Citation Nr: 1318674 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 08-25 739 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for chronic fatigue syndrome. 2. Entitlement to service connection for migraine headaches. 3. Entitlement to service connection for hiatal hernia. 4. Entitlement to service connection for gastroesophageal reflux disease (GERD). 5. Entitlement to service connection for left lower extremity numbness. 6. Entitlement to service connection for right lower extremity numbness. 7. Entitlement to service connection for left shoulder bursitis/subluxation (claimed as left shoulder pain). 8. Entitlement to service connection for right shoulder bursitis/subluxation (claimed as right shoulder pain). 9. Entitlement to service connection for left elbow bursitis (claimed as left elbow pain). 10. Entitlement to service connection for right elbow bursitis (claimed as right elbow pain). 11. Entitlement to service connection for left hip bursitis (claimed as left hip pain). 12. Entitlement to service connection for right hip bursitis (claimed as right hip pain). 13. Entitlement to service connection for left ankle bursitis (claimed as left ankle pain). 14. Entitlement to service connection for right ankle bursitis (claimed as right ankle pain). 15. Entitlement to service connection for left knee patellofemoral syndrome with ligamentous pain. 16. Entitlement to service connection for right knee patellofemoral syndrome with ligamentous pain. 17. Entitlement to a compensable rating for C6 and C7 radiculopathy of the left arm with left carpal tunnel syndrome (left upper extremity numbness). (An additional claim of entitlement to service connection for L4-L5 disc degeneration and posterior disc contusion (i.e., a low back disorder) is being addressed in a separate decision). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and her husband ATTORNEY FOR THE BOARD J.M. Rutkin, Associate Counsel INTRODUCTION The Veteran served on active duty from March to October 1986, from December 1990 to June 1991, and from October 2001 to May 2003. She also had additional service in the Army Reserves. This appeal to the Board of Veterans' Appeals (Board) is from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran and her husband presented testimony in support of her claims during a February 2013 hearing at the RO before the undersigned Veterans Law Judge of the Board (Travel Board hearing). A transcript of the hearing is of record. During her February 2013 Travel Board hearing the Veteran submitted additional private treatment records and written statements, and she waived her right to have the RO initially consider this additional evidence as the Agency of Original Jurisdiction (AOJ), preferring instead to have the Board consider it in the first instance. See 38 C.F.R. § 20.1304(c) (2012) (providing that any pertinent evidence accepted directly at the Board must be referred to the AOJ for initial review unless this procedural right is waived by the appellant). The Veteran also previously had had another hearing at the RO in March 2010 before a different Veterans Law Judge of the Board concerning a claim of entitlement to service connection for L4-L5 disc degeneration and posterior disc contusion (i.e., a low back disorder). This other claim resultantly will be addressed in a separate Board decision authored by this other Veterans Law Judge who presided over that March 2010 hearing. See 38 U.S.C. § 7107(c) (West 2002); 38 C.F.R. § 20.707 (2012) (providing that the Veterans Law Judge who conducts a hearing on an appeal must participate in any decision made on that appeal). The claims for chronic fatigue syndrome (CFS) and a headache disorder are being REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development and consideration. The claims for GERD and hiatal hernia, unfortunately, are being denied. Whereas the Board is dismissing the remaining claims for service connection for bilateral lower extremity numbness, a bilateral shoulder disorder, a bilateral elbow disorder, a bilateral hip disorder, a bilateral knee disorder, a bilateral ankle disorder, and the claim for a compensable rating for C6 and C7 radiculopathy of the left arm with left carpal tunnel syndrome since the Veteran indicated during her February 2013 Travel Board hearing that she is withdrawing her appeal of these several claims. FINDINGS OF FACT 1. GERD and hiatal hernia did not initially manifest during the Veteran's active military service, and the preponderance of the evidence weighs against finding a relationship or correlation between these conditions and her Persian Gulf War service or immunization injections. 2. She has withdrawn her claims of entitlement to service connection for bilateral lower extremity numbness, a bilateral shoulder disorder, a bilateral elbow disorder, a bilateral hip disorder, a bilateral knee disorder, a bilateral ankle disorder, as well as her claim for a compensable rating for her C6 and C7 radiculopathy of her left arm with left carpal tunnel syndrome. CONCLUSIONS OF LAW 1. GERD and hiatal hernia were not incurred in or aggravated by the Veteran's active military service and may not be presumed to have been incurred during her service, including as a result of her Persian Gulf War service. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.317 (2012). 2. The criteria are met for withdrawal of her substantive appeal concerning her claims of entitlement to service connection for bilateral lower extremity numbness, a bilateral shoulder disorder, a bilateral elbow disorder, a bilateral hip disorder, a bilateral knee disorder, a bilateral ankle disorder, as well as her claim for a compensable rating for the C6 and C7 radiculopathy of her left arm with left carpal tunnel syndrome. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.204 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In deciding these claims, the Board has reviewed all of the evidence in the claims file, both the physical claims file and electronic ("Virtual VA") claims file, and has an obligation to provide an adequate statement of reasons or bases supporting this decision. See 38 U.S.C.A. § 7104(d)(1) (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each and every piece of evidence, certainly not in exhaustive detail. See id. The analysis below therefore focuses only on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, so both the medical and lay evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. When the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must weigh against a claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). I. The Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), sets forth VA's duties to notify and assist claimants in substantiating claims for VA benefits. The VCAA was codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002), and the implementing VA regulations are codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will obtain; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). See also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Ideally, this VCAA notice should be provided prior to an initial decision on a claim by the AOJ (which in this particular instance is the RO). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, a delay in provision of the notice is "cured," and therefore harmless, when a fully compliant VCAA notification letter is followed by readjudication of the claim - including in a statement of the case (SOC) or supplemental SOC (SSOC) - after the claimant has had an opportunity to submit additional evidence in response to the notice. This preserves the intended purpose of the notice and allows the claimant opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). A claim of entitlement to service connection consists of five elements: (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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006). The Court has held that notification of what evidence is necessary to substantiate the claim under 38 U.S.C.A. § 5103(a) thus requires notice of all five of these elements, so including concerning the "downstream" disability rating and effective date elements in the event service connection is granted. See id. at 486; Quartuccio, 16 Vet. App. at 187. Here, prior to the initial rating decision in this matter, letters dated in January 2009, April 2009, August 2009, and October 2009 informed the Veteran of all five elements of service connection, gave examples of the types of evidence she could submit in support of her claims, and provided notice of her and VA's respective responsibilities for obtaining relevant records and other evidence on her behalf. Therefore, the duty to notify has been satisfied. See id. VA's duty to assist under the VCAA includes helping the claimant to obtain service treatment records (STRs) and other pertinent records, including of evaluation and treatment since service by VA and privately, as well as providing an examination or obtaining a medical opinion when necessary to make a decision on a claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). Here, the Veteran's STRs and post-service VA medical records are in the file. Private medical records she identified as potentially relevant also have been obtained to the extent possible. She has not identified any other records still needing to be obtained, so there are none outstanding that are obtainable. Thus, the duty to obtain relevant records on her behalf is satisfied. See 38 C.F.R. § 3.159(c). The duty to assist as mentioned also includes providing a medical examination or obtaining a medical opinion when needed to make a decision on the claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Id. Indeed, even when this is called into question, the Board may assume the competency of any VA medical examiner, including even nurse practitioners, as long as, under 38 C.F.R. § 3.159(a)(1), the examiner is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). Here, a VA esophageal conditions examination and a VA Gulf War general examination were performed in December 2011. The examination reports are adequate for making informed decisions on the service-connection claims for GERD and a hiatal hernia. In this regard, the examiner reviewed the claims file and medical history, conducted an examination of the Veteran and recorded the clinical findings, and provided a clear explanation for the opinion stated that is consistent with the examiner's findings and the other competent and credible evidence of record. See Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion" even when the rationale does not explicitly "lay out the examiner's journey from the facts to a conclusion" ) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)); see also D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). There are no apparent inconsistencies or ambiguities in the examination report, and the claimant has not challenged its adequacy or thoroughness, or the competency of the examiner. See Sickels, 643 F.3d at 1365-66; Rizzo, 580 F.3d at 1290-1291. Accordingly, VA's duty to assist with respect to obtaining a VA examination has been met. See 38 C.F.R. §§ 3.159(c)(4); 3.326(a); McLendon, 20 Vet. App. at 83; Barr, 21 Vet. App. at 312. The VA examiner did not provide an opinion specific to the hiatal hernia claim. However, as will be explained below, there is no evidence indicating that a hiatal hernia initially manifested during the Veteran's active military service or is otherwise related to her Persian Gulf War service, in particular. Moreover, because the evidence clearly shows that it is a diagnosed condition, service connection may not be granted for the hiatal hernia as an undiagnosed illness or as a component of a medically unexplained chronic multi-symptom illness stemming from her Persian Gulf War service. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317. Thus, a VA medical opinion regarding her hiatal hernia is unwarranted as there is sufficient evidence already of record to decide this claim. See McLendon, 20 Vet. App. at 83 (holding, in pertinent part, that in order to trigger VA's duty to provide a VA examination and obtain a VA medical opinion, there must be an indication the disability in question may be related to the in-service event, and insufficient evidence to decide the case). The VA examiner also did not address whether the Veteran's GERD or hiatal hernia may be related to immunization injections she reportedly received when deployed to the Persian Gulf, including anthrax and botulinum vaccinations. Such an opinion is not warranted as there is no competent evidence indicating the Veteran's GERD or hiatal hernia may be related to such injections. Specifically, she has not submitted any medical articles or opinions from a competent medical professional suggesting there is a confirmed association between her immunization injections and the later development of GERD or a hiatal hernia. One study she submitted, titled "Vaccines and Gulf War Illness," states that "Gulf War Veterans documented to have received the anthrax vaccine reported a number of medical conditions and symptoms at higher rates than Veterans who said they did not receive the anthrax vaccine. These included significantly higher rates of . . . gastritis, diarrhea . . . and indigestion." However, the study further states that "[a] still greater number of symptoms and health problems were significantly associated with self-reported, but undocumented, receipt of the anthrax vaccine. These results indicate that, while the anthrax vaccine is potentially associated with excess symptoms in Gulf War veterans, self-reported data introduced a bias that led to an overestimate of the vaccine's adverse effects." Indeed, the article notes that "[e]pidemiologic studies have generally not identified the anthrax vaccine to be a prominent risk factor for Gulf War illness. . . . [A]nthrax vaccine has been associated with increased rates of symptoms, Gulf War illness, and poor health status in several studies, using analyses that did not take into account effects of other exposures in theater" (emphasis added). In short, according to the study submitted by the Veteran, an association between anthrax immunizations and various medical conditions, including gastrointestinal conditions, has not yet been determined based on reliable scientific evidence. There is no indication that an individual VA examiner would be able to provide a competent opinion on the likelihood of an association between the Veteran's GERD or hiatal hernia and her reported immunizations during active service when, as indicated by the articles submitted by the Veteran, such has not yet been determined even by scientific studies. As the study noted, the reporting of higher rates of symptoms among Gulf War Veterans who reportedly received the vaccinations was subject to bias, and the study itself does not suggest that any association actually has been found between GERD or a hiatal hernia and anthrax immunizations. Thus, in the absence of any competent evidence indicating the Veteran's GERD or hiatal hernia may be related to immunization injections in service, or to any other environmental factors during her deployment to the Persian Gulf, a VA medical opinion on this issue is not warranted. See id. In sum, VA's duties to notify and assist under the VCAA have been satisfied. The Veteran has had ample opportunity to participate meaningfully in the development of her claims. See Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011) (citing Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding that any error depriving a claimant of "a meaningful opportunity to participate effectively in the processing of his or her claim . . . . must be considered prejudicial")). Any defect in the notice or assistance provided did not affect the outcome of this claim or compromise the "essential fairness of the adjudication," and no such defect has been alleged. See Mayfield v. Nicholson, 19 Vet. App. 103, 116 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, any error in the notice or assistance provided was harmless, and no prejudice exists. See Shinseki v. Sanders 556 U.S. 396, 407, 410 (2009) (holding that the "rule of prejudicial error" requires a case-by-case determination as to whether the error in question was harmless, and that it is the burden of the claimant to show that the error was harmful by at least providing an explanation as to how the error caused harm); see also 38 U.S.C.A. § 7261(b)(2) (West 2002). Accordingly, the Board may proceed with appellate review. II. Procedural Due Process The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) of the Board in February 2013. Under 38 C.F.R. § 3.103(c)(2) (2012), it is the responsibility of the hearing officer to explain fully the issues and suggest the submission of evidence that the claimant may have overlooked and that would be advantageous to the claimant's position. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that the hearing officer has two distinct duties under section 3.103(c)(2). First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Id. at 496 (finding that a hearing officer's inquiries regarding the existence of a current disability and a nexus to service did not equate to explaining to the claimant that these issues were material to substantiating the claim). Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Id., at 496-97. Importantly, the Court observed that the rule of prejudicial error applies in assessing any deficiency with respect to the hearing officer's duties under section 3.103(c). See id. at 498. Citing Sanders, 556 U.S. at 407, 410, the Court noted in this regard that the rule of prejudicial error requires a case-by-case determination as to whether the error in question was harmless. Id. Thus, in Bryant, 23 Vet. App. at 498-99, the Court held that although the hearing officer did not explicitly lay out the material issues of medical nexus and current disability, the "clarity and completeness of the hearing record was intact" and the purpose of section 3.103(c)(2) fulfilled because the record reflected that these issues were developed by VA, including the provision of a VA examination, and there was no indication the appellant had any additional information to submit. Here, the material issue is whether the Veteran's GERD and/or hiatal hernia are related to her active military service, including the results of an undiagnosed illness or medically unexplained chronic multi-symptom illness, or attributable to her immunization injections. During the hearing, the undersigned VLJ explained to the Veteran the criteria for establishing her entitlement to service connection on a direct basis, including by showing that she had relevant symptoms or a relevant diagnosis during service, or by otherwise showing a relationship between her current disability and her period of service, and also explained the criteria pertaining to Gulf War illnesses. See Hearing Transcript, pages 5-6, 16-17. Although the undersigned did not suggest the submission of evidence that may have been overlooked, any deficiencies in the Board hearing under section 3.103(c)(2) were not prejudicial. Specifically, VA has otherwise developed this claim, including obtaining records on the Veteran's behalf and providing a VA examination addressing whether her GERD or hiatal hernia may be an undiagnosed illness related to her Persian Gulf War service, as discussed above with regards to VA's duty to assist under the VCAA. Moreover, she has submitted a number of articles and studies regarding anthrax, botulinum, and other immunization injections during service. She thus has evidenced her actual knowledge of the type of evidence and information needed to substantiate her claims. Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative demonstrating an awareness of what is necessary to substantiate a claim). Consequently, there is no indication there is any outstanding evidence that may have been overlooked, especially in light of the fact that the articles submitted by the Veteran suggest that the health effects of the immunizations have not been definitively determined. Finally, she did not raise any new issues pertaining to her claims at the hearing. Bryant at 499. Thus, given the development undertaken by VA with respect to these claims, and in light of the Veteran's testimony at the hearing and the evidence submitted by her, the "clarity and completeness of the hearing record [is] intact" and the purpose of section 3.103(c)(2) to develop the record has been fulfilled. Id. at 498-99. Accordingly, the Veteran's right to a Board hearing has been satisfied and no prejudicial error exists with regard to the hearing officer's duties under section 3.103(c)(2). See id.; see also Sanders, 556 U.S. at 407, 410. III. Service Connection Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Active military, naval, or air service includes not only active duty (AD) but also any period of active duty for training (ADT) during which the individual concerned was disabled or died from a disease or an injury incurred in or aggravated in the line of duty, or any period of inactive duty training (IADT) during which the individual concerned was disabled or died from an injury - though not also disease - incurred in or aggravated in the line of duty, also when a cardiac arrest or cerebrovascular accident occurs during such training. 38 U.S.C.A. § 101(21), (24) (West 2002); 38 C.F.R. § 3.6(a), (d) (2012). Reserve and National Guard service generally means ADT and IADT. ADT is full-time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). Basically, this refers to the two weeks of annual training, sometimes referred to as "summer camp," that each Reservist or National Guardsman must perform each year. It can also refer to the Reservist's or Guardsman's initial period of training. IADT includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316 , 502, 503, 504, or 505. 38 U.S.C.A. § 101 (23); 38 C.F.R. § 3.6(d). Basically, this refers to the twelve four-hour weekend drills that each Reservist or National Guardsman must perform each year and is often referred to as "weekend warrior" training. These drills are deemed to be part-time training. So to establish status as a "Veteran" based upon a period of ADT, a claimant must establish that he or she was disabled from disease or injury incurred or aggravated in the line of duty during that period of ADT. 38 C.F.R. § 3.1(a), (d); Harris v. West, 13 Vet. App. 509, 511 (2000); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). The fact that a claimant has established status as a "Veteran" for purposes of other periods of service (e.g., AD) does not obviate the need for him or her to establish that he or she is also a "Veteran" for purposes of the period of ADT where the claim for benefits is premised on that period of ADT. Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). Similarly, in order for a claimant to achieve "Veteran" status and be eligible for service connection for disability claimed during his or her inactive service, the record must establish that he or she was disabled from an injury, but not disease, incurred or aggravated during IADT. See Mercado- Martinez v. West, 11 Vet. App. 415, 419 (1998); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). Thus, service connection may be granted for a disability resulting from a disease or an injury incurred or aggravated while performing ADT, or from an injury incurred or aggravated while performing IADT. 38 U.S.C.A. §§ 101(24), 106, 1131 (West 2002). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) held that a three-element test must be satisfied in order to establish entitlement to service connection. Walker v. Shinseki, 708 F.3d 1331, 1333 (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the so-called "nexus" requirement). Id. However, claims for certain chronic diseases - namely those listed in 38 C.F.R. § 3.309(a) - benefit from a somewhat more relaxed evidentiary standard under 38 C.F.R. § 3.303(b). See Walker, 708 F.3d at 1339 (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases"). Specifically, when a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain in a claim for arthritis or abnormal heart action in a claim for heart disease) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The Federal Circuit Court explained that the requirement of showing a continuity of symptomatology after service under subsection 3.303(b) is a distinct and lesser evidentiary burden than the nexus element of the three-part test discussed above. "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" (emphasis added). Walker, 708 F.3d at 1338-1339. Thus, showing a continuity of symptomatology after service is an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation" for chronic diseases. Id. at 1338; see also id. at 1336 (observing that section 3.303(b) provides a "second route by which a Veteran can establish entitlement to service connection for a chronic disease"). A continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. at 1338. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the more relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit Court held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. Thus, if the claimed disability is not one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "the 'nexus' requirement of the three-element test" must be satisfied in order to establish entitlement to service-connected benefits. Id. For example, the Federal Circuit Court held in Walker that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as it found that the claimant's hearing loss was not among the chronic diseases listed in section 3.309(a)). Id. at 1336-37, 1340. Moreover, in the service-connection context, the presumptions of soundness upon entry into service, the presumption of aggravation where a pre-existing disability increases in severity during service, and the presumptive service connection provisions of 38 C.F.R. § 3.307 only apply to AD service, not also ADT or IADT. See Smith v. Shinseki, 24 Vet. App. 40 (2010); Biggins v. Derwinski, 1 Vet. App. 474, 476-78 (1991). So service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Turning now to the facts and circumstances of this particular case. This Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War and, therefore, is considered a Persian Gulf War Veteran under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317(e). Specifically, she served in Operation Desert Shield/Desert Storm from December 1990 to June 1991 and was awarded the Kuwait Liberation Medal, among other commendations. VA regulation provides that compensation will be paid for disability due to undiagnosed illness and medically unexplained chronic multi-symptom illnesses to a Persian Gulf War Veteran who exhibits objective indications of a qualifying chronic disability if that disability (i) became manifest either during active service in the Southwest Asia theater of operations, or (ii) to a degree of 10 percent or more not later than December 31, 2016, and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1) (effective before and after Dec. 29, 2011). For VA purposes, a qualifying chronic disability presently means a chronic disability resulting from any of the following (or any combination of the following): (A) An undiagnosed illness; or (B) A medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms such as Chronic fatigue syndrome, Fibromyalgia, or Functional gastrointestinal disorders (excluding structural gastrointestinal diseases). The term 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, such as diabetes and multiple sclerosis, will not be considered medically unexplained. "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. 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 CFR § 3.317(a)(2)-(4). 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) Unexplained rashes or other dermatological signs or symptoms, (3) Headache, (4) Muscle pain, (5) Joint pain, (6) Neurological signs and symptoms, (7) Neuropsychological signs or symptoms, (8) Signs or symptoms involving the upper or lower respiratory system, (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). Presumptive service connection may be established for certain infectious diseases and long-term health effects associated with infectious disease. 38 C.F.R. § 3.317(c), (d). Presumptive service connection may not be established if there is affirmative evidence the disease was not incurred during a qualifying period of service, 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 a qualifying period of service and the onset of the illness, or if there is affirmative evidence that the disease is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c)(4). In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. See Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or an injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). If signs or symptoms have been attributed to a known clinical diagnosis, service connection may not be established under the specific provisions applicable to Persian Gulf War Veterans. See VAOPGCPREC 8-98 at paragraphs 4-5 (Aug. 3, 1998). Of course, service connection for a diagnosed illness still may be established if otherwise warranted under VA law. The Veteran's GERD and hiatal hernia are attributed to known clinical diagnoses and, thus, ineligible for service connection under sections 1117 and 3.317 based on her Persian Gulf War service. Specifically, a February 2009 private treatment record shows that an esophagogastroduodenocscopy was performed and yielded diagnoses of mild gastritis and GERD "facilitated by a 3 cm sliding hiatal hernia." In the December 2011 VA examination report, the examiner opined that the Veteran's symptoms had a "clear and diagnosed cause, namely gastric reflux, and therefore her GERD was not an undiagnosed condition. Accordingly, because her GERD and associated hiatal hernia are diagnosed conditions, service connection may not be established for these disorders under sections 1117 and 3.317. The preponderance of the evidence also weighs against finding that the Veteran's GERD and hiatal hernia were otherwise incurred in or aggravated by her active military service. In an October 1994 periodic medical history report filled out in connection with her reserve service, she indicated that she had experienced frequent indigestion since 1993 and was treated with Zantac with good results. The diagnosis at the time was considered "unknown." Her STRs otherwise do not mention GERD, a hiatal hernia, or other gastrointestinal symptoms. On a June 1991 report of medical history form, so dated after her deployment to the Persian Gulf, she indicated that she did not have a history of frequent indigestion or stomach or intestinal trouble, although she affirmed having a number of other, unrelated medical conditions in that report. That report is in keeping with her statement in the October 1994 medical history report that her indigestion had begun in 1993. Moreover, she did not report having GERD or gastrointestinal symptoms in a June 2003 post-deployment health assessment report. In short, her STRs indicate she began having indigestion in 1993 or thereabouts, during a time when she was not actively serving and over a year after her period of active service from December 1990 to June 1991. She indicated in her February 2013 hearing testimony that she was activated in December 1990, deployed to the Persian Gulf in January 1991, and returned in April 1991, just a couple of months prior to the conclusion of that period of service in June 1991. Based on her STRs, the Board does not find it credible that her GERD incepted during her active military service. In this regard, a February 2009 private treatment record reflects that he reported having GERD during the Gulf War in 1991 and had been experiencing intermittent reflux since that time. She provided a similar history during her February 2013 Board hearing. However, as this account directly conflicts with the October 1994 medical history report discussed in the preceding paragraph, as well as the June 1991 report of medical history in which she denied indigestion or stomach problems despite reporting a number of other unrelated medical conditions, the Board does not find this account to be credible. See Caluza, 7 Vet. App. at 511 (holding that when determining whether lay evidence is satisfactory, the Board may properly consider, among other things, its consistency with other evidence submitted on behalf of the Veteran); Madden, 125 F.3d at 1480 (observing that "lay evidence which is in fundamental conflict with other lay evidence and is, for that reason, found not credible in a given case, is surely suspect."); see also Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than history as reported by the claimant). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is "credible", or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board must additionally determine whether such evidence is also credible). Only if the evidence is both competent and credible does it ultimately have probative value. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In ascertaining the competency of lay evidence, the Courts generally have held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found competent with regards to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). On the other hand, laypersons equally have been found not competent in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Competent medical evidence, as opposed to lay evidence, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza at 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see also Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). As fact finder, when considering whether lay evidence is satisfactory, the Board may not only consider internal inconsistency of statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, but also the Veteran's demeanor when testifying at a hearing when he has testified. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). See, too, Macarubbo v. Gober, 10 Vet. App. 388 (1997) (similarly holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons or bases for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). To this end, the Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit Court, citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id., at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court similarly has declared that, in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). Here then, in sum, while the Veteran is competent to report that she experienced and was treated for gastrointestinal symptoms, including indigestion or GERD during her active military service, the Board does not find this history to be credible for the reasons discussed above. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that appellant was competent to testify as to factual matters of which he had first-hand knowledge, such as experiencing pain in his right hip and thigh in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy). Because her statements are not consistent, so not credible, with regards to this history, their weight must be discounted. See id. (noting that the witness's credibility affects the weight to be given to his testimony). See also Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the Veteran wrote during treatment than to his subsequent assertion years later); Struck v. Brown, 9 Vet. App. 145, 155-56 (1996) (Contemporaneous medical findings may be given more probative weight). This is especially true when statements or history is given in the course of treatment. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). With regards to her hiatal hernia, she testified during her February 2013 Board hearing that it was not treated during her active military service or within one year of separation, and that it was not discovered until 2009, which is consistent with the February 2009 private treatment record reflecting a diagnosis of a hiatal hernia based on diagnostic imaging. Thus, the preponderance of the evidence shows that her hiatal hernia did not manifest during her active service or until many years later. The Board has considered her contention that her GERD and hiatal hernia were caused by immunization injections during her active service or by exposure to chemicals, fumes, and other environmental factors during her Gulf War service. However, she has not submitted any competent evidence in support of this contention. The studies and articles she submitted do not state that an association has been found or suspected between GERD, a hiatal hernia, or similar conditions and the botulinum vaccine, the anthrax vaccine, or other vaccinations. For example, one article, titled "Gulf War Risk Factor Report Reprints," states that based on a report by the National Academy of Sciences' Institute of Medicine (IOM), titled "Gulf War and Health: Volume 1. Depleted Uranium, Sarin, Pyridostigmine, Bromide, Vaccines," there was "little evidence . . . of adverse effects beyond the transient local and systemic effects seen often with any vaccination." It was noted that this was largely due to "a lack of active monitoring." Thus, there simply is no evidence, other than the Veteran's unsupported statements, substantiating a relationship between her GERD and/or hiatal hernia and her service in the Persian Gulf War, including with regards to immunization injections and exposure to various environmental factors during her deployment. Where medical article or treatise evidence, standing alone, discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay opinion, a claimant may use such evidence to meet the requirement for a medical nexus. Wallin v. West, 11 Vet. App. 509 (1998). However, an attempt to establish a medical nexus between service and a disease or an injury solely by generic information in a medical journal or treatise "is too general and inclusive." Sacks v. West, 11 Vet. App. 314, 317 (1998) (holding that a medical article that contained a generic statement regarding a possible link between a service-incurred mouth blister and a present pemphigus vulgaris condition did not satisfy the nexus element). Still, medical treatise evidence can provide important support when combined with an opinion of a medical professional. Mattern v. West, 12 Vet. App. 222, 228 (1999). See also Rucker v. Brown, 10 Vet. App. 67, 73-74 (1997) (holding that evidence from scientific journal combined with doctor's statements was "adequate to meet the threshold test of plausibility"). There is no such supporting medical opinion here, however. The Veteran herself, as a layperson, does not have the medical expertise to render a competent opinion as to whether her GERD or hiatal hernia are related to environmental factors while serving in the Persian Gulf, or to immunization injections she received during her service, including in anticipation of her Persian Gulf War service. This is a determination that is far too complex to be made based on lay observation alone, as indicated by the articles and studies submitted by her, which show that ongoing investigations are being conducted on any potential health outcomes from the immunization injections, including by the Institute of Medicine, and that such investigations have so far not produced reliable evidence supporting any long-term health consequences. Thus, her lay statements are not competent with respect to this issue and their weight must be discounted. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007)( observing that a layperson can be competent to identify conditions that are simple, such as a broken leg, but is not competent to identify more complex conditions such as a form of cancer); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that lay testimony is competent as to matters capable of lay observation, but not with respect to determinations that are "medical in nature"); Layno v. Brown, 6 Vet. App. 465, 469- 71 (1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration, and that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). The Veteran has not advanced any other arguments in support of her claims, and there is no evidence of record otherwise indicating that her GERD and hiatal hernia may be related to her active military service. In this regard, as shown above, neither condition manifested during her service, and an in-service disease, injury, or event relevant to the incurrence or aggravation of GERD or a hiatal hernia has not been established. Thus, the second and third elements of service connection have not been satisfied. See Shedden, 381 F.3d at 1166-67; 38 C.F.R. § 3.303. Accordingly, the preponderance of the evidence is against these claims. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for a hiatal hernia and GERD must be denied. See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. IV. Dismissals At the outset of her February 2013 Travel Board hearing, and as reaffirmed in an accompanying February 2013 written statement, the Veteran indicated she is withdrawing her appeal of the claims for service connection for bilateral lower extremity numbness, a bilateral shoulder disorder, a bilateral elbow disorder, a bilateral hip disorder, a bilateral knee disorder, a bilateral ankle disorder, as well as her claim for a compensable rating for her C6 and C7 radiculopathy of her left arm with left carpal tunnel syndrome. Under 38 C.F.R. § 20.204(b), appeal withdrawals must be in writing, must include the name of the Veteran, the applicable claim number, and a statement that the appeal is withdrawn, and must be received by the Board prior to issuance of a decision on the issue being withdrawn. In this case, the Board hearing has been reduced to writing via a transcript that includes the Veteran's name, claim number, and a statement that the aforementioned claims are withdrawn. The February 2013 statement is also in writing and includes the Veteran's name and claim number. In withdrawing the above-mentioned claims, the Veteran referred to issues 1 through 13 in the June 2012 SOC, which correspond to issues 5 through 17 on the cover page of this decision, comprising the claims set forth in the foregoing paragraph. When the Board received the Veteran's withdrawal, it had not yet issued decisions on these claims. Accordingly, the criteria are met for withdrawal of the appeal concerning these claims. See id. When pending appeals are withdrawn, there is no longer an allegation of error of fact or law with respect to the determinations that had been previously appealed. Consequently, in such an instance, dismissal of the pending appeal is appropriate. See 38 U.S.C.A. § 7105(d). A "case or controversy" involving a pending adverse determination that he has taken exception to no longer exists as regarding these claims. See Shoen v. Brown, 6 Vet. App. 456, 457 (1994) (quoting Waterhouse v. Principi, 3 Vet. App. 473 (1992)). Accordingly, further action by the Board on these claims would be inappropriate and the Veteran's appeal with respect to these claims thus is dismissed. Id. ORDER The claim of entitlement to service connection for GERD is denied. The claim of entitlement to service connection for a hiatal hernia also is denied. The claim of entitlement to service connection for left lower extremity numbness is dismissed. The claim of entitlement to service connection for right lower extremity numbness is dismissed. The claim of entitlement to service connection for left shoulder bursitis/subluxation (claimed as left shoulder pain) is dismissed. The claim of entitlement to service connection for right shoulder bursitis/subluxation (claimed as right shoulder pain) is dismissed. The claim of entitlement to service connection for left elbow bursitis (claimed as left elbow pain) is dismissed. The claim of entitlement to service connection for right elbow bursitis (claimed as right elbow pain) is dismissed. The claim of entitlement to service connection for left hip bursitis (claimed as left hip pain) is dismissed. The claim of entitlement to service connection for right hip bursitis (claimed as right hip pain) is dismissed. The claim of entitlement to service connection for left ankle bursitis (claimed as left ankle pain) is dismissed. The claim of entitlement to service connection for right ankle bursitis (claimed as right ankle pain) is dismissed. The claim of entitlement to service connection for left knee patellofemoral syndrome with ligamentous pain is dismissed. The claim of entitlement to service connection for right knee patellofemoral syndrome with ligamentous pain is dismissed. The claim of entitlement to a compensable rating for C6 and C7 radiculopathy of the left arm with left carpal tunnel syndrome (left upper extremity numbness) is dismissed. REMAND While the Board sincerely regrets the additional delay that inevitably will result, the remaining claims of entitlement to service connection for CFS and a headache disorder must be remanded for further development. Specifically, another VA Persian Gulf War protocol examination should be provided to determine whether the Veteran has CFS and whether she has a headache disorder related to her Persian Gulf War service. With regard to the claimed CFS, the December 2011 VA examination report indicates the Veteran has CFS, but in the medical opinion section the examiner stated the Veteran did not meet the criteria for CFS, with no explanation provided. Thus, another examination and opinion are required to reconcile these seemingly conflicting findings. Moreover, an explanation in support of the opinion rendered is needed so the Board can make a fully informed decision on this claim. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate); D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). If the examiner finds that the Veteran does not have CFS, the examiner must still address whether the Veteran's fatigue is part of a medically unexplained chronic multi-symptom illness. See 38 C.F.R. § 3.317(b) (providing, in pertinent part, that fatigue may be a symptom of a medically unexplained chronic multi-symptom illness). It is also worth reiterating that, in the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. See Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or an injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). As for the additionally claimed headache disorder, the December 2011 VA examination reports, including concerning the Persian Gulf War examination, do not address whether the Veteran's headaches may be considered an undiagnosed illness or part of a medically unexplained chronic multi-symptom illness associated with her Persian Gulf War service. See 38 C.F.R. § 3.317(b) (providing, in pertinent part, that headaches may be a symptom of a medically unexplained chronic multi-symptom illness). Her headaches sometimes have been associated with her nonservice-connected sinusitis, as reflected in a June 1991 report of medical history, and in May 2008 and February 2009 private treatment records, which reflect that she experienced sinus headaches that improved after sinus surgery. However, a July 2012 private treatment record states that she also has experienced migraine headaches since 2002. She provided a similar history during her February 2013 Travel Board hearing, stating that her headaches had become more severe in the past seven or eight years. Accordingly, a VA medical opinion is needed concerning whether she has a headache disorder because of her Persian Gulf War service, notwithstanding the fact that she also may have sinus headaches, so these other type headaches on account of another, unrelated, cause. In addition, a VA opinion must be provided as to whether the Veteran has a headache disorder caused or aggravated by her service-connected fibromyalgia. See 38 C.F.R. § 3.310(a) and (b) (2012). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). She submitted an article on fibromyalgia stating that tension-type headaches can be a symptom of fibromyalgia. Moreover, VA's Disability Benefits Questionnaire (DBQ) for fibromyalgia reflects that headaches may be a sign or symptom of fibromyalgia. Accordingly, these remaining claims are REMANDED for the following additional development and consideration: 1. Schedule the Veteran for a VA Gulf War examination and any other appropriate VA examination to assess the nature and etiology of her fatigue and headaches. The entire claims file, including a complete copy of this DECISION and REMAND, must be made available to the examiner prior to the examination for review of the pertinent medical and other histories, and the examiner must note in the examination report that the evidence in the claims file has been reviewed. After reviewing the file and examining the Veteran, the examiner must provide an opinion as to whether the Veteran has chronic fatigue syndrome (CFS) and/or whether her reported fatigue is a manifestation of an undiagnosed illness or medically unexplained chronic multi-symptom illness associated with her Persian Gulf War service under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. If the examiner finds that the Veteran does not have CFS, a complete explanation must be provided. The examiner must also provide an opinion as to whether the Veteran has a headache disorder as a manifestation of an undiagnosed illness or medically unexplained chronic multi-symptom illness associated with her Persian Gulf War service under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. Although she has been diagnosed with sinus headaches, she also has reported experiencing migraine headaches since 2002, so of a different variety according to a July 2012 private treatment record. Thus, the examiner must address whether the Veteran may have a headache disorder associated with her Persian Gulf War service overlapping with or distinct from her sinus headaches. The examiner must also provide an opinion as to whether the Veteran has a headache disorder caused or aggravated by her service-connected fibromyalgia, as headaches are a recognized symptom of fibromyalgia. The examiner must provide a complete explanation for all opinions stated. 2. Review the examination reports to ensure they comply with the above remand directives and, in particular, that all opinions are responsive to the questions asked and supported by adequate explanations or rationale. 3. Then readjudicate these remaining claims of entitlement to service connection for CFS and a headache disorder in light of this and all other additional evidence concerning these claims. If these claims continue to be denied, send the Veteran and her representative another SSOC and give them time to respond to it before returning the file to the Board for further appellate consideration of these remaining claims. The Veteran has the right to submit additional evidence and argument concerning these claims the Board is remanding. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise her that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of her claims. Her cooperation in VA's efforts to further develop her claims, including reporting for any scheduled VA examination, is both critical and appreciated. She is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655 (2012). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs