Citation Nr: 1335311 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 09-13 806 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to an increased rating for migraine headaches, currently evaluated as 10 percent disabling. 2. Entitlement to an increased rating for sinusitis, currently evaluated as 10 percent disabling. 3. Entitlement to an increased rating for a gastrointestinal disorder, identified as status post-cholecystectomy with dumping syndrome, gastroparesis and gastroesophageal reflux disease (GERD), currently evaluated as 10 percent disabling. 4. Entitlement to service connection for an acquired psychiatric disorder (claimed as depression), to include as secondary to service-connected disabilities. REPRESENTATION Veteran represented by: California Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL The Veteran and her daughter ATTORNEY FOR THE BOARD E. Woodward Deutsch, Counsel INTRODUCTION The Veteran served on active duty from January 1999 to January 2003. These matters come before the Board of Veterans' Appeals (Board) from November 2004, June 2007, September 2008, and October 2008 rating decisions issued by Department of Veterans Affairs (VA) Regional Offices in San Diego, California; Seattle, Washington; and Oakland, California. In April 2013, the Veteran testified at the Oakland RO before the undersigned, who was authorized to conduct a hearing via videoconference from the Board's Central Office in Washington, D.C. A transcript (Tr.) of the hearing has been associated with the claims file. See 38 U.S.C.A. § 7107(c), (e)(2) (West 2002). During the proceeding, the Veteran submitted additional evidence, accompanied by a waiver of initial review by the Agency of Original Jurisdiction (AOJ). She then testified in support of the three increased rating claims listed on the title page. The Veteran also presented testimony regarding the above-captioned claim for service connection. This issue has not been formally certified for appellate review. Nevertheless, the Board observes that, less than one year after receiving notice of the October 2008 denial of her depression claim, the Veteran submitted an April 2009 written statement in which she essentially disputed that unfavorable rating decision. See April 2009 VA Form 9 (noting, in pertinent part, that the Veteran "ha[d] been receiving [VA] treatment for 'major depressive illness,' secondary to [her] service-connected disabilities," and alleging that "[i]f VA was vigilant in its duty to assist claims, at some point, a review of [her] medical records would have revealed this fact"). The Board considers the Veteran's April 2009 statement to be tantamount to a timely Notice of Disagreement (NOD) with the October 2008 adjudication. See 38 C.F.R. § 20.201 (2013) (identifying a NOD as a written communication from a claimant expressing dissatisfaction or disagreement with an adjudicative determination by the AOJ and a desire to contest the result); see also Gallegos v Principi, 283 F.3d 1309, 1314 (Fed. Cir. 2002) (noting that, while the NOD must be in terms which can be reasonably construed as disagreement with that determination and a desire for appellate review, special wording is not required). Moreover, while mindful that the claim was never addressed in a statement of the case, the Board nevertheless considers the Veteran's recent hearing testimony, in tandem with her previous written statements, to be evidence of her belief that such an issue has been on appeal. Therefore, the Board has the authority to assume jurisdiction of that issue without prejudice to the Veteran. See Percy v. Shinseki, 23 Vet. App. 37, 45 (2009) (finding that VA waives objection to the timeliness of a Substantive Appeal by taking actions that lead the Veteran to believe that an appeal was perfected). Indeed, that is particularly true where, as here, the Board is remanding that issue for further development, an outcome favorable to the Veteran. Conversely, the Board does not have jurisdiction over a claim for a total disability rating based on individual unemployability (TDIU). In this regard, the Board recognizes that the evidence submitted at the recent hearing includes a written statement from two VA treating providers, attesting to the Veteran's inability to work due to her service-connected disabilities. However, that letter does not specify which particular service-connected disabilities interfere with the Veteran's employment and, even more significantly, acknowledges that she continues to work fulltime for the Internal Revenue Service. Moreover, while that letter is dated December 15, 2008, the Veteran has since confirmed that she remains a fulltime Federal employee. See Board Hearing Tr. at 28. Consequently, notwithstanding the tenets of Rice v. Shinseki, the Board finds that the overall evidence of the record does not support a claim for TDIU in connection the Veteran's pending increased rating claims. Cf. Rice v. Shinseki, 22 Vet. App. 447 (2009) (per curiam) (holding that a TDIU claim is part and parcel of pending claims for higher evaluations for individual service-connected disabilities). The issue of service connection for an acquired psychiatric disorder is REMANDED to the AOJ via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the relevant appeal period, the Veteran's service-connected migraine headaches have been manifested by characteristic prostrating attacks occurring at an average frequency of once per month over the last several months. 2. Throughout the relevant appeal period, the Veteran's head pain and shortness of breath requiring daily inhalation therapy and occasional corticosteroid use have been collectively contemplated by her 30 percent disability ratings for migraine headaches and chronic obstructive pulmonary disease with asthma, while her service-connected sinusitis, standing alone, has been manifested by fewer than three incapacitating episodes per year requiring prolonged (lasting four to six weeks) antibiotic treatment and fewer than six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting. 3. Throughout the relevant appeal period, the Veteran's gastrointestinal disorder, identified as status post-cholecystectomy with dumping syndrome, gastroparesis and gastroesophageal reflux disease (GERD)) has been manifested by severe diarrhea, alternating diarrhea and constipation, and more or less constant abdominal distress. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 30 percent, but not higher, for migraine headaches have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code (DC) 8100 (2013). 2. The criteria for a disability rating in excess of 10 percent for sinusitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1, 4.2, 4.3, 4.7, 4.10, 4.97, DCs 6510, 6511, 6512, 6513, 6514, 6522 (2013). 3. The criteria for a disability rating of 30 percent, but not higher, for a gastrointestinal disorder identified as status post-cholecystectomy with dumping syndrome, gastroparesis, and GERD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1, 4.2, 4.3, 4.7, 4.10, 4.114, DCs 7318, 7319, 7327 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Prior to addressing the notice and assistance requirements, applicable law, and facts at issue in this case, the Board notes that it has thoroughly reviewed the lay and medical evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss every piece of evidence submitted by the Veteran or on his behalf. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, with respect to the Veteran's increased rating claims. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The VCAA applies to the instant claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2103). The notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements apply to all five elements of a service-connection claim: Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006). At the outset of its discussion, the Board observes that, following a January 2003 rating decision granting service connection for migraine headaches, sinusitis, and a gastrointestinal disorder (then classified as status post-cholecystectomy), the Veteran expressed general disagreement with the adjudication, but did not specify the particular issues to which she objected. See September 4, 2003, Statement (titled "Notice of Disagreement"). Consequently, the AOJ advised the Veteran in a January 2004 letter that such additional information was required to initiate an appeal. The AOJ further advised the Veteran that she had 60 days from the date of its letter to submit the required information. However, the Veteran declined to respond within that time period. It follows that her September 4, 2003, statement, though styled as a "Notice of Disagreement," cannot be considered a valid NOD. Therefore, the issues on appeal are most appropriately characterized as increased rating claims for which VCAA notification is needed following the award of service connection. Here, the requisite § 5103 notice was provided in a letter dated in April 2004, prior to the initial adjudication of the increased rating claims. That notice letter specifically advised the Veteran of the evidence needed to substantiate those claims, as well as her responsibilities, and those of VA, for obtaining such evidence. Subsequent notice letters, sent in February 2009 and July 2011, described in detail how VA assigns a disability rating and an effective date following the initial grant of service connection. Therefore, the April 2004, February 2009 and July 2011 letters collectively satisfied both the threshold notice criteria and the heightened requirements set forth in Dingess. Moreover, while the February 2009 and July 2011 letters post-dated the initial unfavorable adjudication of the Veteran's increased-rating claims, any prejudice arising from that late VCAA notice has been effectively cured by the subsequent readjudication of the Veteran's claims most recently in a January 2013 supplemental statement of the case (SSOC). See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that the issuance of a fully compliant notification letter followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect). Accordingly, the Board finds that VA has fulfilled its duty to notify with respect to the aforementioned claims such that no further notice is necessary. As for the duty to assist, the AOJ has obtained the Veteran's complete service treatment records, as well as all post-service treatment records that are relevant to her increased-rating claims. The Veteran has not alleged, and the record has not otherwise shown, that any additional records remain outstanding with respect to those issues. Accordingly, the Board finds that further efforts to obtain such records would only burden VA, rather than benefit the Veteran, and should therefore not be undertaken. See Sondel v. West, 13 Vet. App. 213, 221 (1999). Similarly, the Board finds that additional VA examinations are not necessary to decide the Veteran's increased-rating claims. She was previously examined in connection with all three claims in June 2010, and thereafter underwent additional VA examinations that addressed the nature and severity of her gastrointestinal disorder and migraine headaches in July 2011 and April 2013, respectively. The Veteran has not argued, and the record has not otherwise shown, that any of those service-connected disabilities has significantly worsened since it was last examined. As such, while mindful of the passage of time, the Board finds that another VA examination is not necessary to decide any of the issues addressed herein. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); VAOPGCPREC 11-95 (1995). Nor is another Board hearing necessary as the Veteran has already present detailed testimony before the undersigned. 38 C.F.R. § 20.700(a) (2013). The transcript of that April 2013 proceeding reflects that the undersigned set forth the issues of increased compensation at the start of the hearing. The undersigned then focused on the elements necessary to substantiate those claims and sought to identify any further development that was required. Such actions satisfied the duties a hearing officer has to explain fully the issues on appeal and to suggest the submission of evidence that may have been overlooked. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010) (holding that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board). Significantly, the Veteran has not contended, and the evidence has not otherwise shown, that the undersigned failed to comply with 38 C.F.R. § 3.103(c)(2) or otherwise committed prejudicial error, either by failing to fully explain the issues on appeal or by neglecting to suggest the submission of evidence that may have been overlooked. In light of the foregoing, the Board finds that VA's duties to notify and assist have been satisfied with respect to the increased-rating claims decided herein and, thus, appellate review of those issues may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). II. Increased Ratings Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2013). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the appeal. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When rating a service-connected disability, the entire history must be considered. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In considering the appropriate rating to assign in a particular case, when the effects of a service-connected disability have not been clinically disassociated from those of a non-service-connected disorder, all relevant signs and symptoms must be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing 61 Fed. Reg. 52,698 (1996)). Additionally, the anti-pyramiding provision of 38 C.F.R. § 4.14 directs that the evaluation of the 'same disability' or, more appropriately in this case, the 'same manifestation' under various diagnoses is to be avoided. Indeed, in Esteban v. Brown, 6 Vet. App. 259 (1994), the United States Court of Appeals for Veterans Claims (Veterans Court) held that, for purposes of determining whether an appellant is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of or overlapping with the symptomatology of the other two conditions. By way of history, the Board observes that the Veteran has been in receipt of service connection for migraine headaches, sinusitis, and a gastrointestinal disorder, identified as status post-cholecystectomy with dumping syndrome, gastroparesis and GERD, since the day following her release from service (January 27, 2003). She has since submitted a March 31, 2004, petition for additional compensation for each of those disabilities. As such, the rating period on appeal extends from March 31, 2003, one year prior to the date of receipt of her increased rating claims. See 38 C.F.R. § 3.400(o)(2). However, 38 C.F.R. § 4.1 provides that, in evaluating a disability, such disability is to be viewed in relation to its whole recorded history. Therefore, the Board will consider pertinent evidence dated prior to March 31, 2003, but only to the extent that it is found to shed additional light on the Veteran's disabilities in relation to the rating period on appeal. In support of her claims for increased evaluations, the Veteran in essence alleges that her migraine headaches, sinusitis, and gastrointestinal disorder are all significantly worse than indicated by her currently assigned disability ratings. The Board will examine each of the Veteran's claims in the context of the VA Rating Schedule. Thereafter, the Board will assess whether any of those issues warrants referral for extraschedular consideration. 38 C.F.R. § 3.321(b) (2013). A. Higher Schedular Rating for Migraine Headaches The Veteran's service-connected headaches have been rated under DC 8100, which contemplates migraines. 38 C.F.R. § 4.124a, DC 8100 (2013). A 10 percent rating consists of characteristic prostrating attacks occurring an average of one in two months over the last several months. In contrast, the symptomatology required to support a 30 percent rating consists of characteristic prostrating attacks occurring on an average of once a month over the last several months, while the symptomatology for a maximum 50 percent rating includes very frequent completely prostrating attacks productive of severe economic inadaptability. Significantly, for purposes of this appeal, the use of the conjunctive "and" in a statutory provision means that all of the conditions listed in the provision must be met. See Melson v. Derwinski, 1 Vet. App. 334 (1991); compare Johnson v. Brown, 7 Vet. App. 95 (1994) (holding that only one disjunctive 'or' requirement must be met in order for an increased rating to be assigned). Hence, because of the successive nature of DC 8100's criteria -- such that the evaluation for each higher disability rating includes the criteria of each lower disability rating -- each criterion listed in the 50 percent rating must be satisfied in order to warrant that maximum schedular evaluation. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). Additionally, while cognizant that neither the VA Rating Schedule nor the Veteran's Court has specifically defined the term "prostrating," the Board notes that it has been defined by WEBSTER'S NEW WORLD DICTIONARY OF AMERICAN ENGLISH 1080 (3rd College Ed. (1986)), as "utter physical exhaustion or helplessness." A similar interpretation has been presented in DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st ed. (2007)), which has defined "prostration" as "extreme exhaustion or powerlessness." The term "productive of severe economic inadaptability" is also not defined in VA law. However, the Veteran's Court has stated that this term is not synonymous with being completely unable to work and VA has conceded that the phrase "productive of" could be read to mean either "producing" or "capable of producing" economic inadaptability. See Pierce v. Principi, 18 Vet. App. 440, 446-47 (2004). In this case, the Veteran's VA outpatient records and examination reports reflect that she was diagnosed with migraine headaches during active duty and has since relied on prescription medication and rest to treat the symptoms of that disorder. As noted in her June 2010 VA examination report, such symptoms include "pounding" right-sided headaches, rated as a 9 out of 10 in terms of severity; nausea; vomiting; blurry vision; photophobia; and phonophobia. The June 2010 report further notes that, as of that date, the Veteran was experiencing migraines "every other week," which had caused her to miss "a few days of work" on unspecified occasions. The report of the Veteran's subsequent VA examination, in April 2013, describes her migraines as productive of "prostrating attacks" occurring on a monthly basis. That report also describes the Veteran's migraines as productive of bilateral head pain, but notes the duration of such pain to be generally less than one day. Additionally, the April 2013 VA examination report indicates that the Veteran's headaches affect her ability to work and prevent her from leading a normal life, but does not provide specific examples of her occupational or social impairment. The Veteran herself has elaborated on the nature of her migraine-induced impairment at her recent hearing, testifying: [F]or example this last episode I mean I'm responsible for taking my kids to school and I realized having a migraine headache I can take medicine, but the medicine makes me sleepy. So I lay down and tell my kids to hold on, we're going to leave in a little while. I lay down, and next thing I know it was already ten o'clock, and I have a call from my boss because he's looking for me, he's going to fire me. My kids didn't get to school and lost the whole day because I have to take the medication. But I was so bad, I had to take it. And basically the only way that they go away is if I stay in the dark and quiet and basically calm down and lay down. So they keep me out of everything, because I mean, even as a mother I couldn't even function. Board Hearing Tr. at 15. The Veteran has further testified that she experiences such debilitating episodes "more than six times per year," and that during each episode she feels like her "head weighs a ton," she "see[s] flashes of light," and "one side of [her] head hurts like [she] ha[s] rocks in it." Id. at 16. The Veteran has likened her condition to "when you look in binoculars and you would see like chasing light and sparkling," but has acknowledged that taking medication and resting in a dark room generally allows her to feel better. Id. After carefully considering the above medical and lay evidence, the Board finds that, throughout the pendency of this appeal, the Veteran's migraines have most nearly approximated the criteria for the next-higher 30 percent rating under DC 8100. As discussed, such criteria include characteristic prostrating attacks occurring an average of once a month over a period of last several months. This disability picture corresponds to the findings of the April 2013 VA examiner and is also consistent with the results of the previous VA examination, as well as the Veteran's own lay statements and testimony. In contrast, there is nothing in the record that shows that the Veteran's migraine symptoms rise to the level of very frequent completely prostrating attacks that are productive of severe economic inadaptability. To the contrary, the April 2013 VA examiner has expressly determined that the Veteran's incapacitating migraine episodes occur at an average frequency of once per month, rather than "more frequently than once per month," as would be consistent with the criteria for a 50 percent rating. Moreover, the Veteran has acknowledged that, while occupationally and socially debilitating, her migraine symptoms are responsive to medication and rest, and are generally no longer than one day in duration. See April 2013 VA Examination Report. This suggests that, by the Veteran's own admission, her migraines do not cause such "utter physical exhaustion or helplessness," or "extreme exhaustion or powerlessness," as to either produce, or be capable of producing, severe economic inadaptability. Further, the Board considers it significant that, as discussed below, the evidence reveals that a greater share of the Veteran's occupational and social impairment appears to stem from her service-connected gastrointestinal disorder and accompanying depression. Also, as noted above, the Veteran is currently employed full time. As such, while mindful that her current employment, standing alone, does not preclude the assignment of a 50 percent rating under DC 8100, the Board finds that a maximum schedular evaluation is not warranted in this instance. In addition to DC 8100, the Board has considered whether other diagnostic codes might serve as the basis for separate or higher ratings. However, the Veteran herself has not alleged that such evaluations are warranted under other provisions of VA's Schedule for Rating Disabilities. Moreover, there is nothing of record that otherwise suggests that DC 8100 is insufficient to account for the Veteran's migraine symptoms. To the contrary, while the Veteran has complained of non-migraine-related head pain, such symptomatology is expressly contemplated in her currently assigned rating for a different service-connected disability, specifically the sinusitis discussed below. 38 C.F.R. § 4.97, DC 6513. As such, to rely on that symptomatology as the basis for awarding higher compensation for the Veteran's service-connected migraines would constitute unlawful pyramiding. 38 C.F.R. §§ 4.14, 4.25; Esteban, 6 Vet. App. at 261-62. In summary, throughout the pendency of this appeal, the Veteran's migraine headaches have most nearly approximated the schedular criteria for a 30 percent rating under DC 8100 and have not warranted a separate or higher evaluation under any other diagnostic code. The Board will defer its extraschedular analysis until it assesses the Veteran's sinusitis and gastrointestinal disorder under the relevant schedular criteria. B. Higher Schedular Rating for Sinusitis Throughout the appeals period, the Veteran's sinusitis has been rated under DC 6513, which subscribes to the General Rating Formula for Sinusitis. See 38 C.F.R. § 4.97, DCs 6510-6514. Under that General Rating Formula, a 10 percent evaluation is warranted for one or two incapacitating episodes per year of sinusitis requiring prolonged antibiotic treatment (lasting four weeks or more); or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent evaluation is warranted when there are three or more incapacitating episodes per year of sinusitis requiring prolonged antibiotic treatment; or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. Finally, a maximum 50 percent schedular evaluation is assigned following radical surgery with chronic osteomyelitis; or near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. Before applying the above rating criteria to the specific facts at issue, the Board acknowledges that the medical and lay evidence indicates that the Veteran relies on daily inhalational therapy to treat her shortness of breath, wheezing, and related respiratory symptoms. See Board Hearing Tr. at 13-14, 18. Significantly, however, the record reflects that those symptoms are expressly contemplated by the evaluation the Veteran has been assigned for a different service-connected respiratory disorder (chronic chronic obstructive pulmonary disease (COPD) with bronchial asthma). Indeed, the symptoms underlying that disorder have been rated 30 percent disabling under separate provisions of the VA Rating Schedule and are not currently on appeal. 38 C.F.R. § 4.97, DC 6604-6602. As such, for the Board to consider those specific symptoms and rating criteria in evaluating the Veteran's sinusitis would violate the rule against pyramiding. 38 C.F.R. §§ 4.14, 4.25; Esteban, 6 Vet. App. at 261-62. Similarly, for the Board to consider the incapacitating episodes of head pain associated with the Veteran's migraines in connection with her sinusitis claim would also constitute pyramiding. Id. As such, the Board will instead consider the Veteran's non-migraine head pain, and the respiratory symptoms that are not expressly contemplated in her rating for COPD with bronchial asthma, in deciding whether additional compensation is warranted for her sinusitis. In this regard, the report of the Veteran's June 2010 VA sinus examination notes that the symptoms underlying her sinusitis include "frequent nasal pressure signs, tooth ache, pressure pain the frontal face area, bloody pus, and discharge." That report further indicates that such symptoms are productive of flare-ups warranting antibiotic treatment approximately three times per year, but does not refer to the need for "prolonged" treatment (lasting four weeks or more). Nor does the report reference the need for other medications or therapy specifically prescribed for the Veterans' sinusitis. To the contrary, the report notes that the Veteran's other respiratory medications (the orally ingested Cetirizine and the inhaled Flonase and saline nasal sprays) are intended to treat other service-connected respiratory disabilities, which are not on appeal. Moreover, while that report indicates that the Veteran has had to take days off from work because of her sinusitis, it does not specify the duration or the frequency of her absences. The Veteran herself has since attested to sinusitis that impacts her employment. Tellingly, however, she has identified her migraine symptoms, which occur at "least once a week," as "the ones that really take me off of work, at least two or three times a month." See Board Hearing Tr. at 16. The Veteran's statements are consistent with her April 2013 VA examination results, which show that she experiences episodes of non-migraine head pain, but that such episodes, in contrast with her migraine symptoms, are not incapacitating. The Board acknowledges that the Veteran has expressed a belief that her sinusitis and migraines are interrelated. However, by her own admission, no clinician has expressly opined as to such a relationship. See Board Hearing Tr. at 14. As such, the Board has no basis to consider the Veteran's migraine symptoms in connection with her sinusitis claim. In this regard, the Board notes that, because the Veteran is separately service connected for migraines - and, indeed, has now been assigned a higher 30 percent evaluation for that disability - her case closely resembles Esteban and is distinct from Mittleider. As such, the Board is to guard against overcompensating the overlapping symptoms of the Veteran's multiple service-connected disabilities. Compare Esteban, 6 Vet. App. at 261-62, with Mittleider, 11 Vet. App. at 182. Accordingly, taking into account the dictates of Esteban, the Board finds that, throughout the appeals period, the Veteran's sinusitis has encompassed symptoms that overlap with those of her separately service-connected migraine headaches and COPD with bronchial asthma. Moreover, the Board finds that the effects of the Veteran's sinusitis, which do not overlap with her other service-connected disabilities, have not warranted a rating above 10 percent under the applicable schedular criteria. To qualify for a higher 30 percent evaluation, she would need to demonstrate that her sinusitis was productive of three or more incapacitating episodes per year requiring prolonged (lasting four to six weeks) antibiotic treatment; or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. The evidence does not show this. Indeed, despite testifying that she has taken antibiotics for her sinusitis, she has not specifically alleged that such treatment has been prescribed three or more times per year for four to six weeks at a time. Moreover, the April 2013 VA examiner has essentially indicated that the head pain associated with the Veteran's sinusitis is not productive of incapacitating episodes, and there is no lay or medical evidence that refutes that finding. Further, while cognizant of the Veteran's complaints of head pain and purulent discharge associated with her sinusitis, the Board notes that her currently assigned 10 percent rating contemplates three to six non-incapacitating episodes per year of those specific symptoms. The Veteran has neither alleged, nor otherwise submitted evidence, showing that her symptoms are of such severity as to warrant higher compensation under the General Rating Formula for Sinusitis. In addition to the foregoing provisions, the Board has considered whether a higher rating might be assignable under the diagnostic code governing allergic rhinitis. See 38 C.F.R. § 4.97, DC 6522. Although the Veteran is separately service-connected for that respiratory disorder, she has been assigned a noncompensable rating and, thus, the rule against pyramiding does not preclude the award of compensation under DC 6522 in this instance. However, the evidence of record does not warrant such compensation. On the contrary, the Veteran has neither contended nor shown that she suffers from either a 50-percent obstruction of each nasal passage, or complete obstruction on one side so as to warrant a 10 percent rating under DC 6522. Id. Nor has she demonstrated that her diagnosed rhinitis is manifested by polyps sufficient to meet the criteria for a 30 percent rating under that provision. Id.; see e.g., June 2010 VA examination report (noting upon physical examination of the nose mild swelling and mucus, but no obstruction of the nasal passage or any polyps; further noting a March 2010 CT of the sinuses with an impression of "essentially normal" evaluation). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case," and, in this case, the facts do not show that there is any other provision of the VA Rating Schedule that is applicable to the Veteran's sinusitis claim. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). Indeed, the Board finds that her relevant medical history, current diagnoses, and demonstrated symptomatology, do not warrant any change in the diagnostic criteria that have been used to rate her sinusitis, for the reasons set forth above. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Nor does the record support a higher evaluation under those applicable schedular provisions. 38 C.F.R. § 4.97, DCs 6510-6514. Next, the Board will consider whether a higher schedular evaluation for the Veteran's service-connected gastrointestinal disorder is warranted before addressing whether to refer that issue and the aforementioned increased-rating claims for extraschedular consideration. C. Higher Schedular Rating for a Gastrointestinal Disorder Throughout the relevant appeals period, the Veteran's gastrointestinal disorder (identified as status post-cholecystectomy with dumping syndrome, gastroparesis and GERD) has been rated 10 percent disabling under DC 7399-7319. Such diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. See 38 C.F.R. § 4.27 (2013). The hyphenated disability will be rated by analogy under a diagnostic code for a closely related disability that affects the same anatomical functions and has closely analogous symptomatology. 38 C.F.R. §§ 4.20, 4.27 (2013). In this case, the AOJ has determined that the most appropriate diagnostic code for rating the Veteran's gastrointestinal disorder is DC 7319, which pertains to irritable colon syndrome (spastic colitis, mucous colitis, etc.). 38 C.F.R. § 4.114, DC 7319. In considering the applicability of other diagnostic codes, the Board observes that there are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title Diseases of the Digestive System, do not lend themselves to distinct and separate disability ratings without violating the fundamental principle relating to pyramiding. 38 C.F.R. §§ 4.14, 4.113 (2013). Ratings under DCs 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114 (2013). Notwithstanding the provisions regarding the avoidance of pyramiding, the Board notes that, as with the Veteran's service-connected respiratory disorders, it is possible for her to have separate and distinct manifestations attributable to the same digestive disease or injury, which would permit a rating under several diagnostic codes. The critical element permitting the assignment of multiple ratings under several diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. 38 C.F.R. §§4.14, 4.25; Esteban, 6 Vet. App. at 261-62. In this case, the Veteran has reported, and her service treatment records confirm, that she has experienced chronic gastrointestinal discomfort and related symptoms since having her gall bladder removed during active duty. See Report of April 2013VA Esophageal Examination, Medical History. Accordingly, DC 7318, which contemplates residuals of gall bladder removal, is also applicable to her claim. Likewise applicable is DC 7327, which directs that the diverticulitis, and analogous digestive disorders, be rated as irritable colon syndrome, peritoneal adhesions, or ulcerative colitis, depending on the predominant disability picture. 38 C.F.R. § 4.114, DCs 7319, 7327 (2013). However, the rating codes for peritoneal adhesions and ulcerative colitis are not applicable as there is no evidence that the Veteran has either of those conditions. 38 C.F.R. § 4.114, DCs 7301, 7323 (2013). Absent evidence of gastrointestinal manifestations contemplated by other provisions of 38 C.F.R. § 4.114, or elsewhere in the VA Rating Schedule, the Board finds that only appropriate diagnostic codes for rating the symptoms associated with the Veteran's service-connected disability are DC 7318 and DC 7319. 38 C.F.R. § 4.114, DCs 7318, 7319 (2013). Diagnostic Code 7318 provides for a 10 percent rating for residuals of gall bladder removal that are accompanied by mild symptoms, and a 30 percent rating for residuals that are productive of severe symptoms. 38 C.F.R. § 4.114, DC 7318 (2013). Diagnostic Code 7319 directs that a 10 percent rating will be assigned for moderate irritable colon syndrome and related symptoms, to specifically include frequent episodes of bowel disturbance with abdominal distress. The code envisions a 30 percent rating for severe diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, DC 7319 (2013). The terms mild, moderate, and severe, as used in DCs 7318 and 7319 and in other diagnostic codes, are not defined in the Rating Schedule. Thus, rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6 (2010). As noted previously, ratings under DCs 7318 and 7319 cannot be combined. Instead, the Board must consider which code, if any, would provide a higher rating based upon the pertinent evidence of record. Such evidence consists of VA examination reports dated in July 2004, April 2007, June 2010, July 2011, and April 2013; VA outpatient treatment reports; and the Veteran's own written statements and hearing testimony. The relevant VA examination reports collectively show that the Veteran suffers from frequent and persistently recurrent epigastric distress, with alternating diarrhea and constipation, esophageal reflux, regurgitation, and vomiting. Moreover, the Veteran's VA medical records reflect that such symptoms warrant frequent outpatient treatment and prescription medication. Further, the Veteran herself has testified that, despite the highly restrictive diet prescribed by her treating providers, she suffers from daily attacks of diarrhea, which are accompanied by abdominal pain, bloating, palpitations, sweating and shaking. See Board Hearing Tr. at 7-9. The Veteran has further testified that, on one recent occasion, her symptoms were so severe that she passed out and an ambulance was called for her. See Board Hearing Tr. at 9-10. In addition, she has commented on the high toll that her chronic gastrointestinal symptoms exact on her work and family life. Indeed, she has attested that she often feels excluded during office lunch meetings and alienated from her mother, who "cooks to show her affection," and from her teenage daughter, who tends to be embarrassed by the Veteran's condition, particularly during a recent outing when she "basically had an accident in [her] car." See Board Hearing Tr. at 11. The Veteran is competent to attest to her gastrointestinal symptoms, and their effects on her occupational and social functioning, as such matters are within the realm of common knowledge. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Moreover, the Board has no reason to doubt the credibility of her testimony as it is consistent with the clinical evidence of record. Accordingly, applying the aforementioned evidence to the applicable schedular criteria, the Board finds that, throughout the relevant appeals period, the Veteran's gastrointestinal disorder has most closely approximated irritable colon syndrome, manifested by severe diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, DC 7319 (2013). Thus, while mindful that the term "severe" is not expressly defined in the Rating Schedule, the Board finds it is equitable and just in this case to assign a 30 percent rating under DC 7319. See id.; see also 38 C.F.R. § 4.6. That is the maximum evaluation available under both that diagnostic code and DC 7318. Therefore, as ratings under those codes cannot be combined, and as the pertinent evidence of record does not invite consideration under any other provisions of the Rating Schedule, a schedular evaluation of 30 percent, but no higher, is warranted in this instance. D. Extraschedular Consideration Having thus considered the Veteran's claims within the context of the Rating Schedule, the Board recognizes that exceptional or unusual factors may arise that would render the application of the schedular criteria impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the applicable regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111, 115 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the Rating Schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. In applying the Thun criteria to the facts of the instant case, the Board recognizes that the Veteran has attested to occupational and social impairment arising from her service-connected migraine headaches, sinusitis, and gastrointestinal disorder. The Board also acknowledges that the Veteran has submitted written statements, authored by herself and by VA treating providers, which indicate that she is often absent from work and in danger of losing her job, and which therefore recommend for her to be granted total disability compensation. See July 26, 2012, Veteran Statement; December 5, 2008, and February 9, 2009, Statements from "M.R., attending physician" and "F.P., LCSW" (licensed clinical social worker). Nevertheless, the record reflects that, despite the Veteran's debilitating symptoms, she remains employed fulltime. Moreover, as discussed previously, the diagnostic codes used to grant higher schedular ratings for the Veteran's migraine headaches and gastrointestinal disorder (DCs 8100 and 7319) have taken into account the evidence of occupational and social impairment that has been presented in this case. Accordingly, the Board finds that the overall record does not show that either of those disabilities, or the Veteran's sinusitis, adversely impacts her work and family life to an extent beyond that which is contemplated by her currently assigned schedular ratings. Next, the Board observes that neither the Veteran nor her representative has expressly raised the matter of entitlement to an extraschedular rating in connection with any of the aforementioned claims. To the contrary, the parties' contentions have been limited to those discussed above, i.e., that the Veteran's service-connected migraine headaches, sinusitis, and gastrointestinal disorder are more severe than reflected by the currently assigned schedular ratings. See Brannon v. West, 12 Vet. App. 32 (1998) (noting that while the Board must interpret a claimant's submissions broadly, the Board is not required to conjure up issues that were not raised by the claimant). Moreover, the Veteran and her representative have not identified any factors that may be considered to be exceptional or unusual with respect to those service-connected disabilities and the Board has been similarly unsuccessful. Further, the record does not show that the Veteran has required frequent hospitalizations for any of those service-connected disabilities throughout the relevant appeals period. In addition, there has been no unusual clinical picture presented, nor any other factor which has taken those disabilities outside the usual rating criteria. Accordingly, the Board finds that the evidence does not support the proposition that the Veteran's migraine headaches, sinusitis, and gastrointestinal disorder present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). E. Summary In reaching the above determinations, the Board remains sympathetic to the Veteran and does not question the sincerity of her belief that increased ratings are warranted for her migraine headaches, sinusitis, and gastrointestinal disorder. As discussed above, the Board has given careful consideration and, indeed, predicated its assignment of higher ratings, in part, on the Veteran's own assertions of tangible symptoms associated with those disabilities, which she is competent to report. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, while the Veteran and other lay persons are competent to provide opinions on some medical issues, see Kahana, 24 Vet. App. at 435 (2011), the overall nature and severity of her service-connected disabilities, within the context of the applicable schedular or extraschedular rating criteria, are matters that lie beyond the realm of common medical knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (noting that lay persons are not competent to diagnose cancer). Thus, to the extent that the Veteran alleges that additional VA compensation is warranted for her migraine headaches, sinusitis, and gastrointestinal disorder, her contentions are outweighed by the probative assessments of the VA clinicians, upon which the Board has relied in determining the most appropriate ratings for those disabilities. The Board finds the statements by the VA clinicians to be more probative because they have the training and expertise to provide competent medical evidence concerning the service-connected disabilities on appeal. In sum, the weight of the competent and credible evidence shows that the Veteran is entitled to schedular evaluations of 30 percent, but no higher, for both her migraine headaches and gastrointestinal disorder, and is not entitled to separate or higher ratings, on either a schedular or extraschedular basis, for her sinusitis. The Board has considered the assignment of staged ratings, but has ultimately concluded that the above evaluations have most nearly approximated the Veteran's service-connected disabilities throughout the entire pendency of this appeal. See Hart, 21 Vet. App. at 509-10. All reasonable doubt has been resolved in the Veteran's favor in reaching these determinations. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2013). ORDER Entitlement to a disability rating of 30 percent, but no higher, for migraine headaches is granted, subject to the laws and regulations governing the payment of VA compensation. Entitlement to a disability rating in excess of 10 percent for sinusitis is denied. Entitlement to a disability rating of 30 percent (the maximum schedular) for a gastrointestinal disorder, identified as status post-cholecystectomy with dumping syndrome, gastroparesis and gastroesophageal reflux disease, is granted, subject to the laws and regulations governing the payment of VA compensation. REMAND The Veteran, in written statements and testimony before the Board, contends that the residual stress either directly and/or medications prescribed to treat her service-connected physical disabilities have precipitated or, at the very least, aggravated her depression. The Board recognizes that, under applicable law, a claim of service connection for one acquired psychiatric disorder is tantamount to a claim for all service connection for all such applicable disorders. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009) (noting that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). Therefore, the Board has broadened the Veteran's claim for depression to include consideration of all acquired psychiatric disorders evidenced in the record. Unfortunately, before the Board cannot reach the merits of the Veteran's acquired psychiatric disorder claim, further development is needed. 38 C.F.R. § 19.9. I. Service Treatment Records At the recent Board hearing, the Veteran testified that she had received in-service mental health counseling in connection with the domestic violence she had experienced while on active duty. See Board Hearing Tr. at 19, 23. She further testified that her counseling sessions had taken place at MacDill Air Force Base in Tampa, Florida, but that the records from those sessions were "not included with [her] regular medical records." Id. at 23. The Veteran then stated that she had attempted to obtain her in-service mental health records, but that "nobody [had] ever answer[ed]," at the telephone number she had been told to contact. Id. at 23-24. Significantly, it appears from a review of the claims file that efforts have been made to obtain the Veteran's outstanding dental records from MacDill Air Force Base, but not the mental health records she has identified. Accordingly, as the Board is now on notice of the existence of those outstanding, and potentially pertinent, service treatment records, they should be obtained on remand. See 38 C.F.R. § 3.159(c)(2); see also Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). II. VA Medical Records In addition to referencing in-service treatment, the Veteran has attested to ongoing VA treatment for panic attacks and related symptoms of domestic violence and posttraumatic stress disorder (PTSD). See Board Hearing Tr. at 25. However, while the record reflects a history of outpatient mental health treatment at the VA Medical Center in Palo Alto, California, and the Community-Based Outpatient Mental Health Clinic in Monterey, California, the most treatment records associated with the paper claims file and Virtual VA efolder are dated in January 2013, prior to the Veteran's April 2013 hearing. As it therefore appears that subsequent VA mental health treatment records may exist that are pertinent to the Veteran's psychiatric claim, such records should also be obtained on remand. III. VCAA Notice The Veteran's allegations of mental health problems arising from in-service domestic violence are suggestive of a claim for PTSD based on sexual assault. See Board Hearing Tr. at 19. Therefore, to ensure that VA's duty to assist has been fully met in this case, the Board finds that, on remand, the AOJ should provide the Veteran with appropriate notice, pursuant to 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), regarding her claim for an acquired psychiatric disorder, to include taking the steps identified in M-21MR, Part IV, Subpart ii, Chapter 1, Section D, Topic 17 of the VA Adjudication Procedure Manual for developing PTSD claims based on sexual assault and other personal trauma. Additionally, on remand, the Veteran should be afforded VCAA notice that addresses the secondary theory of entitlement raised in connection with her acquired psychiatric disorder claim. 38 C.F.R. § 3.310. IV. Medical Examination In a claim for service connection, VA's duty to assist includes providing a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence that an event, injury, or disease occurred in service, or that certain diseases manifested during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent/recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability; but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). In this case, the Veteran's available VA outpatient medical records show that she has been diagnosed with major depressive disorder, anxiety disorder, and PTSD, thereby satisfying the first requirement of the McLendon test. The remaining McLendon requirements have also been met through evidence that suggests a nexus between the Veteran's current mental health symptoms and active service. Or, in the alternative, a relationship between the current symptoms and one or more service-connected disabilities. However, the Board finds that additional competent evidence is necessary to establish whether service connection is warranted on a direct or secondary basis. Specifically, the Veteran herself has attested to ongoing mental health symptoms since her initial in-service treatment for domestic violence. However, her VA treatment records also reflect a history of post-service psychiatric stressors, including conflicts with her ex-husband and teenage daughter, and tensions with her civilian boss and co-workers. In light of the complexity of the Veteran's mental health picture, her own statements, standing alone, are insufficient to establish a direct nexus between depression, or any other current acquired psychiatric disorder, and her active service. Similarly, the Veteran's statements, and the other documents of record, are insufficient to relate her current mental health problems to one or more service-connected disabilities. Such a secondary theory of entitlement has been raised not only by the Veteran herself but also by her VA mental health treating providers. Indeed, her attending VA physician and social worker have opined that the Veteran's "medical, service-connected disabilities have become so severe, and so pervasive in their overwhelming impact on her work and personal life, that they have led to her current depressive syndrome." See February 9, 2009 Statement from "Dr. M.R., Attending Physician" and "F.P., LCSW." Moreover, a licensed nurse practitioner and case manager at the VA Mental Health Clinic in Monterey has opined that the symptoms of Veteran's service-connected gastrointestinal disorder - specifically her underlying gastroparesis and GERD reflux - have repeatedly caused a choking sensation in her throat, which has exacerbated her panic attacks. See March 27, 2013 Statement from "W.D.B., RNP-BC" (Registered Nurse Practitioner-Board Certified). The above evidence supports the Veteran's claim for secondary service connection by suggesting that one or more service-connected disabilities may have aggravated her depression and related mental health symptoms. Whereas here, the claim for secondary service connection was filed after October 10, 2006, there must be evidence establishing a baseline level of disability for the nonservice-connected condition prior to the aggravation. See 71 Fed. Reg. 52,744 (2006) (codified at 38 C.F.R. § 3.310). The heightened evidentiary burden inherent in the revised regulation has not yet been met on the basis of the lay and clinical evidence presented. In light of the foregoing, the Board finds that the Veteran should be afforded a VA psychiatric examination, which takes into account all pertinent evidence of record, including that which is obtained on remand. Accordingly, the case is REMANDED to the AOJ for the following actions: 1. Provide the Veteran with appropriate notice, pursuant to the VCAA under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), regarding her service connection claim for an acquired psychiatric disorder, to include taking the steps identified in M-21MR, Part IV, Subpart ii, Chapter 1, Section D, Topic 17 of the VA Adjudication Procedure Manual for developing claims for service connection for PTSD based on personal assault. Also provide the Veteran with proper VCAA notice addressing the secondary theory of entitlement raised in connection with her acquired psychiatric disorder claim. 38 C.F.R. § 3.310. 2. Obtain and associate with the paper claims file, or Virtual VA efolder, all records of mental health counseling, or related treatment, provided at MacDill Air Force Base in Tampa, Florida, during the Veteran's period of active service from January 27, 1999, to January 26, 2003. 3. Obtain and associate with the paper claims file, or Virtual VA efolder, all records from the VA Medical Center in Palo Alto, California, and the VA Community-Based Outpatient Mental Health Clinic in Monterey, California, dated since January 2013. 4. If any of the records requested in items 2 and 3 are unavailable, the Veteran in accordance with 38 C.F.R. § 3.159(e). The Veteran should also be advised to submit any additional in-service or post-service treatment records in her own possession in support of her appeal. 5. After the development requested in items 1-4 is complete, schedule the Veteran for an appropriate examination to determine the current nature and etiology of any current acquired psychiatric disorder, to specifically include major depressive disorder, PTSD, and anxiety disorder. The paper claims file and Virtual VA efolder should be reviewed in conjunction with the examination and the examiner's report should note that review. All testing deemed necessary should be conducted and results reported in detail. The VA examiner's report should specifically address the following: a) Diagnose all current psychiatric disabilities. b) Specifically state whether or not each criterion for a diagnosis of PTSD is met. c) If a diagnosis of PTSD is warranted, specify the in-service stressor or stressors (if any) upon which that diagnosis is based. d) Discuss whether it is at least as likely as not (50 percent or more probability) that any other currently diagnosed psychiatric disorder, including major depressive disorder and anxiety disorder (excluding drug or alcohol abuse) had its onset in, or is otherwise related to, the Veteran's active service. e) Discuss whether it is at least as likely as not (50 percent or more probability) that any other currently diagnosed psychiatric disorder, including major depressive disorder and anxiety disorder (excluding drug or alcohol abuse) was (a) caused or (b) aggravated by one or more of the Veteran's service-connected physical disabilities (migraine headaches, chronic obstructive pulmonary disease with bronchial asthma, sinusitis, allergic rhinitis, and a gastrointestinal disorder identified as status post-cholecystectomy with dumping syndrome, gastroparesis and gastroesophageal reflux disease (GERD)), to include any medication taken for the listed service-connected disabilities. If it is at least as likely as not that there was aggravation by one or more service-connected disabilities please specify, to the extent possible, the degree of additional mental disability (pathology/impairment) that resulted from such aggravation, identifying the "baseline" severity of the acquired psychiatric disorder prior to aggravation and the level of severity existing thereafter. In rendering the above opinions, please accept as true the Veteran's account of ongoing mental health problems dating back to her in-service treatment for domestic violence. Please also accept as true the Veteran's account of tangible feelings of anxiety and "panic attacks" coincident with the "choking sensation" that accompanies her service-connected GERD reflux symptoms. All findings, along with a fully articulated rationale for any opinion expressed, must be set forth in the report. If any of the examiner's findings are speculative in nature, it is essential that he or she provide a rationale for why an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that would enable an opinion to be provided or whether the inability to provide the opinion is based on the limits of medical knowledge. 6. Then, readjudicate the issue remaining on appeal. If the requested benefit remains denied, the Veteran and her representative should be provided with a Supplemental Statement of the Case and afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ PAUL SORISIO Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs