Citation Nr: 1136745 Decision Date: 09/29/11 Archive Date: 10/11/11 DOCKET NO. 07-14 916 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for breast cancer, to include as due to radiation, nerve agent, and depleted uranium exposure. 2. Entitlement to service connection for mitral valve prolapse with mild regurgitation/heart murmur. 3. Entitlement to service connection for irritable bowel syndrome (IBS). 4. Entitlement to service connection for chronic constipation. 5. Entitlement to service connection for rash on face and hands. 6. Entitlement to service connection for jaw pain. 7. Entitlement to service connection for endometriosis and ovarian cysts. 8. Entitlement to service connection for bilateral shoulder disability. 9. Entitlement to service connection for bilateral hip disability. 10. Entitlement to service connection for fibromyalgia. 11. Entitlement to service connection for a sleeping disorder. 12. Entitlement to service connection for headaches. 13. Entitlement to service connection for posttraumatic stress disorder (PTSD) with anxiety, depression, and adjustment disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and her husband ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The Veteran served on active duty from November 1987 to September 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2006 decision by the above Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for the listed issues. In December 2008, a hearing was held before the undersigned Veterans Law Judge (VLJ) sitting at the RO. A transcript of the hearing has been associated with the claims file. The appeal was remanded in May 2009 for additional development of the record, to include obtaining service records, VA treatment records, and VA examinations. As noted in the Board's May 2009 remand, the Veteran raised a claim of entitlement to compensation pursuant to 38 U.S.C.A. § 1151 for breast cancer during her hearing. The Board acknowledged that the current appeal included entitlement to service connection for breast cancer but that a claim for benefits pursuant to § 1151 was distinct from the issue currently on appeal. The Board referred the issue to the RO for appropriate action. It does not appear that this claim has been developed or adjudicated. As such, it is again referred for appropriate action by the RO. The issues of entitlement to service connection for a heart condition, rash, jaw pain, ovarian cysts and endometriosis, fibromyalgia, bilateral shoulder and hip disabilities, a sleep disorder, and headaches are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Breast cancer was not manifest in service and is unrelated to service. 2. The Veteran has been diagnosed with IBS which is manifested by frequent episodes of bowel disturbance with abdominal distress. 3. Chronic constipation is a manifestation of the Veteran's IBS. 4. The Veteran does not have a diagnosis of PTSD. 5. An acquired psychiatric disorder other than PTSD was not manifest in service and is unrelated to service. CONCLUSIONS OF LAW 1. Breast cancer was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.311, 3.312 (2010). 2. IBS, to include chronic constipation, originated in service. 38 U.S.C.A. §§ 1101, 1110, 1112. 1113, 1131, 1117, 5103(a), 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310, 3.317 (2010). 3. PTSD was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1154(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2010). 4. An acquired psychiatric disorder other than PTSD was not incurred in or aggravated during service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (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); 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) (West 2002); 38 C.F.R. § 3.159(b) (2010); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper 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 RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). On March 3, 2006, the U. S. Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 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 the elements of the claim as reasonably contemplated by the application. Id. at 486. A letter dated in July 2005 discussed the evidence necessary to support a claim of entitlement to service connection. The Veteran was invited to submit or identify relevant evidence. The evidence of record was listed and the Veteran was told how VA would assist her in obtaining additional relevant evidence. A December 2005 letter provided similar information and also discussed the Veteran's claim for PTSD. A July 2007 letter advised the Veteran of the manner in which VA determines disability ratings and effective dates. In June 2009 the Veteran was advised of the evidence necessary to support a claim of entitlement to service connection for PTSD based on personal assault. A June 2009 letter also discussed this claim. Except as discussed below, the Board finds that the content of the notice fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran has been provided with every opportunity to submit evidence and argument in support of her claim and to respond to VA notices. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of her claim. With respect VA's duty to assist, the Board notes that, to the extent possible, identified treatment records have been associated with the claims file. The available evidence includes service treatment records and personnel records. The Veteran has also been afforded VA examinations. The Board finds that the examinations were adequate in that the examiners reviewed the record, interviewed the Veteran, and performed appropriate examinations prior to providing their conclusions. The reports of record are thorough and consistent with contemporaneous treatment records. Finally, the Board notes that the Veteran has been afforded the opportunity to testify before the undersigned. She has not identified any further evidence or information in support of her claims. The Board acknowledges that that the Veteran has not been afforded a VA medical examination regarding her claim of entitlement to service connection for breast cancer. However, the Board finds that a VA examination is not necessary in order to decide this claim. There are two pivotal cases which address the need for a VA examination, Duenas v. Principi, 18 Vet. App. 512 (2004) and McLendon v. Nicholson, 20 Vet App. 79 (2006). In McLendon, the Court held that in disability compensation claims, the Secretary must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service- connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. Id. at 81. In Duenas, the Court held that a VA examination is necessary when the record: (1) contains competent evidence that the Veteran has persistent or recurrent symptoms of the claimed disability and (2) indicate that those symptoms may be associated with his active military service. The Veteran's service treatment records are devoid of any diagnosis, complaints or abnormal finding referable to breast cancer. Further, the Board finds that there is no credible evidence of in-service manifestations, continuity of symptoms since service, and no competent evidence otherwise showing that the claimed disabilities were incurred in service. While the Veteran may sincerely believe that her claimed disability is related to exposure to radiation, nerve agents, and depleted uranium, she is not competent to offer an opinion in that regard. See 38 C.F.R. § 3.159(c)(4)(i). For the reasons stated, a VA medical examination is not warranted. For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Analysis Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). However, "[a] determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet. App. 309, 314 (1993). Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2010). This includes disability made chronically worse by service- connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that there was a recent amendment to the provisions of 38 C.F.R. § 3.310. See 71 Fed. Reg. 52744- 47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. Although VA has indicated that the purpose of the regulation was merely to apply the Court's ruling in Allen, it was made clear in the comments to the regulation that the changes were intended to place a burden on the claimant to establish a pre- aggravation baseline level of disability for the non-service- connected disability before an award of service connection based on aggravation may be made. This had not been VA's practice, which suggests the possibility that the recent change amounts to a substantive change in the regulation. For this reason, and because the Veteran's claims were filed before the regulatory change was made, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the change, which is more favorable to the claimant. Breast Cancer Service connection for disability that is claimed to be attributable to exposure to ionizing radiation during service can be demonstrated by three different methods. Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). First, there are diseases that are presumptively service connected in radiation-exposed veterans under 38 U.S.C.A. § 1112(c) and 38 C.F.R. § 3.309(d). Second, service connection can be established under 38 C.F.R. § 3.303(d) with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311, if the condition at issue is a radiogenic disease. Third, direct service connection can be established under 38 C.F.R. § 3.303(d) by showing that the disease was incurred during or aggravated by service without regard to the statutory presumptions. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). Under Combee, VA must not only determine whether a veteran had a disability recognized by VA as being etiologically related to exposure to ionizing radiation, but must also determine whether the disability was otherwise the result of active service. In other words, the fact that the requirements of a presumptive regulation are not met does not in and of itself preclude a claimant from establishing service connection by way of proof of actual direct causation. A "radiation-exposed veteran" is defined by 38 C.F.R. § 3.309(d)(3) as a veteran who while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. "Radiation-risk activity" is defined to mean: onsite participation in a test involving the atmospheric detonation of a nuclear device; the occupation of Hiroshima or Nagasaki, Japan, by United States forces during the period beginning on August 6, 1945, and ending on July 1, 1946; internment as a prisoner of war in Japan that resulted in an opportunity for exposure to ionizing radiation comparable to that of veterans who were in the occupation forces of Hiroshima or Nagasaki during the period August 6, 1945, to July 1, 1946; or certain service on the grounds of gaseous diffusion plants located in Paducah, Kentucky, Portsmouth, Ohio, and Oak Ridge, Tennessee; or, in certain circumstances, service on Amchitka Island, Alaska. See 38 C.F.R. § 3.309(d)(ii). Diseases presumptively service connected for radiation-exposed veterans under the provisions of 38 U.S.C.A. § 1112(c) and 38 C.F.R. § 3.309(d)(2) include cancer of the breast. 38 U.S.C.A. § 1112(c)(2); 38 C.F.R. § 3.309(d). In this case, the Board notes that the Veteran is not shown to be a radiation-exposed Veteran as contemplated by § 3.309(d). Therefore, service connection on a presumptive basis pursuant to under 38 U.S.C.A. § 1112(c) and 38 C.F.R. § 3.309(d) is not warranted. With respect to service connection under 38 C.F.R. § 3.303(d) with the assistance of the procedural advantages prescribed in 38 C.F.R. § 3.311, the Board notes that VA, in developing this claim, requested information from the service department pertaining to the Veteran's possible exposure to radiation. The service department responded that there were no such records. As such, referral to the VA Under Secretary for Benefits is not required in this case, as there are no records of radiation exposure upon which to prepare a dose estimate. See 38 C.F.R. § 3.311(a)(2)(iii). Finally, the Board has concluded that service connection is not warranted on a direct basis. In that regard, the Board observes that service treatment records are completely negative for any diagnosis, complaint, or abnormal finding pertaining to breast cancer. A February 1997 record indicates that the Veteran was diagnosed with a benign fibrofatty left breast mass. Breast cancer was diagnosed in 2003, many years following the Veteran's separation from service. A January 2003 VA record indicates a one year history of a breast mass that had recently been found to be invasive ductal carcinoma after excisional biopsy. The Veteran underwent bilateral mastectomy with lymph node dissection on the right. While the record is voluminous, it contains no competent evidence linking the Veteran's post-service breast cancer diagnosis to any incident of her service. Rather, the record demonstrates a remote onset of this disease. The grant of service connection requires competent evidence to establish a diagnosis and, as in this case, relate the diagnosis to the Veteran's service. While the record notes that the Veteran has undergone treatment for breast cancer, it does not contain competent evidence which relates this disease to any incident of service. The Board finds that the negative record in service and for years following service is more probative than the Veteran's more recent statements. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Notably, the Veteran does not assert that she has experienced symptoms since service; rather the record shows that breast cancer was not diagnosed until 2003, and the Veteran does not dispute that finding. The Board has considered the Veteran's lay assertion that he has breast cancer that is the result of exposure to radiation, nerve agents, or depleted uranium during service. Certainly, she is competent to report sensory or observed symptoms, and her statements in that regard are entitled to some probative weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Generally, however, a lay person is not competent to diagnose most medical disorders or render an opinion as to the cause or etiology of any current disorder because he or she does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). In this instance, the Veteran as a lay person has not been shown to be capable of making medical conclusions, especially as to complex medical diagnoses such as diagnosing breast cancer and linking any such disorder to in-service exposures or other incident of military service. See Jandreau (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions); see also Layno v. Brown, 6 Vet. App. 465 (1994) (cautioning that lay testimony that the Veteran suffered a particular illness (bronchial asthma) was not competent evidence because matter required medical expertise). In short, there is no competent evidence that breast cancer is related to service, to include exposure to radiation, nerve agents, or depleted uranium. Absent reliable evidence relating this disability to service, the claim of entitlement to service connection for breast cancer must be denied. The preponderance of the evidence is against the Veteran's claim and the doctrine of reasonable doubt is not applicable in the instant appeal. IBS and Chronic Constipation Service connection may be established for a chronic disability manifested by certain signs or symptoms which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011, and which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1); 71 FR No. 242, pp. 75669-75671 (December 18, 2006). Consideration of a Veteran's claim under this regulation does not preclude consideration of entitlement to service connection on a direct basis. A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): an undiagnosed illness; the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) Chronic fatigue syndrome; (2) Fibromyalgia; (3) Irritable bowel syndrome; or (4) Any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a). The term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a). A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from part 4 of this chapter for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a). A disability referred to in this section shall be considered service connected for purposes of all laws of the United States. 38 C.F.R. § 3.317(a). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multisymptom illness include, but are not limited to: (1) Fatigue (2) Signs or symptoms involving skin (3) Headache (4) Muscle pain (5) Joint pain (6) Neurologic signs and symptoms (7) Neuropsychological signs or symptoms (8) Signs or symptoms involving the respiratory system (upper or lower) (9) Sleep disturbances (10) Gastrointestinal signs or symptoms (11) Cardiovascular signs or symptoms (12) Abnormal weight loss (13) Menstrual disorders. 38 C.F.R. § 3.317(b). Compensation shall not be paid under this section if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). The term "Persian Gulf Veteran" means a Veteran who served on active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War. The Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. In the present case, the record reflects that the Veteran served in the Persian Gulf. On recent VA examination, a diagnosis of IBS was rendered. The voluminous record indicates that the Veteran has undergone treatment for IBS and that she has consistently complained of bowel disturbance and abdominal distress. Under the appropriate criteria for the evaluation of this disability, a compensable 10 percent evaluation requires evidence of moderate IBS with frequent episodes of bowel disturbance and abdominal distress. As IBS has been diagnosed and the record supports a compensable evaluation, the Board has determined that service connection for this disability is warranted under 38 C.F.R. § 3.317. Acquired Psychiatric Disorder Service connection for PTSD requires medical evidence diagnosing the condition in accordance with VA regulations; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d), (f). The Board observes that effective July 12, 2010, the regulations governing adjudication of service connection for posttraumatic stress disorder (PTSD) were liberalized, in certain circumstances, with respect to the evidentiary standard for establishing the required in-service stressor. For cases pending before VA as of that date, the following regulation applies: If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304 (f)(3); see 75 Fed. Reg. 39843 (July 13, 2010). As discussed below, the Veteran does not have a current diagnosis of PTSD; therefore, this amendment does not apply. The Veteran's service treatment records are negative for any diagnosis, complaint, or abnormal finding pertaining to her psychiatric health. On medical board examination in April 1993, the Veteran was psychiatrically normal. At that time, she denied frequent trouble sleeping, depression or excessive worry, and nervous trouble of any sort. The Veteran was afforded a Persian Gulf registry examination in July 1994. At that time, she endorsed post partum depression. She reported that she had felt depressed since discharge, noting that she felt relegated to being a housewife. Post partum depression is noted in a May 1995 consultation request form. A VA treatment record dated in June 1995 notes that the Veteran had been referred to the mental health clinic by the emergency room, where she had been evaluated for depression of postpartum onset and started on Zoloft. The Veteran noted that she had felt depressed since returning from the Persian Gulf. She related that she had served in the Army for six years working as a mechanic until she injured her back. She indicated that she was sent to the Gulf where she worked with the chemical team in Saudi Arabia. The Axis I assessment was rule out postpartum depression. A November 1995 VA treatment record indicates that the Veteran had been taking Zoloft since May 1995. The Veteran reported the new onset of depression one or two years previously prior to the birth of her second child. The assessment was rule out major depressive episode partially resolved on Zoloft and rule out medical causes for mood disorder. The Veteran underwent psychological evaluation for her Social Security Administration disability claim in August 2003. The examiner noted that the Veteran had undergone treatment for breast cancer in 2003, and that a hysterectomy was scheduled for the following week. The Veteran denied previous psychological or psychiatric treatment. The examiner noted that a review of a Women's Center psychiatry noted dated in August 2002 indicated that the Veteran was seen with complaints of job and domestic related stress. Following mental status examination, the diagnosis was adjustment disorder with anxious and depressed mood. In July 2004 a VA provider assessed adjustment disorder with anxiety. A November 2004 VA treatment record notes the Veteran's report of a lifetime of anxious worry focused on various topics depending on the stage of her life. She noted that she had agoraphobic and panic symptoms. The assessment was parent-child relational problem, generalized anxiety disorder, and major depressive disorder in full sustained remission. The provider also noted rule out panic disorder with agoraphobia. In July 2005 a VA group therapy provider noted parent-child relational problem and generalized anxiety disorder. A private psychological report dated in January 2006 indicates the Veteran's report that she had felt depressed for several years, since receiving a medical discharge from the Army. On mental status examination, the Veteran reported that she had visions and saw things happening which weren't really happening; she stated that those experiences began while she was serving in Saudi Arabia. The diagnostic impression was adjustment disorder with depressed mood. On initial VA psychological consultation in January 2007, the diagnostic impression was chronic major depressive disorder and generalized anxiety disorder. In May 2007 the Veteran reported that she has started to work with a new therapist at a VA Community Based Outpatient Clinic and that the therapist had re-explored symptoms of possible PTSD. The Veteran endorsed multiple past traumas including childhood molestation and sexual harassment in the military. The assessment as generalized anxiety disorder, major depressive disorder versus mood secondary to general medical condition, history of panic disorder, rule out attention deficit hyperactivity disorder, and rule out PTSD. The Veteran also met with her VA individual psychotherapist in May 2007. The assessment included rule out PTSD. A subsequent May 2007 treatment note indicates that the provider spent considerable time discussing the Veteran's possible PTSD diagnosis, and indicates that the Veteran endorsed multiple traumas. She described being molested at age 10, being in a car accident just prior to her deployment to Saudi Arabia, having her base hit by missiles, being molested by a military physical therapist, and being harassed by a superior. The assessment included PTSD. The provider noted that it was secondary to both military and non-military trauma. A September 2008 VA treatment record notes the Veteran's report of a sex-related crime she witnessed two weeks previously. The diagnoses were chronic PTSD and mood disorder not otherwise specified. An October 2008 VA outpatient note indicates an Axis I diagnosis of chronic PTSD. PTSD was also noted in December 2008. At that time, the provider noted that the Veteran had been seen for psychotherapy since January 2007. In August 2009 the U.S. Army and Joint Services Records Research Center (JSRRC) indicated that service department records verified the Veteran's report that her in-service harasser pled guilty to rape and was discharged from service. On VA examination in November 2009, the Veteran's history was reviewed. With respect to her military history, the Veteran denied disciplinary infractions sand adjustment problems. She endorsed combat experience. With respect to stressors, the Veteran reported sexual assault during childhood, sexual harassment during service, and sexual assault following service. With respect to the in-service stressor, she denied intense fear, feelings of helplessness, feelings of horror, or other reactions. She stated that her sergeant talked "nasty" to her because he was jealous of her husband. She related that she later discovered that the sergeant was arrested for rape. She endorsed recurrent distressing dreams, feelings of detachment, and impairment in social and occupational functioning. She indicated that she had dreams almost every night but that she did not remember them. She stated that feelings of detachment and diminished interest occurred all of the time. She endorsed daily irritability and difficulty concentrating. She noted that her startle response was variable with her environment. The examiner noted that the Veteran denied all other symptoms associated with PTSD or that she did not endorse them to the severity significant enough to meet the DSM-IV diagnostic criteria for PTSD. He indicated that tests administered included the structured interview for PTSD, the PTSD Checklist for Combat and Non-combat Trauma, and the Minnesota Multiphasic Personality Inventory (MMPI) PTSD subscales. He concluded that the psychological test results were not valid. In that regard, he related that the self-reported measures had a high degree of face validity and as a result were susceptible to exaggeration of the symptoms being measured. He noted that the results of the MMPI showed a degree of psychopathology that was unusual even in a clinical population; he indicated that while the results might represent a "cry for help," it was quite likely that there was some intentional exaggeration of the current symptom picture, possibly for secondary gain issue. He concluded that, given the results of the MMPI, the other measures were more likely than not invalid as a measure of the Veteran's current functioning. He indicated that the Veteran did not meet the criteria for a diagnosis of PTSD, and instead diagnosed depressive disorder not otherwise specified and generalized anxiety disorder. He specifically indicated that she did not meet Criterion C for a diagnosis of PTSD. He found that she did not meet the criteria for military sexual trauma, noting that she was reportedly harassed by sergeant but that harassment itself does not meet the criteria for sexual trauma. He also concluded that the diagnosed depressive disorder and anxiety disorder were not caused by or a result of service, and that generalized anxiety disorder was less likely as not permanently aggravated by service. He noted that the depression and underlying personality characteristics stemmed from childhood traumas and events and not from military experiences. PTSD After careful consideration of the evidence pertaining to this issue, the Board finds that service connection for PTSD is not warranted. In this regard, the Board notes that a key element to establishing service connection is to show that Veteran does have the claimed disability. This element may only be shown through evidence of a diagnosis. The Board acknowledges that VA outpatient psychotherapy notes include a diagnosis of PTSD starting in May 2007. However, this diagnosis does not appear to be based on clinical testing of the sort conducted by the November 2009 examiner, and does not include any in-depth analysis of whether a PTSD diagnosis was appropriate. On the other hand, the November 2009 VA examiner conducted a full examination to include clinical testing. The Board observes that the VA examiner very carefully discussed the various criteria under which PTSD must be diagnosed and concluded that such a diagnosis was not appropriate. The Board has considered the Veteran's own assertion that she has PTSD. However, while she is competent to describe symptoms such as anxiety and depression, she is not necessarily competent to identify the specific underlying psychiatric disorder or disorders that are the source of those symptoms. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Thus, in determining whether she has PTSD, the Board places far more probative weight on the clinical findings of the VA examiner who conducted a full and comprehensive assessment in November 2009. Under these circumstances, the Board must conclude that the Veteran has not met the regulatory requirements of entitlement to service connection for PTSD, and that, on this basis, her claim must be denied. Acquired Psychiatric Disorder other than PTSD To the extent that the Veteran claims that she has an acquired psychiatric disorder other than PTSD that is related to service, the Board observes she has been diagnosed with rule out post partum depression, adjustment disorder with anxious and depressed mood, generalized anxiety disorder, major depressive disorder. The Board notes that there is no evidence of an acquired psychiatric disorder other than PTSD during service or for several years following the Veteran's separation from service. Moreover, when the Veteran sought assistance in July 1994, she endorsed post partum depression. She again reported post partum depression in May 1995 and was started on medication. Job and domestic related stress were noted in August 2003. The Board has considered the Veteran's statements and acknowledges that she is competent to diagnose and report on simple conditions, to include psychiatric symptoms. See Jandreau. However, competency must be distinguished from credibility, and, in this instance, the Board finds that her reports of developing a chronic disability as the result of service is not credible. On seeking treatment in 1995 the Veteran herself initially related her depression as being post partum in onset, which is counter to her more recent statements. Here, the clinical examination was normal on both enlistment and discharge. On medical board examination prior to separation, the Veteran was psychiatrically normal. In summary, there is no credible evidence of a chronic psychiatric disorder in service, and no credible evidence of a continuity of symptomatology since service. As the preponderance of the evidence is against the claim, there is no doubt to be resolved. Therefore, the claim of entitlement to service connection for an acquired psychiatric disorder other than PTSD must also be denied. ORDER Entitlement to service connection for breast cancer is denied. Entitlement to service connection for IBS with chronic constipation is granted. Entitlement to service connection for PTSD is denied. Entitlement to service connection for an acquired psychiatric disorder other than PTSD is denied. REMAND Heart Condition In the May 2009 remand, the Board noted that it was unclear whether the Veteran had a current cardiac condition. It determined that a VA examination was necessary. On VA heart examination in November 2009, the examiner noted that there was no evidence of mitral valve prolapse per echocardiogram in October 2005, but that the test revealed trace mitral regurgitation. He provided an etiology opinion with respect to direct service connection. He also stated that per echocardiogram, the Veteran did not have mitral valve prolapse and that an opinion was not required. However, no opinion was rendered with respect to whether there is objective evidence of current cardiac signs or symptoms (i.e., Mitral regurgitation) that may be attributable to an undiagnosed illness, as directed by the Board's 2009 remand. As such, the examination is inadequate for the purpose of deciding this claim. Rash The Veteran argues that she has a rash that is related to her service in the Gulf War. At her December 2008 hearing, she testified that she experienced rash around her mouth and that a VA dermatologist had told her that she had herpes simplex. Private medical records dated in March 1999 include diagnoses of nasal labial herpes with localized infection in the nose; and acne. The September 2005 letter from the VAMC Tampa regarding the Veteran's participation in the Gulf War Registry includes an assessment of rash, questionable dyshidrotic eczema (hand and perioral rash). In her VA Form 9, the Veteran indicated that her rash was evaluated during her Gulf War registry examination and that the doctor felt this was a condition that fell under symptoms related to the Gulf War. She indicated that the rash was sporadic and moved from place to place. At the hearing, the Veteran reported that she did not have any sores on her face prior to going to the Persian Gulf. She indicated that she got a rash around her mouth and that the VA dermatologist told her she had herpes simplex. Records received as the result of the Board's May 2009 remand include the report of a July 1994 Persian Gulf Registry examination. At that time, the Veteran complained of recurrent blisters which would be painful and then resolve. On VA examination in November 2009, the examiner noted that there was a small area on the right index finger characterized by slight peeling and mild thickening of the skin. No rash or skin lesions were seen on the face or mouth area. However, the examiner noted the Veteran's report that she experienced an outbreak five months previously. He concluded that there was no rash observed and that therefore no opinion was necessary. Unfortunately, the examiner failed to address the history contained in the clams file, that clearly shows that the Veteran has experienced recurrent skin symptoms and that they intermittently resolve. Moreover, the examiner did not, based on this history, provide an opinion regarding whether the Veteran's complaints, signs, and symptoms are related to a known diagnostic entity, and if so, whether that diagnosis is related to service. Jaw Pain Service treatment records show an assessment of possible temporomandibular joint syndrome (TMJ) in March 1991. Dental records dated in May 1992 note day and night bruxism and clenching and that the Veteran has TMJ symptoms. Soft and hard night guards were subsequently provided. The September 2005 letter from the VAMC Tampa regarding the Veteran's participation in the Gulf War Registry includes an assessment of TMJ. In her VA Form 9, the Veteran reported that she was diagnosed and treated for bruxism with TMJ symptoms due to stress and that this was a chronic problem because she still has symptoms. At the hearing, the Veteran testified that she went to the dentist a lot during service and had to keep her mouth open wide and it caused TMJ. She said the doctors verbally told her she has TMJ. In the May 2009 remand, the Board noted that the Veteran had been treated for possible temporomandibular joint syndrome (TMJ) during service, and that she had testified with respect to a continuity of symptoms. The Board also noted that joint pain was also a symptom that might be a manifestation of undiagnosed illness. See 38 C.F.R. § 3.317 (2010). A VA examination was directed. On VA examination in November 2009 a diagnosis of chronic right jaw pain was provided. The examiner concluded that the pain was due to decayed teeth. The Board notes that the Veteran underwent treatment for decayed teeth in service, to include a root canal. She has stated that she has experienced right jaw pain since that time. The examiner did not provide an opinion regarding whether the Veteran's complaints, signs, and symptoms of right jaw are related to a known diagnostic entity (i.e., TMJ), and if so, whether that diagnosis is related to service. Clarification, and if necessary, an additional VA dental examination, should be sought. Ovarian Cysts and Endometriosis Service treatment records show that on report of medical history completed at entrance in August 1987, the Veteran reported a cyst on the right ovary resolved with medication. She had no problems at that time and pelvic examination was normal on clinical evaluation. Gynecologic consultation in October 1990 included an impression of right adnexal tenderness, probably ovulatory in nature. Review of service treatment records shows abnormal cytologic examinations and treatment for pelvic inflammatory disease (PID). Private medical records in July 1997 include an assessment of left ovarian cyst. VA records show that the Veteran underwent a CT scan of the pelvis in January 2005 which showed a cystic lesion in the left adnexa. The Veteran subsequently underwent surgery and diagnosis included left ovarian cyst functional and mild to moderate endometriosis. In her VA Form 9, the Veteran indicated that ovarian cysts were first detected after she had her baby and she still has them at present. At the hearing, she indicated that she thought she was first diagnosed during service. She also indicated that cysts are linked to her breast cancer. On remand in May 2009, the Board noted that the evidence showed treatment for various female issues during service and included the Veteran's report of continuing symptoms since that time. The Board noted that menstrual disorders might also be symptoms of undiagnosed illness. See 38 C.F.R. § 3.317 (2010). An examination was ordered On VA examination in November 2009 the diagnoses were asymptomatic right ovary cyst and endometriosis. The examiner did not provide the requested opinion regarding whether these diagnosed conditions were related to the Veteran's service. As such, this issue must be remanded for the requested opinion. Fibromyalgia Bilateral Shoulder and Hip Disabilities Service treatment records indicate the Veteran was involved in a motor vehicle accident in October 1990 and she complained of neck and shoulder pain following the accident. The Veteran was seen in November 1991 with complaints of pain to the right hip. Assessment was right groin pull. The records contain an undated profile for bilateral hip and back pain. Service treatment records also show complaints of multiple joint pains. The Veteran was given a physical profile in July 1993 for systemic (whole body) joint disease. Records dated in August 1993 includes a diagnosis of chronic pain syndrome. VAMC records include a June 2004 bone density study showing osteopenia of the bilateral hips. The September 2005 letter from the VAMC Tampa regarding the Veteran's participation in the Gulf War Registry includes an assessment of pain syndrome, like fibromyalgia per pain specialty clinic. In her VA Form 9, the Veteran indicated that fibromyalgia was a qualifying chronic Gulf War disability. At the hearing, she reported that she was diagnosed with fibromyalgia in 2004. She also testified that she did not actually injure her shoulders, but injured her neck in the motor vehicle accident and that the pain radiates to her shoulders. She agreed that her complaints were neurological manifestations from the spine. She also noted that after her breast surgery, it is hard to move the muscles. She testified that when she injured her back in the military, that was part of the hips and she has sacroilitis. The Board notes that the Veteran is currently service connected for degenerative disc disease L5-S1 with bilateral sacroilitis; and degenerative disease of the cervical spine. The Veteran underwent a VA joints examination in March 2006 and the examiner indicated that it was less likely than not that the Veteran's bilateral shoulder pain and bilateral hip pain were related to her in-service military motor vehicle accident. The examiner, however, did not address secondary service connection or undiagnosed illness. In the May 2009 remand the Board discussed the history noted above and determined that an additional examination is needed. In that regard, the Board noted that service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2010). Additionally, the Board noted that joint pain is a symptom which may be a manifestation of undiagnosed illness, and that fibromyalgia was a qualifying chronic disability. See 38 C.F.R. § 3.317 (2010). On examination in November 2009, the VA physician diagnosed fibromyalgia and determined that it was not related to service. However, he did not address its severity with sufficient detail for the Board to determine whether it is compensable and therefore subject to service connection pursuant to § 3.317. He also stated that the Veteran's reported shoulder and hip pain was more likely related to fibromyalgia. In light of the inadequacy in the VA examination report regarding the severity of the Veteran's diagnosed fibromyalgia, which would allow the Board to determine whether such disability has manifested to a compensable degree and is therefore subject to service connection under § 3.317, the issues of entitlement to shoulder and hip disabilities must be deferred pending resolution of the fibromyalgia claim. In that regard, the Board notes that further development and adjudication of the Veteran's fibromyalgia claim may provide evidence regarding the claims for bilateral shoulder and hip disabilities. The Board has therefore concluded that it would be inappropriate at this juncture to enter a final determination on that issue. See Henderson v. West, 12 Vet. App. 11 (1998), citing Harris v. Derwinski, 1 Vet. App. 180 (1991), for the proposition that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the claims are inextricably intertwined. Sleep Disorder In her VA Form 9, the Veteran claimed that she had a sleep disorder related to Gulf War syndrome. At the hearing, the Veteran testified that she did not really have a sleep disorder, but rather a problem with sleeping itself. She related that she has nightmares, thrashes, and is unable to sleep. She reported that her psychiatrist has linked the sleep disturbances to anxiety or PTSD. On remand in 2009, the Board directed that a VA psychiatric examiner examine the Veteran and specifically state whether the Veteran has a sleep disorder or whether her complaints relating to sleep disturbance are related to a diagnosed illness. The November 2009 examiner did not respond to this inquiry. Accordingly, the file must be returned to the examiner for the requested opinion. Headaches Service treatment records include a diagnosis of tension headaches in May 1989. On report of medical history completed in April 1993, the Veteran indicated she had frequent or severe headaches. Private medical records note complaints of headaches in 1997. Record dated in November 2001 includes an impression of headaches probably secondary to sinusitis versus migraine. The September 2005 letter from the VAMC Tampa regarding the Veteran's participation in the Gulf War Registry includes an assessment of "chronic headaches?" Prior brain MRI was reportedly negative. In her VA Form 9, the Veteran argued that her headaches were a qualifying chronic disability recognized as related to the Gulf War. At the hearing, the Veteran reported that she started having bad migraines when she started hormonal therapy. She reported current treatment with Botox. The Veteran underwent a VA neurological examination in March 2006 and impression was probable chronic tension type headaches. The examiner indicated that the Veteran's current headaches were less likely than not related to the remote vehicle accident in October 1990. The examiner, however, did not address whether the current headaches were related to her in-service complaints of frequent headaches or undiagnosed illness and in the 2009 remand the Board concluded that additional examination was necessary. The Board observed that headaches are a symptom which may be a manifestation of undiagnosed illness. See 38 C.F.R. § 3.317 (2010). On examination in November 2009, the examiner provided a diagnosis of migraine type headaches. He provided no opinion regarding the etiology of the headaches or whether they were a manifestation of an undiagnosed illness. Accordingly, clarification must be sought. In light of the above discussion, the Board finds that additional development is necessary. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA cardiac examination to determine the nature and etiology of any currently present heart disorder. The claims file should be forwarded to the examiner for review. The examiner should elicit a complete history from the Veteran, the details of which should be recited in the examination report. All necessary testing should be carried out in conjunction with the examination. The examiner should note and detail all reported signs and symptoms of cardiac origin, to include details about the onset, frequency, duration, and severity of all complaints relating to cardiac symptoms, and indicate what precipitates and what relieves them. The examiner should determine whether there are any objective medical indications that the Veteran is suffering from a chronic heart condition. The examiner should specifically determine whether the Veteran's cardiac complaints are attributable to any known diagnostic entity. If not, the examiner should specifically state whether he is unable to ascribe a diagnosis to the Veteran's complaints. Symptom-based "diagnoses," such as pain, are not considered as diagnosed conditions for compensation purposes. If the Veteran's cardiac complaints are ascribed to a known disease entity, the examiner should provide an opinion as to whether it is at least as likely as not that the diagnosed disorder is etiologically related to the Veteran's active service. A complete rationale for all opinions expressed should be provided in the examination report. 2. Schedule the Veteran for a VA dermatological examination to determine the etiology of any currently present skin disorder. The claims folder must be made available to and reviewed by the examiner. The examiner should elicit a complete history from the Veteran, the details of which should be recited in the examination report. All necessary testing should be conducted. The examiner should note and detail all reported signs and symptoms of a skin disorder, to include details about the onset, frequency, duration, and severity of all complaints, and indicate what precipitates and what relieves them. The examiner should determine whether there are any objective medical indications that the Veteran is suffering from signs and symptoms of a skin disorder. The examiner should specifically determine whether the Veteran's complaints are attributable to any known diagnostic entity. If not, the examiner should specifically state whether he is unable to ascribe a diagnosis to the Veteran's complaints. Symptom-based "diagnoses" are not considered as diagnosed conditions for compensation purposes. If the Veteran's skin complaints are ascribed to a known disease entity, the examiner should provide an opinion as to whether it is at least as likely as not that that disorder is etiologically related to the Veteran's active service. A complete rationale for all opinions expressed should be provided in the examination report. 3. Schedule the Veteran for a VA dental examination to determine the etiology of any currently present disability characterized by jaw pain. The claims folder must be made available to and reviewed by the examiner. The examiner should elicit a complete history from the Veteran, the details of which should be recited in the examination report. All necessary testing should be conducted. The examiner should note and detail all reported signs and symptoms referable to right jaw pain, to include details about the onset, frequency, duration, and severity of all complaints, and indicate what precipitates and what relieves it. The examiner should determine whether there are any objective medical indications that the Veteran is suffering from signs and symptoms of jaw pain. The examiner should specifically determine whether the Veteran's complaints of right jaw pain are attributable to any known diagnostic entity. If not, the examiner should specifically state whether he is unable to ascribe a diagnosis to the Veteran's complaints. Symptom-based "diagnoses" are not considered as diagnosed conditions for compensation purposes. If the Veteran's jaw pain complaints are ascribed to a known disease entity, the examiner should provide an opinion as to whether it is at least as likely as not that that disorder is etiologically related to the Veteran's active service. A complete rationale for all opinions expressed should be provided in the examination report. 4. Schedule the Veteran for a VA gynecology examination to determine the etiology of any currently present gynecological disorder. The claims folder must be made available to and reviewed by the examiner. The examiner should elicit a complete history from the Veteran, the details of which should be recited in the examination report. All necessary testing should be conducted. The examiner should note and detail all reported gynecological signs and symptoms, to include details about the onset, frequency, duration, and severity of all complaints, and indicate what precipitates and what relieves them. The examiner should determine whether there are any objective medical indications that the Veteran is suffering from gynecological signs and symptoms. The examiner should specifically determine whether the Veteran's gynecological complaints are attributable to any known diagnostic entity. If not, the examiner should specifically state whether he is unable to ascribe a diagnosis to the Veteran's complaints. Symptom-based "diagnoses" are not considered as diagnosed conditions for compensation purposes. If the Veteran's gynecological complaints are ascribed to a known disease entity, the examiner should provide an opinion as to whether it is at least as likely as not that that disorder is etiologically related to the Veteran's active service. A complete rationale for all opinions expressed should be provided in the examination report. 5. Schedule the Veteran for a VA orthopedic examination to determine the severity of her fibromyalgia and for an opinion regarding the etiology of her claimed bilateral shoulder and hip disabilities. The claims folder must be made available to and reviewed by the examiner. The examiner should elicit a complete history from the Veteran, the details of which should be recited in the examination report. All necessary testing should be conducted. The examiner should specifically indicate whether continuous medication is necessary for control of the Veteran's diagnosed fibromyalgia. The examiner should note and detail all reported signs and symptoms referable to the Veteran's shoulders and hips, to include details about the onset, frequency, duration, and severity of all complaints, and indicate what precipitates and what relieves them. The examiner should determine whether there are any objective medical indications that the Veteran is suffering from orthopedic signs and symptoms referable to her shoulders and hips. The examiner should specifically determine whether the Veteran's shoulder and hip complaints are attributable to any known diagnostic entity (i.e., fibromyalgia). If not, the examiner should specifically state whether he is unable to ascribe a diagnosis to the Veteran's complaints. Symptom-based "diagnoses" are not considered as diagnosed conditions for compensation purposes. If the Veteran's shoulder and hip complaints are ascribed to a known disease entity, the examiner should provide an opinion as to whether it is at least as likely as not that that disorder is etiologically related to the Veteran's active service. 6. Return the file to the examiner who conducted the November 2009 VA psychiatric examination. Following review of the claims file the examiner should indicate whether the Veteran has a diagnosed sleep disorder or whether her complaints are related to a diagnosed illness. If the examiner determines that the requested opinion cannot be rendered without first examining the Veteran, such examination should be scheduled. 7. Schedule the Veteran for a VA neurological examination to determine the etiology of her claimed headaches. The claims folder must be made available to and reviewed by the examiner. The examiner should elicit a complete history from the Veteran, the details of which should be recited in the examination report. All necessary testing should be conducted. The examiner should note and detail all reported signs and symptoms referable to headaches, to include details about the onset, frequency, duration, and severity of all complaints, and indicate what precipitates and what relieves them. The examiner should determine whether there are any objective medical indications that the Veteran is suffering from neurological signs and symptoms characterized by headaches. The examiner should specifically determine whether the Veteran's headaches are attributable to any known diagnostic entity (i.e., right jaw pain or dental caries). If not, the examiner should specifically state whether he is unable to ascribe a diagnosis to the Veteran's complaints. Symptom-based "diagnoses" are not considered as diagnosed conditions for compensation purposes. If the Veteran's headaches are ascribed to a known disease entity, the examiner should provide an opinion as to whether it is at least as likely as not that that disorder is etiologically related to the Veteran's active service. A complete rationale for all opinions expressed should be provided in the examination report. 8. The Veteran is hereby notified that it is her responsibility to report for any scheduled examination, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655. 9. Readjudicate the Veteran's claim, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, she and her representative should be furnished a supplemental statement of the case and afforded an appropriate period of time within which to respond thereto. The appellant has the right to submit additional evidence and argument on the matter or 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. 2010). ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs