Citation Nr: 1324673 Decision Date: 08/02/13 Archive Date: 08/13/13 DOCKET NO. 05-17 537 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for hypertension, including as secondary to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a low back disorder. 3. Entitlement to service connection for skin disorder affecting the face and body, to include as due to undiagnosed illness. 4. Entitlement to service connection for a sinus disorder, or a disorder affecting the sinuses or respiratory tract, including as due to undiagnosed illness. 5. Entitlement to service connection for a headache disorder, including due to undiagnosed illness. 6. Entitlement to service connection for a memory loss disability, including due to undiagnosed illness. 7. Entitlement to service connection for joint aches (also described as fibromyalgia), including as due to undiagnosed illness. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Tresa M. Schlecht, Counsel INTRODUCTION The Veteran served on active duty from August 1969 to July 1971 and from November 1990 to May 1991. During his periods of active duty, he served in the Republic of Vietnam during the Vietnam War from July 1970 to July 1971, and in Southwest Asia during Operation Desert Shield/Storm from January 1991 to April 1991. The Veteran also had reserve component service with the Mississippi Army National Guard from 1973 until he was called to active duty in 1990, with periods of verified and unverified active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). Following his 1991 release from the second period of active duty, the Veteran returned to reserve service until his separation with more than 25 years of active and reserve service. This appeal to the Board of Veterans' Appeals (Board) arises from September 2004 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Veteran and his wife testified at a personal Decision Review Officer hearing at the RO in April 2006. A transcript of the hearing is associated with the claims file. The Board denied some claims on appeals in May 2009; the Board Remanded claims for service connection for hypertension, a skin disorder of the feet, bilateral hearing loss, and a lumbar spine disorder to the AOJ. The Veteran appealed the denied claims to the United States Court of Appeals for Veterans Claims (CAVC); the portion of the Board's 2009 decision remanding certain claims was not disturbed in the appeal. A CAVC Order granted a December 2009 Joint Motion for Partial Remand (JMR), by the Veteran and the VA Secretary ("the parties"). The JMR vacated the Board's May 2009 denials of the service-connection claims for a cardiovascular disorder, a sinus disorder, a skin condition (claimed as rashes of the face and body), headaches, memory loss, and joint aches, and remanded the appeal for further development and readjudication. Following the Court's December 2009 Order, the Board Remanded the claims addressed in that Order in April 2010. In April 2010 and in June 2012, the Board remanded the claims addressed in the Court's Order for further development. In March 2013, the Board requested a medical opinion from the Veterans Health Administration (VHA). The appellant was provided a copy of the VHA opinion following receipt of that opinion in May 2013 and given an opportunity to submit additional evidence and argument in support of the appeal. Following the Board's 2009 Remand, service connection for a cardiovascular disorder, a skin disorder of the feet, and bilateral hearing loss were granted, and the Veteran did not disagree with any aspect of those grants of service connection. No issue regarding service connection for a cardiovascular disorder, a skin disorder of the feet, or hearing loss is before the Board on appeal at this time. During the pendency of the appeal, the Veteran raised claims for service connection for diabetes mellitus and sleep apnea, and, in February 2011, the Veteran sought an increased evaluation for PTSD. By a rating decision issued in November 2012, the RO denied the claims for service connection for sleep apnea and for an increased evaluation for PTSD and granted the claim for service connection for diabetes mellitus and assigned an initial rating. The claims file before the Board, including the electronic file, does not reflect that the Veteran has disagreed with any aspect of the November 2012 rating decision. No appeal for an increased evaluation or increased initial evaluation for any service-connected disability is before the Board at this time; the Board notes that the time allowed for disagreement with that rating decision has not yet expired. The claims files, including all records obtained during the course of the 2011 Remand, and the electronic (virtual) file, have been reviewed. The Veteran submitted additional statements in 2013 essentially reiterating arguments as to why service connection should be granted for the disorders addressed in this appeal. The statements do not require review by the agency of original jurisdiction (AOJ). In a March 2012 communication, the Appeals Management Center (AMC) determined that a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) could be inferred from the record, and referred that claim to the RO of original jurisdiction. No issue regarding a claim for TDIU is before the Board at this time. The claim of entitlement to service connection for a headache disorder, including as due to an undiagnosed illness, is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC, in Washington, DC. FINDINGS OF FACT 1. The Veteran did not incur hypertension during a period of active service or within an applicable presumptive period and hypertensions is not secondary to or caused by any service-connected disability or any incident of service. 2. The medical evidence establishes that the Veteran did not incur a low back disorder during or as a result of his active service. 3. The Veteran has been granted service connection for eczema and tinea pedis affecting the feet, and there is no medical evidence that eczema or tinea of the body or face, when present, are separate disorders. 4. Resolving reasonable doubt in the Veteran's favor, the Veteran was treated chronically for allergies, upper respiratory tract infections, sinusitis, and similar symptoms proximate to his second period of active service, and continues to use medications to control these symptoms. 5. The Veteran's memory loss has been attributed to the Veteran's service-connected PTSD, and the medical evidence establishes that a separate diagnosis of dementia is not warranted. 6. The Veteran's symptoms of joint aches have been attributed to known clinical diagnoses of arthritis of the left knee, left shoulder, cervical spine, and lumbar spine, but no provider has found generalized medically unexplained joint aches or an undiagnosed illness manifested by joint aches, and no diagnosis of fibromyalgia has been assigned by any VA examiner or provider or private provider whose records have been identified during the pendency of this appeal. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension, including as secondary to service-connected PTSD, are not met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2012). 2. The criteria for service connection for a low back disorder, including as due to undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2012). 3. The criteria for service connection for eczema and dermatitis (claimed as jungle rot) of the face or body have been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2012). 4. The criteria for service connection for a sinus disorder have been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2012). 5. The criteria for service connection for a memory loss disability, to include dementia or an undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2012). 6. The criteria for service connection for joint aches (also described as fibromyalgia), including as due to undiagnosed illness, are not met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran seeks service connection for the claimed disorders, contending that the disorders were incurred during or as a result of his periods of active service. Duties to Assist and Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In this case, following the Veteran's submission of claims for service connection in September 2003, also accepted as a request to reopen claims for service connection which had been previously denied, the RO issued March 2004 and June 2004 letters which advised the Veteran of the criteria for service connection. The Board notes that all claims remaining on appeal are considered original claims for service connection, because additional service treatment records have been obtained during the course of the appeal. 38 C.F.R. § 3.156(c). In March 2006, the RO issued a letter which advised the Veteran of the criteria for determining disability evaluation assignments and effective date assignments when any claim for service connection is granted. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Later, the Veteran received numerous post-adjudicative notices following the Board's May 2009 Decision and Remand and the Veteran's appeal to the Court. Following the December 2009 Order from the Court, the Board issued an April 2010 Remand. Following that Remand, letters were issued to the Veteran in April 2010 and April 2012 about VA's duties to the Veteran. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). The Veteran does not allege that he has been prejudiced by any lack of notice. No defect in notice is apparent from the record. If any notice deficiency is present in this case, the Board finds that any prejudice due to an error in notice has been overcome in this case by the complete development conducted following the 2010 and 2012 Board Remands. The record, including the Veteran's testimony at his 2006 personal hearing before the RO and his numerous statements of record, including communications to the Court as part of the Veteran's appeal, demonstrates that the Veteran has actual knowledge of the evidence required to substantiate the claim at issue. See Shinseki v. Sanders/Simmons, 129 S.Ct. 1696 (2009). Duty to assist The Board Remanded certain claims in 2009. In 2010, the Board Remanded additional claims which were addressed in the Court's December 2009 Order. Each claim remaining on appeal was again Remanded in June 2012. Following the 2009 and 2010 Remands, the Veteran was afforded additional VA examinations. In 2013, VHA opinion as to one appealed claim was requested. The numerous examination reports of record, together with the 2013 VHA opinion, are an adequate basis for a decision with regard to each claim addressed on the merits in this decision. The Court's December 2009 Order directed VA to obtain the Veteran's VA clinical records prior to 2004. VA clinical records dated in December 2003 establish that the Veteran sought initial VA psychiatric care in December 2003. The report of an April 2004 medical clinical outpatient visit reflects that the Veteran was presenting as a new patient ("new visit"). See page 339, VA clinical records added to electronic file in April 2012. The electronic (Virtual VA) file associated with this claim for appellate review include more than 600 pages of VA clinical records dated from December 2003 through January 2013. All available VA clinical records have been obtained. All private clinical records identified by the Veteran have been obtained as well. The Court's December 2009 Order directed VA to seek more complete service treatment records for the Veteran. Additional efforts have been made to obtain the Veteran's complete records from his reserve component service. The AMC requested a search for the Veteran's records through the Alabama National Guard, since records from the Mississippi National Guard were not located. An additional request was sent to the Mississippi Army National Guard in April 2010. Requests were also sent to other facilities which might have records, including personnel commands. Following a December 2010 request for records, the National Personnel Records Center responded in April 2011 that they had no records for the Veteran and had no information as to where records for the Veteran might be located. In April 2011, the agency of original jurisdiction (AOJ) entered a formal finding of unavailability of the Veteran's records in the claims file. In March 2012, records were received from the US Army Health Treatment Record Task Force; these records were duplicates of evidence already in the record. In August 2012, additional records were provided by the Mississippi Army National Guard. Following the June 2012 Remand, additional attempts were made to obtain service treatment records. The AOJ contacted the Adjutant General of the appropriate state, the Defense Personnel Records Retrieval Information System (DPRIS), but no additional records could be located. Finally, when the Veteran's reserve records remained incomplete despite all efforts to locate the records, the Veteran's pay records were obtained from the Defense Finance Accounting Service (DFAS). The Board is satisfied that there has been substantial compliance with the requirements of the Court's 2009 Order and the Board's remands. Stegall v. West, 11 Vet. App. 268 (1998). The record reflects that the Veteran was separated from his reserve component service in 2003, at a time when he had completed more than 30 years of creditable service. The record also reflects that the Veteran retired from employment at Ciba Geigy in 2006 with more than 39 years of service. The Veteran did not authorize releases of any records from his private employer. The Veteran has not indicated that he applied for or received disability benefits from the Social Security Administration (SSA). Significantly, neither the Veteran nor his representative has identified any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Some discussion of the Veteran's hearing is necessary. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. Those duties were met here. The issues on appeal were identified at 2006 personal hearing at the RO, and the hearing officer discussed with the Veteran additional evidence necessary to substantiate the claims. The symptoms of the Veteran's disabilities and the bases for his claims were described in detail. The transcript of that hearing is nearly 20 pages in length. The Veteran's testimony establishes that he understood the criteria for service connection, that he understood how to establish service connection based on exposure to herbicides, that he understood how to substantiate service connection based on his Persian Gulf service, and that he understood that he could identify or submit any evidence that might assist him to substantiate the claims. 38 C.F.R. § 3.103(c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board again notes that the Veteran has been advised of VA's duties to him and has been afforded numerous opportunities to identify or submit evidence during the nearly 10 years since the Veteran submitted the December 2003 claims underlying this appeal. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). In view of the above, the Board finds no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Relevant Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. In a recent decision, the Court of Appeals for the Federal Circuit (Federal Circuit) has clarified the interpretation of the methods of establishing service connection under 38 C.F.R. § 3.303. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The criteria for service connection under § 3.303(a) are satisfied, according to the Federal Circuit, when a three-element test is met. The evidence must establish (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service (the so-called "nexus" requirement). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993); see also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Subsection (a) also refers to "each disabling condition...for which [a Veteran] seeks a service connection" and states that "[d]eterminations as to service connection will be based on review of the entire evidence of record." Id. If a Veteran can prove a chronic disease 'shown in service,' and there are no intercurrent causes, the manifestations of the chronic disease present at the time the Veteran seeks benefits establish service connection for the chronic disease. By treating all subsequent manifestations as service-connected, the Veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability compensation is sought. In short, there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease. Id. The second way to establish service connection set forth in § 3.303(b) is restricted to chronic diseases defined as such by VA regulation. If evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not 'shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,' i.e., 'when the fact of chronicity in service is not adequately supported,' then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and the Veteran's service, and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Id. The Federal Circuit held that that the term "chronic disease" as set forth in subsection (b) is properly interpreted as being constrained by § 3.309(a) in that the regulation is only available to establish service connection for the specific chronic diseases listed § 3.309(a) regardless of the point in time when a Veteran's chronic disease is either shown or noted. Id. In this case, a psychosis may be presumed service connection if it appears to the required degree within one year following the Veteran's service, but PTSD, which is the psychiatric disorder addressed in this decision, is not defined as a chronic disorder under the laws governing Veterans' benefits. None of the specific disorders for which the Veteran claims service connection which are addressed in this decision are defined as chronic diseases, for purposes of 38 C.F.R. § 3.303(b), but a presumption of service connection is applicable for a Veteran who served in the Persian Gulf during wartime, if an undiagnosed illness if found to be presented. Service connection may also be granted when a claimed disability is found to be proximately due to or the result of (secondary to) a service-connected disability, or when any increase in severity (aggravation) of a nonservice-connected disease or injury is found to be proximately due to or the result of a service-connected disability, not to the natural progress of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on this secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran served on the ground in Vietnam, and may be presumed to have been exposed to herbicides. 38 C.F.R. § 3.307(a)(6)(iii). Diseases associated with exposure to certain herbicide agents used in support of military operations in the Republic of Vietnam (Vietnam) during the Vietnam era will be considered to have been incurred in service. 38 U.S.C.A § 1116(a)(1). The presumption requires exposure to an herbicide agent and manifestation of the disease to a degree of 10 percent or more within the time period specified for each disease. 38 C.F.R. § 3.307(a)(6)(ii). Hypertension, lumbar spine disorders, joint aches, and memory loss are not among the listed disorders which may be presumed related to exposure to herbicides. 38 C.F.R. § 3.309(e). Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines warrants a presumption of service connection. 38 U.S.C.A 1117(d). 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. § 3.317, 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. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness. A "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). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; and other symptoms not applicable to this claim. 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). Where the evidence does not warrant presumptive service connection, the United States Court of Appeals for the Federal Circuit has determined that a Veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Where service treatment records have been lost or are incomplete, VA has a heightened obligation to assist the Veteran in the development of his claim. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). 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." Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). A Veteran is competent to testify as to a condition within his knowledge and personal observation. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Bruce v. West, 11 Vet. App. 405, 410-11 (1998) (finding Veteran competent to describe dry, itchy, scaling skin); but see Layno v. Brown, 6 Vet. App. 465 (1994) (cautioning that lay testimony that Veteran suffered a particular illness (bronchial asthma) was not competent evidence because matter required medical expertise); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (competent testimony "can be rejected only if found to be mistaken or otherwise deemed not credible). VA will give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d at 1337 ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). Facts and Analysis 1. Claim for service connection for hypertension The Veteran contends that hypertension was first manifested during his Persian Gulf service and has been chronic and continuous since that time. At the time of active duty separation examination in May 1991, the Veteran's blood pressure was 142/94. The examination notes "possible mild hypertension." See service treatment records, in envelope, claims files, volume 1. Private clinical records dated from December 1991 through 1997 disclose no notation that the Veteran's blood pressure was recorded. See private clinical records, Waynesboro Family Medicine & Obstetrics, dated from 1974 to 1997, claims files, volume 1. A 1995 reserve service medical certification does not disclose a blood pressure reading. In May 1996, the Veteran indicated he was in good health and taking no medication. A July 1996 referral for Bruce protocol exercise testing noted a blood pressure of 134/96. The report of that exercise examination includes multiple blood pressure readings. There is no notation that a diagnosis of hypertension was assigned. In December 2000, a blood pressure of 160/120 was recorded, and the examiner noted "worsening hypertension." In May 2001, the Veteran's blood pressure was 154/98. The examiner stated that the Veteran had history of hypertension and heart involvement. Further evaluations, include stress testing and echocardiogram, disclosed left ventricular hypertrophy and mitral valve regurgitation. By 2002, medication to reduce the Veteran's blood pressure was prescribed. In February 2012, the Veteran was afforded VA examination. The examiner noted that the Veteran's statement that hypertension was first diagnosed more than 20 years ago was inconsistent with his report that he had been treated for hypertension for 10 years. The examiner did not provide an opinion as to the onset of the Veteran's hypertension, but did provide an opinion that it was less than likely caused by the Veteran's service-connected PTSD, and was less than likely aggravated by the Veteran's service-connected PTSD. The rationale for the opinion that hypertension was not caused by PTSD was that medical knowledge does not support a conclusion that hypertension is etiologically linked to PTSD. The rationale that hypertension was not aggravated by PTSD was that the increase in the severity of the Veteran's hypertension over the years was consistent with the aging process. In March 2013, the Board sought a VHA medical opinion. In May 2013, the Board provided the Veteran a copy of the opinion received. The VA reviewer concluded that the Veteran's hypertension likely had an onset no earlier than December 2000. The reviewer explained that, although blood pressure readings as high as 142/94 were recorded in 1991, there were no further indications of elevated blood pressure for many years. The reviewer noted that the Veteran did not report clinical symptoms of elevated blood pressure during the period from 1993 to 1997. The reviewer stressed the importance of diagnostic examination results in 1996, some 5 years after the Veteran's separation from his last period of active service, and thereafter. In 1996, the Veteran's blood pressure was 120/80 in 1996 when an electrocardiogram (ECG) and stress testing were conducted, and those diagnostic tests disclosed no abnormality. The Veteran again underwent diagnostic examination of the heart in November 2000, and no findings related to uncontrolled hypertension were present at that time. Based on these facts, among others, the reviewer concluded that it was less than likely as not (less than 50/50 probability) that the Veteran's hypertension was incurred during or resulted from the Veteran's active service, to include his active Persian Gulf service ending in 1991. The 2013 VHA medical opinion is highly persuasive. The reviewer provided a thorough review of the service treatment records and the post-service clinical evidence, and provided a lengthy summary of the pertinent items of evidence. The reviewer provided a lengthy rationale for the conclusion, and explained why isolated elevated blood pressure readings in 1991 were not sufficient to warrant assignment of a diagnosis of hypertension as incurred in service or within a presumptive period following that service. This seven-page opinion places the preponderance of the evidence against a finding that a diagnosis of hypertension may be assigned during the Veteran's second period of service or within an applicable presumptive period thereafter. The Board acknowledges that the provider who signed the opinion did not date the medical opinion. However, it is clear from the record that the Board requested the opinion in March 2013 and that a copy of the opinion was provided to the Veteran in May 2013. Thus, although there is no date on the opinion, that does not detract from the persuasive value of the opinion rendered. Additionally, the Veteran has stated his belief that he first manifested hypertension during his second period of service. However, hypertension does not result in symptoms that may be clearly detected by the layman; rather, the actual detection and diagnosis of hypertension requires specific measuring devices for blood pressure, and an interpretation of the blood pressure readings by a medical professional. The evidentiary value of the Veteran's statements as to his belief about the onset of hypertension is minimal. The unfavorable evidence, including the clinical records for the five years proximate to the Veteran's May 1991 service separation, and the VA medical opinions, including the very persuasive 2013 medical opinion, are of greater weight and value than the two May 1991 entries in the service treatment records and the Veteran's lay belief as to the date of onset of hypertension. The favorable evidence, when weighed against the evidence unfavorable to the claim, does not place the evidence relevant to the claim in equipoise. The preponderance of the lay and medical evidence is against a finding that hypertension was incurred during either period of the Veteran's active service, or within an applicable presumptive period thereafter, or is etiologically related to (caused or aggravated by) the Veteran's service-connected PTSD. The Veteran does not contend that any other service-connected disability or incident of service caused or aggravated hypertension, nor does the record so suggest. The claim must be denied. 2. Claim for service connection for a lumbar disorder Service treatment records reflect that the Veteran sought evaluation for low back pain in January 1991, and was placed on a limited physical profile. In April 1991, the Veteran reported that the back pain was resolving, but he still had loss of sensation in the left thigh. Private medical records of an unidentified provider, with the heading "Family Practice Progress Notes," disclose no notation that the Veteran sought evaluation for back pain in 1991, 1992, 1993, or 1994 (to the extent that those records are legible). In February 1995, the Veteran certified, for his annual medical certification for continued reserve component duty, that he had no medical or dental problems, although he had undergone a root canal since his last periodic evaluation. At the time of periodic examination for reserve service in May 1996, the Veteran's spine and lower extremities were described as normal. In response to the question on the medical history about recurrent back pain, the Veteran reported in May 1996 that he did not have recurrent back pain. A June 1996 physical profile noted that the Veteran had a physical limitation, but the limitation was not related to a lumbar spine or lower extremity disorder, and the profile did not identify any limitation due to a spine or lower extremity disorder. Private treatment records dated from December 1991 to September 1997 include no entry regarding back pain or pain radiating from the back (to the extent that the notes are legible). Private medical records of an unidentified provider, with the heading "Daysheet," submitted by the Veteran, disclose no treatment of or complaints of a back disorder in 1996, 1997, or 1998. The report of December 2000 periodic examination for reserve purposes, and a May 2001 medical evaluation, reflect no diagnosis of a back disorder and disclose no report of back pain or history of a back disorder. On VA examination conducted in March 2005, the Veteran reported back and neck pain, with neck pain extending to the shoulders. He reported numbness in the left hand. He was working as a maintenance worker. He reported obtaining chiropractic treatment for his neck. Radiologic examination disclosed degenerative disc disease of the lumbar spine and spondylosis at L4-S1. The Veteran also reported left thigh pain and numbness in the last six to eight months, suggestive of meralgia paresthetica. The examiner noted that the Veteran's reported "joint aches" were due to degenerative joint disease, but did not provide an opinion as to the etiology or onset of degenerative disease affecting the spine. The Veteran underwent VA registry examination in March 2006. The Veteran reported skin disorders and cardiovascular disorders, but did not report a lumbar disorder. The Veteran did not testify about the onset or chronicity of a lumbar disorder at his April 2006 personal hearing. At a February 2012 VA examination, the Veteran reported that his back pain began in 1990 and 1991. He denied any back trauma or injury since that time. He reported burning pain radiating from the back to the left buttock, down the left leg, ending at the left knee. He reported flare-up triggered an average of twice monthly by activities such as driving, standing, or heavy lifting. He reported relief from sitting in the recliner, use of Ibuprophen, and use of a TENS (transcutaneous electrical nerve stimulation) unit several times per week. The Veteran reported that he had undergone one epidural injection of pain medication, with some relief. The examiner concluded that the Veteran's lumbar spine degenerative disc disease was mot caused or aggravated by an injury in service, but, rather, was consistent with natural aging. The examiner further concluded that a lumbar sprain in service was resolving when the Veteran separated from service and that the separation physical does not document chronic or ongoing lumbar strain with radiculopathy. The Veteran's current spondylosis was a degenerative condition which did not begin in service and did not cause or aggravate a lumbar strain in service or current degenerative disc disease of the lumbar spine. At the time of a private psychiatric evaluation in 2010, the Veteran reported that he sustained an on-the-job injury while employed by Ciba Geigy in 2006 that resulted in a ruptured disc. The Board notes that the Veteran did not describe this on-the-job injury to the examiner who conducted 2012 VA examination. The injury had not yet occurred, apparently, when the Veteran underwent VA examinations in 2005 and 2006. The 2010 private psychiatric report conflicts with some of the Veteran's other statements about the onset and chronicity of back pain. As the Veteran sought out the 2010 private examination, and as the report appears detailed and thorough, the report of that examination is of great weight and persuasive value, and is unfavorable to the claim for service connection for a lumbar disorder, even though the examination was not obtained for the purpose of addressing the claim of entitlement to service connection for a lumbar disorder. The evidence favorable to this claim includes the entries in the service treatment records which show that the Veteran sought evaluation for back pain in service. The only other favorable evidence is the belief expressed by the Veteran that his back pain has been continuous since service. However, the current back disorders, degenerative disease of the lumbar spine and spondylosis, are not disorders which are observable by a lay person. The Veteran is competent to state that he has experienced back pain, but he is not competent to state that the back pain he currently experiences is due to the same disorder which was present when he had back pain in service in 1991. The evidence unfavorable to the Veteran's claims includes the private records from several providers covering the period from 1991 to 1998, since those records fail to disclose that the Veteran sought evaluation for back pain from 1991 to 1998, and the records disclose no medical diagnosis of a back disorder. The unfavorable evidence also includes the Veteran's 1995 statement for reserve purposes (denying recent treatment for any disorder other than a dental disorder), the 1996 reserve service evaluation disclosed no spine, neurologic, or lower extremity disorder, and 2000 and 2001 reserve clinical records, which disclosed no diagnosis of a back disorder and no report of back pain or history of a back disorder. The report of a 2010 psychiatric evaluation is unfavorable to the claim, because that report suggests that the Veteran incurred a 2006 post-service back injury which the Veteran did not report to VA examiners. Finally, the 2012 VA examination report is unfavorable, since the examiner found no evidence a lumbar strain, and no evidence of meralgia paresthetica, which had been suspected in service, and concluded that the present disorders were not incurred or aggravated in service. The preponderance of the clinical evidence is against the claim that the Veteran has a current lumbar disorder that was incurred or aggravated in service. The claim must be denied. 3. Claim for service connection for a skin disorder of the face and body In its June 2012 decision, the Board granted service connection for a skin disability, claimed as jungle rot of the feet, medically identified as tinea pedis, and the Board remanded the claim for service connection for skin rashes of the face and body. By a rating decision issued in June 2012, the Veteran was granted service connection for eczema and dermatitis of the feet, claimed as jungle rot. The Board directed the agency of original jurisdiction (AOJ) to conduct any additional development required to adjudicate the claim for service connection for skin rashes of the face and body. The AOJ noted that no skin rash of the face or body was described in the partial service treatment records from the Veteran's active service, and no skin rash of the face or body was described in the partial service treatment records from the Veteran's reserve component service. The AOJ did not obtain additional medical evidence. The Board notes that the medical opinions obtained during the pendency of the appeal do not address the fact that post-service private records following the Veteran's active service include occasional notations that the Veteran required care for a skin disorder. The medical opinions obtained do not address the significance of the fact that records obtained from the Veteran active and reserve component service are incomplete. The medical opinions obtained do not address the likelihood that any current skin disorder is etiologically related to eczema or dermatitis (tinea pedis) for which service connection has been granted. The Veteran has been pursuing this claim for service connection for skin rashes nearly 10 years. Complete service treatment records will likely never be obtained. The Veteran has manifested tinea on portion of his body during the pendency of this appeal, and has manifested eczema on some portions of his body during the pendency of this appeal. In light of these facts, the Board finds that the Veteran's lay testimony that he has had chronic skin rashes of the body and feet since service is sufficient to place this claim in equipoise. Resolving reasonable doubt in the Veteran's favor, the Board finds that service connection for eczema and dermatitis (claimed as jungle rot) of the body is warranted. 4. Claim for service connection for a sinus disorder The Veteran contends that he is entitled to service connection for a sinus disorder. The Veteran contends that he was first diagnosed with a sinus disorder after his return from his active service in the Persian Gulf. After that period of service, the Veteran testified, he required treatment for a sinus disorder. Some of the private post-service treatment records dated in 1991 through 1997 are essentially illegible, but notes dated in 1991 through 1993 appear to possible reference treatment for colds, sore throats, or disorders manifested by elevation of temperature. Some more legible records in 1994, 1996, and 1997 discuss treatment of a sinus problem or congestion. In 1996, the Veteran noted, in a history he completed for reserve purposes, that he had allergies, especially to insect bites. A typewritten note dated in September 1997 reflects treatment for an upper respiratory tract infections and allergic rhinitis. Private and VA treatment records dated from 2000 to 2004 reflect treatment of seasonal allergies. These records are consistent with the Veteran's testimony that he primarily uses over-the-counter medications for his sinus disorder. For example, partial records of the Veteran's medications from 2002 to 2003 reflect that Claritin was prescribed on an ongoing basis. Given that the Veteran has been pursuing this claim for nearly 10 years, and given that complete service treatment records will likely never be obtained, and given that the partial service treatment records, private, and VA clinical records are consistent with treatment of a sinus disorder with congestion or allergies essentially continuously, if intermittently, since the Veteran's second period of service, the Board finds that the Veteran's lay testimony that he has required treatment of a sinus disorder with congestion and allergies is sufficient to place this claim in equipoise. Resolving reasonable doubt in the Veteran's favor, the Board finds that service connection for a sinus disorder with congestion and allergies is warranted. 5. Claim for service connection for a memory loss disorder The Veteran contends that he has a memory loss disorder. The Veteran contends that he is entitled to service connection for a psychiatric disorder or an undiagnosed disorder manifested as memory loss, separate from the award of service connection for PTSD. The Veteran's outpatient VA treatment records beginning in December 2003 disclose that the Veteran was initially treated for anxiety disorder and depressive disorder. A diagnosis of PTSD was thereafter assigned. At his March 2005 VA examination, the Veteran reported memory loss. The examiner noted the Veteran's VA treatment for anxiety, depression, and PTSD. The examiner concluded that the Veteran's complaints of memory loss required further evaluation. The Veteran continued to receive VA outpatient mental health treatment. VA psychiatric examination was conducted in May 2006. The Veteran reported difficulty concentrating and forgetfulness. A diagnosis of chronic PTSD was assigned. Service connection for PTSD was granted in June 2006. In June 2007, the Veteran was afforded VA psychiatric examination. The examiner noted that the Veteran reported disability retirement due to cardiac surgery and back issues. His psychomotor activity was retarded, his sensorium was mildly clouded, and he reported continuing sleepiness, among other symptoms. The examiner concluded that the Veteran had memory loss related to his service-connected PTSD, and that symptoms of PTSD were exacerbated by the Veteran's general medical health problems. VA outpatient treatment records reflect that the Veteran continued to receive VA outpatient mental health treatment and that medication was prescribed to manage the Veteran's PTSD symptoms. Following Remand of the claim in April 2010, the Veteran submitted the report of a private psychological evaluation conducted in January 2010. The private provider concluded that the Veteran had PTSD as a result of service, and, in addition, had moderate dementia due to his general medical condition. The examiner noted in particular that the Veteran was unable to think abstractly, maintain attention or perception by listening, had deficits in verbal comprehension, and had diminished intellectual functioning (IQ) which impaired his ability to work. The provider concluded that the Veteran was unable to continue working. After the private provider who evaluated the Veteran provided the January 2010 report which assigned a diagnosis of dementia for the Veteran's memory loss, the Veteran continued to seek VA outpatient treatment. VA outpatient treatment records reflect that the Veteran received outpatient mental health treatment and evaluation at least 15 times from January 2010 to January 2013. No VA provider assigned a diagnosis of dementia. The Veteran was afforded VA examination in December 2011. The provider who conducted the VA examination concluded that the Veteran had two psychiatric disorders, PTSD and a depressive disorder secondary to PTSD. The examiner did not assign a diagnosis of dementia. The Veteran has consistently raised complaints of memory loss throughout the pendency of this appeal. The examiners who conducted VA examinations in 2006, 2007, and 2011 attributed the Veteran's complaints of memory loss to his service-connected PTSD and to his general medical conditions. Among other disorders treated during the pendency of this appeal, the Veteran underwent open heart surgery to replace a heart valve, and a diagnosis of diabetes mellitus has been assigned during the pendency of this claim. The treating VA providers have attributed the Veteran's memory loss to known disorders, primarily the Veteran's service-connected PTSD and his general medical disorders. No VA or private provider has opined that the Veteran's memory loss is a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illness. The preponderance of the evidence is against a finding that service connection for the Veteran's memory loss may be presumed related to the Veteran's Persian Gulf service. One provider, DLK, Ph.D, provided an opinion that the Veteran's memory loss was a symptom of dementia. Dr. K. indicated that the Veteran's dementia was due to the Veteran's general medical disorders, which Dr. K. listed as including lumbar degenerative joint disease (for which service connection is not in effect), hearing loss (for which service connection is in effect, with a 20 percent rating), heart disease (for which service connection is in effect, with a 30 percent rating), and hypertension (for which service connection is not in effect). However, as noted in discussions above, the Veteran's VA treatment from December 2003 through the present is documented in over 600 pages of VA clinical records. No VA provider or VA examiner has assigned a diagnosis of dementia. Although Dr. K. assigned a diagnosis of dementia for the Veteran's symptoms of memory loss and cognitive decline in his January 2010 written report, the overwhelming preponderance of the evidence is against a finding that a diagnosis of dementia should be assigned for the Veteran's symptoms of memory loss. The evidence is against a finding that the Veteran's memory loss is a symptom of a disorder separate from PTSD. The Veteran's claim for a separate grant of service connection for a psychiatric disorder other than PTSD manifested by memory loss must be denied. The criteria used to rate PTSD are the same criteria used to rate dementia, as both disorders are evaluated under 38 C.F.R. § 4.124a. In this case, the severity of the Veteran's PTSD is evaluated based on his ability to engage in abstract thinking, his judgment, his long-term and short-term memory, and his occupational and social functioning, among other criteria. As these are the primary symptoms that Dr. K. described in the diagnosis of dementia, it does not appear that the symptoms for which Dr. K. assigned the diagnosis differ from the symptoms used to rate the Veteran's PTSD. Thus, even if dementia were considered a separately-diagnosed psychiatric disorder and service connection were granted, that grant of service connection would not increase the Veteran's disability rating unless the dementia resulted in different manifestations from the already-service-connected PTSD. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009) ("Section 4.14 clearly contemplates that several separately diagnosed disorders may have a single manifestation, and it clearly prohibits the VA from rating that manifestation for each disorder."). Thus, any error in the determination that the Veteran does not currently manifest dementia or that a separate grant of service connection for dementia, if present, is not warranted, would, at most, constitute harmless error, to the extent that symptoms of PTSD and dementia would be overlapping. In any event, the overwhelming preponderance of the evidence is unfavorable to assignment of a diagnosis of dementia, since no other provider who treated or examined the Veteran from 2003 to 2013 assigned a diagnosis of dementia. Rather, the medical evidence establishes that the Veteran's memory loss is medically attributed to service-connected PTSD, and that memory loss is not a manifestation of dementia or of an undiagnosed illness. Although there is a medical opinion which attributes memory loss to dementia rather than PTSD, the medical evidence is so overwhelmingly unfavorable to such a finding that no further development of that contention is warranted. The claim for service connection for memory loss as a manifestation of an undiagnosed illness or as a manifestation of a psychiatric disorder for which service connection and an evaluation separate from PTSD may be granted is denied. 6. Claim for service connection for joint aches In his December 2003 claim, the Veteran sought service connection for "joint aches all over, to include undiagnosed illness." At this personal hearing in April 2006, the Veteran contended that his joints, especially his shoulder and knee, started aching and nobody knew why. The Veteran testified he was taking medication for joint aches, but there was no attempt by the providers to determine why he had aching joints, the Veteran testified. (Tr. 18). The examiner who conducted a March 2005 VA examination determined that the Veteran had arthritis of the cervical spine, lumbar spine, left knee, and left shoulder. The examiner concluded that the Veteran's "joint aches" were "likely related" to his degenerative arthritis of those joints, and that the presence of "joint aches" did not suggest any undiagnosed illness. The examiner who conducted 2006 Persian Gulf registry examination concluded, as had the examiner who conducted the 2005 VA examination, that the Veteran's shoulder pain was due to arthritis of the cervical spine, and that the Veteran had tendonitis of the right shoulder as well. Voluminous and lengthy VA outpatient treatment notes from December 2003 through January 2013 disclose that the Veteran has complained of muscle weakness, joint pain, and joint aches on many occasions. The Veteran's complaints of pain of the knees, shoulders, neck, and back have been identified as due to arthritis, degenerative disease, of those joints. No VA examiner or VA provider has determined that the Veteran has generalized arthritis or generalized unexplained pain in multiple joints. No VA examiner or VA provider has determined that the Veteran has an undiagnosed illness manifested by joint pain or muscle aches. Examiners who provided VA examinations in 2006, 2007, 2011, and 2012 have declined to assign any diagnosis other than degenerative joint disease of specific joints. No private provider whose records have been identified has assigned a diagnosis of generalized arthritis or generalized unexplained pain in multiple joints. No private provider whose records are available for review has determined that the Veteran has an undiagnosed illness manifested by joint pain or muscle aches. Although the Veteran testified that the cause of his joint aches was not known, radiologic examinations of the Veteran's lumbar and cervical spine have been conducted, and several VA providers have noted the bases for diagnosis of arthritis of the diagnosed joints. Because the medical diagnosis for each painful joint is known, the Veteran does not have undiagnosed joint aches or medically unexplained joint aches. Therefore, no presumption of service connection for those joint aches as due to undiagnosed illness is applicable. 38 U.S.C.A. § 1117. The Veteran has not alleged that he incurred an injury to the neck, either knee, or either shoulder during active service or during a specific period when he was performing reserve service. The Board interprets the Veteran's statements and testimony as a claim for generalized joint aches or an undiagnosed illness affecting the joints. It does not appear to the Board that the Veteran has attempted to seek service connection for a right knee disorder, a neck disorder, or a right shoulder disorder, nor does it appear that such claims should be inferred. The Veteran's specific claim for service connection for a lumbar disorder is discussed above. No diagnosis of joint aches as a generalized disorder, an undiagnosed illness manifested by joint aches, or fibromyalgia has been assigned by any examiner or provider who has treated the Veteran during the pendency of this appeal. As noted above, the medical evidence establishes that numerous VA providers have treated the Veteran's complaints of muscle pain and joint aches. The providers have consistently noted that the Veteran has arthritis of certain joints, and that the Veteran has been directed to take Ibuprophen for joint pain. The fact that the voluminous records disclose no notation that the Veteran has fibromyalgia, medically unexplained joint pain, or an undiagnosed or multisymptom illness is persuasive evidence against the Veteran's claim. The medical evidence establishes that the Veteran's joint aches are medically attributed to known, diagnosed disorders or specific joints. There is no evidence that arthritis was present within a presumptive period following the Veteran's active service. The medical evidence is overwhelmingly unfavorable the claim for service connection for joint aches as a manifestation of an undiagnosed illness, a chronic multisymptom illness, to include fibromyalgia. The voluminous records disclose no diagnosis of a joint disability for which service connection may be presumed on the basis of the Veteran's service in Vietnam or his service in the Persian Gulf, and disclose no evidence of actual causation of a joint disorder due to service. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The claim must be denied. ORDER The appeal for service connection for hypertension, including as secondary to service-connected PTSD, is denied. The appeal for service connection for a low back disorder, including as due to undiagnosed illness, is denied. The appeal for service connection for skin rashes on the face and body consistent with eczema or dermatitis with tinea is granted. The appeal for service connection for a sinus disorder manifested by congestion and allergies is granted. The appeal for service connection for a memory loss disability, to include dementia, and to include as due to undiagnosed illness, is denied. The appeal for service connection for joint aches (also described as fibromyalgia), including as due to undiagnosed illness, is denied. REMAND In its December 2009 Order, the Court noted that a headache disorder had been diagnosed. Accordingly, the Order, in light of the Joint Motion For Partial Remand incorporated in the Order, requires VA to obtain medical opinion as to the onset and etiology of the Veteran's headaches, in light of the evidence obtained as directed on Remand. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran an opportunity to submit or identify any relevant records. 2. Obtain updated VA clinical records and associate those records with a file available for appellate review. 3. Afford the Veteran examinations as necessary to determine the current nature and etiology of headaches. The examiner should review the available service treatment records, the reports of VA examinations during the appeal period (from December 2003 to the present), and relevant VA and private records. The examiner should determine whether the Veteran has a separately-diagnosable headache disorder or whether the Veteran's headaches are manifestations of diagnosed disorders; for instance, the possibility that it may be related to the service-connected sinus disability . The examiner should address the following: 1) Does the Veteran suffer from a headache disorder? If so, please describe the nature and type of such headache disorder (tension, migraine, sinus congestion, etc.) 2) If there is a headache disorder, is it at least as likely as not (a 50 percent probability or greater) that the Veteran's current headache disorder had an onset during either of the Veteran's period of active service (July 1970 to July 1971, or January 1991 to April 1991) or was incurred in or results from an event in service, to include exposure to herbicides during Vietnam or environmental hazards during Persian Gulf service (i.e., an undiagnosed illness or medically unexplained chronic multi-symptom illness)? 3) If the answer to the above question is negative, then is it is at least as likely as not (a 50 percent probability or greater) that any headache disorder is due to or secondary to or aggravated by any of the Veteran's service-connected disabilities, in particular, post-traumatic stress disorder with depression, or service-connected sinus disorder? In answering the above questions, the examiner shall address the Veteran's statements regarding the onset and/or chronicity of headaches. A rationale should be given for any opinion rendered. If the examiner is unable to render an opinion without resorting to pure speculation, he/she should so state with supporting rationale. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question. 4. After all actions required above have been completed, readjudicate the appeal. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After an adequate opportunity to respond has been afforded, the appeal must be returned to the Board for appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). [Continued on Next Page] 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). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs