Citation Nr: 21028316 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 14-35 619 DATE: May 11, 2021 ORDER Entitlement for service connection for a right hip disability is denied. Entitlement for service connection for a left hip disability is denied. Entitlement to service connection for right lower extremity sciatica is denied. Entitlement to service connection for left lower extremity sciatica is denied. Entitlement for service connection for a right ankle disability is denied. Entitlement for service connection for a left leg groin muscle disability is denied. Entitlement to service connection for an atrial septal defect/patent foramen ovale is denied. Entitlement to service connection for sinusitis is denied. Entitlement to service connection for cervical spine radiculopathy is denied. REMANDED Entitlement to service connection for generalized pain and multi-joint disability, including fibromyalgia and/or histamine intolerance, is remanded. Entitlement for service connection for a chronic larynx/pharynx disability is remanded. Entitlement to service connection for a cardiac disability other than an atrial septal defect/patent foramen ovale is remanded. Entitlement to service connection for a breast disorder to include bilateral fibrocystic breast disease, breast mass/lump, and hypertrophy of the breast is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had right hip disability at any time during or approximate to the pendency of the claim; her symptoms of right sided thigh numbness are instead symptoms and/or manifestations of her service-connected meralgia paresthetica disability. 2. The preponderance of the evidence of record is against finding that the Veteran has had a left hip disability at any time during or approximate to the pendency of the claim; her symptoms of left sided thigh numbness are instead symptoms and/or manifestations of her service- connected meralgia paresthetica disability. 3. The preponderance of the evidence of record is against finding that the Veteran has had right lower extremity sciatica disability at any time during or approximate to the pendency of the claim; her symptoms of right sided numbness are instead symptoms and/or manifestations of her service-connected meralgia paresthetica disability. 4. The preponderance of the evidence of record is against finding that the Veteran has had left lower extremity sciatica disability at any time during or approximate to the pendency of the claim; her symptoms of left sided numbness are instead symptoms and/or manifestations of her service- connected meralgia paresthetica disability. 5. The preponderance of the evidence of record is against finding that the Veteran has had a right ankle disability at any time during or approximate to the pendency of the claim; her symptoms are symptoms and/or manifestations of her service-connected right foot plantar fasciitis with calcaneal heel spur disability. 6. The preponderance of the evidence of record is against finding that the Veteran has had a left leg groin muscle disability at any time during or approximate to the pendency of the claim. 7. The Veteran's atrial septal defect, a patent foramen ovale (PFO), is a congenital defect that clearly and unmistakably existed prior to service and was not subject to a superimposed disease or injury during service that resulted in additional disability. 8. The preponderance of the evidence of record is against finding that the Veteran has had sinusitis at any time during or approximate to the pendency of the claim; her symptoms of crusty nose and sinus discharge are instead symptoms and/or manifestations of her service-connected chronic allergic rhinitis disability. 9. The preponderance of the evidence of record is against finding that the Veteran has had cervical spine radiculopathy at any time during or approximate to the pendency of the claim; her symptoms of hand and 4th and 5th finger numbness are instead symptoms and/or manifestations of her service-connected bilateral cubital tunnel syndrome. CONCLUSIONS OF LAW 1. The criteria for service connection for a right hip disability have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a left hip disability have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for right lower extremity sciatica have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for left lower extremity sciatica have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for service connection for a right ankle disability have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for service connection for a left leg groin muscle disability have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for service connection for an atrial septal defect/patent foramen ovale have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria for service connection for sinusitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for service connection for cervical spine radiculopathy have not been met. 38 U.S.C. §§ 1110, 1112, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1989 to March 2011. This matter is before the Board of Veterans' Appeals (Board) on appeal of an August 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In April 2020, the Board remanded the case to the RO for additional development. As the requested development has been completed for the issues adjudicated in this decision, no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board also remanded the issues of entitlement to service connection for anal disability, to include hemorrhoids, and to include as secondary to the service-connected gastroesophageal reflux disease and irritable bowel syndrome; costochondritis; and residuals of c-section, to include uterus prolapse, torn cervix, and pelvic floor weakness. However, service connection for these issues were granted in a May 2021 rating decision; representing a full grant of the benefits sought on appeal. Because the evidence indicates that the Veteran may have different conditions or diagnoses for ¬¬¬his claims, the Board is expanding the scope of the claim to encompass any diagnosis raised by the record. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). VA has established certain rules and presumptions for chronic diseases, such as arthritis, certain cardiac disorders, and organic diseases of the nervous system. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Service Connection 1. Entitlement for service connection for a right hip disability 2. Entitlement for service connection for a left hip disability 3. Entitlement to service connection for right lower extremity sciatica 4. Entitlement to service connection for left lower extremity sciatica The Board has grouped these issues together as the Board has determined that the claims have similar facts and analysis. The Board initially notes that the Veteran is service connected for neuralgia paresthetica, specifically, bilateral meralgia paresthetica (MP). A medical article in the file establishes MP is a peripheral nerve disorder involving lateral femoral cutaneous nerve impingement. Damage to the lateral femoral cutaneous nerve from any cause produces MP. Pregnancy often plays a role, but other causes include direct trauma to the nerve during surgery, and prolonged hip extension which produces compression or stretch of the nerve. Any lumbar spine etiology involves the L2 area. Symptoms include pain, numbness, and paresthesias. The crucial issue before the Board is whether the Veteran's symptoms are part of the MP disability or whether these symptoms represent separate, additional disabilities. The Veteran's service providers first diagnosed MP in April 2000. In September 2004, the Veteran complained of sciatic/pelvic pressure while pregnant. Thereafter, the Veteran received treatment for pain that radiated down the lateral thighs bilaterally. In November 2005 an MRI demonstrated a small disc bulge, diagnosed as lumbar spondyloarthropathy, at L5-S1. Follow- up MRIs in March 2007 and October 2008 established a stable L5-S1 condition. In January 2006, the Veteran's service medical providers diagnosed low back pain as well as bilateral lateral cutaneous nerve syndrome. In October 2006, the Veteran reported a history of bilateral lateral thigh numbness from two pregnancies. The numbness worsened after the second pregnancy. After delivery, the Veteran experienced constant pain and a burning sensation in the lateral area of each thigh. The Veteran had decreased sensation to light touch in the lateral thighs bilateral along the route of the lateral cutaneous nerve. The decreased sensation did not follow a dermatome pattern. In August 2008, although the Veteran complained of numbness and tingling in her toes, the neurological examination was normal. She also complained of pain radiating down the left thigh. A September 2008 physical therapy determined the Veteran's radicular pain resulted from a weak core musculature. In November 2009, while being treated for fibromyalgia, the Veteran reported transient numbness and tingling in both lateral lower thighs. In February 2011, just before separation, the Veteran had normal range of motion in her hips. In a January 2011 VA examination, the Veteran referenced hip pain only as it related to fibromyalgia describing pain radiating to the buttocks from the low back. On examination, she had lower back tenderness beginning at L4-L5 that radiated outward over the superior iliac crest bilaterally. The Veteran had normal range of motion in her hips and no joint laxity. The diagnosis was trochanter bursitis. The Veteran reported constant lateral thigh numbness bilaterally in the lateral femoral cutaneous nerve distribution. There was no motor loss. Examination demonstrated loss of sensation for both lateral femoral cutaneous nerves. The examiner diagnosed bilateral MP (lateral femoral cutaneous nerve injury) due to nerve compression. In a November 2020 VA examination, the VA examiner noted the Veteran had lumbar spine disc degeneration and MP or lateral femoral cutaneous nerve impingement. The Veteran reported aching and burning in the lateral areas of her thighs bilaterally since the 1990s. Currently, the Veteran experienced pins and needle sensation in a football shaped area on each thigh, left worse than the right. Examination revealed a patchy decreased sensation in the lateral area of both thighs. The VA examiner stated as likely as not this represented her MP. She did not have any other peripheral nerve diagnosis. As to sciatica, the Veteran did not have any associated objective abnormalities. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). The Veteran reported she had minimal pain in the back that did not radiate. Thus, the examiner concluded the Veteran did not have sciatica or any other lower extremity radiculopathy. Based upon the examination and history, there was no other bilateral lower extremity diagnosis. On examination, the hips had normal range of motion. The Veteran did not have a right or left hip disorder including bilateral trochanter bursitis. The Veteran also denied having trochanter bursitis. The VA examiner also determined the Veteran did not have a muscle injury to her pelvic girdle or thighs. Initially, as noted above, the Veteran claims service connection for a lumbar spine disability which is referred to the RO for a decision. Potentially, her sciatica claim is inexplicably intertwined with that claim. The Board, however, concludes the Veteran does not have sciatica. Therefore, the Board has determined her sciatica claim may be resolved now. While service and other medical records mention sciatica, a closer review of the records demonstrates the Veteran actual complained and sought treatment for her MP, i.e., numbness in the lateral area of her thighs. There is reference to sciatica in August 2008, but the following month, a physical therapist determined the problem had been caused by weak core musculature. It appears that after physical therapy, the problem resolved. Further, her lumbar spine disability involved the L5-S1 area without any symptoms in a dermatome pattern, not the L2 area that results in localized lateral thigh symptoms. A dermatome is an area of skin that's supplied by a single spinal nerve. https://www.healthline.com/health/dermatome/. (accessed April 23, 2021). Dermatomes have a segmented distribution throughout the body. Id. In a similar manner, the Board also finds the Veteran does not have a hip disability. The record does not contain any treatment or diagnosis of the hips. Based upon the record the Board finds it more probative that her medical providers have thoroughly explored the possibility that the Veteran's symptoms, pain, numbness, and tingling are the result of sciatica or a hip disability. However, the evidence establishes that the Veteran's symptoms are related only to her service- connected MP and not manifestations of sciatica or a hip problem. Further, notations of sciatica or hip symptoms appear to be the history as reported by the Veteran to the medical provider. A bare transcription of lay history, unenhanced by additional comment by the transcriber, does not become competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). In this case, to the extent the Veteran's history is commented on by her medical caregivers, they note the appearance of the neurological symptoms such as lateral thigh numbness was associated with MP. The Board therefore concludes that the Veteran did not have or currently has sciatica or a bilateral hip disability, or residuals of either disability. Instead, the symptoms of numbness, tingling, or pain are all part and parcel of her now service-connected MP disability and are compensated under that grant. To establish entitlement to VA disability compensation, there must be a current disability resulting from the injury. Chelte v. Brown, 10 Vet. App. 268, 271 (1997). As there is no competent evidence of a current hip or sciatica disability which is separate and distinct from MP, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The evidence is also against a finding of a hip disability or sciatica at any point during the claims period or shortly prior to the claim being filed. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Furthermore, granting service connection for the Veteran's symptoms as part of a hip disability or sciatica when they are already considered part of the MP disability results in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Board has considered the Veteran's statements that she has suffered from sciatica or a hip disorder. As the Veteran is not shown to have medical education or experience, she is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., bilateral thigh numbness; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or the specific etiology of a condition as these are medically complex issues. Thus, her lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. For the above reasons, the preponderance of the evidence is against the claims and service connection for a left hip disability, a right hip disability, right lower extremity sciatica, and left lower extremity sciatica is denied. 5. Entitlement for service connection for a right ankle disability The Veteran seeks service connection for a right ankle disability. The Board notes she is already service connected for right foot plantar fasciitis with a right calcaneal heel spur (right foot disability). In June 2009, the Veteran was treated for pain in both arches and heels. An X ray demonstrated moderately sized retrocalcaneal and plantar spur in the right foot. In her January 2011 separation examination, the Veteran reported arthritis in various joints and the plantar fasciitis and calcaneal spur in the right foot. She did not report any ankle symptoms. Examination revealed normal ankles. However, that same month, she also separately reported ankle pain which was worse after house cleaning. The following month. February 2011, the Veteran's right heel pain was diagnosed with right Achilles tendonitis. She reported the onset occurred two months earlier or December 2010. Thereafter, through February 2013, the Veteran received treatment for pain and symptoms associated with right Achilles tendonitis. Her medical providers further clarified the Veteran had insertional Achilles tendonitis (May 2012). A September 2012 ultrasound showed the Veteran had a large calcification over the posterior surface of the Achilles tendon at insertion. Starting in November 2012, the Veteran received injections to treat the right Achilles tendonitis. The right ankle was normal in a July 2017 physical examination In May 2018, the Veteran sought treatment for left Achilles tendonitis, but the history noted she had been treated for the right heel several years earlier. She achieved a full recovery after injections into the heel. Physical examination demonstrated a normal right ankle. In a January 2011 VA examination, the Veteran reported the onset of bilateral ankle pain since the early 1990s due to running. She had excruciating pain and stiffness in both ankles upon awaking in the morning. The symptoms improve after getting up and moving around after 1.5 hours. The examiner concluded the Veteran did not have a current right ankle disability or pathology based upon the examination and the X-ray. On the other hand, X-rays demonstrated the calcaneal spurs. The VA examiner also diagnosed bilateral plantar fasciitis, right worse than left, heel spur syndrome, and painful feet secondary to bilateral pes cavus construct. The Board therefore interprets the VA examiner's report that the right foot, but not the right ankle, had disabilities causing the Veteran's symptoms. Further there were no effects upon occupational function. In a November 2020 VA examination, the examiner noted the Veteran claimed right ankle joint stiffness and pain/functional impairment. Nevertheless, after review of the file and examination, the VA examiner concluded the Veteran did not have a current right ankle diagnosis. On examination, the Veteran had normal right ankle range of motion without objective evidence of pain even with weight bearing. There were no other right ankle findings such as weakness, fatigue, swelling, etc. and muscle strength was normal. The ankle was stable. Based upon the foregoing evidence, the Board finds the Veteran does not have a current chronic ankle disability. The record does not contain any treatment or diagnosis of the right ankle. The Board finds it probative that her medical providers have thoroughly explored whether the Veteran's symptoms are related to an ankle disability in addition to or instead of her service-connected right foot disabilities. However, the evidence establishes that the Veteran's symptoms are related only to her service- connected plantar fasciitis and calcaneal spur which are foot problems. Thus, the symptoms are not manifestations of a right ankle disability. The medical evidence in this case notes treatment for insertional Achilles tendonitis. Insertional Achilles tendinitis involves the lower portion of the heel, where the tendon attaches (inserts) to the heel bone. https://orthoinfo.aaos.org/en/diseases--conditions/achilles-tendinitis/. (accessed 21 April 2021). Damaged tendon fibers may also calcify (harden). Id. Bone spurs (extra bone growth) often form with insertional Achilles tendinitis. Id. Thus, the medical evidence establishing the Veteran's right foot calcaneal spur appears to be part of the Achilles tendonitis. Stated another way, all symptoms and diagnosis (right Achilles tendonitis, right heel calcaneal spur, and right foot plantar fasciitis) are related to the right foot as service- connected disabilities. The Board therefore concludes that the Veteran did not have or currently has a right ankle disability. Instead, the symptoms are all part and parcel of her now service-connected right foot disability and are compensated under that grant. To establish entitlement to VA disability compensation, there must be a current disability resulting from the injury. Chelte v. Brown, 10 Vet. App. 268, 271 (1997). As there is no competent evidence of a current right ankle disability which is separate and distinct from the plantar fasciitis and calcaneal spur disabilities, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The evidence is also against a finding of a right ankle disability at any point during the claims period or shortly prior to the claim being filed. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Furthermore, to grant service connection for the symptoms as part of a right ankle disability when they are already considered part of the right foot disability would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Board has considered the Veteran's statements that she has suffered from a right ankle disorder. As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., pain; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or the specific etiology of a condition as these are medically complex issues. Indeed, as discussed above, what the Veteran believes is a problem with her right ankle has been diagnosed and treated as a right foot condition. Thus, her lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. For the above reasons, the preponderance of the evidence is against the claim and service connection for a right ankle disability is denied. 6. Entitlement for service connection for a left leg groin muscle disability The Veteran filed a claim for service connection for "leg pain, left leg in groin area." The August 2011 rating decision noted one treatment for left leg groin muscle pain in March 2004. After thorough review, the Board could not find this treatment record. Nevertheless, for purposes of this analysis, the Board will assume that the Veteran sought treatment for left leg groin muscle pain in March 2004. Thereafter, in August 2011, the Veteran was treated for left groin (inguinal) pain. An MRI demonstrated mild osteoarthritis of the symphysis pubis. Although the interpreting physician could not be sure, additional abnormal findings could represent degenerative changes. The MRI did not demonstrate evidence of a detached labral tear. In a November 2020 VA examination, the VA examiner noted the Veteran claimed service connection for a muscle disability involving the left leg groin area. Nevertheless, the VA examiner determined the Veteran did not have or ever have an injury to the muscle group involving the pelvic girdle or thighs. The Veteran's claimed hip/groin symptoms are associated with MP. There is no separate hip/thigh condition, which the Board reads as including any left groin disability. Thus, the Veteran complained of left groin pain once in service (2004), and then again once after service in 2011. Since that time, she has not complained of any left groin symptoms and the records do not demonstrate any treatment or diagnosis for a left groin disability. The Board therefore finds the Veteran had two acute, transitory episodes of left groin pain, not a chronic left groin disability. Further, there is no evidence to suggest the Veteran has any functional impairment, including occupational functional impairment due to symptoms or problems with the left groin. The evidence is against a finding of a left leg groin disability at any point during the claims period or shortly prior to the claim being filed. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). As there is no competent evidence of a current disability causing left leg groin symptoms, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). After a review of the file, the Board finds that there is no diagnosed left leg groin disability and no functional impairment due to left leg groin symptoms. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018) (Federal Circuit holding that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity"). To the extent the Veteran is asserting she has a left leg groin disability that resulted from service, the Veteran is not shown to have medical education or experience. She is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., pain; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or the specific etiology of a condition as these are medically complex issues. Thus, her lay assertions do not constitute evidence upon which service connection can be granted. There is no competent evidence suggesting any chronic left leg groin disability began during service or would be in any way related to the Veteran's military service. Accordingly, the preponderance of the evidence is against the claim for service connection for a chronic left leg groin disability and that claim is denied. 7. Entitlement to service connection for an atrial septal defect/patent foramen ovale Generally, a veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service. 38 U.S.C. §§ 1111, 1137; 38 C.F.R. § 3.304(b). There are medical principles so universally recognized as to constitute fact (clear and unmistakable proof) of existence of a disability prior to service. 38 C.F.R. § 3.303 (c). This includes when congenital malformations are discovered during service "with no evidence of the pertinent antecedent active disease or injury during service." Id. Congenital or developmental "defects" automatically rebut the presumption of soundness and are therefore considered to have pre-existed service. 38 C.F.R. §§ 3.303 (c), 4.9. Defects are defined as "structural or inherent abnormalities or conditions which are more or less stationary in nature." VAOPGCPREC 82-90 (July 18, 1990). Service connection is generally precluded by regulation for such "defects," because they are not "diseases" or "injuries" within the meaning of applicable legislation. 38 C.F.R. §§ 3.303 (c), 4.9, 4.127; accord Terry v. Principi, 340 F.3d 1378, 1383-84 (Fed. Cir. 2003); Palczewski v. Nicholson, 21 Vet. App. 174, 179 (2007). However, VA's Office of General Counsel has distinguished between congenital or developmental defects from congenital or hereditary diseases. Service connection may be granted for a congenital or hereditary disease if the disease initially manifested in or was aggravated by service. See VAOPGCPREC 82-90, VAOPGCPREC 67-90. For purposes of determining whether a disorder is a congenital defect or a congenital or heredity disease, VA interprets the term "disease" in 38 U.S.C. §§ 310, 331, and the term "defects" in 38 C.F.R. § 3.303 (c), as being mutually exclusive. "Disease" is broadly defined as any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. See VAOPGCPREC 82-90 (citing Dorland's Illustrated Medical Dictionary 385 (26th ed. 1974)). A disease is a condition considered capable of improving or deteriorating. On the other hand, "defect," viewed in the context of 38 C.F.R. § 3.303 (c), is defined as a structural or inherent abnormality or conditions which are more or less stationary in nature and not considered capable of improving or deteriorating. See VAOPGCPREC 82-90 at para. 2. Thus, the litmus test for distinguishing a congenital defect from a congenital disease is whether the disorder in question is capable of changing. If the disorder may improve or deteriorate, then it is not a congenital defect, and consequently is eligible for service connection notwithstanding its congenital or hereditary nature. As noted, the presumption of soundness does not apply to congenital defects because such defects "are not diseases or injuries" within the meaning of 38 U.S.C. §§ 1110 and 1111. However, a congenital defect can still be subject to superimposed or overlying disease or injury. VAOPGCPREC 82-90. If such superimposed disease or injury does occur, service connection may be warranted for the resulting disability. Id. Superimpose is defined as to place or lay over or above something. https://www.merriam-webster.com/dictionary/superimpose (accessed April 19, 2021). Thus, if the Veteran develops a disease or injury to the same anatomical body part as the congenital defect, and that additional disease or injury resulted from service, the additional disease or injury may be service connected. In cases where the veteran seeks service connection for a congenital condition, the Board must indicate whether the condition is a disease or defect and discuss the presumption of soundness. Quirin v. Shinseki, 22 Vet. App. 390, 394-97 (2009). It follows that in such cases where a congenital condition is at issue, a VA medical opinion may be needed to determine whether the condition is a disease or defect, whether the presumption of soundness has been rebutted, and, if so, whether there was aggravation during service. Quirin, 22 Vet. App. at 395. Based upon the Board's review of the evidence, the first indication the Veteran had any heart or cardiac problem occurred in February 2000 when an EKG showed a prolonged wave. A March 2000 echocardiogram was normal. In October 2003, the Veteran reported problems with heart palpitations for a number of years but a Holter monitor failed to show any problem. A nuclear stress test showed a mild defect along the anterior heart wall to the apex. A myocardial profusion study demonstrated findings small areas anteriorly and inferiorly consistent with mild ischemia. A larger segment of septal ischemia could not be excluded. In July 2008, an echocardiogram showed a heart murmur and a left to right shunt across the interatrial septum consistent with a patent foramen ovale (PFO) which is also referred to as an atrial septal defect. The final diagnosis was a PFO. In October 2008, a medical history noted the Veteran had a possible small atrial defect or PFO. She also had a history of a heart murmur and recurrent bouts of palpitations. A June 2010 echocardiogram demonstrated very mild right atrial enlargement but considered basically normal. The medical records also indicate the PFO remained asymptomatic without evidence of volume overload. In a January 2011 VA examination, the VA examiner diagnosed an atrial septal defect which would have been present since birth but not diagnosed until active duty. The examiner also diagnosed mitral valve regurgitation and benign palpitations. It had no effect on occupational or daily functioning. In a second VA examination in November 2020, the examiner stated the Veteran had a PFO that first manifested in July 2008. The Veteran reported they just watched it and the condition has stayed the same. The VA examiner stated the PFO is a hole in the heart that did not close the way it should at both. Furthermore, evidence showed it remained in the same condition since birth and it is asymptomatic. There is no evidence it has been aggravated. Based these facts, the medical questions at issue in this case are whether her PFO is a congenital defect or disease, and if a disease, whether it was clearly and unmistakably not aggravated by service. Turning to the first question, the Board interprets the VA examiners' opinions as concluding that, by definition, a PFO is a congenital defect and not a disease. As the November 2020 VA examiner explained, it is a hole in the heart that did not close properly and remained unchanged since discovered in 2008. Stated another way, the November 2020 VA examiner concluded that PFO is a congenital defect, because the heart is structurally abnormal. Congenital and developmental defects are not "diseases or injuries" in the meaning of applicable legislation for disability compensation purposes. 38 C.F.R. §§ 3.303 (c), 4.9; VAOPGCPREC 82-90. Thus, the Board finds PFO is a condition not considered capable of improving or deteriorating and therefore a defect. If it was a disease, there would have been evidence of change, i.e., improving or deteriorating, even if the deterioration represented the natural progression of the congenital condition. Because, as established by the VA opinions opinion, the PFO is a congenital defect, service connection cannot be granted for this condition. See 38 C.F.R. § 3.303 (c). Further, there is no evidence of a superimposed disease or injury that occurred during service. Again, the VA examiner found that this defect was unchanged. Accordingly, after a review of all the evidence of record, the Board finds the Veteran's November 2020 VA examiner opinion along with various other opinions most probative. This medical evidence establishes that the Veteran has a congenital defect that has remained stable, unchanged, and asymptomatic since diagnosed. Thus, the Board finds that the weight of the evidence demonstrates that the PFO is a congenital defect, which is not a disability for VA compensation purposes. 38 C.F.R. § 3.303 (c), 4.9; see also VAOPGCPREC 82-90. The claim for service connection for a PFO must be denied. 8. Entitlement to service connection for sinusitis The Veteran seeks service connection for sinusitis. The Board notes that she is already service connected for chronic allergic rhinitis (rhinitis). The questions before the Board is whether the Veteran has an additional sinusitis disability and, if so, whether the sinusitis is related to service. Service treatment records demonstrate symptoms that could be related to the sinus. For example, in January 2006, she complained of a constant cough and sinus drip down her throat. The records also demonstrate numerous occasions where she was treated for allergic rhinitis, rhinitis, or oral allergy syndrome. In February 2008, the Veteran was treated for recent bouts of coughing and nasal discharge which her medical provider stated was suggestive of sinusitis. The Board notes that in April 2010, the Veteran reported a history of both sinusitis and hay fever. The service treatment records show that as of August 2010, the active problem list includes both rhinitis and acute sinusitis. At her January 2011separation examination, the Veteran again reported sinusitis, hay fever, frequent colds, and frequent coughs. The sinuses were normal upon examination. After separation, medical records establish treatment for rhinitis (May 2012, and June 2012) and she tested positive for allergens in May 2015. The Veteran also has been treated throat problems, which is discussed in the REMAND section below for her larynx/pharynx disability claim. She was treated once for a sinus infection in February 2014. In a January 2011 VA examination, the Veteran reported problems with crusting accumulating in her nasal passage starting between 1992 and 1995. The problem of recurring intranasal crusting has continued since that time. Upon examination, the Veteran's sinuses were normal, but the Veteran had thin yellow crust throughout both nasal passages. A CT scan indicated there was no evidence of sinusitis. the VA examiner diagnosed chronic rhinitis. The Veteran also received a second VA examination in January 2011 that covered sinusitis and rhinitis. The Veteran reported treatment in 1998 for a crusty nose and problems with chronic dried mucus. She also reported she had sinus infections once a year with the last infection occurring in June 2010. The Veteran denied that she had rhinitis. In the second January 2011 VA examination, the sinuses were normal. Based upon the Veteran's denial of rhinitis history, the examiner also diagnosed perennial allergies. In a November 2020 VA examination, the Veteran reported the onset of symptoms started in the 1990s when her nose looked "angry." Since 2002, she has experienced chronic post- nasal drainage with crusting in her nose. She irrigates her nose daily. She also reported sometimes experiencing sinus headaches. The examiner diagnosed rhinitis and also determined she did not have sinusitis without any of the symptoms, signs, or findings for sinusitis. All observed symptoms, signs, or findings related to rhinitis. After a thorough review of the evidence, the Board finds that the competent and probative evidence on the question of whether the Veteran has sinusitis consists of the medical records and the reports by VA examiners, who are qualified by specialized education, training, or experience to diagnosis a medical condition and to offer an opinion on causation. The VA examiners tasked to determine the nature of the Veteran's disability have diagnosed the Veteran with rhinitis, not sinusitis. Service connection for seasonal rhinitis has already been granted. The Board finds these opinions highly probative as they were made by medical professionals with consideration of the specific facts in this case and after examination of the Veteran. The Board acknowledges one VA examiner in 2011 stated the Veteran had sinusitis. That examiner, however, appeared to be relying entirely upon the history as reported by the Veteran, namely, she denied having rhinitis. A medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). That examiner thus based the diagnosis upon the Veteran's lay opinion by the Veteran, which as noted below, does not establish a diagnosis of sinusitis. The clinical medical evidence establishes treatment for rhinitis, not sinusitis. The Board's review does not establish the Veteran's history of yearly treatment for sinusitis by 2011. The other VA examiners have determined her symptoms such as chronic post- nasal drainage with crusting in her nose relate to rhinitis, not sinusitis. The Veteran presents only subjective evidence of chronic sinusitis; there is no objective evidence establishing sinusitis. A CT scan specifically determined the Veteran did not have sinusitis and there are no other imaging studies such as X-rays that establish the Veteran has chronic sinusitis. Post- service treatment has been mostly for chronic rhinitis, or at best acute sinusitis, e.g., a sinus infection, not chronic sinusitis. Accordingly, the Board assigns less probative weight to the opinion of the one January 2011 VA examiner who diagnosed sinusitis and more probative weight to the other January 2011 VA examiner and the November 2020 VA examiner. There is no other medical opinion or competent and credible evidence in significant conflict with these two VA medical opinions. Although symptoms such as sinus drainage are documented, in the absence of a current disability or diagnosis of a chronic sinus disorder such as chronic sinusitis, there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There is no medical evidence in the file, either service or civilian, that the Veteran has a diagnosed chronic sinusitis disability, including competent and credible evidence of any such disability at any point during the claims period or shortly before the claim was filed. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). Furthermore, to grant the Veteran service connection for the symptoms as part of a sinusitis disability when they are already considered part of the service- connected rhinitis disability would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Board has considered the Veteran's statements, to include her assertions that symptoms beginning in service constitute sinusitis. As the Veteran is not shown to have medical education or experience, she is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., nasal congestion; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or the specific etiology of a condition as these are medically complex issues. Thus, her lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. For the above reasons, the preponderance of the evidence is against the claim and service connection for sinusitis is denied. 9. Entitlement to service connection for cervical spine radiculopathy The Veteran is service connected for degenerative disc disease of the cervical spine. Specifically, an X-ray and MRI at her January 2011 separation examination demonstrated degenerative changes most prominent at C5-C6. She is now service connected for cervical spine degenerative disc disease. Any associated objective neurological abnormalities resulting from the cervical spine may also be service connected. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). She asserts she now has cervical spine radiculopathy resulting from service- connected cervical spine degenerative disc disease. The Veteran is also service connected for a separate neurological abnormality of her upper extremities, bilateral cubital tunnel syndrome. In September 2008, the Veteran complained of numbness which she apparently attributed to cervical radiculopathy. At that time, the Veteran performed her assignment duties at home and flexed her left elbow more than she did when at her service duty station. This irritated the ulnar nerve. The medical providers diagnosed left cubital tunnel syndrome. In March 2009, the Veteran complained of cervical radiculopathy and upper extremity numbness which she noted while typing. Again, her medical providers determined the hand numbness to be very likely the result of the Veteran flexing her elbow greater than normal which irritated the ulnar nerve. On examination she had both a positive Tinel's sign in the left elbow and a positive elbow flexion test. The diagnosis was left cubital tunnel syndrome. In January 2011, the Veteran reported stiff hands and finger pain. The separation examination that same month and the Veteran reported numbness and tingling as well as impaired use of her arms and hands. She reported arthritis in her shoulders and wrists. She also reported cervical radiculopathy/disc degeneration with tingling in the hands. The diagnosis of cubital tunnel syndrome was also noted. In examination, she had a positive Tinel's sign in the right wrist and left elbow. In a January 2011 VA examination, the VA examiner diagnosed bilateral shoulder osteoarthritis, bilateral wrist osteoarthritis, fibromyalgia, bilateral cubital tunnel syndrome, and cervical spondylosis without radiculopathy. The Veteran reported cervical pain since 1996 which now occurred daily. The pain was non-radiating. She also reported numbness in her hands that began with a gradual onset in 2004. The numbness occurred off and on in her 4th and 5th digits and the medial aspect of her hands. Upon examination, the Veteran did not have any motor or sensory loss. She had bilateral ulnar nerve paresthesias which resulted in positive neurological findings in the ulnar nerve distribution. This came from compression of the ulnar nerve at the elbow leading to the cubital tunnel syndrome. In March 2011, the Veteran reported cracking in her neck while lying supine but there was no pain or numbness and tingling. The neurological examination demonstrated normal sensation in the upper extremities bilaterally. A May 2013 MRI revealed stable degenerative changes at C5-C6. In a November 2020 VA examination, the Veteran reported that, while on active duty, she experienced numbness and tingling in the 4th and 5th fingers. She has not experienced numbness, however, for a long time (greater than 5 years). Bilaterally, she did not experience pain, paresthesias and/or dysesthesias, or numbness in her upper extremities. The Veteran denied any current symptoms of upper extremity radiculopathy or a nerve condition. Upon examination, motor function, reflexes, and sensation were normal. The examiner concluded the Veteran did not have any upper extremity nerve problem. The examiner specifically found the Veteran did not have cervical radiculopathy. The Board finds the Veteran does not have cervical spine radiculopathy. The record does not contain any cervical spine radiculopathy treatment or diagnosis. Based upon the record the Board finds her medical providers have thoroughly explored the possibility that the Veteran's symptoms, pain, numbness, and tingling are the result of cervical spine radiculopathy. However, the evidence establishes that the Veteran's symptoms are, at best, related only to her service- connected bilateral cubital tunnel syndrome and not manifestations of cervical spine radiculopathy. She has not experienced any symptoms of cervical spine radiculopathy. Examinations have not demonstrated any signs, findings, or tests demonstrating cervical spine radiculopathy. Finally, the VA examiners have concluded the Veteran does not have cervical spine radiculopathy. Instead, the symptoms of numbness, tingling, or pain are related to the 4th and firth fingers and the medial aspect of her hands. This is all part and parcel of her now service-connected bilateral cubital tunnel syndrome and are compensated under that grant. To establish entitlement to VA disability compensation, there must be a current disability resulting from the injury. Chelte v. Brown, 10 Vet. App. 268, 271 (1997). As there is no competent evidence of a current cervical spine radiculopathy disability which is separate and distinct from cubital tunnel syndrome, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The evidence is also against a finding of cervical spine radiculopathy at any point during the claims period or shortly prior to the claim being filed. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Furthermore, to grant the Veteran service connection for the symptoms as part of cervical spine radiculopathy when they are already considered part of the cubital tunnel syndrome disability would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Board has considered the Veteran's statements that she has suffered from cervical spine radiculopathy. As the Veteran is not shown to have medical education or experience, she is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., bilateral thigh numbness; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis. See Davidson v. Shinseki, 581 F.3d 1313 (2009). The Veteran is not competent to independently render a medical diagnosis or the specific etiology of a condition as these are medically complex issues. Thus, her lay assertions do not constitute evidence upon which service connection can be granted. In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. For the above reasons, the preponderance of the evidence is against the claim and service connection for cervical spine radiculopathy is denied. REASONS FOR REMAND 10. Entitlement to service connection for generalized pain and multi-joint disability, including fibromyalgia and/or histamine intolerance, is remanded. Service treatment records established that the Veteran treated though service for swollen or painful joints such as the shoulders and wrists. In November 2009, a service rheumatologist diagnosed the Veteran with fibromyalgia, a chronic pain disorder that results from impaired pain regulation from the central nervous system. The Veteran suffered from generalized pain in her hands, feet, back, hips, knees, shoulders, and neck. She has also suffered from additional associated symptoms. The Veteran continued to be followed for fibromyalgia while she remained on active duty and post-service care including an August 2013 note that included a diagnosis of fibromyalgia. In a January 2011 VA examination, the examiner stated the Veteran did not meet the criteria for fibromyalgia but did not discuss the diagnosis reached by the service rheumatologist. In that examination, the VA examiner elicited trigger or tender points but not sufficient to establish the fibromyalgia diagnosis. Further some symptoms appeared related to other diagnoses such as wrist symptoms related to carpal tunnel syndrome. In another January 2011 VA examination specifically for neurological disorders, however, the examiner noted the Veteran has had migrating muscle pain in all extremities and the thorax for decades. At the time of this examination, her pain was in her chest and legs. Further, she had trigger points on both the right and left side with some of the trigger points located in her trochanter, i.e., lower extremities. This examiner diagnosed fibromyalgia. In a May 2020 letter, a private allergy and immunology physician, Dr. K. K., advised that after reviewing medical records and several examinations of the Veteran, she has concluded the fibromyalgia diagnosis was incorrect. Instead, the Veteran has histamine intolerance along with many features of non-clonal mast cell activation syndrome (histamine intolerance). In a November 2020 VA examination, the Veteran reported to the VA examiner she had been misdiagnosed with fibromyalgia. Instead, she had histamine intolerance. The examiner concluded she did not have fibromyalgia but rather histamine intolerance. The VA examiner did not offer any opinion as to whether the histamine intolerance is the result of service because it is outside the scope of the requested examination. The Board has determined the Veteran should receive a new VA examination to determine if she has fibromyalgia, histamine intolerance, or both and the relationship of any diagnosis to service. The 2011 VA examinations are conflicting as to whether she had findings consistent with fibromyalgia especially since the findings of trigger points present appear consistent with the rating criteria for fibromyalgia. See 38 C.F.R. § 4.71a, Diagnostic Code 5025. Furthermore, there is no discussion of the detailed analysis by the service rheumatologist as to why the Veteran had fibromyalgia as opposed to something else. As just noted, the 2020 VA examiner did not discuss whether the Veteran had fibromyalgia or histamine intolerance and the relationship of either to service. As to the report by Dr. K. K., while she explained that HI is a relatively new diagnosis and that unfamiliarity lead to the wrong diagnosis, she did not explain how the fibromyalgia is the wrong diagnosis for this Veteran given the medical evidence of symptoms supporting this diagnosis such as the evidence of wide spread pain and trigger points and the analysis by the rheumatologist in 2009. Furthermore, as the letter indicates she has seen and treated the Veteran on multiple occasions, her medical records should be obtained for the Veteran's file. The Board has determined that the records are relevant and there is a reasonable possibility that the records could help substantiate the claim. See Golz v. Shinseki, 590 F.3d 1317, 1322 (Fed. Cir. 2010) (discussing records from the Social Security Administration). Ongoing medical records should also be obtained. 11. Entitlement for service connection for a chronic larynx/pharynx disability is remanded. The Veteran has filed service connection for a chronic larynx/pharynx disability. Treatment records demonstrate she has been diagnosed with laryngopharyngeal reflux. She has also been diagnosed for tongue disabilities such as glossitis, globus hystericus, and geographic tongue. In addition, she has complained of and been treated for throat thickness or fullness symptoms that apparently do not cause swallowing symptoms. Finally, the Veteran has been treated for eustachian tube block and/or dysfunction. The VA examinations of record do not discuss whether the laryngopharyngeal reflux, eustachian tube disorders, or the tongue disorders are related to service. The chronic complaints of the throat thickness or fullness are also not discussed; there has not been a determination whether these complaints are related to the laryngopharyngeal reflux, the tongue disorders, or another disability that may be service connected. Therefore, the Board has determined that the Veteran should receive another VA examination to assist the Board in answering these questions. 12. Entitlement to service connection for a cardiac disability other than an atrial septal defect/patent foramen ovale is remanded. As noted above, the Board denied service connection for the Veteran's PFO because it is a congenital defect. The Board notes that there are other heart conditions of record, such as a heart murmur, arrhythmia, palpitations, PVCs, PACs, supraventricular tachycardia, regurgitation of the tricuspid and mitral valves, imaging studies and tests indicating cardiac ischemia. The question as to whether there is a current separate heart disability related to service was not addressed by the VA examiner in the 2020 VA examination. Accordingly, the Veteran should receive a new VA examination to determine if the Veteran has another heart disorder that resulted from service. 13. Entitlement to service connection for a breast disorder to include bilateral fibrocystic breast disease, breast mass/lump, and hypertrophy of the breast is remanded. The Veteran has filed a claim for fibrocystic breast disease, a breast mass or lump diagnosed as a fibroadenoma in October 2006, and hypertrophy of the breast. As early as October 2007, the Veteran requested breast reduction surgery because of complaints that her breast size caused upper back, shoulder, and neck pain. After service, she received the breast reduction surgery in September 2013. A VA examiner in November 2020 (with an addendum in February 2021) diagnosed breast reduction surgery that treated the fibrocystic breast disease/hypertrophy of the breasts. He also concluded the surgery occurred for cosmetic reasons. He did not discuss whether the surgery occurred to alleviate pain in her back and neck. Breast surgeries that are not medically necessitated, such as reduction mammoplasty for cosmetic purposes and any expected residual effects thereof, are not subject to service connection. If reduction mammoplasty is recommended to alleviate physical discomfort, such as neck pain, then service connection may be considered based upon aggravation. See M21-1 Adjudication Procedures Manual, M21. III.iv.4.j.3. c and d. As noted above, the Veteran is service connected for degenerative disc disease of the cervical spine (including neck pain) and degenerative disk disease of the lumbar spine (including back pain). Breast reduction (reduction mammoplasty) surgery may have been performed to help alleviate symptoms of neck and back pain. A new VA examination should be performed to determine if the 2013 breast reduction surgery occurred only for cosmetic reasons or to help alleviate symptoms, i.e. is secondary to a service-connected disability. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to her claims, including records from Dr. K. K. who prepared the May 2020 letter report. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current generalized pain and multi-joint disability had its onset during service or is otherwise related to an in-service injury, event, or disease, to include fibromyalgia, histamine intolerance, and non-clonal mast cell syndrome. In offering the opinion, the examiner is asked to consider and explain how the Veteran's symptoms, signs, and clinical findings are related to each diagnosis The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 3. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current larynx/pharynx disability had its onset during service or is otherwise related to an in-service injury, event, or disease, to include the Veteran's complaints of fullness or thickness of the throat, and eustachian tube disorder. The VA examiner is asked to provide separate opinions on the relationship of service and the laryngopharyngeal reflux, the throat thickness or fullness, eustachian tube dysfunction/blockage, and tongue disabilities of glossitis, globus hystericus, and geographic tongue. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 4. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current heart disability, other than a atrial septal defect/patent foramen ovale, onset during service or is otherwise related to an in-service injury, event, or disease, to include a heart murmur, arrhythmia, palpitations, PVCs, PACs, supraventricular tachycardia, regurgitation of the tricuspid and mitral valves, and cardiac ischemia. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 5. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current disability of the breast onset during service or is otherwise related to an in-service injury, event, or disease, to include hypertrophy of the breast and October 2013 breast reduction surgery. The examiner should also opine whether any breast disability, to include the need for breast reduction surgery, is proximately due to or aggravated by her service-connected cervical spine disability and/or lumbar spine disability. In offering the opinion, the examiner is asked to consider and discuss whether the breast reduction surgery occurred for cosmetic reasons or to alleviate pain in her cervical spine. The examiner is specifically asked to discuss the October 2007 medical treatment note and any other treatment notes of record indicating that the surgery occurred to help alleviate pain in other areas. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. J.N. MOATS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Russell P. Veldenz, 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.