Citation Nr: 1424277
Decision Date: 05/29/14	Archive Date: 06/26/14

DOCKET NO. 07-01 393	)        DATE      MAY 29 2014

On appeal from the Department of Veterans Affairs Regional Office in North Little Rock. Arkansas

THE ISSUES

1. Entitlement to service connection for carpal tunnel syndrome.

2. Entitlement to service connection for vaginal discomfort and bleeding.

3. Entitlement to service connection for headaches.

4. Entitlement to service connection for sight and speech impairment.

5. Entitlement to service connection for memory and concentration loss.

6. Entitlement to service connection for a respiratory condition.

7. Entitlement to service connection for a bilateral foot disorder.

8. Entitlement to service connection for hypertension.

9. Entitlement to service connection for abdominal pain and ulcers.
 
10. Entitlement to service connection for bronchitis.

11. Entitlement to service connection for sinusitis and allergies.

12. Entitlement to nonservice-connected pension.

13. Entitlement to an initial evaluation in excess of 10 percent for central centrifugal cicatricial alopecia.

14. Entitlement to service connection for deteriorating bone disease of the hands and wrists with nerve damage.

REPRESENTATION 

Appellant represented by:   The American Legion

WITNESS AT HEARING ON APPEAL 

The Veteran

ATTORNEY FOR THE BOARD 

K. Osegueda, Associate Counsel

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INTRODUCTION
The Veteran served on active duty from April 1974 to July 1980.

This matter initially came before the Board of Veterans' Appeals (Board) on appeal from June 2006, April 2007, and May 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas.

In September 2009, the Board remanded the claims of entitlement to service connection for vaginal discomfort and bleeding, headaches, a sight and speech impediment, memory and concentration loss, carpal tunnel syndrome, depression, a respiratory condition, bilateral foot pain, hypertension, abdominal pain and ulcers, bronchitis, allergies and sinusitis; and entitlement to nonservice-connected pension. These issues have since been returned to the Board for appellate review.

In September 2010, the Veteran testified at a videoconference hearing before the Veterans Law Judge concerning the issue of entitlement to an initial evaluation in excess of 10 percent for central centrifugal cicatricial alopecia. A transcript of the hearing has been associated with the record.

In December 2010, the Board remanded the claims for an initial evaluation in excess of 10 percent for central centrifugal cicatricial alopecia and for service connection for deteriorating bone disease for further development. These issues have since been returned to the Board for appellate review.

During the pendency of the appeal, in a December 2013 rating decision, the RO granted service connection for major depression and assigned a 30 percent disability evaluation effective from February 8, 2006. To date, the Veteran has not disagreed with that decision. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). As a result, the issue of entitlement to service connection for depression is no longer on appeal.

In addition to the paper claims file, there are Virtual VA and Veterans Benefits Management System (VBMS) paperless files associated with the Veteran's case. A

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review of the documents in the Virtual VA paperless claims file reveals VA treatment notes that are relevant to the issues on appeal. The RO considered those records and readjudicated the claims in December 2013 supplemental statements of the case (SSOCs).

The issues of entitlement to service connection for vaginal discomfort and bleeding, headaches, memory and concentration loss, abdominal pain and ulcers, a respiratory condition, bronchitis, and sinusitis and allergies; and entitlement to nonservice-connected pension are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ).

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2002).

FINDINGS OF FACT

1. In an April 2013 statement, prior to the promulgation of a decision in the appeal, the Veteran and her representative indicated that the appeal was being withdrawn as to the issue of entitlement to service connection for carpal tunnel syndrome.

2. The Veteran has not been shown to currently have sight and speech impairment that manifested in service or that is causally or etiologically related to her military service.

3. The Veteran has not been showed to currently have a bilateral foot disorder that manifested in service or that is causally or etiologically related to her military service.

4. The Veteran has not been shown to currently have hypertension that manifested in service or within one year thereafter or that is causally or etiologically related to her military service.

3. The Veteran's alopecia affects over 40 percent of her scalp.

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CONCLUSIONS OF LAW

1. The criteria for withdrawal of an appeal by the Veteran have been met for the issue of entitlement to service connection for carpal tunnel syndrome. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2013).

2. The Veteran does not have sight and speech impairment that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013).

3. The Veteran does not have a bilateral foot disorder that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013).

4. Hypertension was not incurred in active service and may not be presumed to have been so incurred. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013).

5. The Veteran does not have a bilateral hand and wrist disorder, to include deteriorating bone disease, that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§3.303, 3.304(2013).

5. The criteria for an initial 20 percent rating for alopecia, but no higher, have been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.118, Diagnostic Code 7830 (2013).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see

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Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and, (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120(2004).

In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded.

With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. §5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing his or her entitlement to increased compensation. However, the notice required by section

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5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of alternative diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009).

Notice should be provided to a claimant before the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112, 115 (2004). However, the notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Id. at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006).

Moreover, the RO did provide the Veteran with notice in April 2006, prior to the initial decision on the claims for service connection for sight and speech impairment, a bilateral foot disorder, and hypertension, in June 2006. The RO also provided the Veteran with notice in April 2010, prior to the initial decision on the claim for service connection for deteriorating bone disease. Therefore, the timing requirement of the notice as set forth in Pelegrini has been met and to decide the appeal would not be prejudicial to the claimant.

Moreover, the requirements with respect to the content of the notice were met in this case. The RO informed the Veteran in the April 2006 and April 2010 notice letters about the information and evidence that is necessary to substantiate her claims for service connection and of the division of responsibilities in obtaining such evidence. The letters also explained how disability ratings and effective dates are determined.

In this case, the Veteran is challenging, in part, the initial evaluation assigned following the grant of service connection for her alopecia. In Dingess, the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby

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rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. See also VAOPGCPREC 8- 2003 (December 22, 2003). Thus, VA's duty to notify has been satisfied with respect to the issue of entitlement to a higher initial evaluation for central centrifugal alopecia.

The duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records and all identified, available, and relevant post-service medical records, including VA treatment records, have been associated with the claims file and were reviewed by both the RO and the Board in connection with the claims. As noted, in remand below, VA treatment notes dated prior to 2006 have not been obtained and associated with the record; however, there is no indication that such records are relevant to the claims being adjudicated herein.

In the September 2009 remand, the Board noted that the record did not include a July 2009 VA examination report identified by the Veteran in a July 2009 statement. Therefore, the issues on appeal at that time were remanded for further development, to include obtaining any outstanding VA treatment notes from the Little Rock VA Medical Center (VAMC), to specifically include a VA examination report dated in July 2009. In May 2013, the Little Rock VAMC indicated that it had no treatment or records pertaining to the Veteran in July 2009. In addition, the Board notes that, in a November 2009 statement, the Veteran indicated that she was afforded a VA dermatology examination in June 2009, rather than in July 2009, as originally reported. The June 2009 VA dermatology examination has been associated with the claims file.

In addition, in the December 2010 remand, the Board noted that there were no VA treatment notes dated after 2009 associated with the claims file. The issues on appeal at that time were remanded for further development, to include obtaining any outstanding VA treatment notes dated after 2009. This development was completed, and the VA treatment notes have been associated with the record. Therefore, the Board's remand directives were completed, and the Board may proceed with this adjudication. Stegall v. West, 11 Vet. App. 268 (1998).

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The Veteran has not identified any other outstanding records that are pertinent to the issues currently on appeal.

The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran was afforded VA examinations in January 2007, February 2007, June 2009, June 2012, and September 2013, in connection with her claims for service connection and for a higher initial rating for her alopecia.

When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations are adequate to decide the case because, as shown below, the examinations were based upon consideration of the Veteran's pertinent medical history, as well as her lay assertions and current complaints, and the examiner described the alopecia in detail sufficient to allow the Board to make a fully informed determination. The examiners also provided the necessary opinions supported by rationale. Id.

In addition, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's alopecia since she was last examined. 38 C.F.R. § 3.327(a) (2013). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95.

Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2013).

With regard to the September 2010 hearing for the increased rating claim, in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010), the Court held that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with 38 C.F.R. § 3.103(c)(2). These duties consist of (1) fully explaining the issues pertinent to the

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claim(s) on appeal; and (2) suggesting the submission of evidence that may have been overlooked. See also 38 C.F.R. § 3.103(c)(2); Procopio v. Shinseki, 26 Vet. App. 76 (2012). At the hearing, the Veterans Law Judge, the Veteran, and the representative outlined the increased rating issue on appeal and engaged in a discussion as to substantiation of that claim. The Veteran's specific symptomatology was discussed in detail by the parties at that hearing. In fact, the Veteran's representative spent a considerable amount of time identifying the relevant evidence and interviewing the Veteran. The Veterans Law Judge also clarified whether any additional relevant evidence was available which could be capable of substantiating this claim. Potential favorable outstanding medical evidence was discussed, which led to the December 2010 remand. The actions of the Veterans Law Judge supplemented the duty to notify and assist and complied with any related duties owed during a hearing. Overall, the hearing was legally sufficient, and there has been no allegation to the contrary.

Although Veteran had originally requested a hearing on the other issues being decided herein, she later withdrew that request in December 2007.

The Board concludes that the Veteran was provided the opportunity to meaningfully participate in the adjudication of her claims, and she did, in fact, participate. Washington v. Nicolson, 21 Vet. App. 191 (2007). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal.

The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the particular claims on appeal. She has been given ample opportunity to present evidence and argument in support of her claims. All relevant evidence necessary for an equitable disposition of the Veteran's appeal of these issues has been obtained, and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2013).

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Withdrawal

The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2013). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. Withdrawal of an appeal will be deemed a withdrawal of the Notice of Disagreement and, if filed, the Substantive Appeal, as to all issues to which the withdrawal applies. 38 C.F.R. § 20.204(c).

In the present case, in an April 2013 statement, the Veteran withdrew the appeal for entitlement to service connection for carpal tunnel syndrome. The Veteran and her representative emphasized that she was still seeking entitlement to service connection for deteriorating bone disease of the hands and wrists with nerve damage.

Hence, with regard to the issue of entitlement to service connection for carpal tunnel syndrome, there remain no allegations of errors of fact or law for appellate consideration for this particular issue. Accordingly, the Board does not have jurisdiction to review that part of the appeal and it is dismissed.

Service Connection

Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including

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that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Sight and speech impairment

The Veteran's service treatment notes include no complaints of, treatment for, or diagnoses of any sight or speech impairment during service.

In a May 2005 private treatment note, the Veteran complained of a stutter; however, the examining physician noted that the Veteran's speech was normal.

In a May 2005 private speech-language pathology report, the Veteran reported that she had increased speech dysfluency beginning in April 2005. She related that she had episodes in which "words won't come out" and "uncontrollable" loss of voice. She indicated that she believed that it was related to exposure to a car contaminated with mold in December 2004. She stated that she was treated for eye problems due to the mold exposure. The examiner noted that the Veteran presented normal speech fluency and phonation, and the examiner opined that situation specific anxiety was causing minor focal dysfluencies. Specifically, she indicated that the Veteran was experiencing elevated anxiety related to the recent loss of her regular income and self-imposed pressure to be successful in her private business. She also indicated that the Veteran's situation was exacerbated by her "high expectations to be a perfect speaker, to never make a speech error."

Upon review of the evidence of record, the Board concludes that the Veteran is not entitled to service connection for sight and speech impairment. Because the evidence does not establish that the Veteran has a current diagnosis pertaining to sight and speech impairment during the pendency of the appeal, the Board finds that the Veteran is not entitled to service connection.

The Board does acknowledge that laypersons are sometimes competent to provide opinions regarding such medical matters as diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the Board finds that

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the medical evidence cited to above is entitled to greater probative weight. The treating providers considered the Veteran's reported symptomatology, yet did not provide any diagnosis. They relied on their medical expertise and training in evaluating the Veteran.

The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110 (West 2002). Thus, the threshold question that must be addressed here (as with any claim seeking service connection) is whether the Veteran actually has the disability for which service connection is sought. In the absence of proof of a present disability, there is no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F. 3d 1328 (1997).

Moreover, the Board finds it notable that the Veteran, herself, indicated her belief that her claimed speech difficulty began after being exposed to mold in December 2004, which would have over 20 years after service. She made no statements concerning her claimed sight impairment.

Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

Bilateral foot disorder

The Veteran's service treatment notes include no diagnoses of any foot disorders during service. In an August 1977 service treatment note, a foot problem was noted; however, the Veteran did not attend her scheduled appointment to evaluate her complaint. In an undated report of medical history completed by the Veteran during her separation examination, she noted that she had no foot trouble.

In a January 2006 VA treatment note, the Veteran reported that she had bilateral foot pain for 50 years.

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In a January 2006 VA emergency department treatment note, the Veteran complained of foot pain since 1974. She was diagnosed with a callous.

In a February 2006 VA treatment note, the physician noted that the Veteran had callouses on her feet and a bunion on her left foot.

During a January 2007 VA feet examination, the Veteran complained of bilateral foot pain. She stated that, while she was in service, she stood on concrete and noted that her issued shoes caused soreness and callouses on her feet. She also indicated that she did not wear boots in service. The Veteran reported that she continued to have swollen, calloused feet since service. She related that she had a dorsal exostectomy at the first metatarsal base area of the left foot and a partial proximal phalangeectomy of the right fourth toe due to a corn in approximately 2004 or 2005. She related that she had current soreness over the dorsal instep area of both feet. The Veteran reported that she also had bad calluses and pain in her arches and heels. An examination of the Veteran's feet showed a very small, thin callus on the medial plantar of the right hallux interphalangeal joint and a similar one on the left. There were no calluses under her metatarsal heads about the toes or the forefoot. She had a buildup of dry skin and some hyperkeratotic skin on the medial plantar of her heels. There were no neurovascular focal lesions, and the foot structure was within normal limits. The dorsal instep was slightly prominent, but not abnormal in any way. On the right, there was mild hallux valgus without a bunion. On the left, there was a very early bunion with hallux valgus. The toes were straight, and there were no areas on the skin that felt like the Veteran had any pressure from abnormal osteostructures. X-rays of the feet were normal with changes from previous surgeries. The examiner provided the following opinion:

My examination did not reveal any correlation between the [Veteran's] complaints and her military service. She is a 51-year-old female that had a normal foot examination other than the areas as described. I do not see a relationship between standing on concrete in normal Oxford shoes and the discomfort she has today.

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I relate it more to her age and the normal chan[g]es that go with age. There is no history of injury or other problems during her service time. The bottom line is that I see no relationship between her subjective complaints today and her military service.

Upon review of the evidence of record, the Board concludes that the Veteran is not entitled to service connection for a bilateral foot disorder.

The Veteran did indicate in that she had had bilateral foot pain for 50 years and that it began in 1974 during service. The Board notes that she is competent to report her experience and symptoms in service and thereafter. While lay persons are generally not competent to offer evidence which requires medical knowledge, such as opinions regarding medical causation or a diagnosis, they may provide competent testimony as to visible symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465,469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). A veteran can attest to factual matters of which he or she had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368(2005).

The Federal Circuit has held that lay evidence is one type of evidence that must be considered, if submitted, when a veteran seeks disability benefits, and competent lay evidence can be sufficient in and of itself for proving the existence of a chronic disease. See Buchanan, 451 F.3d at 1335; 38 C.F.R. §§ 3.303(a), 3.307(b). The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. Buchanan, 451 F.3d at 1336. Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (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

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evidence has been admitted")); see also Ban v. Nicholson, 21 Vet. App. 303 (2007).

In this case, the Board finds that the Veteran is competent to state that she has had bilateral foot problems since her military service. However, her allegations are inconsistent with the contemporaneous record. While there was a complaint of a foot problem during service, there was no treatment for or diagnosis a bilateral foot disorder during service. In addition, as noted above, in a report of medical history completed at separation, the Veteran, herself, denied any foot trouble. As such, there is actually affirmative evidence showing that she did not have a bilateral foot disorder at that time of her separation from service.

Moreover, the Board notes that the Veteran has made inconsistent statements regarding the onset of her symptoms. In January 2006, she indicated that she had bilateral foot pain for 50 years, which would have actually pre-dated her military service. On another occasion in January 2006, she stated that she had foot pain since 1974, which would have been in service. These statements clearly conflict.

In light of the affirmative evidence showing otherwise and the inconsistent statements, the Board finds the Veteran's reported history to be not credible.

Regarding the Veteran's assertion that her current bilateral foot disorder is directly related to her military service, the Board finds that the opinion of the January 2007 VA examiner is of greater probative weight than the Veteran's more general lay assertions. The examiner reviewed and considered the evidence of record, including the Veteran's statements, and provided a medical opinion with a supporting rationale relying on medical training, knowledge, and expertise.

Based on the foregoing, the preponderance of the evidence is against the claim for entitlement to service connection for a bilateral foot disorder. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009).

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Hypertension

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. As cardiovascular-renal disease (which includes hypertension) is considered to be chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

In this decision, all blood pressure measurements are noted in units of pressure in millimeters of mercury (mmHg). For VA compensation purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 or greater; and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 or greater with diastolic blood pressure less than 90. In addition, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2013). Service connection for pre-hypertension is not warranted when an examiner diagnoses pre-hypertension based on readings not recognized in Diagnostic Code 7101. VA Adjudication Procedures Manual, M21-MR,III.iv.4.E.20.33(2012).

The Veteran's service treatment records show that her blood pressure was recorded 19 times on clinical encounters. Her blood pressure was never recorded as 140 or greater systolic, and it was never recorded as 90 or greater diastolic. Her lowest blood pressure recorded was in November 1975, and it was 90/50. Her highest blood pressure recorded was in September 1976, and it was 134/74. In her undated separation examination report, her blood pressure was recorded as 120/60.

The Veteran does not contend, nor do the service treatment records show, an actual diagnosis or treatment for hypertension. Moreover, the measurements over the entire period of active duty and those within several months of discharge were all less than 140 systolic and 90 diastolic.

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In a July 2008 VA treatment note, the physician noted that the Veteran was diagnosed with hypertension three years earlier, or in approximately 2005.

During a January 2007 VA general medical examination, the Veteran reported that she was diagnosed with essential hypertension by her VA primary care physician in 2002. She indicated that she was prescribed medication at that time and that her blood pressure had normalized. The examiner recorded blood pressure readings of 139/84, 136/70, and 136/78. He noted that VA treatment notes showed recent blood pressure readings of and 142/84 in August 2006, and 141/90, 129/70, and 137/81 in November 2006. The examiner diagnosed the Veteran with essential hypertension and noted that the Veteran reported that her hypertension was recently diagnosed.

During a June 2012 VA hypertension examination, the Veteran reported a history of hypertension, and she indicated that she had been treated since 2005. The examiner recorded blood pressure readings of 112/78, 110/76, and 110/70. He indicated that he had reviewed the claims file, and he noted that the Veteran was not diagnosed with hypertension during service or within one year of her separation from service. Therefore, he opined that her hypertension was not service-related.

In a September 2013 VA addendum opinion, another examiner reported that he had reviewed the claims file, and he agreed with the June 2012 VA examiner. He reiterated the opinion that a diagnosis of hypertension was not supported during service or within one year after separation from service; therefore, he opined that the Veteran's hypertension was not related to service.

Upon review of the evidence of record, the Board concludes that the Veteran is not entitled to service connection for hypertension.

The evidence shows that the Veteran did not seek treatment for and was not diagnosed with hypertension again until many years after service. Her service treatment records are negative for any complaints, treatment, or diagnosis of hypertension, and the Veteran herself stated that she did not develop hypertension until either 2002 or 2005. Therefore, the Board finds that hypertension did not manifest during service or within one year thereafter.

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With regard to the years-long evidentiary gap in this case between active service and the earliest manifestations of hypertension, the Board notes that a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board must consider all the evidence including the availability of medical records, the nature and course of the disease or disability, the amount of time that elapsed since military service, and any other relevant facts in considering a claim for service connection. Id.; cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000) (holding that the absence of medical records during combat conditions does not establish absence of disability and thus suggesting that the absence of medical evidence may establish the absence of disability in other circumstances). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness).

In addition to the lack of evidence showing that hypertension manifested during active duty service or within close proximity thereto, the evidence of record does not link any current diagnosis to the Veteran's military service. In fact, the June 2012 and September 2013 VA examiners agreed that the Veteran's hypertension was not causally or etiologically related to service. There is no evidence showing otherwise. Therefore, the Board finds that hypertension did not manifest during service or within one year thereafter and has not been shown to be causally or etiologically to an event, disease, or injury in service.

Based on the foregoing, the preponderance of the evidence is against the claim. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for hypertension is not warranted.

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Bilateral hands and wrists

In a June 1975 service treatment note, the Veteran complained of an accidental puncture wound from a dart to her right wrist. She reported that she had a tingling sensation from her wrist to her elbow. The examiner noted that the Veteran had a very small, superficial puncture wound in her central right wrist. The examiner indicated that the Veteran's right wrist range of motion, sensation, and motor function were normal. The Veteran was instructed to wash the area with soap and water and to return to the clinic if she developed swelling and inflammation. There were no subsequent service treatment notes pertaining to any complaints related to the hands or wrists.

In a January 2006 private treatment note, the Veteran reported that she had numbness in her right hand and she had difficulty opening ajar.

In a February 2006 VA treatment note, the Veteran indicated that she had pain in the right wrist with tingling and numbness in the fingers. Tinel and Phalen tests were positive on the right side.

In another February 2006 VA treatment note, the Veteran reported that she had most of her problems with her right hand since 1998. She indicated that she had numbness and pain in her right hand, and she denied any neck or shoulder injuries. She indicated that her left hand only went numb once in the previous week.

A May 2006 VA x-ray of the Veteran's right hand showed a volar instability pattern to the wrist with cystic erosions of the dorsal proximal ulnar aspect of the lunate. The interpreting radiologist noted that a lunotriquetral ligament injury or occult lunar fracture should be ruled out.

A May 2006 VA magnetic resonance imaging (MRI) study of the Veteran's right hand and wrist showed findings that were most consistent with early Kienbock's disease without significant collapse of the lunate and a small ganglion cyst arising from the pisotriquetral articulation.

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In a July 2006 VA orthopedic treatment note, the Veteran reported a several year history of increased right wrist pain. The orthopedist noted that a carpal tunnel syndrome test was negative. He diagnosed the Veteran with the early stages of Kienbock's disease.

In a January 2007 VA general medical examination report, the examiner noted that a sensory examination showed that the Veteran had normal bilateral upper extremities. Her wrists and hands were normal appearing joints and the joints demonstrated full range of motion without restriction or pain on range of motion.

During another January 2007 VA examination, the Veteran reported that she had a little numbness in her right wrist where she had some "bone deterioration." She related that she did not have much pain in that area, but she had been evaluated in the past year and an electromyography (EMG) and x-rays showed bone disease. She indicated that there was no evidence of carpal tunnel syndrome on the EMG. A physical examination showed good strength in all four extremities, including thumb-to-index finger and thumb-to-small finger bilaterally. She had negative Tinel's sign bilaterally. The Veteran had no atrophy of the small muscles of her hands and no numbness in her hands by pinprick, vibratory sense, or touch. The examiner diagnosed the Veteran with pain in the right wrist secondary to bone disease. He indicated that he thought there was no evidence of carpal tunnel syndrome.

A March 2009 VA treatment note included findings from neuropsychological testing performed in June 2006 and March 2009. The testing showed that the Veteran had mild bilateral tactile sensory imperceptions of the right hand fingertips and left hand fingers. Motor speeds were normal with both hands, but strength was greater on the non-dominant hand. There were no find motor tremor or motor control problems on paper and pencil tasks.

During a March 2010 VA physical medicine rehabilitation consultation, the Veteran reported that she had fallen '"flat on her back" onto a concrete patio at work in October 2009. She complained of pain since that time that spread across her upper back, all the way across her lower back into her rip hip and into her right hand. She

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also wore resting wrist splints and complained of weakness in her right hand. She related that she had "deteriorating bone disease'* in her right hand. A February 2010 VA x-ray of the cervical spine showed loss of the normal lordotic curvature. In a March 2010 addendum, the physician noted that the Veteran reported that her right hand had a "weak grip" and that pain shot into her index and middle fingers. The physician noted that he would order an EMG or nerve conduction study (NCS) to evaluate the Veteran for carpal tunnel syndrome with a thorough needle examination to rule out cervical radiculopathy.

A March 2010 VA EMG and NCV study showed electrodiagnostic evidence consistent with bilateral multilevel acute cervical radiculopathy, involving levels C5-T1. There was no electrodiagnostic evidence consistent with right medial neuropathy at the wrist, bilateral ulnar motor neuropathy, right ulnar sensory neuropathy, or bilateral radial sensory neuropathy.

In an April 2010 statement, the Veteran related that she had no grip in her right hand, she had pain in both hands, and she was unable to lift heavy items. She indicated that she believed that her hand problems were a result of lifting heavy items and typing during service.

In an April 2012 VA physical medicine rehabilitation consultation, the Veteran complained of right wrist and forearm pain that increased with activity, especially with wrist flexion and extension. She indicated that she had the pain for approximately five years and that it had increased in severity since that time. An examination showed range of motion was mildly decreased with right wrist flexion and extension, with finger and thumb flexion and thumb extension, and with pronation or supination. Strength, sensation, and reflexes were within normal limits in both upper extremities. There was some pain with palpation over the carpals on the right and no pain with palpation over the flexor or extensor tendons of the wrist and hand. There were taut and tender muscle bands in the extensors of the wrist and in the hand intrinsics on the right. The examiner noted that his physical findings did not tend to correlate with Kienbock's disease. He also indicated that earlier findings of radiculopathy did not correlate with his examination.

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An April 2012 VA x-ray of the Veteran's right wrist showed stable, mild changes in the lunate that could suggest prior trauma or changes secondary to avascular necrosis.

A May 2012 VA MRI of the right wrist showed continuing Kienbock's defect of the lunate with little change since 2006 and slight interval progressive degenerative subchondral changes in the scaphotrapezial articulation.

During a September 2013 VA peripheral neuropathy examination, the Veteran reported that she had numbness and tingling in her hand and fingers with radiating pain and burning up her arm. She indicated that she had constant, mild pain, mild paresthesias or dyesthesias, and mild numbness in her right upper extremity. Muscle strength testing, reflexes, and sensory examinations were normal in both upper extremities. Phalen's and Tinel's sign were negative in both upper extremities. The examiner diagnosed the Veteran with Kienbock's disease. She also included the following description of Kienbock's disease:

Kienbock's disease, or avascular necrosis of the lunate, is a condition in which the lunate bone, one of eight small carpal bones in the wrist, loses its blood supply, leading to the death of the bone... Damage to the lunate can lead to pain, stiffness, and in late stages, arthritis of the wrist.... There is probably no single cause of Kienbock's disease. Its origin may involve many factors, such as the blood supply (arteries), the blood drainage (veins), and skeletal variations. Skeletal variations associated with Kienbock's disease include a shorter length of the ulna, one of the forearm bones, and also the shape of the lunate bone itself... Trauma, either single of repeated episodes, may possibly be a factor in some cases.

In a September 2013 VA wrist examination, the Veteran reported that she had an unknown wrist injury in service. She indicated that she had pain, weakness, and

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paresthesia of the right hand and wrist. The examiner diagnosed the Veteran with a wrist injury and Kienbock's disease. She opined that it was less likely as not that the present wrist condition was related to service. She noted that there was no medical evidence of a chronic right wrist condition in service or immediately following service; therefore, she determined that there was insufficient evidence to relate the diagnosis to service.

During a September 2013 VA hand and finger conditions examination, the examiner noted that the Veteran had one superficial injury to the right hand in 1975 without any further complaints or documentation of a right hand condition during service or within one year of separation from service. The examiner diagnosed the Veteran with a hand injury and Kienbock's disease. She noted that there was insufficient evidence of any hand or wrist condition since the 1975 acute episode of a simple superficial injury to the right wrist. She related that the Veteran remained in service for five years following the injury and had no other documented injuries or complaints related to the right hand or wrist. She opined that, without documentation of a chronic hand or wrist condition during service or within one year of separation from service, there was no evidence that a chronic condition was related to service.

Upon review of the evidence of record, the Board concludes that the Veteran is not entitled to service connection for a bilateral hand and wrist disorder.

The Veteran did indicate her belief that her current bilateral hand pain, right hand weakness, and inability to lift heavy items was related to carrying heavy objects and typing during service. The Board notes that she is competent to report her experience and symptoms in service and thereafter. While lay persons are generally not competent to offer evidence which requires medical knowledge, such as opinions regarding medical causation or a diagnosis, they may provide competent testimony as to visible symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). A veteran can attest to factual matters of which he or she had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on

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limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362. 368(2005).

The Federal Circuit has held that lay evidence is one type of evidence that must be considered, if submitted, when a veteran seeks disability benefits, and competent lay evidence can be sufficient in and of itself for proving the existence of a chronic disease. See Buchanan, 451 F.3d at 1335; 38 C.F.R. §§ 3.303(a), 3.307(b). The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. Buchanan, 451 F.3d at 1336. Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (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'*)); see also Barr v. Nicholson, 21 Vet. App. 303 (2007).

In this case, the Board finds that the Veteran is competent to state that she has had bilateral hand and wrist problems since her military service. However, her allegations are inconsistent with the contemporaneous record. While there was a treatment of a right wrist injury during service, the examiner noted that it was a superficial puncture injury from a dart. There were no subsequent complaints, treatment, or diagnoses pertaining to any hand or wrist problems during service, despite the Veteran being specifically instructed to return if swelling or inflammation developed. The Veteran also did not seek treatment for over 20 years following her military service.

In addition, the Board notes that the Veteran has made inconsistent statements regarding the onset of her disorder. In February 2006, she reported that she had right hand problems since 1998, which would have been well over 20 years after her separation from service. In March 2010, she reported falling onto her back in October 2009 and stated that the pain spread to her right hand since that time. In addition, she indicated in April 2012 that she had right wrist and forearm pain for

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five years. These statements clearly conflict with the allegation that she has had had hand and wrist problems since service.

For these reasons, the Board finds the Veteran's reported history to be not credible.

Regarding the Veteran's assertion that her current claimed bilateral hand and wrist disorder is directly related to her military service, the Board finds that the opinions of the September 2013 VA examiner are of greater probative weight than the Veteran's more general lay assertions. The examiner reviewed and considered the evidence of record, including the Veteran's statements, and provided a medical opinion with a supporting rationale relying on medical training, knowledge, and expertise.

Based on the foregoing, the preponderance of the evidence is against the claim for entitlement to service connection for a bilateral hand and wrist disorder. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009).

Increased Rating

Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7.

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In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, I Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, as in this case, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 1 Vet. App. 55, 58 (1994).

Similarly, where a veteran appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id.; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (VA's determination of the "present lever' of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending).

In this case, the Veteran's service-connected central centrifugal cicatricial alopecia is currently assigned a 10 percent evaluation pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7830.

Diagnostic Code 7830 provides ratings for signs and symptoms of scarring alopecia. Scarring alopecia affecting 20 to 40 percent of the scalp warrants a 10 percent rating. Scarring alopecia affecting more than 40 percent of the scalp warrants a maximum 20 percent rating. Id.

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Additionally, Diagnostic Code 7831 provides ratings for alopecia areata. Alopecia areata with loss of all body hair warrants a maximum 10 percent rating. 38 C.F.R. § 4.114, Diagnostic Code 7831.

Scars or disfigurement of the head, face, or neck are evaluated under Diagnostic Code 7800. Under that code, a 10 percent evaluation is contemplated when there is one characteristic of disfigurement. A 30 percent evaluation is assigned when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips; or, when there are two or three characteristics of disfigurement. A 50 percent evaluation is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips; or, when there four or five characteristics of disfigurement. An 80 percent evaluation is assigned when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or, when there are six or more characteristics of disfigurement.

There are eight characteristics of disfigurement for purposes of evaluation under § 4.118, as follows: Scar 5 or more inches (in.) (13 or more cm.) in length; scar at least one-quarter in. (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo-or hyper-pigmented in an area exceeding six square (sq.) in. (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six sq. in. (39 sq. cm.); underlying soft tissue missing in an area exceeding six sq. in. (39 sq. cm.); and, skin indurated and inflexible in an area exceeding six sq. in. (39 sq. cm.). Id. at Note I.

Diagnostic Code 7801 and 7802 pertain to scars not of the head, face, or neck. Thus, they are not applicable in this case.

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Under Code 7804. a 10 percent rating is warranted for one or two scars that are painful or unstable on examination. A 20 percent rating is warranted when there are two or three scars that are painful or unstable on examination.

Under Code 7805, scars are rated based on the limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2013).

In a September 2003 psychological evaluation report, conducted in association with a workers' compensation claim, the examining psychologist noted that the Veteran was treated by a private trichologist. In a June 2003 report, the trichologist indicated that she was "amazed at the degree of the applicant's hair, which was badly broken off." She also reported that the Veteran had balding spots and thinning of the hair. She noted that her examination of the Veteran's scalp showed signs of alopecia areata on the right and left side of the temple, and at 9 1/2 inches from the front end of the crown, there were stress signs of balding. Thinning was also observed with broken, very dry. and brittle hair over the Veteran's entire head. The psychologist noted that some photographs from when the Veteran first started treatment showed obvious hair loss. The Veteran indicated that she had been receiving herbal remedy, shampoo, and massage treatments, and that she had enjoyed some positive results.

In an October 2003 private internal medicine evaluation, conducted in association with the Veteran's workers' compensation claim, the examining physician noted that the Veteran had a history of stress-induced alopecia. He noted that the Veteran continued to receive treatments for stress-induced alopecia from a hair treatment technician and a dermatologist.

In a March 2004 private psychological evaluation report, the examining psychologist noted that the Veteran was previously referred to a dermatologist for substantial hair loss and balding. Her scalp hair density was noted to be 50 percent of normal. In the dermatologist's evaluation in February 2003, he noted patches of what appeared to be scarring alopecia at the sides of her scalp. He diagnosed her with vitiligo, cicatricial alopecia, and telogenessluzium. He indicated that telogenessluzium was triggered by work-related stress. The psychologist also noted


that the Veteran underwent hair loss and stress treatment by a private trichologist in June 2003. In her report, the trichologist noted that the Veteran's right and left side temples showed signs of alopecia areata, and she indicated that 9 1/2 inches from the front to the end of the crown showed stress signs of balding, including thinning, broken, very dry. and brittle hair. The psychologist reported that the Veteran underwent treatments three times per week, beginning in May 2003, for scalp treatments and stress control techniques. He noted that the Veteran "benefitted significantly" from the treatment and showed significant growth of new hair. He indicated that she continued to administer her own hair loss treatments on an ongoing basis.

In a July 2006 VA treatment note, the Veteran reported that she had been taking iron tablets since April 2006, and she had some hair regrowth in the front of her scalp. An examination showed alopecia on the frontal scalp and patchy areas on the temple and vertex. The diagnosis was alopecia that was most likely secondary to follicular degeneration syndrome.

During a February 2007 VA skin diseases examination, the Veteran indicated that she was prescribed Synalar solution by a VA dermatologist one year earlier, but she stopped using it because she felt that it increased her hair loss. The examiner noted that the Veteran had alopecia that was patchy in nature in the bitemporal area and along the frontal hairline. There was no appreciable erythema, ulceration, or scaling in those areas, and there was no acne, chloracne, or scarring. The examiner diagnosed the Veteran with central centrifugal cicatricial alopecia. The examiner reported that the total body surface area affected was approximately two percent, and the exposed body surface area affected was approximately two percent.

In July 2007, the Veteran submitted a copy of an agreement with a company for hair replacement. She stated that she entered into the contract because her hair follicles would not grow in certain areas of her head.

During a July 2010 VA dermatology consultation, the Veteran wore a wig. Her alopecia extended posteriorly across the temporal region, and there was no dyspigmentation.

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In a September 2010 VA treatment note, the examining physician noted that the Veteran had alopecia in an androgenic pattern on the front and temporal areas of her scalp. She also had some follicular drop out on the vertex of her scalp.   There was no erythema, inflammation, or scaling. The physician noted that the Veteran would start Rogaine for women.

During a September 2010 videoconference hearing, the Veteran's representative noted that she had alopecia aereta that ebbed and flowed depending on her stress levels and other factors. He indicated that, at the time of the February 2007 VA examination, the area of the Veteran's scalp affected by alopecia was smaller than normal. The Veteran reported that, typically, there was hardly any hair on the top along her forehead and along the sides of her head. She stated that she had to wear scarves and wigs on her head.

In an October 2011 VA treatment note, the physician noted that the Veteran had been using Rogaine, and she was very pleased with the amount of hair growth, most notably in the frontal and temporal scalp areas. The Veteran reported that she had developed scaly patches on her scalp over the past few weeks and that they were caused by stress. She described them as "bumps" underneath the skin. She denied any pustules or drainage from the areas. An examination of the Veteran's scalp showed several excoriated patches on the scalp with thickening and erythema. The physician noted that the Veteran continued to have diffuse thinning of the hair on the scalp in some areas, and there was scarring evidenced by follicle dropout, but there was notable hair growth since the last appointment. The physician diagnosed the Veteran with dermatitis of the scalp and alopecia. She noted that it was difficult to determine whether there was folliculitis or an irritant process given the degree of secondary changes noted. She prescribed Derma Smooth oil to treat the itch and scaliness.

An October 2011 VA addendum to the previous treatment note documented the Veteran's complaints that the "red bumps** on her scalp had increased in severity and they spread down the back, sides, and front of her head. She reported that the

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In a September 2010 VA treatment note, the examining physician noted that the Veteran had alopecia in an androgenic pattern on the front and temporal areas of her scalp. She also had some follicular drop out on the vertex of her scalp. There was no erythema, inflammation, or scaling. The physician noted that the Veteran would start Rogaine for women.

During a September 2010 videoconference hearing, the Veteran's representative noted that she had alopecia aereta that ebbed and flowed depending on her stress levels and other factors. He indicated that, at the time of the February 2007 VA examination, the area of the Veteran's scalp affected by alopecia was smaller than normal. The Veteran reported that, typically, there was hardly any hair on the top along her forehead and along the sides of her head. She stated that she had to wear scarves and wigs on her head.

In an October 2011 VA treatment note, the physician noted that the Veteran had been using Rogaine, and she was very pleased with the amount of hair growth, most notably in the frontal and temporal scalp areas. The Veteran reported that she had developed scaly patches on her scalp over the past few weeks and that they were caused by stress. She described them as "bumps" underneath the skin. She denied any pustules or drainage from the areas. An examination of the Veteran's scalp showed several excoriated patches on the scalp with thickening and erythema. The physician noted that the Veteran continued to have diffuse thinning of the hair on the scalp in some areas, and there was scarring evidenced by follicle dropout, but there was notable hair growth since the last appointment. The physician diagnosed the Veteran with dermatitis of the scalp and alopecia. She noted that it was difficult to determine whether there was folliculitis or an irritant process given the degree of secondary changes noted. She prescribed Derma Smooth oil to treat the itch and scaliness.

An October 2011 VA addendum to the previous treatment note documented the Veteran's complaints that the "red bumps" on her scalp had increased in severity and they spread down the back, sides, and front of her head. She reported that the

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bumps were painful, did not produce exudate, and were approximately the size of a ballpoint pen point.

In a November 2011 VA emergency department treatment note, the Veteran complained of spreading, red, swollen bumps on the top and side of her head. She indicated that the bumps appeared approximately five weeks earlier, and they were aggravated by her use of hair growth medication.

In a November 2011 VA treatment note, the Veteran claimed that her alopecia and scalp dermatitis was worsening. She indicated that she also had tender bumps on her scalp. She noted that she had eruptions of these bumps in the past before she began using Rogaine. The physician noted that the Veteran had a fine papular or follicular non-scaling rash across the top of her scalp with faint erythematous inflammation. There was no purulent drainage, warmth, or nits. The physician instructed the Veteran to use selenium sulfic shampoo daily.

In a November 2011 statement, the Veteran reported that she was recently treated at a VA emergency room for scalp dermatitis. She related that her scalp "felt like it was on fire" and that the dermatitis covered her entire head. She stated that the bumps were very painful and prevented her from combing her hair. She indicated that she broke out in bumps on her scalp when her stress levels increased.

During a November 2011 VA dermatology consultation, the examining dermatologist noted that the Veteran had a longstanding history of chronic alopecia and recurrent outbreaks on her scalp that had been diagnosed as folliculitis in the past. The Veteran indicated that she had a severe outbreak of large nodules on her scalp over the past week. She related that it was difficult for her to sleep or rest her head against any surface. She stated that she was treated at a VA emergency room and that she received a course of doxcycline that remarkably improved her skin condition. She reported that she had been using Rogaine and Derma Smooth on her scalp. She stated that she did not feel that the Derma Smooth had made her scalp any worse since she started using it. Examination of the Veteran's scalp, face, and neck showed several erythematous folliculocentric papules and surrounding scale consistent with folliculitis. She had scarring in the crown and vertex of the scalp

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with follicle dropout and some patchy alopecia on the bilateral temples. There was no evidence of active inflammation. The dermatologist prescribed an extended course of doxycycline.

In a January 2012 VA treatment note, the Veteran noted that she had been gradually tapering off her dose of doxycycline, and she had good hair regrowth. She also indicated that she continued to have a good clinical response to her use of Derma Smooth. Examination of the scalp showed hair loss primarily on the frontal scalp extending onto the temples. There was no appreciable scarring.

During a June 2012 VA skin diseases examination, the Veteran indicated that she had some mild hair regrowth in a few areas of the scalp from the minoxidil that she used on a regular basis. She noted that she also used Derma Smooth oil for itching. She reported that she used topical corticosteroids and other topical medications constantly or near-constantly for twelve months. An examination showed that dermatitis affected less than five percent of the total body area and five to 20 percent of the exposed area. The examiner diagnosed the Veteran with central centrifugal cicatricial alopecia. He noted that the Veteran had areas of prominent hair loss concentrated in the frontal, temporal, and lower occipital areas of the head. She also had thinning of the hair over the crown of her head and fibrosis of the scalp in a few areas with more prominent hair loss. He estimated that over 40 percent of the scalp was affected by scarring alopecia; specifically, he estimated that 70 percent of the scalp had some degree of involvement.

In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to a higher initial evaluation for her alopecia areata with scarring.

At the outset, the Board notes that the Veteran is competent to describe her current symptoms, such as scaly skin, erythematous folliculocentric papules, scarring, and hair loss. Lay persons are competent to provide testimony as to observable symptoms and manifestations of a disorder. Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v.

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Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370, 274 (2002) (finding Veteran competent to testify to symptomatology capable of lay observation); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005).

The Veteran is currently assigned a 10 percent evaluation under Diagnostic 7831, which is the maximum rating available under that code. Consequently, a higher initial evaluation cannot be assigned under that rating criteria.

In order to warrant a higher evaluation under Diagnostic Code 7830, the evidence of record must demonstrate that the Veteran's scarring alopecia affects more than 40 percent of her scalp. In this case, the June 2012 VA examiner reported that the alopecia affected more than 40 percent of her scalp; specifically, he estimated that the alopecia affected approximately 70 percent of her scalp. Therefore, the Veteran is entitled to a higher initial evaluation of 20 percent under Diagnostic Code 7830. The Board also observes that 20 percent is the highest rating possible under Diagnostic Code 7830; therefore, a higher evaluation cannot be assigned under that rating criteria.

Nevertheless, the Board has considered whether an evaluation in excess of 20 percent would be in order under any other relevant diagnostic codes. The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher rating under another Diagnostic Code. See Tedeschi v. Brown, 1 Vet. App. 411,414 (1995).

The Board notes that Diagnostic Codes 7830 and 7831 specifically apply to scarring alopecia and alopecia areata. Therefore, they are the most appropriate diagnostic codes in this case.

Diagnostic Codes 7800, 7801, and 7804 apply to scars of the head, face, or neck. The Board does observe that the Veteran was noted as having scarring in October

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2011 and November 2011; however, the February 2007 VA examiner specifically stated that the Veteran had no scarring. Likewise, in a January 2012 VA treatment note, the examiner noted that there was no scarring on examination of the Veteran's scalp. Moreover, the evidence does not show that the Veteran has visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips; two or three characteristics of disfigurement; or five or more scars that are unstable or painful. Therefore, under Diagnostic Codes 7800 and 7804, the Veteran is not entitled to a higher evaluation for her alopecia.

There are no other Diagnostic Codes pertaining to disabilities of the skin that would be appropriate for rating the Veteran's alopecia. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7833 (2008, 2013). The Board notes that many of these codes specifically apply to disabilities not affecting the head, and others are either did not provide an evaluation in excess of 20 percent or would not be analogous to alopecia. There has been no allegation to the contrary.

Based on the foregoing, the Board concludes that the Veteran's alopecia more nearly approximates the criteria for a 20 percent rating, but no higher.

In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's alopecia is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1).

The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for

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that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization).

The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Veteran's chief complaint of hair loss is fully considered in the assignment of the 20 percent disability rating. Moreover, there are higher ratings available under the diagnostic codes for various symptoms of the disorder, but the Veteran's disability is not productive of such manifestations.

The Board further observes that, even if the available schedular evaluation for the disability is inadequate, the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent hospitalizations for her alopecia, and there is nothing in the record to indicate that the Veteran's disability causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) [noting that the disability rating itself is recognition that industrial capabilities are impaired].

Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected alopecia under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996);

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Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008).

ORDER

The appeal for service connection for carpal tunnel syndrome is dismissed.

Service connection for sight and speech impairment is denied.

Service connection for a bilateral foot disorder is denied.

Service connection for hypertension is denied.

Service connection for a bilateral hand and wrist disorder, to include deteriorating bone disease, is denied.

Subject to the provisions governing the award of monetary benefits, an initial 20 percent evaluation for alopecia is granted.

REMAND

With respect to the Veteran's claim of entitlement to service connection for vaginal discomfort and bleeding, the Board notes that the Veteran was treated for an irregular menstrual pattern during service, that she noted a change in her menstrual pattern in an undated report of medical history during her separation examination, and that she was diagnosed with menometrorrhagia in an October 2003 private internal medicine evaluation. In a February 2006 VA treatment note, the Veteran reported that she had heavy menstrual bleeding since 1980. During a January 2007 VA gynecological conditions examination, the Veteran reported that she had unpredictable menstrual cycles, cramping, and dysmenorrhea that began in service; however, the examiner opined that there was no evidence that the Veteran's current bleeding and vaginal discomfort were caused by an event that occurred during

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service. The examiner noted that the service treatment notes show some dysfunctional bleeding while the Veteran was taking oral contraceptives, and treatment for vaginitis caused by trichomonas and "	type/' The examiner did not address the October 2003 diagnosis of menometrorrhagia.

In addition, a review of the evidence of record shows that the Veteran had a hysterectomy and endometrial ablation in April 2011, and she had endometrial biopsies in September 2010 and December 2011. VA treatment notes from the Central Arkansas Veterans Healthcare System include consent forms for these procedures, but no operative or laboratory reports have been associated with the record.

On remand, the RO/AMC should obtain a clarifying opinion to determine the etiology of the Veteran's claimed vaginal discomfort and bleeding disorder.

With respect to the claim of entitlement to service connection for headaches, the Board notes that the Veteran was treated for headaches in service, and she noted that she had frequent or severe headaches in an undated report of medical history during her separation examination. The Veteran has reported that her headaches were caused by job stress (see March 2004 private medical evaluation for workers' compensation), bronchitis and allergies (see January 2006 statement), and hypertension (see January 2007 VA examination and October 2011 VA treatment note). In a February 2005 VA treatment note, the examiner opined that the Veteran's headaches were due to her carpal tunnel or right shoulder complaints. In a January 2007 VA examination report, the examiner noted that the Veteran had headaches for five to six years and that they were related to "psychological factors." In a July 2012 VA treatment note, a physician opined that the headaches were most probably related to cervical radiculopathy. Therefore, on remand, a clarifying opinion must be obtained to determine the etiology of the Veteran's claimed headache disorder.

With respect to the issue of entitlement to service connection for memory and concentration loss, the Veteran has asserted that her memory and concentration difficulty are caused by her bronchitis and allergies. See January 2006 statement.

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VA treatment notes indicate that the Veteran also requested VA neuropsychological testing to evaluate her memory loss. See June 2009 VA mental health note. The March 2009 VA neuropsychological testing showed mildly abnormal neuropsychological test results and a profile consistent with a personality disorder and/or paranoid traits. The Board notes that the Veteran is service-connected for major depressive disorder. Therefore, on remand, a VA examination should be scheduled to obtain an opinion as to whether the Veteran has a separate memory and concentration disorder, to include as secondary to her service-connected major depressive disorder.

With respect to the issue of entitlement to service connection for abdominal pain and ulcers, the Board notes that the June 2012 VA stomach conditions examination was inadequate. The VA examiner noted that no diagnostic imaging studies or procedures had been performed. In addition, he reported that his review of the claims file showed no treatment for stomach ulcers or a stomach disability in service and no evidence of a current stomach disability related to service. However, the Board's review of the evidence of record finds that the Veteran was diagnosed with peptic ulcer disease and gastritis in an October 2003 private internal medical evaluation, and a September 2006 VA esophagogastroduodenoscopy showed a hiatus hernia. Therefore, on remand, the Veteran should be scheduled for a VA examination to determine whether the Veteran has a current abdominal disorder, and an opinion must be obtained to determine the etiology of the claimed disorder.

With respect to the issues of entitlement to service connection for a respiratory condition, bronchitis, and sinusitis and allergies, the Board notes that the Veteran was treated for rhinitis (see February 1976 and February 1977 service treatment notes) and chest pain upon breathing (see April 1976 service treatment note) during service. However, she also indicated that she smoked three to four packs of cigarettes per day (see November 1978 service treatment note) and that her chest pains disappeared when she quit smoking during service (see December 1978 service treatment note). In an undated report of medical history completed during the separation examination, she noted pain or pressure in her chest, but she denied asthma, shortness of breath, and chronic cough. During a January 2007 VA examination, the Veteran reported that she had upper respiratory allergic symptoms

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with rhinitis, postnasal drainage, and coughing when she was stationed in Africa in the 1970's. The examiner diagnosed the Veteran with exercise-induced asthma; however, he noted that the claims file was not available to him for review, and he did not provide an etiological opinion with respect to these claimed conditions. In a June 2012 VA respiratory examination, the examiner noted that the Veteran was not treated for a chronic bronchial or pulmonary condition in service and that multiple pulmonary function tests (PFTs) were normal. He opined that the Veteran did not have a respiratory condition related to service. However, he also noted that the Veteran was diagnosed with asthma and acute bronchitis in 2006 and that she required the use of inhaled bronchodilator therapy on a daily basis.   In September 2013, a VA examiner noted that he reviewed the Veteran's claims file and there were no changes to the June 2012 VA respiratory examination. Therefore, on remand, a clarifying opinion must be obtained to determine the etiology of the Veteran's claimed respiratory condition, bronchitis, and sinusitis and allergies.

Finally, the Board notes that the claim of entitlement to nonservice-connected pension is inextricably intertwined with other matters being remanded, as the development necessary could be relevant to this claim.

Accordingly, the case is REMANDED for the following action:

(Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.)

1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for her claimed disorders. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file.

A specific request should also be made for any outstanding VA treatment records, to include, but not limited to any VA treatment notes dated prior to 2006 and

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dated after 2013. A request should also be made for any VA hysterectomy, endometrial ablation, and endometrial biopsy procedure notes, operative reports, and laboratory reports related to these procedures dated in September 2010. April 2011. and December 2011.

2. After completing the foregoing development, The AOJ should obtain a clarifying medical opinion from the VA examiner who conducted the January 2007 VA gynecological examination, or, if he or she is not available or unable to provide the requested opinions, an appropriate clinician, to obtain a clarifying medical opinion concerning the Veteran's claimed vaginal disorder, as to the directives set forth below.

Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements.

The examiner should specifically note that the Veteran was treated for an irregular menstrual pattern during service, that she noted a change in her menstrual pattern in an undated report of medical history during her separation examination, and that she was diagnosed with menometrorrhagia in an October 2003 private internal medicine evaluation.

It should be noted that the Veteran is competent to attest to observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation.

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The examiner should identify all current vaginal disorders. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to her military service. In rendering this opinion, the examiner should address the Veteran's treatment and complaints of an irregular menstrual pattern during service and the October 2003 diagnosis of menometrorrhagia.

(The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.)

A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review.

3. The AOJ should obtain a clarifying medical opinion from the VA examiner who provided the January 2007 VA medical opinion, or, if he or she is not available or unable to provide the requested opinions, an appropriate clinician, to obtain a clarifying medical opinion concerning the Veteran's claimed headache disorder, as to the directives set forth below.

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Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements.

The examiner should specifically note that the Veteran was treated for headaches in service and indicated that she had frequent or severe headaches in an undated report of medical history during her separation examination.

It should be noted that the Veteran is competent to attest to observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation.

The examiner should identify all current headache disorders. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to her military service. In rendering this opinion, the examiner should consider the following evidence:

a.	A March 2004 private medical evaluation for
workers' compensation in which the Veteran has
reported that her headaches were caused by job stress;

b.	A January 2007 VA examination report and an
October 2011 VA treatment note, in which the
headaches were said to be related to the Veteran's
hypertension;

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c.	A January 2006 statement in which the Veteran
reported that her headaches were caused by bronchitis
and allergies;

d.	A February 2005 VA treatment note in which the
examiner opined that the Veteran's headaches were
due to her carpal tunnel or right shoulder complaints;

e.	A January 2007 VA examination report in which
the examiner noted that the Veteran had headaches for
five to six years and that they were related to
"psychological factors/* (The examiner should note
that the Veteran is service-connected for major
depression.); and

f.	A July 2012 VA treatment note in which the
examiner opined that the headaches were most
probably related to cervical radiculopathy.

(The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.)

A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review.

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4. The AOJ should schedule the Veteran for a VA examination to determine the nature and etiology of any memory and concentration loss that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements.

It should be noted that the Veteran is competent to attest to observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation.

The examiner should identify all current memory and concentration loss disorders. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to her military service. In rendering this opinion, the examiner should consider the following evidence:

a.	A January 2006 statement in which the Veteran
asserted that her memory and concentration difficulty
are caused by her bronchitis and allergies;

b.	A June 2009 VA mental health note that indicates
that the Veteran requested VA neuropsychological
testing to evaluate her memory loss; and

c.	The March 2009 VA neuropsychological testing
that showed mildly abnormal neuropsychological test
results and a profile consistent with a personality

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disorder and/or paranoid traits. (The examiner should note that the Veteran is service-connected for major depressive disorder.)

(The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.)

A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history!,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review.

5. The AOJ should schedule the Veteran for a VA examination to determine the nature and etiology of any abdominal disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements.

It should be noted that the Veteran is competent to attest to observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation.

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The examiner should identity all current abdominal disorders. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to her military service. In rendering this opinion, the examiner should consider the following evidence:

a.	An October 2003 private internal medical evaluation,
in which the Veteran was diagnosed with peptic ulcer
disease;

b.	A March 2004 private evaluation for workers'
compensation disability, in which the Veteran related that
she had gastrointestinal problems due to stress from her
job;

c.	A March 2005 private treatment note, in which the
Veteran was treated for peptic ulcer disease and gastritis;

d.	A normal VA colonoscopy report, dated in September
2006;

e.	A September 2006 VA esophagogastroduodenoscopy
report, which noted a hiatus hernia was found;

f.	A January 2007 VA examination report, in which the
Veteran reported an onset of gastrointestinal symptoms in
2002; and

g.	A June 2012 VA stomach conditions examination
report.

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 (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.)

A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history!,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review.

6. The AOJ should obtain a clarifying medical opinion from the VA examiner who provided the June 2012 VA medical opinion, or, if he or she is not available or unable to provide the requested opinions, an appropriate clinician, to obtain a clarifying medical opinion concerning the Veteran's claimed respiratory disorder, bronchitis, and sinusitis and allergy disorders, as to the directives set forth below.

Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements.

The examiner should specifically note that the Veteran was treated for rhinitis and chest pain upon breathing in service.

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It should be noted that the Veteran is competent to attest to observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation.

The examiner should identify all current respiratory condition, bronchitis, and sinusitis and allergy disorders. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to her military service. In rendering this opinion, the examiner should consider the following evidence:

a.	February 1976 and February 1977 service
treatment notes, in which the Veteran was treated for
rhinitis;

b.	An April 1976 service treatment note in which the
Veteran complained of chest pain upon breathing;

c.	A November 1978 service treatment note in which
the Veteran indicated that she smoked three to four
packs of cigarettes per day;

d.	A December 1978 service treatment note in which
the Veteran reported that her chest pains disappeared
when she quit smoking;

e.	An undated report of medical history completed
during the separation examination in which the
Veteran noted pain or pressure in her chest, but she

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denied asthma, shortness of breath, and chronic cough;

f.   A January 2007 VA examination report in which the Veteran reported that she had upper respiratory allergic symptoms with rhinitis, postnasal drainage, and coughing when she was stationed in Africa in the 1970's.

In addition, the examiner should comment on the January 2007 VA examiner's diagnosis of exercise-induced asthma and the June 2012 VA examiner's notation that multiple PFTs in the record were normal, despite his finding that she required the use of inhaled bronchodilator therapy on a daily basis.

(The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.)

A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "'that each disability be viewed in relation to its history[,]'* 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review.

7. After completing these actions, the AOJ should conduct any other development as may be indicated by a

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response received as a consequence of the actions taken in the preceding paragraphs.

8. Thereafter, the AOJ should consider all of the evidence of record, and readjudicate the service connection and nonservice-connected pension issues on appeal. If the benefits sought are not granted, the AOJ should issue a Supplemental Statement of the Case and allow the Veteran and her representative an opportunity to respond.

The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013).

J.W. ZISSIMOS 
Veterans Law Judge, Board of Veterans' Appeals

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