Citation Nr: 18141107 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 15-30 176 DATE: October 9, 2018 ORDER A rating in excess of 50 percent for a major depressive disorder (MDD) prior to December 5, 2014, is denied. A 70 percent rating, but no more, for MDD since December 5, 2014, is granted. A 10 percent rating, but no more, for a lumbar and thoracic spine strain is granted. A compensable rating for left ear hearing loss is denied. Service connection for hypertension is denied. Service connection for a traumatic brain injury (TBI) is granted. Service connection for a left-hand disorder is denied. Service connection for chronic fatigue syndrome (CFS) is denied. Service connection for a respiratory disorder is denied. REMANDED Service connection for a right-hand disorder. Service connection for a cervical spine disorder. Service connection for a right knee disorder. Service connection for migraine headaches. FINDINGS OF FACT 1. The Veteran had active service from July 2005 to January 2011. 2. The Veteran served on active duty in the Southwest Asia Theater during the Persian Gulf War, to include service in Iraq, from February 2006 to April 2008. 3. Prior to December 5, 2014, MDD was manifested by subjective complaints of frequent impaired sleep, daily irritability, hypervigilance, detachment from others, diminished interest, difficulty with attention and concentration, depression, and increasing anxiety; objective findings included irritability with no associated periods of violence, and a tendency to isolate himself. 4. Since December 5, 2014, MDD has been manifested by subjective complaints of anxiety and depression that made it difficult to perform daily activities, difficulty concentrating, an inability to perform tasks in a timely manner, intermittent difficulty remembering daily activities, irritability, and trouble falling asleep; objective findings include difficulty with crowds, depression, memory loss, and an intermittent inability to perform activities of daily living, including maintenance of personal hygiene. 5. For the entire period on appeal, a low back disability has been manifested by subjective complaints of chronic, severe, shooting, and sharp back pain that is aggravated by walking or laying down for long periods of time and limits on the ability to perform daily activities with weekly flare-ups with pain of increasing severity; objective findings include pain upon flexion, limited range of motion, and a limited ability to perform strenuous activities and repetitive activities involving the twisting or bending of the lower back. 6. For the entire period on appeal, audiometric testing revealed, at worst, an average puretone threshold of 28 decibels (dBs), and 96 percent speech recognition in the left ear. 7. TBI is etiologically related to service. 8. Hypertension for VA compensation purposes was not shown in service, was not shown within one year of service, and is not etiologically related to service. 9. A left-hand disorder is not shown. 10. The Veteran does not have current diagnoses of either a respiratory disorder or CFS and does not have objective symptoms of an undiagnosed illness or a medically unexplained chronic multi-symptom illness (MUCMI) causing either a respiratory disorder or CFS. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent prior to December 5, 2014 for MDD have not been met. 38 U.S.C. §§ 1155, 5103(a), 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.130, Diagnostic Codes (DCs) 9400, 9411, 9412, 9434 (2017). 2. The criteria for a 70 percent rating, but no more, for MDD disorder as of December 5, 2014 have been met. 38 U.S.C. §§ 1155, 5103(a), 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.130, DCs 9400, 9411, 9412, 9434 (2017). 3. The criteria for a 10 percent rating, but no more, for lumbar and thoracic strain have been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, DCs 5003, 5237 (2017). 4. The criteria for a compensable rating for left ear hearing loss has not been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code (DC) 6100 (2017). 5. Resolving reasonable doubt in his favor, a TBI was incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309, 3.310 (2017). 6. Hypertension was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309, 3.310 (2017). 7. A left-hand disability was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309, 3.310 (2017). 8. CFS was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309, 3.310, 3.317 (2017). 9. A respiratory disorder was not incurred in service. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309, 3.310, 3.317 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. MDD With regard to MDD, all psychiatric disabilities are evaluated under a General Rating Formula for Mental Disorders (“General Rating Formula”). Under the General Rating Formula, the current 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks occurring more than once a week, difficulty in understanding complex commands, impairment of short-term memory (i.e. retention of only highly learned material or forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family, relations, judgment, thinking, or mood, due to symptoms including: suicidal ideation, obsessional rituals which interfere with routine activities, speech that is intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, and an inability to establish effective work and social relationships. The symptoms listed under the rating criteria are meant to be examples of symptoms that would warrant the rating, but they are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Furthermore, the rating code requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment at a level consistent with the assigned rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). MDD Prior to December 5, 2014 In an April 2011 VA examination, the Veteran reported that since 2009 he had experienced symptoms including daily detachment from others, diminished interest, frequent impaired sleep, daily irritability and hypervigilance, occasional exaggerated startle response, daily moderate depressed mood, daily low self-esteem, and psychomotor agitation. He said that he was not currently employed but got along well with his co-workers and supervisors in the Army. He said that while he did not miss any time off work, he had difficulty reporting on time due to oversleeping. He explained that he separated from his wife and that they had frequent arguments due to financial problems and unemployment. He finally denied suicidal ideations and stated that he engaged in occasional social and leisure activities. The examiner found that the Veteran’s ability to perform activities of daily living was not impaired, that he exhibited no delusions, hallucinations, or inappropriate behavior, and that he had no suicidal or homicidal ideations. He had no impairment of thought process or communication, a normal ability to maintain his hygiene, obsessive and ritualistic checking behavior, and no impaired impulse control. His rate and flow of speech were normal and he had no panic attacks; however, he had a daily moderate depressed mood, frequent moderate anxiety, a sleep impairment, low self-esteem, and psychomotor agitation. The examiner diagnosed a moderate major depressive disorder and opined that the Veteran did not meet the DSM-IV criteria for a diagnosis of either PTSD or a generalized anxiety disorder. In an October 2011 medical treatment note, the Veteran reported that he had suicidal thoughts and was admitted for treatment at a mental health clinic. In subsequent medical treatment notes, he denied suicidal ideations. In medical treatment notes between October 2011 and December 5, 2014, the Veteran reported difficulty with attention, concentration, and remembering common information, important dates, phone numbers and basic tasks. He noted that he had increasingly severe anxiety around others and a lack of interest or pleasure in activities he once enjoyed. However, he found stable housing, got two dogs, developed a friendship and graduated as an occupational therapist. Clinicians found that he had adequate grooming and hygiene, was oriented to person, place, time, and purpose, had an anxious mood and congruent affect, a linear and goal directed thought process, logical thought content, intact insight and judgment, and no delusions, obsessions, auditory or visual hallucinations. Based on the above, a rating in excess of 50 percent prior to December 5, 2014 is not warranted. In this regard, the medical treatment notes establish that the Veteran’s depression and anxiety prevent him from functioning appropriately, independently, and effectively. Furthermore, he had difficulty adapting to stressful circumstances; however, the record reflects no suicidal ideations after October 2011. Additionally, the medical treatment notes reveal that his speech was normal, he was oriented to person, place, time, and situation, and he maintained appropriate hygiene. While he exhibited irritability, the examination and medical treatment records do not reflect that his irritability was the result of impaired impulse control. Similarly, while he was isolative, he was able to develop a friendship and graduate as an occupational therapist. Accordingly, prior to December 5, 2014, the medical evidence does not support a rating in excess of 50 percent. MDD Since December 5, 2014 In a December 5, 2014 medical treatment note, the clinician reported that the Veteran’s anxiety and depression made it difficult for him to manage his daily activities, including an inability to perform in crowded environments. The clinician found that the Veteran’s severe anxiety was evidenced by physiological symptoms including diaphoresis, palpitations, and a sensation of shortness of breath when in crowded settings. The clinician opined that performing in crowded settings caused a significant distress and impairment in his mental functioning. In a subsequent January 2015 medical treatment note, the Veteran described experiencing a sense of confusion for several minutes at a time on a daily basis, during which he wondered what he needed to be doing. He further reported difficulty concentrating on a given task, word-finding in conversations, and having a habit of saying the wrong things in conversations. He noted that he often forgot to do things in a timely manner, and would miss ingredients when attempting to follow a recipe. He endorsed fidgeting, difficulty waiting for his turn, easy distractibility, and difficulty listening when spoken to. He said that he experienced intrusive and distressing recollections of service as well as nightmares several times per week. The clinician found that his insight, awareness, and recall appeared intact. His affect was full, his mood was mood euthymic, and he was alert and oriented to person, place, and time. His language abilities and insight appeared intact. His thought processing was logical and coherent and he reported no hallucinations, delusions, and suicidal or homicidal ideations. The clinician diagnosed MDD, PTSD, and insomnia. The Veteran subsequently reported in July 2015 that he had trouble falling asleep, felt tired throughout the day, and experienced irritability, anxiety with sweating, and shortness of breath. The clinician observed that he was isolative and had loss of interest with intermittent suicidal ideations. In a pair of October 2015 VA examinations, the examiner diagnosed PTSD and major depressive disorder. The examiner found that PTSD and MDD were manifested by an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self care, and conversation. The examiner reported that the Veteran symptoms included a depressed mood, anxiety, suspiciousness, panic attacks twice a week, near continuous depression affecting his ability to function independently, appropriately, and effectively, a chronic sleep impairment, mild memory loss, impairment of his short and long term memory, flattened affect, difficulty understanding complex commands, impaired judgment, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work-like setting, an inability to establish and maintain effective relationships, suicidal ideations, obsessional rituals that interfere with routine activities, and an intermittent inability to perform activities of daily living, including maintenance of personal hygiene. Based on the above, a70 percent rating, but no higher, is warranted since December 5, 2014. In this regard, the record reflects that the Veteran’s anxiety and depression made it difficult for him to manage daily activities or handle crowded environments. Additionally, the October 2015 VA examinations endorsed behavior including obsessional rituals that interfere with routine activities, near-continuous depression affecting the ability to function independently, appropriately, and effectively, intermittent inability to maintain personal hygiene, suicidal ideations, an inability to establish and maintain effective relationships, and difficulty in adapting to stressful circumstances including work or a work-like setting. Accordingly, the medical evidence a 70 percent rating is warranted for this period. A 100 percent rating is not warranted. To that end, while the Veteran demonstrated an intermittent inability to perform activities of daily living and impairment of his short and long-term memory, he was consistently oriented to person, place, time, and situation. Additionally, his thought process was linear and goal directed, his thought content was logical, his speech was appropriate, and no delusions and auditory of visual hallucinations were observed. Therefore, a rating in excess of 70 percent is not warranted. The Board has considered multiple statements offered by the Veteran regarding the increased severity of his acquired psychiatric disorder. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, he is not competent to identify a specific level of disability of these disorders according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the VA examinations and medical treatment notes) directly address the criteria under which his acquired psychiatric disorder is evaluated. Moreover, as the clinicians have the requisite medical expertise to render medical opinions regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusions, the Board affords the medical opinions great probative value. As such, these records are more probative than the subjective evidence of complaints of increased symptomatology provided by the Veteran. Lumbar and Thoracic Spine Strain The Veteran is rated under DC 5237 regarding lumbosacral or cervical strains. The Board will also consider all potentially relevant diagnostic codes. In order to warrant a compensable rating, the evidence must show: • degenerative arthritis of the spine with x-ray evidence of involvement of two or more major or minor joint groups (10% under DC 5003); • forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees (10%); • combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees (10%); • muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour (10%); • vertebral body fracture with a loss of 50 percent or more of the height (10%). In an April 2011 VA examination, the Veteran reported that he had daily upper and lower back pain that he rated as a 7 out of 10 in severity. He further related that he had flare-ups on a weekly basis, during which his pain increased to a 9 out of 10 in severity and resulted in his either visiting the emergency room or staying in bed all night. He said that flare-ups lasted several hours and that there were no real precipitating factors. He noted that his flare-ups were alleviated by pressure. Upon examination, his range of motion was measured as forward flexion to 90 degrees, extension to 30 degrees, left lateral flexion to 30 degrees, right lateral flexion to 30 degrees, left lateral rotation to 30 degrees, and right lateral rotation to 30 degrees. While pain was noted upon flexion, it did not increase and the Veteran did not have fatigue, weakness, incoordination, or lack of endurance. The examiner found no swelling, effusion, tenderness, muscle spasm, joint laxity, muscle atrophy, or fibrous or bony residual of fracture. The examiner diagnosed a lumbar and thoracic strain. In subsequent medical treatment notes between April 2011 and September 2015, the Veteran reported chronic back pain. Specifically, in a July 2012 medical treatment note, he noted that his chronic back pain radiated from his low back to his mid-back and was aggravated by walking or laying down for long periods. He was found to have a limited range of motion in his lumbosacral spine with pain. Similarly, he was found in November 2013 and May 2014 medical treatment notes to have constant, severe, shooting, and sharp back pain that impacted his ability to perform daily activities. In a September 2015 VA examination, the Veteran stated that he had low back aches with intermittent radiation of symptoms down his legs bilaterally. The examiner found that he had a bilateral injury to his spinal muscles and diagnosed a muscle injury to the cervical and thoracic lumbar region. The examiner noted that the Veteran was limited in strenuous activities such as running, jumping, or lifting heavy weights, and that he was limited in performing repetitive activities that involved the twisting or bending of his lower back or neck. Based on the above, a 10 percent rating, but no more, is warranted for the Veteran’s lumbosacral strain. The VA examinations and medical treatment notes establish that he experienced constant chronic pain in his lumbosacral spine that made it difficult for him to perform daily activities, including running, jumping, lifting heavy weights, and other repetitive activities involving the twisting or bending of the lower back. Accordingly, a 10 percent rating is warranted and the appeal is granted to this extent. A rating in excess of 10 percent is not warranted. Specifically, the evidence does not show forward flexion greater than 30 degrees but not greater than 60 degrees, a combined range of motion not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. Therefore, the medical evidence does not support a 20 percent rating. Left Ear Hearing Loss With regard to the Veteran’s left ear hearing loss, the Rating Schedule provides rating tables for the evaluation of hearing impairment. Table VI assigns a Roman numeral designation (I through XI) for hearing impairment based on a combination of percent speech discrimination and the puretone threshold average (the sum of the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz (Hz), divided by four). 38 C.F.R. § 4.85. Table VII is used to determine the percentage evaluation by combining the Table VI Roman numeral designations for hearing impairment in each ear. When evaluating service-connected hearing impairment, ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned in audiometric evaluations. Lendenmann v. Principi, 3 Vet. App. 345 (1992). 38 C.F.R. § 4.86 provides for exceptional patterns of hearing impairment. When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hz) is 55 dBs or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. 38 C.F.R. § 4.86(a). Each ear is evaluated separately. When the puretone threshold is 30 dBs or less at 1000 Hz, and 70 dBs or more at 2000 Hz, the rating specialist will determine the Roman numeral designation from either Table VI or Table VIA, whichever results in the higher numeral. That numeral is then elevated to the next highest Roman numeral. 38 C.F.R. § 4.86(b). Each ear is evaluated separately. Turning to the evidence, in May 2011, the Veteran was afforded an audiological examination. The audiometric results were as follows: Hertz 1000 2000 3000 4000 Average Left Ear 10 15 20 65 28 Speech audiometry revealed speech recognition ability of 96 percent in the left ear. Applying the findings to Table VI reveals a numeric designation of Level I on the basis of 28 dBs puretone threshold average and 96 percent speech discrimination. The Board notes that in cases where only one ear is service-connected for hearing loss, the nonservice-connected ear is assigned Roman numeral I for purposes of determining the appropriate rating according to Table VII. See 38 C.F.R. § 4.85(f). Accordingly, the numeric designation for the left ear (Level I) along with the automatically assigned designation for the non-service connected right ear (Level I) entered into Table VII reflect a noncompensable rating for hearing impairment. In November 2011, the Veteran was afforded a second audiological examination. The audiometric results were as follows: Hertz 1000 2000 3000 4000 Average Left Ear 15 10 10 60 24 Speech audiometry revealed speech recognition ability of 100 percent in the left ear. Applying the findings to Table VI reveals a numeric designation of Level I on the basis of 24 dBs puretone threshold average and 100 percent speech discrimination. As previously noted, in cases where only one ear is service-connected for hearing loss, the nonservice-connected ear is assigned Roman numeral I for purposes of determining the appropriate rating according to Table VII. See 38 C.F.R. § 4.85(f). Accordingly, the numeric designation for the left ear (Level I) along with the automatically assigned designation for the non-service connected right ear (Level I) entered into Table VII reflect a noncompensable rating for hearing impairment. A review of the subsequent medical treatment records that a May 2012 speech pathology consult found that the Veteran had no difficulty hearing speech at a normal conversational volume. A September 2014 audiological assessment further diagnosed moderate to moderately severe high frequency sensorineural hearing loss above 3 kHz in the left ear and observed that the testing results had improved in comparison to previous assessments. The Board has considered the lay statements submitted by the Veteran, and recognizes his complaints regarding the worsening severity of his hearing loss. He is competent to describe hearing difficulty; however, his description of his service-connected disability must be considered in conjunction with the clinical evidence of record, as well as the pertinent rating criteria. In this regard, ratings are derived by a mechanical application of the rating schedule. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Thus, the Board has no discretion in this matter and must predicate its determination on the basis of the results of the audiology studies of record. Based upon the results from the examinations discussed above, the criteria for a compensable rating have not been met. Therefore, the appeal is denied. Consideration has also been given to assigning staged ratings for the Veteran’s acquired psychiatric disorder, lumbosacral strain, and left ear hearing loss. However, at no time during the period in question have his disabilities warranted higher schedular ratings than those assigned. Hart v. Mansfeld, 21 Vet. App. 505 (2007). Service Connection Claims Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (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 in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be granted on a presumptive basis for diseases listed in § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Service connection may also be granted on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability, where such disability includes: (a) an undiagnosed illness; (b) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms; or (c) any diagnosed illness that the Secretary determines in regulations warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2). Such disability must have manifested either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. The Board notes that an undiagnosed illness is one which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1); 81 Fed. Reg. 71, 382-84 (Oct. 17, 2016). The term “Persian Gulf veteran” means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e)(1). The “Southwest Asia Theater of operations” refers to Iraq, Kuwait, Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). The Persian Gulf War means the period beginning on August 2, 1990, and ending on the date thereafter prescribed by Presidential proclamation or by law. 38 C.F.R. § 3.2. MUCMI means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(1)(B)(ii). In the case of claims granted on a presumptive basis for Persian Gulf veterans under 38 U.S.C. § 1117, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). Hypertension For VA purposes, hypertension is defined as diastolic blood pressure is predominantly 90 mm 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. As an initial matter, the Veteran has been diagnosed with hypertension. Specifically, multiple medical treatment notes diagnosed hypertension. Therefore, the first element of service connection has been met. With regard to hypertension, the service treatment records reflect blood pressure readings in late 2010 as a systolic blood pressure reading ranging between 142 and 152 and a diastolic blood pressure reading ranging between 85 and 89. In a Report of Medical History at separation, the clinician noted that the Veteran self-reported elevated blood pressure and noted that he met the diagnostic criteria for hypertension. Post-service treatment records reflect blood pressure readings taken in April 2011, August 2011, October 2011 and December 2011 as systolic blood pressure reading ranging between 137 and 147 and a diastolic blood pressure reading ranging between 82 and 96. Furthermore, an April 2011 VA examiner opined that the diagnosis of hypertension in service was not valid on the basis that hypertension as a diagnosis should be made on different occasions and on several outpatient visits. After a review of the evidence, service connection for hypertension is not warranted. Although the Veteran self-reported hypertension, the in-service blood pressure readings are not considered hypertension for VA purposes as the systolic reading was never over 160 nor was the diastolic reading ever over 90. Moreover, the medical examiner similar determined that the in-service diagnosis was not based on the appropriate clinical evaluation of hypertension. Therefore, hypertension was not shown in service or within one year of service. Finally, no medical professional has attributed the Veteran’s hypertension to service. Therefore, the medical evidence does not support the third element of service-connection – a medical nexus. TBI As an initial matter, the Veteran has been diagnosed with a TBI. Specifically, a September 2015 VA examination diagnosed a mild TBI. Therefore, a current disorder has been shown and the first element of service connection has been met. The Veteran has argued that he incurred his disability while serving in Iraq. Specifically, in a February 2014 statement, he said that he encountered situations where he was in close proximity to blasts from grenades, improvised explosive devices, and rocket propelled grenades. He reported that he sustained significant impact to the head from the concussion of the explosions that resulted in him hitting his head on hard surfaces. The Veteran’s DD 214 shows that he served in Iraq in designated imminent danger areas. Furthermore, a review of his STRs reveals that in a June 2007 treatment note, he reported suffering headaches due to a terrorist blast injury. Therefore, an in-service injury has been shown and the second element of service connection has been met. As to nexus, the evidence is in equipoise. On the one hand, a review of the post-service medical treatment records reveals that in a February 2012 medical treatment note, the Veteran reported multiple in-service exposures to explosion blasts. The Veteran was unsure if he suffered memory loss and denied loss of consciousness. The clinician diagnosed a combination of a TBI and behavioral health conditions and found that the history of his injury and the course of clinical symptoms was consistent with a diagnosis of TBI sustained during deployment. This evidence weighs in favor of the claim. On the other hand, a September 2015 VA examiner opined that the Veteran’s TBI was less likely than not incurred in or caused by the Veteran’s in-service concussion or blast exposure headaches. The examiner observed that the Veteran’s TBI symptoms began post-deployment and noted that post-concussion symptoms are generally at their most intense after the injury and improve over time. This evidence weighs against the claim. Nonetheless, as there is evidence weighing both for and against the claim, it places the evidence at least in equipoise on the question of whether the Veteran’s TBI is more likely than not incurred in or caused by active service. For this reason, after resolving reasonable doubt in his favor, service connection for a TBI is warranted and the appeal is granted. Because the Board is granting service connection on a direct basis, all other theories of service connection are rendered moot. Left Hand Disorder For a disability to be service connected, it must be present at the time a claim for VA disability compensation is filed or during or contemporary to the pendency of the appeal. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The record does not show that the Veteran has a confirmed diagnosis of a left hand disability. To that end, an April 2011 VA examination diagnosed a right hand injury with muscle weakness due to a right hand strain; however, it did not diagnose a left hand disability. Furthermore, an April 2011 medical treatment report noted that an MRI found no significant joint or bony abnormality in the Veteran’s bilateral hands. As noted above, service connection may only be granted for a current disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As there are no confirmed diagnoses related to a left hand disability at any time during the pendency of the appeal, service connection is not warranted and the appeal is denied. Respiratory Disorder and CFS As an initial matter, the Veteran’s service personnel records reflect that he served in the Republic of Iraq from February 2006 to April 2008 during Operation Iraqi Freedom. Therefore, he served on active duty in the Southwest Asia Theater during the Persian Gulf War. Further, in February 2014, he claimed service connection for Gulf War Syndrome and alleged exposure to environmental hazards consistent with his service in Southwest Asia, to include oil refinery pollutants, smoke from multiple fires, burn pits, sand, dust, and particulates. He said that as a result of his Gulf War Syndrome, he developed multiple symptoms to include shortness of breath, respiratory problems, and CFS. A review of the Veteran’s STRs reveals that he asserted that he had trouble sleeping in a September 2009 post-deployment health assessment. He further reported in a December 2010 Report of Medical History that he had dizziness and shortness of breath a few times a week. Generally, a veteran is competent to report that which he perceives through the use of his senses, including events capable of lay observation. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Here, the Veteran’s statements are consistent and well-documented throughout the record. Additionally, as described above, his statements are corroborated by the additional evidence of record, such that competent and credible evidence of an in-service event has been found. However, the evidence of record does not demonstrate current disabilities resulting from either the Veteran’s in-service shortness of breath or his in-service fatigue. Specifically, in a September 2015 VA examination, he reported difficulty with breathing on exertion since 2010 following his second tour of duty in Iraq. He said that his endurance had decreased, that he felt increasingly tired, and that he was issued an inhaler but found it unhelpful and did not use it. The examiner noted that the Veteran’s condition did not require the use of oral or parenteral corticosteroid medications, inhaled medications, or oral bronchodilators. The examiner found that he did not have a pulmonary condition and opined that the Veteran was not diagnosed with a respiratory condition. In a subsequent October 2015 VA examination, the Veteran reported respiratory, esophageal, intestinal, musculoskeletal, neurologic, and psychiatric conditions that he said were related to Gulf War syndrome. However, the examiner found that the Veteran had no diagnosed illnesses without an established etiology and reported no additional signs and symptoms that were not addressed through the completion of a VA examination. The Veteran was afforded VA examinations in April 2011 and September 2015 with regard to his claimed CFS. The April 2011 VA examiner noted and subsequent medical treatment notes affirmed that the Veteran had difficulty falling asleep and diagnosed sleep disorder and primary insomnia. Similarly, the September 2015 examiner found that he had chronic fatigue since 2010, to include lowered energy, motivation, and drive. However, the 2015 VA examiner observed no acute onset of CFS and found that the Veteran’s debilitating fatigue did not reduce his activity level to less than 50 percent of his pre-illness level. Ultimately, the examiner found that the Veteran had no signs, symptoms, or cognitive impairments attributable to CFS, that he did not have a diagnosis of CFS, and that his fatigue symptoms were related to his acquired psychiatric disorder. The remaining post-service medical treatment records likewise show the absence of either respiratory symptoms or CFS. In this regard, while the Veteran reported an incident of shortness of breath in December 2012, testing in November 2011, February 2012, and September 2014 consistently found no radiographic evidence of an active cardiopulmonary disease. Similarly, with regard to CFS, he reported difficulty falling asleep and associated fatigue symptoms; however, multiple VA examiners and clinicians reinforced the September 2015 examiner’s conclusion that his fatigue symptoms were associated with his acquired psychiatric disorder. For a disability to be service connected, it must be present at the time a claim for VA disability compensation is filed or during or contemporary to the pendency of the appeal. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Thus, “without competent evidence of current disability,” service connection will not be warranted. Caluza v. Brown, 7 Vet. App. 498 (1995). The Veteran has reported objective signs of respiratory disease and CFS that manifested after his return from the Gulf War. The normal findings in his VA examinations and post-service medical treatment records, however, mean that these manifestations have not been shown to a degree of 10 percent. As there are no diagnoses of a respiratory disorder or CFS and no showings of undiagnosed illnesses present to a degree of 10 percent, the preponderance of the evidence is against the claims and there is no doubt to be otherwise resolved. As service connection is not warranted, the appeals are denied. The Board has considered lay statements offered by the Veteran regarding the etiology of the disabilities addressed above. He is competent to report symptoms and describe his observations because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to offer opinions as to the etiology of any current disorder due to the medical complexity of the matters involved. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Such competent evidence has been provided by the medical personnel who have examined the Veteran during his current appeal and by service records obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to the lay statements that have been submitted. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Right Hand. While the Veteran was afforded a VA examination in April 2011 to assess his right hand disorder, the examiner failed to opine as to whether the current right hand disorder was related to November and December 2010 in-service injury. Accordingly, an examination should be undertaken to determine the nature and etiology of any currently present right hand disability. Cervical Spine. Cervical pain due to muscle spasms has been shown which the Veteran attributes to falling backwards after the enemy threw grenades while on foot patrol and has asserted that it has been continuous since a 2010 in-service accident. Accordingly, an examination should be undertaken to determine the nature and etiology of any currently present cervical spine disorder. Right Knee Disability. A right knee strain has been diagnosed and the Veteran reports knee pain beginning in service. While the Veteran was afforded an examination in April 2011, the examiner failed to opine as to whether his current right knee disorder was related to his November 2010 in-service injury. Accordingly, an examination should be undertaken to determine the nature and etiology of any currently present right knee disability. Migraine Headaches. A review of the record reveals that in September 2015, the Veteran was afforded a VA examination to determine the etiology of his current migraine headache disorder. The examiner opined that a nexus could not be made with certainty but reflected that headaches “may be related to” his Southwest Asia service. This opinion is vague and speculative and relies solely on the absence of evidence in the record. Therefore, the Veteran should be afforded another examination to determine the nature and etiology of any currently present migraine headaches, to specifically include whether the Veteran’s headaches were incurred in, caused by, or continuous since service. The matters are REMANDED for the following actions: 1. Identify and obtain any pertinent, outstanding VA and private treatment records not already of record in the claims file. 2. Schedule the Veteran for an examination to determine the nature and etiology of his right hand disability. The claims file must be made available to, and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s right hand disability is etiologically related to his active service. The rationale for all opinions must be provided. 3. Schedule the Veteran for an examination to determine the nature and etiology of his cervical spine disability. The claims file must be made available to, and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and review of the record, the examiner should provide an opinion as to whether it is as at least as likely as not (a 50 percent probability or greater) that: a) the Veteran’s cervical spine disability is etiologically related to his active service; b) the Veteran’s cervical spine disability is caused or aggravated by a service-connected disability; and c) the symptomatology of the Veteran’s cervical spine disability has been continuous since service. The rationale for all opinions must be provided. 4. Schedule the Veteran for an examination to determine the nature and etiology of his right knee disability. The claims file must be made available to, and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s right knee disability is etiologically related to his active service. The rationale for all opinions provided must be provided. 5. Schedule the Veteran for an examination to determine the nature and etiology of his migraine headaches. The claims file must be made available to, and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that: a) The Veteran’s migraine headaches are etiologically related to his active service; b) The Veteran’s migraine headaches are caused or aggravated by service-connected disability; c) The Veteran’s migraine headaches can be attributed to a known clinical diagnosis; and d) If the Veteran’s migraine headaches cannot be attributed to a known clinical diagnosis, the Veteran’s symptoms are a result of an undiagnosed illness or MUCMI etiologically related to exposure to environmental hazards while serving in Southwest Asia during the Persian Gulf War. The rationale for all opinions must be provided. 6. Then readjudicate the claims on appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. L. HOWELL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Spigelman, Associate Counsel