Citation Nr: 1744177 Decision Date: 10/03/17 Archive Date: 10/13/17 DOCKET NO. 12-17 847A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a skin disability other than non-healing ulcer of the scalp. 3. Entitlement to service connection for difficulty swallowing, to include as a result of a thyroid disability. 4. Entitlement to service connection for arthritis of the bilateral hips. 5. Entitlement to service connection for residuals of a brown recluse spider bite, to include scars and bilateral arm pain and neck pain. 6. Entitlement to service connection for arthritis of the bilateral feet and toes. 7. Entitlement to service connection for arteriosclerosis (claimed as residuals of 2005 stroke). 8. Entitlement to service connection for traumatic arthritis of the neck. 9. Whether new and material evidence has been received to reopen a claim of service connection for vertigo. 10. Entitlement to an initial compensable disability rating for non-healing ulcer of the scalp. 11. Entitlement to an initial disability rating in excess of 30 percent for reactive airway disease prior to January 25, 2012, and in excess of 60 percent thereafter. 12. Entitlement to an initial compensable disability rating for hypertension. 13. Entitlement to VA benefits under 38 U.S.C.A. § 1151 for burns to the mouth. 14. Entitlement to VA benefits under 38 U.S.C.A. § 1151 for a right shoulder disability. 15. Entitlement to VA benefits under 38 U.S.C.A. § 1151 for a left shoulder disability. 16. Entitlement to VA benefits under 38 U.S.C.A. § 1151 for low back disability. 17. Entitlement to VA benefits under 38 U.S.C.A. § 1151 for a kidney disability. 18. Entitlement to VA benefits under 38 U.S.C.A. § 1151 for a neck disability. 19. Entitlement to special monthly compensation (SMC) benefits based on the need for the aid and attendance of another person. 20. Entitlement to a certificate of eligibility for assistance in acquiring an automobile and/or adaptive equipment. 21. Entitlement to a certificate of eligibility for special home adaptation. WITNESSES AT HEARING ON APPEAL The Veteran and her daughter, T.W. ATTORNEY FOR THE BOARD Cheryl E. Handy, Counsel INTRODUCTION The Veteran served on active duty from May 1974 to January 1975, from November 2005 to March 2006, and from October 2006 to December 2007, including service in Southwest Asia. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions issued in December 2008, October 2013, May 2015, December 2015 (two decisions), and June 2016 by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The December 2008 rating decision, in pertinent part, denied service connection for neck pain, hypertension, a skin condition of the scalp, low back pain, and difficulty swallowing. The October 2013 rating decision denied entitlement to special home adaptation and specially adapted housing. The May 2015 rating decision, in pertinent part, granted service connection for reactive airway disease and assigned a 30 percent disability rating effective December 14, 2007 and a 60 percent disability rating effective January 25, 2012, and granted service connection for hypertension and assigned a noncompensable (0 percent) disability rating as of December 14, 2007. The first December 2015 rating decision granted service connection for a non-healing ulcer of the scalp and assigned a noncompensable disability rating as of December 17, 2007. The second December 2015 rating decision denied VA benefits under 38 U.S.C.A. § 1151 for burns to the mouth, a kidney disability, a bilateral shoulder disability, a neck disability, and a low back disability, as well as entitlement to an automobile allowance or adaptive equipment and entitlement to SMC benefits based on the need for the aid and attendance of another person or housebound status. The June 2016 rating decision denied service connection for arthritis of the bilateral hips, arthritis of the bilateral feet and toes, and residuals of a brown recluse spider bite (claimed as bilateral arm and neck pain). The Veteran appeared at a hearing at the RO and offered testimony before a Decision Review Officer (DRO) in March 2010. A transcript of that hearing is included in the claims file. In September 2013 the Veteran appeared at a hearing and offered testimony before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is also included in the claims file. This case was previously before the Board in June 2016, at which time it was remanded for further development with respect to the claims of service connection for a skin disability, a low back disability, and difficulty swallowing, as well as the for the claims for increased initial disability ratings for reactive airway disease and hypertension. The remand directives included scheduling the Veteran for VA examinations of her skin disabilities, her back disability, her difficulty swallowing, and her hypertension, as well as obtaining treatment records for emergency room treatment of the Veteran's reactive airway disease from 2011 to 2012, and issuance of a statement of the case with respect to her scalp ulcer increased rating claim and her claim of entitlement to automotive or adaptive equipment. As the requested development has been completed, no further action to ensure compliance with the remand directive is required. Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that the Veteran's claim for entitlement to a certificate of eligibility for special home adaptation has been considered under that basis, as well as treated as a claim of entitlement to a certificate of eligibility for specially adapted housing, and as claims for both benefits in the alternative. (See Rating Decision, received 10/26/2013, p. 1.) A review of the record shows that the Veteran specifically applied for special home adaptation to the home she already owns. (See Application, received 12/09/2011, p. 1.) For this reason, the Board finds that the claim should be limited to that basis and the issues on appeal have been restyled accordingly. An August 2016 rating decision denied service connection for vertigo, neck arthritis and arteriosclerosis, claimed as residuals of a 2005 stroke. That same month the Veteran submitted a VA Form 9 attempting to appeal that rating decision. However, effective March 24, 2015, a notice of disagreement must be submitted on a prescribed form VA 21-0958. As the rating in question was issued after this date, the Veteran would have been sent the appropriate form with which to initiate an appeal. Because this form was not used, the notice of disagreement must be considered invalid. Those issues will not be considered further in this decision. If she so desires, the Veteran may attempt to reopen those claims. Finally, the issues of entitlement to VA benefits under 38 U.S.C.A. § 1151 for burns to the mouth, for a right shoulder disability, for a left shoulder disability, for a low back disability, for a kidney disability, and for a neck disability are REMANDED to the AOJ pending the outcome of associated civil litigation. The issue of entitlement to service connection for a low back disability is also REMANDED as inextricably intertwined with the low back disability claim under 38 U.S.C.A. § 1151. FINDINGS OF FACT 1. Affording the benefit of the doubt, the Veteran's skin disabilities of actinic keratosis and idiopathic guttate hypomelanosis are found to have had their onset in service. 2. The Veteran's dysphagia was manifested in service. 3. The Veteran's bilateral hip arthritis was initially diagnosed within the first year after service separation. 4. The preponderance of the evidence does not demonstrate that the Veteran has arthritis of the feet and toes as a result of her military service. 5. The Veteran's non-healing ulcer of the scalp is not shown to be disfiguring, does not result in frequent loss of skin covering, does not represent greater than 5 percent of the exposed body surface, and does not require the use of systemic corticosteroids or other immunosuppressants. 6. The Veteran's reactive airway disease required only intermittent use of bronchodilators prior to January 25, 2012, and daily use of them after that time; at no time has the Veteran's pulmonary function testing showed FEV-1 or FEV-1/FVC values of less than 40 to 55 percent nor has she required systemic use of corticosteroids or other immunosuppressants. 7. The Veteran's hypertension requires the use of continuous medication for control but has no demonstrated history of diastolic pressures that were predominantly 100 or greater. 8. The Veteran is shown to require the aid and attendance of another person to assist with bathing, grooming, dressing, housekeeping, and shopping as a result of service-connected disabilities including arthritis in her hands. 9. The Veteran is not service connected for a disability manifested by: loss or permanent loss of use of one or both feet, loss or permanent loss of use of one or both hands, permanent impairment of vision of both eyes or a severe burn injury; nor is she service connected for disability manifested by ankylosis of one or both knees or one or both hips. 10. The Veteran currently has a combined disability rating of 100 percent for disabilities, which are permanent in nature and which preclude locomotion without the aid of braces, crutches, canes, or a wheelchair, in addition to a respiratory disability which is permanent and is rated as 60 percent disabling. CONCLUSIONS OF LAW 1. The criteria for service connection for the skin disabilities of actinic keratosis and idiopathic guttate hypomelanosis have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2016). 2. The criteria for service connection for dysphagia have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2016). 3. The criteria for service connection for bilateral hip arthritis have been met. 38 U.S.C.A. §§ 1110, 1116, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2016). 4. The criteria for service connection for arthritis of the feet and toes have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2016). 5. The criteria for an initial compensable disability rating for a non-healing ulcer of the scalp have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.118, Diagnostic Code 7816 (2016). 6. The criteria for an initial disability rating for reactive airway disease higher than 30 percent prior to January 25, 2012, and higher than 60 percent thereafter have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.97, Diagnostic Code 6602 (2016). 7. The criteria for an initial compensable disability rating for hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.104, Diagnostic Code 7101 (2016). 8. The criteria for entitlement to SMC based on the need for the aid and attendance of another person have been met. 38 U.S.C. §§ 1114 (l), (s), 1502, 1521, 5107(b) (West 2014); 38 C.F.R. §§ 3.350 (b), (i), 3.352(a) (2016). 9. The criteria for entitlement to a certificate of eligibility for an allowance for automobile and/or adaptive equipment have not been met. 38 U.S.C.A. §§ 3901, 3902 (West 2014); 38 C.F.R. § 3.808 (2016). 10. The criteria for entitlement to a certificate of eligibility for special home adaptation have been met. 38 U.S.C.A. §§ 2101 (a), (b), 5107 (West 2014); 38 C.F.R. §§ 3.350 (a), 3.809 (a) (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist VA notified the Veteran of the evidence and information necessary to substantiate her claims in April 2012. Concerning the duty to assist, all identified, pertinent treatment records have been obtained and considered. These include records from both of the periods of service as well as VA treatment and private treatment since service separation. The Veteran has undergone multiple VA examinations related to the disabilities on appeal. See VA examinations from March 2008, May 2008, June 2008, October 2009, December 2010, March 2012, April 2013, August 2015, October 2015, May 2016, and September 2016. She has asserted that the August 2015 VA examination of her skin disabilities was inadequate and the examination report was filled with errors and falsifications. As a result, the Board remanded and required a new VA examination, which was performed in September 2016. There is no argument or indication that any of the other examinations are inadequate or that their findings do not reflect the current severity of the disability. The record also contains numerous Disability Benefits Questionnaires (DBQs) completed by qualified providers which address the disabilities on appeal. In sum, there is no additional notice or assistance that would be reasonably likely to aid in substantiating the Veteran's issues on appeal. As such, the Board will proceed with consideration of the Veteran's appeal. Evidentiary Standards VA must give due consideration to all pertinent medical and lay evidence in a case where a Veteran is seeking service connection. 38 U.S.C.A. § 1154(a). Competency is a legal concept in determining whether medical or lay evidence may be considered, in other words, whether the evidence is admissible as distinguished from weight and credibility, a factual determination going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. The Board, as fact finder, must determine the probative value or weight of the admissible evidence. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005) (citing Elkins v. Gober, 229 F.3d 1369, 1377 (Fed. Cir. 2000) ("Fact-finding in veterans cases is to be done by the Board")). When there is an approximate balance of positive and negative admissible evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). I. Service Connection Claims Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All three elements must be established by competent and credible evidence in order that service connection may be granted. Certain chronic diseases, which are listed in 38 C.F.R. § 3.309 (a), including arthritis, may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires (1) competent evidence (a medical diagnosis) of current chronic disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Facts and Analysis Skin Disability The Veteran seeks service connection for various skin disabilities, which claim has at different times in the adjudication been treated as a claim for only a condition of the scalp other than the non-healing ulcer, which is already service connected. As noted in the Board remand in June 2016, the claim is more appropriately characterized as a broader "skin disability" claim. The Veteran has identified specific skin afflictions for which she believes service connection should be granted and the Board remand in June 2016 asked that the VA examiner identify those conditions which are manifested and provide opinions with respect to them. In addition, the Board will discuss the disabilities shown on the various examinations as well as the specific conditions for which the Veteran has made consistent claims. Should the Veteran wish to raise the issue of entitlement to any skin disability not discussed herein, she is invited to file a specific claim for such disability. At the VA examination in March 2008, the Veteran reported that she had dermatitis in her scalp. (See VA Exam, received 03/12/2008, p. 4.) At the VA examination in May 2008, the Veteran described an itchy scalp rash that was present since an MRI was performed in December 2007. (See VA Exam, received 05/29/2008, p. 1.) She used a medicated shampoo three times per week and a topical solution to relieve itching as needed. She felt that her hair was falling out because of her scalp condition and that she had large abnormal bumps on her head. (p. 2.) She reported symptoms of itching and pain. Physical examination showed no skin abnormalities of the scalp and the examiner stated that the Veteran was clearly shaving her frontal scalp hair because all of the short hairs were exactly the same length. She did have a patch of short hairs of varying lengths on the vertex scalp. The examiner diagnosed a normal scalp and trichotillomania, stating that the Veteran's hair abnormalities were self-induced. The Veteran was seen in November 2011 for complaints of lesions on her face and was requesting a diagnosis of the lesions on her scalp in order to facilitate ordering an oral antifungal medication. (See CAPRI, received 07/14/2015, p. 775.) She reported that she had undergone two punch biopsies of the scalp that had not healed; these had revealed focal actinic keratosis and chronic inflammation/fibrosis. The provider took bacterial and fungal cultures and provided a diagnosis of possible neurotic excoriation. A DBQ completed in July 2012 noted that the Veteran had a diagnosis of alopecia in addition to the prurigo nodules, with a date of diagnosis listed as March 2008. (See DBQ, received 07/06/2012, p. 1.) She had been treated constantly with an antibiotic cream for her scalp ulcer. (p. 3.) The provider noted infections of the skin affected less than 5 percent of the approximate total body area affected. (p. 4.) The provider also noted a diagnosis of alopecia areata with hair loss limited to the scalp and face. (p. 4.) In August 2012, the Veteran was seen for complaints regarding recurrent knots on her scalp over the past four or five years. (See CAPRI, received 07/14/2015, p. 668.) She had been informed by a dermatologist that the condition was benign, but was upset that no one had been able to treat it. She had treated it herself with an antifungal cream and seen improvement, but was concerned that there was a crater on her scalp that was pulsating and causing pain. The provider noted that an examination of the scalp was normal. (p. 669.) Correspondence between the Veteran and the provider shortly thereafter included the provider's statement that he had examined the Veteran's scalp at that visit and had reassured her that he had not found anything abnormal. (p. 651.) A DBQ submitted in September 2012 noted that the Veteran had been diagnosed with vitiligo and prurigo nodules in December 2010 and alopecia and fibrosis in March 2008. (See DBQ, received 12/27/2012, p. 1.) The provider noted that she had vitiligo which affected exposed areas of her skin and had alopecia which was limited to the hair on her face and scalp. (p. 5.) At the Board hearing in September 2013 the Veteran testified that she had a skin disability characterized by abnormally thickened skin, similar to an orange peel. (See Legacy Content Manager Documents (LCMD), Hearing Transcript, received 02/08/2014, p. 34.) She testified that this was related to her chemical exposure in Afghanistan and as a complication of her thyroid disability and possibility related to retention of gadolinium in her brain subsequent to an MRI. (p. 36.) A VA examination in August 2015 noted that the Veteran had a diagnosis of folliculitis, which had resolved. (See DBQ, received 08/28/2015, p. 1.) The examiner noted that the Veteran reported scalp infection and pruritus all over her body, for which she had been treated at the emergency room. (p. 2.) No current skin disability was diagnosed. The examiner noted that the Veteran's nonhealing ulcer of the scalp had been manifested in service, with evidence of treatment following deployment to Afghanistan. (See C&P Exam, received 08/28/2015, p. 50.) The examiner stated that all of the Veteran's other skin disorders had occurred or developed post-service. In a statement submitted in January 2016, the Veteran reported that she had shown the VA examiner her bald spots when she was asked about alopecia. (See Statement in Support, 01/11/2016, p. 1.) She said that the doctor had not looked at her scalp, but had said in the report that the Veteran's skin disability had resolved. The Veteran's daughter also submitted a statement in January 2016 about the VA examination, which she had observed. (See Buddy/Lay Statement, received 01/11/2016, p. 1.) She stated that the examiner did not ask any questions concerning the Veteran's skin disabilities, which the daughter assumed was because they were obvious and visible. She included photos of the Veteran, including one which she stated showed a bald patch on the right side of the Veteran's head which extended all the way back to the non-healing ulcer; she stated that there was one on the other side as well. (p. 7.) In a statement submitted in April 2016, the Veteran discussed her skin disabilities. (See Correspondence, received 04/12/2016, p. 15.) She specifically discussed vitiligo (permanent white patches of destroyed skin pigment), rosacea (red patches), alopecia (bald spots). She also mentioned folliculitis and prurigo, as well as fibrosis of the skin. She asserted that fibrosis of the face and scalp had been diagnosed within one year of service separation. (p. 27.) She also asserted that folliculitis as a result of her hypothyroidism was an active and ongoing medical problem associated with the underlying autoimmune disease. Finally, she asserted that alopecia on her scalp was visible and was a result of her fibrosis, and that the fibrosis was not confined to her scalp but had caused non-healing ulcers on her feet and fibrosis on areas of her face. (p. 28.) At the September 2016 VA examination, the Veteran reported that while she was in Afghanistan, she worked around many different chemicals. (See LCDM, C&P Exam, received 09/20/2016, p. 6.) She specifically named depleted uranium, which she stated was stored in the detention center where she worked and which was used in all bullets used at the detention center. She stated that, as a nurse, she cared for wounded people who had been shot with bullets laced with depleted uranium. She also stated that her rosacea had begun in service in 2007 while in Afghanistan, when redness and bumps presented on her face. She said that her vitiligo had also begun in 2007, first noticed on her face and arms before spreading to her legs and trunk. (p. 7.) She reported a diagnosis of vitiligo from the VA dermatology clinic, although the medical treatment records showed no such diagnosis, and instead listed idiopathic guttate hypomelanosis. She stated that her folliculitis began in April 2007 after her diagnosis with thyroid problems and reported that she had "male pattern hair loss" which was attributed by providers to the fact that she had to wear ball caps for a year while in the military. On physical examination, the examiner evaluated the Veteran's scalp, face, neck, bilateral upper extremities including the hands, back, chest above bra, abdomen below bra, and bilateral lower extremities. (See LCDM, C&P Exam, received 09/20/2016, p. 8.) Findings on examination showed decreased hair density over the bilateral junction of the frontal and temporal hairline, with normal hair density over other areas of scalp, including the vertex. Some sparse canities were also noted. The Veteran had telangiectatic patches over bilateral cheeks with few erythematous papules, as well as erythematous, scaly macules over her face and cheeks. There were excoriations but no primary lesions noted over her anterior neck. There was also a skin-colored papule with central punctum, about 0.8 cm in size, on her right lateral neck. The examiner noted hypopigmented macules, about 0.2 to 0.4 cm in size, over her bilateral proximal upper extremities and bilateral calves. The examiner discussed the applicable diagnoses for the skin disabilities noted on examination. (See LCDM, C&P Exam, received 09/20/2016, p. 9.) Her hair loss was determined to be due to mild androgenetic alopecia, which was not shown on medical treatment as recently as November 2011. For this reason, the examiner offered the opinion that the Veteran's androgenetic alopecia did not have its onset in service or any incident therein. Androgenetic alopecia is an inherited predisposition to a specific pattern of hair loss and is not affected by wearing ball caps or by exposure to any external chemicals. The examiner also diagnosed mild rosacea, which was not likely due to service or manifested in service. The examiner diagnosed actinic keratosis, but was unable to offer an opinion on causation without resorting to speculation, because this disability is the result of sun exposure, which was present both during the Veteran's service in Afghanistan and in her post-service life in Houston. The examiner diagnosed excoriations without primary lesions on the neck, which were not due to service or manifested therein. A diagnosis of idiopathic guttate hypomelanosis was also provided, with the examiner stating that no opinion on causation could be offered without resorting to speculation, because this was caused by sun exposure, which was present both during the Veteran's service in Afghanistan and in her post-service life in Houston. The examiner found no evidence of vitiligo or prurigo on examination. (p. 11.) After considering all of the evidence of record, to include that set forth above, the Board finds that service connection is warranted for the diagnoses of actinic keratosis and idiopathic guttate hypomelanosis. Specifically, the Veteran has reported that these skin disabilities had their onset in 2007 while she was serving in Afghanistan. The September 2016 VA examiner was unable to offer an opinion on causation of these disabilities because they are caused by sun exposure, which occurred both in service in Afghanistan and after service separation in Houston. Applying the benefit of the doubt, the Veteran's skin disabilities of actinic keratosis and idiopathic guttate hypomelanosis are found to have had their onset in service. The Veteran in March 2008 had asserted dermatitis, which was not found on the examination. In August 2012 she sought treatment for recurrent knots on her scalp, but the provider found a normal scalp on examination. The Veteran has asserted on multiple occasions that she has vitiligo and that such was diagnosed in December 2010. However, the record shows that what the Veteran believed to be vitiligo was actually idiopathic guttate hypomelanosis, for which service connection is granted herein. The Veteran has also claimed alopecia on multiple occasions, but the VA examination September 2016 concluded that this was actually a manifestation of a hereditary baldness pattern. The Veteran has asserted a diagnosis of folliculitis, which is not shown in the record and was not shown on the August 2015 or September 2016 VA examination. The Veteran has also asserted entitlement to service connection for rosacea, which was found on the September 2016 VA examination. However, the only medical opinion with respect to that condition is that of the September 2016 VA examiner, which found that rosacea was not manifested in service or otherwise the result of service. Finally, the Board notes that there are multiple diagnoses of prurigo; however, that diagnosis is specifically associated with the Veteran's non-healing scalp ulcer. Therefore, it is accounted for in the rating for that disorder that is already in effect. Dysphagia The Veteran seeks service connection for dysphagia, which is defined by Dorland's Illustrated Medical Dictionary (31st ed., 2007) as "difficulty in swallowing." (p. 587.) The record shows that she was treated for dysphagia in service in June 2007 and September 2007. (See STRs, received 03/03/2013, p. 2; See Medical Treatment Record, received 03/05/2012, p. 1.) The Veteran has reported this to be an ongoing problem since she suffered a stroke in 2005. (See Notice of Disagreement, received 01/04/2016, p. 2.) It had improved shortly afterwards, but worsened after her head injury in Afghanistan in 2007 and her exposure to a crowd control chemical. While the cause of the Veteran's difficulty swallowing in service is unclear - the record shows that diagnoses of hiatal hernia, esophageal stenosis, and gastroesophageal reflux disease (GERD) were all rejected at one point in service - the ongoing complaints have been consistent throughout. The September 2016 VA examination noted that the Veteran complained of difficulty swallowing "everything" including her own saliva. (See C&P Exam, received 09/20/2016, p. 1.) An upper gastrointestinal test with barium swallowing done in 2007 had result in a diagnosis of GERD. The examiner noted in-service dysphagia. In this instance, the elements for a successful claim of service connection have been satisfied. The Veteran has a current disability - dysphagia - which was manifested in service. The Board acknowledges that the Veteran reported that her dysphagia began after a stroke in 2005 and therefore predated her most recent period of service. However, there is also evidence that it worsened in service and therefore the presumption of soundness is not rebutted. 38 U.S.C.A. § 1111. Therefore, service connection for dysphagia is warranted. 38 C.F.R. § 3.303. Bilateral Hip Arthritis The Veteran seeks service connection for bilateral hip arthritis. The April 2016 DBQ notes that she was shown on X-ray to have arthritis in both hips in 2008. (See C&P Exam, received 04/11/2016, pp. 26, 41.) This diagnosis, by X-ray, was made within the first year following service separation. The provider who completed the April 2016 DBQ offered the opinion that the arthritis of the bilateral hips started during her active duty service. (p. 41.) As such, service connection is clearly warranted for arthritis of the hips, because arthritis is one of the chronic diseases entitled to presumptive service connection under 38 C.F.R. § 3.309(a). 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Bilateral Foot and Toe Arthritis The Veteran filed a claim for and has been pursuing service connection for arthritis in her feet and toes. Recent statements from the Veteran, including at the May 2016 examination that she actually is seeking service connection for neuropathy in her feet and toes. After considering the extensive procedural history in this claim, which has been pending since July 2012, the Board has determined that the appropriate course of action is to adjudicate the longstanding claim regarding arthritis. Should the Veteran wish to pursue a claim of entitlement to service connection for neuropathy in her feet and toes, she is invited to file a claim following the standard procedures. The Veteran's service treatment records show that, while she was performing active duty for training from November 2005 to March 2006, she injured her ankle. (See STRs, received 02/26/2008, p. 71.) The document, completed on August 8, 2006, stated that the Veteran had incurred an ankle sprain in the line of duty. The Veteran was treated in May 2005 for complaints of bilateral feet numbness for two weeks. (See STRs, received 10/30/2008, p. 43.) She also complained of cramps at night when she took her boots off. A physical examination showed normal appearance of the feet with no swelling or redness. Her lab results were normal. The provider diagnosed bilateral paresthesias of the feet and referred her for possible vascular surgery. An additional note from the same time frame noted a possible neuropathic etiology for her complaints of pain and numbness in the feet and hands. (p. 80.) A DBQ performed in July 2012 noted diagnoses of traumatic arthritis in May 2005. (See Disability Benefits Questionnaire, received 07/06/2012, p. 1.) It was noted that the Veteran injured both feet on active duty and developed traumatic arthritis and neuropathy, which resulted in alternating pain and numbness, with spasm and lack of circulation to both feet. The examiner also noted evidence of bilateral weak foot, specifically pain and difficulty ambulating and standing for short periods of time. The Veteran required a cane, diabetic footwear, prescription medication for pain, prescription topical cream, and periods of prolonged rest. (p. 3.) The examiner noted that imaging studies of the foot had confirmed evidence of degenerative or traumatic arthritis in multiple joints of both feet. (p. 4.) The examiner further noted that the Veteran's personnel file contained a line of duty finding for traumatic arthritis of both feet dated in May 2005, stating that military doctors had examined the Veteran and felt that her injury was severe enough to warrant further disability compensation claims. In July 2012, the Veteran filed a claim of service connection for bilateral foot arthritis. (See Correspondence, received 07/30/2012, p. 1.) She stated that a recent VA examination had confirmed a diagnosis of traumatic arthritis in both feet and related the condition to an injury incurred while on active duty training in 2005. A DBQ submitted with respect to the Veteran's feet in December 2012 noted a diagnosis of traumatic arthritis made in May 2005 and one of neuropathy made in June 2010. (See DBQ, received 12/27/2012, p. 1.) The provider stated that the Veteran had injured both of her feet on active duty and subsequently developed traumatic arthritis and neuropathy. Her symptoms included alternating pain and numbness in her feet, as well as spasms and a lack of circulation to the feet. The provider stated that as a result of the foot disabilities, the Veteran had pain and difficulty walking or standing for even short periods of time and required a cane, diabetic footwear, prescription medication, prescription topical creams, and periods of long rest. (p. 2.) The provider stated that X-rays of both feet had shown evidence of traumatic arthritis in multiple joints. (p. 3.) The provider also noted the Line of Duty form from May 2005 showing traumatic arthritis of both feet. A note from the Veteran to her doctors in April 2014 stated that she had scars on the tops of both feet from wearing regular footwear. (See CAPRI, received 07/14/2015, p. 287.) She also said that the bones on top of both feet were abnormally prominent due to osteoarthritis. An X-ray of both feet taken in May 2014 was normal, with no evidence of arthritis. (See CAPRI, received 07/14/2015, pp. 138-39.) In a written statement submitted in April 2016, the Veteran reported that she severely injured her right ankle during active duty training in February 2006. (See Statement in Support, received 04/22/2016, p. 2.) She incurred a severely weak right ankle and subsequently developed traumatic arthritis to all joints of the right foot and toes which was made worse by her combat tour in Afghanistan in 2007. She had injured he left ankle in childhood and surgery was required. The injuries to both ankles had resulted in traumatic degenerative changes to the feet in advance of normal wear which was aggravated by continued military combat duty. In a statement submitted in April 2016, the Veteran listed the events in service which were the basis for her various claims. She listed "September 6, 2006, Traumatic Arthritis both feet/ankles noted on military medical records and DA Form 2173 Line of Duty Medical Examination." (See Correspondence, received 04/12/2016, p. 24.) A DBQ completed in May 2016 noted that the Veteran was to be examined for arthritis of the toes, but that a 2014 evaluation had shown "[t]oes normal foot type" on both feet. (See LCDM, CAPRI, received 06/29/2016, p. 59.) The Veteran stated that she was not claiming any injury to her toes, but that she wanted to claim neuropathy in her feet. (p. 60.) The VA examination showed no evidence of any foot deformity or disability and no evidence of pain on examination. (p. 63.) There was no evidence of functional loss for either foot. There was no evidence of traumatic arthritis in the feet or toes on X-ray. (p. 64.) After considering all of the evidence of record, to include that set forth above, the Board finds that the preponderance of the evidence is against the claim of service connection for arthritis of the bilateral feet and toes. Indeed, the preponderance of the evidence is against a finding that the Veteran has arthritis of the bilateral feet and toes. The most recent X-ray of the Veteran's feet, taken in May 2014, shows no evidence of arthritis, a determination confirmed by the most recent VA examination in May 2016. Despite multiple references in both the Veteran's statements and in DBQs from July 2012 and December 2012 to a historical diagnosis of traumatic arthritis in both feet in 2005, there is no record showing such a diagnosis in 2005. The record does not include the Line of Duty statement asserted by the Veteran dated in September 2006 showing traumatic arthritis in 2005; the Line of Duty statement in the record was completed in August 2006 and noted a right ankle sprain in the line of duty in 2005. Treatment records dated in 2005 note possible neurological pain in the feet. The weight of the evidence is against a finding of degenerative changes in the Veteran's feet or toes. For these reasons, the Board finds that service connection for arthritis of the bilateral feet and toes must be denied. II. Claims for Increased Disability Ratings A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). In this instance, staged ratings were assigned for reactive airway disease by the rating decision of May 2015and the appropriate disability ratings for both time periods are on appeal before the Board. Non-Healing Ulcer of the Scalp The Veteran seeks an increased disability rating for a non-healing ulcer on her scalp, which is currently rated as 0 percent (noncompensably) disabling. At present, the Veteran's disability is rated under Diagnostic Code 7816, which provides ratings for psoriasis. Consideration should also be given to other applicable disability rating criteria to include disabilities which affect the skin. Diagnostic Code 7816 provides that psoriasis affecting less than 5 percent of the entire body or exposed areas affected, and; no more than topical therapy required during the past 12-month period, is rated noncompensably (0 percent) disabling. Psoriasis affecting at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period, is rated 10 percent disabling. Psoriasis affecting 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period, is rated 30 percent disabling. Psoriasis affecting more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period, is rated 60 percent disabling. 38 C.F.R. § 4.118. Diagnostic Code 7800 provides ratings for disfigurement of the head, face, or neck. Note (1) to Diagnostic Code 7800 provides that the 8 characteristics of disfigurement, for purposes of rating under 38 C.F.R. § 4.118, are: scar 5 or more inches (13 or more cm.) in length; scar at least one-quarter inch (0.6 cm.) wide at the widest part; surface contour of scar is elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and, skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Diagnostic Code 7800 provides that a skin disorder with one characteristic of disfigurement of the head, face, or neck is rated 10 percent disabling. A skin disorder of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement, is rated 30 percent disabling. 38 C.F.R. § 4.118. Because the Veteran's disability is described as a "non-healing ulcer," consideration should also be given to a rating under Diagnostic Code 7804, as a superficial unstable scar. Diagnostic Code 7804 provides that one or two scars that are unstable or painful are rated 10 percent disabling. Note (1) to Diagnostic Code 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under diagnostic codes 7800, 7891, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable. 38 C.F.R. § 4.118. Another potentially applicable Diagnostic Code is 7806, which provides ratings for dermatitis or eczema. Dermatitis or eczema is to be rated under either the criteria under Diagnostic Code 7806 or to be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118. Diagnostic Code 7806 provides that dermatitis or eczema that involves less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy is required during the past 12-month period, is rated noncompensably (0 percent) disabling. Dermatitis or eczema that involves at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period, is rated 10 percent disabling. 38 C.F.R. § 4.118. A visit to the dermatology clinic in March 2008 noted that the Veteran had a biopsy performed earlier that month with evidence of chronic inflammation, fibrosis and ulceration. (See CAPRI, received 07/14/2015, p. 1030.) On examination there were heme-crusted erosions with a few broken-off hairs in the scalp and lesions located primarily on the posterior vertex of the scalp, with two erosions near the frontal hairline. The provider diagnosed prurigo nodularis with excoriations and, together with the VA chief, discussed the biopsy results with the Veteran in detail. It was explained that the lesions were largely due to her traumatizing the area and the providers recommended that she treat the lesions with topical steroids for at least two months. Although the Veteran verbally denied picking at the sores, the provider noted that she was manipulating them during that same conversation. In May 2010, the Veteran was seen for complaints of an abscess on her scalp causing facial pain for two days. (See CAPRI, received 07/14/2015, p. 939.) She had a history of treatment by dermatology for scalp dermatoses. On examination there was a single small dry crusty scaly area of erosion on the Veteran's scalp. A prior biopsy had shown prurigo nodularis and medication prescribed in the past had provided little relief. The Veteran was seen in December 2010 for complaints regarding her scalp condition. (See CAPRI, received 11/16/2011, p. 1.) The provider diagnosed erythematous excoriated plaques on the vertex of the scalp with no hair loss, erythema, or scaling. A pathology report diagnosed ulceration, fibrosis and chronic inflammation of the area. (p. 3.) No other diagnosis with relation to the Veteran's scalp was noted. A DBQ submitted in December 2012 referenced the Veteran's complaints regarding her non-healing scalp ulcer. (See DBQ, received 12/27/2012, p. 3.) The provider noted that the Veteran was seen for a scalp infection in December 2007 and treated with antibiotics. The sores on the scalp did not heal and she was seen on several occasions by dermatology. Two successive punch biopsies were performed and showed fibrosis with chronic inflammation and ulceration; tar shampoo and steroids were prescribed. All of her sores healed except for the areas of the punch biopsies, which the provider stated were done in the same location, which meant that the second one had most likely gone deeper than the first as a result. She used a topical antibiotic cream on her scalp ulcer on a constant or near-constant basis. The Veteran's scalp ulcer affected less than 5 percent of the exposed area of her skin. (p. 5.) In a statement submitted in April 2016, the Veteran discussed her non-healing scalp ulcer. (See Correspondence, received 04/12/2016, p. 15.) She referred to it as both fibrosis of the skin and a scalp ulcer, which she said resulted in palpable tissue loss and paired asymmetry of the scalp, and disfigurement with hair loss around the ulcer and surrounding areas. She asserted that the diagnosis of fibrosis of skin, confirmed by two punch biopsies of her scalp, were not confined to the scalp area but encompassed the entire skin surface. She asserted that proper rating for this disability was 80 percent. (p. 27.) At the September 2016 VA examination, the Veteran asserted her belief that the punch biopsies of her scalp had included one that went so deep it removed a portion of skull, which was reflected on X-rays and accounted for her migraines. (See LCDM, C&P Exam, received 09/20/2016, p. 8.) The examiner noted that the sample examined in the biopsy was 0.4 cm deep. On physical examination, there was a non-atrophic scar which measured about 0.2 cm by 0.2 cm; no other visible abnormality was noted. (p. 9.) The Board has considered all of the evidence of record, to include that discussed above, and finds that entitlement to a compensable disability rating for non-healing ulcers of the scalp is not warranted. Under the criteria of Diagnostic Code 7816, which was assigned for the Veteran's disability, or under Diagnostic Code 7806 for dermatitis, a compensable (10 percent) disability rating would require that the area affected account for at least 5 percent of the exposed areas of the body or require the use of systemic therapy such as corticosteroids or other immunosuppressants for up to 6 weeks in the previous 12 month period. The Veteran's non-healing scalp ulcer occupies a total surface area of less than one-half square centimeter, or well below the 5 percent of exposed surface area. In addition, while the Veteran has been prescribed antibiotics (see December 2012 DBQ), there is no evidence that it has required systemic corticosteroids or other immunosuppressant medication. A compensable (10 percent) disability rating is likewise not warranted under any other potentially applicable Diagnostic Code. Specifically, the non-healing ulcer does not qualify as a superficial unstable scar under Diagnostic Code 7804, because there is no evidence of frequent loss of covering of skin over the scar. Rather, the Veteran has an absence of hair in that area, not an absence of skin. Likewise, the rating criteria under Diagnostic Code 7800 have not been met, because the Veteran does not have any of the characteristics of disfigurement. While she has described a depressed area on her scalp, this is not supported by the finding on examination, with the September 2016 VA examiner in particular noting the thinness of the sample extracted in the punch biopsies. In addition, the Veteran has claimed that her disability fell within the provision related to gross distortion or asymmetry of one feature or a paired set of features, the Board notes that the scalp near the hairline is not included in the list in 38 C.F.R. § 4.118, that is, the nose, chin, forehead, eyes, ears, cheeks, and lips. For the above reasons, the Board finds that an initial compensable disability rating for non-healing ulcers of the scalp is not warranted. The Board acknowledges that the Veteran's disability has been diagnosed as fibrosis and that fibrosis can present on the skin and is not limited to the scalp. However, in this instance, the only location where fibrosis has been manifested to date is on the Veteran's scalp in this specific area. As such, the rating as currently assigned is likewise limited to the specific affected area, which, as noted, is less than 5 percent of exposed body surface. 38 C.F.R. § 4.118. Reactive Airway Disease A May 2015 rating decision granted service connection for reactive airway disease and assigned initial disability ratings of 30 percent prior to January 25, 2012, and 60 percent thereafter. The Veteran appealed the assigned ratings and both rating periods are before the Board. Diagnostic Code 6602 provides ratings for bronchial asthma. Forced Expiratory Volume in one second (FEV-1) of 56- to 70-percent predicted value, or; the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) of 56 to 70 percent, or; intermittent inhalational or oral bronchodilator therapy, is rated 30 percent disabling. FEV-1 of 40- to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids, is rated 60 percent disabling. FEV-1 less than 40-percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications, is rated 100 percent disabling. 38 C.F.R. § 4.97. A December 2010 VA examination noted the onset of the Veteran's reactive airway disease in 2006 after she had an allergic-type reaction to pepper spray. (See VA Exam, received 12/15/2010, p. 15.) Since that time, she reported that she had been sensitized to certain allergies and irritants and used inhalers to control her symptoms. She reported being treated in the emergency room on four occasions in the preceding twelve months, twice at VA and twice at private facilities. (p. 16.) She experience shortness of breath after walking 100 years and had occasional cough with clear or greenish sputum and wheezing after exposure to certain allergens. She used inhaled bronchodilators on an intermittent basis to address her symptoms. (p. 17.) A chest X-ray showed clear lungs and concluded that the Veteran did not have any current cardiopulmonary disease. (p. 19.) Pulmonary function testing administered in January 2011showed FVC at 85 percent, FEV1 at 87 percent, and FEV1/FVC at 79 percent. (See C&P Exam, received 03/05/2012, p. 2.) A DBQ submitted in December 2012 discussed the Veteran's respiratory disability, noting diagnoses of asthma and chronic bronchitis in November 2006. (See DBQ, received 12/27/2012, p. 1.) The Veteran's disabilities had required 3 intermittent courses of systemic corticosteroids in the past 12 months as well as systemic high dose corticosteroids for control. (p. 2.) She used inhaled bronchodilator and anti-inflammatories daily. She used outpatient oxygen therapy for her asthma, although not on a continuous (greater than 7 hours at a time) basis. She reported three asthma attacks with respiratory failure in the past 12 months. (p. 3.) She sought treatment with her physician for her asthma attacks less than once a month. A May 2012 chest X-ray was reviewed and found to be normal. (p. 6.) Pulmonary function tests had been performed and were reported as FVC of 3.13, FEV-1 of 2.52, and FEV-1/FVC of 81 percent of predicted. The provider felt that the DLCO test was the best reflection of the severity of the Veteran's disability; that test had shown 22.3 percent of predicted values. The provider noted that the Veteran had a history of dyspnea on exertion and was highly susceptible to respiratory failure without emergency intervention. (p. 7.) The Veteran could not be exposed to workplace allergens or irritants; her condition was chronic and would most likely worsen as she aged. The VA examination of October 2015 noted the diagnosis of reactive airway disease from 2004. (See C&P Exam, received 10/15/2015, p. 1.) The Veteran reported that she experienced lung reactions and wheezing to everyday substances such as chemical, colognes, and smokes. She had not used steroids in several years. She described her asthma as persistent, severe, and disabling, although the examiner noted she was treated only with albuterol, normally used for mild intermittent asthma. On examination, she exhibited forced expiratory wheezed but her actual lung examination was normal. (p. 3.) The examiner noted that pulmonary function testing was unlikely to be accurate for the Veteran because it was easily manipulated. The examiner stated that the Veteran's condition had improved over time, but her reported symptoms included extreme reactivity to everyday substances and wheezing and shortness of breath with physical activity. The examiner listed the pulmonary function testing results as FEV-1 at 81 percent for predicted pre-bronchodilator and 93 percent post-bronchodilator; FVC at 81 percent predicted pre-bronchodilator and 86 percent post-bronchodilator; FEV-1/FVC at 98 percent of predicted pre-bronchodilator and 106 percent post-bronchodilator; and, DLCO at 65 percent predicted. (p. 9.) The examiner stated that the test which most accurately reflected the Veteran's current pulmonary function was the FEV-1/FVC test. The examiner noted that the Veteran displayed forced expiratory wheezes on the focused examination which were inconsistent with her normal breathing at other times during the examination. (p. 10.) As part of the October 2015 VA examination, the Veteran had a chest X-ray based on her history of shortness of breath. (See Medical Treatment Records, received 10/19/2015, p. 2.) The X-ray showed no acute findings. Pulmonary function test results showed that the Veteran had an FEV1/FVC ratio of 77 percent, which was 98 percent of predicted, with both FEV1 and FVC showing 81 percent of predicted, with a 15 percent response to bronchodilator for the FEV1 reading. (p. 3.) The provider noted a diagnosis of reactive airways with hyperinflation and air trapping consistent with asthma. In her VA Form 9, submitted in January 2016, the Veteran asserted that her medical records showed regular daily use of inhalers, increased red blood cell count indicating cellular hypoxia resulting in generalized weakness, and an inability to be exposed to common work place allergens. (See VA 9, received 01/14/2016, p. 2.) As a result she felt that her asthma was sufficient to warrant assignment of a permanent and total disability rating under 38 C.F.R. § 3.340. In a statement submitted in April 2016, the Veteran asserted that her service-connected asthma should be rated as 100 percent disabling because it rendered her unable to be exposed to common workplace allergens. (See Correspondence, received 04/12/2016, p. 7.) She asserted that her asthma made it impossible for her to be gainfully employed and that she was entitlement to a total and permanent disability rating as a result of this disability alone. After considering all of the evidence of record, to specifically include the evidence discussed above, the Board finds that the assigned staged ratings of 30 percent and 60 percent are appropriate and there is no basis for increased disability ratings. Specifically, the evidence shows that the Veteran used an inhaled bronchodilator on an intermittent basis only prior to January 25, 2012, as discussed in the December 2010 VA examination. The December 2012 VA examination showed that the Veteran had progressed to a daily use of inhaled bronchodilators. Throughout both rating periods, the Veteran's pulmonary function test results have been better than the findings of FEV-1 or FEV-1/FVC of 40 to 55 percent of predicted values, which are required for a 60 percent disability rating. The Veteran is not shown to have multiple episodes of respiratory failure in a week or require the use of corticosteroids or immunosuppressants, such as would warrant assignment of a rating higher than 60 percent. The Veteran has asserted that a total (presumably 100 percent) disability rating is warranted for her asthma because the reaction to common allergens makes it impossible for her to be gainfully employed and the disability is unlikely to ever get better. At present, the Veteran has a combined disability rating of 100 percent, with a total disability rating based on unemployability having been in effect prior to that. The Board concedes that medical providers have stated that her asthma is likely a permanent condition. However, the specific criteria related to the Veteran's asthma are based on the ability to breathe effectively, as reflected in pulmonary function testing. As such, entitlement to a 100 percent disability rating for reactive airway disease or asthmas is not warranted. 38 C.F.R. § 4.97. Hypertension The Veteran is service-connected for hypertension, which is currently rated as noncompensable (0 percent disabling). She seeks a higher disability rating. Diagnostic Code 7101 provides ratings for hypertensive vascular disease (hypertension and isolated systolic hypertension). Hypertensive vascular disease with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control, is rated 10 percent disabling. Hypertensive vascular disease with diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more, is rated 20 percent disabling. For purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104. At the June 2008 VA examination, the Veteran reported that she had been diagnosed with hypertension in service and that the medication she took for another disability was a diuretic, and she was therefore not taking traditional antihypertensive medication. (See VA Exam, received 06/11/2008, p. 2.) She stated that over the last two years her blood pressure had been normal, although there was evidence of elevated blood pressure in 1999 and in 2004 during visits to the emergency room. At the time of the examination, her blood pressure was 114/65. The examiner stated that a diagnosis of hypertension had been established and noted three historical blood pressures of 143/81, 152/92, and 140/86. A December 2012 DBQ was completed with respect to the Veteran's hypertension. (See DBQ, received 12/27/2012, p. 1.) The Veteran had first been noted to have transient hypertension in April 2007 after she sustained a TBI. She was taking medication for her hypertension. Blood pressure readings were shown as 150/104 in August 2011, 164/93 in October 2010, and 146/90 in December 2010. She stated that she took her blood pressure at home and it was regularly recorded as 100 or more diastolic prior to taking her medication. An EKG performed in June 2010 had shown left atrial enlargement in her heart with a normal sinus rhythm. (p. 2.) The provider noted that the Veteran's multiple health problems, including chronic arthritis pain, headaches, and fibromyalgia, complicated attempts to control her blood pressure, which was increased by pain. The provider noted that the Veteran's blood pressure had not been regularly monitored and medication had not been prescribed prior to June 2010 when the EKG showed heart damage resulting from hypertension. At the VA examination in October 2015, the Veteran declined to have her blood pressure reading taken. (See C&P Exam, received 10/15/2015, p. 12.) She later explained that this was because the examiner did not have a manual blood pressure cuff which she felt was necessary to accommodate her other medical disabilities such as fibromyalgia and neuropathy. (See VA 9, received 01/14/2016, p. 1.) The Veteran stated that her blood pressure readings were normally around 143/85 but were quite labile. (C&P Exam, p. 13.) She attributed her heart and kidney disease to her hypertension, although available creatinine readings were normal. Previous VA examinations had noted EKGs done in June 2010 showed left atrial enlargement, although the VA examiner did not see any diagnosable heart condition at the time of the examination. The Veteran was taking medication for her hypertension. The examiner indicated that her hypertension had no impact on her ability to work. (p. 14.) In a written statement submitted in January 2016, the Veteran included a listing of blood pressure readings that would support an increased disability rating. (See Statement in Support, received 01/04/2016, p. 1.) Specifically, she included the following readings and dates: March 5, 2012, 160/90, May 1, 2012, 162/100 and 161/100; May 25, 2012 167/93; July 6, 2012, 164/97; July 24, 2012 162/93; August 8, 2012, 161/91; August 21, 2012, 155/96; September 26, 2012, 138/82; December 14, 2012, 168/90; and February 12, 2013, 144/92. She stated that the EKG in June 2010, which documented left atrium enlargement also indicated the presence of pulmonary hypertension. In her VA Form 9, submitted in January 2016, the Veteran asserted that the key factor in rating her hypertension should not be her blood pressure readings but the degree of damage resulting from her hypertension. (See VA 9, received 01/14/2016, p. 2.) "A history of blood pressure readings are not required because the cardiac damage itself is prima facie evidence of hypertension, whether the medical records or blood pressure readings currently show it or not." The Veteran stated that the primary cause of left atrium enlargement, as shown on her 2010 EKG, is hypertension over a sustained period of time resulting in cardiac muscle damage. It was her position that this was a severe symptom which required a 60 percent disability rating. In a written statement submitted in April 2016, the Veteran asserted that her pre-treatment blood pressures in service and after service separation for three years were at and above 160/100. (See Correspondence, received 04/12/2016, p. 28.) She had an EKG in 2010 which showed atrium enlargement and confirmed pulmonary hypertension. Her blood pressure was controlled by two medications. However, she asserted that the evidence of heart damage resulting from her high blood pressure as shown on the EKG was a serious symptom of her hypertension and merited a disability rating of 60 percent. At the VA examination in September 2016, the Veteran reported that she had elevated blood pressure in service, but was not formally diagnosed or placed on medication until 2010. (See C&P Exam, received 09/20/2016, p. 1.) An EKG done at that time showed an enlarged atrium. She checked her blood pressure twice a day and averaged 140-160 over 85 to 100. She was taking medication for her condition. The examiner noted that the Veteran did not have a history of diastolic blood pressure readings which were predominantly 100 or more. (p. 2.) The Board has reviewed all of the evidence of record, to specifically include that discussed above, and finds that the evidence does not support assignment of a compensable disability rating for hypertension. A compensable or 10 percent disability rating is assigned where the individual continuous medication for control and has a history of diastolic pressure which is predominantly 100 or more. In this instance, while the Veteran does require medication on a continuous basis to control her blood pressure, she does not have a history of diastolic pressure predominantly greater than 100. At the June 2008 VA examination, the Veteran was not taking medication and had a blood pressure reading of 114/65; historic blood pressure readings noted at that time were all lower than 100 diastolic. The December 2012 DBQ cited three historic blood pressure readings, 150/104, 164/93, and 146/90; only one of these readings had a diastolic reading over 100. At the October 2015 VA examination, the Veteran reported that her blood pressure was normally around 143/85. She submitted a series of blood pressure readings in January 2016; out of the 10 readings provided, only 2 had diastolic pressures of 100 or above, which is not a predominance of the readings. The Board notes the Veteran's statements, including in the December 2012 DBQ, that she regularly recorded blood pressure readings where the diastolic pressure was 100 or above prior to taking her medication. However, this statement is not supported by any specific readings reported by the Veteran and is not consistent with the record of blood pressure readings in the medical evidence, which show diastolic readings predominantly less than 100. Finally, the Veteran has asserted that her blood pressure readings should not be the basis for a disability rating because the cardiac damage or enlarged left atrium is prima facie evidence of hypertension. The Board fully acknowledges that the Veteran has hypertension and service connection is in effect for that disability. The Board notes that the October 2015 VA examination did not show any diagnosable heart disability and the specific cause of any damage that might exist has not been established. Moreover, the rating criteria as presently codified are based on blood pressure readings and not on any resulting cardiac damage. Indeed, if the Veteran believes that compensation is warranted for any cardiac damage which she believes was caused by hypertension, she is invited to file a claim of service connection for that disability. For all of these reasons, the Board finds that an initial compensable disability rating is not warranted for the Veteran's hypertension. 38 C.F.R. § 4.104. III. Additional VA Benefits SMC for Aid and Attendance Under 38 U.S.C.A. § 1114 (l), special monthly compensation is payable if, as the result of service-connected disability, the Veteran is so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C.A. § 1114 (l); 38 C.F.R. § 3.350 (b). Under 38 C.F.R. § 3.352 (a), the following factors will be accorded consideration in determining whether the Veteran is in need of regular aid and attendance of another person: the inability of the Veteran to dress or undress herself, or to keep herself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without such aid; inability of the Veteran to feed herself because of the loss of coordination of upper extremities or because of extreme weakness; and the inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the Veteran from the hazards or dangers incident to her daily environment. 38 C.F.R. § 3.352 (a). It is not required that all the disabling conditions enumerated in 38 C.F.R. § 3.352 (a) be found to exist before a favorable rating may be made. The particular personal functions which the Veteran is unable to perform should be considered in connection with her condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance, not that there is a constant need. 38 C.F.R. § 3.352 (a). A DBQ submitted in December 2012 discussed the functional limitations related to the Veteran's bilateral hand disabilities. (See DBQ, received 12/27/2012, p. 5.) The provider noted that the Veteran regularly used braces on her hands and constantly required assistive devices to reach and hold items and open jars. She required assistive devices to perform normal household chores and grooming. The provider stated that the Veteran's need for assistive devices was such that amputation and replacement with a prosthetic would be equally effective in performing certain tasks. A statement submitted by a VA provider in February 2013 discussed the functional impact of many of the Veteran's service-connected disabilities. (See Third Party Correspondence, received 02/18/2013, p. 1.) The provider noted that the Veteran's fibromyalgia caused severe pain on a daily basis which limited her ability to walk, lift, or sit for long periods of time. It also resulted in weakness that was so disabling that she was unable to attend to the activities of daily living and caused her to stay in bed. The Veteran's thyroid disability resulted in fatigue. In September 2017, the Veteran submitted a statement regarding her need for aid and attendance which was completed by a VA provider. (See VA 21-2680, received 09/22/2017, p. 1.) It listed the disabilities that resulted in her need for aid and attendance as bilateral torn rotator cuffs with frozen shoulders, cervical sprain, levothoracic scoliosis, and herniated discs L1 through L5 in the lumbar spine. She reported that she was able to feed herself and prepare her own meals, but needed assistance with bathing, dressing, hair care, applying braces, housekeeping, and shopping. She stated that it was painful to perform fine and gross motor movements, she could not lift or move objects weighing more than five pounds, could not lift her arms over her head or each across or behind her back, could not sit, stand, lift, reach, or lie flat without severe pain and had difficulty sleeping. The provider stated that she needed aid in dressing and attending to personal hygiene tasks, putting on and taking off her neck, shoulder, and back braces, and in bathing, housekeeping, and shopping. She did not have any restrictions on her ability to leave her home, although she did need a crutch or other aid for traveling more than one block. After considering all of the evidence of record, to include that discussed above, the Board finds that entitlement to SMC based on the need for the aid and attendance of another has been established. Specifically, the evidence included in the September 2017 statement completed by the Veteran and her provider showing that she needs the aid and assistance of another person. The September 2017 statement noted that the Veteran had difficulty with using her hands, especially fine motor skills, and required assistance with bathing, dressing, hair care, applying braces, housekeeping, and shopping. This is sufficient to establish entitlement to the benefit sought. 38 C.F.R. § 3.352 (a). Automobile or Adaptive Equipment Allowance A certificate of eligibility for financial assistance in the purchase of one automobile or other conveyance and of basic entitlement to necessary adaptive equipment will be made when the Veteran/service member has one of the following conditions which is the result of injury or disease incurred or aggravated during active military service: loss or permanent loss of use of one or both feet; loss or permanent loss of use of one or both hands; permanent impairment of vision of both eyes with central visual acuity of 20/200 or less in the better eye with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye; a severe burn injury, such as deep partial thickness or full-thickness burns, resulting in scar formation that cause contractures and limit motion of one or more extremities or the trunk and preclude effective operation of an automobile; amyotrophic lateral sclerosis; for adaptive equipment eligibility only, ankylosis of one or both knees or one or both hips. 38 C.F.R. § 3.808. The term "permanent loss of use," is not defined in 38 C.F.R. § 3.808, but the term "loss of use of a hand or foot" is defined elsewhere as existing when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the elbow or knee with the use of a suitable prosthetic appliance. See 38 C.F.R. § 3.350 (a)(2). That regulation also provides that the determination as to whether such loss of use exists will be made on the basis of the actual remaining function, whether the acts of grasping, manipulation, etc., in the case of the hand, or balance, propulsion, etc., in the case of a foot, could be accomplished equally well by an amputation stump with prosthesis. In the event that the Veteran does not meet the criteria for financial assistance in purchasing an automobile or other conveyance, if he has ankylosis of one or both knees or one or both hips due to a service-connected disability, entitlement to adaptive equipment eligibility only is established. 38 U.S.C.A. § 3902 (b)(2); 38 C.F.R. § 3.808 (b)(6). The Veteran's application for automobile allowance was submitted in October 2012. (See Application, received 10/05/2012, p. 1.) She indicated that her eligibility was based on loss of use of both hands. A March 2013 VA treatment note indicated that the Veteran was requesting to have an adaptive device installed in her car. (See CAPRI, 07/14/2015, p. 504.) Specifically, she wanted an extension on the emergency break because she had arthritis in both hands and had difficulty extending her arm to reach the emergency brakes. The Board has considered all of the evidence of record, to include all of that discussed in the entirety of the decision above. The evidence of record fails to show that the Veteran meets the criteria for the benefit sought because she is not presently service connected for a disability manifested by loss or permanent loss of use of one or both hands or feet, permanent impairment of vision of both eyes as defined above, or ankylosis of one or both knees or one or both hips. She has not suffered an amputation of a hand or foot. The February 2013 VA examination, the April 2016 VA examination, and the September 2017 DBQ all have attested that the Veteran requires braces as well as a cane or crutch in order to walk for any distance at all as a result of her fibromyalgia. However, the evidence does not show that the Veteran has permanent loss of use of either foot. In addition, while the December 2012 DBQ described the Veteran's difficulties with reaching, grasping, or picking up objects, there is no indication in any medical record or VA examination report that she exhibits a permanent loss of use of either hand. Indeed, that examiner found that function would be equally served by amputation with prosthesis. It appears that actual function, as with use of a prosthesis, would remain and thus the evidence weighs against a finding of loss of use here. Additionally, there is no evidence that the Veteran's vision is reduced to the degree specified by the regulation, nor does she have a severe burn injury. The Veteran likewise is not shown to have ankylosis in either of her knees or her hips, notwithstanding the grant of service connection for bilateral hip arthritis herein. In light of all of this, the Board finds that she is not entitled to a certificate of eligibility for an automobile allowance and adaptive equipment, or for adaptive equipment only. 38 C.F.R. § 3.808. Special Home Adaptation Eligibility for assistance in acquiring specially adapted housing under 38 U.S.C.A. § 2101 (a) is provided for a veteran who is entitled to compensation for permanent and total disability due to: (1) the loss or loss of use of both lower extremities, such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; (2) blindness in both eyes, having only light perception, plus the anatomical loss or loss of use of one lower extremity; (3) the loss or loss of use of one lower extremity together with residuals of organic disease or injury which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; or (4) the loss or loss of use of one lower extremity together with the loss or loss of use of one upper extremity which so affect the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. 38 C.F.R. § 3.809 (b). Effective October 25, 2010, 38 C.F.R. § 3.809 was expanded to provide eligibility for assistance in acquiring specially adapted housing under 38 U.S.C.A. § 2101 (a) for veterans entitled to compensation for permanent and total disability due to: (1) the loss or loss of use of both upper extremities such as to preclude use of the arms at or above the elbow; or (2) full thickness or subdermal burns that have resulted in contractures with limitation of motion of two or more extremities or of at least one extremity and the trunk. 38 C.F.R. § 3.809 (b). On December 3, 2013; 38 C.F.R. § 3.809 was further expanded to provide eligibility for assistance in acquiring specially adapted housing under 38 U.S.C.A. § 2101 (a) for veterans who are service-connected for ALS rated 100 percent disabling under 38 C.F.R. § 4.124a, Diagnostic Code 8017. 38 C.F.R. § 3.809 (d). Under the version of 38 C.F.R. § 3.809a which became effective on September 12, 2014, if entitlement to specially adapted housing is not established, a veteran can qualify for a veteran may be issued a certificate of eligibility for assistance in acquiring necessary special home adaptations if the veteran is entitled to compensation under chapter 11 of title 38, United States Code, for a disability that is rated as (1) permanently and totally disabling and: (i) includes the anatomical loss or loss of use of both hands; (ii) is due to deep partial thickness burns that have resulted in contracture(s) with limitation of motion of two or more extremities or of at least one extremity and the trunk; (iii) is due to full thickness or subdermal burns that have resulted in contracture(s) with limitation of motion of one or more extremities or the trunk; or (iv) is due to residuals of an inhalation injury (including, but not limited to, pulmonary fibrosis, asthma, and chronic obstructive pulmonary disease); or is due to blindness in both eyes, having central visual acuity of 20/200 or less in the better eye with the use of a standard correcting lens. 38 C.F.R. § 3.809 (a). The phrase "preclude locomotion" is defined as the necessity for regular and constant use of a wheelchair, braces, crutches, or canes as a normal mode of locomotion although occasional locomotion by other methods may be possible. 38 C.F.R. § 3.809 (c). The Board notes that the "preclude locomotion" loss of use standard under 38 C.F.R. § 3.809 (c) is more expansive than the SMC loss of use standard of 38 C.F.R. § 3.350 (a)(2). Compare 38 C.F.R. § 3.809 (b) and (c) with 38 C.F.R. § 3.350 (a)(2). The language of 38 C.F.R. § 3.809 is clear that the more expansive loss of motion standard is applicable to the home adaptation criteria. In December 2011, the Veteran filed a claim for special home adaptations to the home that she owned. (See Application, received 12/09/2011, p. 1.) She specifically requested a Tempur-Pedic mattress, an above ground pool, a hot tub, replacement of her heating ducts and installation of specific filters or an air cleaner. A DBQ submitted in December 2012 discussed the functional limitations imposed by the Veteran's service-connected disabilities and the assistance she needed as a result. (See DBQ received 12/27/2012, p. 6.) For her asthma, the provider noted that the Veteran needed 1) replacement of home air-conditioning ducts; 2) installation of a central HEPA type air filter system; 3) sealing of attic door; 4) installment of a central water purification system; and, 5) replacement of wallpaper with tile in both bathrooms for allergy relief. For the Veteran's fibromyalgia, TBI, and traumatic arthritis, the provider stated that she required: 1) above-ground swimming pool for daily non-impact exercise to prevent atrophy; 2) heated tub for whole-body soaking to relieve daily muscle spasms and pain not relieved by prescription drugs or non-impact exercise; and, 3) memory foam mattress to help with pain. A statement submitted by a VA provider in February 2013 discussed the functional impact of many of the Veteran's service-connected disabilities. (See Third Party Correspondence, received 02/18/2013, p. 1.) The provider noted that the Veteran's fibromyalgia caused severe pain on a daily basis which limited her ability to walk, lift, or sit for long periods of time. In a statement submitted in April 2016, the Veteran provided an overview of her contentions with respect to her need for housing assistance. (See Correspondence, received 04/12/2016, p. 5.) She disagreed with the statement of the case, specifically with the language stating that the Veteran did not have any service-connected disabilities "related to loss, or loss of use, of upper or lower extremities, blindness or full thickness or subdermal burns." It was her position that her service-connected disabilities were related to loss of use of her upper and lower extremities. She noted that the needed to use a cane to walk because of functional loss of use of both lower extremities, referring to documentation of a stroke in service in 2005 and a TBI in 2007, which resulted in neuropathy and weakness of all extremities, with intermittent numbness, generalized weakness and extreme pain. She also referred to her loss of balance as a result of vertigo and TBI and the symptoms of her fibromyalgia and hypothyroidism. The Veteran also disagreed with the statement of the case with respect to the denial of a special home adaptation grant. (See Correspondence, received 04/12/2016, p. 6.) The AOJ had stated that the Veteran was "not service connected for a respiratory disability rated permanently and totally disabling." In turn, the Veteran noted that she has service-connected asthma that required daily use of inhalers and an inability to be exposed to common workplace allergens, which she argued was sufficient to entitle her to a total (100 percent) disability rating. Her asthma was reasonably certain to last throughout her lifetime and was rated as 60 percent disabling already, but had rendered her unemployable. A VA examination related to the Veteran's fibromyalgia in April 2016 discussed the impact on her functional capacities. (See C&P Exam, received 04/11/2016, p. 24.) The examiner stated that the Veteran was unable to stand or walk for more than an hour at a time and unable to sit for more than two hours at a time. An additional examination conducted on the same date with respect to her bilateral hip arthritis claim noted that there was no functional impact on employment related tasks such as standing, walking, lifting, or sitting as a result of her bilateral hip arthritis. (p. 39.) The Board has considered all of the evidence of record, to include all of that discussed in the entirety of the decision above. Considering all of the above evidence, the Board finds that the evidence is at least evenly balanced as to whether the Veteran's service-connected disabilities result in the loss of use of both lower extremities to the extent that they preclude locomotion without the aid of braces, crutches, canes, or a wheelchair. Specifically, the Board notes the February 2013 VA examination, the April 2016 VA examination, and the September 2017 DBQ all of which have attested that the Veteran requires braces as well as a cane or crutch in order to walk for any distance at all as a result of her fibromyalgia. The Veteran has a combined disability rating of 100 percent based on all of her disabilities, representing total disability with most, if not all, of the disabilities mentioned being permanent in nature including the fibromyalgia. For all of these reasons, the Board finds that the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, and she therefore meets the regulatory definition of "preclude locomotion" sufficiently to find loss of use of both lower extremities under 38 C.F.R. § 3.809 (b)(1). See 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. In addition, the Veteran is shown to have reactive airway disease that is currently rated as 60 percent disabling and which is permanent in nature. Considering the presence of both of these disabilities, the preponderance of the evidence demonstrates that the Veteran meets the statutory and regulatory criteria for a certificate of eligibility for a certificate for special home adaptation. 38 C.F.R. § 3.809(a). In reaching the above conclusion, the Board notes that only entitlement to a certificate of eligibility has been determined herein. The question of whether any of the specific home adaptations requested by the Veteran are appropriate uses of such a certificate or are covered by the grant is not presently before the Board and the Board makes no findings with respect to the Veteran's specific claims. ORDER Entitlement to service connection for the skin disabilities of actinic keratosis and idiopathic guttate hypomelanosis is granted. Entitlement to service connection for dysphagia is granted. Entitlement to service connection for arthritis of the bilateral hips is granted. Entitlement to service connection for arthritis of the bilateral feet and toes is denied. Entitlement to an initial compensable disability rating for a non-healing ulcer of the scalp is denied. Entitlement to an initial disability rating higher than 30 percent for reactive airway disease prior to January 25, 2012, and higher than 60 percent thereafter is denied. Entitlement to an initial compensable disability rating for hypertension is denied. Entitlement to SMC benefits based on the need for the aid and attendance of another person is granted. Entitlement to a certificate of eligibility for automobile and adaptive equipment or adaptive equipment only is denied. Entitlement to a certificate of eligibility for special home adaptation is granted. REMAND The Veteran seeks service connection for the residuals of two brown recluse spider bites, which she has asserted include scars and bilateral arm pain and neck pain. (See Statement in Support, received 04/22/2016, p. 2.) A review of the record shows that the information with respect to this claim is minimal and vague, at best. Specifically, the record does not contain a clear statement regarding the dates and circumstances of the claimed spider bites. Nor does it contain any evidence that the specifically claimed lesions and scars have been given any attention in the various VA examinations and DBQ assessments of record to date. The Veteran submitted a photo of one armpit, which she asserts shows the residuals of one of the bites; the photograph, as scanned into the electronic record, is indistinct. (See Medical Treatment Records, received 08/17/2016, p. 2.) For these reasons, the Board finds that a VA examination that specifically addresses the claimed brown recluse spider bite residuals and includes relevant photos of any scars or lesions is necessary on remand. The Veteran seeks benefits under 38 U.S.C.A. § 1151 based on two separate incidents of treatment at VA, each of which is associated with multiple disabilities. The first, an incident in May 2014, involved the cleaning of the Veteran's dental device with a chemical which she has asserted resulted in disabilities including burns to the mouth and throat and kidney dysfunction. The second involves an incident in August 2014 when the Veteran was X-rayed to determine the nature of her pain complaints; the radiology technician used sandbag weights to assist with alignment. The Veteran has claimed resulting disabilities of the cervical and lumbar spine and both shoulders. The record shows that the Veteran has also brought action with respect to both issues under the Federal Tort Claims Act (FTCA), initiating federal litigation which will include the development of additional evidence to determine any civil liability for any injuries suffered by the Veteran. While the FTCA claims are separate from the VA benefits claims adjudicated herein, the fact that they have the same factual bases means that any evidence associated with the FTCA claims would be relevant and possibly essential to a proper adjudication of the claims brought under 38 U.S.C.A. § 1151. For this reason, the claims brought under 38 U.S.C.A. § 1151 must be remanded until a conclusion is reached in the FTCA claims. In addition, copies of the FTCA claims and any evidence therein should be obtained and associated with the claims file prior to re-adjudication. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with a VA examination to specifically address the claimed brown recluse spider bite residuals, to include scars and bilateral arm and neck pain. The examiner should obtain a detailed history from the Veteran of the bite incidents and the subsequent symptoms. A physical examination of the asserted bite locations to determine if there are remaining lesions or scars is necessary, and color photographs of the area should be taken for the record. The VA examiner should provide an opinion as to whether it is at least as likely as not (probability 50 percent or greater) that the Veteran has any residuals, to include scars or bilateral arm or neck pain, of insect bites in service, to include brown recluse spider bites. The examiner is advised that if the Veteran is shown to have scarring or lesions in the areas of the asserted bites that are determined to NOT be the result of insect bites, including brown recluse spider bites, a discussion of the etiology of such findings is required. The examiner should then offer an opinion as to whether it is at least as likely as not (probability 50 percent or greater) that the scarring or lesion were incurred in service or are otherwise the result of service. The examiner should include a statement of the rationale or reasons for any opinions provided. 2. Obtain all available court records and evidence associated with the Veteran's tort claims under the Federal Tort Claims Act against VA with respect to all of the claims brought under 38 U.S.C.A. § 1151. Specifically, the AOJ must contact the Tort and Administrative Law Group of the VA Office of General Counsel, the applicable United States District Court, and, if necessary, the United States Department of Justice. A PACER search for documents should also be conducted. Associate all evidence obtained with the claims file. If the records are not obtained, and only if after continued efforts to obtain them shows that the records do not exist or further efforts to obtain them would be futile, the AOJ must provide to the Veteran a formal finding of unavailable that accomplishes the following: (a) informs her that VA was unable to obtain the records associated with her tort claims; (b) explains the efforts VA made to obtain such records; (c) provides a description of any further action VA will take regarding the claim, including, but not limited to, notice that VA will decide the claim based on the evidence of record unless the claimant submits the records VA was unable to obtain; and (d) notifies her that she is ultimately responsible for providing the evidence. 3. After completing the above to the extent possible, arrange for a VA examiner to review the record and offer an opinion with respect to the 1151 claim based on dental treatment. Specifically, an examiner with dental expertise should offer an opinion on whether it is at least as likely as not that there was additional disability to the Veteran relating to the use of chemicals in cleaning the Veteran's dental device in May 2014. If so, is it at least as likely as not that the use of such chemicals in cleaning the Veteran's dental device constitutes carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the treatment provider? Finally, the examiner should state whether any additional disability was the result of an event not reasonably forseeable. 4. After completing the above to the extent possible, arrange for a VA examiner to review the record and offer an opinion with respect to the 1151 claim based on x-ray treatment. Specifically, an orthopedist or similarly qualified examiner should offer an opinion on whether it is at least as likely as not that there was additional disability to the Veteran relating to an incident in which a radiologist placed sandbags in the Veteran's hands during an x-ray in August 2014, leading to claimed neck, back and shoulder disabilities. If additional disability is found, is it at least as likely as not that the unexpected and sudden use of sandbags during the x-ray procedure constitutes carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the treatment provider? Finally, the examiner should state whether any additional disability was the result of an event not reasonably forseeable. 5. Thereafter, readjudicate the issues on appeal. If any of the benefit sought on appeal are not granted in full, issue a supplemental statement of the case (SSOC) and provide the Veteran and her representative, if any, an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ Eric S. Leboff Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs