Citation Nr: 18141603 Decision Date: 10/11/18 Archive Date: 10/10/18 DOCKET NO. 13-19 998 DATE: October 11, 2018 ORDER Entitlement to service connection for right ankle disability is denied. Entitlement to service connection for a bilateral eye disability is denied. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for residuals from human papillomavirus (HPV) is denied. Entitlement to service connection for chronic fatigue syndrome (CFS), to include as undiagnosed illness is denied. Entitlement to service connection for a menstrual disorder is granted. Entitlement to service connection for migraine headaches, to include as undiagnosed illness is denied. FINDINGS OF FACT 1. The Veteran does not have a right ankle disorder that is etiologically related to service. 2. The Veteran does not have bilateral eye disability that is etiologically related to service, or which was caused or aggravated by a service-connected disability. 3. Resolving reasonable doubt in her favor, the Veteran likely has tinnitus that is attributable to her active military service. 4. HPV alone does not constitute a disability for which VA compensation benefits may be awarded. There is no evidence or allegation of any current underlying disability or chronic residuals etiologically related to HPV. 5. The Veteran does not have a diagnosis of CFS or a qualifying chronic disability manifested by fatigue due to an undiagnosed illness or a chronic multisymptom illness manifested to a compensable degree. 6. Resolving reasonable doubt in her favor, the Veteran has a menstrual disorder which was caused by or incurred during active service. 7. Migraine headaches were not shown in service and are not etiologically or causally related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for right ankle disability are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2018). 2. A bilateral eye disability was not incurred in or aggravated by service nor is it secondary to a service-connected disability. 38 U.S.C. §§ 1110, 5017 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018). 3. The criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2018). 4. The criteria for service connection for HPV are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2018). 5. The criteria for service connection for CFS or disability characterized by chronic fatigue, to include as due to an undiagnosed illness are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1118, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.317 (2018). 6. The criteria for entitlement to service connection for a menstrual disorder have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2018). 7. The criteria for entitlement to service connection for migraine headaches have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.317 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from December 2003 to July 2007, to include service in Southwest Asia, with period of Reserve duty between October 2007 and July 2011. A June 2017 Board decision remanded this appeal for further development. That development has been accomplished, and the appeal has now been returned to the Board for further action. Stegall v. West, 11 Vet. App. 268 (1998). The Veteran was afforded a hearing before the undersigned in February 2017. A copy of the transcript is of record. Service Connection Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2018). Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). Generally, service connection requires: (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease; and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999). Further, it is not enough that an injury or disease occurred in service; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303 (b). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement for a current disability is satisfied if the disability is shown at any time subsequent to filing the claim, even if not shown currently. McLain v. Nicholson, 21 Vet. App. 319 (2007). Service connection may be established on a presumptive basis for a Veteran who exhibits objective indications of a qualifying chronic disability 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. 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317 (a)(1). The Veteran’s DD-214 indicates active military service in the Southwest Asia Theater of operations during the qualified period of time. 38 C.F.R. § 3.317 (e)(1)(2). As such, these statutory and regulatory provisions are applicable in this case. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Also, non-expert witnesses are competent to report that which they have observed with their own senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Non-expert nexus opinion evidence may not be categorically rejected. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The complexity of the question and whether a nexus opinion or diagnosis could be rendered based on personal observation are factors in determining whether a non-expert nexus opinion or diagnosis is competent evidence. VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (2012); Gilbert v. Derwinski, 1 Vet. App. 49. 1. Entitlement to service connection for a right ankle disorder The Veteran seeks service connection for her right ankle. She testified at her February 2017 hearing that she rolled her ankle while walking without boots. She further testified that she was prescribed ice, heat, and rest for the ankle without further complication or problems with ambulation. Service treatment records are silent for any incident of an ankle injury, treatment for or diagnosis of an ankle condition. A February 2011 VA examination report found no evidence of pain or limitation of range of motion for the right ankle. The examiner stated the Veteran had no evidence of a right ankle disability on physical examination no on x-rays dated March 2011. A February 2018 VA examination report records the Veteran’s assertion that she sprained her right ankle in 2004 which never healed. She also reported she was able to complete the one and one-half mile run component of her Air Force fitness testing with a passing time. The examiner found no current or chronic right ankle disability. The record does not show or suggest that the Veteran has a diagnosis of right ankle disability or any observable signs of any type of right ankle disorder. The Veteran is competent to observe she has ankle discomfort; however, whether such discomfort reflect compensable underlying pathology is a medical question beyond the scope of lay observation. Because she is a layperson, her opinion is not probative evidence in this matter. The only competent evidence in the matter is in the report of the February 2011 and February 2018 VA examination reports which found she does not have a right ankle disorder of any type. Absent any competent evidence of a current disability for which service connection is sought, there is no valid claim of service connection, including on an undiagnosed illness basis, and the appeal in this matter must be denied. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 2. Entitlement to service connection for a bilateral eye disorder The Veteran asserts her bilateral eye condition is related to her active service. At her February 2107 hearing she testified that she first began to need eyeglasses while in service. She further testified that she could recall no trauma or event in service that would have resulted in her eye condition. Initially, the Veteran’s service treatment records dated May 2007 reflect the Veteran’s reports of a left eye sty which she treated with a warm compress until the sty erupted. She further reported no pain, drainage, or impaired vision. A January 2018 VA examination report diagnosed the Veteran with bilateral blepharitis and astigmatism. The Veteran reported wearing corrective aids for her vision. The examiner opined that as the Veteran has blepharitis of both eyes, she as susceptible to developing an eye sty. He also opined the Veteran’s claimed bilateral eye condition was less likely than not related to her active service as there were no eye disorders or infections caused by or related to the Veteran’s prior HPV, and there was no evidence for a causative relationship between HPV and blepharitis. As rationale, he stated there was no ocular pathology related to her history of HPV or astigmatism. Finally, the Board has reviewed the Veteran’s medical treatment records and they do not demonstrate any diagnosis of or treatment for any eye disorders. Based on the foregoing evidence, the Board finds that service connection for a bilateral eye condition is not warranted. First, refractive error of the eye is not a disease or injury within the meaning of applicable legislation providing compensation benefits. See 38 C.F.R. § 3.303 (c); 38 C.F.R. § 4.9; see also, e.g., Winn v. Brown, 8 Vet. App. 510, 516 (1996). VA regulations specifically prohibit service connection for a refractive error of the eye unless such a defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90, 55 Fed. Reg. 45711 (July 18, 1990). In this case, Veteran’s diagnosed bilateral eye disorder is astigmatism, which is considered a refractive error, and her medical records are negative for evidence of aggravation by a superimposed disease or injury during her period of active service. There is no medical evidence of record which diagnoses any other eye disorder. For this reason, service connection for a bilateral eye disorder is not warranted on a direct basis. The Board has also considered if service connection for a bilateral eye disability is warranted on a secondary basis, and finds service connection on a secondary basis is not warranted. In this case, the Board finds the January 2018 VA examiner’s opinion highly probative. The examiner stated the Veteran’s non-service connected blepharitis was the cause of her eye sty, and he opined that as there was no ocular pathology related to the Veteran’s HPV, it was less likely than not that any eye condition would be caused by or related to her prior HPV symptoms. Similarly, there is no medical evidence to support any relationship between the Veteran’s HPV and her claimed bilateral eye condition. As the preponderance of the evidence is against the claim for service connection for a bilateral eye condition, it must be denied. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to service connection for tinnitus The Veteran contends that her tinnitus is attributable to noise exposure she experienced while serving on active duty. Her DD Form 214 indicates that her military occupational specialty was a material management journeyman, or an aircraft maintenance mechanic. She further asserts that her job included working on the flight line around jet engines. Her in-service exposure to acoustic trauma is therefore conceded. She testified at her February 2017 hearing that she first noticed symptoms of tinnitus such as ringing in the ears while in service, currently experiences tinnitus symptoms, and sought treatment for her tinnitus symptoms between six to twelve months after service discharge. The Veteran’s service treatment records are silent as to any complaints of or treatment for tinnitus. An October 2010 VA audiological examination recorded the Veteran’s assertion that her tinnitus symptoms were a result of noise exposure while in service. The examiner stated that he was unable to give an etiological opinion without resorting to speculation as no service treatment records were available for review and the Veteran reported with normal hearing at the time of the examination. A December 2017 VA audiological examination again recorded the Veteran’s assertions of tinnitus symptoms which began in active service. The examiner found the Veteran’s tinnitus was less likely than not related to her active service. As rationale the examiner stated although there was a moderate possibility of exposure to noise while in service, her service treatment records reflected no significant hearing level shift. Medical treatment records reflect the Veteran was treated for tinnitus, but treating physicians did not give a nexus opinion. In adjudicating this claim, the Board must assess the competence and credibility of the Veteran. Washington v. Nicholson, 19 Vet. App. 362 (2005). The Board must also assess the credibility, and therefore the probative value, of the evidence of record in its whole. Owens v. Brown, 7 Vet. App. 429 (1995). In determining whether documents submitted by a Veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). As an initial matter, the Board notes that ringing in the ears is the type of symptoms that is readily amenable to lay observation as it is subjective to the claimant. Thus, the Veteran is competent to report his symptoms and their frequency. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Medical treatment records, correspondence of record, and the Veteran’s own testimony notes her continued reports detailing his tinnitus and his contention that she was exposed to sound in service. Nothing in the record contradicts her statements, and her statements are generally consistent with the circumstances of her service. The Board finds the Veteran’s statements are credible and probative. Upon consideration of the above evidence, the Board finds that, resolving reasonable doubt in the Veteran’s favor, a grant of service connection for tinnitus is warranted. The evidence shows current treatment for tinnitus, which the Veteran has reported began during service and has continued from that time to the present. With regard to the Veteran’s complaints of in-service noise exposure, the Board finds credible her account of noise exposure in service as it is consistent with her military personnel records. The Board acknowledges that the December 2017 VA examiner stated that it was less likely than not that the Veteran’s tinnitus began in, or is otherwise etiologically linked to, her active military service. However, the Board finds that this medical opinion did not give due consideration to the Veteran’s competent account of the onset of symptoms in service and their continuity thereafter, or to her credible and corroborated report of noise exposure in service. Thus, the Board affords the December 2017 VA examination little probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Based upon the Veteran’s noise exposure in service, and reports of continuous symptoms since service, the Board finds tinnitus is a result of military service. With resolution of reasonable doubt in the Veteran’s favor, service connection for tinnitus is warranted. 4. Entitlement to service connection for residuals from human papillomavirus (HPV) The Veteran also seeks service connection for residuals from HPV. At her February 2017 hearing, she testified that she was infected with and treated for HPV while in active service. She further testified that while she had three abnormal pap smears while in service, she had not had any abnormal pap smears during the appeal period as the HPV symptoms had resolved. Finally, the Veteran testified that she had no current diagnosis of any disabilities associated with HPV. Service treatment records dated April 2007 reflect the Veteran was diagnosed with HPV. A June 2007 record reflects the Veteran’s HPV was resolving and would be monitored. The Veteran underwent a VA examination in January 2018. The examiner interviewed the Veteran, reviewed the claims file and noted the history of in-service HPV. The examiner also reviewed pap smears post-service and noted the most recent pap smear conducted in September 2017 was within normal limits. The examiner noted all follow-up pap smears from the original diagnosis of HPV were reported as within normal limits. The overall gynecological exam proved to be unremarkable, with no evidence of HPV, lesions, drainage, discharge, or any current gynecologic disease or disability. In this case, the evidence of record does not provide any medical basis for finding that the Veteran is currently diagnosed with any disability of HPV or residuals associated with the in-service HPV. There is no disputing the in-service treatment records that indicate that she was treated for HPV during service. But merely establishing treatment for symptoms while in service is not tantamount to granting service connection as there also has to be chronic residual disability resulting from that condition or injury. Chelte v. Brown, 10 Vet. App. 268 (1997) (current disability means a disability shown by competent evidence to exist). The Veteran’s HPV during is shown to have resolved and not to have resulted in any current disability. Therefore, it is clear that a continuing permanent disability is not present. Although HPV may be a manifestation of a chronic underlying gynecologic disorder, it does not appear to be disabling itself. Under applicable regulation, the term disability means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1 (2018); Hunt v. Derwinski, 1 Vet. App. 292 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). Pertinent to gynecological disabilities, findings of cervical dysplasia and HPV alone are not service-connectable disabilities, although they may be etiologically related to a later diagnosis of cervical cancer. 60 Fed. Reg. 19,851 (April 21, 1995). They are, therefore, not appropriate entities for the rating schedule. Nothing in the medical evidence shows that the Veteran has exhibited an actual disability manifested by HPV at any time during the current appeal period, and there is no evidence of record to suggest that it causes any impairment of earning capacity. There are no symptoms, manifestations, or any deficits in bodily functioning associated with this finding. At the VA examination, the examiner found insufficient clinical evidence to warrant a diagnosis of HPV or any acute or chronic disorder or residuals of HPV. The Veteran has presented no competent medical evidence to the contrary, and herself has testified that she has no diagnosis of any disability associated with HPV. A clinical finding, without a diagnosed or identifiable underlying malady or condition, does not, in and of itself, constitute a disability for which service connection may be granted. Service connection may not be granted for symptoms unaccompanied by a diagnosed disability. Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001); Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). The record does not otherwise medically suggest that the Veteran has an underlying disability related to HPV, such as carcinoma or carcinoma of the cervix, for which service connection can be granted. In the absence of a clear diagnosis, or abnormality which is attributable to some identifiable disease or injury during service, an award of service connection is not warranted. The presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). Because there was no HPV diagnosed at any time since the claim was filed, and there remains no current evidence of the claimed disorder, no valid claim for service connection exist. Based on this evidentiary posture, service connection cannot be awarded. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As the preponderance of the evidence is against the claim for service connection for HPV, it must be denied. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to service connection for chronic fatigue syndrome (CFS), to include as undiagnosed illness The Veteran claims that she developed chronic fatigue because of an undiagnosed illness caused by her service in the Persian Gulf War. However, because there was no chronic fatigue syndrome diagnosed at any time since the claim was filed, and there remains no current evidence of the claimed disorder, no valid claim for service connection exist. See Degmetich supra; Gilpin supra; Brammer supra. The Veteran testified at her February 2017 hearing that she has not been diagnosed with CFS and her treating physicians have suggested other non-service connected diagnosis might be causing her fatigue. Service treatment records fail to reveal any significant signs or symptoms that can be construed as related to a chronic fatigue syndrome, or difficulties with fatigue in general. Additionally, the post-service record is negative for any evidence of a diagnosis or treatment for chronic fatigue. Medical treatment records in general show that while the Veteran has been evaluated for various medical complaints, there is no evidence that she was treated, or takes medication, for fatigue problems. During VA examination in February 2018, the Veteran reported feeling tired since 2003 which causes her to not go out on the weekends. After examining the Veteran and reviewing her claims file, the examiner found no specific pathology to render an actual diagnosis of chronic fatigue syndrome on examination. While he acknowledged the history of subjective complaints, he concluded that the Veteran has other circumstances with explain her fatigue including working part time, having two children under the age of two, and participating in the Air Force Reserves. As such, her fatigue was therefore not caused by her Gulf deployment. Further, a February 2018 Gulf War examination reflects there were no diagnosed illnesses for which no etiology was established. In this case, the Board finds that the evidence does not establish a currently diagnosed chronic disability manifested by fatigue. The Veteran is considered competent to endorse ongoing symptoms such as tiredness and low energy. Although these symptoms are capable of lay observation, they are not equivalent to a diagnosis of an actual disability. Moreover, the VA examiner found no sufficient clinical evidence to warrant a diagnosis of chronic disability, but instead concluded the Veteran’s complaints were related to other circumstances in the Veteran’s life. The examination report is unrebutted by any other medical evidence to the contrary. Although the Veteran may indeed experience some sort of recurring fatigue, in the absence of competent evidence which suggests that it constitutes a chronic disability, the Board has no basis on which to award service connection. As noted above, under 38 C.F.R. § 3.317, service connection may be granted for signs and symptoms that are objective indications of qualifying chronic disability. Chronic fatigue syndrome is specifically listed as a manifestation of an undiagnosed or medically unexplained chronic multisymptom illness for which service connection may be granted based on Gulf War service. Thus, such symptoms are considered precipitating factors rather than a real clinical diagnosis within the meaning of VA regulations. If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98. Here, the lack of a chronic disability precludes the consideration of an undiagnosed or medically unexplained chronic multi-symptom illness because the findings here are explained. Additionally, the February 2018 examination specified the Veteran had no illnesses that were without an etiology. As such, the requirements for entitlement to service connection for an undiagnosed illness under 38 C.F.R. § 3.317 have not been met. 6. Entitlement to service connection for a menstrual disorder The Veteran seeks service connection for a menstrual disorder. Alternatively, the Veteran asserts entitlement to service connection for a menstrual disorder as a result of her service in the Persian Gulf. Post-service treatment records indicate that the Veteran has received medical treatment for gynecological symptoms, including pelvic pain and abnormal menses. No diagnosis has been rendered. Nevertheless, in light of the Veteran’s consistent gynecological problems, the Board finds the first Shedden element is satisfied. The Veteran’s service treatment records reflect complaints for painful and erratic menses. She was treated with birth control pills and naproxsen. Accordingly, the second Shedden element is met. With regard to the remaining element, a January 2018 VA examination report reflects the Veteran’s reports of continued painful menses. After reviewing the Veteran’s service treatment records and medical history, the examiner opined that it was more likely than not that the Veteran’s current menstrual disorder was incurred while inservice as her current symptoms matched those reported and treated while in service. The examiner stated that he was unable to determine the exact nature of the menstrual disorder, but based on the Veteran’s record and generally accepted medical literature and principles, it was likely a hormonal disorder. In various statements, as well as her February 2017 testimony, the Veteran reported that she has continued to experience the same general symptoms, i.e. pelvic pain and erratic menses, since her active service. After a careful review of the record, the Board finds the evidence supports a grant of service connection for the Veteran’s claimed menstrual disability. Therefore, resolving reasonable doubt in her favor, the Board finds that the Veteran’s menstrual disability, characterized by pain and abnormal menstrual cycles, is related to active service. 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 3.102 (2018). 7. Entitlement to service connection for migraine headaches, to include as undiagnosed illness Finally, the Veteran asserts entitlement to service connection for migraine headaches. She testified at her February 2017 hearing that her migraine headaches first began in service, and that her physician has attributed her headaches to possible tension or stress. Service treatment records reflect the Veteran was seen in June 2007 with headache and nausea symptoms. She was prescribed over the counter pain medication. There is no further mention of any diagnosis or treatment for migraine headaches. A February 2018 VA examination report reflects the Veteran’s complaints of headaches and treatment of the headaches with over the counter pain medication. The examiner opined it was less likely than not that the Veteran’s headaches were related to her active service. As rationale, he stated that review of the Veteran’s medical history reflects her headaches are primarily related to her multiple motor vehicle accidents from 2010 to 2011. He also noted the first mention of a headache symptom was in 2010 following her first motor vehicle accident, which was also three years following her deployment. He opined that temporally the headaches were related to her motor vehicle accidents post-service rather than active service to include her Gulf War service. There is no contradictory medical opinion of record. Medical treatment records note the Veteran’s complaints of headache in connection with neck and shoulder pain resulting from a motor vehicle accident. The treatment records do not provide any etiological opinion or diagnosis concerning migraine headaches. Based on the above, service connection for migraine headaches is not warranted. In this regard, while the service treatment records establish that the Veteran had one documented occurrence of headaches during active service, they do not demonstrate that she had migraine headaches while in service. Furthermore, there is no post-service medical evidence that establishes a relationship between her claimed migraine headaches and her active service. The Board has considered statements made by the Veteran that her headaches were related to her active service. While she is competent to describe her observations, she is not competent to offer an opinion linking her headaches to her active service, as this opinion requires medical expertise and is outside the realm of common knowledge of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d. 1372 (Fed. Cir. 2007). Therefore, she is not competent to provide an etiology opinion in this case. Such competent evidence has been provided by the medical personnel who have examined the Veteran during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination report) directly address whether a relationship exists between the Veteran’s claimed migraine headaches and her active service. Moreover, as the examiner had the requisite medical expertise to render a medical opinion regarding the relationship between her migraine headaches and her active service and had sufficient facts and data on which to base the conclusions, the Board attaches greater probative weight to the clinical findings than to her statements. In sum, the medical evidence does not support a causal nexus between the Veteran’s claimed migraine headaches and her active service. Therefore, the preponderance of the evidence is against the claim, entitlement to service connection for migraine headaches is not warranted, and the appeal is denied. Additionally, as noted above, under 38 C.F.R. § 3.317, service connection may be granted for signs and symptoms that are objective indications of qualifying chronic disability. Headaches are specifically listed as a manifestation of an undiagnosed or medically unexplained chronic multisymptom illness for which service connection may be granted based on Gulf War service. Thus, such symptoms are considered precipitating factors rather than a real clinical diagnosis within the meaning of VA regulations. If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98. Here, the lack of a chronic disability precludes the consideration of an undiagnosed or medically unexplained chronic multi-symptom illness because the findings here are explained. Additionally, the February 2018 Gulf War examination specified the Veteran had no illnesses that were without an etiology. As such, the requirements for entitlement to service connection for an undiagnosed illness under 38 C.F.R. § 3.317 have not been met. REMANDED Entitlement to service connection for sleep disturbances, to include as undiagnosed illness is remanded. Entitlement to service connection for a chronic staph infection involving the forearm is remanded. REASONS FOR REMAND 1. Entitlement to service connection for sleep disturbances, to include as undiagnosed illness is remanded. The Veteran asserts that she has sleep disturbances which began while on active duty in Iraq. She reported her symptoms include waking up in the middle of the night and cause her fatigue. A February 2018 VA examination for CFS reflects part of the examiner’s rationale for a negative etiological opinion for the Veteran’s claimed CFS was that she had sleep disturbances, but no etiological opinion concerning the sleep disturbances was provided. To date, the Veteran has not been afforded a separate examination for her claimed sleep disturbances. Thus, on remand, the Veteran should be afforded a VA examination to determine the nature of her claimed sleep disturbances. 2. Entitlement to service connection for a chronic staph infection involving the forearm is remanded. The Veteran also seeks service connection for chronic staph infection of her forearm. She asserted at her February 2017 hearing that while working as a medic in active service, she noticed a pustule on her forearm which was diagnosed as a staph infection. She further asserted the pustule left a residual scar on her forearm. Medical treatment records dated April 2009 confirm the Veteran was seen and treated for a skin abcess later diagnosed as a staph infection. A February 2018 VA examination report reflects the Veteran was diagnosed with a skin abcess on the forearm in April 2009 during active service, later diagnosed as a staph infection, and noted a scar on the Veteran’s forearm. The Veteran reported the scar would become itchy, raised, and/or tender. The examiner failed to provide an opinion on whether or not the Veteran’s scaring was related to her April 2009 in-service treatment for a staph abcess. The Board still finds that the Veteran’s testimony regarding the presence of scarring related to her staph infection and the notation of a scar on her forearm on the February 2018 VA examination report satisfies the low evidentiary threshold under McClendon, as she clearly has raised the possibility that she experienced scarring as a residual of her in-service condition and its treatment. It is therefore necessary to obtain an addendum medical opinion to provide an opinion as to the nature and etiology of any scars that the Veteran asserts are related to her in-service staph infection. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran’s claimed sleep disturbances. A complete history from the Veteran should be obtained and recorded. All testing deemed necessary by the examiner should be performed and the results reported in detail. The rationale for all opinions should be provided. The Veteran’s electronic claims file must be accessible for review by the VA examiner in conjunction with the examination. Following a review of the claims file and examination of the Veteran, the examiner is then requested to respond to the following: (a) Is it as least as likely as not (a 50 percent probability or greater) that the Veteran’s claimed sleep disturbances are caused by or related to her active service? (b) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran has an undiagnosed illness manifested by sleep disturbances? 2. Then return this appeal to the examiner who conducted the February 2018 skin disability examination, or if unavailable a qualified VA examiner, for the purpose of obtaining an opinion regarding the nature and etiology of the scars related to the Veteran’s staph infection of the forearm. The entire claims file, to include a complete copy of this REMAND, must be made available to the individual designated to examine the Veteran, and the examination report should include discussion of the Veteran’s documented medical history and assertions relating to any residuals of a chronic staph infection, to include scarring. The examiner is requested to furnish an opinion as to the following: (a) Is at least as likely as not (50 percent or better probability) that the Veteran has scars that are a residual of a staph infection that began in or are otherwise attributable to her active duty service. The examiner should set forth all examination findings, along with the complete rationale for the conclusions reached. While a thorough review of the entire claims file should be completed, the examiner should ensure careful review of the Veteran’s testimony at the February 2017 hearing, during which the Veteran stated that she had a scar that was a residual of his chronic staph infection. In addition, the examiner should review the February 2018 VA examination and the examiner’s notation that the Veteran had a scar on her forearm. 3. Then, readjudicate the claims. If any benefit sought on appeal remains denied, furnish the Veteran and her representative with a supplemental statement of the case and afford her the appropriate time period for response. Then, return the case to the Board. THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Peden, Associate Counsel