Citation Nr: 21069022 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 11-15 260 DATE: November 17, 2021 ORDER Entitlement to service connection for tinnitus is granted. Entitlement to service connection for fibromyalgia is granted. Entitlement to service connection for bilateral plantar fasciitis is granted. Entitlement to service connection for right shoulder strain with pain is granted. Entitlement to service connection for left shoulder strain with pain is granted. Entitlement to service connection for right knee strain with pain is granted. Entitlement to service connection for left knee strain with pain is granted. Entitlement to service connection for right hip strain with pain is granted. Entitlement to an increased rating of 100 percent for posttraumatic stress disorder (PTSD) with major depressive disorder (MDD) and alcohol use disorder from March 7, 2015 to September 23, 2019 is granted. Entitlement to a total disability rating based on individual unemployability (TDIU) from March 7, 2015 to September 23, 2019 is denied. REMANDED Entitlement to service connection for headaches is remanded. Entitlement to service connection for breast cancer is remanded. Entitlement to service connection for a gastrointestinal condition, to include irritable bowel syndrome (IBS), is remanded. Entitlement to service connection for gallbladder removal is remanded. Entitlement to service connection for esophageal conditions, to include gastroesophageal reflux disease (GERD) and acid reflux, is remanded. FINDINGS OF FACT 1. The Veteran's tinnitus began in service and has continued to the present. 2. The Veteran's fibromyalgia is secondary to her service-connected acquired psychiatric disorders. 3. The Veteran's bilateral plantar fasciitis is secondary to her now service-connected fibromyalgia. 4. The Veteran's bilateral shoulder strain with pain is secondary to her now service-connected fibromyalgia. 5. The Veteran's bilateral knee strain with pain is secondary to her now service-connected fibromyalgia. 6. The Veteran's right hip strain with pain is secondary to her now service-connected fibromyalgia. 7. From March 7, 2015 to September 23, 2019, resolving reasonable doubt in the Veteran's favor, her psychiatric symptoms more closely approximated total occupational and social impairment. 8. From March 7, 2015 to September 23, 2019, the record does not reflect the Veteran was unable to obtain or retain substantially gainful employment due solely to her service-connected disabilities other than her PTSD with MDD and alcohol use disorder. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2019); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 2. The criteria for service connection for fibromyalgia have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2019); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 3. The criteria for service connection for bilateral plantar fasciitis have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2019); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 4. The criteria for service connection for right shoulder strain with pain have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2019); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 5. The criteria for service connection for left shoulder strain with pain have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2019); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 6. The criteria for service connection for right knee strain with pain have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2019); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 7. The criteria for service connection for left knee strain with pain have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2019); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 8. The criteria for service connection for right hip strain with pain have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2019); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2020). 9. The criteria for an initial disability rating of 100 percent for PTSD with MDD and alcohol use disorder from March 7, 2015 to September 23, 2019 have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2019); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 (2020). 10. The criteria for entitlement to TDIU from March 7, 2015 to September 23, 2019 have not been met. 38 U.S.C. §§ 1155, 5107 (2019); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1984 to April 1988. She appeals a September 2018 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) denying entitlement to service connection for breast cancer in addition to a January 2019 rating decision denying entitlement to service connection for numerous conditions. The Veteran also appealed an August 2019 Board of Veterans' Appeals (Board) decision denying entitlement to a rating greater than 70 percent for PTSD with MDD and alcohol use disorder from March 7, 2015. In a March 2021 Memorandum Decision, the Court of Appeals for Veterans Claims (Court) vacated the Board's decision for this issue only and remanded the appeal for action consistent with the Memorandum Decision. During the appeal, the AOJ increased the Veteran's rating for PTSD to 100 percent, effective September 24, 2019. See November 2019 rating decision. All of these issues are now before the Board. As a preliminary note, the Veteran's representative filed a notice to withdraw representation in September 2021, after certification to the Board. However, a representative's right to withdraw services after an appeal has been certified to the Board requires a showing of good cause with a written motion to withdraw fulfilling the requirements in 38 C.F.R. § 20.6. The representative did not provide good cause or fulfill the requirements of 38 C.F.R. § 20.6. As such, the Board continues to recognize John S. Berry as the Veteran's representative. Service Connection A veteran is entitled to VA disability compensation if there is a current disability resulting from personal injury or disease incurred in, or aggravated by, active service. 38 U.S.C. §§ 1110, 1131. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. See Shedden v. Principi, 381 F.3d 1163, 1167 (2004). Under 38 C.F.R. § 3.303(b), claims for chronic diseases enumerated in 38 C.F.R. § 3.309(a) benefit from a relaxed evidentiary standard. See Walker v. Shinseki, 708 F.3d 1331, 1339 (2013). Tinnitus is such a disease. To show a chronic disease in service, the record must contain a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disease or injury. See 38 C.F.R. § 3.310(a). To prevail on the issue of entitlement to secondary service connection, there must be evidence of (1) a current disability; (2) a service-connected disability; and, (3) a nexus establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). As to the third Wallin element, the current disability may be either proximately (a) caused, or (b) aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The determination of whether the requirements of service connection have been met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. For a claim to be denied on the merits, a preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Tinnitus The Veteran consistently reported she first noticed ringing in her ears while serving in the military and that this ringing has continued to the present day. See, e.g., November 2018 VA examination report; February 2019 VA Form 21-4138. The Veteran's DD Form 214 reflects her military occupational specialty (MOS) was as an administrative clerk, which has a low probability of noise exposure, but the Veteran noted she was assigned to "the rifle range for approximately five to six months" and was exposed to "continuous firing of many small and large weapons...with minimal ear protection." Id. Further, the Veteran's DD Form 214 reflects she received the rifle sharpshooter badge. See DD Form 214. Importantly, tinnitus is a condition capable of lay observation and the Veteran is competent to testify as to her observed symptoms and the actual existence of tinnitus. As the Board finds the Veteran's statements consistent and credible when weighed against the record, her statements regarding the continuity of symptomatology of her tinnitus are probative. In November 2018, a VA audiologist examined the Veteran and opined that he could not provide a medical opinion regarding the etiology of the Veteran's tinnitus without resorting to speculation as "the claims file did not contain any prior audio information for review." As no opinion was provided by the November 2018 VA examiner, there is no evidence contrary to the Veteran's competent reports of her ongoing tinnitus. As such, the Board finds the evidence reflects the Veteran's tinnitus began in service and has continued to the present. Accordingly, service connection for tinnitus is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Fibromyalgia In December 2019, the Veteran underwent a VA examination to assess the nature and etiology of her musculoskeletal pain. There, the VA examiner diagnosed the Veteran with fibromyalgia as she had widespread muscle pain with bilateral upper and lower extremity weakness. Although the VA examiner checked the box that the Veteran did present with pain at tender points, he checked that twelve of eighteen tender points did have pain present. Thus, the Board finds the December 2019 VA examiner diagnosed the Veteran with fibromyalgia. The Veteran contends her fibromyalgia is secondary to her service-connected PTSD. See April 2019 notice of disagreement (NOD). Thus, the Board finds the first and second elements for service connection are met. See Wallin, 11 Vet. App. at 512. As such, the crux of this claim centers on whether there is an etiological relationship between the Veteran's fibromyalgia and her service-connected PTSD. The Veteran submitted evidence citing to numerous medical articles regarding the long-term effects of PTSD on physical pain. See April 2019 NOD. Despite this evidence, the Veteran is not competent to opine on the etiology of her fibromyalgia. The December 2019 VA examiner opined that "it is common medical knowledge that PTSD...does not cause...fibromyalgia," but it was "at least as likely as not" her fibromyalgia was aggravated beyond its natural progression by her service-connected psychiatric conditions. As rationale, the VA examiner noted "triggers of fibromyalgia include physical or psychological stress." The December 2019 VA examiner reviewed the medical and lay evidence of record and examined the Veteran prior to providing his medical opinion. Further, the medical articles of record support the VA examiner's opinion that psychological stress aggravates fibromyalgia. As such, the Board finds the December 2019 VA examination report probative. As there is no probative evidence to the contrary, the Board finds the third element for service connection, a nexus, is met. The Board grants service connection for fibromyalgia. See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-57. Bilateral Plantar Fasciitis, Shoulder Strain, and Knee Strain, Right Hip Strain The Veteran contends her musculoskeletal conditions are secondary to her service-connected PTSD and, as noted above, provided medical articles noting the connection between psychiatric disorders and physical pain. See April 2019 NOD. The record reflects the Veteran has bilateral plantar fasciitis, shoulder strain, and knee strain, in addition to right hip strain, all resulting in functional loss due to pain. See April 2019 VA treatment records (bilateral plantar fasciitis); December 2019 VA examination reports; February 2020 VA treatment records (right shoulder pain). The Veteran is currently service connected for PTSD and, pursuant to the Order above, fibromyalgia. Thus, the Board finds the first and second elements for service connection are met. See Wallin, 11 Vet. App. at 512. As such, the claim centers on whether there is an etiological relationship between the Veteran's musculoskeletal conditions and her service-connected disabilities. The Veteran underwent numerous VA examinations in December 2019 to assess the etiology of her plantar fasciitis, bilateral shoulder and knee conditions, and right hip condition. The December 2019 VA examiner provided a confusing medical opinion, that specifically noted the Veteran's "claimed left shoulder condition (pain) condition [sic] is at least as likely as not proximately due to or the result of the Veteran's service-connected fibromyalgia." At the time of the December 2019 VA examination, the Veteran was not yet service connected for fibromyalgia; however, such confusion is understandable after reviewing the AOJ's instructions to the VA examiner. See December 2019 VA examination report. The VA examiner noted that fibromyalgia causes joint and muscle pain, including left shoulder pain, which was the AOJ's prompted question. Id. However, when discussing whether the Veteran's musculoskeletal conditions were aggravated by her service-connected PTSD, the VA examiner stated, that psychological stress triggers, or aggravates, fibromyalgia and "it is more likely than not that the Veteran's [musculoskeletal conditions] are caused by the Veteran's fibromyalgia." Id. The VA examiner concluded, "therefore, the Veteran's claimed [musculoskeletal conditions] are at least as likely as not aggravated beyond its natural progression by the Veteran's PTSD...." Id. Thus, the VA examiner found a link that the Veteran's musculoskeletal conditions were aggravated by her PTSD, through the intermediate step of aggravating her now service-connected fibromyalgia. As the medical articles provided by the Veteran support this finding and there is no evidence to the contrary, the Board finds the December 2019 VA examination reports probative. Therefore, the Board finds the third element for service connection, a nexus, is met for the aforementioned musculoskeletal conditions. As such, resolving all doubt in the Veteran's favor, the Board grants service connection for a right hip strain with pain and bilateral plantar fasciitis, shoulder strain with pain, and knee strain with pain. See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-57. Increased Rating for PTSD with MDD and Alcohol Use Disorder As noted above, the Court vacated the Board's August 2019 decision denying entitlement to a rating greater than 70 percent for PTSD from March 7, 2015. See March 2021 Memorandum Decision. During the appeal, the Veteran received a 100 percent disability rating for PTSD from September 24, 2019. See November 2019 rating decision. This 100 percent rating is considered a full grant of the benefits sought. See AB v. Brown, 6 Vet. App. 35 (1993). Thus, the period from September 24, 2019 is no longer on appeal and the Board will only consider entitlement to an increased rating for PTSD for the period from March 7, 2015 to September 23, 2019. Disability ratings are determined by applying a schedule of ratings based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Importantly, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); 38 C.F.R. § 3.102. The Veteran's PTSD with MDD and alcohol use disorder is rated under 38 C.F.R. § 4.130, DC 9411. The Veteran contends her psychiatric symptoms were more severe than her 70 percent rating would indicate during the appeal period in question. Under DC 9411, A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or name. Id. The list of symptoms in the above rating criteria are meant to be examples that would warrant a specific rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. On the other hand, if the evidence shows the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Finally, although the Veteran's symptomatology is the primary consideration, the Veteran's level of impairment must be in "most areas" applicable to the relevant percentage rating criteria. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-19 (2013). The AOJ granted a 100 percent rating for total social and occupational impairment based on the September 2019 VA examination and provided an effective date of September 24, 2019, the date of the examination. See November 2019 rating decision. At that examination, the VA examiner found the Veteran exhibited symptoms of near-continuous panic or depression affecting the ability to function independently and effectively, difficulty adapting to stressful circumstances and establishing relationships, suicidal ideation, and persistent delusions, among other symptoms. After examining the Veteran and the record, the VA examiner provided a thorough examination report and specifically noted the Veteran's diagnoses had not changed and noted no worsening of symptoms. See September 2019 VA examination report. In her expert opinion, she found the Veteran's symptoms reflected total social and occupational impairment. Id. The VA examiner noted the Veteran experienced "command auditory hallucinations and suicidal thoughts" since service that have "persisted and continue to remain present at this time" with the most recent auditory hallucination and suicidal ideation occurring the day before the VA examination. Id. This is corroborated by an October 2016 VA Form 21-4138 in which the Veteran noted she was in "danger of hurting [her]self or others" and she experienced delusions and intrusive thoughts. A May 2015 VA treatment record noted the Veteran was "suspicious about peoples' motive and to some extent thinks they are out to hurt her." Thus, the Board finds the Veteran exhibited persistent delusions during the appeal period in question. Both March 2017 and November 2018 VA examiners noted the Veteran suffered from suicidal ideation, social isolation, irritability, and near-continuous panic affecting the ability to function, among other symptoms. During the appeal period, the Veteran separated from her husband of her fourth marriage, and noted to only have effective relationships with her adult son and one or two friends. See March 2017 VA examination report ("does not socialize and has few interactions with people"); September 2017 VA treatment records ("has a friend in Georgia she will call...also has a friend here in town who was also in the military"); November 2018 VA examination report ("separated from her husband of seven years...lives with 26-year-old son...no socialization"). Occupationally, the record reflects the Veteran's employer suspended her more than once during the appeal period and she was separately demoted and put on probation for "acting out," not "getting a grip," and failing to concentrate. Id. Finally, the record notes the Veteran's eating disorder, related to her PTSD, created a persistent danger to herself and displayed gross impairment in thought. See September 2017 VA treatment records (after receiving medication to help with binge eating, "feels like she binges [and purges] a couple of times a week"); August 2018 VA treatment records ("binge eating and purges twice daily"). Overall, the record reflects the Veteran's severe psychiatric symptoms more closely approximate total social and occupational impairment during the entire appeal period, as evidenced by the September 2019 VA examiner's medical opinion. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds the Veteran's symptoms more nearly approximate total social and occupational impairment, the rating criteria for a 100 percent disability rating. As such, the Board grants entitlement to an increased rating of 100 percent for PTSD from March 7, 2015 to September 23, 2019. TDIU When a veteran appeals for a higher disability rating and it is coupled with evidence of unemployability, the issue of entitlement to TDIU is raised for the entire appeal period. See Harper v. Wilkie, 30 Vet. App. 356, 361 (2018). Here, during the pendency of the increased rating claim for PTSD, the Veteran raised the issue of entitlement to TDIU. See April 2019 NOD. Thus, this issue must be considered by the Board for the appeal period at issue, specifically from March 7, 2015 to September 23, 2019. See Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009). Pursuant to the Order above, the Veteran's PTSD is now rated at 100 percent disabling during the entire appeal period. The Court of Appeals for Veterans Claims (Court) has recognized that a 100 percent rating under the rating schedule indicates that a Veteran is totally disabled. See Holland v. Brown, 6 Vet. App. 443, 446 (1994). Thus, if VA has found a Veteran to be totally disabled because of a particular service-connected disability pursuant to the rating schedule, there is no need, and no authority, to otherwise rate that Veteran totally disabled on any other basis. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001). The Veteran is currently service connected for hypertension rated at 20 percent disabling, in addition to an eating disorder and chest scar, both of which are rated as noncompensable. See July 2021 rating decision codesheet. Pursuant to the Order above, the Veteran is now service connected for tinnitus, fibromyalgia, and numerous musculoskeletal conditions. Entitlement to TDIU in this case is moot unless the Veteran claims that she is entitled to TDIU based on an individual disability, which would raise the possibility of entitlement to additional benefits, such as entitlement to SMC. See Bradley v. Peake, 22 Vet. App. 280 (2008). Here, neither the Veteran's statements nor the medical evidence of record suggests a single service-connected disability, other than PTSD, impedes her employability to the extent she cannot secure, follow, or maintain a substantially gainful occupation. In fact, the record reflects the Veteran maintained fulltime employment during the appeal period in question. See May 2015 VA treatment records ("works for CMDR of Galveston Corp of Engineers"); March 2017 VA examination report ("at current employer for four years"); February 2019 VA treatment records ("still working at Army Corps of Engineers"). The record reflects the Veteran's PTSD and psychiatric symptoms severely impacted her ability to work, but does not suggest her remaining service-connected conditions prevented her ability to work during the appeal. Finally, the record reflects the Veteran worked until she suffered a stroke in August 2019 and noted she "may not ever be able to [go back to work] due to the physical effects of the stroke." See October 2019 VA treatment records. Thus, neither the Veteran nor the record reflect the Veteran was unable to work during the appeal period due to her service-connected disabilities other than PTSD. As such, entitlement to TDIU for the Veteran's service-connected disabilities other than PTSD is denied. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). REASONS FOR REMAND The Board notes the Veteran's military personnel and service treatment records (STRs) are largely illegible due to bad copying. See September 2014 STRs and military personnel records. In November 2016, the AOJ noted the option of having the records rescanned, either by (1) submitting a "Personal Information Exchange System (PIES) 099 request," or (b) going "through IPC to reach out to the evidence intake center for rescanning." See November 2016 email correspondence. However, no further development was ever provided to obtain these records. See January 2017 email correspondence; January 2017 AOJ correspondence. As the AOJ has not fulfilled the duty to assist the Veteran in the procurement of her relevant military records, a remand is required. See 38 C.F.R. § 3.159(c). Headaches The Veteran contends her migraines are related to her "gas chamber exposure" in service or, alternatively, are secondary to her service-connected PTSD. See April 2019 NOD; see also October 2019 VA Form 21-526EZ. The Veteran submitted numerous citations to medical articles noting a correlation between PTSD and headaches that state "PTSD sufferers are more likely to have chronic daily headaches...." See April 2019 NOD. In September 2020 a VA examiner opined that the Veteran's headaches were less likely than not caused by her service, and provided the rationale that "to opine causality without definitive objective measures would be to render an opinion based merely on speculation." Thus, the VA examiner's conclusion that the Veteran's headaches were less likely than not related to her service is equally speculative and holds no probative value. Additionally, no opinion was provided to assess the Veteran's contention regarding secondary service connection. A remand is required to properly assess the nature and etiology of the Veteran's current headaches. Breast Cancer Residuals The Veteran was diagnosed with breast cancer in 2013. She contends her breast cancer was caused by exposure to hazardous waste while serving at Camp Pendleton. See April 2019 NOD. As support, the Veteran submitted an argument citing to numerous medical articles, newspaper articles, and Environmental Protection Agency (EPA) articles listing Camp Pendleton as a superfund site due to numerous chemical waste substances, which, the Veteran contends cause breast cancer. Id. Alternatively, the Veteran contends her breast cancer residuals are secondary to her service-connected PTSD and submitted citations to National Institutes of Health (NIH) articles supporting her contention. Id. As the Veteran has not received a VA examination to assess the nature and etiology of her breast cancer residuals, a remand is required. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Gastrointestinal Condition, to Include IBS and Gallbladder Removal; and, Esophageal Condition, to Include GERD and Acid Reflux Similarly, the Veteran contends her remaining issues were caused by exposure to hazardous waste while serving at Camp Pendleton. See April 2019 NOD. As support, the Veteran submitted an argument citing to numerous medical articles, newspaper articles, and EPA articles listing Camp Pendleton as a superfund site due to numerous chemical waste substances, which the Veteran contends cause gastrointestinal conditions, gallbladder conditions, and esophageal conditions. Id. The Veteran also contends these conditions began in service and continued to the present. See November 2018 VA examination report. Legible STRs reflect numerous instances of gastrointestinal distress. See, e.g., September 1986 STRs ("still has diarrhea, acute gastroenteritis"); January 1988 STRs ("pain in right lower quadrant for two days- gastroenteritis vs. PID"). Alternatively, the Veteran contends her gastrointestinal and esophageal conditions are secondary to her service-connected PTSD and submitted citations to NIH articles supporting her contention. Id. In December 2018, a VA examiner opined the Veteran's conditions were less likely than not related to service as there are no records during service or after service reflecting IBS, acid reflux, or GERD. The VA examiner noted the numerous STRs reflecting treatment for gastrointestinal distress, but then stated there were no in-service records related to IBS, acid reflux, or GERD. Thus, the December 2018 VA examination report is inadequate and not probative. Most importantly, the VA examiner did not address any of the Veteran's contentions or provided medical articles, noted above. Thus, a remand is required. The matters are REMANDED for the following action: 1. Obtain any outstanding and updated relevant VA and/or private treatment records and associate the same with the claims file. 2. Obtain the Veteran's Marine Corps records from May 1984 to April 1988, to specifically include all military personnel records and service treatment records and ensure the copy is clear and legible. In doing so, document all avenues taken and the ultimate outcome of such attempts. If these records are not obtainable in a readable version, the Veteran and her representative should be notified, and the record clearly documented. 3. After the development of #1-2 above is complete, schedule the Veteran for an examination to determine the nature and etiology of the Veteran's headaches. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The opinion should include a notation that this review took place. After a thorough review of the record, the examiner should answer the following: (a). Is it at least as likely as not the Veteran's headaches were incurred in or are otherwise related to her time in service, to include the Veteran's contention that her headaches are related to her "gas chamber exposure" in service? (b). Is it at least as likely as not the Veteran's headaches were (i) caused or (ii) aggravated by her service-connected PTSD and MDD with alcohol use disorder? The examiner is directed to consider the Veteran's addendum to the April 2019 NOD containing supporting medical articles and argument for the connection between PTSD and headaches. The examiner should note the Veteran is competent to report her symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, a reason for doing so should also be provided. A full and complete rationale for all opinions must be provided, and a discussion of the facts and medical principles should be considered. 4. After the development of #1-2 above is complete, schedule the Veteran for examinations by an appropriately qualified clinician to determine the nature and etiology of the Veteran's (1.) breast cancer residuals, (2.) gastrointestinal conditions, to include IBS and gallbladder removal, and (3.) esophageal conditions, to include GERD and acid reflux. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The opinions should include a notation that this review took place. After a thorough review of the record, the examiner should answer the following for each of the Veteran's (1.) breast cancer residuals, (2.) gastrointestinal conditions, to include IBS and gallbladder removal, and (3.) esophageal conditions, to include GERD and acid reflux: (a). Is it at least as likely as not the Veteran's condition was incurred in or is otherwise related to her time in service, to include the Veteran's contention that her condition is related to exposure to hazardous substances while serving at Camp Pendleton? The examiner is directed to consider the Veteran's addenda to the April 2019 NODs containing citations to supporting medical articles, newspaper articles, and EPA articles listing Camp Pendleton as a superfund site due to numerous chemical waste substances that are known to cause cancer, gastrointestinal and esophageal conditions. (b). Is it at least as likely as not the Veteran's condition was (i) caused or (ii) aggravated by her service-connected PTSD and MDD with alcohol use disorder? The examiner is directed to consider the Veteran's addenda to the April 2019 NODs containing supporting medical articles and argument for the connection between PTSD and her current conditions. The examiner should note the Veteran is competent to report her symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, a reason for doing so should also be provided. A full and complete rationale for all opinions must be provided, and a discussion of the facts and medical principles should be considered. 5. Thereafter, readjudicate the claim. If any benefit sought remains denied, provide the Veteran and her representative with a Supplemental Statement of the Case (SSOC), and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Bona, Associate Counsel 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.