Citation Nr: 18160618
Decision Date: 12/27/18	Archive Date: 12/27/18

DOCKET NO. 08-13 976
DATE:	December 27, 2018
ORDER
Entitlement to service connection for chronic fatigue is granted.
Entitlement to service connection for short term memory loss is denied.
Entitlement to an initial rating in excess of 30 percent prior to October 24, 2009 for service-connected bronchial asthma is denied.
Entitlement to a 100 percent disability rating from October 24, 2009 to for service-connected bronchial asthma is granted.
REMANDED
Entitlement to service connection for allergic rhinitis is remanded.
Entitlement to service connection for ulcers secondary to service-connected disabilities is remanded.
Entitlement to an initial rating in excess of 20 percent prior to March 31, 2009 and in excess of 40 percent as of March 31, 2009 for service-connected degenerative disc disease of the lumbar spine is remanded.
Entitlement to a disability rating in excess of 30 percent for service-connected sinusitis and deviated septum is remanded.

FINDINGS OF FACT
1. The evidence is at least evenly balanced as to whether the Veteran’s current diagnosis of chronic fatigue is caused by his service-connected disabilities.
2.  The Veteran’s short-term memory loss is a symptom of his service-connected PTSD and not a separate and distinct symptom due to an undiagnosed illness or a symptom associated with a separate and distinct disability not already service-connected.
3.  The preponderance of the evidence shows that prior to October 24, 2009, the Veteran’s forced expiratory volume (FEV-1)/forced vital capacity (FVC) measurement was not 55 percent or less of predicted value and the Veteran’s asthma was not treated with three or more intermittent courses of systemic corticosteroids or immunosuppressive medications in a twelve month period, did not result in at least monthly visits to a physician for required care of exacerbations, or more than one asthma attack with respiratory failure.
4.  The evidence shows that as of October 24, 2009, the Veteran’s forced expiratory volume (FEV-1)/forced vital capacity (FVC) measurement was 12 percent of predicted value.
CONCLUSIONS OF LAW
1.  The criteria for secondary service connection for chronic fatigue are met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310(a).
2.  The criteria for service connection for short term memory loss are not met.  38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310(a), 3.317.
3.  The criteria for an initial disability rating in excess of 30 percent prior to October 24, 2009 for service-connected bronchial asthma are not met.  38 U.S.C. § 1155; 38 C.F.R. § 4.97, Diagnostic Code 6602.
4. The criteria for a 100 percent disability rating as of October 24, 2009 for service-connected bronchial asthma are met.  38 U.S.C. § 1155; 38 C.F.R. § 4.97, Diagnostic Code 6602.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty in the United States Air Force from July 1974 to April 1980 and in the United States Army from May 1982 to February 1997. 
This case is before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated in December 2006, March 2007, April 2008, and August 2009.  
In April 2010, Veteran testified during a Board hearing, and a transcript of the hearing is of record. 
In September 2011, the Board remanded the case to the RO for further development and adjudicative action.
The law requires that the Veterans Law Judge who conducts a hearing on an appeal must participate in any decision made on that appeal. 38 U.S.C. § 7107(c); 38 C.F.R. § 20.707.  In May 2016, the Board sent a letter to the Veteran, which explained that the Veterans Law Judge who presided over his hearing was unavailable to participate in the decision and offered the Veteran a hearing before a different Veterans Law Judge; otherwise, the case would be reassigned.  In June 2016, the Veteran responded that he did not wish to appear at another hearing. Thus, the Board will proceed with adjudicating the issues on appeal.
Service Connection
Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability.  38 C.F.R. § 3.303.  Pursuant to 38 C.F.R. § 3.303(b), a claimant may establish the second and third elements by demonstrating continuity of symptomatology for specific chronic disabilities listed in 38 C.F.R. § 3.309(a).  See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).
Service connection for a claimed disability may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310(a).  Establishing service-connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability.  38 C.F.R. § 3.310(a).
Under 38 U.S.C. § 1117 (a)(1), compensation is warranted for a Persian Gulf Veteran who exhibits objective indications of a ‘qualifying chronic disability’ that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary.  38 U.S.C. § 1117(a)(1)(B); (b)(2); 38 C.F.R. § 3.317 (a)(1)(i).  By history, physical examination and laboratory tests, the disability cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (a)(1)(ii).  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).  Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. 38 C.F.R. § 3.317 (a)(4).  The signs and symptoms which may be manifestations of undiagnosed illness or a chronic Multi-Symptom illness include, but are not limited to, fatigue, headache and muscle and joint pain.  38 U.S.C. §§ 1117(g)(1),(4),(5); 38 C.F.R. § 3.317 (b)(1),(4),(5). 
1. Entitlement to service connection for chronic fatigue
The Veteran contends that his chronic fatigue is an undiagnosed illness related to his service in Southwest Asia theater of operations during the Persian Gulf War.   
The Board concludes that the Veteran has a current diagnosis of chronic fatigue that is caused by his service-connected disabilities.  38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.303(a), 3.310.
A July 2013 VA examiner determined that the Veteran did not meet the criteria for chronic fatigue syndrome.  However, the examiner provided a diagnosis of chronic fatigue.  
Regarding the issue of whether the Veteran’s chronic fatigue is secondary to his service-connected disabilities, the record contains a positive medical opinion.  In this regard, the July 2013 VA examiner provided the opinion that the Veteran’s chronic fatigue is caused by his service-connected degenerative disc disease of the lumbar spine, fibromyalgia, peripheral atherosclerotic disease of the bilateral lower extremities, obstructive sleep apnea, and posttraumatic stress disorder, as well as, nonservice-connected type II diabetes mellitus.  The examiner explained that the Veteran has multiple musculoskeletal, medical, and psychiatric conditions that may cause chronic fatigue.  The examiner noted that the Veteran reported on and off feelings of tiredness and fatigue associated shoulder pains since 1991 and chronic back pains since 1996 and that he wakes up at night due to aches and pain all over his body.  This medical opinion is probative with respect to the issue of whether the Veteran’s chronic fatigue is at least in part caused by his service-connected disabilities, as the physician provided clear explanation for the opinion based on an examination of the Veteran and review of the claims file.  The Board also finds it persuasive that there is no competent medical evidence of record that contradicts this medical opinion.
In light of the foregoing, the evidence is at least evenly balanced with respect to whether chronic fatigue is caused by his service-connected disabilities and the Board resolves any reasonable doubt in favor of the Veteran.  The Board notes that nothing in VA law or regulation requires that the service-connected disability is the sole cause of the current disability in order for the disability to be service-connected.  Accordingly, the Board finds that entitlement to service connection for chronic fatigue is warranted.
2. Entitlement to service connection for short term memory loss, to include as due to an undiagnosed illness.
The Veteran asserts that his short term memory loss is related to active military service, specifically, an undiagnosed illness associated with his service in Southwest Asia during theater of operations during the Persian Gulf War.
The question for the Board is whether the Veteran has a current disability manifested by memory loss that began during service or is at least as likely as not related to an in-service injury, event, or disease or his symptom of memory loss is an undiagnosed illness pursuant to 38 C.F.R. § 3.317.
The Board concludes that the Veteran’s short-term memory loss is a symptom of the Veteran’s service-connected PTSD and such symptom is considered in the rating criteria for mental disorders.
A March 2011 private psychological evaluation documents that the Veteran’s general overall memory was average, verbal memory was average, nonverbal memory was low, recent memory was average, and remote memory was average.  The psychologist noted that the Veteran’s emotional concerns were likely to distract his concentration especially on tasks that emphasize attention to the here and now.  
An August 2013 VA examiner determined that mild memory loss, such as forgetting names, directions, or recent events is a symptom of his PTSD and depression.  The examiner provided the opinion that the Veteran’s claimed short term memory loss is less likely than not caused by condition that is of unexplained etiology (ie., an undiagnosed illness).  The examiner explained that the short-term memory loss as describe by the Veteran is partly as symptom attributable to his diagnosed PTSD and depression secondary to chronic pain syndrome.  The examiner noted that it is also partly due to an organic cause due to his service-connected bronchial asthma and nonservice-connected diabetes mellitus, since hypoxemia and hyper/hypoglycemia is a known etiological factor that brings forth short term memory loss.
While the Veteran believes his memory loss is an undiagnosed illness related to his active military service, he is not competent to provide a diagnosis or the etiology thereof in this case.  The issue is medically complex, as it requires specialized medical knowledge and the ability to interpret complicated diagnostic medical testing to include psychiatric evaluation.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007).  Consequently, the Board gives more probative weight to the competent medical evidence.
Based the competent and credible evidence of record, the Board finds that the claimed short-term memory loss have been competently and credibly associated with a known etiology and diagnosis, namely the Veteran’s PTSD, and therefore service connection based on the law and regulations pertaining to undiagnosed illness incurred due to Persian Gulf service is not warranted.  38 C.F.R. § 3.317. 
Turning to direct service connection, as noted above the August 2013 VA examiner noted that the Veteran’s memory loss were symptoms of his service-connected PTSD and asthma.  The rule against pyramiding states that separate additional ratings are not to be assigned if the symptomatology of one condition is duplicative of the symptomatology of another.  38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994).  In this case, the claimed short-term memory loss is found to be symptoms of his service-connected PTSD.  Furthermore, the currently assigned 50 percent disability rating for PTSD includes consideration of impairment in short- and long-term memory (e.g., retention of only highly learned material or forgetting to complete tasks).  Therefore, the Board finds that his short-term memory loss is fully considered by the currently assigned rating for PTSD, and service connection as separate disability is not warranted on a direct or presumptive basis.  
In conclusion, the preponderance of the evidence weighs against a finding that the Veteran’s short-term memory loss is a symptoms or manifestation of a medical unexplained or undiagnosed chronic multi-symptom illness, and instead shows that the issue is a symptom of PTSD that is currently service-connected.  Accordingly, entitlement to service connection for short-term memory loss is not warranted. 
Increased Rating
Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4.  The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings.  38 U.S.C. § 1155; 38 C.F.R. § 4.1.
If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  All reasonable doubt as to the degree of disability will be resolved in favor of the claimant.  38 U.S.C. § 5107(b); 38 C.F.R. § 4.3.  
Staged ratings must be considered, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal.  Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007).  See also Fenderson v. West, 12 Vet. App. 119, 126 (1999) (applying this concept to initial ratings).  
It is the Board’s responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied.  See Gilbert v. Derwinski, 1 Vet. App. 49 (1990).  
3. Entitlement to an initial rating in excess of 30 percent prior to May 3, 2010 for service-connected bronchial asthma.
The RO granted entitlement to service connection for asthma and assigned a 10 percent disability rating effective August 24, 2006 in a March 2007 rating decision.  The Veteran appealed the disability rating, as well as, the effective date assigned in the March 2007 rating decision.  The Veteran contends that his symptoms of asthma warrant a higher disability rating.  In a March 2011 rating decision, the RO granted a 100 percent disability rating, effective May 3, 2010 for bronchial asthma with obstructive sleep apnea.  The award of a 100 percent disability rating as of May 3, 2010 constitutes the maximum benefit allowed under the rating criteria.  In a September 2011 decision, the Board granted an effective date of May 22, 1998, the original date of claim for service connection.  Thereafter, in an August 2013 rating decision, the RO increased the disability rating for asthma to 30 percent, effective May 22, 1998.  Thus, the remaining issue on appeal is entitlement to a disability rating in excess of 30 percent for bronchial asthma from May 22, 1998 to May 3, 2010.    
The Veteran’s service-connected asthma is currently evaluated as 30 percent disabling prior to May 3, 2010 under 38 C.F.R. § 4.97, Diagnostic Code 6602, which pertains to bronchial asthma.  Under Diagnostic Code 6602, a 30 percent evaluation is warranted for bronchial asthma for the following: forced expiratory volume (FEV-1) of 56 to 70 percent predicted, or; FEV-1/ forced vital capacity (FVC) of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication.  A 60 percent evaluation requires FEV-1 of 40 to 55 percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids.  A 100 percent rating is assigned for FEV-1 less than 40 percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications.  38 C.F.R. § 4.97, Diagnostic Code 6602.
Based on the medical and lay evidence of record, the Veteran’s service-connected asthma more closely approximates a 100 percent disability rating from October 24, 2009 to May 3, 2010, but does not more closely approximate a disability rating in excess of 30 percent prior to October 24, 2009.  In this regard, the evidence shows that from May 22, 1998 to October 23, 2009, the Veteran’s asthma was not treated with intermittent (at least three per year) courses of corticosteroids or resulted in at least monthly visits to a physician for required care of exacerbations.  The medical evidence also reflects that the Veteran’s asthma did not result in more than one attack per week with episodes of respiratory failure or required the daily use of systemic (oral or parenteral) high does corticosteroids or immuno-suppressive medications.  A January 2007 VA examination documented that the Veteran’s asthma is treated with intermittent inhaled bronchodilator and intermittent inhaled anti-inflammatory.  He was prescribed antibiotics for less than four week course one time per year and a frequency course of 4-6 weeks once per year.  His asthma was not treated with oral steroids, parenteral steroids, or immunosuppressive drugs.  A January 2007 pulmonary function test (PFT) reveals post-bronchodilator testing reveals FEV-1 was 87 percent predicted and FEV-1/FVC was 82 percent.  A January 2008 VA examination reflects that the Veteran’s asthma was treated with intermittent inhaled anti-inflammatory medication; however, his asthma was not treated with oral steroids, parenteral steroids, and other immunosuppressive drugs.  The examiner documented that the Veteran did not have a history of respiratory failure.  The January 2008 post-bronchodilator PFT shows FEV-1 was 113 percent predicted and FEV-1/FVC was 83 percent.  Accordingly, the Veteran’s service-connected asthma does not more closely approximate a disability rating in excess of 30 percent prior to October 24, 2009. 
However, a November 24, 2009 private PFT post-bronchodilator testing reflects FEV-1 was 12 percent predicted and FEV-1/FVC was 100 percent.  Pre-bronchodilator testing shows FEV-1 was 20 percent predicted and FEV-1/FVC was 104 percent.  Post-bronchodilator studies are required when PFT’s are done for disability evaluation purposes except when the results of pre-bronchodilator pulmonary function tests are normal or when the examiner determines that post-bronchodilator studies should not be done and states why.  38 C.F.R. § 4.96(d)(4).  Accordingly, the Board will use the pre-bronchodilator results.  The physician conducting the PFT did not indicate which results most accurately reflected the Veteran’s level of disability.  See 38 C.F.R. § 4.96(d)(6) (“When there is a disparity between the results of different PFT’s (FEV-1 (Forced Expiratory Volume in one second), FVC (Forced Vital Capacity), etc.), so that the level of evaluation would differ depending on which test result is used, use the test result that the examiner states most accurately reflects the level of disability.”).  Nonetheless, the physician diagnosed the Veteran severe restrictive and obstructive disorder with poor bronchodilator response.  Furthermore, these PTFT results were documented in the November 2010 VA examination and used to grant a 100 percent disability rating in the March 2011 rating decision.  Thus, resolving any reasonable doubt in the Veteran’s favor, the Board will use the results from FEV-1 in determining the appropriate disability rating.  Under Diagnostic Code 6602, FEV-1 less than 40 percent predicted warrants a 100 percent disability rating.  Thus, the Veteran’s asthma more closely approximates a 100 percent disability rating as of November 24, 2009.  
The Board has considered whether additional staged ratings are appropriate. The evidence of record shows that the Veteran’s asthma symptoms have not been so severe as to warrant a disability rating in excess of 30 percent at any time prior to November 24, 2009.  As such, further staged ratings are not warranted.
REASONS FOR REMAND
1. Entitlement to service connection for allergic rhinitis is remanded.
With respect to the Veteran’s service connection claim for allergic rhinitis, the evidence of record shows that he has a current diagnosis of the claimed disability.  Furthermore, the Veteran’s service treatment records reflect that he was diagnosed with allergic rhinitis and the Veteran has asserted that he has experienced symptoms of allergic rhinitis since discharge from service.  The claims file does not contain a medical opinion on whether the Veteran’s current diagnosis of allergic rhinitis is related to active military.  Accordingly, a remand is necessary to obtain a VA medical opinion.  
2. Entitlement to service connection for ulcers secondary to service-connected disabilities is remanded.
With respect to the Veteran’s service connection claim ulcers as secondary to medications prescribed to treat his service-connected back disability and fibromyalgia, the Veteran was not provided with a VA examination.  During the April 2010 Board hearing, the Veteran testified that he was prescribed Naproxen for joint pain, which caused him extreme stomach pain and he asserted that it aggravated his stomach ulcer.  The medical evidence shows that the Veteran has a current diagnosis of stomach ulcers.  Furthermore, there is medical documentation that the Veteran was prescribed ibuprofen, Naproxen, and Celecoxib for joint pain.  Nonsteroidal anti-inflammatory drugs (like ibuprofen, Naproxen, and Celecoxib) can cause stomach ulcers.  Further, a January 2008 VA examination noted that the Veteran had severe abdominal pain due to Naproxen.   Accordingly, a remand is necessary to obtain a medical opinion with respect to whether the Veteran’s stomach ulcers were caused by or aggravated by medication prescribed to treat his service-connected disabilities. 
3.   Entitlement to an initial disability rating in excess of 20 percent prior to March 31, 2009 and in excess of 40 percent as of March 31, 2009 for service-connected degenerative disc disease of the lumbar spine.  
With respect to the Veteran’s initial rating claim for degenerative disc disease of the lumbar spine, the Veteran’s most recent VA examination that evaluated the severity of his right ankle was conducted in March 2009.  The U.S. Court of Appeals for Veterans Claims (Court) has held that 38 C.F.R. § 4.59 requires VA examination to include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.  Correia v. McDonald, 28 Vet. App. 158 (2016).  The Court has also recently held that that before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner must “elicit relevant information as to the Veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then, if possible, estimate the Veteran’s functional loss in terms of degree of additional range of motion loss due to pain on use or  during flare-ups based on all the evidence of record, including the Veteran’s lay information, or explain why she could not do so.”  Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017).  In this case, the March 2009 VA examination report does not include the information necessary as required by Correia and Sharp.  Thus, the Veteran must be provided with a new VA examination to determine the current nature and severity of his service-connected lumbar spine disability that includes the information required in Correia and Sharp.
4.  Entitlement to a disability rating in excess of 30 percent for sinusitis and deviated nasal septum. 
With respect to the Veteran’s service-connected claim for sinusitis and deviated nasal septum, the most recent VA examination that evaluated his sinusitis and deviated nasal septum was in November 2009.  During the November 2009 VA examination, the Veteran reported experiencing recurrent nasal congestion with copious mucoid nasal discharge, associated nasal pain, and nasofrontal headache.  However, during the April 2010 Board hearing, the Veteran testified that his symptoms of sinusitis to include runny nose, pain, tenderness, and headaches occur constantly, indicating that his symptoms of sinusitis and deviated nasal septum increased in severity.  Accordingly, a new VA examination is warranted to determine the current severity of his service-connected sinusitis and deviated nasal septum.  
The matters are REMANDED for the following action:
1.  Arrange for the Veteran to undergo a VA examination for his service connection claim for allergic rhinitis.  The entire electronic record must be made available to the medical specialist for review.  All indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. 
The examiner should provide an opinion on whether it is at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran’s allergic rhinitis is related to active military service to include any documented symptoms of allergic rhinitis in service. 
The examiner must provide a rationale for all conclusions based on the medical and lay evidence of record. 
2.  Obtain a VA medical opinion with respect to the Veteran’s service connection claim for stomach ulcer by an appropriate medical specialist.  Only arrange for the Veteran to undergo an examination if one is deemed necessary in the judgment of the medical specialist designated to provide the medical opinion.
The medical specialist is requested to provide an opinion as to whether the Veteran’s stomach ulcer is at least as likely as not (i.e., a 50 percent or more probability) (a) caused by or (b) aggravated by his service-connected disabilities to include any medication to treat such disorders, particularly, any nonsteroidal anti-inflammatory drugs used to treat degenerative disc disease of the lumbar spine and fibromyalgia.
The opinion must explicitly address both causation and aggravation to be deemed adequate. The medical specialist is advised aggravation means the service-connected disability caused an increase in the severity of an existing nonservice connected disability. If aggravation is found, the medical specialist must attempt to establish the baseline level of severity of erectile dysfunction prior to aggravation by the service-connected disability.
An explanation must be given for any opinion expressed and the foundation for all conclusions should be clearly set forth.
3.  Schedule the Veteran for an appropriate VA examination to determine the current nature and severity of his service-connected degenerative disc disease of the lumbar spine.  The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed.  All findings should be reported in detail.
The examiner should identify all lumbar spine pathology found to be present.  The examiner should conduct all indicated tests and studies, to include range of motion studies.  The joints involved should be tested in both active and passive motion, in weight-bearing and non weight-bearing.  If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so.
The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present.  
The examiner should also state whether the examination is taking place during a period of flare-up.  If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time.  
Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time.  If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training).
4.  Arrange for the Veteran to undergo a VA examination to evaluate the severity of his service-connected sinusitis and deviated septum.  The claims file must be made available to and be reviewed by the examiner in conjunction with the examination.  All tests deemed necessary should be conducted and the results reported in detail.  The examiner must elicit from the Veteran a detailed history of the symptoms of his sinusitis to include the type symptoms and the frequency of such symptoms. 
After review of the claims file and examination of the Veteran, the examiner should discuss the severity and frequency of all symptoms related to the Veteran’s sinusitis based on the medical evidence of record, the VA examination, and the Veteran’s lay statements.  The examiner should specifically comment as to the frequency (in terms of number of episodes in the last year) and severity of the Veteran’s non-incapacitating episodes of sinusitis characterized by headaches, pain, and purulent discharge or crusting.  The examiner should discuss whether the Veteran experiences nearly continuous sinusitis symptoms after repeated surgeries and whether the Veteran has had radical surgery resulting in chronic osteomyelitis. 
An explanation for all opinions expressed must be provided.

 
L. B. CRYAN
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	B. Berry, Counsel 

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