable post-inflammatory hyperpigmentation and probable contact dermatitis. On VA joints examination in October 1995, the Veteran complained of intermittent right knee pain. There were no objective findings, no swelling, no deformity, no other impairment of the right knee, and flexion to 135 degrees. X-rays of the right knee were negative. The diagnosis was no significant findings. On VA general medical examination in October 1995, the Veteran denied any current complaints. Physical examination was entirely negative. The diagnosis was negative general medical examination. In an ANG "Annual Medical Certificate" dated in July 1996, the Veteran reported that he had joint pain in his elbows and knees. In a September 1996 statement, the Veteran asserted that he was "getting rashes on my body [and] pains in the joints, knees, and elbows." On VA outpatient treatment in September 2002, the Veteran's complaints included joint pain. The assessment included joint pain. In February 2003, no complaints were noted. Physical examination showed firm papules on the back of the Veteran's scalp/neck. The assessment included acne keloidalis nuchae. In May 2003, the Veteran's complaints included a bump on the right arm "that comes and goes, sometimes pruritic, currently not bothering him." Physical examination showed a firm skin-colored plaque on the occipital scalp with surrounding erythematosus crusted papules and a 1 centimeter hyperpigmented nodule on the right flexural upper arm superior to antecubital fossa. The assessment was acne keloidalis nuchae and prurigo nodule. In June 2003, the Veteran stated that his skin lesions "are no longer pruritic." He also reported that his prurigo nodule on the left arm was "no longer pruritic and resolving." Physical examination showed a firm skin-colored plaque on the occipital scalp with minimal surrounding erythema, few crusted lesions, no pustules, and a 1 centimeter hyperpigmented nodule on the right flexural upper arm superior to antecubital fossa that was no longer lichenified. The assessment was unchanged. In August 2003, the Veteran's complaints included scalp lesions, chronic knee and right shoulder pain, and intermittent pain since 1991 in the right big toe joint. It was noted that October 2002 x-rays of the right foot had been normal. A history of chronic pain to the knees and right shoulder "for many [years] with stiffness in the morning, gets better with activities later in the day" was noted. The Veteran reported that he believed that he was exposed to chemicals "during Desert [S]torm in 1991." The assessment included intermittent pain since 1991 in the right big toe joint, a history of lesions to the back of the head in the scalp area and of the right upper extremity, a history of chronic pain to the knees and right shoulder, and mild anemia. In February 2005, the Veteran's complaints included knee and shoulder pain. Physical examination showed moderate pain on range of motion testing, no gross neurological deficits, and no gait or lifting disturbances. MRI scans were unremarkable. Physical examination showed a scalp lesion/scar, no musculoskeletal atrophy, no skeletal deformities, minimal pain ot the knees and shoulders, a full range of motion "to all major joints," and "strong muscle strength without evidence of paresthesias." The assessment included "most likely" joint pain of the knees and shoulders. Muscle strengthening exercises were encouraged. In May 2005, the Veteran's complaints included bilateral shoulder and right knee pain "for 7 years." He described this pain as dull-aching, throbbing, on-off, and rated it as 7/10 on a pain scale (with 10/10 being the worst imaginable pain). The pain was worse in the morning and on prolonged sitting, standing, and ambulating, and on stair climbing, lifting 5-10 pounds of groceries, and on overhead activity. It was noted that recent magnetic resonance imaging (MRI) scans of the left shoulder and left knee were normal and an MRI of the right knee "showed cystic structure posterior to the posterior horn of the lateral meniscus which may be a[n] intra-articular ganglion." His ambulation was independent "but slow due to knee pain." His activities of daily living were independent "but slow due to shoulder pain." Physical examination showed tenderness to palpation and on range of motion testing, left greater than right shoulder pain and in the right knee, full bilateral shoulder flexion, a full range of motion in the left knee without crepitus, 4/5 motor strength in the shoulders and right knee, 3/5 grasp strength, a slightly antalgic gait on the right leg with a "slow, short stride and wide base." The physiatrist concluded that the Veteran had bilateral rotator cuff and bicipital tendonitis and right knee derangement "associated with an intraarticular ganglion cyst at [the] posterior horn of [the] lateral meniscus which affected his shoulder activity and ambulation." The Veteran also had a "[m]ild gait disorder." The Veteran was referred to a physical therapy program twice a week and an occupational therapy program 2 times a week for 4 weeks "to decrease pain, improve strength and mobility" of bilateral shoulder girdle and right knee musculature "which will improve" his skill at his activities of daily living and gait. In August 2005, the Veteran complained that he had been scratching his acne keloidalis nuchae. Physical examination showed erythematosus and crusted papules and plaques on the dorsal neck with 1 pustule. The assessment was acne keloidalis nuchae. Later in August 2005, it was noted that the Veteran had completed rehabilitation treatment for his chronic pain to the bilateral knees and left shoulder "and feels better." The assessment included a history of chronic pain to the knees and left shoulder which was improved. In September 2005, the Veteran complained of right hand swelling in the distal fingers. He reported doing weight-lifting with his hands recently. Physical examination showed no gross phalanx deformity, no numbness/paresthesias, left little finger pain and swelling secondary to old injury with no relief or pain/swelling, and a distal phalanx deformity present. The assessment included right hand contusion secondary to trauma versus degenerative joint disease and left little finger injury with distal collateral ligament injury. He was advised to rest his right hand and stop lifting weights. An addendum to this treatment note dated later in September 2005 indicates that x-rays of the hands showed no acute fracture or dislocation. Physical examination showed bilateral dorsal interphalangeal (DIP) joint and metacarpointerphalangeal (MIP) stiffness with mild pain, a left little finger distal/phalanx contracture (to 70 degrees of flexion with pain and swelling), no redness or heat, and equal hand grip bilaterally. The assessment was bilateral hand arthropathy most likely secondary to "heavy and aggressive" weightlifting and a left little distal phalanx injury with contracture secondary to collateral ligament sprain or partial healed rupture. The Veteran was advised to stop weightlifting. A review of the Veteran's SSA records, which were received by the RO in July 2006, shows that they consist largely of duplicate copies of the Veteran's VA outpatient treatment records. The Veteran was awarded SSA disability benefits for psychiatric disabilities. VA x-rays of the Veteran's shoulders taken in August 2006 were unremarkable. VA x-rays of the Veteran's left knee taken in August 2006 showed a small left knee effusion but otherwise were unremarkable. On VA outpatient treatment in October 2006, the Veteran's complaints included left shoulder and left knee pain. "He denies any falls, accident, or sprain." It was noted that recent x-rays of the Veteran's left shoulder and left knee were unremarkable. Physical examination of the left knee showed a full range of motion without crepitus, 4/5 motor strength in the shoulders, and 5/5 motor strength in the left knee. The assessment was left biceps tendinitis and left knee pain "with negative physical and x-ray finding" and questionable internal derangement. The Veteran was prescribed occupational therapy twice a week for 3 weeks and physical therapy 2-3 times a week for 3 weeks. The Veteran reported to the emergency room (ER) at a VA Medical Center in May 2009 complaining of dizziness associated with mild sharp left-sided chest pain that morning. He reported feeling "jittery." His dizziness lasted for "minutes and resolved after eating a candy." A similar episode had occurred on the previous Sunday morning "also with chest pain and resolved with candy." He was asymptomatic when he was seen in the ER. Physical examination showed he was awake and alert, fully oriented, and in no acute distress. The assessment included dizziness. The diagnosis was chest pain. On VA outpatient treatment in June 2008, the Veteran's complaints included pain over the knee and shoulder joints. He denied any muscle pain, weakness, or immobility. The Veteran rated his knee and shoulder joint pain as 3/10 on a pain scale (with 0/10 being no pain and 10/10 being the worst imaginable pain). Plain x-rays and MRI scans of the knees and shoulders had been unremarkable. Physical examination showed a scalp lesion/scar, no musculoskeletal atrophy, no skeletal deformities, and no edema and only minimal pain to the knees or shoulders. The assessment included a clinically stable musculoskeletal disorder. In August 2008, the Veteran was seen in the ER of a VA Medical Center for complaints of left shoulder and neck pain. He had difficulty moving his neck "in any direction because of pain." Physical examination showed he was in distress from pain, limitation of motion in the neck due to pain, paravertebral tenderness in the cervical spine, intact cranial nerves, and normal strength, sensation, and reflexes. The diagnosis was neck pain/muscular spasm. The Veteran was given a neck brace and discharged from the ER. In a September 2008 statement, the Veteran contended that, because his active service unit had been near Khamisiyah, Iraq, in early March 1991, he had been exposed to nerve gas during active service. Attached to this statement was a copy of a letter from the Office of the Secretary of Defense in which he was advised that, when Iraqi rockets were destroyed by U.S. forces in Khamisiyah, Iraq, in early March 1991, "the nerve agents sarin and cyclosarin may have been released into the air. If you were with your unit at this time, you may have been in an area where exposure to a very low level of nerve agents was possible. However, our analysis shows that the exposure levels would have been too low to activate chemical alarms or to cause any symptoms at the time." (Emphasis in original.) The Veteran also was advised that "low level exposure to nerve agents" was unlikely to cause any long-term health problems. On VA skin diseases examination in June 2010, the Veteran complained of a skin rash "starting 1972 on/off. May be worsening with each episode." He also complained of itching. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran used zinc soap and coal tar shampoo weekly to treat his skin problems. Physical examination showed a healing abrasion of the left wrist and mild eczema and scaling on the groin fold. This affected less than 1 percent of the entire body and zero percent of the exposed areas of the body. The VA examiner opined that he could not determine if the Veteran's skin disability "has any relation to his service, specifically nerve agent exposure" without resorting to speculation. The diagnoses were abrasion secondary to recent trauma of the left wrist that was healing and tinea cruris. On VA chronic fatigue syndrome examination in June 2010, the Veteran complained of chronic fatigue syndrome. When this problem occurred, the Veteran stated that his routine daily activities were restricted 50 percent and these episodes lasted 20-30 minutes. Physical examination showed no deformities and no acute distress. The VA examiner opined that, based on the Veteran's history, physical examination, laboratory studies, and a review of the claims file, "there is no evidence of...a condition with generalized joint pains and dizziness." The assessment included no diagnosis of a condition with joint pains and no diagnosis of a condition causing dizziness. On VA Gulf War General Medical Disability Benefits Questionnaire (DBQ) in October 2011, the Veteran's complaints included joint pain in the wrists, hands, fingers, knees, shoulders, and low back. "The Veteran does not have fatigue. He does not have any signs and symptoms of a skin condition." A history of anemia and "multiple joint pains that include [the] bilateral hands and fingers" was noted. It also was noted that the Veteran's "rheumatoid factor has been checked since 1995 and they have been negative all through." X-rays of the knees, shoulders, and fingers all had been normal. MRI scans of the left knee and left shoulder had been unremarkable. The VA examiner's opinion was that, since "there are images to explain the source of the Veteran's joint pains and there are lab reports to explain why he is being so dizzy, mainly he has been anemic for so long, the Veteran does not have any Gulf War Syndrome diagnosis at this time." On VA skin diseases DBQ in October 2011, the Veteran's complaints included "some itching and some hyperpigmentation and some mild erythema in the inguinal areas bilaterally," and "a keloid on the nuchal region of his scalp." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran reported that his skin condition had begun "a few years after he got out of the military in 1991." Physical examination showed some mild hyperpigmentation and erythema with occasional itching in the inguinal region, bilaterally, affecting 1 percent of the exposed areas of the body and 2 percent of the entire body, and some mild itching in the groin area. The VA examiner opined that the Veteran's two skin disorders "do not result from any nerve gas exposure that he may have been exposed to during the Persian Gulf War." The diagnoses were a mild intertrigo with a possible tinea cruris and a keloid on the nuchal region of the scalp. In a December 2012 addendum to the October 2011 VA skin diseases DBQ, the VA examiner stated, " There is no reason to believe that the skin conditions are associated with exposure to nerve gas. These are common conditions and the intertrigo and tinea cruris are related more to irritation from sweat and maceration. Keloids can be spontaneous or secondary to folliculitis, trauma, etc." The VA examiner also stated that he had reviewed the Veteran's claims file. In an opinion dated in December 2012, a different VA physician stated that she had reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. This VA examiner concluded that the Veteran's "active duty skin conditions, to include warts of his penis and pseudofolliculitis barbae...were acute and transient." The rationale was that there was "a lack of medical evidence to support [the Veteran's] alleged symptomatology" due to his claimed joint condition, skin condition, and dizziness. She also noted that there was no medical documentation "to support these claimed symptoms" during active service or "for at least 15+ years post separation [from service]." She noted further the October 2012 VA examiner's negative nexus opinions between these disabilities and active service. Based on this extensive rationale, the December 2012 VA examiner opined that she was "in total agreement" with the prior examiner's opinions that the Veteran's claimed skin condition was less likely than not related to active service. With respect to the Veteran's claimed disability due to dizziness, the December 2012 VA physician opined that it was less likely than not that this disability was incurred, caused by, or proximately due to active service. She also opined that it was at least as likely as not that the Veteran's claimed dizziness "is a function of his current anemic condition." The rationale for this opinion was there was no medical evidence "to support a claim of dizziness," this condition first was noted "20+ years after separation," and the Veteran currently was anemic. She also noted that, although the Veteran currently was anemic, he had not been anemic during active service. The rationale also relied upon a citation to relevant medical literature which indicated that the objective symptomatology of anemia included dizziness. This physician also opined that "the claimed dizziness condition is as least as likely as not associated with the Veteran's normal aging process." With respect to the Veteran's claimed disability due to joint pain, the December 2012 VA physician opined that the Veteran's joint pain was as least as likely as not due to the normal aging process rather than active service. The rationale for this opinion was that the evidence of record (in this case, the October 2011 VA examination) indicated that "the subjective findings were not consistent with degenerative changes of the joints" and instead "were consistent with a normal and natural progression of aging." The VA physician also noted that there was no record evidence of this condition prior to 1995, approximately 20 years after the Veteran's service separation. Analysis The Board finds that the preponderance of the evidence is against the Veteran's claims of service connection for dizziness and for joint pain, each to include as due to an undiagnosed illness. See 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. The Veteran has contended that he incurred these disabilities during active service or, alternatively, that he incurred an undiagnosed illness during his active service in the southwest Asia theater of operations in the Persian Gulf War which caused or contributed to these current disabilities. The evidence of record does not support the Veteran's assertions concerning in-service incurrence or the presence of current disability due to dizziness or joint pain which could be attributed to active service or any incident of service, to include as due to an undiagnosed illness. The Board notes initially that the presence of a mere symptom (such as dizziness or joint pain) alone, absent evidence of a diagnosed medical pathology or other identifiable underlying malady or condition that causes the symptom, does not qualify as disability for which service connection is available. See generally Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999); vacated in part and remanded on other grounds sub nom., Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). The Veteran's DD Form 214 confirms his service in the southwest Asia theater of operations during the Persian Gulf War; thus, he is considered a Persian Gulf Veteran. See 38 C.F.R. § 3.317(a)(1). The Veteran's service treatment records show that, with the exception of a complaint of dizziness on outpatient treatment in January 1982, there were no complaints or treatment of disabilities manifested by dizziness or joint pain at any time during his active service, including while he was in the Persian Gulf. The Veteran also specifically denied any in-service exposure to chemical warfare or germ warfare in July 1991 immediately following his return from the Persian Gulf and just prior to his separation from active service in August 1991. He subsequently denied any in-service exposure to chemicals during active service, including while he was overseas during the Persian Gulf War, and on outpatient treatment in December 1994, several years after his service separation. The Board acknowledges in this regard that the lack of contemporaneous service treatment records demonstrating disabilities manifested by dizziness or joint pain is not an "absolute bar" to service connection for these disabilities. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). The Board finds it especially significant that, following his overseas deployment in support of Operation Desert Storm, the Veteran himself reported in July 1991 that he had experienced no injuries while in the southwest Asia theater of operations and denied receiving any treatment during that deployment. The Veteran was discharged from active service immediately thereafter. The July 1991 report from the Veteran at his service separation persuasively suggests that he did not experience any disability due to dizziness or joint pain during active service, including while overseas in Operation Desert Storm. The post-service evidence also does not support granting service connection for a disability manifested by dizziness or for a disability manifested by joint pain, each to include as due to an undiagnosed illness. The evidence shows instead that, although the Veteran has been treated for complaints of dizziness and joint pain since his service separation in August 1991, these complaints have been attributed to known clinical diagnoses and are not related to active service or any incident of service, to include as due to an undiagnosed illness. The Board notes in this regard that the Veteran also is not entitled to service connection for disabilities manifested by dizziness or by joint pain on a direct basis. See 38 C.F.R. § 3.303, 3.304. As noted above, the Veteran's service treatment records show no complaints of or treatment for joint pain during active service, to include as due to an undiagnosed illness. Moreover, with the exception of a complaint of dizziness during his first period of active service, the Veteran's service treatment records otherwise show no complaints of or treatment for dizziness during his approximately 7 years of active service. But see Buchanan, 451 F.3d at 1337 (finding that lack of contemporaneous service treatment records not "absolute bar" to granting service connection for claimed disabilities). The post-service evidence shows that, following his service separation in August 1991, the Veteran first complained of and sought treatment for a disability manifested by dizziness in May 1994, or almost 3 years later. It also appears that the Veteran first complained of and sought treatment for joint pain in December 1994, more than 3 years after his service separation. At that time, the Veteran again denied any in-service exposure to chemicals or radiation during active service, including while he was overseas during the Persian Gulf War. He also reported that his joint pain had begun 4-5 months after he had returned from the Persian Gulf. The Board notes in this regard that evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The evidence suggests that, although the Veteran has complained of disabilities due to dizziness and joint pain since his service separation, each of these complaints have been attributed to known clinical diagnoses and were not caused or aggravated by active service, to include as due to an undiagnosed illness incurred during the Persian Gulf War. For example, following VA examination in October 2011, the VA examiner opined that the Veteran experienced dizziness as a result of his long-term anemia. The rationale for this opinion was that the Veteran's laboratory results showed that he was anemic. A different VA physician who reviewed the Veteran's claims file in December 2012 concurred with the October 2011 VA examiner's opinion that the Veteran's dizziness was related to anemia and not to active service or any incident of service, to include as due to an undiagnosed illness. The December 2012 VA physician noted that the medical literature indicated that the objective symptomatology of anemia included dizziness. She also found persuasive support for her negative nexus opinion between the Veteran's claimed dizziness and active service, to include as due to an undiagnosed illness, in the length of time between the Veteran's separation from service and his initial post-service complaints of dizziness in approximately 1995. She noted further that the Veteran had not been anemic during active service although he currently experienced anemia based on a review of relevant laboratory results. With respect to the Veteran's contention that his in-service exposure to nerve agents (which he characterized as "nerve gas") while on active service near Khamisiyah, Iraq, in early March 1991, caused or contributed to disabilities manifested by dizziness or joint pain, the Board notes that it appears that the Department of Defense (DoD) has informed the Veteran that he may have been exposed to "the nerve agents sarin and cyclosarin" while he was on active service in the Persian Gulf in 1991. The DoD also specifically advised the Veteran that, if he had been exposed to these nerve agents while in the Persian Gulf War, such "low level exposure to nerve agents" was unlikely to cause any long-term health problems. The Board notes in this regard that current regulations provide that service connection may not be based on a resort to speculation or even remote possibility. See 38 C.F.R. § 3.102; Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); and Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). Accordingly, even if the DoD letter which the Veteran submitted in September 2008 in support of his claims is viewed in the light most favorable to him, this evidence does not establish service connection for a disability manifested by dizziness or for a disability manifested by joint pain, each to include as due to an undiagnosed illness. The post-service evidence also suggests that the Veteran does not experience any current disability due to dizziness or joint pain which could be attributed to active service or any incident of service, to include as due to an undiagnosed illness. It shows that, following VA examination in June 2010, the VA examiner stated that there was "no diagnosis of a condition causing dizziness [and] no diagnosis of a condition with joint pains." The October 2011 VA DBQ general medical examiner also did not diagnose the Veteran as having dizziness or joint pain following this examination, although he noted that the Veteran complained of multiple joint pains at that examination and the Veteran's prior x-rays were related to these complaints. A different VA physician concluded in December 2012 that, although the Veteran complained of multiple joint pains, his x-rays were normal and were not consistent with his subjective complaints. She opined instead that the Veteran's complaints of joint pain noted on VA examination in October 2011 were at least as likely as not attributed to the normal aging process. A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection is not warranted in the absence of proof of current disability. The Board has considered whether the Veteran experienced disabilities due to dizziness or joint pain at any time during the pendency of this appeal. Service connection may be granted if there is a disability at some point during the claim even if it later resolves or becomes asymptomatic. McClain v. Nicholson, 21 Vet. App. 319 (2007). In this case, although there is evidence that the Veteran experienced both dizziness and joint pain at some point during the pendency of this appeal, the evidence does not support a finding that either of these claimed disabilities are related to active service or any incident of service, to include as due to an undiagnosed illness. In summary, the Board finds that service connection for a disability manifested by dizziness and for a disability manifested by joint pain, each to include as due to an undiagnosed illness, is not warranted. The Veteran also is not entitled to service connection for arthritis of the joints on a presumptive service connection basis as a chronic disease. See 38 C.F.R. §§ 3.307, 3.309. The Veteran's service treatment records show no complaints of or treatment for arthritis at any time during either period of active service. The December 2012 VA physician specifically found that the Veteran initially complained of joint pain in approximately 1995, or 4 years after his service separation (as noted above). The record evidence also does not indicate that the Veteran experienced arthritis of the joints within the first post-service year (i.e., by August 1992) such that service connection for arthritis of the joints is warranted on a presumptive basis as a chronic disease. Id. The Board finally finds that the preponderance of the evidence is against the Veteran's claim of service connection for a skin disability, to include as due to an undiagnosed illness. The Veteran has contended that he incurred a skin disability during active service or, alternatively, that an undiagnosed illness incurred while he was on active service in the Persian Gulf caused or contributed to his current skin disability. The Board recognizes that the Veteran is a Persian Gulf Veteran. See 38 C.F.R. § 3.317(a)(1). However, the evidence of record does not support the Veteran's assertions regarding in-service incurrence of a skin disability or a nexus between such disability and active service or any incident of service, to include as due to an undiagnosed illness. It shows instead that, although the Veteran currently experiences a skin disability (variously diagnosed as mild intertrigo, possible tinea cruris, and a keloid on the nuchal region of the scalp), it is not related to active service, to include as due to an undiagnosed illness. The Veteran's service treatment records show that a small papule on the right scapula was noted on ANG periodic physical examination in December 1986. The Veteran also was diagnosed as having acne keloidis nuchae following outpatient treatment in December 1990, immediately following the beginning of his second period of active service. Following his return from Operation Desert Storm in July 1991, the Veteran denied experiencing any skin rash or infection during his deployment to the Persian Gulf. The Veteran was discharged from active service immediately thereafter. The July 1991 report from the Veteran at his service separation persuasively suggests that he did not experience any skin disability during active service, including while overseas in Operation Desert Storm. The post-service evidence also does not support granting service connection for a skin disability, to include as due to an undiagnosed illness. See 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. The evidence shows instead that, although the Veteran has been treated for complaints of skin problems since his service separation in August 1991, these complaints have been attributed to known clinical diagnoses and are not related to active service or any incident of service, to include as due to an undiagnosed illness. The Board notes in this regard that the Veteran also is not entitled to service connection for a skin disability on a direct basis. See 38 C.F.R. § 3.303, 3.304. As noted above, the Veteran's service treatment records show he was treated for skin disability on two occasions during his approximately 7 years of active service. But see Buchanan, 451 F.3d at 1337. It appears that, following his service separation in August 1991, the Veteran first sought treatment for a skin disability in August 1995, or 4 years later, when he was diagnosed as having probable post-inflammatory hyperpigmentation and probable contact dermatitis. See Maxson, 230 F.3d at 1333. The evidence suggests that, although the Veteran has complained of a skin disability since his service separation, his complaints have been attributed to known clinical diagnoses and were not caused or aggravated by active service, to include as due to an undiagnosed illness incurred during the Persian Gulf War. For example, following VA skin diseases DBQ in October 2011, when the Veteran reported that his skin condition had began "a few years after he got out of the military in 1991," the Veteran was diagnosed as having a mild intertrigo with a possible tinea cruris and a keloid on the nuchal region of the scalp. In a December 2012 addendum to the October 2011 VA skin diseases DBQ, the VA examiner stated, "There is no reason to believe that the skin conditions are associated with exposure to nerve gas. These are common conditions and the intertrigo and tinea cruris are related more to irritation from sweat and maceration. Keloids can be spontaneous or secondary to folliculitis, trauma, etc." The VA examiner also stated that he had reviewed the Veteran's claims file. With respect to the Veteran's assertion that his alleged in-service exposure to nerve gas while on active service near Khamisiyah, Iraq, in early March 1991, caused or contributed to his current skin disability, the Board notes that, following VA skin diseases examination in October 2011, the VA examiner opined that the Veteran's skin disorders "do not result from any nerve gas exposure that he may have been exposed to during the Persian Gulf War." This examiner subsequently opined in a December 2012 addendum to the October 2011 VA examination report, "There is no reason to believe that the skin conditions are associated with exposure to nerve gas." The rationale for this opinion was that the Veteran's intertrigo and tinea cruris were "common conditions" and a keloid could be "spontaneous or secondary to folliculitis, trauma, etc." The Board again notes that, even if the DoD letter which the Veteran submitted in September 2008 in support of this claim is viewed in the light most favorable to him, it does not establish service connection for a skin disability, to include as due to an undiagnosed illness. The Board notes further that the diagnosis of "possible" tinea cruris following VA examination in October 2011 does not establish service connection for a skin disability, to include as due to an undiagnosed illness, because it is too speculative. See 38 C.F.R. § 3.102; Stegman, 3 Vet. App. at 230; and Tirpak, 2 Vet. App. at 611. The Board acknowledges that, following VA examination in June 2010, the VA examiner stated that he could not determine if the Veteran's skin disability "has any relation to his service, specifically nerve agent exposure" without resorting to speculation. The Court has held that, when VA undertakes to provide a Veteran with an examination, that examination must be adequate for VA purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Court also has held that medical opinions using the "mere speculation" language, without more, generally are disfavored because they are inconclusive as to the origin of a disability. See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Sklar v. Brown, 5 Vet. App. 104, 145-6 (1993). The Court has explained that opinions which contain the "mere speculation" language, without more, amount to 'nonevidence' neither for nor against the claim because service connection may not be based on speculation or remote possibility. See Bloom v. West, 12 Vet. App. 185 (1999) (holding that a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). The Court recently held in Jones v. Shinseki, 23 Vet. App. 382 (2010), that, when a medical examiner concludes that he or she is unable to provide a nexus opinion without speculation, this alone does not make the medical opinion inadequate; a medical opinion with such language may be adequate if the examiner sufficiently explains the reasons for this inability. Id. at 389-90. See also Obert v. Brown, 5 Vet. App. 30, 33 (1993) (noting that speculative opinion is not legally sufficient to establish service connection). Before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, however, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence. Cf. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Furthermore, VA must ensure that any medical opinion, including one that states no conclusion can be reached without resorting to speculation, is "based on sufficient facts or data." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2009). Therefore, it must be clear from either the examiner's statements or the Board's decision that the examiner has considered "all procurable and assembled data" by obtaining all tests and records that might reasonably illuminate the medical analysis. See Daves v. Nicholson, 21 Vet. App. 46 (2007). Given the foregoing, the Board finds that the June 2010 VA examination is entitled to little probative weight in adjudicating whether the Veteran's skin disability is related to active service, to include as due to an undiagnosed illness. By contrast, the October 2011 VA examination, the December 2012 addendum, and the VA physician's opinion also prepared in December 2012 are persuasive evidence against granting the Veteran's service connection claim for a skin disability, to include as due to an undiagnosed illness. All of this evidence suggests that, although the Veteran currently experiences a skin disability (variously diagnosed as mild intertrigo, possible tinea cruris, and a keloid on the nuchal area of the scalp following VA examination in October 2011), it is not related to active service or any incident of service, to include as due to an undiagnosed illness. Both the October 2011 VA examiner and the December 2012 VA physician specifically ruled out any medical nexus between the Veteran's skin disability and active service, to include as due to an undiagnosed illness. It is abundantly clear from a review of this evidence that the October 2011 and December 2012 opinions concerning the contended causal relationship between the Veteran's skin disability and active service were based on "sufficient facts and data" and considered "all procurable and assembled data." See Nieves-Rodriguez, 22 Vet. App. at 295, and Daves, 21 Vet. App. at 46. The Board concludes that this evidence is entitled to significant probative value in evaluating whether the Veteran's skin disability is related to active service or any incident of service, to include as due to an undiagnosed illness. The Veteran also has not identified or submitted any evidence, to include a medical nexus, which relates his current skin disability to active service, to include as due to an undiagnosed illness. In summary, the Board finds that service connection for a skin disability, to include as due to an undiagnosed illness, is not warranted. In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. § 7104(a) ("decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) (VA "shall consider all information and lay and medical evidence of record in a case"); 38 C.F.R. § 3.303(a) (service connection claims "must be considered on the basis of the places, types and circumstances of his service as shown by service records, the official history of each organization in which he served, his medical records and all pertinent medical and lay evidence"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown,6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A Veteran is competent to report symptoms that he experiences at any time because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470; Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, dizziness, joint pain, and a skin disability fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The absence of contemporaneous medical evidence is a factor in determining credibility of lay evidence, but lay evidence does not lack credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan, 451 F.3d at 1337; Barr, 21 Vet. App. at 303 ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). In determining whether statements submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). As part of the current VA disability compensation claim, in recent statements, the Veteran has asserted that his symptoms of dizziness, joint pain, and a skin disability have been continuous since service. He asserts that he continued to experience symptoms relating to dizziness, joint pain, and a skin disability (acne on his scalp) after he was discharged from service. In this case, after a review of all the lay and medical evidence, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience continuous symptoms of any of these disabilities after service separation. Further, the Board concludes that his assertion of continued symptomatology since active service, while competent, is not credible. The Board finds that the Veteran's more recently-reported history of continued symptoms of dizziness, joint pain, and a skin disability since active service is inconsistent with the other lay and medical evidence of record. The Veteran now asserts that each of these disorders began in service. As noted above, although a copy of the Veteran's separation physical examination at the end of his first period of active service in May 1983 is not available, in the more contemporaneous medical history he gave at a VA examination conducted in July 1983, approximately 2 months after his service separation, although he complained of back pain, no orthopedic condition and no other specific conditions were found on physical examination of the Veteran. He also did not report, and the VA examiner did not find, any history of complaints of a skin disability. At his separation physical examination in July 1991, just prior to the end of his second period of active service, the Veteran denied all relevant medical history, and clinical evaluation was normal. The Veteran's in-service history of symptoms at the time of service separation is more contemporaneous to service so it is of more probative value than the more recent assertions made many years after service separation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later). The post-service medical evidence does not reflect complaints or treatment related to dizziness, joint pain, or a skin disability for several years following active service. The Board emphasizes the multi-year gap between discharge from active duty service (1991) and initial reported symptoms related to dizziness and joint pain in approximately 1994 (a 3-year gap) and to a skin disability in approximately 1995 (a 4-year gap). See Maxson, 230 F.3d at 1333; see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where Veteran failed to account for lengthy time period between service and initial symptoms of disability). The Board again finds it especially significant that, immediately following his return from active service in the Persian Gulf War in July 1991, the Veteran denied experiencing any dizziness, joint pain, or skin rash or infection during his deployment to the Persian Gulf. The Veteran was discharged from active service immediately thereafter. Such histories reported by the Veteran for treatment purposes are of more probative value than the more recent assertions and histories given for VA disability compensation purposes. Rucker, 10 Vet. App. at 67 (holding that lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). The Veteran did not claim that symptoms of his disabilities began in (or soon after) service until he filed his current VA disability compensation claim. Such statements made for VA disability compensation purposes are of lesser probative value than his previous more contemporaneous in-service histories. See Pond v. West, 12 Vet. App. 341 (1999) (finding that, although Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). During the recent VA compensation claim, the Veteran reported the onset of symptoms to different times. The Board already has noted the Veteran's inconsistencies in describing what happened to him while he was deployed to the southwest Asia theater of operations during the Persian Gulf War. As noted, the Veteran denied experiencing any dizziness, joint pain, or skin disability during active service in the Persian Gulf War on his demobilization and return from overseas in July 1991. He subsequently reported on the service connection claim that each of these disabilities began during his active service in the Persian Gulf War. The Board has already noted the Veteran's inconsistencies in reporting his alleged in-service exposure to nerve agents (which he characterized as "nerve gas") while in the Persian Gulf. Although he initially denied any such exposure when examined by VA clinicians following his service separation, he subsequently has asserted strenuously that, in fact, he was exposed to nerve agents during his Persian Gulf service. The Veteran also reported for the first time on VA examination in June 2010 that he had experienced an intermittent skin rash since 1972, or several years prior to his entry on to active service. He previously had asserted that his skin rash had begun during service. The Veteran then reported on VA examination in October 2011 that his skin rash had begun "a few years after he got out of the military in 1991." These inconsistencies in the record weigh against the Veteran's credibility as to the assertion of continuity of symptomatology since service. See Madden, 125 F.3d at 1481 (finding Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a Veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). The Board has weighed the Veteran's statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, the absence of complaints or treatment for years after service, and his previous statements made for treatment purposes. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of continuity of symptoms since service separation. In reaching the conclusions above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to service connection for a disability manifested by dizziness, to include as due to an undiagnosed illness, is denied. Entitlement to service connection for a disability manifested by joint pain, to include as due to an undiagnosed illness, is denied. Entitlement to service connection for a skin disability, to include as due to an undiagnosed illness, is denied. ____________________________________________ JENNIFER HWA Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs