Citation Nr: 1340004 Decision Date: 12/04/13 Archive Date: 12/18/13 DOCKET NO. 07-14 916 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for mitral valve prolapse with mild regurgitation/heart murmur. 2. Entitlement to service connection for a skin rash, identified as herpes simplex virus (HSV). 3. Entitlement to service connection for skin rash, other than HSV. 4. Entitlement to service connection for jaw pain. 5. Entitlement to service connection for endometriosis. 6. Entitlement to service connection for recurrent ovarian cysts, status post left oophorectomy. 7. Entitlement to service connection for headaches. 8. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) with anxiety, depression, and adjustment disorder. REPRESENTATION Appellant represented by: Mr. Robert V. Chishlom, Attorney at Law WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Murray, Counsel INTRODUCTION The Veteran served on active duty from November 1987 to September 1993. This matter comes before the Board of Veteran's Appeals (Board) on appeal from a May 2006 decision by the above Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for the listed issues as well as various other issues. In December 2008, a hearing was held before the undersigned Veterans Law Judge (VLJ) during a Travel Board hearing held at the RO. A transcript of the hearing has been associated with the claims file. The Travel Board hearing was sufficient to fulfill his right to a hearing under 38 C.F.R. § 20.700(a) (2013). The appeal was remanded in May 2009 to the RO (via the Appeals Management Center (AMC)) for additional development of the record, to include obtaining service records, VA treatment records, and VA examinations. In a September 2011 decision, the Board denied the Veteran's claim for entitlement to service connection for a psychiatric disorder. The Veteran appealed to denial of her claim to the United States Court of Appeals for Veterans Claims (CAVC or Court), which vacated the Board's September 2011 decision and remanded for compliance with instructions contained therein. Also, in September 2011, the Board remanded the remaining claims for entitlement to service connection to the AMC for additional development, to include compliance with the previous 2009 remand instructions for VA examinations with medical opinions that addressed question of undiagnosed illness. The Veteran underwent such additional examinations in September 2011. As there has been compliance with the Board's remand directives, no further action is required and the Board may proceed with adjudication of the claim. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Following the additional development, the AMC, in a September 2012 rating decision, awarded service connection for fibromyalgia, which included the Veteran's claims for bilateral shoulder pain, bilateral hip pain, and sleep disorder, and assigned staged ratings of 10 percent, effective from April 22, 2009 to November 5, 2009, 20 percent, effective from November 6, 2009 to November 21, 2011, and 40 percent, effective from November 22, 2011. The Veteran has not appealed that award and those claims are no longer on appeal. As noted in the Board's 2009 and 2011 remand, the Veteran raised a claim of entitlement to compensation pursuant to 38 U.S.C.A. § 1151 for breast cancer during her hearing. The Board acknowledged that the current appeal included entitlement to service connection for breast cancer but that a claim for benefits pursuant to § 1151 was distinct from the issue currently on appeal. The Board referred the issue to the RO for appropriate action. It does not appear that this claim has been developed or adjudicated. As such, it is again referred for appropriate action by the RO. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. The issues of entitlement to service connection for recurrent ovarian cysts, headaches and a psychiatric disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has diagnosed mitral valve prolapse (MVP) condition. 2. The Veteran's mild valve regurgitation and heart murmur first manifested years after her separation from service, and the preponderance of the competent evidence is against a finding that her conditions are related to her period of service. 3. Giving the Veteran the benefit of the doubt, the weight of the evidence shows that her current diagnosis of herpes simplex virus (HSV) is related to the symptoms she has experienced since service. 4. The competent evidence of record does not show that the Veteran's skin rash, other than HSV, manifested until years after her separation from service, and the preponderance of the competent evidence is against her other skin conditions are related to her period of service. 5. The competent evidence of record demonstrates that the Veteran's jaw pain is related to her decayed teeth and caries, and her jaw pain is not a manifestation of an undiagnosed illness or a chronic multisymptom illness. 6. The competent evidence shows that the Veteran's endometriosis first manifested after her separation from service, and the preponderance of the evidence is against that her diagnosed disorder is related to her period of service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for mitral valve prolapse with mild regurgitation/heart murmur have not been met. 38 U.S.C.A. §§ 1110, 1113(b), 1117, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317 (2013). 2. The criteria for entitlement to service connection for herpes simplex virus (HSV) have been met. 38 U.S.C.A. §§ 1110, 1113(b), 1117, 5107(b) (West 2002); 38 C.F.R. §§ 3.303 (2013). 3. The criteria for entitlement to service connection for skin rash other than HSV have not been met. 38 U.S.C.A. §§ 1110, 1113(b), 1117, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2013). 4. The criteria for entitlement to service connection for jaw pain have not been met. 38 U.S.C.A. §§ 1110, 1113(b), 1117, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2013). 5. The criteria for entitlement to service connection for endometriosis have not been met. 38 U.S.C.A. §§ 1110, 1113(b), 1117, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.317 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159, provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim, defined to include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). In the case at hand, VA sent the Veteran letters in July 2005, December 2005, and July 2007 that provided her with proper notice, including of what was necessary to establish the underlying claims of service connection and VA's responsibilities in claims development as well as notice requirements under Dingess. VA has thereby met its obligations to notify the Veteran of the medical and other evidence needed to substantiate his claim and of what evidence he is responsible for obtaining. Charles v. Principi, 16 Vet. App. 370 (2002); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Concerning the VA's duty to assist, the Board notes that the Veteran's service treatment records, her lay statements of argument, and identified VA and private treatment records have been obtained. Pertinently, the Veteran has not indicated that any other VA treatment reports relevant to his asthma disorder currently exist, nor has she requested that the VA attempt to obtain any other private treatment records. VA has provided the Veteran with a VA Persian Gulf War examination in September 2005, VA jaw examination in October 2005, VA neurologic examination in March 2006, and various VA examinations in November 2009 and September 2011 to determine the nature and etiology of her claimed disorders. In the September 2011 VA examination reports, the examiner addressed the question of whether the Veteran's various complaints were attributable to an undiagnosed illness. Collectively, these examination reports reflect that the examiners reviewed the claims folder, recorded the Veteran's reported history as well as the findings from clinical examination, and rendered appropriate opinions supported by rational statements. Therefore, the Board finds that the evidence of record is adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 [affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim]. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions with respect to the issues on appeal have been met. 38 C.F.R. § 3.159(c)(4). In short, the Board has carefully considered the provisions of the VCAA, in light of the record on appeal and, for the reasons expressed above, finds that the development of these issues has been consistent with said provisions. The Board is satisfied that any procedural errors in the originating agency's development and consideration of the claims were insignificant and nonprejudicial to the Veteran. The Veteran has been accorded ample opportunity to present evidence and argument in support of his claim. See 38 C.F.R. § 3.103. She has retained the services of a representative, and she testified before the undersigned Board member. 2. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. See 38 C.F.R. § 3.303(b). The chronicity provision of 38 U.S.C.A. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Regulations also provide that 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 which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Certain chronic diseases, although not shown in service, may be presumed to have incurred in or aggravated by service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. To prevail on the issue of service connection, a claimant must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). If there is at least an approximate balance of positive and negative evidence regarding any issue material to the claim, the claimant shall be given the benefit of the doubt in resolving each such issue. 38 U.S.C.A. § 5107; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); 38 C.F.R. §§ 3.102. On the other hand, if the Board determines that the preponderance of the evidence is against the claim, it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule is not applicable. Ortiz, 274 F.3d at 1365. Undiagnosed Illness Claims Inasmuch as the record indicates that the Veteran served in served in Southwest Asia from October 1990 to April 1991; she is a Persian Gulf War Veteran within the meaning of the applicable statute and regulation. 38 C.F.R. § 3.317(b). Service connection may be established for a chronic disability resulting from an undiagnosed illness which became manifests during active service in the Southwest Asia Theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1)(i). For purposes of this section, a qualifying chronic disability means a chronic disability resulting from an undiagnosed illness. This further includes such chronic medically unexplained multi-symptom illnesses defined by a cluster of signs or symptoms as chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, or any diagnosed illness that the Secretary determines under 38 U.S.C.A. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2)(i). Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA's Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. 38 C.F.R. § 3.317(a)(5). A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(6). Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b). Here, the competent evidence of record does not demonstrate that presumptive service connection is warranted for a qualifying chronic disability under 38 C.F.R. § 3.317. The Veteran's claimed skin, heart, headaches, jaw, and uterus symptomatology is not eligible to be considered as a qualifying chronic disability under 38 C.F.R. § 3.317, because her symptomatology has been attributed to known condition. The medical records do not establish that the Veteran's skin rash, heart, headaches, teeth, and uterus condition have been attributed to a medically unexplained multi-symptom illness, or as residuals of one of the infectious diseases listed in 38 C.F.R. § 3.317. In this regard, VA and private medical treatment records show that the Veteran's skin conditions have been variously diagnosed, to include herpes simplex virus, eczema, acne and dermatitis; she has been diagnosed with migraine headaches and endometriosis; diagnostic testing reveals that her heart symptoms are related to anatomical conditions identified as mild regurgitation and heart murmur; and her complaints of jaw pain have been attributed to her routine teeth and caries decay. Moreover, the September 2011 VA examiners specifically opined against the findings that the Veteran's recurrent skin rash, heart conditions, headaches, jaw pain, and endometriosis were symptoms of an undiagnosed illness or unexplained multi-symptom illness. Since there are either clinical diagnoses of record for the claimed disorders or known conditions for which the symptoms are attributable to, the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 cannot be used to establish service connection for these conditions. The availability of presumptive service connection for a disability based on a qualifying chronic disability under 38 C.F.R. § 3.317, however, does not preclude an appellant from establishing service connection with proof of direct causation. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 19 Mitral Valve Prolapse (MVP) and Mild Regurgitation/Heart Murmur The Veteran claims entitlement to service connection for MVP with mild regurgitation/heart murmur. She asserts that she has been diagnosed with MVP based on diagnostic testing and she feels that her condition is related to stress of her deployment to Saudi Arabia, leaving her four month old child behind during her deployment, and result of injury sustained in a 1990 motor vehicle accident. See statements in support of claim attached to substantive appeal, VA Form-9. During the December 2008 hearing, the Veteran testified that she did not have a heart condition prior to service and she thinks that all of the stress and going to war could have caused her current problems. She indicated that they have not found any etiology regarding her heart condition other than stress and having PTSD. The Veteran's service treatment records do not show any evidence indicative of heart problems. She did sustain injuries during an October 1990 motor vehicle accident, but she was treated primarily for back and neck complaints. On her April 1993 examination prior to separation, the Veteran's heart was reported as normal on clinical evaluation and on the associated report of medical history, she denied any history of heart problems. Private medical records dated in November 2001 indicate the Veteran was admitted for complaints of chest pain and headaches. It was noted that she had a history of palpitations, for which she had been started on beta blockers. Impression included chest pain syndrome, etiology unclear. Echocardiogram showed mild mitral valve prolapse without significant mitral leaflet redundancy and/or regurgitation. The Veteran presented to the emergency room in December 2001 for complaints of chest pain, but diagnostic tests were negative for cardiac condition. VA echocardiograms dated in February 2002 and October 2005 showed no evidence of mitral valve prolapse. A May 2006 VA stress test was normal, and at that time, the Veteran denied any current symptoms of chest pain but she reported having occasional palpitations which started after she begun treatment with morphine pills. On VA heart examination in November 2009, the examiner noted that there was no evidence of mitral valve prolapse per echocardiogram in October 2005, but that the test revealed trace mitral regurgitation. The examiner concluded that per echocardiogram, the Veteran did not have mitral valve prolapse and that an opinion was not required. The November 2009 VA examiner did opine that the Veteran's mild regurgitation and heart murmur are not related to her period of service. In support of this medical conclusion, the VA examiner noted that the Veteran's service treatment records failed to document any heart problems and the Veteran reported the onset of her cardiac problem was in 2001. Similarly, in a September 2011 VA heart examination report, the VA examiner concluded that there was no objective or subjective evidence to support a diagnosis of mitral valve prolapse. The examiner noted that there was no documentation of heart problems in the Veteran's service treatment records. Although the Veteran had a history of chest pain with a diagnosis of mitral valve prolapse in 2001, subsequent diagnostic testing in 2005 did not document mitral valve prolapse and there was only trace evidence of mild regurgitation. Both the 2009 and 2011 ECHO test results revealed normal heart. The VA examiner found that the Veteran's mitral valve was evaluated as normal in structure and function and there was no evidence of mitral valve stenosis or mitral regurgitation based on clinical testing in 2009 and in 2011. The September 2011 VA examiner noted that mitral valve prolapse and regurgitation were anatomical descriptions, which have not resulted in a diagnosed cardiac condition. Moreover, the VA examiner noted that the Veteran denied any current cardiac symptomatology since 2001 during clinical examination. The September 2011 VA examiner opined that it was less likely than not the Veteran had a documented cardiac condition at this time. Without a current diagnosis of mitral valve prolapse, service connection cannot be granted. One of the requirements for service connection is competent evidence that a claimed disability currently exists. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Here, there is no competent evidence of any current diagnosis for mitral valve prolapse. See November 2009 and September 2011 VA examination reports. The Board has also considered the Veteran's own lay statements in support of her claim, in particular her assertion that her mitral valve prolapse is related to her period of service, to include stress she incurred during her deployment. While the Veteran is competent to attest to circumstances of her service and other facts surrounding her claim, she is not competent to provide an actual diagnosis of a disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also 38 C.F.R. § 3.159(a)(2). Absent a finding of a current diagnosis of mitral valve prolapse, service connection is not warranted. In addition, the Court has held that there can be no valid claim without proof of a present disability. See Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet.App. 141 (1992). Although the 2011 VA heart examination report rules out findings of mild regurgitation or any cardiac disorder, the Board cannot ignore the findings of mild regurgitation and heart murmur in 2009. Regardless, the preponderance of the competent evidence of record is against a finding that the Veteran's mild regurgitation or heart murmur is relate to her period of service. The Veteran's mild regurgitation and heart murmur were not first diagnosed until years after her separation from service, and there is no competent medical evidence linking those conditions to her period of service. Pertinently, the September 2011 VA examiner opined that the Veteran's mild regurgitation and heart murmur were less likely than not related to her period of service as there was no diagnostic evidence of these conditions until years after her separation from service. See 38 C.F.R. § 3.303. Moreover, during the recent VA examination, the Veteran denied any current cardiac symptoms to suggest that her mild regurgitation and heart murmur were aggravated by any of current medical conditions. The Veteran's assertions are the only evidence relating her mild regurgitation and heart murmur to service. However, the Veteran is not a medical professional, and therefore, her beliefs and statements about medical matters do not constitute competent evidence regarding matters that go beyond lay observation, such as etiology of skin diseases. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (under certain circumstances, lay person is competent to identify a simple medical condition). Notably, the question of etiology of heart disorder extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. The Veteran lacks the medical expertise to diagnose the condition and to relate its etiological origin in service. See Bostain v. West, 11 Vet. App. 124, 127 (1998). Therefore, to the extent, her statements attempt to show an etiological connection between her mild regurgitation and heart murmur and service, this is simply not competent or persuasive evidence. Simply put, there is no medical evidence on file linking the Veteran's current diagnosed her mild regurgitation and heart murmur to any aspect of his military service. The Veteran is not a medical professional competent to provide such a link by mere statements alone. Moreover, the Veteran has not asserted continuity of any heart-related problems since her period of service and the medical evidence does not show any treatment for heart-related complaints prior to 1998, and she has denied any cardiac symptoms since 2001. See 38 C.F.R. § 3.307, 3.309; see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In sum, the Veteran does not have a current diagnosed mitral valve prolapse. Further, the weight of the evidence is against a finding that the Veteran's history of mild regurgitation and heart murmur are related to his service. As such, the preponderance of the medical evidence is against an award of service. Consequently, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The claim must be denied. Herpes Simplex Virus (HSV) The Veteran argues that she has a rash that is related to her service in the Gulf War. She reports that she first developed a skin rash, which she described as involving blisters on her hands and around her mouth and nose, shortly after her return from the Persian Gulf. At her December 2008 hearing, she testified that she experienced rash around her mouth and that a VA dermatologist had told her that she had herpes simplex. The Veteran's service treatment records show a single incident of skin problems in February 1992, when the Veteran presented with complaints of itchy bumps on her face and she was observed to have comedones. On her April 1993 examination prior to separation, the Veteran's skin was evaluated as normal on clinical evaluation and on the associated report of medical history, she denied any history of skin problems. Within a year after the Veteran's separation from service, she was afforded a Persian Gulf Registry examination in July 1994. At that time, the Veteran complained of recurrent blisters which would be painful and then resolve. She was assessed with HSV based on her description. A May 1995 VA dermatology consult report shows an assessment of probable HSV and a November 1995 VA dermatology consult report shows a diagnosis of oral herpes simplex. Private medical records dated in March 1999 include diagnoses of nasal labial herpes with localized infection in the nose. Subsequent VA treatment records continue to show diagnosis of herpes simplex. See August 2006 and November 2011 VA treatment records as well as the report of a September 2011 VA examination. During a VA skin examination in November 2009, the Veteran's report that she experienced an outbreak five months previously, but the examiner observed no rash or skin lesions on the face or mouth area and concluded that there was no rash present. Similarly, the VA examiner from a September 2011 VA skin examination failed to address the Veteran's history of herpes simplex or the medical documentation of herpes simplex back to 1994, when he opined that it was less likely than not that the Veteran's current skin conditions were related to her period of service because there was no documentation of her current skin problems until 2003. It is noted that lay evidence can be competent and sufficient to establish a diagnosis or to establish etiology of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) This does not mean, however, that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the lay person is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the 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. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). The Board may not reject the credibility of the veteran's lay testimony simply because it is not corroborated by contemporaneous medical records. Buchanan, 451 F.3d at 1336. In this case, the Veteran has a current diagnosis for HSV. See VA and private treatment records. She has credibly reported that she first experience symptoms of skin rash manifested by blisters on her hands and around her mouth and nose in service, and she has continued to experience similar symptomatology since then. The VA treatment records show that the rash on her hands and around her mouth and nose has since been diagnosed as herpes simplex. A layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Here, although a claimant generally is not competent to diagnose her skin disorder, she is competent to identify and explain the symptoms that she observes and experiences. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Further, the Veteran has been diagnosed with herpes based on the similar symptomatology that she first experienced in service and since then. See Jandreau, 492 F.3d at 1377. While the record does not contain a medical nexus statement that links the Veteran's currently diagnosed HSV to her service, based on the descriptions of the symptoms that she reported first occurred in service and later laboratory testing, she was subsequently diagnosed by VA and private medical professionals with HSV. A diagnosis based on the Veteran's description of symptoms first manifested in service is sufficient evidence to establish a link between the current diagnosed disorder and service. See Id., 492 F.3d at 1376-77; see also Davidson, 581 F.3d at 1316. Also supporting such a link is the reported medical history of skin problems noted in the Persian Gulf War Registry examination and the assessment of herpes simplex based on her description of in-service skin problems only nine months after the Veteran's separation from service in July 1994. Although the Board cannot ignore the negative medical nexus conclusion from the September 2011 VA examiner, the Board finds that the opinion carries limited, if any, probative value as the examiner failed to discuss the medical history of the Veteran's herpes simplex episodes prior to 2003. See Neives-Rodriguuez v. Peake, 22 Vet. App. 295, 304 (2008). Based on the foregoing, the Board finds that the evidence of record is at least in approximate balance as to whether the Veteran's currently diagnosed skin rash disorder (HSV) is related to credible lay evidence of skin rash symptoms since service and a formal medical diagnosis of herpes based on her description of those symptoms only nine months after her separation from service at the Persian Gulf Registry Examination. The Board concludes that the evidence is at least in equipoise as to the question of whether the Veteran's current skin rash disorder (HSV) first manifested in service. 38 C.F.R. § 3.303(b); Savage, 10 Vet. App. at 495-96; see also Hickson, 12 Vet. App. at 253. Consequently, resolving any doubt in the Veteran's favor, the Board finds that the Veteran's HSV is likely related to service. 8 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hence, service connection for HSV is warranted. Skin Rash Other than HSV With regard to the Veteran's skin conditions, other than HSV, the preponderance of the competent evidence is against the findings that those skin conditions are related to her period of service. Although the Veteran's service treatment record do show she was assessed with comedones in 1992, her April 1993 examination prior to separation shows a normal skin evaluation. The Veteran did not complain of a skin condition, other than those skin problems manifested by HSV, during the July 1994 VA Persian Gulf War Registry examination. A March 1999 private treatment record shows that the Veteran presented with cystic type acne on her check and chin, but subsequent VA treatment records note a history of the onset of acneiform following the Veteran's chemotherapy treatment in 2003. See March 2003 VA treatment record. A September 2005 VA dermatology consult note shows an assessment of erythematous papules and pustules on the Veteran's face and an August 2006 VA treatment record shows an assessment of possible eczema involving the Veteran's hands. In September 2011, the Veteran was afforded a VA skin examination. In that examination report, the examiner noted that the Veteran had dermatitis and acne, which were diagnosed skin conditions. Based on a review of the record, the September 2011VA examiner opined that the Veteran's dermatitis and acne were less likely than note related to her period of service, to include the single outbreak noted in 1992. Rather, the VA examiner felt that the Veteran's current skin problems first manifested in 2003 after she began her chemotherapy treatment. While the service treatment record do show that the Veteran was assessed with comedowns in 1992, the physical examination at the time of her separation in 1993 shows her skin was evaluated as normal. Subsequent treatment records do not show that she was diagnosed with chronic skin condition, identified as dermatitis and acne, until 2003, which comes almost a decade after her separation from service. There medical evidence does not show that the Veteran's current dermatitis or acne was first diagnosed during her period of service. See 38 C.F.R. § 3.303. The record also does not show a continuity of symptomatology (or treatment) for skin rash identified as dermatitis and acne following separation from service in 1993 and prior to March 1999, when the Veteran sought private medical treatment for cyst type acne on her face. Moreover, the Veteran's current dermatitis and acne symptoms were not observed until 2003, after she began her chemotherapy. A lengthy period of time between service and the first post-service clinical notation of complaints or symptoms associated with the disability at issue is of itself a factor for consideration against a finding that the current disability is related to service. See Maxson v. Gober, 230 F.3d. 1330, 1333 (Fed. Cir. 2000) (in a claim alleging that a disability was aggravated by service). In addition, the record lacks medical evidence establishing a possible relationship between the Veteran's current skin disorder, identified as dermatitis and acne, and her periods of service. The September 2011 VA examiner concluded that the Veteran's current diagnosed skin disorder (dermatitis and acne) was less likely than not related to her periods of service. The examiner supported this medical conclusion by noting lack of treatment for skin problems following the single outbreak in 1992 as well as the medical evidence showing the onset of her current skin symptoms manifested after she began treatment for chemotherapy in 2003. The Board finds this examination report to be probative evidence of record, and there is no medical opinion contained in the record that links the skin disorders other than HSV, identified as dermatitis and acne, to her service in order to support an award for service connection. See 38 C.F.R. § 3.303. The Veteran's assertions are the only evidence relating her current diagnosed skin other than HSV disorder to service. However, the Veteran is not a medical professional, and therefore, her beliefs and statements about medical matters do not constitute competent evidence regarding matters that go beyond lay observation, such as etiology of skin diseases. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (under certain circumstances, lay person is competent to identify a simple medical condition). Notably, the question of etiology of skin disorder extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. The Veteran lacks the medical expertise to diagnose the condition and to relate its etiological origin in service. See Bostain v. West, 11 Vet. App. 124, 127 (1998). Therefore, to the extent, his statements attempt to show an etiological connection between her current diagnosed skin disorders other than HSV and service, this is simply not competent or persuasive evidence. Simply put, there is no medical evidence on file linking the Veteran's current diagnosed skin disorder other than HSV to any aspect of her military service. There is no competent medical evidence indicating that the Veteran's skin disorder other than HSV is otherwise related to her service. With respect to the Veteran's lay assertions of continuity of symptomatology since service, the Federal Circuit recently held that continuity of symptomatology under 38 C.F.R. § 3.303(b) only applies to those conditions recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran's diagnosed skin disabilities are not listed as chronic conditions. Therefore, service connection based on continuity of symptomatology is not warranted. In sum, the Veteran has a diagnosed skin disorder other than HSV (dermatitis and acne), and the provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 cannot be used to establish service connection for this condition. Further, the weight of the evidence is against a finding that the Veteran's current skin disorder other than HSV is related to his service. As such, the preponderance of the medical evidence is against an award of service. Consequently, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The claim must be denied. Jaw Pain The Veteran seeks entitlement to service connection for jaw pain. She contends that she was diagnosed and treated for bruxism with temporomandibular joint (TMJ) symptoms due to stress and that this was a chronic problem because she still has symptoms. See statement attached to VA Form-9. During her December 2008 hearing, the Veteran testified that she went to the dentist a lot during service and had to keep her mouth open wide and it caused TMJ. She said the doctors verbally told her she has TMJ. Service treatment records show an assessment of possible temporomandibular joint syndrome (TMJ) in March 1991. Dental records dated in May 1992 note day and night bruxism and clenching and that the Veteran has TMJ symptoms. Soft and hard night guards were subsequently provided. Service dental records also show that the Veteran received routine dental care and she had a root canal in 1991. The September 2005 letter from the VAMC Tampa regarding the Veteran's participation in the Gulf War Registry includes an assessment of TMJ. In the report, the examiner noted that the Veteran complained of TMJ pain, but the clinical examination was normal, except for "popping" sounds in the right TMJ with opening and closing. An October 2005 VA dental examination report shows that the Veteran complained of right jaw pain with headaches. She reported a history of some jaw discomfort since she underwent a root canal in service. Clinical examination revealed normal range of motion of the jaw and no popping or clicking sounds were observed. There was evidence of routine dental decay and some TMJ dysfunction. The examiner opined that the Veteran's TMJ symptoms were related to decayed teeth and caries and the symptoms were not associated with an undiagnosed illness. On VA examination in November 2009 a diagnosis of chronic right jaw pain was provided. The examiner concluded that the pain was due to decayed teeth. The Veteran was afforded another VA examination in September 2011. That examination report shows that x-ray films revealed evidence of fractured cementoenamel junction (CEJ) of right side tooth that was nonrestorable, but there was no evidence of TMJ involvement. The VA examiner noted that 2005 VA dental record showed that the Veteran had a history of decayed teeth. The VA examiner opined that it was less likely than not that the Veteran had TMJ disorder, and it was more likely that her jaw pain was secondary to decayed teeth. Although the service treatment records show an assessment and treatment for bruxism with TMJ symptoms, the medical evidence during the appeal period does not show a current diagnosed TJM-related disorder. Rather, the October 2005, September 2009, and September 2011 VA examiners opined that the Veteran's jaw pain was attributable to decayed teeth. Without a current diagnosis of TMJ-related disorder, service connection cannot be granted. One of the requirements for service connection is competent evidence that a claimed disability currently exists. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Here, there is no competent evidence of any current diagnosis for TMJ or TMJ-related disorder. See September 2011 VA examination report with addendum. Absent a finding of a current diagnosis of TMJ-related disorder, service connection is not warranted. In addition, the Court has held that there can be no valid claim without proof of a present disability. See Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet.App. 141 (1992). Pertinently, the Board notes that with respect to dental disabilities, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease, are not disabling conditions for which service connection may be awarded. 38 C.F.R. § 3.381. Absent a demonstration of dental trauma or disease such as osteomyelitis, service connection for treatable carious teeth, replaceable missing teeth, and periodontal disease may be considered solely for the purpose of establishing eligibility for outpatient dental treatment or entitlement to a dental examination. Id.; see also Woodson v. Brown, 8 Vet. App. 352, 354 (1995). The record reflects that the Veteran has already been afforded outpatient dental treatment under the provisions of 38 C.F.R. § 17.161. See November 2010 rating decision. The Veteran does not allege that she sustained physical dental trauma in service, her service dental records do not reveal findings consistent with the Veteran having sustained any form of physical dental trauma or suffered disease such as osteomyelitis in service, the Veteran is not entitled to service connection for her dental disability, which now manifests as routine decayed teeth with jaw pain. See 38 C.F.R. §§ 3. 381, 4.150, Diagnostic Codes 9900-9916. In conclusion, as the Veteran has not been diagnosed with a TMJ-related disorder and her symptoms are attributable to routine teeth decay. However, the Veteran does not have a dental disability attributable to trauma sustained in service, and she has not been diagnosed with any other dental disability eligible for service connection, he has failed to state a valid claim for service connection for a dental disorder. As such, the claim must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). Edometriosis The Veteran seeks entitlement to service connection for endometriosis. The Veteran contends that ovarian cysts were first detected after she had her baby and she still has them at present. During the December 2008 hearing, she indicated that she thought she was first diagnosed with gynecological problems during service. She also indicated that current conditions are linked to her breast cancer. Service treatment records show that on report of medical history completed at entrance in August 1987, the Veteran reported a cyst on the right ovary resolved with medication. She had no problems at that time and pelvic examination was normal on clinical evaluation. Gynecologic consultation in October 1990 included an impression of right adnexal tenderness, probably ovulatory in nature. Review of service treatment records shows abnormal cytological examinations and treatment for pelvic inflammatory disease (PID). Her April 1993 medical history report prior to separation noted that she had been treated for abnormal gynecology examinations for the past three years. None of the service treatment records indicated that the Veteran had been diagnosed or treated for endometriosis during her period of service. VA treatment record dated in October 2003 shows an impression of possible endometriosis based on findings of pain on palpitation of the uterus vaginally; however, an October 2004 VA treatment record shows that diagnostic testing revealed normal endometrial strip. Subsequent diagnostic testing and clinical examination in November 2003 revealed negative findings except for tender uterus. It was felt that the Veteran had irregular menses secondary to her chemotherapy treatment. VA records show that the Veteran underwent a CT scan of the pelvis in January 2005 which showed a cystic lesion in the left adnexa. The Veteran subsequently underwent surgery and diagnosis included mild to moderate endometriosis. On VA examination in November 2009 the diagnosis was asymptomatic endometriosis. No medical opinion was render. Similarly, the VA examiner in a September 2011 VA examination report noted that the Veteran had asymptomatic endometriosis. The September 2011 VA examiner opined that it was less likely than not that the Veteran's endometriosis was related to her period of service, and it was attributable to a diagnosed disorder. In an addendum statement, the September 2011 VA examiner explained that Veteran's endometriosis was less likely than not related to her period of service because it was diagnosed until 2005 and not incurred during her period of service. Based on a review of the foregoing evidence, the Board finds there is no competent and credible evidence that the Veteran's endometriosis had an onset during her period of service, and the weight of the evidence is against a finding that her endometriosis disorder is otherwise related to her period of service. Initially, the Board first observes that there is no medical evidence showing that the Veteran's endometriosis was incurred during her period of service. While the service treatment record do show that she was treated for various gynecological problems during her period of service, there is no medical evidence of endometriosis until 2005. Notably, diagnostic testing was negative for findings of endometriosis prior to 2005. There is no medical evidence that shows the Veteran's endometriosis first manifested during her period of service. 38 C.F.R. § 3.303. In addition, the record lacks medical evidence establishing a possible relationship between the Veteran's endometriosis and her period of service. The September 2011 VA examiner concluded that the Veteran's endometriosis was less likely than not related to her period of service. The examiner supported this medical conclusion by noting the lack medical evidence of endometriosis prior to 2005 as well as the absence of treatment for endometriosis in service. There is no medical opinion contained in the record that links the Veteran's endometriosis to her service in order to support an award for service connection. See 38 C.F.R. § 3.303. The Veteran's assertions are the only evidence relating her endometriosis to service. However, the Veteran is not a medical professional, and therefore, her beliefs and statements about medical matters do not constitute competent evidence regarding matters that go beyond lay observation, such as etiology of gynecology diseases. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (under certain circumstances, lay person is competent to identify a simple medical condition). Notably, the question of etiology of endometriosis is based on diagnostic testing and extends beyond an immediately observable cause-and-effect relationship and, as such, the Veteran is not competent to address etiology in the present case. The Veteran lacks the medical expertise to diagnose the condition and to relate its etiological origin in service. See Bostain v. West, 11 Vet. App. 124, 127 (1998). Simply put, there is no medical evidence on file linking the Veteran's endometriosis to her period of service. The Veteran is not a medical professional competent to provide such a link by mere statements alone. There is no competent medical evidence indicating that the Veteran's disorder is otherwise related to her service. With respect to the Veteran's lay assertions of continuity of symptomatology since service, the Federal Circuit recently held that continuity of symptomatology under 38 C.F.R. § 3.303(b) only applies to those conditions recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran's diagnosed gynecological diseases are not listed as chronic conditions. Therefore, service connection based on continuity of symptomatology is not warranted. In sum, the Veteran's endometriosis did not manifest until a decade after her separation from service, and the weight of the evidence is against a finding that her endometriosis is related to her service. As such, the preponderance of the medical evidence is against an award of service. Consequently, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The claim must be denied. ORDER Entitlement to service connection for mitral valve prolapse with mild regurgitation/heart murmur is denied. Entitlement to service connection for a skin rash, identified as herpes simplex virus (HSV) is granted Entitlement to service connection for skin rash, other than HSV is denied. Entitlement to service connection for jaw pain is denied. Entitlement to service connection for endometriosis is denied. REMAND Unfortunately, another remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that she is afforded every possible consideration. Ovarian Cysts On remand in September 2011, the Board noted that the evidence showed treatment for various gynecological problems during service and included the Veteran's report of continuing symptoms since that time. An examination was ordered On VA examination in September 2011, the diagnoses were asymptomatic right ovary cyst. The VA examiner did provide a negative medical nexus opinion, but the examiner failed to provide an adequate statement in support of this medical conclusion. Instead, the VA examiner only noted that endometriosis was not diagnosed until 2005 but failed to discuss the earlier medical evidence of ovarian-related issues. Pertinently, the Veteran's service treatment records noted that upon her entrance that she had a history of right ovarian cyst that resolved with medication and private treatment records in July 1997 shows findings of two left ovarian cyst on ultrasound. Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As such, this issue must be remanded for to obtain a supplemental medical opinion that is support by a rational statement. Headaches The record now suggests that the Veteran's headache disorder may be caused or aggravated by her service-connected fibromyalgia. See 2011 VA fibromyalgia examination report. A medical opinion has not yet been obtained that addresses that medical question. On remand, the Veteran should be afforded a VA neurologic examination to determine whether her migraine headaches are related to her period of service, to include as secondary to her service-connected fibromyalgia. Under 38 C.F.R. § 3.310 (a), service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury and secondary service connection may be found where a service- connected disability aggravates another condition (i.e., there is an additional increment of disability of the other condition which is proximately due to or the result of a service- connected disorder). Allen v. Brown, 7 Vet. App. 439 (1995). An amendment to 38 C.F.R. § 3.310, effective October 10, 2006, was enacted. See 71 Fed. Reg. 52744 (2006). The amendment essentially codifies Allen and adds language that requires that a baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation. Psychiatric Disorder As noted above, the claim for service connection for a psychiatric disorder, to include PTSD, depression, and adjustment disorder, was remanded by the Court for action in compliance with the instruction in the January 2013 Memorandum Decision. The Court determined that the Board had erroneously relied on an inadequate November 2009 VA examination report, in which the VA examiner found that the Veteran did not have a current diagnosis of PTSD based on only one, and not all, of her claimed in-service stressor events. In addition, the Court felt that the Board failed to reconcile why the previous diagnosis of PTSD in the Veteran's VA treatment records was insufficient to support a current diagnosis. The Court instructed the Board to remand in order to afford the Veteran a new VA examination in conjunction with her claim. As such, the matters are remanded in order to afford the Veteran with a new VA examination to determine the nature and etiology of the Veteran's claimed psychiatric disorder. In addition, the Board notes that during the pendency of the appeal, the Veteran has been awarded service connection for fibromyalgia, and there is now medical evidence of record that suggests that the Veteran's depression disorder is secondary to her fibromyalgia disability. See January 2013 VA examination report as well as August 2013 private medical statement by Dr. J.M. The Board also instructs the VA examiner to provide a medical opinion on whether the Veteran's current psychiatric disorder is proximately caused or aggravated by her service-connected disability. Accordingly, the case is REMANDED for the following action: 1. Ensure that the Veteran has been provided with proper notice regarding the evidence and information necessary to substantiate her claim of entitlement to service connection on a secondary basis under 38 C.F.R. § 3.310. 2. By appropriate means, and with any necessary assistance from the Veteran, the RO/AMC should seek to identify and obtain any outstanding records of pertinent medical treatment that are not yet on file. 3. Update the claims folder with the Veteran's VA treatment. 4. Once all the available records have been obtained and associated with the claims folder, arrange for the Veteran's entire claims file, to include a complete copy of this REMAND, should be forwarded to an appropriate specialist in order to obtain a supplemental VA medical opinion regarding the etiology of the Veteran's recurrent ovarian cysts, status post left oophorectomy. Based on a review of the claims file, including the Veteran's reported medical history and assertions in the previous 2009 and 2011 VA examination reports, and the results of any further examination if necessary, the examiner should answer the following: Provide a clear medical conclusion on whether the Veteran's recurrent ovarian cysts, status post left oophorectomy, is at least as likely as not (50 percent or greater probability) had an onset during her period of service or is otherwise related to her period of service. In doing so, the examiner should consider the history of right ovarian cyst, resolved, noted at induction, the in-service treatment for various gynecological problems as well as the post-service treatment for recurrent ovarian cysts starting in 1997. A rationale for any opinion advanced should be provided. If an opinion cannot be formed, the examiner should so state and provide a reason why. 5. Once all the available records have been obtained and associated with the claims folder, schedule the Veteran for a VA neurologic examination to determine the etiology of her migraine headaches, to include as proximately caused by her service-connected fibromyalgia. The claims folder must be made available to and reviewed by the examiner. The examiner should elicit a complete history from the Veteran, the details of which should be recited in the examination report. All necessary testing should be conducted. Based on a review of the claims file, including the Veteran's reported medical history and assertions, and the results of examination, the examiner should answer the following: Provide a clear medical conclusion on whether the Veteran's migraine headaches are at least as likely as not (50 percent or greater probability) had an onset during her period of service as manifested by her in-service complaints, or is otherwise related to her period of service, to include as proximately caused or aggravated by her service-connected fibromyalgia. In doing so, the examiner should consider the in-service complaints of headaches and diagnosis of tension headaches as well as the post-service treatment for migraine headaches. A rationale for any opinion advanced should be provided. If an opinion cannot be formed, the examiner should so state and provide a reason why. 6. Once all the available records have been obtained and associated with the claims folder, schedule the Veteran for a VA psychiatric examination to determine the nature and etiology of her claimed disorder, to include as proximately caused by her service-connected fibromyalgia. The claims folder must be made available to and reviewed by the examiner. The examiner should elicit a complete history from the Veteran, the details of which should be recited in the examination report. All necessary testing should be conducted. Based on a review of the claims file, including the Veteran's reported medical history and assertions, and the results of examination, the examiner should answer the following: a). Provide a clear medical conclusion on whether the Veteran had PTSD that satisfies the DSM-IV criteria. In doing so, the examiner should reconcile the previous diagnosis of PTSD in the Veteran's VA treatment records compared to the finding of no PTSD diagnosis during the 2009 VA examination. b). If the Veteran is diagnosed with PTSD, the examiner is requested to provide an opinion as to whether it is related to any confirmed in-service stressor(s). In this regard, the examiner should be advised that service records show the Veteran was involved in a motor vehicle accident in October 1990; VA concedes that there is evidence sufficient to corroborate the claimed sexual harassment; or the examiner should indicate whether "fear of hostile military activity" is a stressor that supports a diagnosis of the Veteran's PTSD. c). If the Veteran is diagnosed with a psychiatric disability other than PTSD, the examiner is requested to identify each psychiatric disorder and to provide an opinion as to whether each or any psychiatric disorder other than PTSD is related to active military service or is proximately caused or aggravated by her service-connected fibromyalgia. In doing so, the examiner should reconcile the conflicting medical opinions contained in the 2013 VA and private examination reports. A rationale for any opinion advanced should be provided. If an opinion cannot be formed, the examiner should so state and provide a reason why. 7. Thereafter, the RO/AMC should re-adjudicate the issues of entitlement to service connection. If any of the benefits sought remain denied, the RO/AMC must furnish a supplemental statement of the case (SSOC), before the claims file is returned to the Board, if otherwise in order. 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). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs