Citation Nr: 1339212 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 00-20 817A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a low back disability, including as due to an undiagnosed illness as a result of Persian Gulf War service. 2. Entitlement to service connection for a chronic gastrointestinal disability, claimed as gastroenteritis, including as due to an undiagnosed illness as a result of Persian Gulf War service. 3. Entitlement to service connection for night sweats, including as due to an undiagnosed illness as a result of Persian Gulf War service. 4. Entitlement to service connection for memory loss, including as due to an undiagnosed illness as a result of Persian Gulf War service. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Layton, Counsel INTRODUCTION The Veteran served in the United States Army from August 1987 to February 1992, including a period of time in Southwest Asia from October 1990 to March 1991 with the 18th Airborne as a missile crew member. This case comes before the Board of Veterans' Appeals (Board) on appeal from a January 1999 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which, inter alia, denied service connection for gastroenteritis, night sweats, memory loss, and a back condition. The Veteran's original claims sought service connection for, among other things, a respiratory condition and joint pains, to include knee pains. In April 2011, the RO granted service connection for asthma, evaluated as 10 percent disabling effective January 9, 1998. Later, in June 2013, the Appeals Management Center granted service connection for right and left knee patellofemoral syndrome, each knee evaluated as 10 percent disabling effective August 8, 1996. The Veteran's appeal concerning service connection for a respiratory condition and service connection for joint pains, to include knee pains, is now moot because each disability has been service connected. The Veteran has not disagreed with either the assigned disability rating or the effective date for either disability. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (holding that when an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection.) Therefore, these matters have been resolved and are not in appellate status. The Veteran provided testimony before the undersigned Acting Veterans Law Judge at the VARO on Travel Board in August 2009; a transcript is of record. The issue of entitlement to service connection for headaches has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The competent and credible evidence of record is in equipoise as to whether the Veteran's currently diagnosed low back disability was incurred during his military service. 2. The most probative evidence of record does not support a finding that the Veteran has a gastrointestinal disability resulting from undiagnosed illness that was shown during active service or currently manifested to a compensable degree; and there is no evidence of currently diagnosed gastrointestinal disability that is related to active military service or events therein. 3. The most probative evidence of record does not support a finding that the Veteran has night sweats attributable to a source other than his service-connected PTSD resulting from undiagnosed illness that was shown during active service or currently manifested to a compensable degree; and there is no evidence of a current disability manifest by night sweats other than service-connected PTSD. 4. The most probative evidence of record does not support a finding that the Veteran has memory loss attributable to a source other than his service-connected PTSD resulting from undiagnosed illness that was shown during active service or currently manifested to a compensable degree; and there is no evidence of a current disability manifest by memory loss other than service-connected PTSD. CONCLUSIONS OF LAW 1. Resolving doubt in favor of the Veteran, the Veteran has a low back disability that was incurred during his active duty service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). 2. The Veteran's claimed gastrointestinal disability was not incurred in or aggravated by active service, nor may it be presumed to be related to his period of service in the Persian Gulf. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2013). 3. The Veteran does not have a disability manifested by night sweats other than service-connected PTSD that was incurred in or aggravated by active service, nor may such claimed disability be presumed to be related to his period of service in the Persian Gulf. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2013). 4. The Veteran does not have a disability manifested by memory loss other than service-connected PTSD that was incurred in or aggravated by active service, nor may such claimed disability be presumed to be related to his period of service in the Persian Gulf. 38 U.S.C.A. §§ 1110, 1117, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by or on behalf of the appellant. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). I. Stegall Concerns In October 2009 and February 2012, the Board remanded the appeal to the RO, via the Appeals Management Center (AMC), for further development. The Board instructed the RO to obtain the Veteran's service treatment records and outstanding post-service treatment records. These records have been obtained to the extent possible and associated with the Veteran's claims file. The Board also requested that the Veteran be scheduled for a VA examinations. The Veteran underwent the requested VA examinations in July 2010, March 2011, April 2011, and June 2011. An addendum was obtained later in June 2011. In particular, VA examinations provided insight into the nature of the Veteran's claimed disorders, and opinions were obtained. In light of the aforementioned actions, the Board finds that there has been substantial compliance with the requirements articulated in the Board's prior remands. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999). II. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her 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) (West 2002); 38 C.F.R. § 3.159(b) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the Court held that VA 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. The August 2000 Statement of the discussed the evidence necessary to support a claim for service connection. In addition, a letter dated in October 2009 informed the Veteran of the manner in which VA determines disability ratings and effective dates, and the Veteran was invited to submit or identify pertinent evidence. The content of the notice provided to the Veteran fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran has been provided with every opportunity to submit evidence and argument in support of his claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims. Therefore, the record reflects that he was provided with a meaningful opportunity during the pendency of his appeal such that any error in the timing of the notice did not affect the essential fairness of the adjudication now on appeal. With respect to VA's duty to assist, service treatment records, private treatment records, and VA treatment records have been obtained and associated with the record. VA examinations were conducted. The Board finds that the examinations were adequate in that they were performed by trained health care providers who reviewed the record, interviewed the Veteran, and performed appropriate physical examinations prior to providing their conclusions. The Veteran has not otherwise identified any additional evidence or information which could be obtained to substantiate the claim. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations. As noted above, the Veteran also was afforded a hearing before the undersigned Acting Veterans Law Judge (AVLJ), during which he presented oral argument in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2013) requires that the Veterans Law Judge or Decision Review Officer who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ fully explained the issues on appeal during the hearing and asked questions specifically regarding the elements necessary to establish the benefits sought. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the evidence necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the evidence necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the AVLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). III. Service Connection Claims A. Law and Regulations Service connection is warranted for disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. §§ 1110, 1131. To establish a right to compensation for a present disability, a claimant must show: "(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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). However, "[a] determination of 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). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). Service connection may be established for a chronic disability manifested by certain signs or symptoms which 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, and which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1); 71 FR No. 242, pp. 75669-75671 (December 18, 2006). Consideration of a Veteran's claim under this regulation does not preclude consideration of entitlement to service connection on a direct basis. A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): an undiagnosed illness; the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) Chronic fatigue syndrome; (2) Fibromyalgia; (3) Functional gastrointestinal disorders; 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 any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a). 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). "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). Disabilities that have existed for 6 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. 38 C.F.R. § 3.317(a). A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a). A disability referred to in this section shall be considered service connected for purposes of all laws of the United States. 38 C.F.R. § 3.317(a). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) Fatigue (2) Signs or symptoms involving skin (3) Headache (4) Muscle pain (5) Joint pain (6) Neurologic signs and symptoms (7) Neuropsychological signs or symptoms (8) Signs or symptoms involving the respiratory system (upper or lower) (9) Sleep disturbances (10) Gastrointestinal signs or symptoms (11) Cardiovascular signs or symptoms (12) Abnormal weight loss (13) Menstrual disorders. 38 C.F.R. § 3.317(b). Compensation shall not be paid under this section if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). The term "Persian Gulf Veteran" means a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d). 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; 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. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002). B. Low Back Disability The Veteran is claiming entitlement to service connection for a low back disability, which he contends is due to his military service. As to Shedden element (1), the current competent medical evidence of record demonstrates a diagnosis of recurrent lumbosacral strain. Shedden element (1) is, therefore, satisfied. With regard to Shedden element (2), evidence of an in-service incurrence of a disease or injury, the Board observes that an undated service treatment record documents the Veteran's complaint of low back pain for the previous two weeks. Additionally, on a Report of Medical History (RMH) completed in July 1991 towards the end of his active duty service, the Veteran indicated that he experienced recurrent back pain. A service examiner annotated on the RMH that the Veteran experienced periods of lower back pain. Additionally, the Veteran has testified that during his military service, he had back problems and sought treatment from a field medic for back spasms. See the August 2009 Board hearing transcript, page 18. The Board notes that the Veteran is competent to attest to being treated for back spasms while on active duty. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (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). Therefore, although the Veteran as a lay person has not been shown to be capable of making medical conclusions, he is competent to report the circumstances of being treated for back pain while on active duty. Further, the service treatment records substantiate his assertions. Accordingly, Shedden element (2) is arguably met. Turning to crucial element (3), medical nexus, the Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that the competent and probative evidence of record is in equipoise concerning a nexus between the Veteran's low back disability and his military service. There are two medical opinions of record which address the question of medical nexus. First, in March 2011, a VA compensation and pension examiner gave the Veteran a diagnosis of chronic lumbar strain and opined that the strain was the result of the low back problems the Veteran experienced while he was on active duty. To support her given opinion, the examiner remarked that there was evidence of the Veteran's history of back problems while on active duty in the claims file. Second, in June 2011, a different VA compensation and pension examiner gave the Veteran a diagnosis of chronic lumbar strain and opined that the strain was less likely as not caused by or a result of military service. The examiner said that there was no available evidence of complaints of back pain while the Veteran was on active duty, and there were no complaints of back pain in the past twelve years of outpatient records. The Board notes that the June 2011 VA compensation and pension examiner's rationale is not supported by the evidence of record. The June 2011 examiner remarked that there was no available evidence of complaints of back pain while the Veteran was on active duty, but as described above, there is official documentation of the Veteran's back pain while he was on active duty. Additionally, while the June 2011 VA examiner said there were no complaints of back pain in the past twelve years of outpatient records, treatment records from November 2005, December 2003, October 2003, June 2003, April 1998, August 1996, and April 1996 all describe the Veteran's history of back pain. In evaluating the probative value of competent medical opinion evidence, the Court has stated in pertinent part: "The probative value of medical evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches...As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicator..." See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Likewise, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). As reviewed above, the negative opinion of the June 2011 VA examiner does not appear to be supported by the evidence of record, whereas the opinion of the March 2011 VA examiner appears to have a basis in the service treatment records. At the very least, the medical opinions of record appear to be in equipoise. In light of the fact that the Veteran is currently diagnosed with recurrent lumbosacral strain; the service treatment records which show that he began to experience symptoms during his active duty; the fact that post-service treatment records document his ongoing complaints of back pain; and in light of the most persuasive medical examiner's opinion that the Veteran's lumbosacral strain began while he was on active duty, the Board finds that the evidence is, at the very least, in relative equipoise as to whether the Veteran's low back disability had its onset in service or is otherwise related to service. Therefore, the Board will resolve doubt in favor of the Veteran and grant the Veteran's claim. In summary, for the reasons explained above, having resolved doubt in favor of the Veteran, service connection for a low back disability is warranted. C. Gastrointestinal Disability Service treatment records show that on demobilization examination in July 1991, the Veteran denied experiencing weight loss, belly pain, nausea, diarrhea, or bloody bowel movements. On a separate RMH completed in July 1991, the Veteran indicated that he did not experience dizziness or fainting spells, frequent indigestion, or stomach, liver, or intestinal trouble. On VA compensation and pension general examination in April 1998, the Veteran complained of stomach pain and fatigue. He said that he had nausea and vomiting several times a week, and he had diarrhea every three days. The examiner found that the abdomen was not tender, and rectal examination was normal. A GI series yielded normal results. The examiner gave a diagnosis of gastroenteritis of unknown etiology. A VA treatment record from January 2004 contains the Veteran's complains of lightheadedness. The examiner gave a diagnosis of gastroenteritis and prescribed koapectate for diarrhea and Phenergan for nausea. During the Veteran's August 2009 Board hearing, he remarked that post-service, he began to throw up every morning. He experienced nausea in the mornings. The Veteran told a VA stomach examiner in July 2010 that he had nausea every morning, but after a few hours, the nausea would settle down. The examiner indicated that there was no history of vomiting or diarrhea. The examiner gave no diagnosis for the Veteran's early morning nausea. Also in July 2010, a VA gastrointestinal examiner noted the Veteran's complaints of nausea. This examiner also noted that there was no history of vomiting or constipation. This examiner also gave no diagnosis. In March 2011, a VA examiner recorded the Veteran's complaints of nausea without vomiting. It was noted that the nausea would resolve in 20 to thirty minutes and did not require treatment. An upper GI yielded normal results. The examiner considered the Veteran's report that his nausea started while on active duty, but the examiner could find no documentation of it in the records. The examiner opined that there was no identifiable etiology of the Veteran's nausea. The examiner explained that since the etiology of the Veteran's nausea could not be identified, she could not opine as to whether the Veteran's nausea was a result of Persian Gulf War service without resorting to speculation. Having reviewed the evidence pertaining to this claim, the Board has determined that service connection on a presumptive basis for a gastrointestinal disability is not warranted. In that regard, the Board observes that the Veteran's claimed symptoms have been medically ascribed to the diagnosis of gastroenteritis by VA examiners in April 1998 and January 2004. As the Veteran has been given a medical diagnosis of gastroenteritis, service connection cannot be granted for the Veteran's complaints as due to an undiagnosed illness. As such, service connection for gastroenteritis cannot be granted on a presumptive basis under 38 C.F.R. § 3.317. In cases where a Veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. §§ 1110 and 1131 is warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (specifically addressing claims based on ionizing radiation exposure). Thus, the presumption is not the sole method for showing causation. In this case, however, there is no medical evidence of record indicating that the Veteran's gastroenteritis was caused or aggravated by his active duty service. In point of fact, the only VA examiners of record to offer an opinion regarding the etiology of the Veteran's gastroenteritis and nausea indicated that the etiology was unknown. See VA examination reports from April 1998 and March 2011. The March 2011 examiner further explained that since the etiology of the Veteran's nausea could not be identified, she could not opine as to whether the Veteran's nausea was a result of Persian Gulf War service without resorting to speculation. In Jones v. Shinseki, 23 Vet.App. 382 (2009), the Court held that a determination that a diagnosis or etiology opinion is not possible without resort to speculation is a medical conclusion just as much as a firm diagnosis or a conclusive opinion. Thus, before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence. See Stefl v. Nicholson, 21 Vet.App. 120, 124 (2007) (a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The examiner's opinion that the Veteran's nausea could not be related to military service without result to mere speculation is competent, reasoned, and fully consistent with the evidence. It is sound and logical reasoning that as the etiology of the Veteran's nausea could not be identified, it would be mere speculation to relate it to his Gulf War Service. Accordingly, the Board relies on the opinion given. See Jones, supra. Significantly, there are no medical etiology opinions of record which support the Veteran's claim. The Board acknowledges the Veteran's contentions that he experiences gastroenteritis symptoms as a result of his active duty. As acknowledged previously, the Veteran can attest to factual matters of which he had first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, while the Veteran is competent to report what comes to him through his senses, he does not have medical expertise to render an opinion on their etiology in this case; there is no observable cause and effect relationship. See Layno v. Brown, 6 Vet. App. 465, 469- 470 (1994). The Board further notes that while the Veteran now states that he has experienced nausea and symptoms of gastroenteritis since his time on active duty service, he clearly indicated on two separate treatment history reports in July 1991 following his Gulf service that he did not experience weight loss, belly pain, nausea, diarrhea, bloody bowel movements, dizziness or fainting spells, frequent indigestion, or stomach, liver, or intestinal trouble. As such, his present assertions of a continuity of symptoms are not credible. In summary, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection, and the benefit-of-the-doubt rule is not for application. D. Night Sweats and Memory Loss The service treatment records are negative for any signs, symptoms, or diagnoses of night sweats or memory loss. On demobilization examination in July 1991, the Veteran denied experiencing nightmares or having trouble sleeping. On a separate RMH completed in July 1991, the Veteran indicated that he did not experience frequent trouble sleeping, loss of memory, amnesia, nervous trouble of any sort, or periods of unconsciousness. On VA examination for posttraumatic stress disorder (PTSD) in April 1998, the examiner noted that the Veteran had poor memory. The diagnosis given was PTSD. On VA examination for PTSD in April 2004, it was noted that the Veteran would wake up in the middle of the night sweating and terrified with guild, anger, and feelings of isolation. The diagnosis given was PTSD, moderate to severe. On VA general examination in July 2010, the examiner indicated that while the Veteran reported that he would wake up two or three times a week with night sweats, there was no diagnosis or evidence of night sweats or memory loss in the medical records. The examiner opined that there was no diagnosis established for night sweats, and there was no evidence of memory loss. Another VA general examiner recorded the Veteran's complaints of night sweats in March 2011. The examiner wrote that there was no documentation of the Veteran's night sweats in the claims file. The examiner also opined that as no other medical problems had evolved associated with his night sweats, his night sweats were likely a distinct, independent condition. On VA examination for PTSD in April 2011, the examiner recorded that the Veteran experienced symptoms of irritability, poor anger management, night sweats, low mood, and hypervigilance. The examiner further observed that the Veteran had problems with short term memory, and the examiner indicated that the Veteran relived traumatic events from his service through dreams of being shot at and night sweats. The examiner gave a diagnosis of PTSD. The Veteran has instituted a claim for service connection for memory loss and night sweats as a result of an undiagnosed illness; however, the Board has determined that service connection on a presumptive basis for memory loss and night sweats is not warranted. In that regard, the Board observes that while the July 2010 VA examiner indicated that there was no diagnosis for night sweats or memory loss, and the March 2011 VA examiner indicated that no other medical problems had evolved with the Veteran's night sweats, the Veteran's psychiatric records contain ample evidence of both night sweats and memory loss. Indeed, to whatever extent the July 2010 and March 2011 VA examination reports indicate that the Veteran either does not have memory loss or night sweats; or has night sweats as a distinct, independent condition; they are outweighed by the reports of the April 1998, April 2004, and April 2011 VA examiners, in which they all considered the Veteran's reported symptoms of night sweats and/or memory loss within the psychiatric examinations, and each examiner gave the Veteran a diagnosis of PTSD. This evidence strongly suggests that the Veteran's claimed memory loss and night sweats are related to his PTSD. As the Veteran has been given a medical diagnosis of PTSD, service connection cannot be granted for the Veteran's complaints as due to an undiagnosed illness. As such, service connection for memory loss and night sweats cannot be granted on a presumptive basis under 38 C.F.R. § 3.317. The Board further notes that the Veteran has been awarded a grant of service connection for PTSD throughout the period of appeal, with a 50 percent disability rating from January 9, 1998, 100 percent disability rating from April 15, 1998, 50 percent disability rating from June 1, 1998, and 100 percent disability rating from June 24, 2000. Concerning the Veteran's PTSD, psychiatric disabilities other than eating disorders are rated pursuant to the criteria of a General Rating Formula. See 38 C.F.R. § 4.130 (2013). Under the formula, a 10 percent rating is assigned when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. As noted above, the weight of the evidence suggests that the Veteran's night sweats and memory loss are associated with the Veteran's PTSD, a disability for which the Veteran has already been awarded service connection. The pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14. Disabilities may be rated separately without violating the prohibition against pyramiding unless they constitute the same disability or symptom manifestations. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). In examining the rating criteria for PTSD, the Board notes that night sweats are not specifically mentioned. However, the rating criteria are based on "such symptoms as." With regard to the use of the phrase "such as" in 38 C.F.R. § 4.130, ratings are assigned according to the manifestations of particular symptoms. The use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The rating criteria for PTSD, as listed above, specifically mention chronic sleep impairment, panic attacks, and memory loss. As such, the rating criteria suggest that symptoms such as night sweats and memory loss are considered in establishing a disability rating for PTSD. Accordingly, as the evidence suggests that the Veteran is already receiving compensation for these symptoms as a result from his service-connected PTSD disability rating, awarding a second separate evaluation for these symptoms would result in prohibited pyramiding. 38 C.F.R. § 4.14. Again, the Veteran can attest to factual matters of which he had first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, while the Veteran is competent to report what comes to him through his senses, he does not have medical expertise to render an opinion on their etiology in this case; he has not had the training to associate his symptoms of night sweats and memory loss to a specific diagnosis. See Layno v. Brown, 6 Vet. App. 465, 469- 470 (1994). In this case, to whatever extent the Veteran's statements can be construed to assert that his night sweats and memory loss constitute a diagnosable disability separate from his PTSD, the Board finds them outweighed by the VA psychiatric evidence of record. The VA psychiatric evidence was prepared by psychiatric professionals who had the training necessary to offer educated observations, and their evidence suggests that the Veteran's night sweats and memory loss are associated with his PTSD. In summary, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claim for service connection, and the benefit-of-the-doubt rule is not for application. ORDER Entitlement to service connection for a low back disability is granted. Entitlement to service connection for a chronic gastrointestinal disability, claimed as gastroenteritis, including as due to an undiagnosed illness as a result of Persian Gulf War service, is denied. Entitlement to service connection for night sweats, including as due to an undiagnosed illness as a result of Persian Gulf War service, is denied. Entitlement to service connection for memory loss, including as due to an undiagnosed illness as a result of Persian Gulf War service, is denied. ____________________________________________ J. K. BARONE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs