Citation Nr: 18160002 Decision Date: 12/20/18 Archive Date: 12/20/18 DOCKET NO. 17-54 181 DATE: December 20, 2018 ORDER Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for plantar fasciitis is denied. Entitlement to service connection for an eye disability, claimed as blurred vision, is denied. Entitlement to service connection for a sinus disability is denied. Entitlement to service connection for a pulmonary disability due to asbestos exposure is denied. Entitlement to service connection for a respiratory disability, to include residuals of pneumonia and restrictive lung disease, is denied. Entitlement to service connection for a psychiatric disability, to include major depressive disorder, is denied. Entitlement to a rating higher than 50 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a rating higher than 10 percent for scar on the bridge of the nose is denied. Entitlement to a rating higher than 0 percent for residuals of a nose fracture is denied. Entitlement to an effective date of July 22, 2013, but not earlier, for service connection for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for headaches is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for orthostasis, claimed as dizziness, is remanded. FINDINGS OF FACT 1. A preponderance of the competent and credible evidence of record shows that the Veteran’s low back disability is not related to active service. 2. A preponderance of the competent and credible evidence of record shows that the Veteran’s left knee disability is not related to active service. 3. A preponderance of the competent and credible evidence of record shows that the Veteran’s right knee disability is not related to active service. 4. A preponderance of the competent and credible evidence of record shows that the Veteran’s plantar fasciitis is not related to active service. 5. A preponderance of the competent and credible evidence of record shows that the Veteran’s eye disability, claimed as blurred vision, is not related to active service. 6. A preponderance of the competent and credible evidence of record shows that the Veteran’s claimed sinus disability, to include sinusitis, allergic rhinitis, or Reinke’s edema, is not related to active service. 7. A preponderance of the competent and credible evidence of record shows that the Veteran’s claimed pulmonary disability is not related to active service. 8. A preponderance of the competent and credible evidence of record shows that the Veteran’s claimed respiratory disability, to include residuals of pneumonia and restrictive lung disease, is not related to active service. 9. A preponderance of the competent and credible evidence of record shows that the Veteran’s major depressive disorder is not related to active service. 10. The Veteran’s PTSD has been manifested by symptoms productive of no more than occupational and social impairment with reduced reliability and productivity. 11. The Veteran’s residuals of a nose fracture have not been manifested by 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side for any period on appeal. 12. The Veteran’s scar on the bridge of the nose has not been manifested by two or more characteristics of disfigurement, visible or palpable fissure loss, or gross distortion or asymmetry of the nose. 13. The Veteran filed a claim for service connection for anxiety and depression that is date-stamped as received by VA on July 22, 2013. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 2. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 3. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 4. The criteria for service connection for plantar fasciitis have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 5. The criteria for service connection for an eye disability, claimed as blurred vision, have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 6. The criteria for service connection for a sinus disability, to include sinusitis, allergic rhinitis, or Reinke’s edema, have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.303. 7. The criteria for entitlement to service connection for a pulmonary disability due to asbestos exposure have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.303. 8. The criteria for service connection for a respiratory disability to include residuals of pneumonia and restrictive lung disease have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.303. 9. The criteria for service connection for major depressive disorder have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 10. The criteria for a rating higher than 50 percent for PTSD have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9411. 11. The criteria for a rating higher than 0 percent for residuals of a nose fracture have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.97, Diagnostic Code 6502. 12. The criteria for a rating higher than 10 percent for scar of the bridge of the nose have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code 7800. 13. The criteria for an effective date of July 22, 2013, but not earlier, for service connection for PTSD, are met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.102, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Service connection may be established for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in service incurrence or aggravation of a disease or injury; and (3) evidence, generally medical, of a causal relationship between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be established for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Furthermore, service incurrence will be presumed for certain chronic diseases if manifest to a compensable degree within the year after active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. 1. Entitlement to service connection for a low back disability 2. Entitlement to service connection for a left knee disability 3. Entitlement to service connection for a right knee disability 4. Entitlement to service connection for plantar fasciitis 5. Entitlement to service connection for an eye disability, claimed as blurred vision The record shows that the Veteran has current low back, bilateral knee, foot, and eye disabilities. For example, X-rays from May 2016 found mild multilevel degenerative disc disease of the lumbar spine, chondromalacia, and cartilage abnormalities of both knees. A May 2016 podiatry note contains a diagnosis of plantar fasciitis. A September 2016 treatment record contains diagnoses of convergence insufficiency, emmetropia with presbyopia, dry eyes, and floppy eye lid syndrome. The remaining questions are whether there was an in-service incurrence or aggravation of a disease or injury; and whether there is a causal relationship between the claimed in-service disease or injury and the current disabilities. The Board finds that the preponderance of evidence is against a finding that the amu current low back, left knee, right knee, plantar fasciitis, and eye disabilities were caused or aggravated by active service. Notably, the service medical records are silent for any signs, symptoms, or diagnoses of any low back disability, disability of either knee, plantar fasciitis, or eye disability. Additionally, the Veteran has sought ongoing medical treatment through the VA. However, none of the Veteran’s medical treatment providers has given any indication that the any current low back, bilateral knee, plantar fasciitis, or eye disabilities are related to active duty. The Board finds that the competent evidence of record does not support a finding that relates any current low back, bilateral knee, plantar fasciitis, or eye disability to service. Therefore, as there is no competent evidence linking a currently diagnosed disability to service, the claims must be denied on a direct basis. Having reviewed the evidence pertaining to this claim, the Board has additionally determined that service connection on a presumptive basis for a low back, left knee, right knee, or foot disability is not warranted. As the evidence is negative for signs, symptoms, or diagnoses of arthritis to a compensable level during the Veteran’s first post-service year, service connection for a low back, left knee, right knee, or foot disability cannot be granted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. The Board acknowledges the Veteran’s contentions that he experiences low back, bilateral knee, plantar fasciitis, and eye disabilities as a result of active duty. The Veteran can attest to factual matters of which he had first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). However, while the Veteran is competent to report what comes to him through his senses, he does not have medical expertise to provide an opinion on the etiology of low back degenerative changes, knee cartilage problems, plantar fasciitis, convergence insufficiency, emmetropia with presbyopia, dry eyes, and floppy eye lid syndrome. The etiology of the claimed disabilities presents a complex medical question as there is no observable cause and effect relationship. Layno v. Brown, 6 Vet. App. 465 (1994). While the Board has considered the Veteran’s contentions regarding the presence of symptoms, the Board ultimately places more probative weight on the objective laboratory findings and observations of the VA medical professionals, who have the medical training and knowledge to perform and interpret the necessary medical tests. In addition, the Veteran has not submitted any competent medical evidence that supports a finding that any current low back, knee, plantar fasciitis, or eye disability is due to service. The Veteran has not been provided a VA examination in connection with these claims for service connection. As the evidence of record is against finding credible evidence of an event, injury, or disease during service that would support a finding of incurrence or aggravation of the claimed disabilities, a VA examination is unnecessary as it is not reasonably likely to result in favorable findings. The preponderance of the evidence is against the claims for service connection on a direct basis. Accordingly, the Board finds that the preponderance of the evidence is against the claims for service connection for low back, left knee, right knee, plantar fasciitis, and eye disabilities, and the claims must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Entitlement to service connection for a sinus disability The service medical records show that in March 1977, the Veteran had a nasal trauma. Service connection has already been granted for residuals of a nasal fracture and a scar as a result of that documented in-service nasal injury. The Veteran claims that he has additional sinus disability consisting of sinusitis, allergic rhinitis, and Reinke’s edema as a result of the in-service trauma that should be service-connected. However, none of the Veteran’s medical treatment providers have given any indication that the Veteran’s claimed additional residuals could be related to active duty service. The only evidence which provides any connection between the Veteran’s claimed additional residuals and service comes from lay statements, which are not shown to have the medical competence to provide medical opinions diagnosing a disability or relating a disability to service. It is to be noted that the Board is not free to substitute its own judgment for that of a medical expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991). However, the Board is required to assess the credibility and weight to be given to evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The Board has considered the Veteran’s lay statements. Laypersons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, as to the specific issues in this case, whether claimed sinusitis, allergic rhinitis, or Reinke’s edema were caused by active service, to include as a result of an in-service nasal trauma, those issues fall outside the realm of common knowledge of a layperson. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As a layperson, it is not shown that the Veteran possesses the medical expertise to provide such opinions, and no competent nexus opinions are of record. In August 2016, the Veteran underwent VA examination. The examiner noted that the Veteran currently had episodes of sinusitis and purulent discharge. The Veteran also had chronic laryngitis. A laryngeal endoscopy revealed moderately severe bilateral Reinke’s edema. In September 2016, a VA examiner reviewed the available records and remarked that the Veteran incurred a nasal fracture in 1977 from which he healed without deformity. The examiner’s review of the post-service treatment records showed no significant nasal deformity or obstruction from the healed nasal fracture. Therefore, the examiner stated that there was no evidence to associate the Veteran’s chronic sinusitis, allergic rhinitis, or Reinke’s edema with the nasal fracture diagnosed 37 years prior. The examiner opined that it was less likely than not that the claimed disabilities were related to the service-connected injury. The Board finds the VA examiner’s opinion to be more probative than the Veteran’s assertions. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The opinion of the VA examiner is highly probative because it was supported by detailed rationale and was provided by a trained medical professional. The VA examiner specifically identified and discussed the Veteran’s contentions and theory concerning service and his claimed residuals. Additionally, the examiner also referenced the Veteran’s contentions and addressed what the treatment records did and did not show. Accordingly, the VA examiner’s opinion is found to carry significant weight. Among the factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion. Hayes v. Brown, 5 Vet. App. 60 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence); Wood v. Derwinski, 1 Vet. App. 190 (1992). The probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion reached. As is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). The Board is sympathetic to the Veteran in that it is clear he sincerely believes he has additional residuals as a result of his in-service nasal trauma that warrant service connection. However, the evidence of record does not support that contention. Although the Board is appreciative of the Veteran’s faithful and honorable service to our country, considering the record before the Board, this claim must be denied because the preponderance of the evidence is against the claim. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1991). 7. Entitlement to service connection for a pulmonary disability due to asbestos exposure 8. Entitlement to service connection for a respiratory disability, to include residuals of pneumonia and restrictive lung disease The Veteran contends that he has current pulmonary disorder as a result of exposure to asbestos while serving on active duty aboard the USS Kitty Hawk. The Veteran also contends that he has a current respiratory disorder related to in-service pneumonia and bronchitis. The Veteran’s service personnel records show that he served aboard the USS Kitty Hawk. A November 1976 service treatment record shows treatment for bronchitis. In January 1977, the Veteran was treated for pneumonia. In January and February 1977, the Veteran was treated for mild bronchitis. An April 2016 VA treatment record contains the Veteran’s report of dyspnea either at rest or with activity. Medical studies were performed, and the examiner found no evidence to suggest a cardiac or pulmonary etiology. The treatment provider stated that with normal lung function and a normal CT scan of the lung, there was no evidence consistent with a primary parenchymal disease. The provider explained that normally asbestosis would cause either plaques or parenchymal disease, and neither of those were evident. On VA examination in January 2017, the examiner diagnosed dyspnea of uncertain etiology. The Veteran stated that the onset of symptoms occurred about eight to ten years previously. The examiner found no current evidence of a structural lung disease such as asthma, COPD, or interstitial lung disease. The Veteran complained of a chronic cough and a lot of mucus. An X-ray found no evidence of acute abnormality or findings to suggest asbestosis. The examiner opined that the Veteran’s claimed conditions were less likely than not incurred in or caused by his service, as the X-ray findings did not support the presence of an asbestos-related pulmonary disease. Service connection may be established when all the evidence establishes a medical nexus between service and current complaints. In this case, the most persuasive evidence of record is against a finding of a connection between service and the Veteran’s current pulmonary and respiratory symptoms. The Board acknowledges that the Veteran is competent to report that he experiences breathing problems. However, the April 2016 VA treatment provider found no evidence to suggest a cardiac or pulmonary etiology for the Veteran’s dyspnea, and the January 2017 VA examiner opined that the Veteran’s claimed conditions were less likely than not incurred in or caused by his service. The Board finds the January 2017 VA examiner’s opinion, in conjunction with the April 2016 treatment record, to be more probative than the Veteran’s assertions because of the medical training and experience of the examiners. The opinion of the January 2017 VA examiner in conjunction with the April 2016 treatment record is highly probative because they were supported by detailed rationale and provided by trained medical professionals. The VA examiner specifically identified and discussed the Veteran’s contentions and theory concerning service and his symptoms. They explained why the evidence did not reflect the presence of an asbestos-related disability. Additionally, the examiners also referenced the Veteran’s contentions. Accordingly, the January 2017 VA opinion and April 2016 treatment record are found to carry significant weight. There is no further indication in the claims file that any pulmonary or respiratory symptoms have a relationship to service. Thus, in light of the negative medical opinion of record, the Board finds that service connection for a pulmonary disability due to asbestos exposure, and for a respiratory disability, to include residuals of pneumonia and a restrictive lung disorder, is not warranted. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). The Veteran has not submitted any medical evidence that supports a finding that he has any asbestos-related pulmonary disability or that any current respiratory disability is related to service. The Veteran is not competent to diagnose pulmonary or respiratory disabilities or to make etiological opinions because he is not shown to have the requisite medical training. Therefore, the Board finds that the VA examiner’s opinion is the most persuasive evidence because of the medical training and experience and the review of the evidence of record. As the preponderance of the evidence is against the claim of entitlement to service connection for a pulmonary disability due to asbestos exposure, and for a respiratory disability, to include residuals of pneumonia and a restrictive lung disorder, the claims must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 9. Entitlement to service connection for major depressive disorder Service connection has previously been granted for PTSD. The Veteran claims that he also has depression that is related to active duty. On VA examination in March 2014, the examiner diagnosed major depressive disorder. The examiner specified that the Veteran did not have more than one mental disorder. The examiner opined that it was less likely than not that the Veteran’s depression was incurred in or caused by his service. The examiner stated that the onset of the Veteran’s depressive disorder came after the death of his only child who was killed in a car accident in 2003. The examiner commented on the service medical records and found that other than a March 1978 medical progress note which included a list containing the words “anxiety” and “hyperactivity” with diagnoses related to blood pressure problems, there was no history related to mental health in the service medical records. The examiner felt that the in-service notation of anxiety and hyperactivity was better explained by issues surrounding the Veteran’s in-service blood pressure problems. On VA examination in June 2017, the examiner diagnosed PTSD and major depressive disorder. The examiner indicated that the Veteran’s unwanted intrusive memories, flashbacks, nightmares, panic level, anxiety attacks, hyperarousal, suspiciousness, avoidance behaviors, and irritability were consequences of PTSD. His anhedonia, feelings of isolation and hopelessness, morbid ideation, hypomaniac motivation, and sleep changes were symptoms of his major depression. The examiner administered the Veteran the Structured Inventory of Malingered Symptoms, and the Veteran produced an extreme score of 61. The examiner explained that the Veteran’s extreme score on that inventory suggested a conscious attempt to exaggerate the severity, frequency, and intensity of his psychopathology symptoms. Therefore, assessment of the Veteran’s symptoms was very difficult. The examiner opined that the Veteran’s PTSD symptoms had the greater part of their origins in the Veteran’s active duty military experience, but it appeared much more likely that the Veteran’s depressive disorder was much more attributable to other life losses, traumas, and recent life changes. Service connection has previously been granted for PTSD. In this case, the most persuasive evidence of record is against a finding of a connection between service and the Veteran’s currently diagnosed depression. Having reviewed the evidence pertaining to this claim, the Board has determined that service connection on a presumptive basis for a psychosis is not warranted. As the evidence is negative for signs, symptoms, or diagnoses of a psychosis to a compensable level during the Veteran’s first post-service year, service connection for a psychosis cannot be granted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. The Board acknowledges that the Veteran is competent to report that he experiences depressive symptoms. However, the March 2014 and June 2017 January 2017 VA examiners opined that the Veteran’s diagnosed depression was less likely than not incurred in or caused by service, and more likely related to other causes after service. The Board finds the March 2014 and January 2017 VA examiners’ opinions to be more probative than the Veteran’s assertions because of the medical training and experience of the examiners. The opinions of the March 2014 and January 2017 VA examiners are highly probative because they were supported by detailed rationale and provided by trained medical professionals. The VA examiners specifically identified and discussed the Veteran’s contentions and theory concerning service and his symptoms. Significantly, they both provided an alternative etiology for the Veteran’s diagnosed depression. Accordingly, the March 2014 and January 2017 VA opinions are found to carry significant weight. There is no further indication in the claims file that the Veteran’s diagnosed depression has a relationship to service. Thus, in light of the negative medical opinions of record, the Board finds that service connection for depression is not warranted. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). The Veteran has not submitted any medical evidence that supports a finding that his diagnosed depression disability is related to service. The Veteran is not competent to differentiate between which of his psychiatric symptoms are due to PTSD and which are due to a depressive disorder because he is not shown to have the requisite medical training. Therefore, the Board finds that the VA examiners’ opinions are the most persuasive evidence because of the medical training and experience and the review of the evidence of record. As the preponderance of the evidence is against the claim of entitlement to service connection for depression, the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, that does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). 10. Entitlement to a rating higher than 50 percent for posttraumatic stress disorder Psychiatric disabilities other than eating disorders are rated pursuant to a General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under the General Rating Formula, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for 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 affected 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 worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned 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. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. The Board notes that in accordance with the General Rating Formula, a 100 percent rating is applicable if the manifestations of the service-connected psychiatric disability result in total occupational and social impairment. Although the rating formula lists specific symptoms that are indicative of total impairment, the symptoms listed in the rating formula are only examples, and evidence of those specific symptoms is not required to show that the Veteran is totally disabled. In rating a mental disability, VA is required to consider all symptoms that affect social and occupational functioning, and not limit consideration to those symptoms listed in the rating formula. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary consideration is whether the manifestations of the service-connected psychiatric disability result in a level of social and occupational impairment, regardless of whether the Veteran demonstrates the symptoms listed in the rating formula. When rating 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. A December 2016 rating decision established service connection for PTSD, effective May 31, 2016. The Veteran disagreed with the initially assigned rating. During the course of the appeal, a 50 percent rating was assigned, effective May 31, 2016. In a June 2017 decision, a temporary 100 percent rating based on inpatient psychiatric treatment was granted from May 4, 2017, to June 30, 2017. The Board will thus consider entitlement to a higher rating prior to May 4, 2017, and as of July 1, 2017. While an earlier effective date is assigned for service connection below, a rating has not been assigned for that period. VA outpatient and private treatment records from 2016 through the present show that the Veteran has received ongoing mental health treatment. The records generally show occasional suicidal ideation, poor concentration, sleep disturbances, irritability, and trouble concentrating. On VA examination in October 2016, the examiner diagnosed PTSD and major depressive disorder. The examiner remarked that the symptoms attributable to PTSD were physiological reactions to cues that resembled aspects of a traumatic event and avoidance of distressing memories. Symptoms that were attributable to both PTSD and depression were diminished interest in participation in significant activities, problems with concentration, sleep disturbance, suspiciousness, panic attacks, difficulty adapting to stressful circumstances, and anger. Symptoms that were primarily attributable to depression were depressed mood, anxiety, mild memory loss, disturbance of motivation and mood, difficulty in establishing and maintaining work and social relationships, suicidal ideation, and neglect of personal appearance and hygiene. The summary of occupational and social impairment with regard to all mental diagnoses was occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The examiner summarized the Veteran’s symptoms of PTSD as causing occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner stated that the Veteran’s symptoms of major depression were of primary concern as they had resulted in four psychiatric hospitalization. In a June 2017 statement, K.S. stated that he noticed the Veteran constantly losing his train of thought. K.S. stated that the Veteran never completed tasks, constantly lost his train of thought, and lost interest in his daily tasks. K.S. found the Veteran to be irritable and constantly angry. A June 2017 letter from R.C., M.D., shows that the Veteran’s PTSD symptoms had worsened over the prior year. Dr. C. stated that the Veteran’s PTSD was characterized by increased flashbacks, nightmares, and depression. On VA examination in June 2017, the examiner provided diagnoses of PTSD and major depressive disorder. The examiner indicated that the Veteran’s unwanted intrusive memories, flashbacks, nightmares, panic level, anxiety attacks, hyperarousal, suspiciousness, avoidance behaviors, and irritability were consequences of PTSD. His anhedonia, feelings of isolation and hopelessness, morbid ideation, hypomaniac motivation, and sleep changes were symptoms of major depression. The examiner felt that the Veteran’s symptoms were best summarized as an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran was separated from his spouse and had problematic relationships with his adult daughter and grandchildren. He had not had productive employment since 2006. The examiner indicated that due to his multiple psychiatric diagnoses, the Veteran experienced a depressed mood, anxiety, suspiciousness, a near-continuous panic or depression, chronic sleep impairment, impairment of short and long-term memory which included retention of only highly learned material, flattened affect, disturbances of motivation and mood, inability to establish and maintain effective relationships, and suicidal ideation. The examiner administered the Veteran the Structured Inventory of Malingered Symptoms, and the Veteran produced an extreme score of 61. The examiner explained that the Veteran’s extreme score on that inventory suggested a conscious attempt to exaggerate the severity, frequency, and intensity of his psychopathology symptoms. Therefore, assessment of the Veteran’s symptoms was very difficult. The examiner opined that the Veteran’s PTSD symptoms had the greater part of their origins in the Veteran’s active duty experience, but it appeared much more likely that the Veteran’s depressive disorder was much more attributable to his other life losses, traumas, and recent life changes. For the periods prior to May 4, 2017, and from July 1, 2017, the Board finds that a rating higher than 50 percent for service-connected PTSD is not warranted. The Board notes that a 70 percent rating is provided for 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 worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. Notably, the Veteran has psychiatric diagnoses of PTSD and depression. However, service connection is only in effect for PTSD. In rating the Veteran’s disability, the Board is mindful that VA is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so. Mittleider v. West, 11 Vet. App. 181 (1998). Here, VA examiners have specifically differentiated symptoms that were attributable to service-connected PTSD and nonservice-connected major depressive disorder, and which symptoms were attributable to both. The symptoms attributed to just the non-service connected major depressive disorder by medical evidence have been excluded from the rating for the service-connected PTSD. The Board acknowledges that the October 2016 VA examiner summarized the Veteran’s level of impairment due to all of the Veteran’s mental diagnoses as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. However, the examiner was able to specify that the level of impairment due to PTSD was occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The June 2017 VA examiner summarized the Veteran’s psychiatric symptoms as comprising occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. Those summaries, as provided by the VA examiners, are indicative of the symptomatology contemplated by a 50 percent, and no higher, rating for the service-connected PTSD. The Board finds that the symptoms actually recorded by the examiners attributed solely to PTSD or to both of the Veteran’s psychiatric diagnoses are not suggestive of the level of severity contemplated by the examples in the Diagnostic Code criteria for a 70 percent rating. While the October 2016 VA examiner found that the Veteran had suicidal ideation and neglect of personal hygiene, the examiner attributed those symptoms solely to the nonservice-connected major depressive disorder. While acknowledging that the June 2017 VA examiner attributed a near-continuous panic or depression, impairment of short and long-term memory which included retention of only highly learned material, and suicidal ideation to both the Veteran’s service-connected and non-service-connected diagnoses, the examiner also gave objective evidence in the form of objective test results indicating a conscious attempt on the part of the Veteran to exaggerate the severity, frequency, and intensity of his psychopathology symptoms. The results of the Structured Inventory of Malingered Symptoms administered by the June 2017 VA examiner have not been refuted. Notably, the June 2017 VA examiner specified that due to the evidence of malingering, assessment of the Veteran’s symptoms was very difficult. Therefore, the Board finds the June 2017 VA examiner’s summarization of the Veteran’s psychiatric symptoms as comprising occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation, to be of greater probative weight than the specific symptoms reported by the Veteran at the time of the examination. The examiner’s summarization was based not only on the present examination but also on a longitudinal review of the available records, whereas the symptoms reported at the time of the June 2017 VA examination were made in connection with objective evidence of exaggeration. The Board acknowledges that the Veteran is competent to report readily observable symptoms such as depression, inability to sleep, experiencing nightmares, and suicidal thoughts. However, competent medical evidence shows that the Veteran has more than one psychiatric diagnosis. The Veteran has not been shown to have the medical expertise necessary to differentiate between symptoms attributable to his service-connected PTSD and symptoms attributable to his non-service-connected major depressive disorder. Additionally, as objectively shown by the Structured Inventory of Malingered Symptoms administered by the June 2017 VA examiner, the Veteran has been shown to exaggerate his symptoms. For these reasons, the Board finds the Veteran’s self-report of his symptoms to be of less probative value and outweighed by the opinions and observations of the VA examiners of record. The Board finds that a review of the records shows an overall condition that more nearly approximates the criteria for a 50 percent rating for the periods prior to May 4, 2017, and from July 1, 2017. Considering the record as a whole, the Veteran’s disability has not shown to manifest to the severity required for the next higher rating of 70 percent for the periods prior to May 4, 2017, and from July 1, 2017. The Board finds that the Veteran’s psychiatric symptoms more nearly approximate a condition that is productive of no more than occupational and social impairment with reduced reliability and productivity, as noted by the VA examiners. From May 4, 2017 to June 30, 2017, the Veteran is in receipt of a schedular 100 percent disability rating for his psychiatric disability. No higher schedular rating is possible. Consequently, as the preponderance of the evidence is against the claim for higher ratings for the periods prior to May 4, 2017, and from July 1, 2017, the claim for an increased rating must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49. 11. Entitlement to a rating higher than 0 percent for residuals of a nose fracture The Veteran’s residuals of a nose fracture are rated pursuant to Diagnostic Code 6502, used for rating traumatic deviation of the nasal septum. A 10 percent rating is warranted when there is 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. 38 C.F.R. § 4.97, Diagnostic Code 6502. On VA examination in August 2016, the examiner found that the Veteran did not have a loss of part of the nose. An X-ray of the nasal bones found no fracture, dislocation, bony lesion, or soft tissue abnormality. The impression was a normal nose. Additionally, the VA treatment records have not shown obstruction of the nasal passages. Therefore, the probative evidence of record does not document that the Veteran’s residuals of a nose fracture have resulted in 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side for any period on appeal. To the extent that the Veteran has reported observable symptoms, such as difficulty breathing through his nose, those reports are probative evidence which has been properly considered by the Board. Layno v. Brown, 6 Vet. App. 465 (1994). However, to the extent that the Veteran asserts that his residuals of a nose fracture have resulted in 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side for any period on appeal, the Board finds that those statements, while competent, are less probative and persuasive than the objective medical findings from trained medical examiners, as the Veteran lacks the medical expertise to properly asses his condition. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds that the findings of the examiners are more persuasive because of their medical training. Accordingly, the Board finds that the preponderance of the evidence is against the claim of entitlement to a rating higher than 0 percent for residuals of a nose fracture for the entire period on appeal. Therefore, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 12. Entitlement to a rating higher than 10 percent for scar of the bridge of the nose The Veteran’s scar of the bridge of the nose is rated pursuant to Diagnostic Code 7800. Diagnostic Code 7800 provides that compensation is warranted for scars affecting the head, face or neck that are associated with one or more characteristics of disfigurement. The eight characteristics of disfigurement are: (1) Scar is 5 or more inches (13 or more centimeters) in length; (2) Scar is at least one-quarter inch (0.6 centimeters) wide at the widest part; (3) Surface contour of scar is elevated or depressed on palpation; (4) Scar is adherent to underlying tissue; (5) Skin is hypo-or hyper-pigmented in an area exceeding six square inches (39 square centimeters); (6) Skin texture is abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 square centimeters); (7) Underlying soft tissue is missing in an area exceeding six square inches (39 square centimeters); and (8) Skin is indurated and inflexible in an area exceeding six square inches (39 square centimeters). 38 C.F.R. § 4.118, Diagnostic Code 7800, Note (1). Diagnostic Code 7800 provides that a scar with one characteristic of disfigurement of the head, face, or neck is rated 10 percent. A scar of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement, is rated 30 percent. A scar of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement, is rated 50 percent. A scar of the head, face, or neck with visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement, is rated 80 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7800. On VA examination in August 2016, the examiner found that the Veteran had a scar on the bridge of his nose which measured 2.5 centimeters by 0.4 centimeters. The Veteran did not have scars of the nose exposing both nasal passages. The Veteran did not have scars causing loss of part of one ala. The Veteran did not have other scars causing other obvious disfigurement. The nose scar was not painful. The scar was stable. The scar was not due to a burn. There was no elevation, depression, adherence to underlying tissue, or missing underlying soft tissue. There was no abnormal pigmentation. There was no gross distortion or asymmetry of facial features or tissue loss. The scar did not cause a limitation of function. The Board finds that a rating higher than 10 percent is not warranted for the service-connected scar, bridge of nose, as the evidence does not show at least two characteristics of disfigurement, visible or palpable tissue loss, or gross distortion or asymmetry of one feature or paired set of features. As observed by the VA examiner, the scar is not at least five inches in length. The scar is not at least one-quarter inch (0.6 centimeters) wide. The surface contour or the scar is not elevated or depressed on palpation. The scar is not adherent to underlying tissue. The skin is not hypo- or hyper-pigmented in an area exceeding six square inches (39 square centimeters). The skin texture is not abnormal in an area exceeding sic square inches (39 square centimeters). The underlying soft tissue is not missing in an area exceeding six square inches (39 square centimeters). The skin is not indurated and inflexible in an are exceeding six square inches (30 square centimeters). The objective medical evidence does not reflect visible or palpable tissue loss and either gross distortion or asymmetry of the nose. Therefore, a rating higher than 10 percent is not warranted. Accordingly, the Board finds that the preponderance of the evidence is against the claim of entitlement to a rating higher than 10 percent for scar of the bridge of the nose for the entire period on appeal. Therefore, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Effective Date In order for benefits to be paid to any individual under the laws administered by VA, a specific claim in the form prescribed by VA must be filed. 38 C.F.R. § 3.151(a). A claim or application is defined by VA regulation as a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). An informal claim is any communication or action, indicating intent to apply for one or more benefits. 38 C.F.R. § 3.155(a). Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. 38 C.F.R. § 3.155(a). The general rule regarding the assignment of effective date for an award based on an original claim for VA benefits is that the effective date shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400. An exception to the general rule applies if an application for benefits is received within one year from the date of a Veteran’s separation from active service, and an award is made on the basis of that application. In that limited situation, the effective date of the award is made retroactive to the day following the date of separation from service. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2). Otherwise, the effective date will be the later of the date of receipt of claim or the date entitlement arose. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(b)(2). VA has a duty to maximize a claimant’s benefits. Buie v. Shinseki, 24 Vet. App. 242 (2011); AB v. Brown, 6 Vet. App. 35 (1993); Bradley v. Peake, 22 Vet. App. 280 (2008). Therefore, a case encompasses all potential claims raised by the evidence, applying all relevant laws and regulations, regardless of whether the claim is specifically labeled. Szemraj v. Principi, 357 F.3d 1370 (Fed. Cir. 2004); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). 13. Entitlement to an effective date earlier than May 31, 2016, for service connection for posttraumatic stress disorder (PTSD) In a statement date-stamped as received by VA on July 22, 2013, the Veteran requested that the VA open a claim for disability compensation benefits for, among other issues, anxiety and depression. A May 2014 rating decision adjudicated other issues raised in the July 2013 claim; the issues of entitlement to service connection for anxiety and depression were not adjudicated. On a claim date-stamped as received by VA on May 31, 2016, the Veteran filed claims for service connection for PTSD, major depressive disorder, tears, and crying a lot. A December 2016 rating decision denied service connection for major depressive disorder and established service connection for PTSD, effective May 31, 2016. On review of all evidence, both lay and medical, the Board finds than an earlier effective date of July 22, 2013, but not earlier, is not warranted for service connection for PTSD. The RO’s previous assignment of the May 31, 2016, effective date was based on the date of the Veteran’s specific claim of entitlement to service connection for PTSD where the Veteran specifically stated PTSD as the diagnosis. However, at that time, there was still a pending claim for service connection for depression. A claim for benefits remains pending until it is finally adjudicated. 38 C.F.R. § 3.160(c); Adams v. Shinseki, 568 F.3d 956 (Fed. Cir. 2009). If a claim is left pending without a final adjudication, the claim may be addressed when a subsequent claim is adjudicated by the VA, in which case the effective date for any resulting award of benefits will be the effective date applicable to the earlier claim. Adams v. Shinseki, 568 F.3d 956 (Fed. Cir. 2009); Myers v. Principi, 16 Vet. App. 228 (2002). When a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran, as a lay person, is not expected to make a psychiatric diagnosis. The claim for service connection for depression, some of which is shown to be due to PTSD is considered a claim for service connection for a psychiatric disability. Extending every reasonable doubt to the Veteran, the Board construes the Veteran’s July 22, 2013, claim for service connection for anxiety and depression as encompassing a claim for service connection for a psychiatric disability, to include depression and PTSD. There is no dispute as to the date of receipt of that claim. That claim was not adjudicated until the December 2016 rating decision. Therefore, that claim was pending until it was adjudicated in the December 2016 rating decision, which established service connection for PTSD. Notably, the Veteran has not claimed that an unadjudicated claim for service connection for a psychiatric disability was filed prior to July 22, 2013. No prior VA examiner had identified a psychiatric disability as a result of the Veteran’s service. The Board finds that there is no evidence of record prior to July 22, 2013, that can be interpreted as a claim, formal or informal, for service connection for PTSD. That date of receipt of the claim was more than one year following separation from service. Therefore, the appropriate effective date is the date of receipt of the claim on July 22, 2013. The Board can find no basis for the assignment of any earlier effective date. Accordingly, the Board finds that an effective date of July 22, 2013, but not earlier, is warranted for service connection for PTSD. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for headaches A January 1977 treatment record shows that the Veteran had headaches. In March 1977, the Veteran was treated for headaches. An August 1977 service medical record reflects that the Veteran had headaches for the prior four months. An October 2014 VA treatment record indicates that the Veteran went to the emergency room the prior night. The Veteran reported that he was prescribed oxycodone for severe pain in the feet and continued headaches. At April 2015 and April 2015 VA rheumatoid consultations, the Veteran denied experiencing chronic headaches. June 2015, July 2015, and August 2015 VA chiropractic records indicate that the Veteran did not have headaches. A September 2015 VA treatment record shows that the Veteran denied experiencing chronic headaches. The Veteran again denied experiencing headaches during a February 2016 VA outpatient treatment. A March 2016 VA treatment record contains the Veteran’s report that he was in a motor vehicle accident the prior week. He reported nausea and a headache. On VA examination in August 2016, the examiner diagnosed headache, not otherwise specified. The Veteran reported that he began experiencing headaches shortly after being attacked by a fellow sailor in March 1977. The examiner stated that the first reference to a headache in the post-service treatment records was from February 2016, following a motor vehicle accident. The examiner reviewed the claims file and noted that the while the service medical records documented three complaints of headache after a documented in-service assault, the records were silent regarding headaches until after the Veteran was involved in a motor vehicle accident in 2016. Due to the absence of supporting evidence of headaches continuing from service, the examiner opined that it was less likely than not that the Veteran’s current headache condition was incurred in service. The Board notes that the August 2016 VA examiner based the negative etiology opinion on the premise that the first reference to a headache in the Veteran’s post-service treatment records was from February 2016 following a motor vehicle accident. However, as reviewed above, an October 2014 VA treatment record contains the Veteran’s report that the previous evening he was prescribed oxycodone for continued headaches. Thus, the August 2016 VA examiner based the negative etiology opinion on an incorrect factual premise. Once VA provides an examination or obtains an opinion, even if not required to do so, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, remand is required to schedule the Veteran for a VA examination for an etiology opinion regarding headaches, based on an accurate review of the records. 2. Entitlement to service connection for sleep apnea is remanded. The Veteran underwent a sleep study in October 2015 which resulted in a diagnosis of sleep apnea. On VA examination in January 2017, the examiner remarked that the onset of the Veteran’s sleep apnea was in October 2015. The examiner opined that the Veteran’s sleep apnea was less likely than not incurred in or caused by service. The examiner stated that there was no evidence in the service medical records to support an onset of sleep apnea during active duty and noted that the Veteran was first diagnosed with sleep apnea in 2015. An examination is inadequate where the examiner does not comment on the Veteran’s reports, but instead relies on an absence of medical records to provide a negative opinion. Dalton v. Nicholson, 21 Vet. App. 23 (2007), Therefore, remand is required to schedule the Veteran for a VA examination for an etiology opinion regarding sleep apnea that is supported by sufficient rationale. 3. Entitlement to service connection for orthostasis, claimed as dizziness, is remanded. The service medical records show that in March 1977, the Veteran reported experiencing nausea. A service medical record from August 1977 shows that the Veteran experienced dizziness for the prior four months. A May 2016 VA treatment record shows that the Veteran had orthostasis due to the multiple medications that he had been prescribed. The VA’s statutory duty to assist the Veteran includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Remand is required to provide the Veteran a VA examination, which adequately addresses any relationship between currently diagnosed orthostasis, and either service or medication prescribed for service-connected disabilities. The matters are REMANDED for the following action: 1. With any necessary authorization from the Veteran, obtain all of the relevant outstanding treatment records. All attempts to locate records must be documented in the claims file. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of any headache disability. The examiner must review the claims file and should note that review in the report. A complete history should be elicited from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. Concerning any headache disability identified, the VA examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that any headache disability had its onset in service, was aggravated by service, or is otherwise related to any incident of service. In this matter, the examiner is asked to discuss the significance, if any, of the documented March 1977 in-service nose fracture. The examiner should also opine as to whether it is at least as likely as not (50 percent probability or greater) that any headache disability was caused by the Veteran’s other service-connected disabilities. The examiner should further opine as to whether it is at least as likely as not (50 percent probability or greater) that any headache disability has been aggravated (permanently increased in severity beyond the natural progress of the disorder) by any other service-connected disabilities. If it is determined that there is another likely etiology for headaches, that should be stated. Any opinion expressed should be accompanied by a complete rationale. The examiner must consider the Veteran’s statements and all lay statements regarding onset in-service and statements regarding the continuity of symptomatology. 3. Schedule the Veteran for a VA examination to determine the etiology of the Veteran’s diagnosed sleep apnea. The examiner must review the record and must note that review in the report. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that sleep apnea had its onset in or is otherwise related to service. The examiner should also opine as to whether it is at least as likely as not (50 percent probability or greater) that sleep apnea was caused by the Veteran’s other service-connected disabilities, to include nasal fracture and PTSD. The examiner should further opine as to whether it is at least as likely as not (50 percent probability or greater) that sleep apnea has been aggravated (permanently increased in severity beyond the natural progress of the disorder) by any service-connected disabilities, to include nasal fracture and PTSD. If it is determined that there is another likely etiology for sleep apnea, that should be stated. A complete rationale for all opinions expressed should be clearly provided. The examiner must consider the Veteran’s statements and all lay statements regarding onset in-service and statements regarding the continuity of symptomatology. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of any orthostasis disability. The examiner must review the claims file and should note that review in the report. A complete history should be elicited from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. Concerning any orthostasis disability identified, the VA examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that any headache disability had its onset in service, was aggravated by service, or is otherwise related to any incident of service. In this matter, the examiner is asked to discuss the significance, if any, of the March 1977 and August 1977 service treatment records which document nausea and dizziness. The examiner should also opine as to whether it is at least as likely as not (50 percent probability or greater) that any orthostasis disability was caused by the Veteran’s other service-connected disabilities, to include as secondary to medication prescribed for service-connected disabilities. The examiner should further opine as to whether it is at least as likely as not (50 percent probability or greater) that any headache disability has been aggravated (permanently increased in severity beyond the natural progress of the disorder) by any other service-connected disabilities, to include as secondary to medication prescribed for service-connected disabilities. If it is determined that there is another likely etiology for orthostasis, that should be stated. Any opinion expressed should be accompanied by a complete rationale. The examiner must consider the Veteran’s statements and all lay statements regarding onset in-service and statements regarding the continuity of symptomatology. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Layton, Counsel