Citation Nr: 18158871 Decision Date: 12/19/18 Archive Date: 12/18/18 DOCKET NO. 16-07 290 DATE: December 19, 2018 ORDER Entitlement to service connection for nasal polyps, claimed as nasal tumors / nosebleeds, is granted. Entitlement to a maximum schedular initial rating of 30 percent for allergic rhinitis is granted. Entitlement to a rating in excess of 70 percent for persistent depressive disorder is denied. A total disability rating based on individual unemployability (TDIU) due specifically to service-connected persistent depressive disorder is granted. Entitlement to an effective date prior to April 8, 2013, for the award of service connection for persistent depressive disorder is denied. Entitlement to an effective date prior to April 8, 2013, for the award of service connection for allergic rhinitis is denied. Entitlement to service connection for pseudotumor cerebri (or substantially similar disability, variously diagnosed) is granted. Entitlement to service connection for disability manifested by headaches, secondary to pseudotumor cerebri (or substantially similar disability, variously diagnosed), is granted. Entitlement to service connection for disability manifested by dizziness / vertigo, secondary to pseudotumor cerebri (or substantially similar disability, variously diagnosed), is granted. Entitlement to service connection for disability manifested by vision problems / visual disturbances (not including refractive error), secondary to pseudotumor cerebri (or substantially similar disability, variously diagnosed), is granted. Entitlement to service connection for tinnitus, secondary to pseudotumor cerebri (or substantially similar disability, variously diagnosed), is granted. Entitlement to service connection for kidney disease is denied. Entitlement to service connection for a cyst of the left hand is denied. Entitlement to service connection for left carpal tunnel syndrome is denied. Entitlement to service connection for right carpal tunnel syndrome is denied. REMANDED Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left elbow disability is remanded. Entitlement to service connection for a right elbow disability is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left shin disability is remanded. Entitlement to service connection for a right shin disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a disability manifested by generalized muscle fatigue / body aches is remanded. Entitlement to service connection for a disability manifested by dyspnea / breathing problems is remanded. Entitlement to service connection for a disability manifested by chest pain is remanded. Entitlement to service connection for a disability manifested by frequent urination is remanded. Entitlement to service connection for a disability manifested by gastrointestinal symptoms / blood in stool is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his recurrent nasal polyps with nosebleeds is at least as likely as not related to his in-service nasal polyps. 2. The Veteran’s service-connected allergic rhinitis includes involvement of service-connected nasal polyps. 3. The Veteran’s persistent depressive disorder has not been productive of total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name; or other symptoms of comparable nature and severity. 4. The Veteran has been rendered unable to secure or follow a substantially gainful occupation due to his service-connected disability of persistent depressive disorder rated 70 percent disabling. 5. The Veteran filed an original claim for service connection for “depression and anxiety,” including the diagnosis of persistent depressive disorder, on April 8, 2013; the Veteran did not file any formal or informal claim of entitlement to service connection for this disability prior to April 8, 2013. 6. The Veteran filed an original claim for service connection for “sinus problems,” including the diagnosis of allergic rhinitis, on April 8, 2013; the Veteran did not file any formal or informal claim of entitlement to service connection for this disability prior to April 8, 2013. 7. Resolving reasonable doubt in the Veteran’s favor, his pseudotumor cerebri (or substantially similar disability, variously diagnosed) had its onset during the Veteran’s active duty military service. 8. Resolving reasonable doubt in the Veteran’s favor, his disability manifested by headaches is proximately due to his service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed). 9. Resolving reasonable doubt in the Veteran’s favor, his disability manifested by dizziness / vertigo is proximately due to his service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed). 10. Resolving reasonable doubt in the Veteran’s favor, his disability manifested by vision problems / visual disturbances (not including refractive error) is proximately due to his service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed). 11. Resolving reasonable doubt in the Veteran’s favor, his tinnitus is proximately due to his service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed). 12. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the pendency of this appeal, a disability involving kidney disorder or disease. 13. The evidence of record does not show that a cyst of the left hand began during active duty service or is otherwise related to an in-service injury, event, or disease. 14. The evidence of record does not show that the Veteran’s left carpal tunnel syndrome began during active duty service or is otherwise related to an in-service injury, event, or disease. 15. The evidence of record does not show that the Veteran’s right carpal tunnel syndrome began during active duty service or is otherwise related to an in-service injury, event, or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for recurrent nasal polyps with nosebleeds have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for a maximum schedular disability rating of 30 percent for allergic rhinitis with nasal polyps have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.97, Diagnostic Code 6522. 3. The criteria for a rating in excess of 70 percent for persistent depressive disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Codes 9433 & 9434. 4. The criteria for entitlement to a TDIU due to the Veteran’s persistent depressive disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. 5. The criteria for an effective date prior to April 8, 2013, for the award of service connection for persistent depressive disorder have not been satisfied. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 6. The criteria for an effective date prior to April 8, 2013, for the award of service connection for allergic rhinitis have not been satisfied. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 7. The criteria for service connection for pseudotumor cerebri (or substantially similar disability, variously diagnosed) have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 8. The criteria for service connection for disability manifested by headaches have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310(a). 9. The criteria for service connection for disability manifested by dizziness / vertigo have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310(a). 10. The criteria for service connection for disability manifested by vision problems / visual disturbances (not including refractive error) have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310(a). 11. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310(a). 12. The criteria for service connection for kidney disease have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 13. The criteria for service connection for a cyst of the left hand have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 14. The criteria for service connection for left carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 15. The criteria for service connection for right carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1983 to November 1987. These matters have come to the Board of Veterans’ Appeals (Board) on appeal from October 2014 and October 2015 rating decisions issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). Preliminary Service Connection Determination 1. Entitlement to service connection for nasal polyps, claimed as nasal tumors / nosebleeds, is granted. A veteran is entitled to service connection for a disability resulting from a disease or injury incurred or aggravated during active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disease diagnosed after discharge may still be service connected if all the evidence establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). As discussed throughout the breadth of this Board decision, the Veteran suffers from a multitude of disabilities of varying descriptions and diagnoses (or of unknown diagnostic nature). The Veteran has claimed entitlement to service connection for various disabilities involving his sinuses, and the RO’s October 2014 rating decision granted service connection for “allergic rhinitis, claimed as sinus condition,” while denying service connection for “nasal tumors/nose bleeds.” The RO appears to have relied upon the findings and opinion presented in a July 2014 VA examination report in which the VA examiner concluded: “The veteran[’]s rhinitis and septoplasty are the same conditions diagnosed during military service.” Notably, at the time of the July 2014 VA examination report, the VA examiner found no polyps on examination of the Veteran; the VA examiner did not otherwise remark upon the Veteran’s documented history of nasal polyps both during service and following service. A May 2015 VA examination report did note the presence of nasal polyps. The RO adjudication of these matters has resulted in a situation where the Veteran’s allergic rhinitis is a recognized service-connected disability, but his nasal polyps have not been formally recognized as part of the established service-connected disability picture. This is reflected in the fact that the Veteran’s allergic rhinitis has been rated noncompensably disabling despite the fact that the presence of nasal polyps as part of the disability would meet the criteria for a higher disability rating (as discussed in more detail, below). The Board here clarifies that the evidence of record well establishes that the Veteran has a history of significant and recurrent nasal polyps documented during service, following service, and as recently as his most recent VA medical records in the claims-file from 2017. Surgical treatments have been performed to remove such polyps on multiple occasions (including during service in 1987, and following service, reportedly in approximately 2000), but the polyps have recurred each time. The Board finds that the evidence of record sufficiently establishes that the Veteran’s recurrent nasal polyps dating back to his time in military service are etiologically linked to his service, regardless of whether they are considered as part of his service-connected rhinitis or otherwise considered as their own disease process that was documented and surgically treated during his active duty military service. The Board finds that service connection for the Veteran’s nasal polyps, claimed as nasal tumors / nosebleeds, is warranted. Increased Ratings Disability ratings are determined by comparing a Veteran’s symptomatology during the pertinent period on appeal 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 applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. With a claim for an increased initial rating, separate staged ratings may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). In a claim for increase in a previously established rating, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the evidence contains factual findings that demonstrate distinct time periods when the service connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, staged ratings are to be considered. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Lay evidence may be competent to address any matter not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises or statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). The Board has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence pertinent to the issue on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when evidence is created is irrelevant compared to when the Veteran was actually experiencing the symptoms. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran’s disabilities prior to the rating period on appeal to see if it supports a higher rating during the rating period on appeal. The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as to the claims being decided. 2. Entitlement to a maximum schedular initial rating of 30 percent for allergic rhinitis is granted. The RO assigned a noncompensable disability evaluation for the Veteran’s service-connected allergic rhinitis under Diagnostic Code 6522, which provides ratings for allergic or vasomotor rhinitis. See 38 C.F.R. § 4.97, Code 6522. Under this Code, allergic or vasomotor rhinitis without polyps, but with greater than 50-percent obstruction of nasal passage on both sides or complete obstruction on one side, is rated 10 percent disabling. Allergic or vasomotor rhinitis with polyps is rated 30 percent disabling. The Veteran’s service treatment records and post-service medical records clearly document that the Veteran’s nasal disabilities have featured medically assessed nasal polyps prior to the rating period on appeal in this case. The July 2014 VA examiner indicated that there were no nasal polyps at that time. A May 2015 VA examination report focusing on the Veteran’s nasal passages shows that nasal polyps were clinically noted at that time. An April 2015 VA medical report shows that the Veteran described: “I have polyps in my nose which they took out but I have one on this right side coming back and the ones on the left are still bleeding….” A June 2016 VA medical report shows a clinical assessment of “nasal polyps.” VA medical reports including those dated in August 2016 and February 2017 show that left sided nasal polyps were noted, and the nasal polyps problems are discussed in a June 2017 VA medical report. The Board finds that the evidence reasonably clearly establishes that the Veteran’s nasal passages have been regularly affected by nasal polyps shown both before and after the July 2014 VA examination report. Although the July 2014 VA examination report contains a checkmark indicating no nasal polyps at that time, the Board finds that reasonable doubt can be resolved in the Veteran’s favor to simply conclude that the recurrent nasal polyps that have been a documented component of his nasal disability essentially throughout its history have been a part of the disability throughout the appeal period from April 2013 onward in this case. Allergic rhinitis with polyps warrants a 30 percent rating, the maximum schedular rating available under the applicable Diagnostic Code 6522. The Board finds that a 30 percent maximum schedular initial rating is warranted for the Veteran’s allergic rhinitis with polyps in this case. 3. Entitlement to a rating in excess of 70 percent for persistent depressive disorder is denied. The Veteran’s service-connected persistent depressive disorder is rated under the General Rating Formula for Mental Disorders (regardless of whether considered under Diagnostic Code 9434, as currently coded by the RO, or under Diagnostic 9433 for persistent depressive disorder (dysthymia). A 70 percent rating is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Codes 9433 and 9434. A 100 percent rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126 (a). The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). When determining the appropriate disability rating to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, (2002). Because the use of the term such as in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be due to those symptoms; a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The April 2015 mental disorder disability benefits questionnaire (DBQ) completed by a private psychiatrist and submitted in support of the Veteran’s claim shows that the private psychologist specifically selected the option to indicate that the Veteran’s disability manifests in “Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood.” The private psychologist did not find that the Veteran’s disability manifested in “Total occupational and social impairment” and specifically found that the disability did not manifest in such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. In completing the DBQ’s section for identifying pertinent symptomatology, the private psychologist found no symptomatology of the nature and severity contemplated by the criteria for a schedular 100 percent rating. The private psychologist’s responses on the April 2015 DBQ correspond to the criteria for a 70 percent rating and do not more nearly approximate disability satisfying the criteria for a schedular 100 percent rating. The private psychologist’s April 2015 DBQ with additional written opinion is the most favorable evidence regarding the Veteran’s claim for increased disability compensation for his mental health disorder. The private psychologist ultimately concludes that the Veteran’s persistent depressive disorder to “sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his persistent depressive disorder.” That opinion serves as a basis for the Board’s award of a TDIU on the basis of the mental health disorder later in this decision. Thus, it is notable that the April 2015 DBQ from this private psychologist clearly indicates that the Veteran’s mental health disorder does not manifest in total occupational and social impairment due to the nature and severity of symptoms contemplated by the schedular rating criteria for the depressive disorder. While the Board finds that this evidence reasonably supports an award of a TDIU due to the mental health disorder, the evidence does not support an award of a schedular 100 percent rating through application of these rating criteria. The Board finds that the September 2014 and June 2015 VA mental health rating examination reports present findings essentially consistent with the April 2015 private psychologist’s DBQ with regard to not indicating total occupational and social impairment due to symptoms of the nature and severity as those contemplated by the criteria for a 100 percent schedular rating. Neither the September 2014 nor the June 2015 VA examination reports indicate such impairment. The Board finds that the evidence of record does not show total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The evidence does not otherwise show symptoms of the nature and severity contemplated by the criteria for a rating in excess of 70. Additional references to the Veteran’s mental health are presented in evidence of record beyond the most detailed pertinent evidence discussed by the Board in this decision. The additional evidence of record does not present findings concerning the Veteran’s mental health that significantly expand upon, revise, or contradict the findings discussed by the Board in this decision. None of the other evidence of record presents findings or indications significantly contrary to those discussed above, featuring the Veteran’s own description of his symptoms in addition to specialized clinical examination findings and medical assessments. Nor does any other evidence of record otherwise probatively indicate that the criteria for an increase of the disability rating for the mental health disability are met in this case. Not only does the evidence reflect that the Veteran’s depressive disorder did not manifest in the symptoms listed as examples for the criteria for an increased rating, but his psychiatric symptoms are not otherwise shown to have been of similar severity, frequency, and duration as contemplated by the criteria for a higher rating. See Vazquez-Claudio, 713 F.3d at 118. The Board finds that the Veteran’s disability picture, taken as a whole and in combination with the objective psychiatric examinations, have most nearly approximated the criteria for the 70 percent rating assigned. The Board finds that the psychiatric disability picture has not manifested in such severity to warrant any additional or further increased ratings during any portion of the period on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). In reaching this conclusion, the Board has considered the benefit-of-the-doubt rule. However, as the preponderance of the evidence is against the award of an increased rating, that doctrine is not applicable to this extent. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). With consideration of all of the evidence, the Board finds that no rating in excess of 70 percent is warranted in this case. (The Board notes, however, that the Veteran will be awarded a TDIU for this period under different criteria.) 4. Entitlement to a TDIU due specifically to service-connected depressive disorder is granted. A claim for TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this appeal, the disabilities for which a rating appeal has been properly within the Board’s jurisdiction are the Veteran’s depressive disorder and his allergic rhinitis. The Board need not consider any disability other than the service-connected depressive disorder and the allergic rhinitis in adjudicating the TDIU component of the Veteran’s claim for increased disability ratings in this case. This form of TDIU claim is known as a Rice TDIU, because it was raised during the administrative appeal of the Veteran’s claims for increased ratings for his service-connected depressive disorder and allergic rhinitis and it is, therefore, a component of those claims for benefits related solely to those disabilities. See Rice v. Shinseki, 22 Vet. App. 447, 454-455 (2009). Such a claim is limited to the question of whether a veteran is unemployable exclusively due to the service-connected disabilities with ratings on appeal. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is unable, by reason of his service-connected disabilities, to secure or follow a substantially gainful occupation consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. A threshold requirement for eligibility for a TDIU under 38 C.F.R. § 4.16(a) is that, if there is only one such disability, it must be rated at 60 percent or greater; and if there are two or more disabilities, at least one disability must be rated at 40 percent or greater, and sufficient additional disability must bring the combined rating to 70 percent or greater. 38 C.F.R. § 4.16(a). For the above purpose of identifying one 60 percent disability, or one 40 percent disability in combination, disabilities resulting from common etiology will be considered as one disability. However, even where the Veteran does not meet these schedular requirements, 38 C.F.R. § 4.16(b) codifies VA’s policy under which all veterans who are unable to secure a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. It is the policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation due to service connected disability shall be rated totally disabled. 38 C.F.R. § 4.16(b). Thus, if a Veteran fails to meet the schedular requirements above, an extraschedular rating is for consideration where the Veteran is nonetheless unemployable due to service connected disability. Id.; see also Fanning v. Brown, 4 Vet. App. 225 (1993). The Board may not grant a TDIU on an extraschedular basis in the first instance. Rather, the matter must be referred to the Director of the Compensation and Pension Service (Director) for extraschedular consideration. Bowling v. Principi, 15 Vet. App. 1, 10 (2001). The Veteran raised a claim of entitlement to a TDIU during the pendency of this appeal, including in correspondence received in August 2018 that included a copy of an April 2015 private psychologist’s assessment that concludes: “[The Veteran] cannot sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his persistent depressive disorder.” The author found that the “severity of his symptom complex relates back to his original claim date of 05/28/2013,” and that the disorder “has continued uninterrupted to the present and prevents him from sustaining gainful employment.” The Board finds that the opinion is supported by a detailed discussion of the author’s analysis. The August 2018 correspondence additionally included a July 2016 vocational assessment that concludes: “The Veteran is totally and permanently precluded from performing work at a substantial gainful level due to the severity of his service connected depression and allergic rhinitis and the record supports this finding as far back as the date of filing.” The authoring expert vocational consultant attributes the unemployability to “a combination of physical and emotional conditions which interact in terms of severity level,” but the multi-page detailed discussion of the author’s analysis and rationale explains the pertinent impairment essentially entirely in terms of the Veteran’s mental health disability. The Board finds that the opinion is supported by a detailed discussion of the author’s analysis, including with discussion of the pertinent mental-health medical evidence and the Veteran’s occupational history. The Board finds that the competent evidence discussed above is probative and reasonably indicates that the Veteran’s service-connected depressive disorder, considered alone, causes impairment that renders the Veteran unable to secure or follow a substantially gainful occupation consistent with his education and occupational experience. The Veteran’s depressive disorder is assigned a 70 percent schedular rating, satisfying the threshold for a schedular TDIU under 38 C.F.R. § 4.16(a). The Board notes that the Veteran reported that he had not worked in the “past several years” during his September 2014 VA mental health examination. The Board finds no evidence of record that significantly contradicts the supportive probative evidence concerning the impact of the Veteran’s service-connected depressive disorder upon his employability during the rating period for consideration in this appeal. The Board finds that a TDIU based upon the impairment from the Veteran’s depressive disorder is warranted. The Board finds that none of the evidence or contentions of record reasonably indicate that the Veteran’s allergic rhinitis, considered alone, has rendered him unemployable. The Board finds that the depressive disorder considered alone (or considered in combination with the allergic rhinitis) has rendered the Veteran unemployable. The Board has specified that the impairment associated with the depressive disorder is sufficient to establish entitlement to a TDIU in this case because this specificity of finding is potentially more advantageous to the Veteran than an award of TDIU on the basis of a combination of disabilities. [This is because special monthly compensation by reason of being housebound may be awarded on either a statutory basis or factual basis. Both bases require that the Veteran have a single disability rated totally disabling (i.e., 100 percent). 38 U.S.C. § 1114(s); 38 C.F.R § 3.350(i). The total disability rating requirement may be met by a finding of a TDIU where that award is based on one single condition. Bradley v. Peake, 22 Vet. App. 280, 293 (2008) (a TDIU rating can qualify for compensation at the 38 U.S.C. § 1114(s) rate, but only if based on a single disability); VAOGCPREC 66-91 (Aug. 15, 1991) (several separately ratable disabilities cannot be combined to achieve a single total rating in order to qualify for special monthly compensation).] Effective Dates 5. Entitlement to an effective date prior to April 8, 2013, for the award of service connection for persistent depressive disorder is denied. 6. Entitlement to an effective date prior to April 8, 2013, for the award of service connection for allergic rhinitis is denied. The Veteran’s December 2014 notice of disagreement initiated appeals that included the effective date of award for each grant of service connection (with assignment of initial ratings / evaluations) for the Veteran’s depressive disorder and allergic rhinitis. The November 2015 statement of the case addressed the appeals for earlier effective date appeals together with the appeals for higher initial ratings / evaluations, listing the pertinent appeal issues as (1) “Service connection for persistent depressive disorder, chronic and severe, with anxious distress was granted with an evaluation of 70 percent effective April 8, 2013,” and (2) “Service connection for allergic rhinitis claimed as sinus condition was granted with an evaluation of 0 percent effective April 8, 2013.” Both issues were addressed in the statement of the case with the finding that the effective date of “April 8, 2013 is upheld.” The Veteran’s December 2015 VA Form 9 Substantive Appeal included the Veteran’s mark of the box to indicate: “I want to appeal all of the issues listed on the statement of the case ….” Although the rest of the Veteran’s explanation of his appeal with the December 2015 VA Form 9 is ambiguous as to whether he was still asserting entitlement to earlier effective dates, the Board finds that the effective date issues are in appellate status by the Veteran’s selection of the option on the VA Form 9 to appeal all of the issues from the statement of the case. The Board shall accordingly proceed with appellate review of these issues. The assignment of effective dates of awards is generally governed by 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award based on an original claim for compensation benefits shall be the date of receipt of the claim or the date entitlement arose, whichever is later. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2). However, if a claim is received within one year from the date of discharge or release from service, the effective date of an award for disability compensation to a Veteran shall be the day following the date of discharge or release. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2); see also Wright v. Gober, 10 Vet. App. 343, 346-48 (1997). The effective date of an award of increased disability compensation shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if the claim is received within one year from such date, otherwise, the effective date shall be the date of receipt of claim. 38 C.F.R. § 3.400(o)(2). The RO has determined that the Veteran’s April 8, 2013, claim for service connected disability benefits raised the issues of entitlement to service connection for depressive disorder and allergic rhinitis disabilities. The Veteran has not clearly disputed this finding or identified an earlier claim filed for these benefits. When the RO later granted service connection for the Veteran’s depressive disorder and allergic rhinitis, it determined that the pertinent impairments were shown to have been present since at least as early as the claims filed on April 8, 2013. On this basis, the RO assigned an effective date of April 8, 2013, for each of the pertinent awards. The Board finds no basis for assignment of any effective date earlier than April 8, 2013, for either of the pertinent grants. The Veteran does not contend that the grants arise from a claim for these benefits prior to April 8, 2013, nor does the claims-file document any suggestion that the grants arise from any earlier such claim. The April 2013 claim was clearly not filed within a year of the Veteran’s discharge from service, nor does the Veteran contend otherwise. The Board generally cannot assign an effective date for these awards earlier than the date of the Veteran’s claim under the pertinent laws and regulations. As explained above, the effective date shall be the date of receipt of the claim or the date entitlement arose, whichever is later. The undisputed facts in this case provide that the later of those two dates is the date of the claim for both awards: April 8, 2013. The Veteran has not identified any alternative applicable facts, laws, regulations, or other manner of theory that may authorize an effective date earlier than the date of claim for each award in this case. Accordingly, the appeal for an effective date prior to April 8, 2013, for the grants of service connection for depressive disorder and allergic rhinitis must be denied as a matter of law. The law is dispositive in this matter. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Disorders diagnosed after discharge may still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection for the claimed disorder, there must be evidence of (1) a current disability, (2) incurrence or aggravation of a disease or injury in service, and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). For chronic diseases listed in 38 C.F.R. § 3.309(a), the linkage element of service connection may also be established by demonstrating continuity of symptoms since service. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 38 C.F.R. § 3.307(a)(3) provides for presumptive service connection for chronic diseases that become manifest to a degree of 10 percent or more within 1 year from the date of separation from service. Notwithstanding the lack of evidence of disease or injury during service, service connection may still be granted if all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. See 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992). Effective March 14, 2017, VA has amended 38 C.F.R. §§ 3.307 and 3.309 to establish presumptive service connection for eight identified diseases (adult leukemia, aplastic anemia and other myelodysplastic syndromes, bladder cancer, kidney cancer, liver cancer, multiple myeloma, non-Hodgkin’s lymphoma, and Parkinson’s disease) when a service member has served at U.S. Marine Corps Base Camp Lejeune for no less than 30 days (either consecutive or nonconsecutive) between 1957 and 1987. However, carpal tunnel syndrome and cysts of the hand are not among the listed diseases. Notwithstanding, entitlement to service connection can still be pursued on a direct basis. Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed.Cir.1994). 38 U.S.C. § 1154(a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability benefits. 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. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When analyzing lay evidence, the Board should assess the evidence and determine whether the disability claimed is of the type for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). VA law provides that a veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where clear and unmistakable evidence establishes that an injury or disease existed prior to service and was not aggravated by service. 38 U.S.C. §§ 1111, 1132, 1137. The presumption of soundness attaches only where there has been an induction examination during which the disability about which the veteran later complains was not detected. See Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The regulations provide expressly that the term noted denotes [o]nly such conditions as are recorded in examination reports, 38 C.F.R. § 3.304(b), and that [h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions. Id. at (b)(1). When the presumption of soundness applies, the law further provides that the burden to show no aggravation of a pre-existing disease or disorder during service is an onerous one that lies with the government. See Cotant v. Principi, 17 Vet. App. 116, 131 (2003); Kinnaman v. Principi, 4 Vet. App. 20, 27 (1993). Importantly, the VA Office of the General Counsel determined that VA must show by clear and unmistakable evidence that there is a pre-existing disease or disorder and that it was not aggravated during service. See VAOPGCPREC 3-03 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA’s duty under the second prong of this rebuttal standard attaches. Id. The Board must follow the precedent opinions of the General Counsel. 38 U.S.C. § 7104(c). Also pertinent is the decision of the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) in Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004), issued on June 1, 2004, summarizing the effect of 38 U.S.C. § 1111 on claims for service-connected disability, in pertinent part: When no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran’s disability was both preexisting and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any increase in disability [was] due to the natural progress of the preexisting condition. 38 U.S.C. § 1153. If this burden is met, then the veteran is not entitled to service-connected benefits. However, if the government fails to rebut the presumption of soundness under section 1111, the veteran’s claim is one for service connection. This means that no deduction for the degree of disability existing at the time of entrance will be made if a rating is awarded. See 38 C.F.R. § 3.322. On the other hand, if a preexisting disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. In that case section 1153 applies and the burden falls on the veteran to establish aggravation. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation under section 1153 arises, the burden shifts to the government to show a lack of aggravation by establishing that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; see also 38 C.F.R. § 3.306; Jensen, 19 F.3d at 1417. Wagner, 370 F. 3d at 1096. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as to the claims being decided. 7. Entitlement to service connection for pseudotumor cerebri (or substantially similar disability, variously diagnosed) is granted. 8. Entitlement to service connection for disability manifested by headaches, secondary to pseudotumor cerebri (or substantially similar disability, variously diagnosed), is granted. 9. Entitlement to service connection for disability manifested by dizziness / vertigo, secondary to pseudotumor cerebri (or substantially similar disability, variously diagnosed), is granted. 10. Entitlement to service connection for disability manifested by vision problems / visual disturbances (not including refractive error), secondary to pseudotumor cerebri (or substantially similar disability, variously diagnosed), is granted. 11. Entitlement to service connection for tinnitus, secondary to pseudotumor cerebri (or substantially similar disability, variously diagnosed), is granted. The Veteran asserts that he suffers from a disability manifested by headaches as a result of his military service and/or his service-connected disabilities. After resolution of reasonable doubt in the Veteran’s favor, the Board finds that service connection can be granted in this case for a disability manifested by headaches. The evidence of record clearly and thoroughly documents that the Veteran has a long-term history of seeking medical treatment for severe headaches. The diagnostic nature and etiology of the headaches has not been entirely clearly established despite significant efforts on the part of medical professionals to evaluate the pathology. Nevertheless, the Board notes that there is no significant indication in the evidence of record that medical professionals have found any reason to doubt the credibility of the Veteran’s symptom complaints, and the Board’s own review of the evidentiary record likewise reveals no reason to doubt the significant functional impairment from headaches the Veteran has described. The Board observes that some medical reports suggest a diagnosis of migraine headaches to explain the Veteran’s symptom pattern, but the Board also observes that other competent medical evidence strongly suggests that the Veteran’s pertinent pathology (or perhaps multiple pathologies) may be of a nature elusive to clear diagnostic identification to date. As discussed in detail further below, the Veteran’s headaches are indicated by substantial quantities of medical evidence to be part of a set of symptomatic manifestations that are of unclear diagnostic attribution but may be attributed to pseudotumor cerebri or other pathology involving debilitating pressure upon the Veteran’s brain and spine. Preliminarily, the Board notes that one relatively straightforward avenue to establishing entitlement to service connection for the disability manifested by headaches in this case is presented by an April 2015 private medical opinion from a private provider named Dr. H.S. that concludes: “It is as likely as not that the headaches are permanently aggravated by the veteran[’]s service connected depression & allergic rhinitis.” The Board notes that other medical records suggest various other suspected etiologies for the headaches over time, although none appear to have been convincingly confirmed in the context of the failure of any prescribed treatments to deliver significant sustained relief of the Veteran’s symptoms. The Board also notes that a July 2014 VA examination report includes a medical opinion authored by a physician assistant that the Veteran’s headaches are unlikely related to military service because “[t]he medical record is silent regarding any headaches since leaving military service.” The VA examiner summarized the Veteran’s recorded medical history as being “silent after leaving military service in 1987 for any diagnosis or treatment of headaches.” As discussed in detail below, the Board finds that the Veteran has a documented post-service history of significant difficulties with headaches, and the Board finds the July 2014 VA medical opinion to be unpersuasive in light of its failure to accurately account for the significant facts of this case. Beyond the opinion of Dr. H.S. indicating that the Veteran’s headaches are as likely as not aggravated by his service-connected disabilities, the Board finds that the evidence of record contains significant and strong suggestions that the Veteran’s unusual symptom pattern associated with his headaches had its onset during his military service and involves a significantly broader array of impairments than merely the headaches themselves. The Board notes that the medical evidence of record reflects that the Veteran suffers from pathology or pathologies that result in substantially disabling impairments while largely eluding diagnostic identification from the multitude of medical professionals the Veteran has engaged for assistance. To adequately consider and analyze the pertinent facts in this complex case, the Board shall first discuss the details of the Veteran’s pertinent recent medical history. Informed by the recent medical information, the Board shall then discuss the pertinent indications in the Veteran’s service treatment records in the context of his overall medical history. Private medical reports, including dated in February 2013, March 2013, November 2013, March 2014, April 2014, May 2014, and others, show that the Veteran has been medically assessed with “780.4 Dizziness” by his private physician, and the dizziness episodes are associated with additional significant symptomatology. The February 2013 private medical report describes that the dizziness episodes were associated with “blurred vision, headache, ‘popping’ or a sense of pressure in ears, tinnitus and sinus pressure.” The March 2013 private medical report, amongst others with similar content, discusses that the Veteran’s dizziness is associated with “headache, nausea, vertigo, [l]oss of appetite, ear pressure and ‘echoing’ sensation in ears.” Later reports, such as the April 2014 report, re-add “tinnitus” to the list of symptoms associated with the problem. Private reports including the April 2014 report also document that the Veteran “states that the symptoms go back to his basic training at the Marine Base at Camp Lejeune in North Carolina.” The Veteran described that the symptoms, particularly the “lightheadedness, tilting, and imbalance” were “quite severe,” and that “[t]he frequency of the episodes is essentially constant and increasing in intensity.” A March 2013 report from a different private medical provider shows diagnoses of “780.4 Dizziness” and “388.30 Unspecified tinnitus” made by that provider. A May 2014 private medical record shows that the Veteran underwent an MRI (Magnetic Resonance Imaging) study to investigate the cause of his symptomatology, but the findings do not appear to have resolved the uncertainty regarding the pathological origin of the Veteran’s problems. A June 2014 private medical report shows that the Veteran was evaluated for his history of “vertigo and tinnitus” in which he gets “dizzy and unsteady when he changes his head position.” Some of the episodes featuring “severe dizziness” were noted to be accompanied by “a bitemporal headache and nausea.” A March 2013 report from another different private medical provider shows that one of the Veteran’s treating physicians described the Veteran’s “somewhat unusual and very nonspecific history of lightheadedness or dizziness….” The report discusses the authoring physician’s understanding that “for reasons unclear to me, he had a CT scan or MRI prior to his discharge in the Marine Corp, but this was some 20 years ago, and he does not know the results of that but says that some of the symptoms he has were present as he was getting discharged.” The report then describes that in August of 2012, the Veteran “had the sudden onset of feeling nauseous … and felt very lightheaded and says if he had a gun he would have shot himself because he thought he was dying.” The report continues: “This unusual sensation of being very lightheaded lasted about 5 minutes and [he] was still a bit dizzy but not as bad for another hour-and-a-half or so.” The report explains that “[s]ince then he has noted episodes of some dizziness, occasionally seeing flashes of light, and notes that he is dizzy if he bobs his head up and down.” The report notes the Veteran’s description that “6 weeks ago it became worse, so he sought medical help,” but that multiple prescribed medical treatments had not helped. The report describes that the Veteran “feels a constant pressure in both ears and also has tinnitus which is worse at night….” The authoring physician remarked: “A totally new symptom to me that no one has ever described before is that when he blinks his eyes he can hear it and feel it in his ears, and I am totally unclear what that might mean.” After an examination, the physician was unable to make any diagnostic determination, stating: “it could be any number of illnesses,” and indicating that “I have no real suggestions for this man.” An April 2015 VA medical record shows that the Veteran described having been recently diagnosed with pseudotumor cerebri and was in severe pain (“i am in such [expletive] pain i don’t know what to do….”) The Veteran described that “nothing is going to help me with this [expletive] head problem, i have seen 5 or 6 quacks, they ran every kind of test they could think of … and they couldn[’]t find nothing, i finally got to see [a] neurologist … and we tried the diamox and i can[’]t [tolerate] it[.] [S]he said there isn[’]t anything i could take so we did they spinal tap[,] lasted for 5 to 6 months and so we did another spinal tap….” The Veteran described that “on top of my head there feels like there is bones coming out of my head…. I am just in pain 24/7….” The Veteran explained that he had come “to see the va system to see if i can get some help …. [I] have these vertigo attacks and when you have them you want to shoot yourself[.] [M]y ears ring all the time[.]” The April 2015 Disability Benefits Questionnaire (DBQ) completed by Dr. H.S. indicates that the veteran was experiencing “headaches occurring daily that last all day” and he “become nauseous, sensitive to light & sound, and experiences visual changes.” The report indicates that “the severity of these headaches are a 10/10 on a pain scale and occur daily.” A May 2015 VA optometry report again references the Veteran’s diagnosis of “pseudotumor cerebri” and notes that the Veteran was receiving treatment from a private neurologist, had a noted “increased CSF on lumbar puncture,” had a “[h]istory of visual fluxations [sic] consistent with migraine.” A June 2015 VA neurology report discusses the Veteran’s history of “headaches for a very long time,” and that “now since last spring 2014 he complains of having blackout x2 weeks,” and noted that the Veteran “had been to the ER with a complete cardiac workup” that was negative for any revelatory abnormalities. The Veteran described that he “continued to have headaches, blurry vision and vertigo [a]nd ringing in the ears ‘ulcerating can hear heartbeat whooshing sound[,] severe neck pain feels like it hit me with a hammer.” The report notes that the Veteran had “continuous … mild headaches,” but also experienced another type of headache that was “severe” such that he “has to go and lay down.” The Veteran described “extreme nausea,” “vomiting,” “vertigo,” “light sensitivity,” and “[a]t times … his peripheral vision is impaired … [with] black swirls.” The report discusses that the Veteran had tried a number of prescribed treatments that had failed to relieve his symptoms. The report discusses that the Veteran’s private neurologist “has diagnosed him with pseudotumor cerebri,” and “performed LP [lumbar puncture] twice” with the lumbar puncture showing “opening pressure of 320 mm CSF and the Veteran “felt better afterwards with resolution of headache and the whooshing sound he was experiencing.” The report explains that the Veteran was then prescribed a medication that he was unable to tolerate, and then switched to an alternative medication. However, “his headaches have returned to set pressure predominately[.] [W]hen he squeezes his eyes shut [there] is whooshing sound and [he] feels dizzy.” The report noted that the Veteran had symptoms “present all the time to some extent,” but they were “worsened with head movements.” Additionally, the report notes that the Veteran described “he has had these symptoms since he was at the age of 19 or 20 while he was in the military and has gotten worse over years.” The recorded medical impression was “a long history of headaches with symptoms that sound like visual aura. These symptoms have changed since spring of 2014 when he blacked out twice and was seen in the hospital.” The medical impression summarized that the Veteran “states he continues to have headache, ringing in the ears, vertigo, nausea and vomiting, neck and low back pain and shoulder pain…. [A] local neurologist … diagnosed him with pseudotumor cerebri….” The medical impressions section additionally listed “Migraine with visual aura.” VA medical records from October 2015 document that the Veteran underwent another spinal tap procedure in connection with the continuing diagnostic investigation and treatment of his difficulties. The preoperative diagnosis was “? pseudotumor cerebrei [sic]” and the postoperative diagnosis was “Increased CSF pressure.” The Veteran’s pain level was “8/10” prior to the procedure, and was “2/10” after drainage. In the associated VA neurology treatment record from the same date, the Veteran reported that nothing had changed since his June 2015 consultation, and thus the same findings were repeated in the report. A week later, another October 2015 VA medical report notes that the Veteran was experiencing “light headedness and shortness of breath” while continuing to experience “headache.” The Veteran was taken to an emergency room due to his additional report of chest pain. Notably, during October 2015, testing performed on the fluid removed during the Veteran’s spinal tap revealed findings indicative of neurosyphilis, although also with some contrary findings as well. An October 2015 VA medical report includes an infectious disease expert’s remark that “it would be very difficult to r/o [rule out] neurosyphilis at this point.” Another October 2015 VA medical report lists a diagnosis of “neurosyphilis” and comments that the Veteran’s “h/o [history of] chr[onic] HA [headaches] and low back pain … may or may not be related to” the neurosyphilis diagnosis. Diagnostic uncertainty remained, however, as other October 2015 VA medical records indicate confusion regarding whether the Veteran’s abnormal serology represented neurosyphilis or not. While one October 2015 VA infectious disease consultation report notes “a history of chronic headaches, neck pain and lower back pain …. Was felt to be pseudotumor cerebri,” it then lists “neurosyphilis” as a current problem, and not pseudotumor cerebri. VA medical providers contacted the U.S. Center for Disease Control (CDC) to discuss the case, and an October 2015 report details that the response from CDC including that the CDC found: “this is a confusing case because the laboratory data contradict each other.” A VA infectious disease specialist then remarked: “Given the available data, it seems unlikely that this patient has syphilis.” A plan to proceed with penicillin treatment appropriate for treating syphilis was nevertheless agreed upon. A note was added to the report indicating that the Veteran “agrees to complete the treatment as we cannot be sure that he does not have neurosyphilis --though it is probable.” Other October 2015 VA reports show that the Veteran’s headaches were “still persistent,” and there remained questions and uncertainty as to whether the Veteran may have neurosyphilis, pseudotumor cerebri, both, neither, and/or some other pathology. The Veteran’s symptoms continued to include blurry vision, vertigo, ringing in the ears, “can hear heartbeat, whooshing sound,” severe neck pain, extreme nausea, vomiting, light sensitivity, and impaired peripheral vision. In November 2015, the Veteran underwent another spinal tap. In December 2015, the Veteran was “still having nausea, vertigo, pain and headaches.” VA medical reports from January 2016 show the continuing persistence of the symptoms, noting that the Veteran was “frustrated with the system” and that “[n]o one knows what is wrong with him.” The January 2016 VA medical records show that the Veteran “[c]ontinues to have headaches and white dots/ lights in his vision that get worse when headaches worsen. Headaches never go away. No relief from last LP [lumbar puncture / spinal tap].” The January 2016 records continue to reflect significant diagnostic uncertainty and confusion in attempting to identify and explain the Veteran’s pathology. March 2016 VA records continue to show these problems and that the Veteran was “still overwhelmed and upset that he has all these things wrong with him and nobody knows what is going on with him.” VA medical records from April 2016 show he was still struggling with “severe headache” and other symptoms. In April and May 2016, a VA neurologist’s uncertain assessment was “? migraines,” further noting remaining questions regarding the complex and confusing history of attempts to diagnose the Veteran’s problems. An apparent addendum to the report from June 2016 discusses the Veteran’s history of symptoms with headaches, blurry vision, vertigo, ringing in ears, “can hear heartbeat whooshing sound,” severe neck pain, extreme nausea, vomiting, light sensitivity, and black swirls in peripheral vision; notably, the neurologist remarked: “This is all consistent with increased intracranial pressure as migraine headaches, infection, inflammation….” May 2016 VA medical reports show that another spinal tap was arranged, and a shunt was considered, in further treatment of his symptoms. The Veteran continued to experience “intermittent and blurry vision,” with “3 episodes in the last 4 days w/ blurry [vision] peripherally and flashes of light w/ massing headaches.” A June 2016 report notes that this “will be the 5th or 6th” spinal tap the Veteran had undergone. An August 2016 VA medical report shows that the Veteran continued to experience problems featuring “lose vision,” “vertigo,” “headache,” “neck pain, 10/10,” and “nausea.” A February 2017 VA medical report shows that the Veteran was still experiencing headaches, dizziness, and nausea “every day,” along with “episodes of blurred vision, flashing lights, dark circles.” He reported that he had not had “episodes of total vision loss since October.” An April 2017 VA medical report notes that neurosurgeons “did not feel that his presentation was consistent with pseudotumor cerebri,” further reflecting diagnostic uncertainty and confusion in efforts to explain the Veteran’s symptoms. Multiple VA medical records, including in May 2017, indicate that the Veteran completed treatment addressing the possible neurosyphilis and that subsequent testing was negative for indications of neurosyphilis, yet the Veteran’s symptoms persisted. Other records from 2016 and 2017 refer to findings of a benign acoustic neuroma in the Veteran’s right ear, but it does not appear that the Veteran’s pertinent severe symptom pattern was medically considered attributable to this finding to any significant degree. A May 2017 VA medical record documents that the Veteran was “requesting his records be electronically sent to John[s] Hopkins Hospital for their review about his pseudotumor. He wishes to pursue going there even if the VA will not pay…. [H]e is not satisfied with his treatment at the VA.” A June 2017 VA medical report describes the Veteran as “[a] very complex patient,” and discusses some of the confusing indications. The report also includes the comment: “Patient has enjoyed diagnoses such as neuro syphil[i]s vs pseudo tumor cerebri, neither of which are still active.” While this report yet further reflects the medical confusion and uncertainty regarding the diagnostic identification of the Veteran’s problems, the Board does not find that the medical evidence overall reflects that pseudotumor cerebri had been clearly ruled out as a possible diagnosis in the Veteran’s case. A July 2017 VA medical record documents that the Veteran expressed “I don’t know how much more I can take,” and referenced suicide although assuring the author that he would not commit suicide. The Veteran described “extreme headache and neck pain, as well as the ‘swirls’ he sees in his eyes....” A July 2017 VA medical report documents the Veteran’s expression of desperate frustration and agony: “My [expletive] head hurts so bad. I have a pseudotumor. Nobody’s done a damn thing and I just keep suffering. I have blurry vision, swirls and white spots. I’m sweating, my ears pound. Nobody [expletive] cares…. They don’t know how to deal with it … pain drugs don’t work for me…. Nobody understands. They just keep throwing [expletive] pills at me…. My back and neck hurt so bad. I [defecated on] myself.” The Board finds that that the Veteran’s symptoms have been investigated by numerous medical professionals over a significant period of time, but the Veteran’s pathology or pathologies have eluded any medically confident diagnostic identification. Significantly, the Board notes that the extensive medical evidence of record does not suggest that any medical professional has cast doubt upon the validity of the Veteran’s description of his symptom experience. The Board notes that the Veteran has undergone numerous difficult and painful treatments and procedures in attempts to obtain a medical understanding of his problems, and he appears now to be further pursuing private medical expert assistance at potentially significant personal expense. Even though there is no clearly confirmed diagnosed pathology medically identified as the cause of the Veteran’s reported symptoms, the Board is satisfied that the Veteran suffers from the disabling symptomatology that he has credibly and consistently described throughout the pendency of this appeal. Furthermore, although the medical evidence indicates there is some uncertainty regarding whether the Veteran’s difficulties represent a case of pseudotumor cerebri, the Board finds that the Veteran has been diagnosed with pseudotumor cerebri by some of the treating medical experts involved in his treatment, and that the Veteran’s symptoms significantly correspond to the symptom profile associated with such a diagnosis. Although the diagnosis is not univocally agreed upon by all of the medical providers involved in the Veteran’s treatment, the Board finds that no other diagnosis is more persuasively presented. The Board finds that there is little doubt that the Veteran is suffering from a significant disability, and that both objective and subjective signs have been medically identified as suggesting pseudotumor cerebri as a plausible diagnosis. For the purposes of this analysis of disability benefits entitlement, the Board finds that it is most reasonable to conclude that it is at least as likely as not that the Veteran’s pertinent symptomatology represents manifestations of pseudotumor cerebri or another disability reasonably approximating the functional impairment of pseudotumor cerebri. For the sake of some clarification of terminology, the Board takes judicial notice of the fact that pseudotumor cerebri is also known as idiopathic intracranial hypertension (IIH), and is a condition characterized by increased intracranial pressure (pressure around the brain) without a detectable cause. “The most common symptoms of intracranial hypertension are headaches and visual loss, including blind spots, poor peripheral (side) vision, double vision, and short temporary episodes of blindness…. Other common symptoms include pulsatile tinnitus (ringing in the ears) and neck and shoulder pain.” See National Institutes of Health: Idiopathic Intracranial Hypertension, available at https://nei.nih.gov/health/iih/intracranial (last accessed November 7, 2018). The Board additionally observes that “pulsatile tinnitus” is a term denoting perceivable objective noise in one’s ears including in connection with one’s pulse / blood-flow / heartbeat, consistent with the Veteran’s symptoms. Accordingly, the Board is satisfied that the Veteran’s current (albeit somewhat uncertain) diagnosis of pseudotumor cerebri reasonably well contemplates the Veteran’s pertinent impairments for the purposes of the Board’s analysis in reviewing this appeal. Significantly, the Board finds that several of the Veteran’s symptoms medically attributed to the pathology the Board has identified as pseudotumor cerebri are reasonably shown to have had onset during his active duty military service. The Veteran’s service treatment records present contemporaneous documentation of a significant patterns of symptoms that correspond to those symptoms now medically associated with his pseudotumor cerebri (or substantially similar disability, variously diagnosed). An October 1984 service treatment report indicates that the Veteran suffered “lacerations to forehead + L cheek just below L eye received from a fight.” The Veteran reported “blurred vision” and “pain” when he closed his eye. In the context of the rest of the Veteran’s documented medical history, and his own contentions, there is no significant indication that this incident resulted in any chronic residuals of importance to the analysis in this claim. During service in July 1985, the Veteran’s service treatment records show that he sought treatment for complaints of “blurry vision” with “H/A [headaches]” on an “intermittent” basis of 6 years duration. The Veteran described that the episodes occurred approximately once every three months and lasted 15 minutes to an hour. In August 1985, the Veteran’s service treatment records show he sought treatment for “complaints of nausea queasy feeling, lightheadedness, dizzy + weakness…. Also eyes blurry at times.” At that time, the Veteran was not experiencing a headache. The medical assessment at the time was a probable viral stomach upset. In October 1986, the Veteran sought treatment for symptoms medically documented as “visual aura followed by left side headaches.” Another October 1986 service treatment record notes the Veteran’s complaint of headaches or light-headedness (somewhat illegible) and documents a medical assessment of “blurring of vision [with] H/A [headaches] - unclear etiology - probable migraine in origin.” The Veteran was referred for neurological consultation. Another October 1986 service treatment record documents the Veteran’s account of having previously (in October 1979) fallen from a bicycle such that he “hit the L side of his head on cement,” and that he was told he had a skull fracture and concussion. The report is not entirely legible, but the medical assessment at that time noted essentially normal examination findings, but a plan to further evaluate for concerns associated with the concussion and blurry vision history of the past six years. Further notes from that time document that the Veteran was experiencing “intermittent blurring of vision of peripheral fields [with] peripheral light flashing …. Episodes last 90 mins [with] increasing frequency” from once every “2 months” to once every “10-14 days over the last 6 mo[nths].” The report describes that “episodes lead into bitemporal headaches - constant + goes into generalized H/A [headache] that resolves after 30 minutes.” Another October 1986 service treatment record shows that the Veteran was assessed with “headaches” without a definitive determination of etiology. A service treatment record with an illegible date (May 28th of an unreadable year in the 1980s) describes that during his “freshman year in high school,” the Veteran had “sustained hairline fracture and mild concussion” associated with a head injury. The service treatment record is difficult to read, but appears to describe that following the accident the Veteran “began to experience visual phenomena” and spells of feeling “dizzy” and perceiving “sand across vision.” It also appears to describe associated difficulty with a “weak eye muscle.” At this point, the Board finds it appropriate to clearly acknowledge this information suggesting that the Veteran may have suffered a head injury prior to service that may have been causally / etiologically significant to the onset of his pertinent symptomatology in this case. The Board has considered this information, but finds that the Veteran is presumed to have been in sound health in all pertinent respects upon his entry to active duty service; the presumption of soundness applies in this case because the Veteran’s February 1983 service enlistment medical examination did not note any pertinent disability at that time. Moreover, the Board finds that the evidentiary record does not present the required showing of clear and unmistakable evidence that the Veteran had a pertinent disability pre-existing his service plus the required showing of clear and unmistakable evidence that any such pre-existing disability was not aggravated by service to meet the threshold to rebut the applicable presumption of soundness in this case. Accordingly, the Board concludes that the presumption of soundness applies and is unrebutted in this case such that the Veteran is considered to have been unafflicted by pertinent disabilities when his active duty service began. Any manifestations of the pertinent disabilities shown during the Veteran’s active duty service must be considered to have had their initial onset during active duty service for the purposes of the Board’s analysis. A May 1987 service treatment report shows that the Veteran sought treatment for twice-monthly episodes of “peripheral flashing” with “blurred peripheral vision … flashing white lights peripherally” lasting 30-60 minutes. At this time, the symptoms were associated with dizziness but were not noted to be associated with headaches. The Veteran described that he had experienced these episodes since suffering a “hairline skull fx” in bike accident in 1981. Another May 1987 service treatment report shows that the Veteran was medically assessed as having “visual disturbances by hx.” Another service treatment report of an unknown date (probably from May 1987) indicates that the Veteran’s in-service difficulties led to referral for “skull xrays.” A June 1987 skull x-ray series failed to reveal a cause of the Veteran’s symptoms, producing “normal” findings. In July 1987, the Veteran was referred for diagnostic imaging (featuring a CAT scan) of the brain, apparently due to an inability to otherwise discern the nature of the pathology resulting in his symptoms. The July 1987 scan revealed only “normal” findings, and there is no indication that any further explanation of the Veteran’s symptoms was derived from completed diagnostic testing. An August 1987 medical history questionnaire shows that the Veteran reported ongoing problems with “blurred/double vision,” explaining “from time to time I have eye problems, doctors don’t know why.” The Board notes that the Veteran’s service treatment records contain no indication that the evaluating medical professionals were able to determine a clear cause of the Veteran’s symptom reports, but there is also no indication that the medical professionals doubted the validity of the Veteran’s report of symptoms. The Board finds that the service treatment records sufficiently document that, during active duty service, the Veteran was experiencing a significant portion of the unusual symptom pattern that is now medically attributed to his pseudotumor cerebri (or substantially similar disability). During service, as currently, the Veteran’s symptoms prompted medical providers to investigate with diagnostic imaging that failed to reveal a diagnostic explanation for the difficulties. The evidence in this case is far from unequivocally clear, but the Board finds that significant efforts at medical diagnostic evaluation of the Veteran have reasonably maximized the extent of clarity that can be achieved regarding the understanding of the Veteran’s complex and diagnostically elusive disability. The Board finds that the evidence in this case sufficiently indicates that the Veteran’s pseudotumor cerebri (or substantially similar disability) is reasonably shown to have had onset of key symptomatology during the Veteran’s active duty service. The Board finds that the current symptomatic pseudotumor cerebri (or substantially similar disability) is linked to the in-service manifestations of several of the same key symptoms. The positive evidence is at least in equipoise with the negative. Accordingly, service connection for pseudotumor cerebri is warranted. The Board additionally finds that the Veteran’s claims on appeal seeking to establish service connection for headaches, dizziness, vision problems, and tinnitus each feature impairment that has been repeatedly associated in the medical evidence with the Veteran’s pseudotumor cerebri (or substantially similar disability) pathology. Accordingly, the Board finds that service connection for headaches, dizziness, vision problems, and tinnitus is warranted. The Board finds that the Veteran’s claim for service connection for vision problems, in the context of his contentions and medical history, is reasonably clear in that it pertains to the Veteran’s vision problems associated with the distortions of vision associated with his symptomatic episodes of pseudotumor cerebri (or substantially similar disability). The Board finds that service connection for those claimed vision problems is warranted. For the sake of clarity, the Board notes that service connection for refractive error is not available. Refractive error is not a disease or injury within the meaning of applicable legislation. 38 C.F.R. § 3.303(c). Accordingly, service connection for any refractive error is not warranted and is not part of the award of service connection for vision problems in this decision. The Board also notes that in the various medical investigations seeking to diagnose the Veteran’s pertinent pathology or pathologies, some of the Veteran’s medical records note concern regarding findings of fluid on his brain, or hydrocephalus. The Board recognizes that a July 2015 RO rating decision adjudicated and denied a claim of entitlement to service connection for hydrocephalus, and that claim is not in appellate status before the Board at this time. The Board finds that the July 2015 RO rating decision is no impediment to the grants of service connection made at this time, as the Board finds that the Veteran’s pertinent pseudotumor cerebri (or substantially similar disability, variously diagnosed) is sufficiently distinct from hydrocephalus as to constitute its own disability entity subject to a separate claim warranting independent consideration for entitlement to service connection. The Board notes that many of the Veteran’s medical records refer to pseudotumor cerebri and fluid on the brain as separate medical entities, often amongst other possibly pertinent pathologies in the investigation of the Veteran’s complex and diagnostically elusive disability picture. In summary, the Board finds that service connection for pseudotumor cerebri (or substantially similar disability), headaches, dizziness, vision problems, and tinnitus is warranted. 12. Entitlement to service connection for kidney disease is denied. The Veteran contends that he suffers from a disorder of the kidneys as a result of his military service, claimed in April 2013 as “kidney condition.” The Board notes that the Veteran identified a separate disability manifested by “frequent urination” as part of his claim in April 2013, and the two different issues of entitlement to service connection for (1) “kidney condition,” and (2) “frequent urination” have been maintained as separate claims throughout the adjudication of this case. Service connection is limited to those cases where disease or injury has resulted in a disability. In the absence of proof of a present disability for which service connection is sought, there is no valid claim of service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The requirement of having a current disability is met when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). A disability under 38 U.S.C. § 1110 refers to functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (2018). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of a kidney disorder and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Veteran’s medical records include references to the Veteran having a history of suffering from kidney stones in the past. Among these references, a May 2017 VA medical report specifically states: “He had kidney stones in 1996.” The evidence does not otherwise indicate that the Veteran has had a kidney disorder during the pendency of this claim on appeal filed in 2013. Significantly, a VA medical opinion based upon review of the claims-file addressed the Veteran’s contentions in this matter in October 2014, including with attention to the Veteran’s concern that such disorder may be caused by his exposure to contaminated water at Camp Lejeune. The October 2014 VA medical opinion was prepared by a VA physician who is also a “Member, Subject Matter Expert Panel; Camp Lejeune Contaminated Water Project.” Based upon two hours of review and consideration, the expert’s October 2014 VA medical opinion clearly concludes: “evidence of record is negative for any chronic GU/renal condition.” In this regard, the reviewing expert explains: “A review of the vast PMRs [private medical records] from 2004-14 noted in VBMS were silent with regards to the diagnosis or treatment for a urinary or renal condition of a chronic nature, or medication associated with any such condition.” The expert notes that “the veteran was seen at regular intervals during this time period for multiple conditions, but he was also seen for annual DOT exams w/ urinalyses.” Furthermore, the VA expert explains: “The majority of the treatment records from [Dr. S.W.] include a serum Creatinine level and GFR. Without exception these were noted to be in the normal range (sCr 0.6-1.3, GFR>90).” Additionally, the VA expert notes that “[t]he most recent record from 05/2014 notes a sCr 0.8mg/dl and GFR 114.79. Prior urinalyses were also reviewed from [a private] Medical Center dated 2010 and 2012, these were also both noted to be unremarkable.” The October 2014 VA medical opinion unambiguously concludes that the Veteran has no kidney disorder, and that “given the absence of any apparent renal/GU disease process[,] no medical opinion is warranted. The lack of evidence of pathology precludes the establishment of any nexus.” The Board finds that October 2014 VA physician’s conclusion that the Veteran does not have a kidney disorder is competent medical evidence informed by thorough review of the pertinent evidence and presented with a persuasive and detailed rationale. For these reasons, the October 2014 VA medical opinion is adequate for the purposes of appellate review, and it is probative evidence weighing against finding that the Veteran has a kidney disorder. The Board accepts the conclusion of the pertinent medical evidence that the Veteran does not have a kidney disorder. There is no contrary medical evidence of record indicating that the Veteran has been diagnosed with a kidney disorder during the pendency of the claim on appeal beginning in 2013. While the Veteran has asserted that he has a kidney disorder, and is competent to report subjective symptoms such a frequent urination, the Veteran’s report of frequent urination is addressed as a separate issue from this claim of entitlement to service connection for a kidney disorder. Distinct for the kidney disorder issue, the ‘frequent urination’ issue been claimed as a separate disability issue amongst the Veteran’s service-connection claims, it has been adjudicated separately by the Agency of Original Jurisdiction (AOJ), and it has been certified to the Board separately. While the Board finds that the ‘frequent urination’ issue may potentially be intertwined with neurological-etiological investigations requiring further evidentiary development, the specific issue of entitlement to service connection for a kidney disorder can be fully resolved at this time by the evidence persuasively and clearly indicating that the Veteran does not have a kidney disorder, with no contrary competent evidence on this point. The Veteran is not competent to establish a diagnosis of a kidney disorder. A diagnosis of a kidney disorder requires specialized medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (Whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the Veterans’ Court). In Jandreau, the Federal Circuit specifically determined that a layperson is not considered competent to testify when the issue was medically complex, as is the question of establishing a diagnosis of a kidney disorder in this case. Setting aside the urinary frequency that is addressed separately as its own issue on appeal, neither the Veteran’s testimony nor any other evidence of record has identified a functional impairment associated with the kidneys that may otherwise be considered to satisfy the requirement of a current disability to support an award of service-connected disability benefits. See Saunders v. Wilkie, 886 F.3d 1356 (2018) (holding that a disability under 38 U.S.C. § 1110 refers to functional impairment of earning capacity). The Board concludes that the Veteran does not have a kidney disorder. Accordingly, the claim for service connection for a kidney disorder must be denied. 13. Entitlement to service connection for a cyst of the left hand is denied. 14. Entitlement to service connection for left carpal tunnel syndrome is denied. 15. Entitlement to service connection for right carpal tunnel syndrome is denied. Review of the claims-file does not provide clarity as to whether the Veteran has current disabilities associated with carpal tunnel syndrome or a left hand cyst. The Board does observe that the Veteran’s medical records indicate a history of undergoing surgical treatment for bilateral carpal tunnel syndrome during the mid-1990s, including as noted in a February 2006 private medical report. In any event, even assuming for the limited purposes of this analysis that the Veteran has current disabilities associated with carpal tunnel syndrome and a left hand cyst (or residual disability from past such pathologies), the Board finds that the criteria for entitlement to service connection for such disabilities are not met in this case. The Veteran’s service treatment records (STRs) are silent for any complaints, findings, treatment, or diagnoses relating to carpal tunnel syndrome or a left hand cyst. The Veteran had no pertinent abnormalities noted upon complete medical examination in October 1987. There is otherwise no evidence of record that shows onset of carpal tunnel syndrome or a cyst of the left hand during active military service. Consequently, service connection for carpal tunnel syndrome or a cyst of the left hand on the basis that such became manifest in service and persisted is not warranted. There is also no competent (medical) evidence in the record that tends to relate any carpal tunnel syndrome or left hand cyst to the Veteran’s service. See 38 C.F.R. § 3.303. His post-service treatment records do not include opinions relating any pertinent pathology to his military service. Notably, the Veteran does not specifically assert (and the evidence does not support a finding) that he had carpal tunnel syndrome or a left hand cyst during military service. The only evidence in the record relating carpal tunnel syndrome and/or a left hand cyst to his military service is in his presentation of his claims for benefits asserting this belief. He does not provide any clear explanation as to why he believes carpal tunnel syndrome and/or a left hand cyst may be related to service. The Board observes that the Veteran’s May 2013 correspondence introducing his contention that he suffers from various disabilities due to exposure to contaminated water at Camp Lejeune specified the disabilities pertinent to that theory as “nose bleeds, dizzy, frequent urination, muscle fatigue.” The Veteran did not indicate that he believed that he suffered from carpal tunnel syndrome and/or a left hand cyst due to contaminated water. Nevertheless, the Board has considered that other items of record show that the Veteran has at times expressed a broad generalized concern that many of his health concerns may be the result of exposure to contaminated water at Camp Lejeune. The Veteran’s service personnel records show he served at Camp Lejeune during his active duty service, as confirmed by the RO’s own finding documented in the November 2015 statement of the case, including that “we have recognized your exposure to contaminated water.” The Board’s review of the record reveals no reason to disturb or differ from this finding. Accordingly, the Veteran’s exposure to contaminated drinking water at Camp Lejeune is accepted for the purposes of the analysis in this appellate review. With regard to considering whether the Veteran’s claimed conditions of carpal tunnel syndrome and a left hand cyst may be attributable to exposure to contaminated water at Camp Lejeune, North Carolina, the Board is sympathetic to the Veteran’s concerns regarding such exposure and the health risks therefrom. However, none of these claimed conditions are included in the list of presumptive diseases under 38 C.F.R. § 3.309. Consequently, the Board finds that the Veteran cannot prevail on his claims for service connection for carpal tunnel syndrome and left hand cyst based upon this presumptive theory of entitlement. The Board has reviewed the record for any indication of competent medical evidence otherwise suggesting that carpal tunnel syndrome or a left hand cyst could have been causally linked to the pertinent contaminated water exposure. However, the Board finds no suggestion of record that there is any medical support for the possibility of such an etiological link for these disabilities. The Board finds that service connection cannot be awarded for carpal tunnel syndrome or left hand cyst based upon a theory of entitlement that the claimed conditions are due to exposure to contaminated water at Camp Lejeune. The Board must still consider whether service connection is warranted on any other available theories of entitlement. Unfortunately, the Board finds that the evidence is insufficient to establish entitlement to service connection on any other theory of entitlement. The preponderance of the evidence is also against a finding that service connection on a direct basis is warranted. There is no evidence indicating in-service onset of carpal tunnel syndrome or a left hand cyst, and there is no evidence indicating any other manner or basis for finding that carpal tunnel syndrome or a left hand cyst was otherwise caused by any aspect of the Veteran’s military service. The Veteran’s bare assertions of such a nexus, without any supporting medical opinion or citation to medical literature, have no probative value. To identify a medical causal link between contaminated water exposure and carpal tunnel syndrome and/or a left hand cyst features complex medical questions. The Veteran is a layperson, lacking in medical training/expertise. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). In summary, the competent evidence of record does not show that the Veteran’s claimed carpal tunnel syndrome of the left and right sides and cyst of the left hand are, or may be, in any way related to his service. Consequently, the preponderance of the evidence is against the claims of entitlement to service connection for carpal tunnel syndrome of the left and right sides and for cyst of the left hand, and his appeals in these matters must be denied. REASONS FOR REMAND 1. Entitlement to service connection for a left shoulder disability is remanded. 2. Entitlement to service connection for a right shoulder disability is remanded. 3. Entitlement to service connection for a left elbow disability is remanded. 4. Entitlement to service connection for a right elbow disability is remanded. 5. Entitlement to service connection for a back disability is remanded. 6. Entitlement to service connection for a neck disability is remanded. 7. Entitlement to service connection for a left knee disability is remanded. 8. Entitlement to service connection for a right knee disability is remanded. 9. Entitlement to service connection for a left shin disability is remanded. 10. Entitlement to service connection for a right shin disability is remanded. 11. Entitlement to service connection for a left ankle disability is remanded. 12. Entitlement to service connection for a right ankle disability is remanded. 13. Entitlement to service connection for a disability manifested by generalized muscle fatigue / body aches is remanded. 14. Entitlement to service connection for a disability manifested by dyspnea / breathing problems is remanded. 15. Entitlement to service connection for a disability manifested by chest pain is remanded. 16. Entitlement to service connection for a disability manifested by frequent urination is remanded. 17. Entitlement to service connection for a disability manifested by gastrointestinal symptoms / blood in stool is remanded. Review of the medical evidence in this case contains a substantial array of information regarding efforts to medically assess the Veteran’s significantly complex disability picture featuring pseudotumor cerebri (or substantially similar disability, variously diagnosed). The Board notes that a wide variety of symptoms and impairments have been discussed as associated or potentially associated with the Veteran’s now service-connected disability picture, without a medical clarity. Notably, the most recent medical records available for review in the claims-file are VA records from July 2017, and they clearly reflect that substantial medical uncertainty remained concerning ongoing efforts to identify and manage the Veteran’s significant medical problems. The Board finds it important to note that the Veteran’s dissatisfaction with the progress being made by his medical providers at that time led to a decision documented in a May 2017 VA medical report: Pt. and his wife walked into clinic requesting his records be electronically sent to John[s] Hopkins Hospital for their review about his pseudotumor. He wishes to pursue going there even if the VA will not pay.... Pt. states John[s] Hopkins has several doctors that treat pseudotumors and he is not satisfied with his treatment at the VA. His next step is to see the center director on this matter. The Board finds that any records of evaluation and treatment from the Veteran’s planned consultations at Johns Hopkins, in addition to any other new medical records from VA or private providers, could be significant to the Board’s efforts to complete adequately informed appellate review of the Veteran’s remaining claims of entitlement to service-connection for any disabilities that have been reasonably suggested in medical evidence to be possibly intertwined or associated with the Veteran’s now service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed). Furthermore, the significant breadth of varied symptomatology and impairments that the medical evidence has suggested may be associated with the newly service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed) will now necessarily be the subject of further evidentiary development as the AOJ must undertake appropriate action to make an informed determination of the initial disability rating assignment(s) in connection with the new entitlement. Such forthcoming development, including any new VA examination report(s), is likely to yield relevant evidence pertaining to those amongst the Veteran’s service connection claims that involve impairment that medical evidence has suggested may be linked to his newly service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed). Accordingly, the Board finds it is most appropriate to defer adjudication and remand the remaining claims of service connection for each disability for which the existing evidence of record reasonably suggests a possible association with the newly service-connected pathology (but for which the evidence is currently insufficient to establish entitlement to service connection). The Board shall now offer some discussion of its identification of claims for disabilities about which the medical evidence reasonably suggests a possible association with his newly service-connected pathology. The Board notes that the publicly available medical treatise information regarding pseudotumor cerebri, including that discussed above in this decision, expressly indicates that neck and shoulder pain is commonly associated with the pathology. The Veteran’s complaints of neck and shoulder pains have been medically discussed in connection with his now service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed) in the medical evidence of record, including with multiple notations of severe neck pain sometimes associated with the Veteran’s symptomatic episodes of the pathology. In medical records such as a June 2015 VA medical report, the Veteran’s symptom-set discussed in connection with investigation of pseudotumor cerebri has included neck and low back pain. While the Veteran suffers from medically identified diagnoses of distinct disabilities including a right shoulder disability, the medical evidence reasonably indicates that the Veteran’s right shoulder pain may include aspects of pathology linked to his newly service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed). The Veteran’s now service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed), has been associated with an objectively documented abnormally high level of pressure in his cerebrospinal fluid, including as medically measured in spinal tap / lumbar puncture procedures, directly affecting his head and his spine. Publicly available medical treatise information confirms that back pain can be associated with pseudotumor cerebri. The Veteran has undergone several lumbar puncture procedures in direct connection with the newly service-connected pathology. During one phase of the medical efforts to diagnose the Veteran’s health problems, an October 2015 medical report shows that a doctor commented that the Veteran’s back pain “may or may not be related to the same” pathology responsible for his headaches. (The Board observes that the doctor was at that time contemplating the possibility that the Veteran’s diagnostically elusive pathology may involve neurosyphilis.) In medical records such as a June 2015 VA medical report, the Veteran’s symptom-set discussed in connection with investigation of pseudotumor cerebri has included neck and low back pain. While the Veteran suffers from medically identified diagnoses of distinct disabilities including back disabilities, the medical evidence reasonably indicates that the Veteran’s back pain may include aspects of pathology linked to his newly service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed). The Veteran’s medical records contain suggestions of a broad array of symptoms that may be associated with (including possibly caused or aggravated by) the Veteran’s poorly understood newly service-connected pathology and/or associated with his previously-established service-connected mental health disability. For example, the Board observes that an October 2015 VA medical report shows that the Veteran described his now service-connected headaches and blurry vision as accompanied by “muscle spasm in legs, back and neck,” and he explained that “in the morning my pain will go from my feet to my head.” A December 2015 VA medical record shows that the Veteran consulted a VA medical provider regarding his symptom set of “nausea, vertigo, pain and headaches,” contemplating his complaints of pain beyond his headaches in connection with his complex pathology; the VA medical provider suggested: “perhaps his symptoms could also be related or worsened by his anxiety.” The Veteran indicated that “[h]e thought this may be possible.” The VA medical provider noted that the Veteran had taken “an anti-anxiety medication” that had “helped him so much,” as the Veteran had reported that it “was the first time he ever felt so much better. [H]e stated ALL of his symptoms were gone.” It is furthermore important to note that the Veteran’s newly service-connected pathology involving some manner of neurological dysfunction is indicated by the medical evidence to be intertwined with his previously-established service-connected mental health disorder. Several medical reports reflect that the Veteran’s suffering associated with the symptoms of the service-connected pathology involving neurological dysfunction have significantly fed and aggravated aspects of his service-connected mental health disorder, including with regard to suicidal thinking and anxiety. This is important because the Veteran’s private medical records, including but not limited to a May 2014 report from Dr. S.W., show that he has been medically assessed with “polyarthralgia” and “non-cardiac chest pain.” Broad review of the Veteran’s medical records reveals that his complaints of chest pain led to cardiac testing that revealed no abnormalities (apart from hypertension), and the Veteran’s episodes featuring chest pain are, as noted in the May 2014 report from Dr. S.W., “[a]ssociated [with] symptoms includ[ing] anxiety, body aches, a sense of impending doom, nausea, rapid heart beat and dyspnea.” The Board finds that the medical evidence indicates that the Veteran’s symptoms of chest pains and polyarthralgia / generalized pain are associated with episodes of the manifestation of his symptoms of the newly service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed) and symptoms of his previously-established service-connected mental health disorder. The Board concludes that the Veteran’s claims for service connection for a disability manifested by chest pain and a disability manifested by generalized muscle fatigue / body aches are thus intertwined with the pending development concerning his newly service-connected disability, and these claimed disabilities must furthermore be considered as possibly service-connected as secondary to (caused or aggravated by) his established service-connected disabilities. In light of the Board’s findings regarding the need to remand the issue of entitlement to service connection for a disability manifested by generalized muscle fatigue / body aches together with other issues involving pain potentially associated with service-connected disabilities, the Board further finds that other issues on appeal concerning the etiologies of disabilities manifested by pain must likewise be remanded pending further development. Specifically, the claims of entitlement to service connection for disabilities of the right ankle, left ankle, right elbow, left elbow, right knee, left knee, right shin, and left shin, are to be remanded at this time. While the Veteran suffers from medically identified diagnoses of distinct disabilities of some of these body-parts, the medical evidence reasonably indicates that the Veteran’s pertinent painful symptoms may include aspects of pathology linked to his newly service-connected pseudotumor cerebri (or substantially similar disability, variously diagnosed). The Board notes that the above-discussed May 2014 report from Dr. S.W. also includes “dyspnea” (shortness of breath) among the set of symptoms associated with the Veteran’s symptomatic episodes of his newly service-connected complex pathology. As discussed above, the medical evidence of record includes suggestions that such symptomatic episodes involving chest pains and dyspnea may be related to his newly service-connected complex pathology and/or his previously-established service-connected mental health disorder. The Board finds that the issue of entitlement to service connection for a disability manifested by dyspnea / breathing problems is to be remanded at this time pending pertinent further development. The Veteran’s claim of entitlement to service connection for a kidney disorder has been denied on the basis of the absence of a kidney disorder, as discussed above. However, his separately adjudicated additional claim of entitlement to service connection for a disability manifested by frequent urination is not limited to consideration of a kidney disorder, and the Veteran’s competent and significant descriptions of his symptoms and impairments associated with his newly service-connected complex pathology have indicated that difficulties with frequent urination may be associated with those problems. For instance, an April 2015 VA medical report documents that the Veteran’s account of suffering with the pertinent symptomatology included his explanation that after “another spinal tap” associated with the evaluation of the newly service-connected complex pathology, the Veteran had “a tremendous headache” that did not relent, and that “on top of my head there feels like there is bones coming out of my head, between that and my back and I can’t stop pissing, I can’t work....” The Board finds that the evidence of record suggests that the Veteran may have experienced causation or aggravation of a disability manifested by frequent urination associated with the spinal tap procedures performed for his newly service-connected pathology and/or associated with the newly service-connected pathology itself. The Board finds that the issue of entitlement to service connection for a disability manifested by frequent urination is to be remanded at this time pending pertinent further development. Finally, with regard to the issue of entitlement to service connection for a disability manifested by gastrointestinal symptoms / blood in stool, the Board finds that a remand for additional development is necessary to support adequately informed appellate review. The Board also notes that the Veteran’s service treatment records document at least one instance during service of potentially significant gastrointestinal symptoms. A July 1985 service treatment record shows that the Veteran sought treatment for problems with vomiting and diarrhea. Service treatment records from August 1985 shows that the veteran continued to seek treatment for symptoms including “diarrhea” and “abdominal pain esp[ecially] after eating” that appear to have persisted for weeks. The medical assessment was “R/O [Rule out] Viral Gastroenteritis.” A more conclusive medical assessment of these symptoms is not apparent from the Board’s review of the service treatment records. A January 2016 VA medical report shows that the Veteran described that some of the medication prescribed in attempts to manage his newly service-connected complex pathology had caused him “gastric upset.” An October 2015 VA medical report shows that medications employed in efforts to manage the service-connected pathology had “chewed up my stomach too much.” Such reports suggest a possible link between medical treatment of his service-connected pathology and his claimed gastrointestinal disorder. A July 2017 VA medical report documents the Veteran’s report that he defecated upon himself during an episode of painful symptomatology directly or indirectly associated with his service-connected pathology. The Board finds that the evidence of record reasonably raises the questions of whether the Veteran currently has a gastrointestinal disorder, to include with any involvement of blood in stool, that is (a) etiologically linked to the Veteran’s in-service gastrointestinal complaints, or (b) caused or aggravated by his service-connected disabilities (to include medications prescribed in treatment thereof). A remand for a VA examination with medical opinion is warranted to inform appellate review of this issue. The matters are REMANDED for the following action: 1. Associate with the claims-file any outstanding pertinent treatment records, including additional VA treatment records (such as those that may have been created since the last such update of the claims-file in July 2017). Ask the Veteran to complete a VA Form 21-4142 for Johns Hopkins Hospital concerning the medical evaluation and treatment he informed VA he was pursuing in 2017. Make two requests for the authorized records from Johns Hopkins Hospital, unless it is clear after the first request that a second request would be futile. 2. After the record is determined to be complete, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s claimed gastrointestinal disorder. The examiner must opine as to whether it is at least as likely as not that the Veteran has a gastrointestinal disability, including with attention to the Veteran’s reports of gastrointestinal distress and blood in his stool. The examiner must then also opine as to whether any found gastrointestinal disorder (1) is at least as likely as not etiologically linked to the Veteran’s in-service gastrointestinal symptoms documented in his service treatment records in July and August 1985, (2) is proximately due to his service-connected disabilities, or (3) has been aggravated beyond its natural progression by his service-connected disabilities (including the use of medications prescribed for treatment of service-connected disabilities). 3. After the record is determined to be complete, schedule the Veteran for an examination by an appropriate clinician (or clinicians) to determine the nature and etiology of each of the Veteran’s claimed disabilities manifested by (a) left shoulder pain/impairment, (b) right shoulder pain/impairment, (c) left elbow pain/impairment, (d) right elbow pain/impairment, (e) left knee pain/impairment, (f) right knee pain/impairment, (g) left shin pain/impairment, (h) right shin pain/impairment, (i) left ankle pain/impairment, (j) right ankle pain/impairment, (k) back pain/impairment, (l) neck pain/impairment, (m) generalized muscle fatigue / body aches, (n) dyspnea / breathing problems, (o) chest pain, and (p) frequent urination. For each claimed disability, the examiner must opine as to whether it is at least as likely as not that the Veteran has a disability that is proximately due to his service-connected disabilities, including his psychiatric disorder and/or pseudotumor cerebri (or substantially similar disability, variously diagnosed), including any prescribed medications or medical procedures (such as spinal taps) used in connection with the service-connected disabilities. For each claimed disability, the examiner must also opine as to whether it is at least as likely as not that the Veteran has a disability that has been aggravated beyond its natural progression by his service-connected disabilities, including his psychiatric disorder and/or pseudotumor cerebri (or substantially similar disability, variously   diagnosed), including any prescribed medications or medical procedures (such as spinal taps) used in connection with the service-connected disabilities. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Barone, Counsel