Citation Nr: 1326002 Decision Date: 08/15/13 Archive Date: 08/26/13 DOCKET NO. 05-20 466 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for chest pain, including as a qualifying chronic disability under 38 C.F.R. § 3.317. 2. Entitlement to service connection for an upper respiratory disorder/bronchitis, including as a qualifying chronic disability under 38 C.F.R. § 3.317. 3. Entitlement to service connection for vertigo/vomiting, including as a qualifying chronic disability under 38 C.F.R. § 3.317. 4. Entitlement to service connection for a weakened immune system, including as a qualifying chronic disability under 38 C.F.R. § 3.317. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from August 1990 to December 1993, that included service in the Southwest Asia theater of operations from December 1990 to April 1991. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from a January 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, that, in pertinent part, denied the claims on appeal. In October 2007, August 2009, November 2010 and June 2012, the Veteran's claims were remanded to the RO via the Appeals Management Center (AMC) in Washington, D.C., for further evidentiary development. The matters of entitlement to service connection for vertigo/vomiting and an upper respiratory disorder/bronchitis, including as qualifying chronic disabilities under 38 C.F.R. § 3.317, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, chest pain, diagnosed as costochondritis, had its onset during her active military service. 2. Weakened immune system symptoms have been attributed to the known clinical diagnosis of Hodgkin's lymphoma, that was not manifested during active service and is not otherwise related to the Veteran's active service, including a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for costochondritis are met. 38 U.S.C.A. §§ 1110, 1117, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2012). 2. The criteria for service connection for a weakened immune system, including as a qualifying chronic disability under 38 C.F.R. § 3.317, are not met. 38 U.S.C.A. §§ 1110, 1117, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). 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; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In February 2003, October 2005, and January 2008 letters, the AOJ notified the Veteran of information and evidence necessary to substantiate her claims. She was notified of the information and evidence that VA would seek to provide and the information and evidence that she was expected to provide. In the January 2008 letter, the Veteran was informed of how VA determines disability ratings and effective dates, as required by Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The claims were readjudicated after the January 2008 letter The AOJ satisfied its duty to notify the appellant under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). VA has done everything reasonably possible to assist the Veteran with respect to her claims for benefits in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). Her service treatment and personnel records and VA and private records have been associated with the claims file, to the extent available. All reasonably identified and available medical records have been secured. A review of the Veteran's Virtual VA electronic file does not reveal any additional evidence relevant to the service connection claims on appeal. Further, in October 2003, the Veteran was afforded a VA examination, in connection with her claims on appeal, the report of which is of record. The Board's October 2007 remand was for the purpose of scheduling the Veteran for VA examination and obtaining VA medical records, including records of a cardiology evaluation performed in February 2003. Records indicated that she failed to report for her scheduled examinations. She contended that she was unable to attend the scheduled exams and attempted to reschedule them. VA medical records, dated from June 2002 to December 2007 were obtained, although it does not appear that the February 2003 cardiology evaluation was received. Nevertheless, the August 2012 VA examiner discussed the negative results of the 2003 stress test as noted below. Moreover, given the Board's determination herein, to grant the claim for service connection for chest pain, any failure to obtain the requested cardiology consultation records is not prejudicial. In August 2009, the Board found that the Veteran showed good cause as to why she was unable to attend the scheduled VA examinations and remanded her case to schedule her for new VA examinations and obtain private treatment records identified by her. There has been substantial compliance with this remand, the Veteran underwent VA examination in January 2010 and records from Drs. G.L., T.R., and W., were obtained, as well as VA medical records, dated to July 2009. In November 2010, the Board remanded the Veteran's case again for the purpose of scheduling her for a new VA examination in light of McClain v. Nicholson, 21 Vet. App. 319 (2007). There has been substantial compliance with this remand, as she was scheduled for VA examination in January 2011 and, in December 2011, the examiner provided an Addendum to his report. The Board's June 2012 remand was for the purpose of scheduling the Veteran for new VA examinations. There has been substantial compliance with this remand as the Veteran underwent VA examinations in August 2012. The August 2012 examination reports are adequate for rating purposes as the claims file was reviewed, the examiners reviewed the pertinent history, examined the Veteran, provided clinical findings and diagnoses, and offered etiological opinions with rationale from which the Board can reach a fair determination. The records satisfy 38 C.F.R. § 3.326. The August 2012 VA examination reports cure the deficiencies in the October 2003 and January 2010 and January 2011 reports as to the matters in appeal. Id. The Board finds the duties to notify and assist have been met. II. Factual Background and Legal Analysis The Veteran asserts that she has chest pain and a weakened immune system due to military service, including as a qualifying chronic disability under 38 C.F.R. § 3.317. Thus, she contends that service connection is warranted for these claimed disorders. Upon review of the pertinent evidence of record, and with consideration of the law and regulations applicable to the Veteran's case, the Board is of the opinion that the evidence is in equipoise as to her claim for service connection for chest pain, diagnosed as costochondritis, and it may be granted. However, the evidence of record preponderates against the Veteran's claim for service connection for a weakened immune system, including as due to a qualifying chronic disability under 38 C.F.R. § 3.317, and service connection is not warranted. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To do so, the Board must assess the credibility and weight of all the evidence, including the medical 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 appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Under 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012), a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (to the effect that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a)). Case law has established that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the appellant's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). 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." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). This is a direct service connection theory of entitlement. Certain chronic diseases may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.307, 3.309 (2012). This is also a direct service connection theory of entitlement In addition, secondary service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). With regard to the matter of establishing service connection for a disability on a secondary basis, the United States Court of Appeals for Veterans Claims (Court) has held that there must be evidence sufficent to show that a current disability exists and that the current disability was either caused or aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Additionally, when aggravation of a non-service-connected disability is proximately due to or the result of a service-connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id.; see also 38 C.F.R. § 3.310(b). With regard to a claim for secondary service connection, the record must contain competent evidence that the secondary disability was caused by or aggravated by the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). A service connection claim must be accompanied by evidence that establishes that the claimant currently has the claimed disability. See Degmetich v. Brown, 104 F.3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). See also Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) (to the effect that complaints of pain alone do not meet the current disability threshold). More recently, the court held that the current disability requirement is satisfied when a claimant has a disability at the time of filing the claim or during the pendency of that claim, even if the disability has since resolved. McClain, 21 Vet. App. at 319. See also Romanowsky v. Shinseki, No. 11-3272, (U.S. Vet. App. July 10, 2013) (noting that a diagnosis is "sufficiently proximate to the filing of a claim so as to constitute evidence of a 'current diagnosis' is a factual finding to be made by the Board in the first instance."). Although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of cardiac and infectious disease pathology, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In this case, the Veteran asserts that she has a disability due to her service during the Persian Gulf War. A Persian Gulf veteran is defined as a veteran who served on active duty in the Armed Forces in the Southwest Asia Theater of operations during the Persian Gulf War. See 38 U.S.C.A. § 1117(f) (West 2002); 38 C.F.R. § 3.317(d) (2012). Under 38 U.S.C.A. § 1117(a)(1), compensation is warranted for a Persian Gulf veteran who exhibits objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. Effective December 29, 2011, VA extended the presumptive period in 38 C.F.R. § 3.317(a)(1)(i) through December 31, 2016 (for qualifying chronic disabilities that become manifest to a degree of 10 percent or more after active duty in the Southwest Asia theater of operations). See 76 Fed. Reg. 81834-36 (Dec. 29, 2011). Furthermore, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a), (b). A "qualifying chronic disability" includes (a) undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases)) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. See 38 C.F.R. § 3.317(a)(2); see also 75 Fed. Reg. 61995-97 (2010); 76 Fed. Reg. 41696-98 (July 15, 2011). The term "objective indications of a qualifying chronic disability" include both "signs," in a medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. See 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or a chronic multi-symptom illness include the following: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. See 38 U.S.C.A. § 1117(g). A Persian Gulf veteran is a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317. In cases where a veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. § 1110 is nevertheless warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Thus, the presumption is not the sole method for showing causation. However, as noted above, where the issue involves a question of medical diagnosis or causation, as presented here, a veteran must establish the existence of a disability and a connection between the veteran's service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Inasmuch as the Veteran's service records show that she served in Southwest Asia from December 1990 to April 1991, she is a Persian Gulf War veteran within the meaning of the applicable statute and regulation. The question remains, however, as to whether the record supports a finding that her claimed disorders are a manifestation of an undiagnosed illness or other qualifying chronic disability associated with her Persian Gulf War service, or are otherwise related to her active military service or service-connected disability. A. Chest Pain Service treatment records show that, in November 1992, the Veteran was seen for complaints of chest pain for three days. She described tightness in her chest and sharp pains in the left chest for several days. Upon clinical evaluation, the assessment was stress with inadequate rest. On a November 1993 Report of Medical History, completed when she was examined prior to separation from service, the Veteran denied having pain or pressure in her chest or heart trouble. On examination at that time, her heart, chest, and lungs were normal. Post service, VA and private medical records, dated from 1996 to 2009, include a June 2001 private record that shows that the Veteran had complaints that included chest pains. When initially seen in the VA outpatient clinic in June 2002, the Veteran's complaints included occasional chest pains. A May 24, 2002 private report of a chest x-ray shows a normal chest. An October 2002 VA Persian Gulf Registry examination includes chest pains among the Veteran's symptoms that had their onset in January 1991. A chest x-ray performed at that time was negative. According to an October 18, 2002 VA outpatient record, the Veteran complained of chest pain, described as a squeezing pain over the left chest, that usually lasted from 2 to 10 minutes, and occurred once every couple of weeks. On examination, her heart had a regular rhythm and rate (RRR) and there was no murmur. The assessment was chest pain and an echo stress test was requested. Results of the stress test performed in 2003 were negative for ischemia according to the August 2012 VA heart condition examination report. A May 5, 2003 VA outpatient record describes the Veteran's history of atypical chest pain that she had earlier that day that was brief and sharp. Her pain was not related to exertion and she did not experience shortness of breath. She denied any palpitations and gastrointestinal and genitourinary complaints. On examination, the Veteran's heart had a RRR without murmur or gallop. Her pulses were intact in the upper and lower extremities. It was noted that a chest x-ray in June 2002 was normal. A September 2003 private medical record reflects that the Veteran's chest x-ray was clear. The October 2003 VA general medical examination report does not discuss findings regarding chest pain. Results of an electrocardiogram performed in 2009 were normal according to the August 2012 VA heart condition examination report. The January 2010 VA examination report reveals that the Veteran denied chest pain for two years and did not recall when she last had chest pain. The examiner reported that chest pains were noted in "[service medical records] left chest wall 2001". No evidence of any disease process of the chest or heart disease was found by the VA examiner. Results of a chest x-ray performed in 2011 were normal, according to the August 2012 VA heart condition examination report. The January 2011 VA examination report reflects that the Veteran had no current complaints of chest pain. The August 2012 VA heart condition examination report indicates that the examiner reviewed the Veteran's medical records and performed a clinical evaluation. The VA examiner noted that there was no historical or documentary evidence of a heart condition for the Veteran. She had complaints of chest pain for several years - left side anterior squeezing pain that occurred at random and lasted less than one minute. A stress test in 2003 was negative for ischemia and a chest x-ray in 2011 was normal. According to the VA examiner, the Veteran's chest pain was "more likely than not musculoskeletal in origin (i.e. costochondritis)." There were no known precipitating or alleviating factors. Her chest pains were currently ongoing. Other than the Veteran's reported history, there were no other "objective medication indications that the [V]eteran is suffering from chest pain symptoms." The VA examiner noted that her service treatment records document treatment for chest pain and opined that "it is more likely than not that the [V]eteran's current chest pain (costochondritis) is etiologically related to her military service." In order to establish service connection for the Veteran's claimed disability due to an undiagnosed illness, the legal criteria provide, in pertinent part, that the illness or symptoms not be attributable to any known clinical diagnosis by history, physical examination, and/or laboratory tests. 38 C.F.R. § 3.317. While acknowledging the Veteran's complaints of chest pain since serving in the Gulf War, such symptoms have been attributed to costochondritis. Thus, service connection for chest pain, claimed as due to an undiagnosed condition, is not warranted. Here, the objective evidence as to direct-inservice incurrence is in equipoise. The October 2003 VA examiner did not discuss findings regarding chest pain, the January 2010 VA examiner found no evidence of any disease process of the chest or heart disease, and the January 2011 VA examiner found no current complaints of chest pain. However, the August 2012 VA examiner noted that the Veteran's service treatment records document treatment for chest pain and opined that it was more likely than not that the Veteran's current chest pain (costochondritis) was etiologically related to her military service. As such, resolving reasonable doubt in the Veteran's favor, the Board concludes that service connection for chest pain, diagnosed as costochondritis, is warranted. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. The benefit of the doubt has been resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. B. Weakened Immune System The Veteran contends that, since service, she has become sick easily and her sicknesses last longer than normal. In a March 2003 signed statement, her mother described the Veteran as energetic, hard working, and active before service and said that, in the years since the Veteran returned from Saudi Arabia, she was constantly sick due to her immune system being very low. Service treatment records do not discuss complaints or diagnosis of, or treatment for, a weakened immune system. When examined for separation in November 1993, the Veteran's vascular and other bodily systems were all reported as normal. A May 17, 2001 private treatment record from Dr. M., indicates that the Veteran had a history of a weakened immune system. A June 15, 2001 private treatment record indicates that the Veteran complained of fatigue, headaches, and swollen and tender lymph nodes. The clinical assessment included chronic fatigue syndrome. According to May 31, 2002 printed medication information provided by Wal-Mart, the Veteran was prescribed Valtrex, an antiviral used for "patients with normal immune systems" to treat herpes zoster. When initially seen in the VA outpatient clinic on June 17, 2002, the Veteran complained of a weakened immune system. The October 2003 VA general medical examination report does not discuss findings of a weakened immune system. A report of an October 2003 VA computed tomography (CT) study of the Veteran's brain includes the radiologist's note of mild prominence of the adenoids and the physician's query if there was "[a]ny evidence for immunocompromise?" According to a December 30, 2004 private medical record, the Veteran was treated for a viral syndrome. A June 2005 private sleep study report shows that the Veteran's past medical history included a weakening immune system. The January 2010 VA examination report reflects that the Veteran reported that she became ill easily and became sick if she was around a sick person. She reported never being informed that she had a weakened immune system. The Veteran had head colds two or three times a year. According to the VA examiner, the Veteran was "[n]oted to have . . . weakened immune system 6-01 in [service medical records]." The January 2011 VA examination report indicates the Veteran did not have a history of positive human immunodeficiency virus (HIV) or other immuno-compromised conditions. The VA examiner opined that there was no medical evidence to support the diagnosis of immunocompromised for this Veteran. According to the August 2012 VA examination report, the examiner reviewed the Veteran's medical records and performed a clinical evaluation. The Veteran complained of weakness, easy fatigability, and dyspnea on mild exertion. The diagnosis was Hodgkin's disease. The VA examiner noted that, since approximately 2003, the Veteran had nonspecific symptoms and radiologic findings consistent with the condition of Hodgkin's lymphoma. In the VA examiner's opinion, it was at least as likely as not that this Veteran's Hodgkin's disease began in approximately 2003. After her definitive diagnosis in 2011, the Veteran underwent chemotherapy and was currently in remission. The VA examiner explained that the Veteran's claimed "weakened immune system" was most likely due to her Hodgkin's lymphoma, so there were objective medical indications that she had a weakened immune system (Hodgkin's) during the pendency of the appeal. Review of the Veteran's medical records included review of the June 2001 notation of immunosuppression and the October 2003 radiology report. According to the VA examiner, during the Veteran's time in service, from 1990 to 1993, there was no diagnosis of immunosuppresion, Hodgkins, or "weakened immune system". The VA examiner opined that it was considered less likely than not that the Veteran's Hodgkin's was directly related to her military service. Further, her service-connected conditions (chronic fatigue syndrome, irritable bowel syndrome, headaches, and warts) were not recognized risk factors for the development of Hodgkin's disease. Therefore, it is considered less likely than not that the Veteran's Hodgkin's disease was caused or aggravated by her service-connected conditions. In order to establish service connection for the Veteran's claimed disability due to an undiagnosed illness, the legal criteria provide, in pertinent part, that the illness or symptoms not be attributable to any known clinical diagnosis by history, physical examination, and/or laboratory tests. 38 C.F.R. § 3.317. While acknowledging the Veteran's complaints of a weakened immune system since serving in the Gulf War, such symptoms have been attributed to Hodgkin's lymphoma. Thus, service connection for a weakened immune system, claimed as due to an undiagnosed condition, is not warranted. Considering the Veteran's claim on a direct-incurrence basis, although the evidence shows that the Veteran currently has Hodgkin's lymphoma, no competent evidence has been submitted to show that this disability is related to service or any incident thereof. On the other hand, the record reflects that her vascular and other body systems were normal on separation from service and the first post service evidence of record of nonspecific symptoms consistent with Hodgkin's lymphoma is reported to be from 2003, more than ten years after the Veteran's separation from service. The Court has indicated that the normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service is probative evidence against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of low back condition); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability). In fact, in August 2012, the VA examiner opined that the Veteran's weakened immune system symptoms were most likely due to Hodgkin's lymphoma that began in approximately 2003. The examiner stated that it was considered less likely than not that the Veteran's Hodgkin's was directly related to her military service. Further, her service-connected conditions (chronic fatigue syndrome, irritable bowel syndrome, headaches, and warts) were not recognized risk factors for the development of Hodgkin's disease. Therefore, it was considered less likely than not that the Veteran's Hodgkin's disease was caused or aggravated by her service-connected conditions. There is no medical opinion of record that contradicts this VA examiner's opinion. There are no grounds to grant the Veteran's claim on a direct-incurrence basis. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. The preponderance of the objective and credible evidence of record is against her claim for service connection for a weakened immune system, including as a qualifying chronic disability under 38 C.F.R. § 3.317 and on a secondary basis, and service connection is not warranted. In adjudicating this claim, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). Lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witness's personal knowledge. Barr v. Nicholson, 21 Vet. App. 303 (2007); see also 38 C.F.R. § 3.159(a)(2) (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 the facts or circumstances and conveys matters that can be observed and described by a lay person). The Veteran is competent to describe her observable symptoms, such as feelings of weakness. Hence, her report of experiencing a weak feeling since discharge from service is competent. Barr, 21 Vet. App. at 303; Buchanan, 451 F.3d at 1331. The Veteran is not competent to say, however, that the weakness felt since discharge from service was actually the same condition that has been identified currently. While the Veteran might sincerely believe that the post-service conditions appeared the same, the VA physician explained that, since approximately 2003, but no earlier, the Veteran had nonspecific symptoms consistent with Hodgkin's lymphoma that was definitively diagnosed in 2011. To the extent that the Veteran is now claiming that immune system problems have persisted since service, this is inconsistent with the overall record which reflects immune symptomatology surfaced after service, the Veteran's own reports of symptoms dating from 2003 and the service separation examination and history showing no immune system disability. Given her statements and the medical record, any reports of a continuity of symptomatology would not be credible. The Board has considered the Veteran's statements as to her incurrence during service, in light of her service treatment records, post-service medical evidence, and the August 2012 VA medical opinion. The Board finds that the objective medical evidence of record is most persuasive and of most probative value. The record reflects that the Veteran was not treated on even one occasion for weakened immune system problems during military service. The post service records show that, in 2003, more than ten years after her discharge from service, there were nonspecific symptoms and radiologic findings consistent with Hodgkin's lymphoma that was definitively diagnosed in 2011. Further, the August 2012 VA examiner, who reviewed the Veteran's in-service treatment records and her post-service medical records, and performed a clinical evaluation, concluded that her weakened immune system symptoms were attributable to Hodgkin's lymphoma that was less likely than not related to military service, including service-connected disabilities. The Veteran's contentions are outweighed by the medical evidence and opinion of the August 2012 VA examiner that reflects that she did not have a weakened immune system disorder related to her active military service or a service-connected disability. The Veteran's contentions as to etiology are not deemed competent and thus are not probative. In sum, the medical opinions are against a link between the current disability and service, there is no competent and credible evidence of a continuity of symptoms; nor is there other competent and credible evidence linking the current Hodgkin's disorder to service or a service-connected disability. Thus, a clear preponderance of the objective and probative medical evidence of record is against the Veteran's claim for service connection for a weakened immune system, including as a qualifying chronic disability under 38 C.F.R. § 3.317. Reasonable doubt does not arise, and the claim must be denied. Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001). ORDER Service connection for costochondritis granted. Service connection for a weakened immune system, including as a qualifying chronic disability under 38 C.F.R. § 3.317, is denied. REMAND The Veteran also seeks service connection for an upper respiratory disorder/bronchitis and vertigo/vomiting, including as qualifying chronic disabilities under 38 C.F.R. § 3.317. In June 2012, the Board remanded the Veteran's case to afford her VA examinations that were performed in August 2012 and January 2013. As to the claim for service connection for an upper respiratory disorder/bronchitis, the Board asked if, during the pendency of her claim, the Veteran had a chronic upper respiratory disorder/bronchitis. If so, the examiner was then asked to comment as to the likelihood that the current respiratory disorder had its onset in service or was related to upper respiratory disorder/bronchitis noted in service in June 1991. In August 2012, a VA examiner found that the Veteran did not have a chronic upper respiratory disorder/bronchitis during the pendency of this claim and stated that "[s]he has occasional acute [upper respiratory infections]." However, it is unclear to the Board if the Veteran's "occasional" acute upper respiratory infections are related to her upper respiratory disorder/bronchitis noted in service (including the June 1991 service treatment records). Further clarification is needed. As to the claim for service connection for vertigo/vomiting, in January 2013, a VA examiner found that "the most likely diagnosis would be viral labyrinthitis (vestibular neuronitis) incurred on active duty with subsequent resolution." The VA examiner stated that the Veteran appeared "asymptomatic at the present time, with no significant vestibular symptoms present. It is at least as likely as not that acute viral labyrinthitis occurred on active duty, although there appears to be no significant residual symptoms present." Although the VA examiner commented that there were no "significant" residual symptoms present, it is unclear to the Board if the Veteran has any residual symptoms from the viral labyrinthitis in service. Further, the VA examiner did not indicate as to whether the labyrinthitis was caused or chronically worsened by the Veteran's service-connected disabilities (including chronic fatigue syndrome, irritable bowel syndrome (IBS), chronic headache disorder, warts on the hands, and herpes skin rashes) as requested by the Board. This needs to be done prior to appellate consideration of the Veteran's case. Accordingly, these issues are REMANDED for the following actions: 1. Return the claims file and a copy of this Remand to the physician who performed the August 6, 2012 VA respiratory conditions examination at the Fort Worth, Texas, VA Outpatient Center, or another similarly qualified physician. (A clinical evaluation should be scheduled only if deemed necessary by the examiner.) Request that the examiner review the examination report and then address the following: a. In the August 2012 report, the VA examiner remarked that the Veteran did not have a chronic upper respiratory disorder/bronchitis during the pendency of her claim and that "[s]he has occasional acute [upper respiratory infections]." b. The examiner is requested to address whether it is at least as likely as not (50 percent probability or more) that the Veteran's occasional acute upper respiratory infections are related to her upper respiratory disorder/bronchitis noted in service (including the notations in the June 1991 service treatment records). A rationale should be provided for all opinions rendered. 2. Then return the claims file and a copy of this Remand to the physician who performed the January 25, 2013 VA otolaryngology examination at the North Texas HCS in Dallas, Texas, or another similarly qualified physician. (A clinical evaluation should be scheduled only if deemed necessary by the examiner.) Request that the examiner review the examination report and then address the following: a. The examiner stated that the most likely diagnosis of the Veteran's symptoms would be viral labyrinthitis (vestibular neuronitis) incurred on active duty with subsequent resolution. The VA examiner also stated that the Veteran appeared "asymptomatic at the present time, with no significant vestibular symptoms present. It is at least as likely as not that acute viral labyrinthitis occurred on active duty, although there appears to be no significant residual symptoms present." b. The examiner should clarify what is meant by "significant" residual symptoms. Does the Veteran have any residual symptoms from the viral labyrinthitis in service? If so, the examiner should describe all symptoms attributable to the Veteran's viral labyrinthitis in service. c. The examiner should also comment on whether it is at least as likely as not (50 percent or greater likelihood) that the Veteran's labyrinthitis was caused or chronically worsened by her service-connected disabilities (chronic fatigue syndrome, IBS, chronic headache disorder, warts on the hands, and herpes skin rashes). If made chronically worse, what is the baseline level of labyrinthitis disability and what is the permanent, measurable increase in current labyrinthitis pathology attributable to the service-connected chronic fatigue syndrome, IBS, chronic headache disorder, warts on the hands, and herpes skin rashes? A rationale should be provided for all opinions rendered. 3. Finally, after completion of the above and any other necessary development, review the expanded record and determine if any of the benefits sought can be granted. If any benefit sought is not granted in full, the Veteran and her representative should be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ RYAN T. KESSEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs