Citation Nr: 1320106 Decision Date: 06/21/13 Archive Date: 07/02/13 DOCKET NO. 07-31 012A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for disability manifested by fatigue and weakness, to include as due to undiagnosed illness. 2. Entitlement to service connection for a bilateral knee disorder, to include as due to undiagnosed illness. 3. Entitlement to service connection for hypertension. 4. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance of another person or on account of being housebound. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran has verified active duty service in the United States Army from June 1968 to June 1971 and from January 1991 to May 1991, with additional unverified service in the Army Reserve. Official service personnel records confirm the Veteran served in the Southwest Asia theater of operations from January 1991 to May 1991 and is thereby a Persian Gulf Veteran. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in December 1992 and October 2006 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied entitlement to the benefits currently sought on appeal. In January 2009, the Board denied the Veteran's claim for SMC based on the need for aid and attendance of another person or on account of being housebound. He appealed to the United States Court of Appeals for Veterans Claims (Court) which, by Order dated September 25, 2009, granted a Joint Motion for Remand (Joint Motion). Pursuant to the Joint Motion, the parties agreed that there were a number of unadjudicated pending claims, with jurisdiction resting both at the Board and at the RO levels, resolution of which may ultimately affect the special monthly compensation determination. Each of the issues listed on the cover page of this document have been determined by the Joint Motion to be perfected for the Board's consideration. The Board remanded the above claims for further development in July 2010. The requested development having been partially completed, the claims again are before the Board. The Board has not only reviewed the Veteran's physical claims file, but also his Virtual VA electronic claims file to ensure a total review of the evidence. As discussed in the July 2010 Board remand, the parties agreed in the September 2009 Joint Motion that several claims were pending before the agency of original jurisdiction (AOJ), but remained unadjudicated. Specifically, these issues were entitlement to service connection for respiratory distress, loss of motor control, back pain, joint pain, cardiac disorder, cerebral atrophy, seizure disorder, irritable bowel syndrome, chronic fatigue syndrome, and memory loss (all to include as a result of undiagnosed illness). The July 2010 Board remand referred these issues to the AOJ. As will be discussed in greater detail below, however, there is no indication that the AOJ has adjudicated these claims. While, an April 2012 memorandum from the Appeals Management Center (AMC) to the RO directed that the RO adjudicate the claims, again, there is no evidence in the paper claims file or the Veteran's Virtual VA electronic claims file that any steps in this regard have been undertaken. As at the time of the Board's July 2010 remand, the Board does not have jurisdiction over these issues as of yet, and they are REFERRED to the AOJ for appropriate action. The issues of entitlement to service connection for hypertension and entitlement to SMC based on the need for aid and attendance of another person or on account of being housebound are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran had active service in the Southwest Asia theater of operations from January 9, 1991 to May 8, 1991. 2. Affording the Veteran the benefit of the doubt, the Board concludes that he has fatigue and weakness resulting from undiagnosed illness that was shown during active service and is currently manifested to a compensable degree. 3. The most probative evidence of record does not support a finding that the Veteran has a bilateral knee disability resulting from undiagnosed illness that was shown during active service or currently manifested to a compensable degree; and there is no evidence of currently diagnosed disability manifested by bilateral knee pain that is related to active military service or events therein. CONCLUSIONS OF LAW 1. The Veteran's fatigue and weakness may be presumed to be related to his period of service in the Persian Gulf. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2012). 2. The Veteran's bilateral knee disability was not incurred in or otherwise related to active service, nor may it be presumed to be related to his period of service in the Persian Gulf. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran 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 Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. A VCAA letter dated in July 2010 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claims. The letter informed him that additional information or evidence was needed to support his claims, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The letter also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Furthermore, even if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced Veteran Service Organization and has submitted argument in support of his claims. These arguments have referenced the applicable law and regulations necessary for a grant of entitlement to service connection. In that regard, while the Board acknowledges that the July 2010 letter did not provide the Veteran with specific information as to the evidence needed to establish entitlement to service connection based on an undiagnosed illness or request that the Veteran provide VA with the specific symptoms he attributed to an undiagnosed illness due to his service in Southwest Asia, the Veteran has submitted numerous statements and other documents of record that have discussed in detail his current symptoms he attributes to his service in Southwest Asia. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claims and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file, to include those directed by previous Board remand. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time otherwise referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). In that regard, the Veteran was provided a general VA medical examination in June 1992, where he was diagnosed (in relevant part) with recurrent knee pains and exposure to oil and smoke. In addition, as directed by the July 2010 Board remand the Veteran was afforded VA examinations for his service connection claims in August 2010. The Board finds the August 2010 VA examination reports to be thorough and complete. The opinions expressed were based on the Veteran's reported history and review of the claims file. The opinions were supported by a complete rationale. Based on the opinions of record and the fact there is no rule as to how current an examination must be, the Board concludes the opinions in this case are adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Based on the July 2010 VA notice letter, the association of VA treatment records, the August 2010 VA examinations, and subsequent readjudication of the claims, the Board finds that there has been substantial compliance with its July 2010 remand directives with respect to the above service connection claims. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis, will be presumed if they are manifest to a compensable degree within one year following active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2010). However, the Veteran was not diagnosed with arthritis of the knees in service or within one year of either of his periods of service. As such, service connection for this disorder may not be granted on a presumptive basis. In the present case, the Veteran has contended that he suffers from fatigue and weakness and bilateral knee problems that are manifestations of one or more undiagnosed illnesses resulting from his service in the Southwest Asia theater of operations from January 1991 to May 1991. With regard to such claims, in November 1994, Congress enacted the Persian Gulf War Veterans' Benefits Act, as title I of Public Law No. 103-446. That statute, in part, added a new section 1117 to title 38, United States Code, authorizing VA to compensate any Persian Gulf Veteran suffering from a chronic disability resulting from an undiagnosed illness, or combination of undiagnosed illnesses, which became manifest either during active duty in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more within a presumptive period following service in the Southwest Asia theater of operations during the Persian Gulf War. In establishing the presumptive period, the Secretary was to review any credible scientific or medical evidence, the historical treatment afforded other diseases for which service connection is presumed, and other pertinent circumstances regarding the experience of Persian Gulf Veterans. In February 1995, VA implemented the Persian Gulf War Veterans' Benefits Act by adding a regulation at 38 C.F.R. § 3.317, which defined qualifying Gulf War service, established the presumptive period for service connection, and denoted a broad but non-exclusive list of signs and symptoms which may be representative of undiagnosed illnesses for which compensation may be paid. In the original version of 38 C.F.R. § 3.317, the presumptive period during which a Veteran had to experience manifestations of a chronic disability was two years after the date on which he last performed active service in the Southwest Asia theater of operations during the Gulf War. In April 1997, VA published an interim rule which extended the presumptive period to December 31, 2001. This extension of the presumptive period was adopted as a final rule in March 1998, and, in October 1998, Public Law No. 105-277, §1602(a)(1), added 38 U.S.C.A. § 1118, which codified the presumption of service connection for manifestations of an undiagnosed illness. The Veterans Education and Benefits Expansion Act of 2001 (VEBEA), Public Law No. 107-103, 115 Stat. 976 (2000), amended various provisions of 38 U.S.C.A. §§ 1117, 1118. Section 202 of the VEBEA re-styled the term "chronic disability" in 38 U.S.C.A. § 1117 as "qualifying chronic disability," and expanded compensation availability for Persian Gulf Veterans to include "a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms", as well as "[a]ny diagnosed illness that the Secretary determines in regulations . . . warrants a presumption of service-connection." The VEBEA also codified, in statute, with slight modification, the non-exclusive list of signs or symptoms recognizable under 38 C.F.R. § 3.317(b), in new 38 U.S.C.A. § 1117(g), to include (2) Unexplained rashes or other dermatological signs or symptoms and (3) Headache. In addition, the VEBEA extended the presumptive period, during which an undiagnosed illness must be manifested to the requisite 10 percent degree, to December 31, 2006. The changes effected by the VEBEA were mandated to become effective on March 1, 2002. The presumptive period has since been extended to December 31, 2016. To afford the Veteran the maximum benefit of the law, to whatever extent those changes are pertinent to the issues in this case, the Board will consider both the pre- and post-VEBEA law. In order to obtain a grant of service connection pursuant to 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317, a Veteran needs to present some evidence (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) which became 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 C.F.R. § 3.317(a); see Neumann v. West, 14 Vet. App. 12, 22 (2000), vacated on other grounds, 14 Vet. App. 304 (2001) (per curiam order); Gutierrez v. Principi, 19 Vet. App. 1 (2004). 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 multisymptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service-connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. Medically unexplained chronic multisymptom illnesses are defined by a cluster of signs or symptoms, and are currently limited to chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome (IBS), as the Secretary has not determined that any other conditions meet the criteria for a medically unexplained chronic multi symptom illness. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2) (2012); 75 Fed. Reg. 61995-97 (Oct. 7, 2010) (adding diabetes and multiple sclerosis as examples of chronic multi-symptom illnesses of partially understood etiology and pathophysiology). 38 C.F.R. § 3.317 also allows for service connection on a presumptive basis for certain enumerated infectious diseases. See 75 Fed. Reg. 59968-72 (Sept. 29, 2010) (amending 38 C.F.R. § 3.317(c) to allow for presumptive service connection for nine infectious diseases.) As none of the enumerated diseases are at issue in this case, the Board has omitted listing the diseases or discussing them. Section 3.317 explicitly acknowledges that a claimant's "signs or symptoms" need not be shown by medical evidence; however, the regulation does specifically require some "objective indications" of disability. See 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 undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Lastly, compensation shall not be paid under section 3.317 if there is affirmative evidence that an undiagnosed illness was not incurred during active military service in the Southwest Asia theater of operations during the Persian Gulf War; if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). A Persian Gulf Veteran is a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(d) (2012); 75 Fed. Reg. 59968-72 (Sept. 29, 2010) (reordering this part of the regulation to 38 C.F.R. § 3.317(e)). The Persian Gulf War is defined as the period beginning August 2, 1990, and ending on a date to be prescribed by Presidential proclamation or law. 38 U.S.C.A. § 101(33); 38 C.F.R. § 3.2(i). The Veteran's military records document that he served in Southwest Asia during the pertinent time period. Therefore, the above-described provisions possibly apply to this case. In cases where a Veteran applies for service connection under 38 C.F.R. § 3.317, but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. §§ 1110 and 1131 are warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (specifically addressing claims based on ionizing radiation exposure). Thus, the presumption is not the sole method for showing causation. However, as noted above, where the issue involves a question of medical diagnosis or causation, as presented here, a claimant must establish the existence of a disability and a connection between the Veteran's service and the disability. Again, the Veteran has contended that he has fatigue and weakness, as well as bilateral knee problems, due to one or more undiagnosed illness stemming from his service in Southwest Asia. The crucial inquiry here that must be addressed is whether the evidence supports a finding of a "qualifying chronic disability" manifested by an undiagnosed illness as defined above. Fatigue and Weakness The Veteran's service treatment records from his first period of active service do not include complaints of chronic fatigue or weakness and, indeed, the Veteran does not contend that such problems began during such service. Instead, the Veteran alleges that his current fatigue and weakness problems are related to his second period of service, which occurred in Southwest Asia from January 1991 to May 1991. The evidence of record indicates that the Veteran was not afforded a physical examination at the time of entrance or separation from his second period of service. Approximately one year after separation from service, the Veteran brought his claim for fatigue and weakness that he indicated had started during his service in Southwest Asia. He was afforded a general VA medical examination in June 1992, but did not specifically discuss fatigue and weakness at that time (other than in the context of bilateral knee problems, discussed in greater detail below), but the examiner did note that the Veteran reported exposure to oil and smoke. An October 1992 private treatment record noted reports of resolving fatigue that were related to treatment for heart problems. In support of his claim, a November 1992 statement from a fellow service member discussed multiple days of close-proximity exposure to oil fires and burning storage facilities in Kuwait. As the Veteran had not been afforded a physical at the time of his second separation from active service, in May 1991, he was provided with an examination by the military in December 1992. The Veteran reported bilateral knee problems, but not general fatigue and/or weakness. A February 1993 private treatment record indicated that the Veteran had experienced fatigue "for 3 months after the Gulf War." A June 1993 private treatment record noted vague complaints of fatigue. A March 1994 private treatment record noted ongoing treatment for fatigue, which the treatment provider opined was related either to posttraumatic stress disorder or a separate chronic fatigue syndrome. Other near contemporaneous private treatment records reached the same conclusion. Over the subsequent years, the Veteran reported continuing, but decreased, episodes of fatigue and weakness. December 2003 statements from the Veteran's family documented ongoing problems with fatigue. By May 2006, VA treatment records indicated that the Veteran's problems included chronic fatigue. A July 2010 treatment record included a past history that was significant for Gulf War syndrome. As noted above, the Veteran was afforded a VA examination in August 2010. The examiner extensively detailed the Veteran's treatment history. The Veteran reported the gradual onset of problems about a year and a half after separation from his second period of service, which the examiner found to be consistent with the medical evidence of record. Currently the Veteran's fatigue was constant and was unaffected by the amount of exercise. The examiner noted that the Veteran's clinical history and features did not meet the criteria for chronic fatigue syndrome. The examiner diagnosed fatigue and myopathy and concluded that the Veteran's disability pattern related to fatigue and weakness, despite not meeting the criteria for chronic fatigue syndrome, met the criteria for a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology. With respect to the Veteran's fatigue and weakness, the Board has considered that fatigue is listed among the possible manifestations of an undiagnosed illness or medically unexplained chronic multi-symptom illness for purposes of presumptive service connection. 38 U.S.C.A. § 1117(g)(1); 38 C.F.R. § 3.317(b)(1). Weakness is not a symptom specifically listed in statute or regulation. In addition, the Board notes that the Veteran is a Persian Gulf Veteran. Furthermore, the Board finds that fatigue and weakness are the type of symptomatology that a layperson can competently observe and report. See, e.g., Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Thus, the Veteran's reports of fatigue and weakness beginning shortly after service and continuing to the present are credible and probative. Moreover, these assertions are supported by the medical evidence of record. As to etiology, the Board notes that the August 2010 VA examiner did not find that the Veteran met the criteria for chronic fatigue syndrome, but that the Veteran's symptoms were consistent with a finding of a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology. While the Board recognizes that the Veteran has not been diagnosed with any of the chronic multi-symptom illnesses formally recognized by VA, fatigue is specifically listed as a sign or symptom that might be a manifestation of an undiagnosed illness. The August 2010 VA examiner, moreover, clearly found that the most likely cause of the Veteran's fatigue and weakness was his military service in Southwest Asia. As noted above, a claim may be denied if there is affirmative evidence that an undiagnosed illness was not incurred during active military service in the Southwest Asia theater of operations during the Persian Gulf War; if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). In this case, there is no evidence of a supervening condition, willful misconduct, or the abuse of alcohol or drugs. The Board recognizes that there is medical evidence of record speculating that the Veteran's fatigue and weakness may have been due to heart or psychiatric problems. These early treatment records, however, were not definitive and subsequent VA treatment records have specifically attributed the Veteran's fatigue and weakness problems to chronic fatigue. Therefore, as the medical and lay evidence of record contains complaints of fatigue and weakness, no specific diagnosis has been rendered with regard to these complaints, the Veteran is a Persian Gulf War Veteran, and there is no affirmative evidence that an undiagnosed illness was not incurred during active military service in the Southwest Asia theater of operations during the Persian Gulf War, the Board will resolve all reasonable doubt in favor of the Veteran and grant his claim for service connection for fatigue and weakness as due to an undiagnosed illness on a presumptive basis under 38 C.F.R. § 3.317. Bilateral Knee Claim The Veteran's service treatment records from both his first and second periods of active service include no complaints, treatment, or diagnoses of a chronic bilateral knee disability. The Veteran sought treatment for intermittent bilateral knee pain in April 1992, at which time he reported experiencing some knee problems while serving in the Persian Gulf. Specifically, he slept in a bunk bed at times and experienced knee pain when jumping out of the bed. In addition, the Veteran had experienced intermittent problems with the bilateral knees over the previous year. The Veteran was a runner who averaged 2 to 3 miles every other day and the knee pain prevented running. The treatment provider's assessment was bilateral patellar tendonitis, bilateral pattelofemoral pain syndrome, and bilateral patella alta. The Veteran was afforded a general VA examination in June 1992. At that time, the Veteran reported recurrent bilateral knee pain, especially with running. Examination of the knees, however, was normal with normal range of motion. Contemporaneous x-rays of the knees also were within normal limits. The diagnoses included recurrent knee pains. At the time of a December 1992 military separation examination, the Veteran reported bilateral knee pain; however, contemporaneous examination of the bilateral lower extremities was normal. A December 1992 private treatment record noted prior treatment for bilateral knee pain. Current pain, however, was of a different type than past pain, as it now was along the joint line. The treatment provider's impression was nonspecific knee pain. A November 1993 private treatment record included complaints of fairly constant bilateral knee pain that prevented running. The treatment provider's impression was non-specific synovitis. A February 1994 private treatment record indicated that until several months previously the Veteran had run from 16 to 19 miles per week. Physical examination was consistent with patellofemoral dysfunction. In December 2005, the Veteran attributed his bilateral knee problems to years of parachute jumping. The Veteran was afforded a VA examination in August 2010. The examiner noted review of the claims file. After service, the Veteran had worked as a heavy equipment mechanic and truck driver. He had stopped working in 2005 due to cognitive and memory problems. The examiner extensively discussed the Veteran's documented history of knee problems. X-rays of the knees showed bilateral degenerative changes with chondrocalcinosis. Following a physical examination and interview of the Veteran, the examiner diagnosed bilateral knee patellofemoral syndrome that was without functional limitation. As to etiology, the examiner concluded that it was less likely than not that the bilateral knee disability was caused by or a result of service because the Veteran was not treated for a knee condition within a year of separation from service. (The Board notes that the opinion indicated that the Veteran was treated for a knee condition within a year of separation from service, which clearly was a typographical error based on the Veteran's treatment history discussed at extensive length earlier in the examination report.) See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (observing that medical reports must be "read as a whole" in the determination of adequacy); see also Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (noting that an adequate medical report need not "explicitly lay out the examiner's journey from the facts to a conclusion," as long as the rationale is clear from a reading of the report as a whole). Subsequent treatment records indicate ongoing knee problems, including a September 2010 VA treatment record noting episodic right knee pain. As to the Veteran's bilateral knee problems, the Board has considered that joint pain is listed among the possible manifestations of an undiagnosed illness or medically unexplained chronic multi-symptom illness for purposes of presumptive service connection. 38 U.S.C.A. § 1117(g)(5); 38 C.F.R. § 3.317(b)(5). However, in the present case, the Veteran's joint pain has been attributed to a specific diagnosis, namely bilateral patellofemoral syndrome. As discussed above, multiple VA and private treatment providers, including the August 2010 VA examiner, have considered the Veteran's attributions of bilateral knee problems due to his service in the Persian Gulf region. Multiple examiners and treatment providers, however, have attributed the Veteran's bilateral knee problems to patellofemoral syndrome, patellar tendonitis, and/or patella alta. The Board recognizes that between the initial bilateral knee diagnoses in April 1992 and the diagnosis by the August 2010 VA examiner, some treatment providers failed to attribute the Veteran's bilateral knee problems to a specific disability. The Board, however, finds the well reasoned and documented diagnoses by the April 1992 treatment provider, August 2010 VA examiner, and others finding a specific diagnosis for which to attribute the Veteran's bilateral knee problems to be the most probative evidence of record. Moreover, the Board notes that x-rays contemporaneous to the August 2010 VA examination found bilateral degenerative changes with chondrocalcinosis. Therefore, the Veteran's bilateral knee pain the Veteran is attributed to a known clinical diagnosis. See 38 C.F.R. § 3.317(a)(1)(ii). As such, to the extent his bilateral knee pain is explained, the associated disability is not "undiagnosed" or "medically unexplained" for purposes of applying the Persian Gulf presumption. 38 C.F.R. § 3.317(a)(2)(i) and (ii). In summary, presumptive service connection under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 is not permitted here for his bilateral knee pain. With respect to granting service connection for this claim on a direct basis, no medical professional has attributed his symptoms or underlying diagnosed disorder to the Veteran's military service. Indeed, the August 2010 VA examination report specifically considered the Veteran's claims, but concluded that his bilateral knee disability was not due to his military service. The examiner's opinion included an extensive discussion of the Veteran's treatment and reported history. When the Veteran first sought treatment for his bilateral knees, while he noted some in-service problems, since service the problems had been intermittent in nature and the Veteran had been able to run 2 to 3 miles per day. The Board finds the August 2010 VA examiner's opinion compelling, as it was based on a review of the claims filed, the Veteran's reported history, diagnostic testing, and physical examination. The opinion included a sufficient rationale for the opinion expressed. The Board acknowledges the Veteran's assertions that his current bilateral knee pain was caused by his military service in the Persian Gulf region. As discussed, the Veteran can attest to factual matters of which he has first-hand knowledge, such as bilateral knee pain, and his assertions in that regard are entitled to some probative weight. See Washington, 19 Vet. App. at 368. The type of evidence that will suffice to demonstrate entitlement to service connection, and the determination of whether lay evidence may be competent to satisfy any necessary evidentiary hurdles, depends on the type of disability claimed. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). For example, lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, the layperson is reporting a contemporaneous medical diagnosis, or 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). Regarding nexus, although without describing specific situations, the Federal Circuit also has explicitly rejected the view that medical evidence is necessarily required when the determinative issue is etiology. See id., at 1376-77. In short, the Board cannot determine that lay evidence as to diagnosis and nexus lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). In this case, the Board finds that the Veteran is not competent to determine the etiology of his knee disability, as the cause is not something that can be readily observable by a lay person. Rather, it involves the inner workings of a complex joint. Furthermore, the Veteran reported while seeking initial treatment in April 1992, that while he had experienced some problems with his knees in service that since service, the problems had been intermittent in nature and had allowed him to run 2 to 3 miles every other day. In light of the complexity of diagnosing a bilateral knee disability or otherwise attributing bilateral knee problems to a specific etiology in the absence of consistent reports of a continuity of symptomatology, the Board affords significantly more weight to the conclusions of the August 2010 VA examiner, which were based on the examiner's complete review of the claims file, the Veteran's contentions, and physical examination. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Accordingly, the Board finds that the preponderance of the evidence is against service connection for a bilateral knee disorder, so there is no reasonable doubt to resolve in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for disability manifested by fatigue and weakness is granted. Entitlement to service connection for a bilateral knee disorder is denied. REMAND The Veteran also is seeking entitlement to service connection for hypertension and SMC based on the need for aid and attendance of another person or on account of being housebound. A review of the claims file reveals that a remand is necessary before a decision on the merits can be reached for these issues. Hypertension To this point, the Veteran's original claim for entitlement to service connection for hypertension has been treated as a claim for direct service connection and the July 2010 notice letter provided by the AMC addressed the issue accordingly. The letter did not provide the Veteran with proper notice of the requirements for establishing service connection on a secondary basis, as the AMC had not been instructed to do so. However, during the Veteran's April 1996 RO hearing he appeared to clarify the basis (or at a minimum one of the bases) for his claim for entitlement to service connection for hypertension. Essentially, the Veteran claimed that his hypertension was aggravated by his service-connected posttraumatic stress disorder (PTSD). The Veteran contended that whenever he became tense, for example when visiting a doctor, his blood pressure would rise. He stated that his hypertension medications had been discontinued and that his blood pressure was being regulated by antidepressant medication. A July 1994 VA treatment record potentially supports the Veteran's contention, in that it noted that blood pressure medication had been discontinued in December 1993 and that his episodic high blood pressure was better regulated by antidepressant medication. As the possibility of service connection on a secondary basis was raised, the Veteran must be provided an opportunity to provide all relevant evidence to substantiate the claim. The July 2010 notice letter, therefore, is inadequate, as it failed to inform the Veteran of the requirements for establishing service connection on a secondary basis prior to the final adjudication of the Veteran's claim. Thus, upon remand, the Veteran should be given appropriate VCAA notice, according to the aforementioned requirements, and notice of the requirements for establishing secondary service connection, according to 38 C.F.R. § 3.310. Finally, the Board notes that the Veteran was afforded a VA examination for his hypertension in August 2010. As the VA examiner was not requested to consider the possibility of an etiology based on aggravation of the hypertension by the Veteran's service-connected PTSD, no such opinion was provided. The Board has a duty to consider all potential theories of entitlement raised by the record. In light of the lay and medical evidence suggesting an association between the Veteran's hypertension and service-connected PTSD, the Board finds that a supplemental opinion from the August 2010 VA examiner is warranted to clarify whether any current hypertension disability was permanently aggravated by the Veteran's service-connected PTSD. As the Veteran's hypertension was diagnosed many years prior to his service in Southwest Asia (which in turn was the cause of his service-connected PTSD), the Board concludes that an opinion regarding causation is not warranted. SMC As noted in the Introduction and as discussed by the June 2010 Board remand, there are a number of issues found by the September 2009 Joint Motion to be unadjudicated but pending before the Board and the agency of original jurisdiction. The June 2010 Board remand found that adjudication of these claims was necessary prior to determining entitlement to the SMC benefits sought, to enable determination as to whether any determined need for aid and attendance or housebound status was due to service-connected versus nonservice-connected causes. See 38 C.F.R. §§ 3.351, 3.352 (2012). As discussed above, these claims were not developed and adjudicated prior to readjudication of the SMC claim. As such, a remand is required. See Stegall v. West, 11 Vet. App. 268 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Accordingly, the case is REMANDED for the following action: 1. Ensure that all VCAA notice obligations are satisfied in accordance with 38 U.S.C.A. §§ 5102, 5103, and 5103A, implementing regulations, interpretative precedent Court decisions, and any other applicable legal precedent. In particular, the Veteran should be informed of how to establish his claim of secondary service connection for hypertension under 38 C.F.R. § 3.310. 2. After the above development is completed and the Veteran given appropriate time to respond, obtain a supplemental opinion from the examiner who conducted the August 2010 hypertension examination. If the examiner is not available, obtain an opinion from another appropriate medical professional. If the reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The claims file must be made available to and reviewed by the reviewer/examiner. The reviewer/examiner is asked to provide an opinion regarding whether it is as least as likely as not (50 percent probability or more) that any current hypertension disability was permanently aggravated beyond its natural progression by the Veteran's service-connected PTSD. (No opinion is required regarding secondary causation or the Veteran's direct theory of entitlement involving aggravation of a preexisting condition.) In that regard, the examiner/reviewer is requested to consider, and discuss as necessary, the Veteran's allegations during his April 1996 RO hearing and the July 1994 VA treatment record noting that the Veteran's high blood pressure was being regulated by antidepressant medication. It would be helpful if the examiner/reviewer would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner/reviewer should provide a complete rationale for any opinion provided. 3. Thereafter, readjudicate the issue of entitlement to service connection for hypertension, following all necessary procedures to include issuance of a supplemental statement of the case if the determination remains unfavorable to the Veteran. 4. Complete all necessary procedural steps, including notice, assistance, and adjudication, for the referred claims of entitlement to service connection for respiratory distress, loss of motor control, back pain, joint pain, cardiac disorder, cerebral atrophy, seizure disorder, irritable bowel syndrome, chronic fatigue syndrome, and memory loss (all to include as a result of undiagnosed illness). 5. After readjudication of the issue of entitlement to service connection for hypertension and after initial adjudication of the referred claims has been completed, schedule the Veteran for a VA Aid and Attendance or housebound examination to determine the level of impairment caused by his service-connected disability or disabilities. The Veteran's claims file and a copy of this remand should be made available to the examiner for review. The record should clearly indicate all disabilities for which service connection is in effect at the time of examination. All necessary studies and tests must be conducted. An adequate supporting rationale must be provided for each opinion reached. The examiner is specifically asked to: (a) Opine whether the Veteran is permanently bedridden or permanently housebound due to service-connected disability alone; (b) Opine whether the Veteran's service-connected disability or disabilities (individually or in the aggregate) render him so helpless as to need the regular aid and attendance of another person; (c) If either of these questions is answered in the affirmative, please state the approximate date at which you find the aid and attendance requirement or housebound status was realized given the medical facts before you; (d) To the extent possible, the examiner is also asked to differentiate between the effects of service-connected disability or disabilities, and that of any nonservice-connected disabilities with regard to the above determinations. 7. Then review the Veteran's claims file and ensure that the foregoing development actions have been completed in compliance with the instructions herein, and that no other notification or development action is needed in addition to that directed above. If further action is required, it should be undertaken prior to further claims adjudication. 8. Finally, readjudicate the issue of entitlement to special monthly compensation currently on appeal. If the determination remains unfavorable to the Veteran, he and his representative must be furnished a supplemental statement of the case which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and his representative should be afforded the applicable time period in which to respond before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ Bethany L. Buck Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs