Citation Nr: 21026836 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 11-16 452 DATE: May 4, 2021 ORDER The claim of entitlement to service connection for hearing loss is denied. The claim of entitlement to service connection for fibromyalgia, to include as due to an undiagnosed illness, is denied. The claim of entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness, is denied. An initial rating of 70 percent for posttraumatic stress disorder (PTSD) prior to March 5, 2014, is granted. A rating of 50 percent for PTSD from May 1, 2014, to September 9, 2015, is granted. The claim of entitlement to a rating in excess of 50 percent for PTSD from September 9, 2015, to May 16, 2019, is denied. The claim of entitlement to a rating in excess of 70 percent for PTSD as of May 16, 2019, is denied. REMANDED The claim of entitlement to service connection for migraine headaches, to include as due to an undiagnosed illness, is remanded. The claim of entitlement to service connection for sleep apnea, to include as due to an undiagnosed illness, is remanded. The claim of entitlement to service connection for endometriosis, to include as due to an undiagnosed illness, is remanded. The claim of entitlement to service connection for a thyroid condition, to include as due to an undiagnosed illness, is remanded. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities prior to August 18, 2010, is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record fails to establish that the Veteran had a diagnosis of hearing loss for VA purposes throughout the appellate period. 2. The preponderance of the evidence of record fails to establish that the Veteran had a diagnosis of fibromyalgia throughout the appellate period. 3. The preponderance of the evidence of record fails to establish that the Veteran had a diagnosis of chronic fatigue syndrome throughout the appellate period. 4. Prior to March 5, 2014, the Veteran's PTSD manifested with symptoms most closely analogous to occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but did not rise to the level of a total occupational and social impairment. 5. Between May 1, 2014, and May 16, 2019, the Veteran's PTSD manifested with, at worst, occupational and social impairment with reduced reliability and productivity, but did not reach the level of causing occupational and social impairment in most areas of life. 6. Since May 16, 2019, the Veteran's PTSD manifested with symptoms most closely analogous to occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but did not rise to the level of a total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for hearing loss are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for fibromyalgia are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 3. The criteria for service connection for chronic fatigue syndrome are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 4. The criteria for an initial rating prior to March 5, 2014, of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411. 5. From May 1, 2014, to September 9, 2015, the criteria for a rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411. 6. From September 9, 2015, to May 16, 2019, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411. 7. Since May 16, 2019, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Air Force from June 1985 to March 1989 and November 1990 to March 1991, including service in the Southwest Asia (SWA) Theatre of Operations during the Persian Gulf War. The instant matter is on appeal from May 2009, January 2011, April 2011, and October 2011 rating decisions. In August 2017, the Veteran testified before the undersigned in a videoconference hearing. A transcript of the proceedings has been associated with the record. The Board most recently remanded these issues for additional evidentiary development in March 2018. In that development period, the Regional Office granted entitlement to service connection for otitis media and psoriatic arthritis effective the date of the Veteran's claim, as well as granted the maximum statutory rating for the Veteran's labyrinthitis, 30 percent, for the entire period on appeal. As neither the Veteran nor the evidence of record have raised the issue of extraschedular consideration for labyrinthitis, the Board finds that these decisions constitute grants of full benefits sought on appeal, and these issues are no longer before the Board. Service Connection Generally, service connection will be granted for a disability resulting from an injury or disease caused or aggravated by service. 38 U.S.C. §§ 1110. A grant of service connection for a disability requires: (1) a present disability or persistent or recurrent symptoms of a disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the in-service event, injury, or disease. 38 C.F.R. § 3.303; see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Under 38 U.S.C. § 1117 (a)(1), compensation is warranted for a Persian Gulf War Veteran who exhibits objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the SWA Theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. Furthermore, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a), (b). Because the Veteran served in SWA during his active service, he is a Persian Gulf Veteran within the meaning of the applicable statute and regulation. The Board notes that Congress revised 38 U.S.C. § 1117, effective March 1, 2002. In the revised statute, the term "chronic disability" was changed to "qualifying chronic disability," and the definition of "qualifying chronic disability" was expanded to include (a) undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. Effective June 10, 2003, VA promulgated revised regulations to, in part, implement these statutory changes. See 38 C.F.R. § 3.317 (a)(2). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). For purposes of 38 C.F.R. § 3.317, the term "medically unexplained chronic multi-symptom illness"(MUCMI) means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs, and that has features such as fatigue, pain, and/or disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317 (a)(2)(ii). Chronic multi-symptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, are not to be considered medically unexplained. Id. The term "objective indications of chronic disability" includes both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Additionally, disabilities that have existed for six months or more, as well as disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. 38 C.F.R. § 3.317 (a)(4) (providing that the six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to: (1) fatigue, (2) unexplained rashes or other dermatological signs or symptoms, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs and symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, and (13) menstrual disorders. 38 C.F.R. § 3.317 (b). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue."). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). 1. The claim of entitlement to service connection for hearing loss The Veteran contends that she is entitled to service connection for hearing loss. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. For the purposes of applying VA laws, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 hertz is 40 decibels (dB) or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, and 4000 hertz are 26 decibels or greater; or when the speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Board concludes that the Veteran does not have a current diagnosis of hearing loss for VA purposes and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In the Veteran's February 1984 entrance audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 0 0 LEFT 0 10 0 5 0 In the Veteran's January 1989 separation audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 0 0 0 0 LEFT 0 5 0 5 0 Post-service VA treatment records reflect normal hearing in July 2009 except for at the 8kHz range in the left ear. In July 2011, the Veteran reported that she experienced difficulty hearing when her tinnitus was occurring. In the August 2017 hearing before the undersigned, the Veteran stated that she has not been told that she has a diagnosis of hearing loss. In May 2019, the Veteran underwent a VA examination to assess her claimed hearing loss. In the audiological evaluation, pure tone thresholds, in decibels, were as follows: May 2019 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 15 20 15 20 17.5 96% LEFT 20 15 15 15 16.25 96% The Veteran reported that she experienced increased difficulty hearing lower sounds when she returned from Desert Storm. She needed to turn up the volume on her television or stereo as a result. She sometimes asks people to repeat themselves when in conversation. The examiner concluded that the Veteran had normal hearing in both ears, and she did not meet the VA definition of hearing loss. After a thorough review of the evidence of record, the Board concludes that the Veteran does not have a diagnosis of hearing loss for VA purposes, nor has she throughout the period on appeal. The Veteran has reported increased difficulty hearing when her tinnitus occurs. She is separately service connected for tinnitus, and the rating criteria for tinnitus contemplates sound heard in one or both ears attributable to the condition. Furthermore, a VA audiology examination confirmed the Veteran's normal hearing bilaterally in May 2019. While the Veteran believes she has a current diagnosis of hearing loss, she is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Despite the reported complaints, the evidence fails to show functional impairment of such severity to warrant service connection for a hearing loss disability. Consequently, the Board gives more probative weight to the competent medical evidence finding no diagnosis of hearing loss for VA purposes. As the preponderance of the evidence of record is against the claim, the rule regarding reasonable doubt is not for application. Accordingly, the Veteran's claim of entitlement to service connection for hearing loss must be denied. 2. The claim of entitlement to service connection for fibromyalgia The Veteran contends that she has a present diagnosis of fibromyalgia that is etiologically related to her active duty service. Here, it has been conceded that the Veteran served in SWA during the Persian Gulf War. Therefore, she is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). The Veteran reports experiencing symptoms of diffuse joint and muscle pains since her deployment to SWA, but she did not recall a specific onset. She endorses daily pain in her hands, elbows, shoulders, wrists, knees, and ankles. The Veteran underwent a VA examination in July 2011 to assess her condition. The examiner concluded that there was no evidence of fibromyalgia, to include her service and post-service treatment records. The examiner did note that the Veteran was followed by rheumatology for psoriatic arthritis. VA treatment records reflect a suspicion of fibromyalgia, and a prescription to treat her symptoms in March 2014. The Veteran has repeatedly reported a diagnosis of fibromyalgia to other treating clinicians, and such has been noted in those related treatment records. In May 2019, the Veteran underwent a second VA examination to assess her claim of fibromyalgia. This examiner also concluded that she did not have a diagnosis of fibromyalgia. The Veteran's claimed disability pattern represented a disease with a clear and specific etiology and diagnosis. The condition causing her reported symptoms was not fibromyalgia, but instead psoriatic arthritis. In the present case, while the Veteran contends that her symptoms of joint and muscle pain are caused by fibromyalgia, the preponderance of the medical evidence of record reflects that such are actually caused by her psoriatic arthritis. While fibromyalgia was suspected around 2011 to 2014, subsequent evaluations have ruled this out as the diagnosis. Instead, the reported symptoms are the result of her psoriatic arthritis, for which she is already service connected. The VA examinations of record have not identified symptoms outside of the psoriatic arthritis diagnosis that would be entitled to consideration as either an undiagnosed disability or MUCMI. Instead, the symptoms were the result of a disease with a clear and specific etiology and diagnosis: psoriatic arthritis. Accordingly, the Veteran's condition is neither an undiagnosed illness nor a MUCMI that would otherwise warrant service connection under the Gulf War presumptive conditions. The Board finds that the reported signs or symptoms of fibromyalgia are not diagnosed as fibromyalgia, and the medical evidence does not support a diagnosis of fibromyalgia nor does it support a diagnosis of undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptom illness with a partially explained etiology. According to the VA examiner, the Veteran's reported symptoms are attributable to her psoriatic arthritis. She does not have a present diagnosis of fibromyalgia, nor does she have signs and symptoms indicative of an undiagnosed illness or MUCMI. Accordingly, service connection for fibromyalgia is not warranted. 3. The claim of entitlement to service connection for chronic fatigue syndrome The Veteran contends that she has a present diagnosis of chronic fatigue syndrome (CFS). As noted previously, Persian Gulf service has been conceded. The Veteran reports experiencing daily fatigue. VA treatment records reflect that she exhibited an abnormal sleep pattern that caused fatigue, and she was later diagnosed with insomnia and exhaustive fatigue. An October 2010 note indicates that she met the criteria for CFS. Subsequent treatment records, however, attribute the Veteran's fatigue to other medical conditions. Her PTSD is noted to cause nightmares and middle onset insomnia, which results in daytime fatigue. Additionally, the Veteran was diagnosed with sleep apnea, and she had inconsistent compliance with her CPAP. In a November 2003 VA examination, an examiner concluded that the Veteran's described fatigue was the result of her multiple medical conditions, including a back disability, endometriosis, tinnitus, and residuals of a thyroidectomy. The examiner also indicated that sleep apnea had to be ruled out as a potential cause. The Veteran underwent a second VA examination in May 2019. She reported chronic tiredness, and she had a history of diagnosed obstructive sleep apnea, psoriatic arthritis, and depression. The Veteran endorsed difficulty falling and staying asleep. The Veteran's claimed disability pattern represented a disease with a clear and specific etiology and diagnosis. She did not have a diagnosis of CFS, but instead had multiple medical conditions that caused excessive tiredness. Instead, her fatigue was secondary to her depression, sleep apnea, and chronic pain, all of which interfered with her ability to sleep. The Board finds that the reported signs or symptoms of CFS are not diagnosed as CFS, and the medical evidence does not support a diagnosis of CFS nor does it support a diagnosis of undiagnosed illness, a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, or a diagnosable chronic multi-symptom illness with a partially explained etiology. According to the VA examiner, the Veteran's symptoms described as CFS are attributable to her depression, sleep apnea, and chronic pain. She does not have a present diagnosis of CFS, nor does she have signs and symptoms indicative of an undiagnosed illness or MUCMI. Accordingly, service connection for CFS is not warranted. Increased Rating Disability ratings are determined by application of a ratings schedule which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, pyramiding, which is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disabilities must be reviewed in relation to their entire history. 38 C.F.R. § 4.1. VA must also interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. VA is also required to evaluate functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Functional loss may be due to pain if supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Functional impairment may be due to pain, including during flare-ups, or from repetitive use. Mitchell v. Shinseki, 25 Vet. App. 32, 43-44 (2011). The Veteran's PTSD is rated under Diagnostic Code 9411, 38 C.F.R. § 4.130. Mental disorders are rated under the General Rating Formula for Mental Disorders pursuant to 38 C.F.R. § 4.130. A 10 percent rating is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and an inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the 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. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). However, a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration, and that those symptoms have resulted in the type of occupational and social impairment associated with that percentage. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 465. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.159; see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. 4. The claim of entitlement to an initial rating in excess of 30 percent for PTSD prior to March 5, 2014 The Veteran contends that she is entitled to an initial rating in excess of 30 percent for PTSD. After a thorough review of the record, the Board finds that a 70 percent rating, but no higher, is warranted prior to March 5, 2014. Around February 2008, VA treatment records reflect that the Veteran suffered from increased thoughts of suicide without intent or plan. She reported freezing when she heard airplanes or sirens, difficulty socializing and being in relationships, as well as challenges controlling her anger. She experienced nightmares and sleeplessness. In February 2008, she reported several near panic episodes, obsessions, and phobias, as well as persistent excessive worry. Through this time, she remained alert and oriented on evaluation. She presented appropriately dressed and exhibited sufficient attention and concentration. Speech remained clear and spontaneous. Thought processes and content were relevant, and judgment was within normal limits. In May 2010, VA treatment records reflect ongoing symptoms of hyperarousal, intrusion, and avoidance behaviors. She described sadness, and feelings of isolation from others. The Veteran denied suicidal or homicidal ideation. In an August 2010 hearing before a Decision Review Officer (DRO), she endorsed anxiety, panic, attacks, problems sleeping, nightmares, withdrawal or isolation, and difficulty getting along with others. In November 2010, the Veteran underwent a VA examination to assess the severity of her PTSD. She reported significant isolation and avoidance of people. She became angry and lashed out at others at work. She described symptoms of jumpiness, anxiety, nightmares, and flashbacks. Sleep was variable, and she experienced depressive symptoms with crying spells. She reported thinking "daily 'about why I should live, but I don't talk about it, because it's so shameful.'" She had thoughts of harming her sister in law. The Veteran denied hallucinations but endorsed numerous panic attacks prior to the period on appeal. She lived with her parents, a cousin, and a nephew. She went to church weekly, and generally maintained her hygiene. She did not require significant help with housework, but her finances were in "disarray". On examination, she reported reasonably well groomed, and she did not exhibit movement abnormalities. Speech was normal, and her thoughts were generally linear and logical. She denied suicidal and homicidal ideations, as well as hallucinations. No delusions were elicited. Her mood was euthymic with affect full in range and appropriate. She was fully alert and oriented. In March 2011, VA treatment records reflect ongoing treatment for her PTSD. She reported to appointments appropriately dressed and groomed. She was fully alert and oriented with speech and thoughts within normal limits. Symptoms remained relatively consistent through her regular treatment appointments. By way of example, in July 2013, she reported doing better with managing interpersonal boundaries and internalized anger. She participated in a group dance class to increase her social interactions. Overall mood was euthymic, though she became anxious and irritable in response to particular stressors. Daytime fatigue had improved with dancing, and she denied suicidal and homicidal ideation. In November 2013, she reported one significant panic attack recently, but her PTSD symptoms were around her baseline. Later that month, a friend passed away, and she reported shock and grief to her treating clinician. In December 2013, she reportedly had a conversation with her mother about her PTSD and suicidality, which "shocked" her mother. During this time, she continued to report to treatment appropriately dressed and groomed. Her mental status examination was predominantly within normal limits, and she continued to deny suicidal and homicidal ideation. No delusions or hallucinations were found. In March 2014, the Veteran checked in to in-patient treatment for PTSD following a particularly strong suicidal ideation. She received a total disability rating for this hospitalization, which is not on appeal. After a thorough review of the medical and lay evidence of record, the Board finds that the Veteran is entitled to an initial 70 percent rating for her PTSD, but no higher. The Board recognizes that the Veteran suffered from deficiencies attributable or exacerbated by his PTSD. The Board's determination of the appropriate degree of disability is a finding of fact. In applying the ratings schedule, the Board considers the severity, frequency, and duration of psychiatric symptoms to determine the appropriate disability evaluation. See, e.g., Brewer v. Snyder, No. 15-2800, 2017 U.S. App. Vet. Claims LEXIS 90, at 13 (Vet. App. Jan. 31, 2017); citing Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). While symptoms are listed under each category for evaluation, the particular symptoms are to be demonstrative of that overall level of severity, frequency, and duration. Mauerhan v. Principi, 16 Vet. App. 436, 442 (U.S. 2002). As such, the Board has considered the symptoms specific to the Veteran throughout the period on appeal and determined the analogous evaluation pursuant to the ratings schedule in 38 C.F.R. § 4.130. When considering the severity, frequency and duration of the impairments as delineated in the 70 percent evaluation, the Board notes that the symptoms listed present a significant impediment to daily life. Symptoms such as obsessional rituals which interfere with routine activities, near-continuous panic or depression, and the inability to establish and maintain effective relationships, present obstacles to routine functioning on a daily basis. Personal hygiene and grooming are not limited to one particular sphere, but affect work, school, and family relations. Spatial disorientation and intermittently illogical speech are markedly severe symptoms associated with basic cognitive function and the ability to interact with the world. Suicidal ideation, in of itself, represents the impulse or desire to remove oneself from the world entirely. As exemplified by the symptoms listed in this category, the 70 percent evaluation is appropriate for deficiencies that harm most areas of life. Either symptoms are continuous, or near continuous, or represent such a severity that routine daily functions are chronically impeded. In contrast, the evaluation for a 100 percent impairment includes symptomatology that presents a total impairment to daily functioning. Not only are the representative symptoms of the most severe possible from a psychiatric disorder, but they interfere with the ability to independently engage in activities of daily life. Persistent delusions or hallucinations, disorientation to time or place, and significant memory loss all prevent the person from routine engagement with the world. The ability to even maintain the most basic hygiene standards has been harmed by the severity or frequency of the associated symptomatology. When symptoms of a psychiatric disorder are so severe as to present a total impairment to occupational and social activity, then a 100 percent evaluation should be afforded. Throughout the period on appeal, the Veteran regularly endorsed symptoms of anxiety, depressed mood, panic attacks, nightmares, hypervigilance, and social withdrawal. She also endorsed suicidal ideation without plan or intent on several occasions during this period. Her overall symptomatology most accurately fits the nature, severity, and frequency of symptoms listed in the 70 percent rating criteria. While certainly severe, the manifestations of the Veteran's service-connected PTSD in this timeframe do not rise to the level of a total occupational and social impairment for the purposes of 38 C.F.R. § 4.130. Her impairments, while touching on many areas of his life, are not of such severity to interfere with routine functions necessary for daily life. The Veteran was consistently alert and oriented in all spheres and maintained her grooming and hygiene. She was not actively violent towards others, and her mental faculties remained intact throughout this period. While initially more isolated, the Veteran started to engage in a group dance class on a regular basis in addition to going to church. In sum, the Veteran's symptoms do not mirror the severity, frequency and duration of ones such as persistent delusions or hallucinations, or inability to attend to basic hygiene. She continues to perform the activities of daily living, including maintaining her hygiene and grooming. Resolving reasonable doubt in favor of the Veteran, her PTSD is more adequately represented by an initial rating of 70 percent prior to March 2014. While the Veteran certainly continues to cope with serious manifestations of her PTSD, they do not rise to the level of a total occupational and social impairment as contemplated by the rating schedule for this initial period on appeal. As the preponderance of the evidence weighs against the claim for an evaluation in excess of 70 percent, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's PTSD is entitled to an initial rating of 70 percent, but no higher, prior to March 2014. 5. The claim of entitlement to a rating in excess of 30 percent for PTSD from May 1, 2014, to September 9, 2015 The Veteran discharged from in-patient PTSD treatment, and her total disability rating ended effective May 1, 2014. The Regional Office assigned a subsequent disability rating of 30 percent. The Board finds that a 50 percent rating for this period more adequately encapsulates the severity of the Veteran's PTSD symptoms. In May 2014, the Veteran reported sobriety since her hospitalization, and she denied suicidal and homicidal ideation, intent, or plan. She reported "doing well overall." She reported for regular mental health counseling appropriately attired and well groomed. Attention was variable, but her memory remained intact. She was fully alert and oriented during treatments with cooperative and open behavior. Speech remained clear and coherent. Affect was flat, and she exhibited initial onset insomnia, reduced interests, reduced energy, reduced concentration, and anhedonia related to her depression. Thought processes and content were relevant, judgment was within normal limits, and her insight was fair. Her high-risk status was downgraded in June 2014 following an appropriate clinical review. Regular mental health counseling continued into 2015. The Veteran continued to report panic attacks, stressors related to her family, and anxiety. She expressed concerns with her difficulty trusting others and seemed to spend money "frivolously" in a subconscious attempt to sabotage her changes of moving forward in life. She exhibited normal motor activity and speech. She was alert and oriented without indications of mania or hypomania. Thoughts were mostly linear with appropriate content. She denied suicidal ideation, homicidal ideation, and hallucinations. Insight and judgment were fair. In April 2015, the Veteran expressed continued stress and difficulty in dealing with her parents and aunt. She was a caretaker for them while living in the same house, but she felt that her family members did not respect her boundaries or acknowledge her difficulties. She endorsed panic attacks and anxiety but found that a recent medication change had helped these symptoms. She felt somewhat socially phobic around that time, so she did not go out with her friends. The Veteran reported for her treatment appropriately dressed with good grooming and hygiene. Normal motor activity and speech were noted. She was alert and oriented with good eye contact. She reported being less anxious at that time, and she engaged with her treating clinician with some appropriate joking. She did not appear manic or hypomanic. Thoughts were mostly linear with appropriate content. She continued to deny suicidal ideation, homicidal ideation, and hallucinations. Insight, judgment, and impulse control were fair. In May 2015, the Veteran endorsed some increased symptomatology associated with her PTSD in the form of flashbacks in the previous month. She also reported ongoing nightmares. Her anxiety had increased around the time of the appointment, and she felt short-tempered and tense. She described difficulty sustaining attention and following through on tasks. Given her difficult home situation, she inquired about another period of residential treatment for her PTSD. Her mental status examination was largely within normal limits. She denied suicidal and homicidal ideation. These symptoms remained consistent until September 2015. After a thorough review of the evidence of record, the Board finds that a rating of 50 percent from March 2014 to September 2015 is warranted. During this period on appeal, the Veteran reported symptoms including anxiety, depression, panic attacks, nightmares, and some social isolation. She continued to experience some insomnia associated with her depression as well. Her family was a stressor for her as she acted as a caretaker for three aging adults who placed significant demands on her time and capabilities. She reported difficulty establishing relationships with others, and some concerns with concentration or attention. Overall, the manifestations of her PTSD presented occupational and social impairment with reduced reliability and productivity. She continued to experience active symptoms related to her PTSD, but she remained capable of caring for her ailing parents and managing their affairs while also endorsing improvement following her inpatient treatment. However, in this time, the Veteran consistently denied suicidal and homicidal ideation, which contrasted with the initial period on appeal in which she reported passive suicidal ideation without intent or plan. There was no indication of violent impulses. Speech remained within normal limits, and there was no indication of obsessional rituals that interfered with routine activities. While she experienced panic attacks, such did not rise to the level of near continuous panic or depression that affected her ability to function independently or appropriately. Resolving reasonable doubt in favor of the Veteran, her PTSD is more adequately represented by a rating of 50 percent from March 2014 to September 2015. While the Veteran certainly continues to cope with serious manifestations of her PTSD, they do not rise to the level of occupational and social impairment in most areas of life as contemplated by the rating schedule for this initial period on appeal. As the preponderance of the evidence weighs against the claim for an evaluation in excess of 50 percent, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's PTSD is entitled to a rating of 50 percent, but no higher, from March 2014 to September 2015. 6. The claim of entitlement to a rating in excess of 50 percent for PTSD from September 9, 2015, to May 16, 2019 The Veteran underwent a VA examination in September 2015 to assess the severity of her PTSD. The examiner noted diagnoses of PTSD and unspecified depressive disorder that caused occupational and social impairment with reduced reliability and productivity. Symptoms included depressed mood; anxiety; chronic sleep impairment; mild memory loss; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and, difficulty in adapting to stressful circumstances, including work or a worklike setting. Her mood and affect were flat and moderately depressed on examination. She did not appear to pose any threat of danger or injury to self or others. Subsequent VA treatment records reflect relatively consistent symptomatology. By way of example, in September 2016, the Veteran reported that she was "stressed" due to boundaries with her parents, which increased her anxiety. She denied suicidal and homicidal ideation. She was alert and oriented on evaluation with a reasonable appearance and cooperative behavior. Speech was within normal limits. There was no perceptual disturbance noted. Thought processes and content were within normal limits. Insight and judgment were good. She also denied any aggressive thoughts. In January 2017, the Veteran's mood was noted to be mostly stable, but with some increase in headaches and panic attacks. She endorsed several panic attacks per day, but there was no indication that these interfered with her ability to conduct her daily business. She presented to treatment casually and neatly dressed. She was alert and oriented with good eye contact. Her mood was "better", and her affect was at baseline. Thoughts were mostly linear with appropriate content. She denied suicidal ideation, homicidal ideation, and hallucinations. Insight, judgment, and impulse control were fair. In July 2017, VA treatment records reflect that the Veteran was "ok" but "nervous" at her appointment. Her family had placed increased tasks on her, which increased her anxiety. The Veteran was organizing a family trip to another state at the time, and her parents continued to require a significant level of care. She denied suicidal and homicidal ideation. She presented alert and oriented on evaluation with reasonable appearance and cooperative behavior. Speech was within normal limits, as were her thought processes and content. Insight and judgment were good. In August 2017, the Veteran testified before the undersigned in a videoconference hearing. She endorsed symptoms of short-term memory loss, panic attacks several times per week, some difficulty understanding commands, sleep impairment, difficulty maintaining social relationships, and impaired thinking. She did not provide elaboration on her impaired thinking, but she reported sharing these details with her clinician. In April 2018, VA treatment records reflect some overall anxiety related to world events. She experienced a panic attack a couple of weeks before the appointment, but eventually calmed herself and went out on an errand. She also noted her remote history of a suicide attempt but reported that she would not attempt again because "it made things worse." She denied suicidal ideation, intent, and plan. She was alert and oriented on evaluation with reasonable appearance and cooperative behavior. Speech was within normal limits with normal thought processes and content. Insight and judgment remained good. In May 2018, records reflect that the Veteran was "still pretty stable" on her medications with no recent mood episodes. Anxiety also remained stable recently. In June 2018, she reported that she was "back on track", and "the anxiety has calmed down a lot. I'm not having nearly the panic attacks that I was having." In October 2018, the Veteran consumed alcohol for the first time in a year or more but noted that "it just did not do much for me" and she was attempting to control her blood sugar. In January 2019, the Veteran reported that she began a romantic relationship, though she felt obstacles to the closeness she desired caused by both her familial caregiving and history of trauma. She denied suicidal and homicidal ideation. She was alert and oriented with reasonable appearance and cooperative behavior. Speech was normal, thought processes and content were within normal limits, and both insight and judgment were good. In March 2019, the Veteran continued to discuss her ongoing caregiving responsibilities with her parents but noted that her romantic relationship was strong and mutually supportive. She again denied suicidal and homicidal ideation. After a thorough review of the medical and lay evidence of record, the Board finds that a 50 percent rating, as awarded by the Regional Office, is appropriate for this period. Through this period on appeal, the Veteran's symptoms have remained relatively consistent, with her treating clinician also remarking that she was largely stable without recent mood episodes. She continued to experience symptoms related to her PTSD, such as anxiety, nightmares, flashbacks, and panic attacks. She also continued to act as a caregiver for her parents, which was a significant source of stress and anxiety. In this period, the Veteran also reported beginning a romantic relationship, which she described as strong and mutually supportive. She consistently denied suicidal and homicidal ideation, intent, and plan. Her mental status evaluations were largely within normal limits, and she continued to carry out the responsibilities of her caregiver role without reporting significant incidents. When considering the overall frequency, severity, and duration of her symptoms, the Board finds that such are most adequately represented by a 50 percent rating. This period on appeal did not reflect more severe symptoms such as suicidal ideation, obsessional rituals, or intermittently illogical, obscure, or irrelevant speech. While she experienced frequent panic attacks, such did not rise to the level of near-continuous panic or depression that affected her ability to function independently. Instead, the Veteran continued to act as a caregiver for her parents in this time, managing their health-related tasks in addition to her own. She did not report periods of unprovoked irritability, spatial disorientation, neglect of her personal appearance or hygiene in this time, or symptoms of similar severity or frequency. As a result, a 50 percent rating from September 2015 to May 2019 most accurately represents the overall severity of her PTSD, and a rating in excess of 50 percent is not warranted. 7. The claim of entitlement to a rating in excess of 70 percent for PTSD as of May 16, 2019 The Veteran underwent another VA examination to assess the severity of her PTSD in May 2019. At this time, the examiner determined that her diagnosis caused occupational and social impairment with reduced reliability and productivity. Symptoms included depressed mood; anxiety; chronic sleep impairment; mild memory loss; memory loss for names of close relatives, own occupation, or own name; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and, difficulty in adapting to stressful circumstances, including work or a worklike setting. She presented with content mood and calm affect. She was alert and oriented on examination. Speech was logical and coherent. Judgment and insight were good. There were no unusual thought processes or content. She denied suicidal and homicidal ideation, and she did not present with an increased imminent risk of harm to herself or others. VA treatment records reflect a similar level of symptomatology throughout her routine care. By way of example, in January 2020, the Veteran reported that she was a "little nervous" but her panic attacks were decreasing. She expressed stress and anxiety related to caretaking of her parents and familial issues. She also reported flashbacks related to service. The Veteran expressed that, with her increased nerves, she did not want to "get to the point she is yelling at anyone." She denied suicidal ideation, homicidal ideation, and hallucinations. She was appropriately dressed and exhibited good hygiene and grooming. She was also alert and oriented with normal speech. She was nervous, described as "kind of on edge", with congruent affect. Thought processes and content were normal. She denied delusions, depersonalization, and obsessions. In March 2020, the Veteran endorsed increased anxiety and stress due to the COVID-19 pandemic, as well as caretaking her parents through the pandemic. In May 2020, she reported an anxiety attack three weeks prior to the appointment but without recurrence. Her mood was reportedly "more balanced ... a lot more stable." Sleep varied, but her appetite was fine. She continued to deny suicidal and homicidal ideation. In September 2020, the Veteran discussed losing a number of family and friends, and the grief associated with that loss. She denied suicidal and homicidal ideation. In October 2020, the Veteran underwent another VA examination to assess her PTSD. She described intrusive thoughts and nightmares approximately once per week. Veteran reported getting anxiety when out in public and having someone stand behind her. She felt sad with a loss of interest in activities, poor sleep, and problems with concentration. She also referenced passive suicidal ideation without immediate plans to harm herself or others. She continued to see her romantic partner, as well as care for her parents. The examiner concluded that her PTSD caused occupational and social impairment with deficiencies in most areas. Identified symptoms included depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss; disturbances of motivation and mood; and, difficulty in adapting to stressful circumstances, including work or a worklike setting. She was alert and oriented on examination with flat affect. Thoughts were clear and connected, but it took time for her to form her thoughts. She was casually dressed, made good eye contact, and used a soft tone. She denied hallucinations, delusions, or psychosis. After a thorough review of the medical and lay evidence of record, the Board finds that a 70 percent rating as awarded by the Regional Office is appropriate for this time period. In sum, since May 2019, the Veteran's symptoms appear to have remained largely consistent with the previous period discussed, but with the addition of passive suicidal ideation. She endorsed new passive suicidal ideation without intent or plan in the VA examination, but denied such to her treating clinicians. She continued to experience anxiety, panic attacks, nightmares, and flashbacks. The Veteran also still acted as primary caregiver for her elderly parents. Outside of the most recent VA examination, she reported feeling "more balanced" in her mood and exhibited varying levels of anxiety depending on external and internal stressors. Panic attacks, overall, were decreasing as well. While certainly severe, the manifestations of the Veteran's service-connected PTSD in this timeframe do not rise to the level of a total occupational and social impairment for the purposes of 38 C.F.R. § 4.130. Her impairments, while touching on many areas of his life, are not of such severity to interfere with routine functions necessary for daily life. The Veteran was consistently alert and oriented in all spheres and maintained her grooming and hygiene. She was not actively violent towards others, and her mental faculties remained intact throughout this period. In sum, the Veteran's symptoms do not mirror the severity, frequency and duration of ones such as persistent delusions or hallucinations, or inability to attend to basic hygiene. She continues to perform the activities of daily living, including maintaining her hygiene and grooming. As the preponderance of the evidence weighs against the claim for an evaluation in excess of 70 percent, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's PTSD is not entitled to a total disability rating since May 2019. REASONS FOR REMAND 1. The claim of entitlement to service connection for migraine headaches is remanded. The Board regrets the additional delay, but remand is necessary in order to obtain an adequate medical opinion with regard to the Veteran's migraine headaches. While the May 2019 VA examination report provided an opinion with respect to SWA exposures, the June 2011 medical opinion pertaining to direct service connection is insufficient for adjudication. The opinion provided a conclusory rationale that did not consider the Veteran's competent lay reports of headaches with an onset when she returned from deployment to the Gulf. As a result, remand is necessary in order to obtain a new medical opinion with respect to direct service connection. 2. The claim of entitlement to service connection for sleep apnea is remanded. Similarly, remand is also necessary in order to obtain and adequate opinion with respect to the etiology of the Veteran's sleep apnea. The Veteran's service treatment records document sleep complaints, and a diagnosis of a sleep disorder while on active duty service. The Veteran's roommate from her station in Germany provided a statement that she would snore loudly while asleep. The November 2020 medical opinion, however, does not address this lay report of symptoms. Accordingly, remand is necessary in order to obtain a more thorough medical opinion as to the etiology of the Veteran's sleep apnea. 3. The claim of entitlement to service connection for endometriosis is remanded. Remand is also necessary to obtain an adequate opinion with regard to the etiology of the Veteran's endometriosis. The Veteran's service treatment records reflect multiple complaints of severe menstrual cramps during active duty service for which she received Motrin. The Veteran has reported that her oral contraceptives were also prescribed to treat these severe menstrual symptoms. Unfortunately, the June 2019 medical opinion only cites to one instance of menstrual cramps in its rationale, and it does not address the Veteran's competent lay reports of regular pain around her menstrual cycle. Accordingly, remand is necessary in order to obtain a medical opinion based upon the complete record. 4. The claim of entitlement to service connection for a thyroid condition is remanded. Remand is also necessary to obtain an adequate opinion addressing the etiology of the Veteran's thyroid condition. In November 2010, a medical opinion was obtained with respect to direct service connection. A nexus was denied overall, but the examiner stated that it was "not possible" to state that the onset of her multinodular goiter (MNG) occurred during military service, and it was "unclear" if abnormal thyroid lab results during active duty were only transient in nature. This opinion is insufficient as it provides an incomplete rationale for its findings. Accordingly, a new medical opinion is necessary to address direct service connection on remand. 5. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities prior to August 18, 2010 is remanded. As the Veteran is asserting entitlement to TDIU, the Board finds that this issue is inextricably intertwined with the resolution of the remanded issues. The appropriate remedy where a pending claim is inextricably intertwined with a claim currently on appeal is to defer the claim on appeal pending the adjudication of the inextricably intertwined claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, this issue is remanded for readjudication following evidentiary development. The matters are REMANDED for the following action: 1. Obtain any relevant, outstanding VA treatment records that are not already associated with the claims file. If no records are available, the claims folder must indicate this fact and the Veteran should be notified in accordance with 38 C.F.R. § 3.159 (e). All attempts to contact the Veteran should be documented in the record. 2. Once the aforementioned development is complete, obtain a medical opinion addressing the etiology of the Veteran's claimed migraine headaches. An examination may be scheduled if deemed necessary and may be conducted via telehealth if pandemic restrictions remain in effect. A complete copy of the claims file must be provided to the examiner, including a copy of this remand. The examiner should consider lay reports of observable symptomatology. After a thorough review of the record, the examiner should opine as to the following: (a.) Is it at least as likely as not (i.e. a probability of 50 percent or more) that the Veteran's migraine headaches had an onset during active service or within one year of separation from service, or, otherwise resulted from active military service? Please specifically address the Veteran's report of onset after her deployment. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 3. Once the aforementioned development is complete, obtain a medical opinion addressing the etiology of the Veteran's sleep apnea. An examination may be scheduled if deemed necessary and may be conducted via telehealth if pandemic restrictions remain in effect. A complete copy of the claims file must be provided to the examiner, including a copy of this remand. The examiner should consider lay reports of observable symptomatology. After a thorough review of the record, the examiner should opine as to the following: (a.) Is it at least as likely as not (i.e. a probability of 50 percent or more) that the Veteran's sleep apnea had an onset during active service or within one year of separation from service, or, otherwise resulted from active military service? Please specifically address the Veteran's roommate's report of snoring during service. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 4. Once the aforementioned development is complete, obtain a medical opinion addressing the etiology of the Veteran's endometriosis. An examination may be scheduled if deemed necessary and may be conducted via telehealth if pandemic restrictions remain in effect. A complete copy of the claims file must be provided to the examiner, including a copy of this remand. The examiner should consider lay reports of observable symptomatology. After a thorough review of the record, the examiner should opine as to the following: (a.) Is it at least as likely as not (i.e. a probability of 50 percent or more) that the Veteran's endometriosis had an onset during active service or within one year of separation from service, or, otherwise resulted from active military service? Please specifically address the Veteran's report of lay symptoms during service. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 5. Once the aforementioned development is complete, obtain a medical opinion addressing the etiology of the Veteran's thyroid condition. An examination may be scheduled if deemed necessary and may be conducted via telehealth if pandemic restrictions remain in effect. A complete copy of the claims file must be provided to the examiner, including a copy of this remand. The examiner should consider lay reports of observable symptomatology. After a thorough review of the record, the examiner should opine as to the following: (a.) Is it at least as likely as not (i.e. a probability of 50 percent or more) that the Veteran's thyroid condition had an onset during active service or within one year of separation from service, or, otherwise resulted from active military service? Please specifically address the July 1992 medical records. (Continued on the next page) The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 6. Following completion of the foregoing, the AOJ should review the record and readjudicate the claims on appeal. If any remain denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and her representative an opportunity to respond, and return the case to the Board. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Fisher, 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.