Citation Nr: 1339222 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 10-09 718 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for joint pain, to include as due to undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C.A. §1117. 2. Entitlement to service connection for a left knee disability. 3. Entitlement to service connection a sinus disability. 4. Entitlement to service connection for bilateral upper extremity peripheral neuropathy. 5. Entitlement to service connection for a stroke condition. 6. Entitlement to service connection memory loss. 7. Entitlement to initial compensable rating for eczema. REPRESENTATION Appellant represented by: New Jersey Department of Military and Veterans' Affairs ATTORNEY FOR THE BOARD L. A. Rein, Counsel INTRODUCTION The Veteran had active service from February 1973 to December 1973 and from August 2004 to October 2005. Service in Southwest Asia is shown in the record. These matters come to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. In his March 2010 substantive appeal, the Veteran requested a hearing before the Board. In a June 2012 letter, the Veteran, through his representative, stated that he wished to forego Board hearing and requested that his appeal be forwarded and rated based upon the evidence of record. In light of this correspondence, the Board finds that the hearing request has been withdrawn and will proceed accordingly. In October 2012, the Board remanded these matters for additional development and remanded claims for service connection for an eye condition and for diarrhea. An August 2013 rating decision granted service connection for pinguecula (claimed as an eye condition) and granted service connection for diverticulitis (claimed as diarrhea) and assigned initial noncompensable ratings for each disability. As that is considered a full grant of the benefits sought, those issues are no longer before the Board. The issue of entitlement to service connection for joint pain, to include as due to undiagnosed illness or other qualifying chronic disability, pursuant to 38 U.S.C.A. §1117, is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's left knee disability that pre-existed active service is not shown by clear and unmistakable to have been aggravated beyond the natural progression of the condition during active service. 2. The competent evidence reasonably shows that the Veteran has a sinus condition related to active service. 3. The Veteran's bilateral upper extremity peripheral neuropathy is presumed to be related to the Veteran's active service. 4. The preponderance of the evidence is against a finding that the Veteran is currently diagnosed with stroke and/or TIA residuals that are attributable to his active service or a service-connected disability and a stroke and/or TIA did not manifest within one year of active service. 5. The evidence of record shows that the Veteran's memory loss has been attributed to his service-connected posttraumatic stress disorder (PTSD). 6. The Veteran's eczema does not cover at least 5 percent of the entire body, or at least 5 percent of the exposed area affected; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were not used; and not one of eight characteristics of disfigurement was evident. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability are not met. 38 U.S.C.A. §§ 1110, 1111, 1153, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306, 3.307, 3.309 (2013). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for a sinus disability are met. 38 U.S.C.A. §§ 1110, 1111, 5107 (West 2002), 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 3. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for peripheral neuropathy of the bilateral upper extremities are met. 38 U.S.C.A. §§ 1110 , 1112, 1113, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 4. The criteria for service connection for stroke condition have not been met. 38 U.S.C.A. §§ 1110, 1111, 5107 (West 2002), 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306, 3.307, 3.309 (2013). 5. The criteria for service connection for memory loss have not been met. 38 U.S.C.A. §§ 1110, 1111, 5107 (West 2002), 38 C.F.R. §§ 3.102, 3.303 (2013). 6. The criteria for an initial compensable rating for eczema have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Codes 7800-7806 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to notify and assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 3.159 (2013); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in May 2006, June 2009, and November 2012. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and his representative suggest actual knowledge of the elements necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the most recent August 2013 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained examinations with respect to the claims remaining on appeal. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2013). That determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d) (2013). Service connection may be presumed for certain chronic diseases which develop to a compensable degree within one year after discharge from service, even though there is no evidence of such disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002 & Supp. 2013); 38 C.F.R. 3.307, 3.309(a) (2013). If a chronic disease or injury is shown in service, subsequent manifestations of the same chronic disease or injury at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b) (2013). The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a), which includes arthritis, stroke (to the extent it is a cardiovascular-renal disease), and peripheral neuropathy (as an organic disease of the nervous system), which are conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a) (2013). Service connection based on a continuity of symptomatology can be warranted under 38 C.F.R. § 3.303(b) (2013) for chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2) . In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308 -09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). Left knee disability A Veteran is presumed in sound condition except for defects noted when examined and accepted for service. Noted denotes only conditions that are recorded in examination reports. The existence of conditions prior to service reported by the Veteran as medical history does not constitute a notation of the conditions, but will be considered together with all other material evidence in determining the question of when a disease or disability began. 38 C.F.R. § 3.304(b)(1) (2013). Clear and unmistakable evidence that the disability existed prior to service and was not aggravated by service will rebut the presumption of soundness. Once the presumption of soundness has attached, VA holds the burden of proving by clear and unmistakable evidence that both (1) the Veteran's disease or injury pre-existed service, and (2) that the disease or injury was not aggravated by service. 38 U.S.C.A. § 1111 (West 2002). Clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. Vanerson v. West, 12 Vet. App. 254 (1999) (clear and convincing burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). It is an onerous evidentiary standard, requiring that the no-aggravation result be undebatable. Cotant v. West, 17 Vet. App. 116 (2003). Concerning clear and unmistakable evidence that the disease or injury was not aggravated by service, the second step necessary to rebut the presumption of soundness, a lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the pre-existing condition. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); 38 U.S.C.A. § 1153 (West 2002). The burden is on the government to rebut the presumption of soundness by clear and unmistakable evidence that a condition was both preexisting and not aggravated by service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). see also VAOPGCPREC 3-03 (July 16, 2003); Wagner; Monroe v. Brown, 4 Vet. App. 513 (1993); Green v. Derwinski, 1 Vet. App. 320 (1991). The appellant is not required to show that the disease or injury increased in severity during service before VA's duty under the second, aggravation, prong of this rebuttal standard attaches. See Horn v. Shinseki, 25 Vet. App. 231 (2012); Cotant; Wagner. The Veteran asserts that he has a current left knee disability related to his second period in service, from August 2004 to October 2005. Service treatment records (STRs) for this period show that in June 2005, the Veteran's left knee was examined. It was noted that the Veteran was three years out of ACL reconstruction. A September 2005 health assessment notes that the Veteran was status post ACL reconstruction, left knee. A November 2006 VA examination report reflects that the Veteran reported having had a left ACL repair done in about 2003. During a July 2013 VA examination, the Veteran reported that he sustained an injury to his left knee in 2001 and had an ACL tear which was surgically repaired. The July 2013 VA examiner stated that based on the claims file, history provided by the Veteran and physical examination, he believed that the Veteran's left ACL surgery was prior to 2004, surgery was in 2001. Although there are no STRS noting that on entry the Veteran was post-ACL surgery of his left knee, the evidence of record clearly shows that he had a left ACL repair, and that this surgery was performed prior to the Veteran's entry into his second period of service in August 2004. Hence, the Board finds that the presumption of soundness is rebutted by clear and unmistakable evidence, and that there is clear and unmistakable evidence that Veteran's preexisting left knee disability was not aggravated in service. 38 U.S.C.A. § 1111 (West 2002); 38 C.F.R. § 3.304(b) (2013). A June 2005 STR notes that the Veteran had an acute onset of pain and clicking in the left knee. He was unable to fully extend the knee. The radiologic report reflected that there was no acute fracture, a prior ACL repair, positive joint fluid, mild degenerative joint disease of the knee joint and patello-femoral articulation, nondisplaced patella. The assessment was knee sprain. He was to be assigned sedentary work for three days, and then no running, marching, jumping or prolonged standing more than thirty minutes. In an August 2005 post deployment health assessment, the Veteran indicated that during deployment he had a chronic cough, weakness, headaches, muscle aches, chest pain or pressure and diarrhea. He denied having had or currently having swollen, stiff or painful joints, dizziness, fainting, or light headaches, difficulty breathing, A November 2006 VA examination report reflects that x-rays revealed mild degenerative joint disease and mild status post ACL repair. The diagnosis was normal examination of his knees, but his left was status post anterior cruciate ligament repair in 2003. The July 2013 VA examiner diagnosed ACL tear in 2001 and left knee degenerative joint disease. He stated that based on a review of the claims file, history and physical examination, he believed that the Veteran's left knee disability was a pre-existing disability and it was not aggravated or made worse beyond the natural progression of his knee joint. His rationale was based on the fact that he had a major knee injury which was the ACL tear, it is quite common to develop degenerative joint disease after these type of injuries. It is not uncommon for someone to return to a normal physical activity lifestyle, which is seen with athlete's who sustained this type of injury. He also opined that the Veteran's left knee degenerative joint disease is due to the pre-existing ACL injury and not his military service. The July 2013 VA examiner provided a concise discussion of the rationale for all the opinions expressed, as provided above. The Board finds that such medical evidence and opinion serves as clear and unmistakable evidence of no increase in severity of any preexisting left knee disability during service. The Board acknowledges the apparent inconsistency in the standards applied by the examiner, in that he did not use the terminology of "clear and unmistakable" in the language of his opinion. However, the written rationale for the opinion is of such thoroughness and detail that the Board concludes that such evidence meets the evidentiary threshold of clear and unmistakable evidence that the Veteran's pre-existing left knee disability was not aggravated during or as a result of service. See 38 U.S.C.A. § 1111; Cotant. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the physician's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). The Board may only rely on such opinion if it is supported by an explanation of the basis for such an opinion or if the basis is otherwise apparent in the Board's review of the evidence. Jones v. Shinseki, 23 Vet. App. 382 (2010). In this case, the Board finds that opinion is supported by a rationale that was apparently provided after the VA physician considered all procurable and assembled data and has provided a clear explanation for his opinions. Significantly, neither the Veteran nor his representative has presented or identified any contrary medical opinion that supports the claim for service connection. The Board also notes that VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The only other evidence of record supporting the Veteran's claim is his own lay statements. The Board notes that the Veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. §§ 3.303(a), 3.159(a) (2013); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). However, a determination of whether a pre-existing left knee disability was aggravated in service beyond its normal progression requires specialized training for a determination as to causation, and is therefore not susceptible of lay opinions on etiology. Consequently, his statements do not constitute competent medical evidence in support of his claim. The Board finds the preponderance of the evidence in this case is against the claim for entitlement to service connection for a left knee disability. Therefore, the claim must be denied . 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Sinus Disability A May 2005 service treatment record entry shows treatment for post nasal drip. An August 2005 post-deployment self health assessment questionnaire reflects that the Veteran's was in Southwest Asia from September 2004 to September 2005. The Veteran indicated that his health stayed about the same or got better during this deployment. He was seen in sick call four times. The Veteran reported that he had symptoms of chronic cough, weakness, headaches, and chest pain or pressure during deployment. While deployed, the Veteran indicated that he was often exposed to vehicle or truck exhaust fumes and sand/dust. The Veteran stated that his health in general was good. He indicated that he developed a medical or dental problem during the deployment. He was concerned about SPOD exposure. In his March 2006 claim for VA benefits, the Veteran noted that his sinus condition began in September 2004, while in Iraq, and has continued to the present day. An October 2006 Gulf War examination report reflects that the Veteran reported that during service he was diagnosed with upper respiratory infections and nasal polyps. He had symptoms of anosmia and nasal congestion. The Veteran underwent polypectomy at a civilian hospital on July 21, 2006. He still complains of occasional epistaxis. A November 2006 ENT examiner did not find a current sinus disability. A brain MRI in December 2008 revealed evidence of severe right maxillary sinus mucosal thickening and mild bilateral ethmoid sinus mucosal thickening, with hypoplastic change of bilateral frontal sinuses. A July 2013 VA examination report reflects that the VA examiner reviewed the claims file. The Veteran was diagnosed with chronic sinusitis and multiple recurrent nasal polyps. The VA examiner also noted that the Veteran had rhinitis. It was noted that the Veteran had a nasal polypectomy with sinus drainage in 2006 and in 2009. A nasal endoscopy was performed and the results noted were congested mucosa and right nasal polyp. The VA examiner opined that the Veteran's sinus disability with recurrent nasal polypectomy manifested in December 2008. The VA examiner opined that the Veteran's sinus disability was at least as likely as not due to his sinus disability that manifested in December 2008 and the current sinus and nasal condition of current nasal polyps. However, the VA examiner failed to opine whether the sinus disability that manifested in December 2008, barely 3 years after discharge, is related to the Veteran's service. With regard to the Veteran's assertions that sinus symptoms began during active duty and have continued following service, the Board finds that the Veteran is competent and credible to report the onset of symptoms of his sinus symptoms as well as continuity of symptomatology. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology that is not medical in nature); see also Layno v. Brown, 6 Vet. App. 465, 469-470 (1994) (finding lay testimony competent when it concerns features or symptoms of injury or illness); see also Caluza v. Brown, 7 Vet. App. 498 (1995) (credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony). While the Board is aware that the Veteran's sinusitis is not a chronic disease listed under 38 C.F.R. § 3.309(a), the Board has nonetheless found that the Veteran had sinus symptoms in service and that those symptoms continued after discharge, as is permissible under 3.303(a) in conjunction with any injury or disease a Veteran may assert is related to service. In this regard, the Veteran was treated in service for post-nasal drip, and then shortly after discharge from service, in March 2006 and again in October 2006. The Veteran has continued to report sinus problems since service. Based on the Veteran's competent and credible statements, the May 2005 service treatment record, treatment for sinus conditions contemporaneous to the Veteran's discharge from service, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran's sinus disability began during service, and as such service connection is warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. [Continued on Next Page] Bilateral upper extremity peripheral neuropathy In the Veteran's March 2006 claim for benefits, he stated that he had numbness and tingling in both hands, wrists and all fingers since September 2004. An October 2006 Gulf War examination report reflects that the Veteran reported of numbness in the first through third fingers of both hands for the past one to two years. He was not treated in service for these complaints. The Veteran was referred for a neurological VA examination. An October 2006 VA neurological examination report reflects that the Veteran complained of a history of numbness of both hands, mostly all the fingertips off and on since he was in service. The numbness comes and goes. There is no pain and no significant paresthesia. The diagnosis was peripheral neuropathy of the bilateral hands. However, no etiological opinion was provided. In July 2013, the Veteran underwent a peripheral nerve examination. The VA examiner found that there was no objective evidence of neuropathy or radiculopathy detected at that time. In this regard there was no electrodiagnostic evidence of peripheral neuropathy or radiculopathy based on EMG testing performed contemporaneous with the examination. Even though the July 2013 VA examiner found no current disability, the Veteran was found to have peripheral neuropathy of the bilateral hands during the course of the claim, thus, service connection can be granted. See McCain v. Nicholson, 21 Vet. App. 319 (2007). Consideration is given to the Veteran's assertion of experiencing continuous numbness in his bilateral upper extremities since service. In this regard, the Veteran is competent to say that he developed numbness and tingling in his hands in service and the Board accepts his statements as credible. Layno v. Brown, 6 Vet. App. 465 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007). In this case, the Board finds that the Veteran experienced "chronic" symptoms of upper extremity numbness and tingling during service and continuous symptoms after discharge, with a diagnosis of peripheral neuropathy of the bilateral hands in October 2006, less than a year after discharge from service so as to warrant presumptive service connection for bilateral upper extremity peripheral neuropathy under the provisions of 38 C.F.R. § 3.303(b). As such, service connection is granted for bilateral upper extremity peripheral neuropathy. Stroke condition The Veteran contends that he injured his head in June 2004 while driving a vehicle to a camp in Kuwait. The medical evidence shows that the Veteran has been examined for what physicians suspected were stroke-like transient ischemic attacks (TIA) events. The Veteran claimed service connection for strokes. The Board must consider the Veteran's description of the claim, the symptoms he describes, and the information of record that pertains to the claimed disability. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board observes that TIA events are sometimes referred to as 'ministrokes' or having stroke-like symptoms that are transient and not permanent or long lasting. The Board finds that the scope of the Veteran's claim for strokes should include the TIA events described by physicians. An August 2005 post-deployment self health assessment questionnaire reflects that the Veteran's was in Southwest Asia from September 2004 to September 2005. The Veteran indicated that his health stayed about the same or got better during this deployment. He was seen in sick call four times. The Veteran reported that he had symptoms of chronic cough, weakness, headaches, muscle aches, skin disease or rashes, chest pain or pressure and diarrhea during deployment. While deployed, the Veteran indicated that he was often exposed to vehicle or truck exhaust fumes and sand/dust. The Veteran stated that his health in general was good. He indicated that he developed a medical or dental problem during the deployment. He was concerned about SPOD exposure. A February 2009 VA brain injury assessment notes that the Veteran stated he injured his head in June 2004 while on active duty while driving a vehicle to a camp in Kuwait and suspected that his TIA attacks were related to that event. The evidence shows that there were two TIA events during December 2008. A January 2009 VA neuropsychological treatment note states that the Veteran had no memory of the events and the examiner reported the events based on the observations of the Veteran's wife. The Veteran's wife stated that she and the Veteran were eating dinner when the Veteran said he felt very tired. She noticed at that time that the Veteran's right hand became weak, then the Veteran's eyes began rolling back in his head and when he stood up from the table he lost his balance, and seemed to be very confused. The Veteran went to bed and slept and woke up without problems. Two days later, however, the Veteran had another experience and was taken to the hospital. At the hospital, a CT scan was performed but negative results were reported. The Veteran was admitted to rule out TIA and a diagnosis of acute transient ischemic attack was made. A MRI report indicates that no obvious intracranial pathology noted. A December 20, 2008, physician's note states that there was no evidence of associated seizure activity, tongue biting, or incontinence. The physician noted negative head trauma, negative headache, negative chest pain, negative dyspnea, and negative gastrointestinal bleeding. A February 2009 VA brain injury assessment provided impressions of PTSD, adjustment disorder, and neurocognitive and neurobehavioral deficits secondary to cerebrovascular events. A February VA neurologic assessment determined that all testing was negative; no diagnosis was provided, but the occurrence of a TIA was noted. A July 2013 VA central nervous system examination report reflects that the claims file was reviewed by the examiner. The VA examiner concluded that the Veteran was diagnosed in 2008 with thrombosis, TIA or cerebral infarction. The Veteran provided a history of TIA, transient memory loss and mental confusion lasting for a few hours in 2008 to 2009 and was hospitalized with a diagnosis of TIA versus ischemic stroke. He was initially treated with plavix and is maintained on aspirin. MRI and CT scans of the brain were unremarkable. Carotid Doppler showed moderate bilateral carotid stenosis at bulb. The Veteran also had associated right sided weakness which resolved within one hour. It was noted that the Veteran's central nervous system condition required aspirin. Current treatment noted was watchful waiting. The VA examiner diagnosed transient ischemic attack that resolved with no focal neurological deficit. He opined that there was no relationship between past head trauma and TIA which occurred in 2008. He noted that the Veteran gave a remote history of head trauma in 2004 and TIA in 2008. The VA examiner explained that TIA is usually caused by carotid artery stenosis or embolic phenomenon from heart to brain and the Veteran has a history of hypertension, CABG and CAD and carotid stenosis. He opined that the TIA is not caused or related to the past history of head trauma. In this case, there are no service treatment records showing that the Veteran injured his head in service. However, even if the Board were to accept, without making an actual determination, that such event occurred based solely on the Veteran's contentions, the claim for service connection for a stroke condition would still fail. In this regard, there is no evidence of stroke residuals within a year after discharge from service or that the Veteran, in fact, sustained a residual disability after a TIA in 2008. Absent competent evidence of a current disability, there can be no valid claim for service connection. Degmetich v. Brown, 104 F.3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Significantly, moreover, the only medical opinion of record as to a nexus of the post-service stroke and/or TIA to the Veteran's reported past history of head trauma in service weighs against the claim. The July 2013 VA examiner provided a concise discussion of the rationale for the unfavorable opinion expressed, as provided above. The Board finds that the based on the above medical findings, that the Veteran sustained a transient ischemic attack in 2008 that resolved with no focal neurological deficit. Further, the VA examiner opined that the 2008 TIA is not caused or related to the past history of head trauma. The Board may only rely on such opinion if it is supported by an explanation of the basis for such an opinion or if the basis is otherwise apparent in the Board's review of the evidence. Jones v. Shinseki, 23 Vet. App. 382 (2010). In this case, the Board finds that opinion is supported by a rationale that was apparently provided after the VA physician considered all procurable and assembled data and has provided clear and legitimate explanations for the opinion. Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the physician's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). Significantly, neither the Veteran nor his representative has presented or identified any contrary medical opinion that supports the claim for service connection. The Board also notes that VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The only other evidence of record supporting the Veteran's claim is his own lay statements. The Board notes that the Veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. §§ 3.303(a), 3.159(a) (2013); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). However, a determination of whether the Veteran has residuals of a stroke and/or TIA, or if a post-service stroke and/or TIA is related to head trauma in service are complex etiological questions akin to the type of medical matters which courts have found laypersons are not competent to provide. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (Board must determine whether the claimed disability is a type of disability for which a lay person is competent to provide etiology or nexus evidence). Consequently, his statements do not constitute competent medical evidence in support of his claim. The Board finds the preponderance of the evidence in this case is against the claim for entitlement to service connection for a stroke condition. Therefore, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Memory loss The Veteran contends that he has a memory loss disability related to service. An October 2006 VA Gulf War examination report reflects that the Veteran stated he noticed short-term memory loss since he returned from Iraq and Kuwait. The Veteran was referred for a VA neurological examination. An October 2006 VA neurological examination report reflects that the Veteran was diagnosed with mild short-term memory disturbance. An August 2011 Vet Center records includes mild memory loss as a symptom. A February 2012 VA examination report reflects that the Veteran's mild memory loss, such as forgetting names, direction or recent events, and impairment of short and long term-memory are symptoms of the Veteran's service-connected PTSD. Initially, the Board points out that memory loss, alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). More importantly, the Board finds that there is absolutely no evidence that the Veteran's memory loss is a symptom of a disorder separate from his service-connected PTSD. The Board notes that while it is possible for separately diagnosed psychiatric disorders to be service connected as distinct disabilities, see Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009), the evidence of record fails to establish that the Veteran has memory loss unrelated to PTSD that is directly related to a separately diagnosed disability such that an award of service connection can be made. Moreover, even if service connection for a separately diagnosed psychiatric disorder were granted, that grant of service connection would not increase the Veteran's disability rating unless that disability resulted in different manifestations from the already-service-connected PTSD. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009) ("Section 4.14 clearly contemplates that several separately diagnosed disorders may have a single manifestation, and it clearly prohibits the VA from rating that manifestation for each disorder."). Thus, any error in the determination that the Veteran does not currently demonstrate a separate disability manifested by memory loss or that a separate grant of service connection for memory loss (i.e. dementia, vascular dementia, undifferentiated somatoform disorder, etc.), if present, is not warranted, would, at most, constitute harmless error, to the extent that symptoms of PTSD and the additional psychiatric disability would be overlapping. As such, the claim for service connection for memory loss is denied. Increased rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's eczema of the left hand has been assigned a 0 percent rating under a general set of criteria applicable to skin disorders found at 38 C.F.R. § 4.118, Diagnostic Code 7806 (2013). Pursuant to that Diagnostic Code, dermatitis or eczema is rated 0 percent if less than 5 percent of the entire body or less than 5 percent of exposed areas affected and, no more than topical therapy required during the past 12 months. A 10 percent rating is warranted when at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. The Board also notes that Diagnostic Code 7800 is applicable and was amended effective October 23, 2008. However, as the Veteran's claim was received prior to October 23, 2008, the older criteria apply because he has not requested rating under the amended criteria. Diagnostic Code 7800 for rating disfigurement of the head, face, for neck provides a 10 percent rating for one characteristic of disfigurement. A 30 percent rating is warranted for disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent rating is warranted for disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. An 80 percent rating is warranted for disfigurement with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement. 38 C.F.R. § 4.118 (2008). There are eight characteristics of disfigurement are: (1) scar 5 or more inches (13 or more centimeters) in length, (2) scar at least one quarter inch (0.6 centimeters) wide at the widest part, (3) surface contour of scar elevated or depressed on palpation, (4) scar adherent to underlying tissue, (5) skin hypo- or hyper- pigmented in an area exceeding six square inches (39 square centimeters), (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 square centimeters), (7) underlying soft tissue missing in an area exceeding six square inches (39 square centimeters), and (8) skin indurated and inflexible in an area exceeding six square inches (39 square centimeters). 38 C.F.R. § 4.118, Diagnostic Code 7800 (2008). The pertinent evidence includes an October 2006 VA Gulf War examination report in which the Veteran complained of a rash involving both hands. The VA examiner noted that the rash is pruritic and involved the left first and second fingers. The Veteran had been prescribed Lidex cream and has only used this medication over the past 12 months. He denied any history of fever, chills, skin cancer, or weight loss. The rash has been stable over time. Physical examination revealed scaly and erythematous 1 centimeter patch over the medial left and lateral first index finger distally. No other skin lesions were noted and no scarring was evident. The diagnosis was eczema (allergic dermatitis) and the VA examiner determined that the total body surface area and total exposed body surface area involved were, each, less than 1 percent. There was no gross disfigurement. A July 2013 VA skin disease examination report reflects that the claims file was reviewed by the VA examiner. The diagnosis was eczematous dermatitis. The Veteran provided a history of a skin rash in both hand and fingers on and off associated with irritation and itching. The Veteran stated that he uses topical cream. The VA examiner noted that the Veteran was treating his condition with topical corticosteroids for six weeks or more, but not constant. There was no scarring or disfigurement of the head, face or neck, no benign or malignant skin neoplasms, or any systemic manifestations due to the Veteran's eczema. The total body area of the skin affected on examination was less than 5 percent and the total exposure area was reported as none. Other pertinent findings noted was a scaly rash in palmar aspect of the fingers. The VA examiner opined that the Veteran's skin condition does not impact his ability to work. During the entire appeal period, the Veteran's eczema has been manifested, at most, by scaly and erythematous 1 centimeter patch over the medial left and lateral first index finger distally, representing less than 5 percent of the total body surface, and less than 5 percent of the exposed areas was affected. There was no evidence of abnormal skin texture, pain, tenderness, keloid formation, edema, inflammation, or gross distortion. Therefore, the Board finds that a compensable rating under Diagnostic Code 7806 is not warranted as there is no evidence that at least 5 percent of the entire body or at least 5 percent of exposed areas were affected. In addition, the Veteran has only used topical corticosteroids for more than six weeks; however, this is not used on a constant basis. Additionally, a compensable rating under Diagnostic Code 7800 is not warranted as there is no evidence that the Veteran had one characteristic of disfigurement noted in Note (1) of Diagnostic Code 7800. In sum, the Board finds that the Veteran's symptomatology only warrants the currently assigned 0 percent disability rating, and no more. Therefore, the Veteran's claim for an initial compensable rating is denied. The Board has also considered whether the Veteran's claim for an increased rating should be referred for consideration of an extraschedular evaluation pursuant to 38 C.F.R. § 3.321(b)(1) (2013) and has concluded that no such referral is warranted. The Veteran's symptoms are fully contemplated by the schedular rating criteria. A higher rating is available for eczema. However the Veteran does not meet the criteria for a higher rating. There is nothing in the record to suggest that his disability picture is so exceptional or unusual as to render impractical the application of the regular schedular standards. The evidence does not show frequent hospitalization or marked interference due to the disability so as to render the schedular rating standards inapplicable or inadequate. Therefore, the Board finds that referral for consideration of an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to service connection for a left knee disability is denied. Service connection for a sinus disability is granted. Service connection for bilateral upper extremity peripheral neuropathy is granted. Entitlement to service connection for a stroke condition is denied. Entitlement to service connection for memory loss is denied. An initial compensable rating for eczema of the left hand is denied. REMAND A remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the terms of that remand. Stegall v. West, 11 Vet. App. 268 (1998). Once VA undertakes the effort to provide an examination, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303 (2007). In the October 2012 remand, the Board noted that the Veteran has been found on examination to have back pain and right knee pain, but no disability has been diagnosed. He has claimed service connection for joint pain and is a Persian Gulf War Veteran. Therefore, the Board determined that an examination was needed to determine whether the Veteran may have joint pain as the result of any undiagnosed illness. 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 prior to December 31, 2011. 38 C.F.R. § 3.317(a)(1)(i). Furthermore, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. 38 U.S.C.A. § 1117 (West 2002 & Supp. 2013); 38 C.F.R. § 3.317(a), (b) 1. 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. 38 U.S.C.A. § 1117(f) . In this case, the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War. Pursuant to 38 U.S.C.A. § 1117, the definition of "qualifying chronic disability" includes (a) undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms. See 38 C.F.R. § 3.317(a)(2). 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. 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. 38 U.S.C.A. § 1117(g). In the October 2012 remand, the Board specifically instructed that the Veteran was to be scheduled for a VA joints examination and the examiner was requested to state whether or not the Veteran has objective indications of a chronic disability manifested by joint pain, including signs in the medical sense and objective evidence perceptible to an examination physician and other non-medical indicators that are capable of independent verification, that have been present for a period of six months or more. If so, the examiner should state for each joint affected whether the chronic disability manifested by joint pain can be attributed to any known medical causation. The examiner was requested to specifically comment upon previous examination findings of pain in the neck, back, left shoulder, and knees. However, in the August 2013 supplemental statement of the case, the AMC focused solely on the fact that there were negative findings as to joint or muscle symptoms in a July 2, 2013 VA general medical examination report to continue the denial of the claim. Actual findings responsive to the questions posed in the October 2012 remand were not provided within the July 2013 VA examination. Specifically, the Veteran's history of joint and muscle pain were not commented upon in relation to the negative findings upon examination. As the Veteran was never afforded an adequate VA examination, an additional remand is warranted. Accordingly, the case is REMANDED for the following actions: 1. Arrange for the Veteran to undergo an additional VA Gulf War protocol examination at an appropriate VA medical facility. Such examination should conform to the guidelines for conducting Gulf War examinations set forth in the Under Secretary for Health's Information Letter, dated April 28, 1998 (IL 10-98-010). The entire claims file, to include a complete copy of this REMAND, must be made available to the examiner designated to examine the Veteran, and the report of the examination should include discussion of the Veteran's documented medical history and assertions. All necessary tests and studies should be accomplished (with all findings made available to the examiner prior to the completion of his/her report), and all clinical findings should be reported in detail. The examination report must provide a complete rationale for all opinions. (a) The examiner is requested to conduct a comprehensive general medical examination, and provide details about the onset, frequency, duration, and severity of joint pain. (b) With respect to each complaint or symptom, the examiner should specifically state whether any of the Veteran's complaints or symptoms are attributable to a known diagnostic entity, and if so, specifically identify those symptoms and the anatomy involved. The examiner is requested to provide a complete explanation for his/her findings. (c) If there is a known diagnosis such that there is a medical explanation for the joint pain, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that each diagnosed disability began in or is related to active service. The examiner should be aware that the Veteran is competent to attest to factual matters of which he had first-hand knowledge. In providing the opinions requested above, the examiners must consider the Veteran's statements regarding the onset of his conditions, in addition to his statements regarding the continuity of symptomatology. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant's report of in-service injury and instead relied on the absence of evidence in the service treatment records to provide a negative opinion). 2. Then, readjudicate the claim. If the decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs