Citation Nr: 1327609 Decision Date: 08/28/13 Archive Date: 09/05/13 DOCKET NO. 06-03 353 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a stomach disorder, including an undiagnosed illness manifested by stomach pain. 2. Entitlement to service connection for a memory disorder, including an undiagnosed illness manifested by memory loss. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel INTRODUCTION The Veteran served on active duty from August 1988 to August 1991, and served in the Southwest Asia Theater during the Persian Gulf War. He had subsequent service with the U.S. Naval Reserve from August 1991 to February 1996. This appeal to the Board of Veterans' Appeals (Board) arose from an August 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied the benefits sought on appeal. In February 2008, November 2009, August 2011, and October 2012, the Board remanded the case to the RO, via the Appeals Management Center (AMC), in Washington, DC, for additional development. The AMC/RO completed the additional development as directed, continued to deny the claims remaining on appeal, and returned the case to the Board for further appellate review. FINDINGS OF FACT 1. The Veteran had active service in the Southwest Asia Theater of operations during the Persian Gulf War. 2. The Veteran does not have a current stomach disability or exhibit objective indications of a qualifying chronic disability involving stomach pain. 3. The Veteran does not have a current memory disability or exhibit objective indications of a qualifying chronic disability involving memory loss. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for a stomach disability, to include as due to undiagnosed illness manifested by stomach pain as a result of service in the Southwest Asia Theater during the Persian Gulf War, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 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 criteria for establishing service connection for a memory disability, to include as due to undiagnosed illness manifested by memory loss as a result of service in the Southwest Asia Theater during the Persian Gulf War, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 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 Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, in an April 2005 letter, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claims, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. March 2006 and March 2008 letters also advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence that impacts those determinations. The case was last adjudicated in June 2013. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran including service treatment and personnel records, post service private and VA treatment records, records from the Social Security Administration (SSA), VA examination reports and medical opinions, and lay statements from the Veteran and family members. The Board also notes that actions requested in the prior remands have been undertaken. Here, VA requested and/or obtained additional treatment records pertinent to the Veteran's claims, obtained SSA records, and obtained supplemental VA examination and medical opinion evidence necessary to decide the claims. The Board notes that VA did not complete the action requested to verify the exact dates of the Veteran's service in the Southwest Asia Theater of operations during the Persian Gulf War. However, his service treatment records reflect that he received medical treatment aboard the USS Saratoga between August 1990 and March 1991, and publicly available U.S. Naval records document that the USS Saratoga was in the Red Sea in the Southwest Asia theater of operations during those dates. Thus, no further action is required regarding the exact dates of the Veteran's service in the Southwest Asia theater of operations. The Board finds that VA has substantially complied with the prior remand directives and a decision on the merits can proceed. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). The Board observes the Veteran also has a Virtual VA paperless claims file, which is a highly secured electronic repository that is used to store and review documents involved in the claims process. The Board has reviewed the contents of the paperless file, and there are pertinent records related to the issues on appeal that are not also in the paper claims file. The Board notes further that the June 2013 supplemental statement of the case (SSOC) references those records and notes that they were considered in the de novo review while the case was on remand. Thus, the Board may properly consider them in the decision below. See Disabled American Veterans , et al v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). The Board notes that the Virtual VA claims file also contains VA treatment records dated from December 2012 to May 2013 that were associated with the electronic claims file prior to the June 2013 SSOC, but not were listed as evidence or discussed in the June 2013 SSOC. If the SSOC was prepared before the receipt of the additional evidence, an SSOC will be furnished to the appellant and his representative, unless the additional evidence received duplicates evidence previously of record which was discussed in the SSOC or prior SSOC or the additional evidence is not relevant to the issue(s) on appeal. See 38 C.F.R. § 19.37(a). The Board has thoroughly reviewed these VA treatment records and finds that they are not relevant to the issues on appeal because they reflect no complaints or findings of stomach problems and because though they reflect treatment for mental disorder, they contain no complaints or findings of memory loss. Accordingly, the Board finds that a remand for the RO to review these records and issue an SSOC is not required and that the Veteran is not prejudiced by the Board's decision to proceed with a final decision on the appeal. VA has considered and complied with the VCAA provisions discussed above. The Veteran was notified and aware of the evidence needed to substantiate the claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument. Therefore, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the Veteran. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Conway, 353 F.3d at 1374; Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Criteria & Analysis The Veteran asserts that he has a stomach disorder due to exposure to an environmental hazard in the Gulf War and memory loss related to military service. Applicable law provides that service connection will be granted if it is shown that the veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. 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). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established for a Persian Gulf Veteran who exhibits objective indications of chronic disability that cannot be attributed to any known clinical diagnosis, but instead results from an undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1)(i) (2012). See also 76 Fed. Reg. 81834 (Dec. 29, 2011). A "Persian Gulf Veteran" includes a veteran who served on active naval service in the Southwest Asia theater of operations, including the Red Sea, during the Persian Gulf War. 38 C.F.R. § 3.317(e). "Objective indications of a chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(2)-(5). Effective March 1, 2002, the law affecting compensation for disabilities occurring in Persian Gulf War Veterans was amended. 38 U.S.C.A. §§ 1117, 1118. Essentially, these changes revised the term "chronic disability" to "qualifying chronic disability," and involved an expanded definition of "qualifying chronic disability" to include (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2)(B); 38 C.F.R. § 3.317. The term "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). With claims based on undiagnosed illness, the Veteran is not required to provide competent evidence linking a current disability to an event during service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). Signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multi-symptom illness include: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C.A. § 1117(g); 38 C.F.R. § 3.317(b). Section 1117(a) of Title 38 of the United States Code authorizes service connection on a presumptive basis only for disability arising in Persian Gulf Veterans due to "undiagnosed illness" and may not be construed to authorize presumptive service connection for any diagnosed illness, regardless of whether the diagnosis may be characterized as poorly defined. VAOPGCPREC 8-98 (Aug. 3, 1998). Compensation may be paid under 38 C.F.R. § 3.317 for disability which cannot, based on the facts of the particular Veteran's case, be attributed to any known clinical diagnosis. The fact that the signs or symptoms exhibited by the Veteran could conceivably be attributed to a known clinical diagnosis under other circumstances not presented in the particular Veteran's case does not preclude compensation under § 3.317. Id. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. A review of the Veteran's service treatment records reflects that he received medical treatment aboard the USS Saratoga between August 1990 and March 1991 while in the Southwest Asia theater of operations during the Persian Gulf War. Thus, he is considered a Persian Gulf Veteran. 38 C.F.R. § 3.317(e) (2012). See also 76 Fed. Reg. 81834 (Dec. 29, 2011). The Veteran's service treatment records are silent for complaints, findings, diagnosis, or treatment for memory problems. In May 1989, he sought emergency treatment aboard the USS Saratoga for complaints of nausea and vomiting, dizziness, and headaches for two months. On examination, the abdomen was benign. The assessment was motion sickness and Meclizine was prescribed. In March 1990, he complained of headache, stomach ache, and sore throat. The assessment was upper respiratory infection. In reports of medical history dated in February 1988 at enlistment and in July 1991 at separation, he denied currently or ever having stomach trouble or loss of memory or amnesia. On enlistment and separation examination, clinical evaluation of the abdomen and viscera and psychiatric functioning were reported as normal. His service treatment records also contained records from his Naval Reserve service. They were silent for complaints or findings related to stomach or memory problems, he denied such problems in reports of medical history in August 1991 and December 1992, and examination reports dated in August 1991 and December 1992 again documented normal psychiatric functioning and stomach on clinical evaluation. In December 1992, weight was recorded as 219 pounds and height was 72 inches (six feet). In each report of medical history from active duty and Naval Reserve service, the Veteran also denied currently or ever having frequent trouble sleeping, depression or excessive worry, or nervous trouble of any sort. Post-service private treatment records from the clinic at his Federal workplace dated from February 1992 to January 1998 reflected numerous complaints beginning in December 1992 of nausea and vomiting, upset stomach, indigestion, or stomach pain (January 1993, twice in August 1993, June 1994, twice in November 1994, December 1994, May 1995, June 1995, September 1996, twice in February 1997, and July 1997). He also complained of diarrhea twice in July 1994. The diagnosis variously included gastrointestinal disturbance, altered comfort, diarrhea, nausea, and health seeking behavior. An April 1997 note from C. Brooks, M.D., indicated that the Veteran was under his care since February 1997 and was totally incapacitated during that time. The diagnosis was status post exploratory laparotomy of abdomen. Dr. Brooks reported that the Veteran was feeling much better, the wound healed well, and he was able to return to work. In a July 1997 note, Dr. Brooks indicated that the Veteran had been under his care since June 1997 and was now able to return to work. The diagnosis was soft tissue injury from a motor vehicle accident. A January 2005 VA primary care note reflects that the Veteran presented to establish care. He reported problems with intermittent recurrent abdominal pain with cramping and nausea since 1991with no clear precipitating factors. He stated that over the counter antacids are often beneficial, but trials of protime pump inhibitors such as Prilosec did not help. He conveyed that he had an esophagogastroduodenoscopy (EGD) in 1996 that was unremarkable. During a review of systems he had no gastrointestinal complaints of dysphagia, odynophagia, history of change in stool pattern, melanin or hematochezia. Objectively, his weight was 215 pounds and his abdomen was soft, nontender with no bruits or masses. The assessment was history of recurrent abdominal pain primarily in the right quadrant. The physician discussed the possibility of further evaluation and treatment. The impression of a visceral or vascular ultrasound study was liver and gallbladder are normal in appearance. The Veteran was afforded a VA general medical examination in July 2005. He stated that he was exposed to nuclear weapons, jet fuels, and fumes while on the USS Saratoga and got sick on the ship with stomach pains, but no one ever gave him a diagnosis for his stomach pains. He reported that he continues to have stomach pains and had abdominal surgery, which was initially for an appendectomy, but [his appendix] was apparently normal but still removed, and nothing else was found during the surgery. He described nausea-type pain in the mid-abdomen with occasional abdominal cramps and indicated there was no pattern to his pain. Food did not bother his stomach and nothing ever brought on the pain. He denied any associated nausea, vomiting, diarrhea, constipation, melena, or bright red blood in stools. Appetite was good with no weight loss. His weight was recorded as 197 pounds. Following a review of the claims file and physical examination, the impression was abdominal pains, etiology unknown to this day with a normal ultrasound of his abdomen status post appendectomy. The Veteran was also afforded a VA mental disorders examination in July 2005. He stated that he saw Dr. Brooks twice in 1996 and was advised to seek counseling, but never followed through. He complained of memory loss since 1994, stating that he forgets his children's names and has forgotten that he has a job and then did not go to work. He denied any problematic substance use, including alcohol. He reported being a very good employee and skilled mechanic and a good father. He disclosed that he was arrested three times: around 1996 for burglary of a motor vehicle, but denied that it happened; in 1999 for passing a hot check (possession of a forged document); and in 2003 for possession of cocaine. On mental status examination, informal testing revealed that he could remember his address and two telephone numbers, his brother's address and his brother's work number, and he was able to remember how to get from the VA Compensation and Pension office to the parking lot where his car was with no need for additional directions. The examining psychologist remarked that these findings were inconsistent with the Veteran's report of memory problems so disabling that he cannot remember whether he is employed. The examiner added that the Veteran described some mental health symptoms of depression, anxiety, irritability, and sleep problems, but nothing that comprised a clear diagnosis. The examiner concluded that there was no diagnosed mental disorder. In a September 2005 lay statement, the Veteran's daughter indicated that the Veteran has had stomach problems and at times has memory loss where he forgets names and everyday things. She noticed that he had "been through stages of depression" and she had "seen signs of anxiety attacks." In October 2005 letters, two of the Veteran's sisters indicated that the Veteran always seemed to have stomach problems in the last couple years. They also believed he was depressed, "quick tempered and hostile," and had an inability to maintain relationships. In an April 2006 rating decision, the RO denied entitlement to service connection for headaches and depression. August 2007 nursing notes reflect the Veteran's reports of depression and "rages" for weeks or months and that he had been in physical fights with others. He indicated that his brother, who works for VA, told him to get help for his problems. Following an evaluation by a primary care physician, the assessment was depression/symptoms of PTSD/insomnia. Psychotropic medications were prescribed. The impression of a November 2007 VA CT head study was no acute intracranial abnormality. During a January 2008 VA primary care visit, he complained of losing two jobs due to not being able to get along with others. He disclosed that a judge told him earlier in the week that he had an anger management problem. The impression was mood disorder. During a February 2008 mental health assessment, he described current psychiatric complaints, but did not report any memory problems. On mental status examination, his memory was intact for immediate, recent, and remote events. The diagnosis was bipolar I disorder; rule out PTSD. Immediate, recent, and remote memory was also intact on subsequent mental status examinations in April, August, October, and December 2008; and in March, May, August, and November 2009. He did not report memory problems during any of these visits. In a March 2009 addendum, the VA examiner who conducted the July 2005 general medical examination again detailed his review of the claims file, including the previous July 2005 VA examination reports. He opined that the Veteran's complaint of short-term memory loss was not at least as likely as not a result of an undiagnosed illness or an underlying disease or injury. He noted that there was no treatment for memory complaints in the service treatment records and although the Veteran reported difficulty remembering his daughters' names and whether he had a job on VA examination in July 2005, he showed good memory on mental status examination when asked different addresses and names. The examiner also opined that the Veteran's "stomach pains [were] not at least as likely than not related to undiagnosed illness or to an underlying disease or injury." He reasoned that the Veteran was not treated for this condition while in active duty and on VA examination in July 2005 his intermittent, mid-abdominal pain had no pattern or other associated symptoms. A September 2009 VA primary care note included general abdominal pain among a list of prior medical history problems. The Veteran did not describe current abdominal problems. On examination, the abdomen was soft with no tenderness and his weight was 238 pounds. The diagnosis included inguinal discomfort. An October 2009 VA nursing note documents the Veteran's complaint of intermittent abdominal pain for less than two months. He described groin pain the same day to his primary care physician. The impression was suspected inguinal hernia. A few days later in October 2009, he reported that he was informed of a left inguinal hernia during a physical for his job. He denied nausea, vomiting, diarrhea, constipation, or other complaints. The diagnosis was left inguinal hernia and surgery was scheduled for the next week. During an October 2009 preoperative history and physical, he denied abdominal pain. A February 2010 response from the Fort Worth VA Outpatient Clinic indicated that the Veteran had not received treatment other than a February 2003 immunization. A March 2010 response from P. Rutledge, M.D., indicated that the Veteran was last seen in November 1995 and his treatment records had been destroyed. A March 2010 VA mental health note documented intact immediate, recent, and remote memory on mental status examination. The Veteran underwent VA examination in June 2010 to evaluate his claimed memory loss. When asked about his memory problem, the Veteran responded that "it comes and goes. Where I'm supposed to be-like I forgot I was supposed to be here. I have an overseer for my Social Security." He stated that he cannot work with people because he forgets things he is supposed to do, it leads to confrontation, it gets violent, and then others do not want him there. When asked how long his memory had been impaired to such a degree that he could hardly function, he stated that "it got this bad when I was working at the Bureau" in the early 1990s after getting out of the service. The examiner commented that it was noteworthy that in his VA examination five years ago, he described himself as a "good employee and a skilled mechanic." When pressed about this issue, the Veteran then reported that it was only in "the past three to four years" that his memory functioning had been as impaired as it is now. Following a review of the claims file and mental status examination, the diagnosis was cognitive disorder, not otherwise specified (NOS). The examiner indicated that the Veteran was being referred to a neuropsychologist for formal, standardized memory testing. The examiner noted, however, that on the previous mental disorders VA examination five years ago, the examiner believed there were some inconsistencies in the Veteran's report of memory impairment. The examiner added that on the current examination, too, there were some seeming inconsistencies in the Veteran's reporting of his memory problems. Although he said that his memory problems "come and go," he first said that his memory problems were so bad he could hardly function while he was working at the Bureau in the early 1990s. The examiner stated that this was inconsistent with the Veteran's reporting on VA examination in 2005. The Veteran was afforded another VA stomach examination in July 2010 by the same examiner who conducted the July 2005 examination. The examiner indicated that he again reviewed the claims file. The Veteran stated that he had nausea four to five days a week, vomits twice a week, and Mylanta helped without causing side effects. He reported very seldom having stomach pains and occasional left upper quadrant cramping. He denied diarrhea, constipation, melena, or bright red blood in stools. He endorsed having a lot of anxiety. He stated that his appetite was good with no weight changes. He reported that nothing brings on the nausea and vomiting except for stress. On examination, his weight was 210. The abdomen was benign without organomegaly or tenderness, hernias, redness, inflammation, swelling, underlying soft tissue involvement, scaliness, irregularities, atrophic changes, or limitation of function caused by the well-healed scar. The impression of an abdominal radiology report was no evidence of gallstones; nonspecific bowel gas pattern, no soft tissue mass; pelvic phleboliths. The diagnosis was anxiety, which brings on nausea and vomiting; no evidence of any kind of abdominal disorders. The examiner opined that this is less likely than not related to the military since military records were negative for abdominal pains and nausea and vomiting except for sea sickness. The secondary diagnosis was exploratory laparotomy and appendectomy with no residuals and no complaints; no residuals from the scar. The examiner also opined that it was speculative to say that the current stomach disability was related to an undiagnosed illness in Southwest Asia during the Gulf War. The Veteran was afforded a VA neuropsychological examination in July 2010. He stated that "some things I can remember, some things I can't." He reported forgetting what he was talking about during a conversation and forgetting orders or directions given to him. He also described "losing perspective" when working with someone, which he described as forgetting to do things that were asked of him. He described forgetting his children's names, losing words, stumbling through conversations, forgetting doctor appointments, misplacing things around the house, being accused of asking repetitive questions, going into a room only to forget what he needed once he gets there, and getting lost in familiar places. He stated that these cognitive difficulties likely started in 2002 and since then have gotten "way worse." In addition to reviewing the claims file and conducting a clinical interview, the neuropsychologist administered five standardized neuropsychological tests. The examiner indicated that the Veteran's effort and motivation was objectively assessed and his performance on this measure demonstrated poor effort and motivation at a level that was below chance. As a result, a reliable and valid assessment of his current cognitive abilities could not be completed. The examiner summarized that despite the Veteran's concern about his memory functioning since 2002 and that it had become "way worse" since then, he had not mentioned his memory difficulties to other providers, including his nurse practitioner in Mental Health that he had been seeing since 2008. The examiner opined that given the inconsistencies noted during this and other evaluations, the reported memory difficulties were less likely than not related to military service. The Veteran was afforded another VA stomach examination in September 2011. He reported daily nausea and right and left upper quadrant sharp abdominal pain that began in 1991. He stated that he had been taking Mylanta since 1991 and it helps his symptoms slightly. He denied any weight loss. Following a review of the claims file and physical examination, the examiner indicated there were no signs or symptoms of a stomach disorder and no stomach disorder was diagnosed. In September 2011, he was afforded another VA examination to assess his memory function. The neuropsychologist indicated that she reviewed the claims file. The examiner indicated that at the time of the evaluation, the Veteran was alert and oriented to person, place, time, and situation. Prior to any cognitive testing, effort testing was administered to ensure that he was putting forth adequate effort on any subsequent cognitive assessment. He was administered a test of effort and scored below the cut-off, indicating reduced efforts. The examiner noted that the Veteran had also scored below the cut-off on effort testing with a different neuropsychologist in July 2010. She explained that when tests of effort are low, it is indicative that the patient is not putting forth good effort, and any cognitive assessment administered could not be reliably interpreted. As in the case of attempted neuropsychological evaluation in 2010, resulting poor effort on the current assessment did not allow for any further cognitive testing, as any results obtained would be considered invalid and unreliable. The examiner added that although there may be a number of reasons for such reduced effort, the presence of malingering should be strongly considered. Records associated with the Veteran's claim for SSA disability benefits were received in November 2012. In his 2009 application, he claimed disability based on "bipolar/PTSD" and provided information about seven jobs he had held between November 1992 and December 2005, including the dates of employment, job title, type of business, hours worked per day, number of days per week, and rate of pay. He was determined to be disabled for SSA purposes based on the primary diagnosis of bipolar disorder and secondary diagnosis of PTSD. VA treatment records dated from March 2011 to November 2012 document intact memory on examinations in August 2011 and in February, June, August, and September 2012. The records did not reflect complaints, findings, diagnosis, or treatment for stomach or memory problems. As explained above, VA treatment records dated from December 2012 to May 2013, which are associated with the Virtual VA claims file, are not relevant to the issues on appeal because they reflect no complaints or findings of stomach problems and because though they reflect treatment for mental disorders and a May 2012 spinal cord injury resulting in tetraplegia, they contain no complaints or findings of memory loss. In February 2013, a VA psychologist reviewed the Veteran's claims file, including prior examination reports and treatment records, to determine whether the Veteran had a memory disorder or undiagnosed illness manifested by memory loss related to his military service. The psychologist opined that based upon thorough review of the claims file and the Veteran's VA treatment records, there is no indication of memory impairment. She noted that the Veteran was the historian for his evaluations providing details of his past and demonstrating no impairment negotiating his way around the clinic to and from the parking lot. The psychologist also reasoned that there had been two attempts to conduct VA neuropsychological evaluations to determine the presence of a memory deficit. In both cases the effort testing indicated in-depth cognitive testing would be invalid due to reduced effort. Based on this information, the psychologist concluded that there was no evidence of a memory impairment. In June 2013, a VA physician reviewed the Veteran's claims file and opined that it was less likely than not that the Veteran's claimed stomach disorder was incurred in, caused by, or aggravated by his time in military service. Supporting her conclusion, the physician observed that numerous studies and examinations to evaluate the claimed gastric condition did not find clinical evidence to support the Veteran's claimed gastric condition, including the [1997] laparoscopic procedure resulting in an appendectomy, 2005 VA examination, July 2010 radiographs, and the [January 2005] ultrasound visceral study. The Board has considered the medical and lay evidence of record and finds that the preponderance of the evidence is against the Veteran's claims of service connection for stomach or memory disorders, including an undiagnosed illness manifested by stomach pain or memory loss. Initially, the Board acknowledges that the Veteran is competent to describe symptoms he experiences related to his claimed disabilities such as abdominal pain and memory loss. See Barr v. Nicholson, 21 Vet. App. 303 (2007). As a lay person, however, the Veteran is not competent to provide a medical diagnosis regarding a chronic stomach or memory disorder as such matters require medical testing and expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Thus, the Board accords significantly greater probative value to the medical evidence of record than to the lay assertions of the Veteran or his family members on these points. In this case, the Board finds that service connection for a stomach disorder or a memory disorder is not warranted because there is no evidence of a current stomach or memory disability. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110, 1131. Where, as here, the claims file is void of any competent medical evidence establishing that the Veteran currently has a stomach disability or a memory loss disability, the conditions for which service connection is sought are not established, and thus, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board also finds that service connection is not warranted for either of the claimed disabilities due to undiagnosed illness or a medically unexplained chronic multi-symptom illness as a result of service in the Southwest Asia Theater during the Persian Gulf War because the medical evidence of record does not reflect objective indications of chronic disability, which includes "signs" or "objective evidence perceptible to an examining physician." See 38 C.F.R. § 3.317(a)(3). Regarding a claimed stomach disorder, despite the Veteran's subjective complaints of stomach problems or pain made in the course of seeking medical treatment in the 1990s and in January 2005, clinical, surgical, and radiological evaluations failed to reveal objective indications of chronic disability, and his October 2009 complaint of abdominal pain and groin pain was attributed to a left inguinal hernia. In addition, the Board finds that the June 2013 VA medical opinion is persuasive and probative evidence against the claim for service connection for a stomach disability because it was based on a thorough review of the claims file, including prior VA examinations and VA and private treatment records, and was supported by an articulated medical explanation that is consistent with the remaining record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value to a medical opinion). Again, the Veteran was not shown to have a diagnosed stomach disability; or an undiagnosed illness manifested by stomach pain due to any environmental hazard during Persian Gulf service. Moreover, to the extent that the July 2010 VA examiner diagnosed "anxiety, which brings on nausea and vomiting" with "no evidence of any kind of other abdominal disorders," the Board finds that service connection for a stomach disability secondary to an anxiety disorder is not warranted. Here, service treatment records are silent for complaints, findings, diagnosis, or treatment for anxiety or other psychiatric symptoms, and the RO denied service connection for depression in an April 2006 rating decision and service connection for PTSD in a January 2009 rating decision. Therefore, because service connection for an anxiety disorder is not in effect and because active duty and Naval Reserve reports of medical history reflect that the Veteran explicitly denied ever having depression or excessive worry, or nervous trouble of any sort, service connection for a stomach disability, which is not confirmed by objective "signs," is not warranted on a secondary basis. See 38 C.F.R. § 3.310. Similarly, the Board notes that despite the Veteran's subjective complaints of memory loss, which were made in the course of seeking VA compensation benefits but not during his numerous visits with mental health professionals, memory impairment was not shown on VA examinations or during VA treatment for mental health problems. Moreover, VA twice attempted to provide neuropsychological testing to obtain formal testing data regarding the claimed memory loss, but testing could not be completed on either occasion because the Veteran did not put forth adequate effort. The Court has held that VA's duty to assist the veteran in developing the facts and evidence pertinent to a veteran's claim is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Finally, the Board finds that the opinions of the July 2010 VA neuropsychologist and the February 2013 VA psychologist are persuasive and probative evidence against the claim of service connection for a memory disorder because they were based on a review of the claims file, including previous VA examination reports and treatment records, neuropsychological evaluation (in July 2010), and supported by an articulated medical explanation that was consistent with the remaining record. See Nieves-Rodriguez, 22 Vet. App. at 302-04. Again, contrary to the Veteran's subjective reports of memory loss, he has demonstrated intact memory functioning as described in the July 2005 VA examination report, in reporting his work history on his SSA application, and during regular VA mental status examinations. In summary, the Veteran is not shown to have a current stomach or memory disability or shown to exhibit objective indications of a qualifying chronic disability involving the stomach or memory loss. Under these circumstances, the Board is unable to find that there is a state of equipoise of the positive and negative evidence, and the claims must be denied. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Entitlement to service connection for a stomach disorder is denied. Entitlement to service connection for a memory disorder is denied. ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs