Citation Nr: 1337139 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 96-23 563 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a sleep disorder, to include as due to undiagnosed illness. 2. Entitlement to service connection for a skin disorder, to include as due to undiagnosed illness. 3. Entitlement to service connection for thyroid disorder/trembling/fatigability, to include as due to undiagnosed illness. 4. Entitlement to service connection for a lung disorder/allergies, to include as due to undiagnosed illness. 5. Entitlement to service connection for a hiatal hernia, to include as due to undiagnosed illness. 6. Entitlement to service connection for arthritis of multiple joints (hips, ankles, elbows, and knees), to include as due to undiagnosed illness. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD A. Haddock, Associate Counsel INTRODUCTION The Veteran had active service from October 1968 to September 1979 and from November 1990 to March 1991; with service in Southwest Asia. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 1995 rating decision by the Montgomery, Alabama Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in April 2000, October 2002, July 2009, May 2012, and most recently in November 2012 when it was remanded for further development. The Board notes that in 2002, the Veteran's claims files were misplaced and later rebuilt. However, it appears that at this time, his original claims files have been located and are available for review. The Board notes that in his July 1993 claim for service connection, the Veteran claimed entitlement to service connection for a sleep disorder. Based on evidence of record, the RO determined that the Veteran's sleep disorder had been diagnosed as sleep apnea, and in the June 1995 rating decision, and numerous adjudications since, including the most recent August 2013 supplemental statement of the case (SSOC), he was denied service connection for sleep apnea. However, the Veteran has consistently asserted that he is not seeking service connection for sleep apnea, but that since his separation form active service in 1991, he has been treated for sleep disorders separate and distinct from sleep apnea that he alleges were caused by his service in Southwest Asia. As such, the Board has limited its consideration accordingly, to exclude the Veteran's sporadic diagnoses of obstructive sleep apnea. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a complete review of the evidence. It appears that the issues of entitlement to service connection for memory loss, headaches, sexual dysfunction, night sweats, bowel problems, all as due to an undiagnosed illness, are raised by the record in an August 1996 statement submitted by the Veteran, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action (if needed). The issues of entitlement to service connection for a sleep disorder, hypothyroidism, a lung disorder/allergies, and arthritis of multiple joints; to include as due to undiagnosed illness, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A skin disorder did not initially manifest during the Veteran's active military service, and the preponderance of the evidence weight against finding a relationship or correlation between such a condition and his Persian Gulf war service or immunization injections. 2. A hiatal hernia did not initially manifest during the Veteran's active military service, and the preponderance of the evidence weighs against finding a relationship or correlation between such a condition and his Persian Gulf War service or immunization injections. CONCLUSIONS OF LAW 1. The criteria for service connection for a skin disorder, to include as due to undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2013). 2. The criteria for service connection for a hiatal hernia, to include as due to undiagnosed illness, have not been met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the claims folders. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to these claims. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Compensation may be paid to any Persian Gulf War veteran "suffering from a chronic disability resulting from an undiagnosed illness (or combination of undiagnosed illnesses)." 38 U.S.C.A. § 1117. These may include, but are not limited to, fatigue headache, and joint pain. 38 C.F.R. § 3.317(b). Such chronic disability must have manifested either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more no later than December 31, 2016, and must not be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. 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. A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms such as: (1) chronic fatigue syndrome (CFS); (2) fibromyalgia; (3) irritable bowel syndrome (IBS); or (4) 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; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). Accordingly, under these regulations service connection may be granted on a presumptive basis if there is evidence (1) that the claimant is a Persian Gulf veteran; (2) who exhibits objective indications of chronic disability resulting from an undiagnosed illness, a medically unexplained chronic multi-symptom illness (such as CFS, fibromyalgia, or IBS) that is defined by a cluster of signs or symptoms, or resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) which became manifest either during active military, naval, or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016; and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. §§ 1117, 1118; 38 C.F.R. § 3.317; 76 Fed. Reg. 81,834, 81,835 (interim final rule December 29, 2011). In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. See 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 an 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). If signs or symptoms have been attributed to a known clinical diagnosis, service connection may not be established under the specific provisions applicable to Persian Gulf War Veterans. See VAOPGCPREC 8-98 at paragraphs 4-5 (Aug. 3, 1998). Of course, service connection for a diagnosed illness still may be established if otherwise warranted under VA law. See generally Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). In reviewing the evidence, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage v. Gober, 10 Vet. App. 488, 496 (1997), citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). Lay 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). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F .3d 1331, 1337 (Fed.Cir.2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept 14, 2009). In evaluating a claim, the Board's duty is to assess the credibility and probative weight of the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran seeks service connection for a skin disorder and a lung disorder and/or allergies, claimed as due to an undiagnosed illness. The Veteran's DD Form 214 shows that he had service in Southwest Asia from December 1990 to January 1991 in support of Operation Desert Shield. Thus for the purposes of this decision, the Board concedes that the Veteran had qualifying service in the Southwest Asia theater of operations as defined by 38 C.F.R. § 3.317. A review of the Veteran's STRs shows that on a November 1991 Report of Medical History, associated with a quadrennial Army Reserve examination, the Veteran denied any history of skin disease, stomach, liver, or intestinal trouble, and rupture/hernia. Of record are numerous private, and VA treatment records, as well as several VA examinations. As the relevant documents are dated from 1989 through 2013, for organizational purposes, the Board will discuss the evidence in date order, with the earliest evidence listed first. Private treatment records show that, in August 1992, the Veteran reported he was having some chest pain and he was unsure if it was caused by stress. The Veteran's physician prescribed nitroglycerin for esophageal spasm on a clinical basis and it was noted that further evaluation by a gastroenterologist my be necessary. In September 1992, the Veteran reported that the nitroglycerin had provided some relief, but he was still having mild reflux symptoms. The Veteran was referred for a gastroenterology consultation. A November 1992 private treatment record shows that the Veteran was seen for complaints of a rash on his arm, which was noted to be an allergic reaction. In April 1993, the Veteran was afforded a Persian Gulf War examination. At that time he reported symptoms of skin burning. There was no finding or diagnosis made to account for such symptoms, and no opinion as to the etiology of his symptoms was provided. The Veteran did not report any symptoms, or diagnosis, of a hiatal hernia or reflux. In March 1994, the Veteran was afforded a VA examination. At which time he reported a history of hiatal hernia with reflux and episodic symptoms. After examination, reflux esophagitis with hiatal hernia was noted; mild symptoms of which were documented. There was no opinion as to etiology provided. The Veteran did not report any symptoms of a skin disorder, nor were such symptoms found on examination. There was no diagnosis made related to a skin disorder. In February 1995, the Veteran was afforded another Persian Gulf War examination. The examination report, and an accompanying Persian Gulf War Registry Medical History sheet, reflects the reports of his various medical conditions which he attributed to his service in Southwest Asia. He reported that he had recently been given a diagnosis of rosacea on his face and upper trunk. He reported that he had been using homeopathic therapies for his rosacea, with marked improvement. It was noted that the physical examination conducted in conjunction with the report, was unremarkable. There were no findings made or opinions provided as to etiology of the Veteran's reported rosacea. There were no reports or findings as to a hiatal hernia. In a November 1997 letter, Dr. P.A. noted that the Veteran had tested positive for antibodies to squalene, a synthetic vaccine adjuvant. In her letter, Dr. P.A. indicated that she had discussed with the Veteran that squalene was known to induce nonspecific atypical autoimmune disease, causing symptoms unique to each patient, but which typically included arthralgias, myalgia, chronic fatigue, chronic headaches, rashes, photosensitive rashes, low grade fevers of unknown origin, gastrointestinal problems, and others. Dr. P.A. advised the Veteran to follow up with his primary care physician. In April 1999, the Veteran was afforded another VA examination. At that time he reported that his symptoms began after receiving an immunization prior to his deployment to Southwest Asia. The examiner noted that the Veteran presented with a rash, which by history had been termed as folliculitis. It was noted that he had some acne-form lesions over his forehead and facial area, as well as over his shoulder and back. The examiner noted that they were moderately disfiguring and were consistent with a seborrheic type of dermatitis. The examiner did not provide an etiology opinion for the Veteran's dermatitis, but did note that there were no dermatological biopsy reports in his claims file. Further, the examiner diagnosed a hiatal hernia, by history, but noted that the Veteran had no symptoms at the time of examination. An etiology opinion for the hiatal hernia was not provided. In July 2012, a medical opinion was obtained by VA from an independent medical expert in the field of internal medicine, Dr. M.K. from Beverly Hospital in New Jersey, as to whether the Veteran's various claimed medical conditions could have resulted from an immunization he received prior to his deployment to Southwest Asia. Specifically, Dr. M.K. was asked to opine whether it was possible to determine whether the Veteran had received an immunization continuing squalene, and if so to what extent could the Veteran's claimed medical conditions have resulted from, or be related to, any such immunization. Dr. M.K. was also asked to comment on studies submitted by the Veteran suggesting a correlation between squalene antibodies and the presence of signs and symptoms of Gulf War Syndrome and the significance of the November 1997 letter from Dr. P.A. indicating the Veteran had tested positive for the squalene antibody. In his July 2012 opinion, Dr. M.K. discussed the study conducted by Dr. P.A. which linked the incidence of the anti-squalene antibodies and Gulf War Syndrome; however he found it not at least as likely as not that the Veteran received an immunization containing squalene, and that the Veteran's reported symptoms resulted from any such immunization. Dr. M.K. based his opinion on various studies conducted by organizations such as the Food and Drug Administration, the World Health Organization, and the Department of Defense, among others, that showed squalene was a naturally occurring substance in the human body and that since 1997 it had been used in over 22 million flu vaccinations in Europe without any evidence of significant vaccine related adverse events. He also referenced studies that showed squalene antibodies were no more common in Gulf war Veterans than in the general population and that one in ten people had squalene antibodies in their body. With regard to the Veteran's reported conditions on appeal, Dr. M.K. provided no discussion specific to the Veteran's skin disorder or hiatal hernia in his opinion. In May 2013, the Veteran was afforded VA examinations of his skin disorder and esophageal condition. On May 2013 VA skin examination, the Veteran reported that while on active service, he had pimples on his upper chest, back, and sometimes his thighs, which he associated with poor digestion. He reported that when his digestion improved, his skin cleared up. He reported that he had acne when he was young, but that it started again following his service in Southwest Asia. After examination, superficial acne, affecting areas other than his face and neck, was diagnosed. No opinion as to etiology was provided. On May 2013 VA esophageal condition examination, the Veteran reported that he had been given a diagnosis of a hiatal hernia after an esophagogastroduodenoscopy (EGD) in 1992. He reported that he believed the onset of his hiatal hernia was when he began to have central chest pain in January 1991 while in Southwest Asia. He reported that during his active service, in 1991, when he complained of chest pain he was assessed with pleurisy, but that the pain continued. The examiner reviewed the treatment note in question, and noted that the complaints noted clearly indicated a chest wall/pleura condition rather than a GI problem. The examiner reviewed additional STRs, which showed that he had a complaint of chest pain during a reserve quadrennial examination in April 1986, which was attributed to stress; and the above referenced a [January] 1991 complaint of chest pain in the upper and mid chest, accompanied by complaints of an upper respiratory infection and a productive cough. [The Board notes that the VA examiner mistakenly noted the date of the January 1991 treatment record as June 1991.] After examination, the Veteran was given a diagnosis of gastroesophageal reflux disease and a hiatal hernia. No opinion as to etiology was provided. In an August 2013 VA Gulf War examination, the examiner reviewed the Veteran's various May 2013 VA examination and his claims files, and opined that there was no clinical evidence that the Veteran's acne skin condition or hiatal hernia and GERD were incurred during active service; or were manifest to a compensable degree during his active service or within one year of active service. Also of record are numerous lay statements from the Veteran, as well as his spouse and several of his friends, made in support of the Veteran's claim. The Veteran has consistently asserted that prior to his deployment to Southwest Asia he was well and healthy, and that after his return he developed a host of medical problems, including the conditions claimed herein. The Veteran's spouse, in her various statements in support of the Veteran's claim, has reiterated his assertions that after returning from Southwest Asia, his health was not as good as it was prior. In several buddy statements, many of the Veteran's friends, all of whom had know the Veteran for many years and some who were members of his former Army Reserve Unit, stated that they had always known the Veteran to be in very good health and physical condition prior to the Persian Gulf war, but that immediately following his deployment, and for several years afterward, the Veteran's health drastically suffered, and he was not the same man. At the outset, the Board notes that the Veteran's skin condition, which has been variously diagnosed as rosacea, seborrheic dermatitis, and acne; and his hiatal hernia with reflux; are attributed to known clinical diagnoses and, thus, ineligible for service connection under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 based on his Persian Gulf War service. What remains for consideration, is whether the Veteran's claimed disabilities can otherwise be related to the Veteran's active service. To the extent that the Veteran has attempted to claim that his current skin disorder and his hiatal hernia had their onset in service and it has continued since, the Board finds that the preponderance of the evidence is against the Veteran's claim. In this regard, the Board notes that not only is there no evidence that the Veteran was treated for any skin problems or symptoms attributable to a hiatal hernia while on active service, but the Veteran specifically denied experiencing any skin problems or stomach, liver, or intestinal trouble and rupture or hernia in a report of medical history associated with an August 1991 Army Reserve promotion examination, providing fatual evidence against this own claims. As such, service connection for such disabilities on the basis that such became manifest in service, and continued since, is not warranted. Further, there is only one documented instance showing that the Veteran received treatment for a skin problem following his separation from active service, in November 1992 when he was noted to have an allergic reaction rash on his arm. The Board notes that the Veteran reported symptoms of skin burning at his April 1992 VA Gulf war examination; however, no diagnosis was made at that time. There is no evidence that the Veteran was diagnosed with a skin disorder until February 1995, when he reported at a VA examination that he had been diagnosed with rosacea of the face and neck, but that it was responding well to treatment. The Veteran was later diagnosed with seborrheic dermatitis at his April 1999 VA examination, but there was no etiology opinion provided at that time. At his May 2013 VA examination, the Veteran was diagnosed with acne, and an August 2013 VA opinion stated that his acne was not related to his active service, as there was no clinical evidence showing service incurrence. The Board notes that the claims files do not contain a record of when the Veteran was officially diagnosed with a hiatal hernia. However, private treatment records show that in August 1992 he complained of chest pain, at which time he was prescribed nitroglycerin for esophageal spasm, and after reporting that the nitroglycerin had provided some relief in September 1992, he was referred for a gastroenterology consultation. Based on this medical evidence, it can be assumed that the Veteran's hiatal hernia was present at the time of his August 1992 visit to his private physician. The Veteran reported his diagnosed hiatal hernia at his March 1994 and April 1999 VA examinations; however, etiology opinions were not provided at those times, which only provides more evidence against this claim. Based on the above evidence, the Board concludes that the contemporaneous medical evidence, which shows that the Veteran denied any history of skin problems in August 1991, five months after separation from active service, and was not diagnosed with a skin disability until 1994, three years after active service tends to weigh against the claim. The only competent (medical) evidence in the record that addresses the issue of whether the Veteran's skin disability is related to his active service is the report from the August 2013 VA examination, when the examiner opined that the Veteran's skin disability were not related to his active service. The examiner explained that there was simply no clinical evidence suggesting his skin disability was incurred during active service. As there is no contrary opinion of record, the Board has found the August 2013 opinion to be persuasive. With regard to the Veteran's hiatal hernia with reflux, the only competent (medical) evidence in the record as to whether the Veteran's diagnosed hiatal hernia with reflux is related to his active service is the report from the August 2013 VA examination, when the examiner opined that there was no clinical evidence showing that the Veteran's hiatal hernia was incurred during active service, or that such disability became manifest within one year of the Veteran's separation from active service. As there is no contrary medical opinion of record, the Board has found this opinion persuasive. The Board acknowledges the Veteran's statements that it is his contention that his hiatal hernia first became manifest in January 1991, when he complained of chest pain while deployed in Southwest Asia, and that he was misdiagnosed with pleurisy; however, the evidence weighs against this assertion. Specifically, the Board notes that the Veteran relayed this belief to the May 2013 VA examiner, who after a review of the Veteran's January 1991 STR, indicated that the treatment note indicated a chest wall/pleura condition and not a GI problem. While the Board notes that the Veteran is competent to report when his symptoms began, whether his hiatal hernia began during active service, and specifically whether it was the cause of chest pain in January 1991, is a medical question not capable of resolution by mere lay observation; it requires medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, the Veteran's expressions of his belief that his hiatal hernia began during active service, but was misdiagnosed as pleurisy, do not merit any substantial probative value. It is of limited probative weight. Further, the Board acknowledges that Veteran's statements that his skin disorder and hiatal hernia with reflux are related to his active service, to include an immunization he received during his second period of active service. The Board notes that of record is an independent medical opinion that competently opines that the immunization the Veteran received did not contain squalene, or that it was responsible for his claimed conditions, as the Veteran has alleged. However, the Board will address the Veteran's lay statements. Essentially, the Veteran has offered his opinion as to the etiology of his claimed disabilities; however, he has not demonstrated that he has any knowledge or training in determining the etiology of such conditions. In other words, he is a layman, not a medical expert. The Board recognizes that there is no bright line rule that laypersons are not competent to offer etiology opinions. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (rejecting the view that competent medical evidence is necessarily required when the determinative issue is medical diagnosis or etiology). Evidence, however, must be competent evidence in order to be weighed by the Board. Whether a layperson is competent to provide an opinion as to the etiology of a condition depends on the facts of the particular case. In Davidson, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) drew support from Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) for support for its holding. Id. In a footnote in Jandreau, the Federal Circuit addressed whether a layperson could provide evidence regarding a diagnosis of a condition and explained that "[s]ometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Veteran seeks to offer etiology opinions rather than provide diagnoses, the reasoning expressed in Jandreau is applicable. The Board finds that the question of whether the Veteran currently has a skin disorder and a hiatal hernia with reflux due to his active service, to include as due to an immunization received in service, is too complex to be addressed by a layperson. This connection or etiology is not amenable to observation alone. Rather it is common knowledge that such relationships are the subject of extensive research by scientific and medical professionals. Hence, the Veteran's opinion of the etiology of his current disabilities, however sincere, is not competent evidence and is entitled to low probative weight. In sum, the Veteran's skin disorder and hiatal hernia, have been attributed to known clinical diagnoses and do not warrant service connection under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 based on his Persian Gulf War service; the competent (medical) evidence of record shows that there is no clinical evidence establishing that the Veteran's skin disorder or hiatal hernia were incurred during active service; and the evidence of record does not support the Veteran's assertions that his skin disorder and hiatal hernia were caused by, or related to an immunization he received during his active service. Based on the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a skin disorder and hiatal hernia with reflux. Consequently, the benefit-of-the-doubt rule does not apply and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002). Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the required notice should be furnished prior to the issuance of the appealed rating decision, any initial errors of notice will not be prejudicial if: (1) corrective actions (e.g., issuance of a post-adjudication notice letter containing the required information) are taken, and (2) the appeal is readjudicated (e.g., in a Supplemental Statement of the Case). See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Here, the VCAA duty to notify was satisfied by way of numerous letters sent to the Veteran in August 1996, January 2010, December 2012, January 2013, and March 2013. These letters informed the Veteran of what evidence is required to substantiate his claim and of his and VA's respective duties for obtaining evidence. The Veteran was also informed of how VA assigns disability ratings and effective dates. VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished and therefore appellate review of the claim addressed above may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records (STRs) and pertinent postservice VA and private treatment records. Further, the Veteran has been afforded numerous VA examinations. Most recently, in May 2013 in accordance with the Board's November 2012 remand, the Veteran was afforded a VA examination of the skin and of his esophageal condition and an August 2013 VA addendum opinion was obtained. The Board notes that the May 2013 VA examinations were conducted after a full reading of the Veteran's claims files and the August 2013 addendum opinion provides an explanation of rationale. Under these circumstances, the Board finds these examinations and the opinions are adequate and that there has been substantial compliance with the November 2012 remand instructions, and an additional remand to comply with the Board's directives is not required. See Barr v. Nicholson, 21 Vet. App. 303 (2007); D'Aries v. Peake, 22 Vet. App. 97, 104-106 (2008); Stegall v. West, 11 Vet. App. 268 (1998). Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, 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 in the development of his 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). ORDER Entitlement to service connection for a skin disorder, to include as due to undiagnosed illness, is denied. Entitlement to service connection for a hiatal hernia, to include as due to undiagnosed illness, is denied. REMAND The Board finds that additional development is needed before the Veteran's remaining claims on appeal are decided. The Veteran has claimed entitlement to service connection for a sleep disorder and the Board notes that the Veteran has been diagnosed with various sleep disorders, including sleep apnea, nocturnal myoclonus, alpha intrusions, and idiopathic hypersomnia. As noted above in the introduction, the Veteran has consistently asserted that he is not claiming entitlement to service connection for "sleep apnea", yet the only VA medical opinions of record deal with "sleep apnea". As such, the Board finds that a new VA examination is warranted to determine if the any of the Veteran's diagnosed sleep disorders, to exclude sleep apnea, are etiologically related to his active service, to include as due to an undiagnosed illness. In this regard, the Board notes that of record is a July 1995 letter from the Veteran's private physician, which states that the Veteran's symptoms of fragmented sleep and daytime sleepiness are symptoms associated with Desert Storm Syndrome. Such letter should be addressed on remand. With regard to the Veteran's claim of entitlement to service connection for a thyroid disorder/trembling/fatigability, the Board notes that while on active service in January 1991, the Veteran was treated for an episode of trembling, fatigue, and other symptoms, which was attributed to a psychiatric disorder. The Veteran asserts that following his return from Southwest Asia, he continued to experience symptoms of trembling and severe fatigue, which was noted by his private physician in a June 1992 letter. Further, while being treated for a psychiatric disorder on active service in February 1991, the Veteran was afforded routine laboratory testing. A treatment record shows that thyroid T3 uptake was 35, Thyroxin was 4.6 and FTI [free thyroid index] was 1.6. Post service laboratory testing in August and December 1991, shows that the Veteran's thyroid levels were abnormal. The Veteran was diagnosed with hypothyroidism in September 1992. The Board notes that in a July 2013 opinion, a VA examiner opined that there was no clinical evidence showing an incurrence of a thyroid disorder during active service, particularly since the Veteran had not been diagnosed with hypothyroidism until September 19992. However, the VA examiner did not address the August 1991 and December 1991 findings of abnormal thyroid levels, merely less than 6 months following separation from active service. Further, there is no indication whether the thyroid levels noted in February 1991, during active service, were normal or abnormal, and as the Board is certainly not qualified to make such a finding, the Board finds that a new VA examination is warranted. With regard to the Veteran's claim of service connection for a lung disorder/allergies, the Board notes that the March 1978 STR, submitted by the Veteran, shows that at that time he had a diagnosis of chronic sinusitis. Further, a January 1991 STR shows that while serving in Southwest Asia, the Veteran was noted to have a history of chronic bronchitis, and he complained at that time of trouble breathing due to the dust storms, as well as symptoms of an upper respiratory infection. There are several private treatment records associated with the claims file that show the Veteran received treatment, both before and after his service in Southwest Asia, for episodes of sinusitis and bronchitis. The Veteran was afforded a VA examination in May 2013, at which time he was diagnosed with asthma and chronic obstructive pulmonary disease (COPD). In an August 2013 VA opinion, the examiner opined that there was no clinical evidence that the Veteran's asthma or COPD were incurred in active service. However, the August 2013 VA opinion does not discuss any possible relationship between the Veterans history of chronic sinusitis and chronic bronchitis to his currently diagnosed asthma and COPD. Further, there is no opinion of record that discusses the etiology of the Veteran's chronic sinusitis and chronic bronchitis. As such opinions are necessary in order to decide the Veteran's claim of entitlement to service connection for a lung disorder/allergies, this matter must be remanded for a new VA examination. Finally, the Board notes that the Veteran has alleged that he was first diagnosed with arthritis in multiple joints in March 1978, during his first period of active service. Of record is a March 1978 report of medical history that appears to have at one time been associated with a promotion examination. This document notes that the Veteran reported a history of swollen or painful joints, and it is noted that he had pain in his left knee and hip, but no swelling. The Board notes that the Veteran's STRs from his first period of active service are not currently associated with the claims file; nor is there a memorandum to the file indicating such records are unavailable. As these records may contain information pertinent to the Veteran's claim of entitlement to service connection for arthritis of multiple joints, they must be obtained and associated with the claims file. Further, the Board finds that on remand, current private and VA treatment records should be obtained and associated with the claims file. Accordingly, the case is REMANDED for the following action: 1. The RO or AMC should obtain the Veteran's service treatment record from his first period of active service, from October 1968 to September 1979, and associate them with the claims file. 2. The RO or AMC should ask the Veteran to identify all providers of evaluation or treatment he has received for arthritis, variously diagnosed lung condition, thyroid disorder, and variously diagnosed sleep disorder, and to provide releases for VA to obtain records of any such identified evaluations and treatment. The RO should attempt to secure for the record copies of the complete clinical records from all providers identified. If any identified private provider does not respond to the RO's or AMC's request for records, the Veteran must be so advised, and reminded that ultimately it is his responsibility to ensure that private medical records are received. 3. Then, the Veteran should be afforded a VA examination with an examiner with sufficient expertise to determine the nature and etiology of the variously diagnosed sleep disorder (if any). The claims file must be made available to and reviewed by the examiner. All tests and studies deemed necessary by the examiner should be performed. After examination and review of the claims file, the examiner should opine as to whether it is at least as likely as not (a 50 percent or better probability) that any diagnosed sleep disorder, to exclude sleep apnea, is etiologically related to the Veteran's active service, to specifically include whether they are related to his service in the Persian Gulf and/or undiagnosed illness resulting from such. If no sleep disorder is diagnosed, the examiner should opine whether it is at least as likely as not (a 50 percent or better probability) that the Veteran's reported sleep impairment symptoms (not attributable to any diagnosed sleep apnea - if any) are related to the Veteran's active service, to specifically include whether they are related to his service in the Persian Gulf and/or undiagnosed illness resulting from such. The complete rationale for all opinions expressed must be provided. The examiner should specifically address the July 1995 letter from the Veteran's private physician relating his sleep disorders to his Gulf war service. 4. The Veteran should be afforded a VA examination with an examiner with sufficient expertise to determine the nature and etiology of the Veteran's variously diagnosed lung condition and allergies. The claims file must be made available to and reviewed by the examiner. All tests and studies deemed necessary by the examiner should be performed. After examination and review of the claims file, the examiner should opine as to whether it is at least as likely as not (a 50 percent or better probability) that any diagnosed lung condition or allergies is etiologically related to the Veteran's active service (either his period of active service from October 1968 to September 1979 or his active service from November 1990 to March 1991). The examiner is asked to specifically address the March 1978 record which notes that the Veteran had a history of chronic sinusitis and the January 1991 STR noting he suffered from chronic bronchitis 5. The Veteran should be afforded a VA examination with an examiner with sufficient expertise to determine the nature and etiology of the Veteran's thyroid disorder/trembling/fatigability. The claims file must be made available to and reviewed by the examiner. All tests and studies deemed necessary by the examiner should be performed. After examination and review of the claims file the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or better probability) that any currently diagnosed thyroid disorder is etiologically related to the Veteran's active service. The examiner should specifically address the thyroid function test results reported in February 1991, August 1991, and December 1991. Further, if symptoms of trembling and fatigue are shown on examination, and are not shown to be manifestations of the Veteran's thyroid disorder, the examiner is asked to opine as to whether it is at least as likely as not (a 50 percent or better probability) that such symptoms are etiologically related to the Veteran's active service, to specifically include whether they are related to his service in the Persian Gulf and/or undiagnosed illness resulting from such. The supporting rationale for all opinions expressed must be provided. 6. the Veteran should be afforded a VA examination with an examiner with sufficient expertise to determine the nature and etiology of any currently present arthritis of the joints. The claims file must be made available to and reviewed by the examiner. All tests and studies deemed necessary by the examiner should be performed. After examination and review of the claims file, the examiner should opine as to whether it is at least as likely as not (a 50 percent or better probability) that any diagnosed arthritis of any joint is etiologically related to the Veteran's active service (either his period of active service from October 1968 to September 1979 or his active service from November 1990 to March 1991). For any joint pain found not to be related to a diagnosed disability, to include arthritis, the examiner should opine as to whether it is at least as likely as not (a 50 percent or better probability) that such joint pain is etiologically related to the Veteran's active service, to specifically include whether they are related to his service in the Persian Gulf and/or undiagnosed illness resulting from such. The complete rationale for all opinions expressed must be provided. The examiner is asked to specifically comment on the Veteran's statements that he was diagnosed with arthritis of multiple joints in March 1978, as well as the March 1978 report of medical history noting his reported history of swollen joints and left knee and hip pain. 7. The RO or the AMC should undertake any other development it determines to be warranted. This is complex case. The RO/AMC should insure that all development requested be undertaken. 8. The RO or the AMC should ensure that all development sought is completed, and then re-adjudicate the claim. If the benefits sought remain denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order for further review. The appellant has the right to submit additional evidence and argument on matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs