Citation Nr: 1124331 Decision Date: 06/27/11 Archive Date: 07/06/11 DOCKET NO. 06-23 987 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a bilateral wrist and hand disorder. 2. Entitlement to service connection for a respiratory disorder, claimed as asthma and chronic cough. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Barstow, Associate Counsel INTRODUCTION The Veteran had active military service from November 1990 to June 1991. She also had service in the Reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an April 2005 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia denied service connection for a bilateral wrist and hand disorder and denied service connection for a respiratory disorder, claimed as asthma and chronic cough. In May 2009, the Veteran testified at a hearing before the undersigned. A transcript of the hearing has been associated with the claims file. The case was remanded by the Board in July 2009 to afford the Veteran VA examinations. A review of the record indicates that the Board's remand directives were substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. A bilateral wrist and hand disorder was first diagnosed many years after the Veteran's active duty and is not causally or etiologically related to such service. 2. At no time during the current appeal has a respiratory disorder been diagnosed; there is no indication that the Veteran's respiratory complaints are the result of an undiagnosed illness or medically unexplained chronic multi-symptom illness. CONCLUSIONS OF LAW 1. A bilateral wrist and hand disorder was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.317 (2010). 2. A respiratory disorder was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, a pre-decisional notice letter in February 2005 complied with VA's duty to notify the Veteran with regards to the service connection claims on appeal. Specifically, this letter apprised the Veteran of what the evidence must show to establish entitlement to the benefit, what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. Since the Board has concluded that the preponderance of the evidence is against the claims for service connection, any questions as to the appropriate disability ratings or effective dates to be assigned are rendered moot, and no further notice is needed. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Regarding VA's duty to assist, the RO obtained the Veteran's service treatment records (STRs), post-service medical records, and secured examinations in furtherance of her claims. VA has no duty to inform or assist that was unmet. The Veteran has not identified any additional pertinent medical records, which have not been obtained and associated with the claims folder. Pertinent VA opinions with respect to the issues on appeal were obtained in December 2009 (bilateral wrists and hands) and March 2010 (respiratory). 38 C.F.R. § 3.159(c)(4). To that end, 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 VA examinations obtained in this case are sufficient, as they considered all of the pertinent evidence of record, including the statements of the Veteran, and provided explanations for the opinions stated. Thus, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the issues adjudicated herein has been met. 38 C.F.R. § 3.159(c)(4). II. Analysis Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (1995). Certain chronic diseases, including arthritis, may be presumptively service connected if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307(a)(3); 3.309(a) (2010). In addition to service connection on a direct basis, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2011. 38 U.S.C.A. § 1117 (West 2002 & Supp. 2010); 38 C.F.R. § 3.317 (2010). For purposes of section 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). An undiagnosed illness is defined as a condition that, by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). A medically unexplained chronic multi-symptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. A medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2). Additionally, effective September 29, 2010, presumptive service connection is warranted with the manifestation of the following infectious diseases: (i) brucellosis, (ii) campylobacter jejuni, (iii) Coxiella burnetii (Q fever), (iv) malaria, (v) mycobacterium tuberculosis, (vi) nontyphoid salmonella, (vii) shigella, (viii) visceral leishmaniasis, and (ix) West Nile virus. 75 Fed. Reg. 59,968, 59,971 (Sept. 29, 2010); to be codified at 38 C.F.R. § 3.317. In the present appeal, the Veteran is not claiming service connection for any of those diseases. Additionally, a veteran is considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, except where clear and unmistakable evidence demonstrates that an injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111. Thus, veterans are presumed to have entered service in sound condition as to their health. This presumption attaches only where there has been an induction examination in which the later complained-of disability was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulation provides expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b), and that "[h]istory of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions." Id. at (b)(1). Prior provisions of 38 C.F.R. § 3.304(b) only required a finding that clear and unmistakable evidence showed that a injury or disease existed prior to service in order to rebut the presumption of soundness. However, the provisions of 38 C.F.R. § 3.304(b) were invalidated as being inconsistent with 38 U.S.C.A. § 1111. See generally Cotant v. Principi, 17 Vet. App. 116 (2003), Jordan v. Principi, 17 Vet. App. 261 (2003), Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004), VAOPGCPREC 3-2003 (July 16, 2003). Pursuant to these developments, it is now clear that in order to rebut the presumption of soundness at service entry, there must be clear and unmistakable evidence showing that the disorder preexisted service and there must be clear and unmistakable evidence that the disorder was not aggravated by service. See 38 C.F.R. § 3.304 (b) (2010). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 3-2003 (July 16, 2003). Before these above cited precedent opinions, VAOPGCPREC 3- 2003, and the recent regulatory amendment, VA had the burden to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability pre-existed service. If VA met this burden, however, it then had the burden to rebut the presumption by a preponderance of the evidence (a lower standard) that the preexisting disorder was not aggravated by service. Now, VA must also show by clear and unmistakable evidence that the preexisting disorder was not aggravated during service (a higher standard). A preexisting injury or disease will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306(b) (2010); Falzone v. Brown, 8 Vet. App. 398, 402 (1995). Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). 1. Bilateral Wrist and Hand Disorder The Veteran contends that she has a bilateral wrist and hand disorder that is related to her military service, including being the result of chemical exposures while stationed in Southwest Asia during the Persian Gulf War. According to the Veteran's DD 215, she had service in Southwest Asia and received the Southwest Asia Service Medal and Kuwait Liberation Medal. Thus, her service in the Southwest Asia theater of operations during the Persian Gulf War is confirmed. The Veteran's testimony at her May 2009 hearing indicates that she began experiencing problems with her bilateral wrists and hands during her deployment. She also indicated that she might have fibromyalgia. The Veteran's STRs show that she fractured her right wrist in 1988, prior to her active service. The medical evidence shows, and the Veteran acknowledges, that she had a preexisting right wrist injury prior to her period of active service. Thus, the Board finds that the presumption of soundness with regards to the Veteran's right wrist has been rebutted. Prior to her active service, a record dated in March 1990 reveals that the Veteran reported having numbness in both hands. A nerve conduction study in April 1990 was normal. An orthopedic consult in November 1990 shows that the Veteran had a healed fracture in the right wrist; she had some weakness in grasp in her right hand and also lacked 30 degrees of supination. In her November 1990 deployment examination, the Veteran indicated having swollen and painful joints. A notation that the Veteran could not fully dorsiflex her right wrist was made. Her demobilization examination in May 1991 indicated a shortened right wrist and a positive Tinel sign in the right wrist. Carpal tunnel syndrome in the right wrist was diagnosed. According to post-service medical records, the Veteran reported having bilateral arm and joint pain in the evenings in April 2006. The Veteran was afforded a fee-based examination for her right wrist in May 2006. She reported fracturing her wrist in 1988 and having symptoms for 18 years. Following an exhaustive examination, the Veteran was diagnosed with right wrist fracture with residuals of mild to moderate degenerative joint disease, wrist flexion and extension contractures, and decreased sensation. No medical opinion was provided. None of the Veteran's post-service medical records indicate a diagnosis of fibromyalgia or indicate that her symptoms are the result of an undiagnosed illness. Additionally, none of the Veteran's post-service medical records contain any opinion relating a bilateral wrist and hand disorder to her military service, including being the result of chemical exposures while stationed in Southwest Asia during the Persian Gulf War. The Veteran was afforded a VA examination in December 2009. The examiner noted that the Veteran was found to have carpal tunnel syndrome and status post-Colles fracture of the right wrist in May 1991. In June 2009, bilateral nerve conduction studies showed carpal tunnel syndrome on both sides. Regarding her right wrist, the Veteran reported the 1988 fracture that was treated uneventfully. Residual disability included some restriction of motion. The examiner noted that in reviewing the Veteran's service records, neither wrist caused any significant problems. The Veteran reported that in 1995, both wrists began to hurt and she began to have some numbness in the fingertips. She had a right carpal tunnel release in 2002; a diagnosis of carpal tunnel syndrome was clinically made and she did not have any electrodiagnostic studies done at that time. Following an exhaustive examination, the Veteran was diagnosed with a healed right wrist Colles avulsion fracture; right wrist metacarpophalangeal joint (MCP) degenerative joint disease; and left wrist MCP degenerative joint disease. With regards to the Veteran's right wrist, the examiner opined that during the Veteran's military service, there was no evidence that the wrist caused problems, although there was a curious diagnosis of carpal tunnel syndrome although there was no basis for the diagnosis in her separation examination. The examiner opined that it was less likely as not that the Veteran's healed right wrist fracture was permanently aggravated by her military service. Subsequent to that, she was found to have carpal tunnel syndrome. The examiner concluded that first carpometacarpal joint arthritis of the right wrist with prior carpal tunnel syndrome and minimal disability in the right hand was less likely as not related to her military service. Turning to the Veteran's left wrist MCP degenerative joint disease, the examiner also opined that it was less likely as not related to her military service. The examiner also opined that the Veteran did not have the symptoms to warrant a clinical diagnosis of carpal tunnel syndrome. Therefore, such diagnosis could not be made at that time. Based on a review of the evidence, the Board finds that service connection for a bilateral wrist and hand disorder is not warranted. Beginning with the Veteran's right wrist, the evidence does not indicate that her preexisting healed fracture was aggravated by service. As discussed by the December 2009 examiner, the Veteran's STRs do not show any aggravation of her preexisting right wrist injury. The only medical opinion of record, that of the December 2009 VA examiner, indicates that it was less likely as not that the Veteran's healed right wrist fracture was permanently aggravated by her military service. That opinion is uncontradicted. Thus, the Board finds that the Veteran's preexisting right wrist injury clearly and unmistakably was not aggravated by her military service. Additionally, her STRs do not show any in-service incurrence or aggravation of an injury or disease to her wrists or hands. Therefore, the Board finds that the evidence does not support a finding of an injury or disease to her wrists and hands actually occurred. In reaching this conclusion, the Board acknowledges that the evidence does indicate exposure to chemicals in service. However, no medical professional has indicated that such exposure caused any injury or disease to her wrists and hands. The Board also acknowledges the Veteran's testimony regarding her symptomatology beginning in service. The Board acknowledges the Veteran's competent testimony regarding having bilateral wrist and hand problems since service. The Board finds that this lay evidence is competent and credible as to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Competent testimony is limited to that which the witness has actually observed, and is within the realm of her personal knowledge; such knowledge comes to a witness through use of her senses, that which is heard, felt, seen, smelled or tasted. Layno v. Brown, 6 Vet. App. 465 (1994). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the later is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno at 469; see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("Although interest may affect the credibility of testimony, it does not affect competency to testify."). However, the provisions concerning continuity of symptomatology do not relieve the requirement that there must be some evidence of a nexus to service. For service connection to be established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage v. Gober, 10 Vet. App. 488, 495-98 (1997). In this case, there is no medical evidence that relates any current disorder to the Veteran's subjective complaints. In other words, in the current appeal, the Veteran has simply contended that she has experienced bilateral wrist and hand problems since service. Such contentions alone do not support a grant of service connection for a bilateral wrist and hand disorder based on continuity of symptomatology. Moreover, there is no nexus evidence to support a finding of service connection. No medical professional has provided any opinion that the Veteran has a bilateral wrist and hand disorder that is related to her military service. The Board acknowledges that the May 1991 demobilization examination showed a diagnosis of carpal tunnel syndrome and that the Veteran was also diagnosed with carpal tunnel syndrome in 2009. However, the December 2009 examiner noted that the in-service examination did not provide any basis for the diagnosis. In this regard, the Board observes that nerve conduction studies in April 1990 were normal. The Veteran's STRs do not include any nerve conduction studies to support the diagnosis of carpal tunnel syndrome. As opined by the December 2009 examiner, carpal tunnel syndrome is a clinical diagnosis. In light of the VA examiner's opinion and the lack of nerve conduction studies showing carpal tunnel syndrome in service, the Board cannot conclude that any post-service carpal tunnel syndrome had its onset in service. Additionally, the Board finds that the evidence does not support a finding that the Veteran's complaints are related to diagnosis of fibromyalgia or are the result of an undiagnosed illness. As noted above, the Veteran's medical records do not reveal any diagnosis of fibromyalgia. Rather, her bilateral wrist and hand complaints have been attributed to carpal tunnel syndrome and arthritis. As such, there is no indication that the Veteran has either fibromyalgia or an undiagnosed illness. Moreover, as there is no evidence that arthritis was manifest to a degree of 10 percent or more within one year of the Veteran's discharge from service, service connection on a presumptive basis is not warranted. See 38 C.F.R. §§ 3.307, 3.309. Furthermore, as previously discussed herein, the claims folder contains no competent evidence of a relationship between a bilateral wrist and hand disorder and the Veteran's active duty. Without evidence of an in-service event, injury, or disease to the Veteran's bilateral wrists and hands or competent evidence of an association between a bilateral wrist and hand disorder and her active duty, service connection for a bilateral wrist and hand disorder is not warranted. The Board acknowledges the Veteran's belief that she has a bilateral wrist and hand disorder that is related to her military service. The Board also acknowledges that the Veteran is a nurse; accordingly, she does have the specialized medical education, training, and experience necessary to render competent medical opinion as to diagnosis and etiology of a disability. Espiritu v. Derwinski, 2 Vet. App. 492 (1992); 38 C.F.R. § 3.159(a) (1) (2010). However, the Board finds that the Veteran's assertions are outweighed by the copious medical records, which do not indicate that any bilateral wrist and hand disorder is related to her military service. Accordingly, and based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for a bilateral wrist and hand disorder. As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for a bilateral wrist and hand disorder is denied. See 38 U.S.C.A §5107 (West 2002 & Supp. 2010). 2. Respiratory Disorder The Veteran contends that she has a respiratory disorder, claimed as asthma and a chronic cough that was incurred in her military service. She contends that she first experienced symptomatology after being exposed to oil fires and other toxic chemicals when stationed in Southwest Asia during the Persian Gulf War. The Veteran's STRs include a May 1991 record following her deployment indicating that she had had a cough for nine months while deployed. However, in her demobilization examination also dated in May 1991, the Veteran answered no to having shortness of breath, a chronic cough, or asthma. A reserve record dated in November 1996 reveals that she reported having asthma following her service in Southwest Asia. Post-service medical records include a bronchochallenge report dated in January 2000. However, no diagnosis was made. A record dated in February 2005 reveals a complaint of dyspnea; a second record also dated in February 2005 shows that the Veteran denied having a cough and shortness of breath. In May 2005, the Veteran denied having a cough, shortness of breath, or dyspnea. At a fee-based psychiatric examination, the Veteran reported having an asthma-like condition that had been present since 1991. The examiner diagnosed, in pertinent part, asthma-like symptoms still under observation. A review of the Veteran's post-service medical records does not contain a clear diagnosis of any respiratory disorder. Additionally, there are no medical opinions indicating that the Veteran's complaints were related to her service. The Veteran testified at her May 2009 hearing that she had no respiratory problems prior to service and that they began following smoke from oil fires. She testified that her respiratory problems were chronic since service. The Veteran was afforded a VA examination in March 2010. She reported that the onset of asthma and a chronic cough was in May 1991. The Veteran reported exposure to burning oil fires in service and felt that she was exposed to Sarin gas when dumps were exploded. Following an exhaustive examination that included pulmonary function testing, the diagnosis was no organic respiratory pathology or condition found. The examiner explained that the Veteran complained of cough with normal examination, normal pulmonary function tests, and very limited service records about that condition. The examiner opined that it was at least as likely as not that her respiratory symptoms of dyspnea were related to her service-connected severe PTSD with agoraphobia and panic attacks causing dyspnea. Based on a review of the evidence, the Board finds that service connection for a respiratory disorder is not warranted. Her STRs do not show any in-service incurrence or aggravation of an injury or disease to her respiratory system. Therefore, the Board finds that the evidence does not support a finding of an injury or disease to her respiratory system actually occurred. In reaching this conclusion, the Board acknowledges that the evidence does indicate exposure to chemicals from fires in service. Furthermore, the Board acknowledges the Veteran's competent and credible testimony, in addition to the May 1991 service record, indicating that she first experienced coughing in service. However, no medical professional has indicated that such exposure caused any injury or disease to her respiratory system. Moreover, no chronic respiratory disability has been shown. Even though the Veteran has continued to report respiratory complaints post-service, there is no competent medical evidence of any underlying respiratory disability to account for her complaints. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110, 1131; see Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In other words, the evidence must show that the Veteran currently has the disability for which benefits are being claimed. Here, there is no competent medical evidence reflective of a respiratory disorder at any time during the current appeal. As discussed above, the March 2010 examiner found no organic respiratory pathology or condition. Rather, the examiner opined that the Veteran's symptom of dyspnea was at least as likely as not related to her service-connected severe PTSD with agoraphobia and panic attacks. That opinion is uncontradicted. The Board acknowledges the representative's argument that the Veteran's respiratory complaints are the result of an undiagnosed illness and that a new examination is necessary to obtain a medical opinion regarding whether the Veteran's respiratory symptoms are attributed to an undiagnosed illness. However, the Board finds that the March 2010 examiner's opinion attributing the Veteran's symptoms to her panic attacks associated with her service-connected PTSD is adequate. There is no indication that the examiner does not possess the medical expertise to render such opinion. In other words, the evidence of record does not show that the March 2010 examiner's opinion is incorrect. Furthermore, the Board cannot substitute its medical judgment and find that the examiner incorrectly attributed the Veteran's symptoms to her PTSD instead of an undiagnosed illness. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Therefore, a new opinion is not necessary. The Board also acknowledges that signs or symptoms involving the respiratory system (upper or lower) may be manifestations of an undiagnosed illness or medically unexplained chronic multi-symptom illness. See 38 C.F.R. § 3.317(b). However, the only medical opinion of record, that of the March 2010 examiner, indicates that the Veteran's symptoms are the manifestations of a symptom associated with her service-connected PTSD. No medical professional has provided any opinion to indicate that the Veteran's respiratory complaints are a manifestation of an undiagnosed illness or medically unexplained chronic multi-symptom illness. Therefore, the Board cannot find that the Veteran has a undiagnosed illness or medically unexplained chronic multi-symptom illness that is manifested by respiratory signs or symptoms. Rather, her complaints have been related to a symptom of a service-connected psychiatric disability. Additionally, there is no nexus evidence to support a finding of service connection. No medical professional has provided any opinion that the Veteran has a respiratory disorder that is related to her military service. Therefore, the Board cannot conclude that the Veteran has a respiratory disorder that was incurred in her service or that is related to her service. Furthermore, as previously discussed herein, the claims folder contains no competent evidence of a relationship between a respiratory disorder and the Veteran's active duty. Without evidence of an in-service event, injury, or disease to the Veteran's respiratory system or competent evidence of an association between a respiratory disorder and her active duty, service connection for a respiratory disorder is not warranted. The Board acknowledges the Veteran's belief that she has a respiratory disorder that is related to her military service. The Board also acknowledges that the Veteran is a nurse; accordingly, she does have the specialized medical education, training, and experience necessary to render competent medical opinion as to diagnosis and etiology of a disability. Espiritu, 2 Vet. App. 492; 38 C.F.R. § 3.159(a) (1). However, the Board is more persuaded by the objective pulmonary function test at the March 2010 examination, which failed to show any organic respiratory pathology or condition. Additionally, the Board is also persuaded by the copious medical records, which do not indicate a respiratory disorder related to her military service. Accordingly, and based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for a respiratory disorder, claimed as asthma and chronic cough. At no time since the Veteran filed her claim for service connection for a respiratory disorder in February 2005 has any chronic respiratory disorder been diagnosed or have her symptoms been attributed to an undiagnosed illness or medically unexplained chronic multi-symptom illness. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (in which the Court held that, in the absence of proof of a present disability, there can be no valid claim). See also McClain v. Nicholson, 21 Vet. App. 319 (2007) (which stipulates that a service connection claim may be granted if a diagnosis of a chronic disability was made during the pendency of the appeal, even if the most recent medical evidence suggests that the disability resolved). As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for a respiratory disorder, claimed as asthma and chronic cough is denied. See 38 U.S.C.A §5107. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for a bilateral wrist and hand disorder is denied. Entitlement to service connection for a respiratory disorder, claimed as asthma and chronic cough is denied. ____________________________________________ ROBERT E. SULLIVAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs