Citation Nr: 21024689 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 15-34 139 DATE: April 23, 2021 ORDER Service connection for left shoulder degenerative joint disease is granted. Service connection for left hand arthritis is granted. Service connection for tinnitus is granted. The claim of entitlement to service connection for hyperlipidemia is denied. The claims of entitlement for higher ratings under DC 7802 for scars of left palm and left thigh are denied. A 20 percent initial rating for three painful scars (left palm due to burn injury, left thigh due to shrapnel removal, and right hand due to surgical reduction) effective from March 1, 2013, is granted. A 10 percent initial rating for right first metacarpal MCP and MCC joint arthritis (right thumb arthritis) effective from March 1, 2013, is granted. REMANDED The claim of entitlement to service connection for hearing loss is remanded. The claim of entitlement to service connection for serous otitis is remanded. The claim of entitlement to service connection for a left eye disability is remanded. The claim of entitlement to service connection for a right knee disability is remanded. The claim of entitlement to service connection for a right ankle disability is remanded. The claim of entitlement to service connection for a left ankle disability is remanded. The claim of entitlement to service connection for an acquired psychiatric disability is remanded. The claim of entitlement to service connection for a heart disability is remanded. The claim of entitlement to service connection for sleep apnea is remanded. The claim of entitlement to service connection for the residuals of a cold injury to the cheeks and fingers is remanded. The claim of entitlement to an initial rating higher than 10 percent for cervical spine degenerative joint and disc disease is remanded. The claim of entitlement to an initial rating higher than 10 percent for thoracolumbar spine degenerative joint and disc disease is remanded. The claim of entitlement to an initial rating higher than 10 percent for asthma is remanded. The claim of entitlement to an initial rating higher than 10 percent for GERD is remanded. The claim of entitlement to an initial compensable rating for left knee degenerative joint disease is remanded. The claim of entitlement to an initial compensable rating for traumatic brain injury (TBI) is remanded. The claim of entitlement to an initial compensable rating for headaches is remanded. The claim of entitlement to an initial compensable rating for left nasal ala status post hemangioma excision is remanded. FINDINGS OF FACT 1. The Veteran was diagnosed with arthritis of the left shoulder during service. 2. He was diagnosed with left hand arthritis during service. 3. His tinnitus incepted during service. 4. Hyperlipidemia is not a disability for VA compensation purposes. 5. Neither the Veteran’s left palm burn scar nor the left thigh shrapnel wound have resulted in an area or areas covering 144 inches or more. 6. The Veteran’s left palm burn scar is painful and numb, his left thigh shrapnel scar is painful and irritating, and his right hand surgical scar is painful in cold weather. 7. The Veteran’s right first metacarpal MCP and MCC joint arthritis causes him to have painful motion in the right hand. CONCLUSIONS OF LAW 1. The criteria are met for service connection for left shoulder arthritis. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. The criteria are met for service connection for left hand arthritis. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 3. The criteria are met for service connection for tinnitus. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 4. The criteria are not met for service connection for hyperlipidemia. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.303. 5. The criteria are not met for compensable ratings for the left palm or for the left thigh. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.118, DC 7802. 6. The criteria are met for an initial 20 percent rating effective March 1, 2013, for three painful scars of the left hand, left thigh, and right hand. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.118, DC 7804. 7. The criteria are met for an initial 10 percent rating effective March 1, 2013, for right first metacarpal MCP and MCC joint arthritis. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.59, 4.71a, DC 5010-5228. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June to July 1980 and from September 1981 to February 2013. This appeal is from a May 2014 rating decision. In January 2021, the Veteran had a personal hearing with the undersigned VLJ. Service Connection Service connection is granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for a disease diagnosed after discharge, where all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 1. Service connection for left shoulder degenerative joint disease is granted. 2. Service connection for left hand arthritis is granted. At the September 2012 VA examination, conducted prior to separation, the Veteran was diagnosed with left shoulder degenerative joint disease and left hand osteoarthritic changes, which is arthritis. These are considered chronic. 38 C.F.R. § 3.309(a). Accordingly, service connection for left shoulder and left hand arthritis is granted. 38 C.F.R. § 3.303(a). 3. Service connection for tinnitus is granted. At the September 2012 VA examination, prior to separation from service, the Veteran reported that he had experienced intermittent tinnitus during service. At the April 2014 VA examination, he reported having tinnitus since service. At the January 2021 hearing, the Veteran reported that his ear rang at times during service. Tinnitus is capable of self-diagnosis. Charles v. Principi, 16 Vet. App. 370 (2002). The Veteran has consistently reported that he has had tinnitus symptoms in and since service. He is competent to report having the diagnosis, and the Board finds his statements are credible. Accordingly, service connection for tinnitus is granted. 4. The claim of entitlement to service connection for hyperlipidemia is denied. The Veteran claims service connection for hyperlipidemia. “Hyperlipidemia” is “a general term for elevated concentrations of any or all of the lipids in the plasma, such as hypertriglyceridemia, hypercholesterolemia, and so on.” See Dorland’s Illustrated Medical Dictionary 903 (31st ed. 1994). A finding of hyperlipidemia is a laboratory result and not, in and of itself, a disability for VA compensation purposes. 61 Fed. Reg. 20440, 20445 (May 7, 1996). The Board stresses that service connection can only be granted for a disability resulting from disease or injury. See 38 U.S.C. §§ 1110, 1131. Thus, despite the diagnosis of hyperlipidemia, this is not a disease or disability for purposes of VA compensation. Service connection for hyperlipidemia is not possible as matter of law. As there is no basis in the law to grant the Veteran’s appeal, the claim for service connection for hyperlipidemia must be denied. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Increased Rating Disability ratings are assigned in accordance with VA’s Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate diagnostic codes (DCs) identify the various disabilities. See generally 38 C.F.R. Part 4. If two disability evaluations are potentially applicable, the higher evaluation 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. Reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Board notes that, during his personal hearing, the Veteran reported that he was seeking to have his scars and his right thumb arthritis rated on the basis of his testimony that the scars were painful and the right thumb arthritis caused him to have painful motion. For the scars, his representative asserted there was no contention that they had any other symptoms than pain. For the right thumb, his representative asserted there was no argument that it should be rated higher than 10 percent. Accordingly, the Board is granting these claims based upon the assertions made during the hearing. Although the evidence has not been completely developed for these claims (the file does not contain VA treatment records and he has not had examinations since April 2014), the Board finds he is not prejudiced by deciding these issues immediately. The Board is granting the benefit sought based on the evidence and his contentions. He has represented what he is seeking and there is no indication that additional development would materially change the results. 5. The claims of entitlement for higher ratings under DC 7802 for scars of left palm and left thigh are denied. 6. A 20 percent initial rating for three painful scars (left palm due to burn injury, left thigh due to shrapnel removal, and right hand due to surgical reduction) effective from March 1, 2013, is granted. The Veteran is service connected for the residuals of a burn injury on the left palm, and of a shrapnel injury on the left thigh. They are both currently rated noncompensably under DC 7802, which pertains to burn scars or scars from other causes, not of the face, neck, or head, and not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. He is also service connected for surgical scar on the right hand, which is rated noncompensably as a part of his right thumb arthritis under DC 5010-5228. 38 C.F.R. § 4.71. At the September 2012 VA examination, prior to his separation, he was diagnosed with left palm hypesthesia secondary to burn scarring, and with a left thigh scar from the removal of a piece of shrapnel. At the April 2014 VA examination, he was diagnosed with scars of the left thigh, left palm, and right hand. The Veteran reported these scars were painful, but the examiner indicated that none of his scars were painful. At his January 2021 personal hearing, the Veteran reported that his scars were all painful. As above, the Veteran is competent to report his own symptoms. The Board has no reason to doubt his credibility, and therefore the statements are probative. Under DC 7802, in order to be assigned a compensable rating, the scar must cover an area or areas of 144 square inches or more. 38 C.F.R. § 4.118. The Veteran’s scars do not combine to cover this much area. The Veteran’s scars are painful. Under DC 7804 one or two painful scars warrants a 10 percent rating, three or four warrant a 20 percent rating, and five or more warrants a 30 percent rating. Here, the Board finds that an initial 20 percent rating is warranted for three painful scars. 38 C.F.R. § 4.118, DC 7804. The Board notes that this rating requires removing the right-hand scar from the right thumb arthritis, which is also on appeal and discussed just below. The Board finds is the more appropriate criteria to use when rating the scar, and allows for him to achieve a higher rating for scars than if only considering the two scars that were separately assigned and appealed. In sum, a 20 percent initial rating is granted for painful scars of the left hand, left thigh, and right hand. 6. A 10 percent initial rating for right first metacarpal MCP and MCC joint arthritis effective from March 1, 2013, is granted. The Veteran asserts his right thumb arthritis causes painful motion. It is rated noncompensably under DC 5010-5228, which pertains to limited motion of the thumb due to arthritis. 38 C.F.R. § 4.71a; see also 38 C.F.R. § 4.27 (explaining and setting forth the procedure for assigning diagnostic criteria to unlisted disabilities, including the use of hyphenated ratings). Under DC 5010, arthritis due to trauma is rated under the criteria applicable for DC 5003, which pertains to degenerative arthritis. 38 C.F.R. § 4.71a. Under DC 5003, arthritis is rated based on limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. If the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate codes, an evaluation of 10 percent is applied for X-ray evidence of involvement with 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted for X-ray evidence of involvement with 2 or more major joints or 2 or more minor joint groups with occasional incapacitating episodes. 38 C.F.R. § 4.71a, DCs 5003, 5010. A Note to the criteria indicates that the 10 and 20 percent ratings set forth above will not be combined with ratings based on limitation of motion. Therefore, whichever criteria (either X-ray evidence of arthritis or limitation of motion) yields the higher benefit is the criteria that is applied. The Board notes that the rating criteria applicable to DC 5010 have been amended effective February 2021. These new criteria are not applicable, as the available evidence is all dated prior to February 2021. The record does not show X-ray evidence of 2 or more major joints or minor joint groups. 38 C.F.R. § 4.45. Under DC 5228, limited motion of the thumb with a gap of less than one inch between the thumb pad and the fingers, with the thumb attempting to oppose the fingers, warrants a 0 percent rating. A gap of one to two inches warrants 10 percent. A gap of more than two inches warrants a 20 percent rating. 38 C.F.R. § 4.71a. When evaluating disabilities that are based on limited motion, it is necessary to consider both the schedular criteria and any functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss due to pain is rated at the same level as functional loss where motion is impeded. Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to a healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). The September 2012 VA examination showed painful motion and full range of motion. The April 2014 VA examiner did not find painful motion. During his January 2021 hearing, he reported having painful motion, which is sufficient to grant a 10 percent rating. A higher rating is not warranted because there is no indication that he has had any gap between the thumb pad and the fingers at any time, even after repetitive use and during flares. Accordingly, a 10 percent rating is warranted starting from March 1, 2013. REASONS FOR REMAND As a threshold matter, the Board notes the record contains no post-service treatment records apart from VA examinations. The SOC (statement of the case) shows that the Veteran’s VA treatment records were reviewed, but none were associated with the claims file. It is essential that a complete set of post-service VA treatment records be associated with the claims file. 1. The claim of entitlement to service connection for hearing loss is remanded. 2. The claim of entitlement to service connection for serous otitis is remanded. The Veteran has not been tested for hearing loss since April 2014. He has reported an increase in hearing loss trouble; therefore, an examination should be scheduled. On examination, opinion should also be obtained as to whether the Veteran has any residual symptoms of a serous otitis ear infection he had the summer before separation. 3. The claim of entitlement to service connection for a left eye disability is remanded. As above, it is not clear whether the Veteran has a current diagnosis of the left eye that may be service connected. He reports that he was injured in the left eye by a loose strap, but that he was told that it had resolved. He has not been examined since April 2014, and an updated examination should be provided. The record shows the Veteran was diagnosed with pinguecula while in service, which was not identified at the April 2014 VA examination. The record also shows that the Veteran underwent PRK surgery to correct refractive error while in service. While the usual effects of surgical treatment in service are not directly service connectable, service connection is available via aggravation if shown during service. 38 C.F.R. § 3.306(b)(1). 4. The claim of entitlement to service connection for a right knee disability is remanded. 5. The claim of entitlement to service connection for a right ankle disability is remanded. 6. The claim of entitlement to service connection for a left ankle disability is remanded. The Veteran reports ongoing symptoms of pain and instability in the right knee, as well as pain in the ankles. He asserts he has functional loss due to these symptoms. On remand, he must be provided with VA examinations for determinations on whether he has any chronic diagnoses related to service. The Board notes he served in the Persian Gulf, which should also be considered if there are no specific diagnoses for these joints. 7. The claim of entitlement to service connection for an acquired psychiatric disability is remanded. The Veteran asserts that he has an acquired psychiatric disability that is related to his service. He served for over thirty years, and was exposed to multiple stressors. During service, he was not diagnosed with anything, but he has not been examined since 2014. The Veteran asserts that he has mental health symptoms that are related to his TBI. On remand, an updated examination for an acquired psychiatric disability will be conducted, as well as TBI, discussed below. 8. The claim of entitlement to service connection for a heart disability is remanded. The Veteran asserts that he was diagnosed with having had a myocardial infarction during service. His records show that he was given diagnostic studies during service after complaining of chest pain. A September 2012 record notes that he had previously had abnormal EKGs, from 1999 to 2009. He reported no functional limitations. Testing in September 2012 showed normal heart and heart function. He was diagnosed with atypical chest pain, with no cardiac etiology demonstrated. At the April 2014 VA examination, he reported having no symptoms, and was not diagnosed with any cardiac disability. At his personal hearing, he did not report having any symptoms or diagnoses, but said that he was told that he would need to monitor his heart for the rest of his life. On remand, his VA treatment records must be obtained, as discussed above, and if evidence is received showing complaints or symptoms of a cardiac disability, then he shall be given a VA examination. 9. The claim of entitlement to service connection for sleep apnea is remanded. The Veteran was diagnosed with a snoring disorder during service. The Board notes that the September 2012 sleep study indicates the Veteran’s “supine sleep was reduced,” which made the study “technically limited.” Given he reported having apneic episodes and was diagnosed with a snoring disorder during service, an updated sleep study and opinion should be obtained. 10. The claim of entitlement to service connection for the residuals of a cold injury to the cheeks and fingers is remanded. The Veteran complains of the residuals of frostbite, which he noted might not be documented in his STRs. He reports he served in the Arctic Circle and developed symptoms in the cheeks and fingers, but was not treated. He reports he has recurrent symptoms in the cold weather. The September 2012 VA examiner opined that the Veteran’s statements were supported by his record of service, although there was no documentation of the injury in the record. He indicated that such an injury had the potential for causing future functional impairment, and that it should be monitored. The April 2014 VA examiner noted there was insufficient documentation, examination findings, or ancillary studies showing an abnormality. He was not clear about what sort of studies could be conducted or whether any had been. On remand, a more thorough examination shall be conducted. 11. The claim of entitlement to an initial rating higher than 10 percent for cervical spine degenerative joint and disc disease is remanded. 12. The claim of entitlement to an initial rating higher than 10 percent for thoracolumbar spine degenerative joint and disc disease is remanded. The Veteran has reported an increase in severity in his neck and back disabilities, including asserting symptoms of neurological abnormalities. An updated examination must be conducted. Further, as mentioned, updated treatment records must be obtained. 13. The claim of entitlement to an initial rating higher than 10 percent for asthma is remanded. The Veteran asserts that his inhaled albuterol is an anti-inflammatory medication. Unfortunately, the medical records do not specify that, and there is no other evidence that confirms that is the case. The April 2014 VA examination form does not contain a specific question regarding inhalational anti-inflammatory medication. On remand, he shall be given an updated VA examination. 14. The claim of entitlement to an initial rating higher than 10 percent for GERD is remanded. The Veteran has asserted his GERD is worse than currently rated, and that he experiences daily symptoms that are productive of considerable impairment of health. The last examination was in April 2014. An updated examination must be scheduled, and treatment records obtained. 15. The claim of entitlement to an initial compensable rating for left knee degenerative joint disease is remanded. The record requires development. VA treatment records must be obtained. He should be given an updated VA examination, as he has complained of increased symptoms, including instability. 16. The claim of entitlement to an initial compensable rating for traumatic brain injury (TBI) is remanded. The Veteran asserts that the current examination for TBI and residuals is inadequate. He argues that it was not performed by one of the four accepted specialties qualified to evaluate TBI (physiatrist, psychiatrist, neurologist, or neurosurgeon). He argues he has psychiatric and cognitive symptoms. On remand, an updated examination must be conducted, and his treatment records must be obtained. 17. The claim of entitlement to an initial compensable rating for headaches is remanded. He reports symptoms that are more severe than reflected on the April 2014 VA examination. Given the time that has passed and his report, a new examination should be conducted. His treatment records must also be obtained. 18. The claim of entitlement to an initial compensable rating for left nasal ala status post hemangioma excision is remanded. This disability is currently rated under the criteria applicable to allergic rhinitis (DC 6522) that is a result of the removal of benign neoplasms (DC 6820). 38 C.F.R. §§ 4.71a, 4.27. He had a nasal polyp removed during service, and allergic rhinitis is rated on obstruction of the nasal passage and whether there are polyps. 38 C.F.R. § 4.71a, DC 6522. An updated examination on whether he has any obstruction should be scheduled, and the treatment records obtained. The matters are REMANDED for the following action: 1. Associate a complete set of VA treatment records with the claims file. Ask the Veteran to identify and authorize VA to obtain any private records, or to provide them himself. 2. After completion of directive 1, schedule an appropriate examination for a report on whether the Veteran has a hearing loss disability for VA purposes. If so, the examiner is asked whether it is as likely as not (50/50 probability or greater) related to his service. The examiner is advised that his noise exposure is conceded, and the Veteran served for over 30 years. The examiner is also asked whether it is as likely as not (50/50 probability or greater) that the Veteran has any residual disability from serous otitis ear infection during service. If this question is more appropriately answered by another clinician, the examiner is asked to so notify the scheduling authority. All opinions must be accompanied with explanation. 3. After completion of directive 1, schedule the Veteran for an appropriate examination for a report on whether it is as likely as not (50/50 probability or greater) that any eye disability is related to service. The examiner is asked to conduct a thorough examination, including eliciting a detailed history from the Veteran, and to provide a list of all diagnoses. The Veteran was diagnosed with pinguecula and presbyopia during service, and he also had a PRK surgery during service. As far as the PRK surgery, if any diagnosis is related to that, the examiner is asked whether it is considered a “usual effect” of that surgery. That is, would the identified diagnosis be expected to occur following PRK? If expected to be found following PRK, the examiner is next asked whether there was aggravation of that diagnosis during service? “Aggravation” is considered to have happened when there is a permanent increase in severity during service that is not attributed to the natural progress of the disability. If any of the current disabilities are not considered a “usual effect” of PRK, then the examiner is asked whether it is as likely as not (50/50 probability or greater) that the diagnosis or symptom was caused by or incepted during service. All opinions must be accompanied with explanation. 4. After completion of directive 1, schedule the Veteran for an appropriate examination of the right knee and bilateral ankles for report on whether he has any chronic disabilities of these joints, and if so, whether any of them are as likely as not (50/50 probability or greater) related to his service. If, after examination, the Veteran’s symptoms cannot be attributed to a specific diagnosis, the examiner is asked to so state. As for the right knee, the record shows he has complained of right knee pain and limited motion since service. During service he was diagnosed with patellar tendonitis, and X-ray revealed slight effusion. As for the ankles, the record shows he has complained of pain in the ankles since service. He sprained his right ankle in 1989 and 1995. The examiner is asked to conduct a complete examination and to elicit from the Veteran a detailed history of his symptoms in and since service. All opinions must be accompanied by explanation. 5. After completion of directive 1, schedule the Veteran for an appropriate examination for a report on whether the Veteran has a current diagnosis of any acquired psychiatric disability (that is, diagnosed at any time since his separation from service). If so, the examiner is asked whether it is as likely as not (50/50 probability or better) that it is related to his service. The examiner is asked to elicit from the Veteran a detailed history, review the record, and conduct a thorough examination. All opinions must be accompanied with explanation. 6. After completion of directive 1, if evidence suggests the Veteran has any current cardiac symptoms, including ongoing chest pain, or cardiac diagnosis, then schedule him for an appropriate examination for a report on whether it is as likely as not (50/50 probability or greater) that any current diagnosis is related to service, including consideration of whether any current symptoms are related to his atypical chest pain diagnosed during service. The examiner is asked to review the record and elicit from the Veteran a detailed history of his symptoms. All opinions must be supported with explanation. 7. After completion of directive 1, schedule the Veteran for an appropriate examination for a report on whether he has sleep apnea or any other sleeping disorder that is as likely as not (50/50 probability or greater) related to service. The examiner is asked to review the record and to conduct a thorough examination, including the scheduling of a sleep study if necessary for diagnosis. For each diagnosis, the examiner is asked if it is related to service, or to the symptoms complained of in service, including primary snoring disorder. All opinions must be supported with explanation. 8. After completion of directive 1, schedule the Veteran for an appropriate examination for a report on whether the Veteran has any residuals of a cold injury to the cheeks and fingers, and if so, whether it is as likely as not (50/50 probability or greater) that it is related to service. The examiner is asked to review the record and to elicit from the Veteran a detailed history of his symptoms at the time of the injury, what he was advised to do if no treatment was rendered, and his symptoms since service. The April 2014 VA examiner mentioned the possibility of diagnostic studies that could show abnormality, which this examiner is asked to discuss and consider conducting if reasonably available. All opinions must be supported with explanation. 9. After completion of directive 1, schedule the Veteran for an appropriate examination for a report on the current severity of his cervical and thoracolumbar disabilities. The examiner is asked to conduct a thorough examination including neurological. The examiner is asked to elicit from the Veteran a detailed history of his symptoms since separation, in general and during flares and after repetitive use. The examiner is asked to conduct range of motion testing, and to provide an estimate of any additional functional loss during flares and after repetitive use. If unable to provide an estimate in terms of degrees of motion, then the examiner is asked to explain why the Veteran’s statements were not helpful in that regard. All opinions must be supported with explanation. 10. After completion of directive 1, schedule an appropriate examination for a report on the current severity of his asthma. The examiner is asked to indicate whether the Veteran has been prescribed inhalational anti-inflammatory medication, and whether albuterol is anti-inflammatory. Updated respiratory testing should be conducted. All opinions are to be supported with explanation. 11. After completion of directive 1, schedule an appropriate examination for a report on the current severity of GERD. The Veteran reports that he has daily symptoms of epigastric distress as well as feelings of regurgitating, but without vomiting. He reports he has to be careful of what he eats and has to be careful of any prescribed medications. He asserts his GERD is productive of considerable impairment of health. The examiner is asked to elicit from the Veteran a detailed history and to document his symptoms. After reviewing the record, and interviewing and examining the Veteran, the examiner is asked to opine on whether his GERD results in considerable or severe impairment of health. All opinions must be supported with explanation. 12. After completion of directive 1, schedule the Veteran for an appropriate examination for a report on the current severity of the left knee. The examiner is asked to conduct a thorough examination and to elicit from the Veteran a detailed report on the history of his left knee symptoms, both generally and during flares and after repetitive use. The examiner is asked to question the Veteran about his knee “giving out.” The examiner is asked to opine on the extent of his functional loss, in terms of lost range of motion, during flares and after repetitive use. If unable to provide an estimate, then the examiner must explain why the Veteran’s statements regarding his function were not helpful in that regard. The examiner is asked to conduct testing for recurrent subluxation, instability, and patellar instability. The examiner is asked whether the Veteran has any symptoms of the semilunar cartilage, including pain, locking, and effusion into the joint. All opinions must be accompanied by explanation. 13. After completion of directive 1, schedule the Veteran for an appropriate examination with an examiner qualified to conduct TBI evaluations for a report on the current severity of his TBI. He reports having both mental health and cognitive symptoms. The examiner is asked to elicit from the Veteran a detailed history. A thorough examination must be conducted, and all opinions supported with explanation. 14. After completion of directive 1, schedule the Veteran for an appropriate examination for a report on the current severity of the Veteran’s headaches. The examiner is asked to elicit from the Veteran a detailed history of his symptoms, their treatment, and how they impact his everyday life and at work. The examiner is asked to review the record prior to the examination and to provide explanation for all rendered opinions. 15. After completion of directive 1, schedule the Veteran for an appropriate examination for a report on the current severity of left nasal ala status post hemangioma excision. The examiner is asked whether the Veteran has nasal passage obstruction of greater than 50 percent in both nostrils, or polyps. The examiner is asked to list any other symptoms reported or found. All opinions must be supported with explanation. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Gibson 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.