Citation Nr: 1612127 Decision Date: 03/25/16 Archive Date: 03/29/16 DOCKET NO. 13-31 575 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for migraine headaches. 2. Entitlement to service connection for left side numbness (face, arm, hand, upper body), including on a secondary basis. 3. Entitlement to service connection for a bilateral eye condition. 4. Entitlement to service connection for reactive airway disease (claimed as respiratory condition/coughing and breathing). 5. Entitlement to service connection for a skin condition. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD P. Wirth, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1985 to March 1987, from January 1993 to June 1993, from March 2003 to March 2005, and from March 2008 to December 2008, including service in Iraq from April 2008 to October 2008. In addition, the Veteran served in the Army Reserve until she retired in October 2011. This case comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. In October 2013, the Veteran filed a timely Substantive Appeal (VA Form 9). In September 2015, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) at the RO. A transcript of the hearing is associated with the claims file. Also in September 2015, the Veteran's representative submitted additional argument and evidence accompanied by a waiver of the Veteran's right to have this evidence initially considered by the RO. Accordingly, the Board may consider this evidence in the first instance. See 38 C.F.R. § 20.1304(c) (2015). In March 2016, the Veteran submitted additional medical evidence without a waiver of initial consideration of the evidence by the RO. However, under 38 U.S.C. § 7105(e), if the claimant or the claimant's representative submits new evidence with or after a substantive appeal received on or after February 2, 2013, then it is subject to initial review by the Board, unless the claimant explicitly requests agency of original (AOJ) consideration. In the present case, the Veteran's Substantive Appeal was received in October 2013. As the Veteran did not explicitly request that the AOJ (in this case the RO) review the additional evidence, the evidence is properly before the Board for initial review. The Board has recharacterized the Veteran's claim relating to migraine headaches. The Veteran's claim was certified to the Board in March 2014 as entitlement to an increased rating for traumatic brain injury (TBI) with migraine headaches. The Veteran actually contends, however, that her headaches should have a separate rating and should not be subsumed by the TBI rating. See September 2015 Hearing Transcript at 3. The Board notes that a January 2013 VA examiner opined that the Veteran's migraine headaches are not due to her TBI. Accordingly, the Board has characterized the headache issue on appeal as one for service connection of migraine headaches, instead of as a claim for an increased rating for TBI with migraine headaches, and finds no prejudice to the Veteran in so doing. See generally Clemons v. Shinseki, 23 Vet. App. 1 (2009) (when a veteran makes a claim, the veteran is seeking service connection for symptoms, regardless of how those symptoms are diagnosed or labeled); See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board also has reframed the issues certified to it as entitlement to service connection for presbyopia and for acne, to entitlement to service connection for a bilateral eye condition and for a skin condition, respectively. The Board finds that the broader claims more accurately reflect the Veteran's actual claims and additional diagnoses that have emerged during the course of this appeal. The Veteran is not prejudiced by such action. The issues of entitlement to service connection for a bilateral eye condition, reactive airway disease, and a skin condition are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's migraine headaches are not a manifestation or residual of her TBI. 2. Resolving doubt in favor of the Veteran, the evidence, as a whole, supports finding that the manifestations and/or symptoms of migraine headaches were present in service. 3. The medical evidence subsequent to the June 2009 VA examination shows that the Veteran has a diagnosis of left-sided numbness of the face, arm, hand, and upper body. 4. Resolving doubt in favor of the Veteran, the Veteran's left-sided numbness is secondary to an injury or illness of service origin, to include either her service-connected degenerative disc disease of the cervical spine and/or migraine headaches. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for migraine headaches have been met. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015). 2. The criteria for establishing service connection for left side numbness of the face, arm, hand, and upper body have been met. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As the Board's decision to grant service connection for migraine headaches and for left side numbness is completely favorable, no further action is required to comply with the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations. As noted above, the January 2010 rating decision at issue granted service connection for residuals of TBI with migraine headaches, with an evaluation of 10 percent effective December 2, 2008. The Veteran contends that her headaches should be rated separately, based on direct service connection or as secondary to a service-connected disability such as degenerative joint disease of the neck or back, and should not be subsumed by the TBI rating. See September 2015 Hearing Transcript at 3. The Veteran testified at her Board hearing that the injury causing the TBI occurred in 2008 in Iraq, but that her headaches actually began in 2003 when she had her first in-service injury to her neck and back. The headaches got worse in Iraq from wearing the gear, being around loud noises, and getting jostled around, but the severity of the headaches got worse right away after the TBI. Id. at 4-5. The Veteran has headaches all of the time of varying severity, and takes medication twice a day for the headaches. Id. at 6. The Veteran also seeks service connection for left side numbness of the face, hand, and upper body. The Board notes that the January 2010 rating decision granted service connection for degenerative disc disease of the cervical spine. It also granted service connection for degenerative disc disease of the lumbar spine with intervertebral disc syndrome (IVDS), and for peripheral neuropathy of the left lower extremity. General Law Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2015). Service connection also may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2015). In addition, service connection can be established on a secondary basis by demonstrating that the disability is proximately due to or the result of an already service-connected disease or injury. 38 C.F.R. § 3.310(a) (2015); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). Generally, in order to prove service connection, a veteran must show: (1) a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009), (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value. Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107 (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the veteran. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2015). Background A December 2003 service treatment record shows the Veteran presented with left-sided neck pain with a radicular component of discomfort with tingling and pinprick sensation affecting the entire left arm, forearm, and left hand. Onset was the prior evening while performing physical training. She denied a similar prior problem. On examination, the Veteran exhibited guarded cervical range of motion with all directions. There was no evidence of weakness in the hands or arms. The assessment was acute torticollis (cervical strain) with secondary erratic dysfunction. The Veteran had ongoing complaints of neck and left arm pain with extensive private evaluation and treatment. January 2004 cervical spine x-rays and March 2004 magnetic resonance imaging (MRI) of the cervical spine show multiple degenerative changes of the Veteran's cervical spine. A July 2004 treatment record shows that over the weekend the Veteran's symptoms of left arm pain increased. She also developed left face numbness and pain, but no weakness. She had a headache over the weekend, but it was gone as of the appointment. The assessment was paresthesia of the left face of unknown cause and cervical radiculopathy. She was referred to a neurosurgeon. A September 2004 letter from a neurosurgeon provides that the Veteran's recent MRI of the brain was essentially, completely normal, with no explanation for her left face and global upper extremity symptoms. It continues that "[s]ince her cervical and lumbar MRI scans also did not reveal a cause of her symptoms, we are left without explanation for her subjective symptomatology, with no objective findings." In October through December 2004, the Veteran underwent a course of physical therapy for neck and occasional lumbar pain, with moderate headaches. A January 2005 treatment record shows follow up for neck, left arm/hand pain/numbness, and left face numbness/pain behind the eye. It is noted that the Veteran was involved in a motor vehicle accident about three months ago. Her vehicle was rear-ended, but she never sought treatment. The assessment was left face paresthesias more prominent and left cervical radiculopathy. January 2005 x-rays of the cervical spine show that the mild right C3-4 and C4-5 and moderate bilateral C5-6 neural foraminal stenosis appeared slightly more pronounced when compared to the prior January 2004 x-rays. A February 2005 MRI of the brain was performed to evaluate the Veteran for multiple sclerosis. The Veteran had three very small, somewhat rounded, nonspecific foci in the brain, which were probably incidental findings related to early atherosclerotic change. Demyelinating disease was not absolutely excluded, but the foci did not have the classic appearance often seen in patients with multiple sclerosis. A February 2005 treatment record of a neurologist shows the Veteran reported "that her troubles began in December 2003 around Christmas when she suffered a neck injury, with onset of pain and paresthesias radiating into the left arm. It was thought this was most likely due to cervical spondylosis and was treated conservatively, but the arm[] symptoms 'really didn't seem to go away.'" Facial paresthesias began last summer, and three months ago there was increasing paresthesias and a sense of weakness as well. The Veteran felt like her left hand was not working that well. The impression was diffuse paresthesias and cervical spondylosis. It was noted that, although the Veteran does have cervical spondylosis, there was no major evidence of radiculopathy at that time. The Veteran's only real weakness (per her description, grip weakness) did not correlate with the C7 narrowing noted on her MRI. It also was noted that the Veteran had three areas of increased signal intensity on the MRI of her brain, and, given the Veteran complaints of facial paresthesias (which could not be explained on the basis of her cervical spine findings), the neurologist determined that it was probably prudent to repeat her MRI to rule out the limited possibility of demyelinating disease. A latter February 2005 note after the repeat MRI shows that the neurologist determined that the Veteran's symptoms were most likely the consequence of her cervical spondylosis, as there was little to support a diagnosis of demyelinating disease at that time. In December 2003, the Veteran received a temporary physical profile due to cervical strain. A later profile also noted numbness in the right (the Board believes this was in error and should have been left) part of her face, neck, arm, and hand. In February 2005, a permanent physical profile due to cervical strain was put in place. A September 2008 service treatment record while the Veteran was on active duty in Iraq shows the Veteran complained of a non-stop headache located in her left temple, accompanied by numbness in her left arm from the shoulder to the fingertips. She reported that she was riding in a convoy when she was jarred and twisted her neck. The headache was of recent onset, was steady, and had lasted more than one week. She also had pain in her neck, which was of recent onset, on the left, and did not radiate. She had numbness of the left side of the face, the left shoulder, and the left medial arm, without lightheadedness or dizziness. On examination, there was sensory numbness only, which was not progressive. There was no motor weakness by history or on examination. The assessment was that the symptoms were consistent with C-6 nerve impingement times three weeks. It was noted that the Veteran was leaving the country in a few days and was advised to seek further care. The Veteran's September 2008 Post-Deployment Health Assessment (DD Form 2796) shows that the Veteran checked that she had sick call for bad headaches and was still bothered by them. It also shows the Veteran reported concerns about "neck strain, with numbness in arm and hand." Similarly, at an October 2008 post-deployment Soldier Readiness Check, the Veteran reported acute problems with neck strain. March 2009 x-rays of the cervical spine show muscle spasm with degenerative disc disease, most prominent at C5-C6 bilaterally and C6-C7 on the left, and prominent anterior osteophyte of C4. An April 2009 MRI shows mild to moderate degenerative disease of the cervical spine, worse at the C5-6 and C6-C7 levels where there was mild disc osteophyte complexes demonstrated. At the C6-C7 lever, there was minimal dural compression and mild ventral cord indentation with no abnormal cord signal demonstrated. In May 2009, the Veteran's VA physician sent a letter to the Veteran summarizing the results of recent testing. The physician stated, in pertinet part: "The neck did show quite a bit of damage, which should not come as a surprise to you, with what they call disc osteophyte complexes at C5-C6 and C6-C7. What this means is, it is a combination of a bulging disc and arthritis that combines to cause patients a lot of pain, stiffness, and sometime numbness in their arms." The Veteran was afforded a VA examination in June 2009, which was performed by QTC Medical Services. The examiner found that the Veteran experienced a "Focal injury" TBI that was classified as mild in terms of severity and had stabilized. The examiner diagnosed TBI with migraines. The Veteran did not report any headaches prior to 2008 when the TBI occurred. With respect to her left side numbness, the Veteran reported being diagnosed in 2003 with a neck condition accompanied by numbness to the hand and body due to an injury on active duty during physical training. The Veteran reported a second injury in 2008 in Iraq. The examiner found, however, that there was no pathology to render a diagnosis of numbness to the face, leg, hand, or body. Also in June 2009, the Veteran had an additional VA examination to assess for cognitive impairment due to TBI. The examiner found no cognitive impairment as a result of the TBI. There was no note of any headaches. An October 2010 military treatment record shows the Veteran complained of headaches since 2008 after deployment. The Veteran also reported that at times the left side of her face and her left arm went numb and her fingers tingled. The assessment was intervertebral disc degeneration - cervical. A December 2010 MRI of the brain done to evaluate the Veteran's headaches was normal. In January 2013, the Veteran underwent a review evaluation for residuals of TBI. The Veteran reported progressive, constant, chronic headaches that the examiner opined were not congruent with the typical course of post-traumatic headaches associated with mild TBI. The examiner ultimately determined that the Veteran had a mild TBI without any residuals. (The Board notes that the examiner was fully aware that the Veteran had been granted service connection for TBI with migraine headaches, but the examiner did not find that diagnosis consistent with his current examination.) The examiner determined that the Veteran's current migraine headaches at least as likely as not had onset during active duty service, but are less likely as not a result or residual of in-service head trauma based on the available records for review and medical literature review. The examiner did not, however, render an opinion regarding the most likely etiology of the Veteran's headaches. He noted that service treatment records document headaches. He also noted the October 2010 treatment record in which the Veteran complained of headaches since 2008 after deployment. The examiner also noted a November 2010 Department of Defense neurosurgery consultation that shows the Veteran reported experiencing daily headaches described as stabbing pain in her left temple and in a left periorbital location. This was associated with left temporal hyperesthesia and occasional blurring of vision in her left eye. She noted no days without headache and some days that were quite intense. The assessment was that the Veteran had two independent issues. The first was her cervical spondylosis, which quite likely was responsible for her left arm paresthesias and tricep weakness. The neurosurgeon concluded that it was unlikely, however, that her headaches were related to her cervical spine pathology given their location and quality. The Veteran had some characteristics suggestive of temporal arteritis (location/temporal hypersensitivity/visual changes). A private March 2013 primary care treatment record provides that the Veteran's "clinical presentation of left-sided paresthesias in the setting of her headaches is consistent with complicated migraine." It was noted that a February 2013 brain MRI revealed findings consistent with a chronic migraine sufferer. The MRI showed suspected chronic small vessel ischemic change that can be seen with vasculitis, demyelination, or in association with chronic migraine headaches. March 2014 and August 2014 private treatment records document headaches and numbness of the left side. An October 2015 private record from a provider in Germany states that the Veteran is a pain patient at the office. The diagnoses include migraine headaches, neuropathic pain syndrome, radiculopathy, and lumbago. Analysis Resolving doubt in favor of the Veteran, the Board finds that the evidence, as a whole, supports finding that the manifestations and/or symptoms of migraine headaches were present in service. See DeLisio v. Shinseki, 25 Vet. App. 45, 56(2011) (holding that "entitlement to benefits for a disability or disease does not arise with a medical diagnosis of the condition, but with the manifestation of the condition and the filing of a claim for benefits for the condition" (citing 38 U.S.C. § 5110(a)). The Board finds further that the Veteran's migraine headaches are not a manifestation or residual of her TBI, and should be service connected on a direct basis. The Board acknowledges that the cause of the Veteran's headaches is unclear. Nonetheless, the Board finds the opinion of the January 2013 VA examiner to be highly probative concerning the matters at hand. The examiner found that the Veteran's current migraine headaches most likely had their onset during active duty service, and were most likely not related to the Veteran's TBI. The examiner based his opinions on a very comprehensive review of the Veteran's medical records and the medical literature. With respect to the Veteran's left-sided numbness, the Board finds that medical evidence subsequent to the June 2009 VA examination shows that the Veteran has a diagnosis of left-sided numbness of the face, arm, hand, and upper body. Resolving doubt in favor of the Veteran, the Board finds further that the Veteran's left-sided numbness is caused by either her service-connected degenerative disc disease of the cervical spine and/or migraine headaches. The Board again acknowledges that the cause of the Veteran's left-sided numbness is unclear. For example, when the Veteran was evaluated extensively after her December 2003 in-service injury, physicians could not find an objective cause for the Veteran's numbness. Finally, after ruling out other possible causes, a neurologist determined in February 2005 that the Veteran's symptoms were most likely the consequence of her cervical spondylosis. In September 2008, it was found, without performing imaging tests, that the Veteran's symptoms were consistent with C-6 nerve impingement. In May 2009, the Veteran's VA physician explained that the Veteran has a combination of a bulging disc and arthritis that sometimes causes numbness in the arms. In November 2010, a neurosurgeon opined that it was quite likely that the Veteran's spondylosis was responsible for her left arm paresthesias and tricep weakness. In contrast, a March 2013 primary care provider found that the Veteran's clinical presentation of left-sided paresthesias was consistent with complicated migraine. While the precise etiology of the Veteran's left-sided numbness is unclear, the Board finds that that the evidence, as a whole, supports finding that it is secondary to either her cervical disability or migraine headaches. In sum, after consideration of the lay and medical evidence of record, the Board finds that service connection of migraine headaches on a direct basis is warranted. 38 C.F.R. §§ 3.102, 3.303 (2015). The Board finds further that service connection of left side numbness of the face, arm, hand, and upper body as due to the Veteran's service-connected degenerative disc disease of the cervical spine and/or migraine headaches is warranted. 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). ORDER Entitlement to service connection for migraine headaches is granted. Entitlement to service connection for left side numbness (face, arm, hand, upper body), including on a secondary basis, is granted. REMAND Although the Board regrets the additional delay, the Board finds that further development is needed prior to disposition of the Veteran's claims for service connection of a bilateral eye condition, reactive airway disease, and a skin condition. Bilateral Eye Condition The Veteran seeks service connection for a bilateral eye condition. The Veteran testified at her September 2015 Board hearing that she has conjunctivitis and dry eyes. Her dry eyes began when she was in Iraq. She was prescribed eye drops for environmental exposure. Her dry eyes have been consistent since Iraq and she continues to use eye drops. If she stares at the computer too long, is outside, or is driving, her eyes get really dry, blurry, and ache. Hearing Transcript at 13. An April 2008 pre-deployment eye examination shows the Veteran was wearing over-the-counter reading glasses that helped with blurred near vision. She had no other complaints. The Veteran was diagnosed with a refractive error (hypermetropia) and presbyopia. The Veteran was given a prescription for trifocals for use at the computer and at near distances. A May 2008 Iraq service treatment record shows the Veteran complained of decreased computer vision with her current glasses that were only two months old. Eye trauma was denied. There was no note of pain, redness, or other irritation of the eyes. The diagnosis was presbyopia. A later May 2008 record shows the Veteran reported that she had had redness of the right eye for three weeks. She also reported that 48 hours earlier her left eye had been hit by a seat belt. There was mild tenderness of the inferior lid. The assessment was normal ocular health in both eyes. It was recommended that the Veteran use artificial tears three times a day in both eyes based on environment exposures and for UV protection. In July 2008, the Veteran reported having bloodshot eyes for approximately four weeks, with her right eye being itchy. This was combined with a feeling of her ears being underwater and a sore throat for seven days. The assessment was allergic rhinitis. She was prescribed multiple medications, including Refresh eyedrops. A September 2008 service treatment record shows the Veteran complained of bloodshot eyes for six months. No eye examination was performed; however, the Veteran was prescribed Refresh Plus eye drops. The Veteran's September 2008 Post-Deployment Health Assessment shows the Veteran reported red, itchy eyes. At an October 2008 post-deployment Soldier Readiness Check, the Veteran reported an eye injury, but no other eye disorders. An April 2009 VA Deployment & Environmental Health Consult Report shows that the Veteran reported some chronic redness in the left eye. At a June 2009 VA eye examination, the Veteran reported being diagnosed with presbyopia that had existed for eight years. The Veteran reported pain, redness, sensitivity to light, and blurred vision. The Veteran was diagnosed with presbyopia, and a small, benign papilloma on the left lower lid that was causing no problem. A June 2009 VA optometry note shows the Veteran complained of blurry vision at all distances in both eyes that was slowly progressing. She was using over-the-counter reading glass for near and intermediate distances. The Veteran reported a history of redness, which looked like broken blood vessels, since Iraq with slight itchiness. There was a history of exposure to sandstorm and a burning garbage environment. She also was hit by a seat belt in 2008 in Iraq with "dull achy pain, stable, constant." On examination, the conjunctiva had no abnormalities and there was no note of redness or dry eyes.. The assessment was refractive error in the right and left eyes, presbyopia; angle recession of the right eye that does not impact intraocular pressure; and choroidal nevus of the left eye. A September 2010 military optometry treatment record shows a chief complaint of "medical progress." The conjunctiva bulbar, cornea, and tearfilm were recorded as within normal limits. There was a note that "[e]dema in the conjunctival potential space - better but still there." The diagnoses were conjunctivitis, unspecified, and conjunctiva, degeneration, pinguecula. The assessment was to continue Lotemax four times a day. A March 2015 after visit summary provided to the Veteran by a private provider shows diagnoses this visit of dry eye syndrome, bilateral (primary); cataract incipient, senile, left; blepharitis, unspecified laterally; and posterior vitreous detachment, left. The Veteran has been diagnosed with several different eye conditions since the time of the June 2009 VA examination. Therefore, the Board is of the opinion that a VA examination, including a medical opinion, would be helpful in resolving the issues raised by the instant appeal. As such, this case is remanded for a new VA eye examination to consider whether any of the Veteran's currently diagnosed eye conditions are etiologically related to the Veteran's service, including as a result of her service from April 2008 to October 2008 in Iraq. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005) (stating that VA has discretion to schedule a veteran for a medical examination where it deems an examination necessary to make a determination on the veteran's claim); Shoffner v. Principi, 16 Vet. App. 208, 213 (2002) (holding that VA has discretion to decide when additional development is necessary). Reactive Airway Disease The Veteran seeks service connection for reactive airway disease claimed as a respiratory condition with coughing and difficulty breathing. At her September 2015 Board hearing, the Veteran testified that her respiratory condition started when she was in Iraq. She had pneumonia and chronic bronchitis. She coughed uncontrollably. She reported being very ill and was prescribed an inhaler. The Veteran testified that she has been diagnosed with chronic bronchitis, asthma, and COPD. Hearing Transcript at 15. An April 2008 Iraq service treatment record shows the Veteran complained of post-nasal drip, a sore throat, and a non-productive cough for three days. She also had watery stools for one day. The assessment was acute upper respiratory infection. A later April 2008 service treatment record shows the Veteran had a second visit for the same respiratory condition. She was still blowing her nose, was coughing to the point of no sleep, and had nasal drainage. Her ears felt like she was underwater. Her chest hurt from coughing and it was hard to breath. Her symptoms started after a two-day sandstorm. The assessment was upper and lower respiratory symptoms with congestion/sinus pressure and cough. Antibiotics were used to treat the persistent/worsening sinus/cough symptoms. A July 2008 treatment record shows the Veteran reported having bloodshot eyes for approximately four weeks, with her right eye being itchy. This was combined with a feeling of her ears being underwater and a sore throat for seven days. The assessment was allergic rhinitis. Although it is difficult to read, the Veteran's September 2008 Post-Deployment Health Assessment appears to show that the Veteran checked that she had gone to sick call for a cough lasting more than three weeks and trouble breathing, but that they were not bothering her still. The Veteran did not add any specific concerns about a respiratory condition or her breathing. At an October 2008 post-deployment Soldier Readiness Check, the Veteran reported acute problems with coughing. On her October 2008 Report of Medical Assessment, the Veteran noted that she had been treated for upper respiratory since her last examination An April 2009 VA Deployment & Environmental Health Consult Report shows that the Veteran reported that she "developed respiratory issues and had chronic cough and shortness of breath much of the time she was deployed. It was a productive cough and she is not a smoker." At the June 2009 VA examination, the Veteran reported that her respiratory condition began in 2008. It was noted that the Veteran was exposed to burning garbage, sandstorm, pollution, pesticides, depleted uranium, and various insects while she was in Iraq. The examiner diagnosed the Veteran with reactive airway disease based on the history reported by the Veteran. However, the examiner did not find any objective factors of an airway disease. The Veteran's pulmonary function tests and chest x-ray were normal. A July 2009 VA treatment record shows a diagnosis of bronchitis. A May 2010 private treatment record shows a lung function diagnostic performed in Germany was interpreted as "moderately severe obstruction, partially reversible." A photocopy of a May 2010 prescription includes a handwritten note that states in English "for the control of COPD which developed after breathing in air from burning garbage and sandstorms in Iraq from APR-OCT 2008." The author of this note is unknown. An August 2010 military treatment record shows the Veteran was taking medications for asthma and allergy. The assessment includes asthma, unspecified, mild. In September 2010, a permanent physical profile was put in place due to cervical degenerative disc disease and COPD. A March 2013 private treatment record shows the Veteran has a diagnosis of COPD. In September 2015, the Veteran submitted a copy of a record entitled "Environmental/Occupational Health Workplace Exposure Data" that includes an assessment for individuals deployed to Sather AB, Baghdad International Airport in Iraq from June 1 to September 30, 2008. With respect to airborne dust, it provides the following environmental exposure data and risk assessment: The level of airborne particulate matter is high at Sather AB due to wind blown dust and sand. Acute health effects associated with exposures to airborne particulates include eye, nose, and throat irritation, sneezing, coughing, sinus congestion and drainage, and aggravation of asthma conditions. Long-term/chronic effects have not been specifically determined, though attribution has been made to increased potential for asthma. Based on air sampling performed at Sather AB in May 03 and Jun-Aug 04, airborne concentrations of PM 10 (particulate matter with diameters less than 10 microns) ranged from 120 to 512 µg/m3 and exceed the US Army Military Exposure Guideline (MEG-Air) for a 1-year period. Manganese, detected at 0.8 µg/m3 also exceeded the 1-year MEG. The hazard severity for the PM 10 and manganese was assessed to be negligible by the US Army Center for Health Promotion and Preventive Medicine (USACI-IPPM). Note: the MEGs are based on an exposure duration of one year (360 days nominal); most, if not all, USAF deployments are 120 days or less, making the MEG a very conservative limit. With respect to airborne emissions from petroleum production/other nearby industrial/disposal activities, the record provides the following environmental exposure data and risk assessment: There are multiple industrial activities near Sather AB. Chemical storage and processing plants are located within 5-10 miles, primarily to the east and south. However, operations at these facilities have been severely limited as consequence of combat activities in/around BIAP. Multiple industrial activities, to include manufacturing, construction, and petroleum refining are located in the greater Baghdad metropolitan area. With the prevailing winds from the northwest, Sather AB is located downwind from only a few industrial activities, primarily light to medium manufacturing facilities. Army units on BIAP burn trash/garbage, notably upwind of Sather AB at Log Base Seitz. These burns on RIAP are at significant distances from Sather AB; however the potential health risk is unknown. Since the time of the June 2009 VA examination when the examiner did not find any objective evidence of an airway disease, the medical evidence of record shows diagnoses of COPD, asthma, bronchitis, and allergies pertaining to the Veteran. The Veteran has also submitted potentially relevant evidence concerning environmental exposures she may have encountered in Iraq and their effect on respiratory conditions. Therefore, the Board is of the opinion that a VA examination, including a medical opinion, would be helpful in resolving the issues raised by the instant appeal. As such, this case is remanded for a new VA examination to consider whether any of the Veteran's currently diagnosed respiratory conditions are etiologically related to the Veteran's service, including as a result of her service from April 2008 to October 2008 in Iraq. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005); Shoffner v. Principi, 16 Vet. App. 208, 213 (2002). In addition, because the existing record does not clearly document where the Veteran was stationed in Iraq, the RO should identify the Veteran's duty station. Skin condition The Veteran seeks service connection for a skin condition. At her Board hearing, the Veteran testified that she is fair complected, and the intense sunshine in Iraq really affected her skin. She saw a dermatologist and had skin growths and cysts removed, and has discoloration of the skin. See September 2015 Hearing Transcript at 10. The dermatologist diagnosed the Veteran with cysts and overactive skin growth brought on by years of exposure to the sun and then intense exposure of the sun when she was in Iraq. She has to put cream on her skin. Id. at 11. The Veteran's September 2008 Post-Deployment Health Assessment shows the Veteran reported bumps on her face. At the June 2009 VA examination, the Veteran reported her skin condition began in 2008 and involves areas of the skin that are exposed to the sun. She noted bumps and discoloration on the face, neck, hands, and arms; exudation face bumps; shedding face bumps; and arm spots. The examiner diagnosed the Veteran with superficial acne of the face. On examination, the acne was characterized as superficial cysts covering one percent of the face and neck. An August 2010 military dermatology note shows that the Veteran reported that "she developed multiple growths on the face over the past several years." She also reported progressive discoloration of the skin on the back of the forearms. On examination, the Veteran was found to have multiple white to creamy yellow papules with central umbilication on the face. A 1 millimeter firm white papule overlying the right lateral orbital rim was also found. Mottled hyper- and hypopigmentation on the dorsum of the bilateral forearms and arms was found. There was a sharp cutoff at the mid upper arm. There were no lesions on the ear or neck. The Veteran was diagnosed with sebaceous gland disorder hyperplasia and skin color and pigmentation. A single milum on the right lateral orbital was expressed at that visit. The Veteran was prescribed a topical cream. September and October 2010 military dermatology notes show the Veteran's sebaceous hyperplasia on the face was treated with hyfrecation. In October 2010, a skin tag was removed from the left lower eyelid. A billing statement from a German provider shows that the Veteran received dermatologic care in January and February 2014. The document was sent for translation, but unfortunately was largely illegible. The portion of the document that was legible shows services were performed by a dermatologist. In March 2016, the Veteran submitted a letter from the same dermatologist that has been translated by an unknown source. It shows that the Veteran has been diagnosed with angioma, sebaceous gland hyperplasia, seborrhea, and acne tarda. It continues as follows: [The Veteran] is skin type 1 high sensitivity to UV light and therefore UV-related skin damage. The patient should, in order to prevent light damage, avoid the direct sunlight, and apply sunscreen with a high SPF and consistently sun protection clothing. Again, given that the Veteran has been diagnosed with additional skin conditions since the time of the June 2009 VA examination, the Board finds that a VA examination, including a medical opinion, would be helpful in resolving the issues raised by the instant appeal. As such, this case is remanded for a new VA examination to consider whether any of the Veteran's currently diagnosed skin conditions are etiologically related to the Veteran's service, including as a result of her service from April 2008 to October 2008 in Iraq. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005); Shoffner v. Principi, 16 Vet. App. 208, 213 (2002). Accordingly, the case is REMANDED for the following action: 1. Obtain personnel records as are necessary to identify the Veteran's duty station while she was stationed in Iraq from April 2008 to October 2008. 2. After the above development has been completed, schedule the Veteran for a VA eye examination with an appropriate examiner competent to identify and determine the etiology of any current eye conditions the Veteran may exhibit, including as due to environmental exposures the Veteran may have encountered during her service in Iraq. The electronic claims file and a copy of this remand must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. After the record review and a thorough examination and interview of the Veteran, the VA examiner is asked to respond to the following: (a) Identify all current eye conditions, bilateral or otherwise, applicable to the Veteran. In this regard, the Board notes that during the period on appeal the Veteran has been variously diagnosed with presbyopia; a refractive error (hypermetropia); a small, benign papilloma on the left lower lid; angle recession of the right eye that does not impact intraocular pressure; choroidal nevus of the left eye; conjunctivitis, unspecified; conjunctiva, degeneration, pinguecula; dry eye syndrome, bilateral; cataract incipient, senile, left; blepharitis, unspecified laterally; and posterior vitreous detachment, left. The Board also notes that in May 2008 the Veteran was hit by a seat belt in the left eye. (b) For each eye condition diagnosed, provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that such eye condition was incurred in, caused by, or etiologically related to the Veteran's service, including as due to environmental exposures the Veteran encountered during her active duty service in Iraq from April 2008 to October 2008 such as wind blown dust and sand, bright sunlight, etc., given the nature, complexity, and natural trajectory of the condition and when it was diagnosed. In rendering the above opinions, if it is shown that the Veteran had service at Sather AB, the examiner is to consider and discuss the relevance to the Veteran of a document entitled "Environmental/Occupational Health Workplace Exposure Data" that includes an assessment for individuals deployed to Sather AB from June 1 to September 30, 2008. The record is located in the Veteran's Veteran Benefits Management System (VBMS) electronic claims files with a receipt date of 09/14/2015 at page 26. All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached must be provided. If the examiner believes that an opinion cannot be provided without resorting to speculation, then he/she must provide a detailed medical explanation as to why this is so. 3. After the development in paragraph 1 above has been completed, schedule the Veteran for a VA examination with an appropriate examiner competent to identify and determine the etiology of any current respiratory conditions the Veteran may exhibit, including as due to environmental exposures the Veteran may have encountered during her service in Iraq. The electronic claims file and a copy of this remand must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. All indicated tests and studies should be accomplished, including pulmonary function tests, and all clinical findings should be reported in detail. After the record review and a thorough examination and interview of the Veteran, the VA examiner is asked to respond to the following: (a) Identify all current respiratory conditions applicable to the Veteran. In this regard, the Board notes that during the period on appeal the Veteran has been variously diagnosed with upper and lower respiratory symptoms/infections, allergic rhinitis, bronchitis, COPD, asthma, and allergies. . (b) For each respiratory condition diagnosed, provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that such respiratory condition was incurred in, caused by, or etiologically related to the Veteran's service, including as due to environmental exposures the Veteran encountered during her active duty service in Iraq from April 2008 to October 2008 such as burning garbage, sandstorm, pollution, pesticides, depleted uranium, and various insects, etc., given the nature, complexity, and natural trajectory of the condition and when it was diagnosed. In rendering the above opinions, if it is shown that the Veteran had service at Sather AB, the examiner is to consider and discuss the relevance to the Veteran of a document entitled "Environmental/Occupational Health Workplace Exposure Data" that includes an assessment for individuals deployed to Sather AB from June 1 to September 30, 2008. The record is located in the Veteran's Veteran Benefits Management System (VBMS) electronic claims files with a receipt date of 09/14/2015 at page 26. All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached must be provided. If the examiner believes that an opinion cannot be provided without resorting to speculation, then he/she must provide a detailed medical explanation as to why this is so. 4. After the development in paragraph 1 above has been completed, schedule the Veteran for a VA dermatology examination with an appropriate examiner competent to identify and determine the etiology of any current skin condition the Veteran may exhibit, including as due to environmental exposures the Veteran may have encountered during her service in Iraq. The electronic claims file and a copy of this remand must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. After the record review and a thorough examination and interview of the Veteran, the VA examiner is asked to respond to the following: (a) Identify all current skin conditions applicable to the Veteran. In this regard, the Board notes that during the period on appeal the Veteran has been variously diagnosed with acne, sebaceous gland disorder hyperplasia, hyper- and hypopigmentation of the skin, a skin tag, angioma, seborrhea, and acne tarda. (b) For each skin condition diagnosed, provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that such skin condition was incurred in, caused by, or etiologically related to the Veteran's service, including as due to environmental exposures the Veteran encountered during her active duty service in Iraq from April 2008 to October 2008 such as wind blown sand and dust, sunlight, etc., given the nature, complexity, and natural trajectory of the condition and when it was diagnosed. In rendering the above opinions, if it is shown that the Veteran had service at Sather AB, the examiner is to consider and discuss the relevance to the Veteran of a document entitled "Environmental/Occupational Health Workplace Exposure Data" that includes an assessment for individuals deployed to Sather AB from June 1 to September 30, 2008. The record is located in the Veteran's Veteran Benefits Management System (VBMS) electronic claims files with a receipt date of 09/14/2015 at page 26. All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached must be provided. If the examiner believes that an opinion cannot be provided without resorting to speculation, then he/she must provide a detailed medical explanation as to why this is so. 5. Readjudicate the claim after the development requested above has been completed. If any benefits sought on appeal remain denied, the Veteran and her representative should be furnished with a supplemental statement of the case and be given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if 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 2014). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs