Citation Nr: 1805433 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 12-04 006 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a disability manifested by myalgias of the back and neck. 2. Entitlement to service connection for a disability manifested by atypical chest pain. 3. Entitlement to service connection for a disability manifested by memory loss. 4. Entitlement to higher initial disability ratings for rhinitis, currently evaluated as 0 percent (noncompensable) disabling for the period prior to August 5, 2016, and as 10 percent disabling for the period from August 5, 2016. 5. Entitlement to a 10 percent evaluation based on multiple, noncompensable, service-connected disabilities. REPRESENTATION Appellant represented by: Colorado Division of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from August 1988 to October 1992, including combat service in Iraq, and his decorations include the Valorous Unit Award. These matters initially came to the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision that, in pertinent part, denied service connection for myalgias, for atypical chest pain, and for memory loss; and that granted service connection for rhinitis evaluated as 0 percent (noncompensable) disabling effective May 24, 2010. The RO also denied entitlement to a 10 percent evaluation based upon multiple noncompensable service-connected disabilities. The Veteran timely appealed the denials of service connection and appealed for higher ratings. In December 2015, the Veteran testified during a video conference hearing before the undersigned. During the hearing, the undersigned granted the Veteran's request for a 90-day abeyance to submit additional evidence or argument directly to the Board. In March 2016, the Veteran submitted additional evidence to the Board. The Board accepts that evidence for inclusion in the record. See 38 C.F.R. § 20.709 (2017). In August 2016, the Board remanded the matters for additional development. The Board is satisfied there was substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Court has held that a request for a TDIU, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for higher compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Board notes that the Veteran continues to work. While the Veteran has indicated that he is unable to perform some work activities due to his service-connected disabilities, he has not alleged that his service-connected disabilities prevent him from obtaining or maintaining substantially gainful employment. The matter is not raised by the record, and the Board finds it unnecessary to remand the matter for further action. FINDINGS OF FACT 1. The Veteran had active service in the Southwest Asia theater of military operations (SWA) during the Persian Gulf War. 2. The Veteran does not have an undiagnosed illness, characterized by muscle pain and joint pain; and does not have a disability manifested by myalgias of the back and neck that either had their onset in active service, or are otherwise related to a disease or injury during active service-to include service in SWA. 3. The Veteran does not have an undiagnosed illness, characterized by respiratory or cardiovascular problems; and does not have a disability manifested by atypical chest pain that either had its onset in active service, or is otherwise related to a disease or injury during active service-to include service in SWA. 4. The Veteran does not have an undiagnosed illness, characterized by memory loss; and does not have a disability manifested by memory loss that either had its onset in active service, or is otherwise related to a disease or injury during active service-to include service in SWA. 5. Throughout the rating period, the Veteran's rhinitis has been manifested by subjective complaints of interference with breathing, no polyps, and with greater than 50 percent obstruction of each nostril. 6. For the period from May 24, 2010, the Veteran is in receipt of a compensable rating. CONCLUSIONS OF LAW 1. A disability manifested by myalgias of the back and neck, to include as a disability due to undiagnosed illness, was not incurred in or aggravated in service. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). 2. A disability manifested by respiratory or cardiovascular problems, to include as a disability due to undiagnosed illness, was not incurred in or aggravated in service. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). 3. A disability manifested by atypical chest pain, to include as a disability due to undiagnosed illness, was not incurred in or aggravated in service. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). 4. A disability manifested by memory loss, to include as a disability due to undiagnosed illness, was not incurred in or aggravated in service. 38 U.S.C. §§ 1110, 1117, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). 5. For the period prior to August 5, 2016, the criteria for a 10 percent disability rating for rhinitis are met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.97, Diagnostic Code 6522 (2017). 6. The criteria for a disability rating in excess of 10 percent for rhinitis are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.97, Diagnostic Code 6522 (2017). 7. For the period from May 24, 2010, there is no legal entitlement to a 10 percent disability evaluation for multiple noncompensable service-connected disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 3.324 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). These duties have been satisfied in this appeal. All available records identified by the Veteran as relating to his claims have been obtained, to the extent possible. Reports of VA examinations in connection with the claims on appeal are of record and appear adequate. The opinions expressed therein are predicated on a substantial review of the record and consideration of the Veteran's complaints and symptoms. The Veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. Given these facts, there is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C. § 5103A(a)(2). II. Service Connection Service connection is awarded for disability that is the result of a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. Id. The Federal Circuit has held that section 3.303(b) applies only to those chronic conditions specifically listed in 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Notably, neither myalgias of the back and neck, atypical chest pain, nor memory loss are considered chronic or presumptive diseases. See 38 U.S.C. § 1101. Specific to Persian Gulf War service, service connection may be granted for objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms-to include muscle pain and joint pain, respiratory signs or symptoms, and neurological signs or symptoms. The chronic disability must have become manifest either during active military, naval, or air service in the Southwest Asia theater of military operations (SWA) during the Persian Gulf War, or to a degree of 10 percent or more disabling not later than December 31, 2021, and must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. A Persian Gulf Veteran is a Veteran who served on active military, naval, or air service in SWA during the Persian Gulf War. 38 U.S.C. § 1117(e); 38 C.F.R. § 3.317(d). In this case, the Veteran's DD Form 214 shows service in SWA, and confirms receipt of the Southwest Asia Service Medal. This medal generally indicates service in the area and time period referenced under 38 C.F.R. § 3.317. When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Veteran contends that service connection for disabilities manifested by myalgias of the back and neck, by atypical chest pain, and by memory loss is warranted based on his service in SWA during the Persian Gulf War. He also contends that service connection is warranted on the basis that he was involved in a vehicular accident that occurred while deployed in Iraq; and, thereby, hurt his back and sustained mild head injuries. The Veteran is competent to describe his symptoms. Service treatment records reflect that the Veteran's spine, lungs and chest, and head were normal upon clinical evaluation at separation from active service in September 1992. Neither defects nor any diagnoses were noted by the examiner. On a "Report of Medical History" completed by the Veteran at that time, he checked "no" in response to whether he ever had or now had recurrent back pain; bone, joint, or other deformity; swollen or painful joints; head injury; pain or pressure in chest; or loss of memory or amnesia. Chest X-rays at the time also were normal. In December 2015, the Veteran testified that he was driving a vehicle on the main highway to go to a phone center in Iraq; and that, on the return trip, it was so dark that he did not see an 18-wheeler with a trailer backing up on the highway. The Veteran testified that he tried to swerve and that he hit the sand, and that his vehicle rolled over three or four times. The Veteran testified that he hurt his back and had mild head injuries, and that another soldier who was tossed from the vehicle was medevac'd to a hospital. The Veteran testified that his memory has worsened since the accident, and that he now had to write everything down at work. In March 2016, another former service member confirmed the in-service motor vehicle accident and that the Veteran was treated with medication for back pain. In this case, the Veteran saw combat with the enemy while serving as a wheel vehicle repairer in Iraq. His Form DD 214 reflects receipt of the Valorous Unit Award, among other awards. Hence, he is entitled to the considerations afforded under 38 U.S.C. § 1154(b); and his lay statements regarding the circumstances of his in-service injuries are accepted as credible and persuasive for purposes of establishing an incident in service. A. Myalgias of the Back and Neck During a VA examination in December 1993, the Veteran reported that his joints ached off and on approximately once every two-to-three weeks. He tried to stretch the joints, and reported that his discomfort lasted from one-to-three hours at a time and seemed to resolve on its own. The December 1993 examiner diagnosed arthralgias by history, and noted currently insufficient evidence to make a diagnosis of any acute or chronic disorder. VA records show complaints of back pain in December 2009. During a May 2010 VA examination, the Veteran complained of myalgias and described pain all over his arms, back, and legs. Following examination, diagnoses included elevated CPK (creatine phosphokinase) with myalgias, due to or caused by excessive body building. The May 2010 examiner opined that this is a known condition that is non-pathologic, and that is not due to environmental exposures. Reports of VA examinations in August 2016 show diagnoses of degenerative joint and degenerative disc disease at L5-S1 (thoracolumbar spine disability) and degenerative disc disease of the cervical spine, status-post discectomy at C6-C7 (cervical spine disability). In as much as the August 2016 examiner attributed the Veteran's myalgias of the back and neck to known clinical diagnoses, they cannot be considered undiagnosed illnesses or qualifying chronic disabilities for entitlement to service connection based on the Veteran's service in the Persian Gulf. As to service connection on a direct basis, the August 2016 examiner opined that the Veteran's myalgias of the back and neck are less likely than not incurred in or caused by the in-service injury, event, or illness. In support of the opinion, the examiner indicated that there are no records of a back injury sustained in active service, or of any acute neck injury or chronic neck condition in active service. The August 2016 examiner noted that another former service member confirmed that the Veteran had a motor vehicle accident in active service, resulting in temporary back pain; and that the Veteran was given medication and told to rest for about one week. The former service member did not mention any neck pain. Nor is there any description of persistent back problems or of a chronic back problem, and the August 2016 examiner noted that the Veteran failed to report any chronic back problem at his separation examination in 1992. While the Veteran currently reported having back pain since leaving active service, his prior medical records were deemed more credible by the August 2016 examiner. In this regard, the August 2016 examiner reasoned that memories fade with time, and that the Veteran's denial of anabolic steroid use in May 2010 was contradicted by his private medical records. The August 2016 examiner then opined that it is more likely than not that the purported acute back pain in 1991 was an acute muscle strain which resolved with time, as is usually the case; and that it is more likely than not that the Veteran's chronic degenerative joint and disc disease at L5-S1 is the result of years of strenuous weightlifting with anabolic steroid use. The Board finds this opinion to be persuasive in finding that current thoracolumbar spine disability is not related to disease or injury in active service. The August 2016 examiner reviewed the medical history and provided a rationale. Therefore, the opinion is afforded significant probative value. Nieves-Rodriguez, 22 Vet. App. at 304. With regard to the Veteran's neck pain, the August 2016 examiner noted that the Veteran had neck surgery around 2013; no private medical records were provided of the surgery, which reasonably would be expected to contain a history of onset. The August 2016 examiner then opined that it is more likely than not that the Veteran sustained an acute C6-C7 disc herniation around 2013 that was completely unrelated to the in-service motor vehicle accident or active service. The Board notes the normal findings in service treatment records establish that a cervical spine disability was not "noted" during active service or within the first post-service year. Clearly, the Veteran did not have characteristic manifestations sufficient to identify a chronic disease entity; and current cervical spine disability subsequently was diagnosed long after service. Here, the evidence is against a finding that the Veteran's cervical spine disability was incurred in active service. There is no showing of arthritis of the cervical spine during active service or within the first year after separation; and current cervical spine disability subsequently was diagnosed long after service. The Board is within its province to make a determination as to whether the evidence supports a finding of service incurrence. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). As indicated above, the first credible showing of pertinent disability is many years after active service with no competent evidence that either disability is in any way related to active service. While the Veteran is competent to report symptoms of back pain and neck pain, he is not competent to provide an etiology opinion linking current myalgias of the back and neck to active service, as this is beyond the capacity of a lay person to observe. Moreover, even if he were competent to render a diagnosis and opinion, his opinion is outweighed by the August 2016 examiner's opinions that current myalgias of the back and neck are not related to disease or injury in active service. The Veteran had specifically denied recurrent back pain at his separation examination; and there was no mention of neck pain following the in-service motor vehicle accident. The August 2016 examiner's opinions are entitled to greater probative weight as the examiner reviewed the history, conducted a physical examination, and provided opinions that generally are supported by a rationale. Lastly, the August 2016 examiner opined that it is extremely unlikely that any service-connected disability caused, contributed to, or aggravated the Veteran's degenerative disease. In support of the opinion, the examiner reasoned that the Veteran's service-connected disabilities (PTSD, sleep apnea, irritable bowel syndrome, and rhinitis) have no influence on the thoracolumbar spine or cervical spine, or on the development of degenerative joint disease; and that disabilities of the knees have not resulted in any significant gait disturbance or biomechanical effect that would influence the lumbar or cervical spine. The Board agrees. In short, for the reasons and bases stated above, the Board concludes that the evidence weighs against granting service connection for myalgias of the back and neck. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Atypical Chest Pain Service treatment records include chest X-rays taken in 1988 that reveal a right lower lobe infiltrate. The report of a December 1993 VA examination reveals that the Veteran was evaluated for symptoms of a bad cold in Germany after Desert Storm; and that he was told that he had walking pneumonia. The Veteran reportedly was treated with antibiotics, felt better after several days, and did not return for follow-up. On examination in December 1993, the Veteran's chest was clear to auscultation and percussion; and, on cardiac examination, he had a regular rate and rhythm with no detectable murmurs, rubs, or gallops. The assessment was right lower-lobe infiltrate by history occurring after discharge from Persian Gulf duty and currently asymptomatic and with radiographic evidence of normal chest X-ray. Chest X-rays taken in April 2010 also were normal. During a May 2010 VA examination, the Veteran complained of chest pain. The examiner noted that the Veteran was exposed to oil and fire smoke and burning trash in Kuwait; and that, since his discharge from active service, the Veteran has had no exposures to fumes, smoke, or dust. He reported that his lungs have felt kind of restricted in that it was hard to take deep breaths; and that he had frequent chest congestion and nose congestion with a dry cough, occurring about every two months or so and lasting about two weeks. Following examination, the May 2010 examiner diagnosed atypical chest pain of unknown etiology; and opined that it must be considered an undiagnosed illness. In support of the opinion, the examiner reasoned that there was not enough evidence to attribute this to any cardiac disease or to a side effect of body building. There was no left ventricular hypertrophy, and METs (metabolic equivalents) level was estimated to be from 7 to 10. The report of an August 2016 VA examination reflects a medical history of periods of atypical chest pain. The Veteran then contended that these were anxiety attacks, which still occurred monthly for 45-to-60 seconds at a time and possibly were related to his PTSD. The chest sensations did improve with medication. The Veteran reported no chest pains with any physical activity. The August 2016 examiner estimated that the Veteran's METs level, given his athletic activities, would exceed 10 and without any symptoms in the chest. All diagnostic tests were normal. Following examination, the August 2016 examiner opined that the Veteran does not now have, or at any time in the past has had, a documented heart or chest abnormality or condition to explain his "atypical chest pains." In support of the opinion, the examiner reasoned that there is no heart or chest diagnosis associated with the Veteran's atypical chest pain. The examiner indicated that the Veteran stated the symptoms, which still occasionally recurred, are more likely than not due to mild anxiety associated with his chronic PTSD symptoms; and are treated appropriately and effectively with medication. The Veteran is competent to testify as to symptoms he has experienced that are capable of lay observation, such as atypical chest pain. The question therefore becomes whether a disability manifested by respiratory signs or symptoms or by cardiovascular signs or symptoms has become manifest to a degree of 10 percent or more disabling since his service in SWA. For the reasons outlined below, the Board finds that one has not. The diagnostic criteria applicable to evaluating diseases of the heart are found in 38 C.F.R. § 4.104. Several diagnostic codes relate to the cardiovascular system and are explained herein, to the extent of reaching the required 10 percent disability threshold. Primarily, a 10 percent rating is warranted for diseases of the heart where, (1) stress test results demonstrate, generally, a workload of greater than 7 METs (metabolic equivalents) but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness or syncope, or; (2) when continuous medication is required. Although one examiner estimated the Veteran's METs level to be from 7 to 10, there is no showing of dyspnea, fatigue, angina, dizziness or syncope; and an exercise stress test in 2000 was normal. Moreover, the Veteran has associated the atypical chest pain with mild anxiety due to PTSD, for which medication works well for treatment as needed. There is no evidence that continuous medication is required for atypical chest pain. With regard to a respiratory condition, the Board notes that the Veteran already is service-connected for rhinitis, which is separately evaluated as shown below. The anti-pyramiding provision of 38 C.F.R. § 4.14 directs that the evaluation of the 'same disability' or, more appropriately in this case, the 'same manifestation' under various diagnoses is to be avoided. Other diagnostic criteria applicable to evaluating diseases of the trachea and bronchi, and of the lungs and pleura are found in 38 C.F.R. § 4.97. Primarily, a 10 percent rating is warranted for respiratory diseases where pulmonary function testing demonstrates a forced expiratory volume in one second (FEV-1) of 71 to 80 percent predicted, or; a force expiratory volume in one second to forced vital capacity ratio (FEV-1/forced ventilatory capacity (FVC)) of 71 to 80 percent predicted, or; a diffusion capacity of carbon monoxide, single breath (DLCO (SB)) of 66 to 80 percent predicted. Here, there is no showing of any pulmonary function testing results meeting the required 10 percent disability threshold. Specifically, pulmonary function testing in May 2010 demonstrated FEV-1 of 94 percent predicted and FEV-1/FVC of 101 percent predicted. Moreover, VA records dated in May 2016 show no history of chronic obstructive pulmonary disease, no dyspnea, and no current pneumonia. The Board finds that the overall evidence does not demonstrate that any respiratory disease manifested to a degree of 10 percent or more disabling at any time since the Veteran's active service in SWA. Furthermore, if the Veteran's atypical chest pain was rated by analogy to muscle injury under 38 C.F.R. § 4.73, Diagnostic Code 5321, none of his symptoms would warrant a compensable evaluation. His report of chest pain, even if credible, would not be compensable. The Board notes that respiratory signs or symptoms and cardiovascular signs or symptoms are objective signs of undiagnosed illness or of chronic multisymptom illness. 38 C.F.R. § 3.317(b). Here, although the Veteran has complained of atypical chest pain, those complaints have not been associated with any respiratory finding or cardiac pathology or other objective signs or symptoms that are compensably disabling. While the Veteran is credible in his descriptions, he has not exhibited symptomatology of a compensable nature that would warrant a finding of undiagnosed illness. In sum, the normal findings in service treatment records establish that neither a respiratory nor heart disease was "noted" during active service or within the first post-service year. In addition, the Veteran did not have characteristic manifestations sufficient to identify a chronic disease entity. In fact, despite his complaints, no respiratory or cardiac disease or injury has ever been identified. Rather, the Veteran has atypical chest pain, which is treated as mild anxiety due to PTSD. Nothing in the record reflects that findings of atypical chest pain have resulted in disability (impairment) or rise to a compensable level. For the reasons and bases stated above, the Board concludes that the evidence weighs against granting service connection for a disability manifested by atypical chest pain. C. Memory Loss During a May 2010 VA examination, the Veteran complained of memory loss and reported a vague sense of not being able to recall important information. At the time he denied any history of head trauma or loss of consciousness. The examiner noted that the Veteran complained of a subjective feeling of decreased memory, but in fact performed well on examination and in the normal range; and did not fulfill criteria for any psychiatric diagnosis with regard to cognitive disorder. Following examination, the May 2010 examiner opined that memory loss was not a diagnosable illness from a psychiatric standpoint at the time, despite subjective complaints. In support of the opinion, the examiner reasoned that there was no significant objective evidence of detectable cognitive impairment or decline. During a May 2014 VA examination, the Veteran described some memory inefficiency, such as difficulty remembering times and dates and misplacing items. He had some difficulty recalling dates and sequences in his autobiographical history. His performance on cognitive screening fell just below the normal range, and had difficulty with cube copy and was unable to answer one abstract question. He missed three of the five words on delayed recall. The May 2014 examiner opined that the Veteran's cognitive difficulties were likely related to his heightened state of anxiety during the evaluation; and that symptoms of mild anxiety were attributable to PTSD. During an August 2016 VA examination, the Veteran reported being the restrained driver in an in-service "rollover" motor vehicle accident. He estimated that he lost consciousness for five-to-ten minutes. He reported receiving pain medication and being off duty for three-to-four days due to back pain and headache. He reportedly returned to full duty and "felt okay." His current concerns regarding concussion were limited to memory difficulty. Following examination, the August 2016 examiner found no records indicating that the Veteran sustained a traumatic brain injury while in active service; and noted that the former service member who confirmed the motor vehicle accident had not mentioned a head injury for the Veteran. The examiner also noted that the Veteran had denied any head injury at his separation examination. Also in August 2016, other VA examiners diagnosed PTSD, mild; and opined that the Veteran's memory loss is at least as likely as not a symptom of PTSD. In support of the opinion, one examiner reasoned that memory loss is a common manifestation of PTSD due to problems concentrating and was associated with anxiety and dissociative symptoms of PTSD. The examiner explained that it was not memory loss per se, but instead problems attending to the environment resulting in failure to take in necessary information; and that the Veteran compensated for this failure through use of external aids, such as a notepad and pen. The August 2016 examiner also opined that it is less likely as not that the service-connected PTSD has aggravated the Veteran's memory impairment. In support of the opinion, the examiner reasoned that there is no psychiatric diagnosis associated with memory loss which could be aggravated; and that memory loss is a symptom of PTSD. In as much as the August 2016 examiner attributed the Veteran's memory loss to a known clinical diagnosis, it cannot be considered an undiagnosed illness or a qualifying chronic disability for entitlement to service connection based on the Veteran's service in the Persian Gulf. As to service connection on a direct basis, the normal findings in service treatment records establish that memory loss was not "noted" during active service or within the first post-service year. In addition, the Veteran did not have characteristic manifestations sufficient to identify a chronic disease entity. In fact, despite his complaints, no cognitive disorder has ever been identified. Rather, the Veteran has symptoms of memory loss attributed to PTSD. Nothing in the record reflects that findings of memory loss have resulted in disability (impairment) or rise to a compensable level. For the reasons and bases stated above, the Board concludes that the evidence weighs against granting service connection for a disability manifested by memory loss. III. Higher Ratings Disability evaluations are determined by comparing a Veteran's symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2017). The Veteran's entire history is reviewed when making disability evaluations. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 4.3 (2017). The Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). He is also competent to report symptoms of rhinitis. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe the symptoms and their effects on employment and daily activities. The Board will consider not only the criteria of the currently assigned diagnostic code, but also the criteria of other potentially applicable diagnostic codes. Service connection has been established for rhinitis, effective May 24, 2010. The RO currently assigned an initial 0 percent (noncompensable) disability rating under 38 C.F.R. § 4.97, Diagnostic Code 6522, pertaining to allergic or vasomotor rhinitis, prior to August 5, 2016; and assigned a 10 percent disability rating from August 5, 2016, based on evidence of nasal congestion. A 10 percent disability rating is assigned for allergic or vasomotor rhinitis without polyps, but with greater than 50-percent obstruction of the nasal passages on both sides or complete obstruction on one side. A 30 percent disability rating is assigned for allergic or vasomotor rhinitis with polyps. 38 C.F.R. § 4.97, Diagnostic Code 6522 (2017). Alternatively, under the General Rating Formula for sinusitis (Diagnostic Codes 6510 through 6514), a 10 percent rating requires one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating requires three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating requires osteomyelitis following radical surgery or; near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. 38 C.F.R. § 4.97, Diagnostic Codes 6510 through 6514 (2017). A note following Diagnostic Codes 6510 through 6514 defines an incapacitating episode of sinusitis as one that requires bed rest and treatment by a physician. A May 2010 VA examiner noted mild restrictive airways disease with some bronchodilator response. In October 2010, the Veteran asserted that his chronic nonallergic rhinitis was more severe than currently rated. During a November 2011 VA examination, the Veteran reported the onset of nasal congestion at the time of his discharge from active service in 1992; and that the nasal congestion would come and go. He reported persistent nasal congestion over the last two years. About fifteen months ago, he started using "Flonase," two puffs in each side of his nose once a day, which helped reduce nasal congestion. The Veteran reported having no sinus problem or infection, and reported no increase in nasal congestion since the May 2010 VA examination. Examination in November 2011 revealed that there was not greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis, and that there was not complete obstruction on one side due to rhinitis. Nor was there permanent hypertrophy of the nasal turbinates. There were no nasal polyps, and there were no other pertinent findings. The Veteran did not have chronic sinusitis. In September 2015, the Veteran's treating physician indicated that the Veteran was suffering from severe rhinitis and nasal airway obstruction. Computed tomography scans of the paranasal sinuses in October 2015 revealed normal aeration character of paranasal sinuses; soft tissue prominence/swelling of right inferior nasal turbinate; and septal deviation to the left not associated with meatal compromise. In December 2015, the Veteran testified that he recently underwent a procedure by an ear, nose, and throat physician, in order to try to clear airways and look for polyps. During an August 2016 VA examination, the Veteran reported that he had a septoplasty done in February 2016 for chronic nasal congestion. He indicated that computed tomography of his sinuses in October 2015 revealed a septal deviation. The Veteran reported that the surgery provided some relief, but he still had congestion at the end of the day. The Veteran reported breathing through his nose while seated or standing and resting, but that he had to breathe through his mouth with any exertion due to nasal congestion. He continued to use Flonase daily. The Veteran did not recall any broken nose in his lifetime, but noted having a slight bloody nose and black eyes after the in-service rollover motor vehicle accident. Examination in August 2016 revealed that there was greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis; however, neither side was completely obstructed. There was permanent hypertrophy of the nasal turbinates. There were no nasal polyps. The examiner also noted that the Veteran's deviated septum was traumatic, and there was not at least 50 percent obstruction of the nasal passage on both sides due to traumatic septal deviation. Nor was there complete obstruction on either side due to traumatic septal deviation. There were no other pertinent findings. The Veteran did not have chronic sinusitis. The examiner noted that the Veteran remained a mouth-breather with any activity due to reduced nasal air flow, even after surgery. The examiner also opined that it is more likely than not that the Veteran's deviated septum was due to a traumatic event-namely, the documented motor vehicle accident in active service. Here, the Board is presented with evidence from differing examiners. The Board is unconvinced that the Veteran became worse on the date of examination. Rather, the August 2016 examination seems to be more consistent with the prior lay and medical evidence. In this regard, the Veteran's rhinitis has been symptomatic, as indicated by reports of daily nasal congestion, throughout the rating period. Recent examination shows that there was greater than 50 percent obstruction of the nasal passage on both sides. Together, the evidence warrants an initial 10 percent, but no higher, disability rating for rhinitis. Computed tomography scans in October 2015 revealed no polyps. His symptoms do not meet or approximate the criteria for a disability rating in excess of 10 percent for rhinitis at any time under Diagnostic Code 6522. Additionally, the anti-pyramiding provision of 38 C.F.R. § 4.14 directs that evaluation of the 'same disability' or, more appropriately in this case, the 'same manifestation' under various diagnoses is to be avoided. Indeed, in Esteban v. Brown, 6 Vet. App. 259 (1994), the Court held that, for purposes of determining whether a Veteran is entitled to separate ratings for different problems or residuals of an injury, without violating the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of, or overlapping with the symptomatology of the other conditions. Pursuant to Diagnostic Code 6502, a maximum 10 percent disability rating is warranted for traumatic deviation of the nasal septum with 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. 38 C.F.R. § 4.97, Diagnostic Code 6502 (2017). Here, the assigned 10 percent disability rating under Diagnostic Code 6522 already contemplates nasal obstruction; hence, no separate disability rating for traumatic deviated septum can be assigned without violating the regulatory prohibition against pyramiding under 38 C.F.R. § 4.14. No other diagnostic code is applicable. Again, the evidence as a whole shows that the Veteran's disability has met the criteria for an initial 10 percent, but no higher, disability rating. The Board has considered the Veteran's lay assertions regarding severity and finds that they support an initial 10 percent, but no higher, disability evaluation. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. IV. Multiple Noncompensable Evaluations Whenever a Veteran is suffering from two or more separate permanent service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree under the Rating Schedule, the rating agency is authorized to apply a 10 percent rating, but not in combination with any other rating. See 38 C.F.R. § 3.324 (2017). The provisions of 38 C.F.R. § 3.324 are predicated on the existence only of noncompensable service-connected disabilities. Once a compensable rating for any service-connected disability has been awarded, the applicability of the provisions under 38 C.F.R. § 3.324 is rendered moot. See Butts v. Brown, 5 Vet. App. 532, 541 (1993). Since the Board has uniformly assigned a 10 percent evaluation for rhinitis, the application of provisions of 38 C.F.R. § 3.324 is rendered moot. ORDER Service connection for a disability manifested by myalgias of the back and neck is denied. Service connection for a disability manifested by atypical chest pain is denied. Service connection for a disability manifested by memory loss is denied. For the period prior to August 5, 2016, a 10 percent disability rating for rhinitis is granted, subject to the regulations governing the award of monetary benefits. A disability rating in excess of 10 percent for rhinitis is denied. For the period from May 24, 2010, entitlement to a 10 percent evaluation for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324 is dismissed. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs