Citation Nr: 20009683 Decision Date: 02/05/20 Archive Date: 02/05/20 DOCKET NO. 17-48 337 DATE: February 5, 2020 ORDER Entitlement to service connection for a fibrocystic breast disorder is dismissed. Entitlement to service connection for residuals of a head injury (other than headaches) is denied. Entitlement to service connection for a right arm disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for residuals of a midline episiotomy is denied. Entitlement to service connection for recurrent vaginitis is granted. Entitlement to service connection for a disability manifested by chest pain and pressure is denied. REMANDED Entitlement to service connection for headaches is remanded. Entitlement to service connection for a skin rash of the arms and knees is remanded. Entitlement to service connection for a sinusitis (to include rhinitis) is remanded. Entitlement to service connection for tinnitus is remanded. FINDINGS OF FACT 1. Prior to the promulgation of a decision in the appeal, the Veteran withdrew her claim for entitlement to service connection for a fibrocystic breast disorder. 2. The most probative evidence of record reflects that the Veteran has no residuals of a head injury which began during or are etiologically related to her active duty service. 3. The most probative evidence of record does not demonstrate that the Veteran has a right arm disability which began during or is etiologically related to her active duty service. 4. The most probative evidence of record does not demonstrate that the Veteran has a left knee disability which began during or is etiologically related to her active duty service. 5. The most probative evidence of record reflects that the Veteran does not have any residuals of a midline episiotomy which began during or are etiologically related to her active duty service. 6. The most probative evidence of record demonstrates the Veteran’s recurrent vaginitis cannot be reasonably disassociated from her active duty service. 7. The most probative evidence of record does not demonstrate that the Veteran has a disability manifested by chest pain and pressure which began during is etiologically related to her active duty service. CONCLUSIONS OF LAW 1. The criteria for the withdrawal of the appeal for entitlement to service connection for a fibrocystic breast disorder have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 2. The criteria for entitlement to service connection for residuals of a head injury have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 3. The criteria for entitlement to service connection for a right arm disability have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 4. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 5. The criteria for entitlement to service connection for residuals of a midline episiotomy have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 6. The criteria for entitlement to service connection for recurrent vaginitis have been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 7. The criteria for entitlement to service connection for a disability manifested by chest pain and pressure have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1982 to June 1986. In November 2019, she testified at a Central Office hearing before the undersigned Veterans Law Judge. A hearing of that transcript is associated with the evidence of record. Although all the evidence of record has been thoroughly reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). The analysis in this decision focuses on what the evidence shows or fails to show with respect to the matters decided herein. The Veteran should not assume that pieces of evidence not explicitly discussed herein have been overlooked. See Allday v. Brown, 7 Vet. App. 517, 527 (1995) (finding that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Withdrawn Claim 1. Entitlement to service connection for fibrocystic breast disorder The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. A substantive appeal may be withdrawn by a veteran or his or her authorized representative in writing or at a hearing at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. At her November 2019 hearing before the Board, the Veteran and her representative withdrew the appeal for entitlement to service connection for a fibrocystic breast disorder. Thus, there remains no allegation of error of fact or law for the Board to address with respect to this issue, the Board does not have jurisdiction over it, and the claim is withdrawn. Service Connection Claims Service connection may be established for disability due to a disease or injury that was incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In general, in order to prevail on the issue of service connection the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (finding service connection presupposes a current diagnosis of the condition claimed). The requirement that a current disability be present is satisfied “when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim... even though the disability resolves prior to the Secretary’s adjudication of the claim.” McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). 1. Entitlement to service connection for residuals of a head injury (other than headaches) The Veteran is claiming entitlement to service connection for residuals of a head injury. To the extent she is claiming entitlement to service connection for headaches, as a residual of a head injury, that claim is discussed in the remand portion below. The record contains a 1982 service treatment record documenting that the Veteran complained of a knot on the left side of her forehead after she ran into someone’s shoulder blade and she felt dizzy. The examiner noted a 1.5 by 1.5-inch swollen area that was slightly tender to palpation. The examiner assessed a bruise, prognosis was good, and the Veteran was sent home without further treatment. On her March 1986 report of medical history for separation purposes, she noted she experienced a head injury and that she had a laceration which had resolved. Notably, the Veteran did not report a headache at this evaluation. At her November 2019 hearing before the Board, the Veteran testified that she had a collision with another soldier during service, which resulted in a laceration on her forehead. She indicated she received treatment during service following the head injury and it caused her to experience headaches during and since active duty. The Veteran testified that she did not require stitches and that there was no scarring on her forehead, but that she had “a little knot there.” Neither the Veteran nor her representative indicated that the Veteran experienced any residuals of the head injury other than the aforementioned headaches. At a February 2019 VA psychiatry consult, the Veteran reported a history of a head injury during active duty service basic training over thirty years ago. The Veteran informed the examiner she did not remember details, thought she was taken to the hospital, and was unsure if an investigation was performed. The Veteran was afforded an October 2018 VA examination to determine whether she had a diagnosis of a traumatic brain injury (TBI) or any residuals of her in-service head injury. At the examination, the Veteran stated she did not have a clear idea of when her head injury occurred during service; she denied ever being treated or evaluated for this condition. The Veteran complained of current symptoms of mild memory loss; judgment and visual special orientation were normal, social interactions were regularly appropriate, and she was always oriented to person, time, place, and situation. Motor activity was mildly decreased due to pain from arthritis and degenerative joint disease. The Veteran reported subjective symptoms of mild to moderate headaches and mild anxiety; the examiner noted the Veteran’s headaches and hypersensitivity to sound appeared to be related to her anxiety. There were no neurobehavioral effects and communication and consciousness were normal. Neuropsychological testing was completed, and the Veteran performed well. Based on the examination and with consideration of the Veteran’s subjective symptoms, the examiner found there was no diagnosis related to the Veteran’s claimed condition of residuals of a head injury. The examiner provided a negative opinion, explaining that there was no neurocognitive diagnosis and that the Veteran’s memory problems, low energy, and poor concentration are attributed to her significant depression and present-day anxiety due to family and social circumstances. The examiner further reasoned that there was no evidence of a direct head injury and that when asked, the Veteran herself did not recall the specific incident; service treatment records reflect she ran into someone’s shoulder blade, felt dizzy, and had a swollen area on her skull, possibly with a bruise and laceration. The examiner concluded this was a minor situation which did not result in any neurocognitive symptomatology. There are no conflicting medical opinions of record. The Board recognizes that the Veteran is competent to report symptoms she experiences, as this requires only personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, as a lay person, the Veteran is not competent to determine she has any residuals of a head injury, as this required specialized medical education, experience, and training, which she has not demonstrated. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir 2007); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (holding that where the determinative issue is one of medical causation or diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). Based on the foregoing, the Board finds that service connection for residuals of a head injury (other than headaches) must be denied. As the preponderance of the evidence is against the Veteran’s claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). 2. Entitlement to service connection for a right arm disability The Veteran is claiming entitlement to service connection for a right arm disability. At her November 2019 hearing before the Board, she testified that during service she was exercising on parallel bars and fell, injuring her right arm and left leg. She stated her right forearm took the brunt of her weight when she fell on it and that she wore a sling for a week or two following this incident. Regarding current symptoms, she indicated she felt like her elbow had a tendency to pop at times and that there were days she was unable to move her elbow. In March 1985, the Veteran sought treatment for pain in her right arm; she informed the examiner she fell off an exercise bar onto her arm one week prior. Examination revealed tenderness to the right wrist and forearm with full range of motion and normal strength. The assessment was a contusion. At her March 1986 separation physical, her right arm was normal and she did not report any difficulties with her right arm or elbow on the accompanying medical history form. VA treatment records dated October 2017 indicate the Veteran presented for an electromyography evaluation relating to symptoms of pain and tingling in her right arm. She indicated these symptoms began six months prior shortly after she threw out her back bending over to pick up an object. The Veteran described symptoms of tingling in the forearm and cramping tight muscles in the neck and shoulders. She also indicated she noticed decreased strength in her right hand but felt that may be related to “arthritis” issues. The Veteran attended an October 2018 VA examination and reported she believed she fell during service and sprained her back, right arm, and knee. She indicated she experienced pain from the right side of the neck radiating down the neck to the hand with tingling in the hands and reported this had been present since 1984. The examiner diagnosed cervical upper arm radiculopathy and found that this condition was less likely than not (less than a 50 percent probability) related to the Veteran’s active duty service. The examiner explained that there was no evidence of an in-service right arm condition that would lead to tingling of the right forearm thirty years later, when symptoms were first noted in medical records, and that the Veteran’s symptoms were most likely related to a cervical neck condition. There are no conflicting medical opinions of record. The Board recognizes that the Veteran is competent to report symptoms she experiences, as this requires only personal knowledge. See Layno, 6 Vet. App. at 470. However, as a lay person, the Veteran is not competent to determine she has a right arm disability which is etiologically related to service, as this required specialized medical education, experience, and training, which she has not demonstrated. See Jandreau, 492 F.3d at 1376-77; see also Jones, 12 Vet. App. at 385. Based on the foregoing, the Board finds that service connection for a right arm disability must be denied. Consideration has been given to the benefit of the doubt doctrine; however, as the evidence weighs against the claim, it is not applicable. See 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. at 56. 3. Entitlement to service connection for a left knee disability The Veteran is claiming entitlement to service connection for a left knee disability. At her November 2019 hearing before the Board, she testified that during service she was exercising on parallel bars and fell, injuring her right arm and left leg. She stated she was treated during service and believed that she was instructed to elevate her knee and ice it but did not remember any treatment aside from that. She indicated that since service she has experienced pain and popping and that she has fallen several times. The Veteran’s representative indicated the Veteran was issued a cane primarily due to instability of the left knee. The Veteran’s service treatment records show a single visit in December 1983 for left knee pain; diagnosis was a muscle strain. In connection with her March 1985 treatment following a fall on the parallel bars, there is no mention of any left knee pain or injury. At her March 1986 separation physical, the Veteran’s left knee was normal and on her accompanying medical history form she did not report any knee problems. The Veteran was afforded an October 2018 VA examination and stated she believed she fell on the left knee during basic training. She reported current symptoms as knee swelling and aching and indicated she had fallen relating to her knee giving out. She stated she used a self-purchased knee brace on occasion for support and sometimes used a cane for ambulation due to her back. The examiner diagnosed possible minimal patellofemoral osteoarthritis (confirmed by x-rays) and found it was less likely than not (less than a 50 percent probability) due to the Veteran’s active duty service, reasoning that the type of trauma she experienced during service would not lead to osteoarthritis, and that her condition, which was minimal, was more likely related to aging and normal wear and tear. There are no conflicting medical opinions of record. The Board recognizes that the Veteran is competent to report symptoms she experiences, as this requires only personal knowledge. See Layno, 6 Vet. App. at 470. However, as a lay person, the Veteran is not competent to determine she has a left knee disability which is etiologically related to service, as this required specialized medical education, experience, and training, which she has not demonstrated. See Jandreau, 492 F.3d at 1376-77; see also Jones, 12 Vet. App. at 385. Based on the foregoing, the Board finds that service connection for a left knee disability must be denied. Consideration has been given to the benefit of the doubt doctrine; however, as the evidence weighs against the claim, it is not applicable. See 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. at 56. 4. Entitlement to service connection for residuals of a midline episiotomy 5. Entitlement to service connection for recurrent vaginitis The Veteran is claiming entitlement to service connection for residuals of a midline episiotomy and repair following a vaginal childbirth. Initially, the Board notes that service connection is already in effect for recurrent urinary tract infections. At her hearing before the Board, the Veteran felt that when she had a spontaneous vaginal birth with a midline episiotomy that she “could feel what they were doing, but when [she] saw it, [she] just thought it could have been done a little better.” She indicated she had feminine issues which she felt began after her episiotomy and continued to this day. She reported experiencing infections and also indicated she had a condition called pelvic congestive syndrome. She also reported that she experienced urinary incontinence and recently underwent a procedure where coils were inserted in her abdomen. The Veteran testified she had a noticeable painful scar at the episiotomy site and indicated she was not able to have sex due to pain. She further testified that when she experienced infections, she had vaginal discharge, which she believed was due to the episiotomy. A review of the Veteran’s service treatment records reflect she had a spontaneous vaginal delivery with a midline episiotomy and repair in July 1984. On her separation medical health history form, the only gynecological condition reported was recurrent urinary tract infections. The Veteran established care with the VA Healthcare System in May 2011 and underwent a routine women’s health (gynecological) examination; her only complaint was irregular menses and the examiner assessed rule out perimenopause or hyperthyroid. The examiner noted a normal gynecological examination (aside from discharge attributed to a vaginal infection). Significantly, the recto-vaginal assessment that was noted to be within normal limits. The Veteran did not voice any complaints regarding pain with intercourse or a painful scar due to the midline episiotomy. At an April 2013 gynecological examination, the examiner documented a normal gynecological examination and that a recto-vaginal assessment was within normal limits. The examiner noted the Veteran was in perimenopause and that her only complaint was breast tenderness. Again, the Veteran did not voice any complaints regarding pain with intercourse or a painful scar due to the midline episiotomy. A June 2013 pelvic ultrasound was performed to rule out the potential of fibroids, cysts, and hyperplasia. The radiologist’s impression was dilated vascular structures along the left side of the uterus, likely multiple pelvic veins, which could be seen with pelvic congestive syndrome in the appropriate clinical setting. The radiologist also noted a small simple cyst and a small fibroid and indicated that no treatment was needed at that time. A May 2016 gynecological examination report reflects the Veteran had not been seen for her annual examination since 2013. The examiner documented a normal gynecological examination to include a normal recto-vaginal assessment. For the first time in the record, the Veteran complained of pelvic pain during intercourse and the examiner noted rule out fibroid and indicated pelvic congestive syndrome was suggested previously in 2013. The Veteran was afforded an October 2018 VA examination and indicated that since her episiotomy she had experienced pain with sexual relations, tenderness in the area, and frequent urinary tract infections. She further reported frequent vaginal infections, intermittent pelvic cramps, and urinary frequency and pressure (improved with embolization procedure two years prior). The examiner found it was less likely than not (less than a 50 percent probability) that the Veteran had any residuals from this procedure, reasoning that a review of her in-service and post-service medical records failed to reflect any diagnosis of a chronic condition related to the midline episiotomy and repair and that there was no pathology present at the examination to render a diagnosis. The examiner noted that the Veteran had been diagnosed with pelvic congestion syndrome, status post menopause, history of uterine fibroids, and dyspareunia, and there was no evidence found that any of these conditions are related to the episiotomy scar and gynecologic examinations (including the scar area) had been normal. There are no conflicting medical opinions of record. The Board recognizes that the Veteran is competent to report symptoms she experiences, as this requires only personal knowledge. See Layno, 6 Vet. App. at 470. However, as a lay person, the Veteran is not competent to determine she has any residuals of a midline episiotomy, as this required specialized medical education, experience, and training, which she has not demonstrated. See Jandreau, 492 F.3d at 1376-77; see also Jones, 12 Vet. App. at 385. The Board recognizes that at her hearing before the Board the Veteran complained of pain with intercourse at her midline episiotomy scar site and stated she experienced this since the 1984 operation. However, at her 2011 and 2013 gynecological evaluations, the Veteran did not mention any pain with intercourse, and the first mention of this was at her 2016 gynecological evaluation. Weighing the evidence, the Board affords more weight to the Veteran’s statements to treating providers rather than her statements made in further of her claim for compensation. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Based on the foregoing, the Board finds that service connection for residuals of a midline episiotomy must be denied. Consideration has been given to the benefit of the doubt doctrine; however, as the evidence weighs against the claim, it is not applicable. See 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. at 56. The Board notes that the Veteran, as a lay person, cannot be expected to know the exact disability she is claiming service connection for. Therefore, the Board has construed the Veteran’s claim broadly as one for a gynecological condition. In this regard, the Board has considered the Veteran’s lay statements, her service treatment records, and an October 2018 VA examination. At that examination, while the examiner did not link the Veteran’s recurrent urinary tract infections and recurrent vaginitis to residuals of her midline episiotomy, the examiner did note chronic in-service symptoms of each disability and found a positive relationship between them and the Veteran’s active service. As noted previously, the Veteran is already service-connected for recurrent urinary tract infections. Service treatment records demonstrate treatment for chronic yeast infections/vaginitis during service and VA treatment records dated throughout the appeal demonstrate treatment for and diagnoses of vaginitis. Based on the foregoing, the Board finds that service connection for recurrent vaginitis is warranted. 6. Entitlement to service connection for a disability manifested by chest pain and pressure The Veteran is claiming service connection for a disability manifested by pain and pressure in her chest. At her November 2019 hearing before the Board, the Veteran testified she first began experiencing pain and pressure in her chest during service and that she went to sick call for this. She stated it felt like someone was sitting on her chest. She recounted a night (but did not give a date) when she was unable to breathe and went to the emergency room and was “all swollen up” when she arrived; she indicated medical professionals told her if she had waited to seek treatment, she would have been unable to breathe. When asked if this was related to an allergic reaction, the Veteran indicated she initially thought that also but had not consumed anything and as unsure what she was reacting to. She stated that medical professionals did note she experienced hives and told her she would have gone into anaphylaxis shock had she not come in. The Veteran testified that when she first sought treatment through VA and explained her symptoms, she was informed she may have anxiety. She further described symptoms as feeling like her heart was palpitating really fast and that the pressure normally came on when she was lying down. The Veteran went on to say she felt like she was having a heart attack and that she was on medication for high blood pressure. On her March 1986 separation medical history form, the Veteran marked the box “yes,” indicating that she experienced pain or pressure in her chest and the examiner summarized occasional chest pain. At an October 2018 VA examination, the Veteran described the history of her disability as chest pain and heart racing. She noted she took antidepressants and was told that her symptoms were due to anxiety. The examiner found no establish diagnosis, to include costochondritis, for the Veteran’s claimed condition of chest pain and pressure, and therefore, no opinion was rendered. The Board recognizes that the Veteran is competent to report symptoms she experiences, as this requires only personal knowledge. See Layno, 6 Vet. App. at 470. However, as a lay person, the Veteran is not competent to determine she has a diagnosed disability manifested by chest pain and pressure as this required specialized medical education, experience, and training, which she has not demonstrated. See Jandreau, 492 F.3d at 1376-77; see also Jones, 12 Vet. App. at 385. To the extent the Veteran has claimed her symptoms of chest pain or pressure are due to her hypertension and/or her psychiatric disorders, neither of these conditions are service-connected. Entitlement to service connection for hypertension was denied in an April 2019 rating decision and the Veteran has never filed a claim (formal or informal) for a psychiatric disorder. Absent a diagnosis of a disability manifested by chest pain and pressure and absent any indication that these symptoms are related to a service-connected disability, service connection must be denied. See Brammer, 3 Vet. App. at 225; see also McClain, 21 Vet. App. at 321. The Board recognizes the recent decision in Saunders v. Wilkie that “pain alone can serve as a functional impairment and therefore qualify as a disability.” 886 F.3d 1356, 1363-64 (Fed. Cir. 2018). However, the Court in Saunders cautioned that a Veteran cannot demonstrate service connection simply by asserting subjective pain; to establish a disability, a veteran’s pain must amount to functional impairment. Id. at 1367. The Court held that “[t]o establish the presence of a disability, [a] veteran will need to show that [his or] her pain reaches the level of functional impairment of earning capacity.” Id. at 1367-68. The Board acknowledges the Veteran’s subjective claims that she believes she has a disability manifested by chest pain and pressure; however, her subjective statements alone do not suffice to establish the presence of disabilities. The Veteran has not asserted, and the evidence does not suggest, that these claimed symptoms have caused functional impairment of earning capacity. As such, the available lay and medical evidence of record does not demonstrate that the Veteran has had a disability manifested by chest pain and pressure throughout the pendency of the claim. See Saunders, 886 F.3d at 1367-68. Based on the foregoing, service connection for a disability manifested by chest pain and pressure must be denied. Consideration has been given to the benefit of the doubt doctrine; however, as the evidence weighs against the claim, it is not applicable. See 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. at 56. Additional Considerations At her November 2019 hearing before the Board, the Veteran’s representative alleged that VA failed to “fulfill[] its duty to assist in that it did not provide any etiology from which a reliable evaluation could have been made prior to final adjudication,” and that “[t]he examinations have said it was not related to service, denied.” The representative further stated that the examinations “did not establish an etiology, nor provide a reliable evaluation from which the Veteran could even come back and ask, well, how do I get that information? Or, how do I get a nexus letter for that?” The Board has reviewed the development and adjudication undertaken by the Agency of Original Jurisdiction, to include the VA examinations performed in connection with the Veteran’s claims, and finds no duty to notify or assist errors on the part of VA. Notably, the August 2013 letter to the Veteran provided her with the requisite notice under VA law, regulation, and caselaw. To the extent that the representative argues VA examiners failed to inform the Veteran how to obtain nexus opinions to substantiate her claim, this is also not part of VA’s duties to notify and assist. Moreover, the Veteran’s representative made it very clear at the hearing that she and the Veteran had discussed obtaining nexus letters from her treating providers, thus demonstrating that the Veteran was well aware of how to substantiate her claims in this way. Additionally, the representative specifically requested that the record be held open for sixty days from the date of the hearing (until January 5, 2020) for submission of the aforementioned opinions; regrettably, no such opinions have been received to date. The Board reminds the Veteran and her representative that while the VA benefits system is veteran friendly, VA’s duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board next turns to the representative’s argument that VA failed to fulfill its duty to assist because the VA examiners did not provide an opinion on the etiology of the Veteran’s claimed disabilities. The Board finds this argument also fails. The Board notes that there is no requirement under VA law, regulation, caselaw that VA examiners provide an opinion on the etiology of a disability if no nexus to service is found. The fact that examiners found no nexus between the Veteran’s claimed disabilities and her active service does not then require them to provide an opinion how a specific disability manifested due to nonservice-connected causes. Rather, VA examiners are only required to provide an adequate rationale for the conclusions reached, which the Board finds they have done. REASONS FOR REMAND 1. Entitlement to service connection for headaches is remanded. The Veteran is claiming entitlement to service connection for headaches (including migraines), to include as due to an in-service head injury. The Veteran was afforded an October 2018 VA examination and the examiner provided a negative opinion; however, the examiner did not address the Veteran’s in-service 1982 head injury in formulating this opinion. Accordingly, a remand is required for this purpose. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Entitlement to service connection for a skin rash of the arms and knees The Veteran is claiming entitlement to service connection for a skin condition, claimed as a skin rash on the arms and knees. At her November 2019 hearing before the Board, she stated she experienced a skin rash on her arms and behind her knees during service sometime in 1982 or 1983 and was treated with a topical cream. She indicated she continues to experience this rash and has self-treated with over the counter medication. She testified she believed the diagnosis was eczema that VA doctors had prescribed a topical cream. The Veteran indicated she experienced skin flare-ups when the weather became cold and her skin became dry. Service treatment records reflect the Veteran sought treatment in January 1983 for an itchy rash on her neck, arms, and behind both knees; the examiner assessed possible eczema. The following week, the Veteran sought continued treatment for her skin condition and the examiner assessed atopic dermatitis, provided her with a cream, and informed her to follow up in one week. At her follow-up appointment, the examiner noted the Veteran’s atopic dermatitis was resolving. On her March 1986 separation medical health history form, the Veteran did not note any symptoms of a skin condition and at her March 1986 separation examination her skin was normal. The Veteran was afforded a VA skin examination in June 2017 to determine the etiology of any skin condition found. The examiner noted that the Veteran experienced hives, indicated this was a type of urticaria likely related to anxiety, that the Veteran took Benadryl for relief. The examiner did not make any formal diagnoses pertaining to the skin, and therefore, did not provide an etiology opinion. Since that examination was performed, VA treatment records dated February 2019 contain a diagnosis of eczema and indicate she used a topical medication for relief. Accordingly, a remand is required to obtain a new examination and opinions pertaining to all diagnosed skin disorders. See Barr, 21 Vet. App. at 311. 2. Entitlement to service connection for sinusitis (to include rhinitis) The Veteran has claimed entitlement to service connection for sinusitis. At her November 2019 hearing before the Board, the Veteran testified she began experiencing symptoms in August 1982 during basic training. She reported seeking treatment during service for these symptoms and indicates she was given Claritin. Following active duty service, the Veteran testified she continued to experience symptoms and treated with over the counter medication for her sinuses. She denied receiving any treatment from VA for her sinusitis and stated she continued to treat with over the counter medication, such as Benadryl. At her October 2018 VA examination, she indicated she never had problems with allergies until she entered active duty service. She reported post-nasal drainage, nasal congestion, and sinus headaches. The examiner diagnosed rhinitis and did not render an opinion because there was no diagnosis of sinusitis (which the Veteran claimed). The Board recognizes that the Veteran, as a lay person, cannot be expected to know the exact diagnosis for which she is claiming service connection. Given that the Veteran has a current diagnosis of rhinitis, which may have overlapping symptoms with sinusitis, the Board finds a remand is required to obtain a medical opinion. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). 3. Entitlement to service connection for tinnitus The Veteran is claiming entitlement to service connection for tinnitus, which she believes is due to acoustic trauma during active duty. Her military occupational specialty (MOS) was a radio teletype operator in the communications center; according to the Department of Defense (DoD), this MOS carries a moderate probability of exposure to noise. At her October 2018 VA audiological examination, she indicated her constant (right ear) and intermittent (left ear) tinnitus began many years prior, after shooting a weapon on the firing range during military service. The examiner concluded the Veteran’s tinnitus was secondary to her bilateral hearing loss disability. At her November 2019 hearing before the Board, the Veteran’s representative erroneously stated that the Veteran was service-connected for hearing loss; however, entitlement for service connection for hearing loss was denied in an October 2014 unappealed rating decision. The October 2018 VA examiner provided a negative opinion regarding direct service connection, citing to the lack of medical evidence of significant auditory threshold shifts during service and lack of documentation of complaints of hearing loss during service. The examiner also indicated that there was no exposure to noise during service, despite the fact that the Veteran’s MOS carries a moderate probability of noise exposure. Based on the foregoing, the Board finds a new examination and opinion is warranted. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that medical examiner cannot rely solely on the absence of medical records corroborating the incurrence or continuity of a disorder, and furthermore, cannot ignore a Veteran’s statements regarding lay observable symptoms). The matters are REMANDED for the following action: 1. Afford the Veteran the appropriate VA examination to determine the etiology of her headaches. The examiner must obtain from the Veteran, and record in the examination report, a complete history regarding the onset and continuity of symptoms. Following a complete review of the evidence of record, and with consideration of the Veteran’s lay statements, please provide the following opinion: Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s headaches began during or are etiologically related to her active duty service, to include as due to head trauma. Why or why not? A complete rationale for this opinion must be provided. If the examiner is unable to form any opinion without resorting to speculation, he or she must indicate why this is so. The examiner is informed that an opinion based solely on the lack of corroborating medical evidence during service is not adequate. 2. Afford the Veteran the appropriate VA examination to determine the etiology of her skin conditions. The examiner must obtain from the Veteran, and record in the examination report, a complete history regarding the onset and continuity of symptoms. Following a complete review of the evidence of record, and with consideration of the Veteran’s lay statements, please provide the following opinions: (a) Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s eczema began during or is etiologically related to her active duty service. Why or why not? (b) Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran has a skin disorder manifested by hives (treated with Benadryl) which began during or is etiologically related to her active duty service. Why or why not? A complete rationale for this opinion must be provided. If the examiner is unable to form any opinion without resorting to speculation, he or she must indicate why this is so. The examiner is informed that an opinion based solely on the lack of corroborating medical evidence during service is not adequate. 3. Afford the Veteran the appropriate VA examination to determine the etiology of her rhinitis. The examiner must obtain from the Veteran, and record in the examination report, a complete history regarding the onset and continuity of symptoms. Following a complete review of the evidence of record, and with consideration of the Veteran’s lay statements, please provide the following opinion: Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s rhinitis began during or is etiologically related to her active duty service. Why or why not? A complete rationale for this opinion must be provided. If the examiner is unable to form any opinion without resorting to speculation, he or she must indicate why this is so. The examiner is informed that an opinion based solely on the lack of corroborating medical evidence during service is not adequate. 4. Afford the Veteran the appropriate VA examination to determine the etiology of her tinnitus. The examiner must obtain from the Veteran, and record in the examination report, a complete history regarding the onset and continuity of symptoms. Following a complete review of the evidence of record, and with consideration of the Veteran’s lay statements, please provide the following opinion: Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran’s tinnitus began during or is etiologically related to her active duty service. Why or why not? The examiner must consider that the Veteran’s military occupational specialty (radio operator) carries a moderate probability of exposure to noise. A complete rationale for this opinion must be provided. If the examiner is unable to form any opinion without resorting to speculation, he or she must indicate why this is so. The examiner is informed that an opinion based solely on the lack of corroborating medical evidence during service is not adequate. 5. The Veteran is informed that it is her responsibility to report for any scheduled examinations and to cooperate in the development of the claims and that the consequences for failure to report for any VA examination without good cause may include denial of a claim. See 38 C.F.R. §§ 3.158, 3.655. In the event that the Veteran does not report for any scheduled examination, documentation showing that she was properly notified of the examination must be associated with the record. 6. Then, the Veteran’s claims must be readjudicated. If any benefit sought on appeal is not granted to the Veteran’s satisfaction, she and her representative must be provided a Supplemental Statement of the Case and be given an adequate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jessica L. O'Connell The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.