Citation Nr: 1201526 Decision Date: 01/13/12 Archive Date: 01/20/12 DOCKET NO. 09-13 387 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUE Entitlement to an initial disability rating in excess of 10 percent for service-connected hypothyroidism. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Michael Holincheck, Counsel INTRODUCTION The Veteran served on active duty from February 1969 to January 1972. He had additional service in the Army National Guard with a period of active duty from August 2002 to July 2003. The Veteran also had service in the United States Naval Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. The Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge in October 2009. A transcript of the hearing is included in the claims folder. The Board remanded the case for additional development in March 2011. The agency of original jurisdiction (AOJ) conducted the requested development and re-adjudicated the Veteran's claim in August 2011. The Veteran was issued a supplemental statement of the case (SSOC) at that time. He was given 30 days to respond to the SSOC with additional argument or evidence. The Veteran wrote to the AOJ to provide his assessment of the additional evidence added to the record, specifically, a VA examination from April 2011 and an addendum report of July 2011. He did not provide any new evidence but argued that the evidence of record supported his claim for a higher rating for his service-connected hypothyroidism. He submitted a copy of examination reports from January 2009 and April 2011, the July 2011 addendum, and the transmittal letter from the SSOC. The Veteran made a submission to the Board that was received in September 2011. He provided copies of VA examinations from January 2009 as well as April 2011 and addendum of July 2011. In addition to the examination reports and addendum, he provided a copy of the SSOC as well as the Board's remand of March 2011. The Veteran has not submitted new evidence that requires consideration by the AOJ. See 38 C.F.R. § 20.1304 (2011). The Veteran's contentions will be considered by the Board in its appellate review. FINDINGS OF FACT 1. The Veteran's diagnosed hypothyroidism is treated by a daily dose of Synthroid. Laboratory results of his TSH level reflect values within a normal range during the pendency of the appeal. 2. The Veteran's complaints of a 50-pound weight gain, muscular weakness, fatigability, constipation, cold intolerance, mental sluggishness, and constipation as reported by him in his lay statements and testimony have either not been clinically demonstrated or not been clinically related to his service-connected thyroid disability. CONCLUSION OF LAW The criteria for a rating in excess of 10 percent for hypothyroidism have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.7, 4.10, 4.119, Diagnostic Code 7903 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Background The Veteran submitted a claim for VA disability compensation that was received in January 2008. Entitlement to service connection for hypothyroidism was one of the issues claimed. The Veteran's service treatment records (STRs) were received in the development of his claim. The STRs did not show any service-related treatment for the Veteran's hypothyroidism. He was noted to be taking Synthroid, prescribed by a private physician, when he submitted his annual medical certificate in May 2006. This was the first evidence in his STRs of medication being used for treatment of hypothyroidism. The Veteran had a physical examination for retention in the National Guard in February 2007. He did not make any complaints of symptoms related to his hypothyroidism such as fatigability, constipation, mental sluggishness, weight gain, cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought), depression, bradycardia or sleepiness. He did report episodes of heart burn and hemorrhoids. The examiner noted that the hemorrhoids were in the past and that the Veteran had received medication for treatment. The Veteran reported that he was taking Levothroid on his annual medical certificate submitted in May 2007. The STRs also reflect that the Veteran was placed on a permanent profile in March 2007. The profile noted the two medical conditions as cardiac-related and degenerative joint disease. The cardiac condition pertained to residuals from aorta bi-femoral surgery that was done in January 2004, a medical condition unrelated to the Veteran's thyroid disability. The Veteran's reserve unit received orders to active duty that would commence in June 2007. He completed a pre-deployment questionnaire in April 2007. He indicated his health was very good at that time. The medical examiner indicated that the Veteran had no medical conditions that required referral, to include fatigue, malaise, or multisystem complaint. The Veteran completed a Periodical Record-Supplemental Medical Data form in June 2007. He reported treatment for his hypothyroidism. He denied receiving any psychiatric or mental health counseling as an inpatient or outpatient in the last 10 years. The Veteran reported for his active duty in June 2007. However, he developed problems in performing physical tasks that were related to residuals from his aorta bi-femoral surgery. He was relieved from active duty in June 2007. He was to undergo a military occupational specialty (MOS)/medical retention board (MMRB). A statement from his commanding officer, dated in October 2007, noted that the commanding officer was unaware of any limitations of the Veteran's performance due to his vascular condition. He noted that the Veteran had always taken the physical test (PT) and passed. He had passed as recently as October 2007. The Veteran was evaluated and determined to not be fit for retention in the National Guard. He was retired from the National Guard effective in December 2007. There was no indication of any impairment of his ability to carry out his military duties as a result of his hypothyroidism. The STRs contain several notations of weight measurement for the Veteran. These include outpatient visits as well as on physical examinations. The Veteran weighed 157 pounds at the time of a National Guard physical examination in June 1997. He weighed 163 pounds when he was examined in November 2001. At an examination in February 2007, his weight was 165 pounds. Two clinical entries from June 2007, one week apart, recorded the Veteran's weight as 160 and 165 pounds, respectively. Old records from the Veteran's Naval Reserve service record that he weighed 157 pounds at the time of a screening performed in October 1990. His weight was recorded as 149 pounds at the time of a physical examination in February 1988. As noted, the Veteran submitted his claim for VA benefits in January 2008. Records were obtained from the three private sources identified by the Veteran. Records from Tanner Clinic, S. Foote, D.O., covered a period from August 2003 to July 2007. The Veteran had a physical examination in September 2003. An entry from October 2003 noted that the Veteran was seen to review the laboratory results from his examination. The Veteran admitted to having fatigue and poor motivation. He was given a diagnosis of hypothyroidism and prescribed Synthroid for treatment. Additional entries noted the diagnosis of the Veteran's cardiovascular condition to include arteriosclerosis and aortic occlusion. In December 2003 he was seen for complaints of bilateral hand tingling and numbness, severe nervousness and waking up with anxiety. He was noted to be scheduled for vascular surgery in January 2004 and had financial concerns at home. He was assessed with panic attacks and anxiety. He had been prescribed Xanax on an earlier December 2003 visit. This was related to his expression of having anxiety after having stopped smoking. In April 2004 the Veteran reported that he was seeing a psychiatrist who was treating him for anxiety and depression. He was taking Xanax, Zoloft, and Ambien to treat his symptoms. In December 2004 the Veteran reported he was doing well and was finishing up with his psychiatrist. It was noted that the Veteran had been weaned off Xanax. However, in January 2005, he was concerned about his depression and anxiety. He reported that he was seeing a psychologist who was having a psychiatrist fill out his medications. The psychiatrist had moved on and the Veteran was out of medications. Included in the records was a report of a sleep study that provided a finding of mild sleep apnea in January 2004. In August 2005, the Veteran complained of fatigue. He would awaken tired and it would get worse through the day. He would have a poor night's sleep. He also had abdominal discomfort in the area of his incision site. The Veteran continued to be seen through May 2007. His hypothyroidism was monitored with laboratory studies done to evaluate his status. There were no entries to show complaints of cold sensitivity/intolerance, mental sluggishness, constipation, or weight gain. The Board notes that the records from Dr. Foote include 25 weight measurements dating from August 2003 to May 2007. The maximum weight recorded was 176.4 pounds in January 2005. The lowest weight recorded was 155 pounds just after the Veteran's surgery in January 2004. The last weight listed, in May 2007, was 170 pounds. Records from B. Morrill, D.O., for the period from January 2004 to January 2008, were also obtained. The older records pertained to treatment for the Veteran's cardiovascular condition and were from another physician. The Veteran continued to be prescribed Synthroid for his hypothyroidism, but there were no specific treatment entries that addressed symptoms associated with the diagnosis. The Veteran's weight was measured on two occasions in 2007. He weighed 162 pounds in June 2007 and 169 pounds in December 2007. The records also show evaluations of complaints of abdominal pain. Particular studies were done in light of the Veteran's abdominal surgery on his aorta in 2004. A July 2007 ultrasound noted the presence of the graft from the prior surgery. A computed tomography (CT) scan of the abdomen showed fatty infiltration of the liver, a small hiatal hernia and post-surgical changes of the aorta. A colonoscopy from January 2008 found evidence of a polyp in the sigmoid colon. There were no specific examinations conducted for complaints related to constipation. Records from S. Cain, M.D., related to the Veteran's cardiovascular surgery with treatment from December 2003 to January 2004. The initial visit in December 2003 was on a consultation from Dr. Foote. The Veteran had developed what was described as buttock claudication. Dr. Cain noted a history of angioplasty done on an artery of one of the Veteran's legs in 1997. A recent cardiac catheterization by a Dr. Humiston, was said to be negative. Dr. Cain noted that the Veteran had a thyroid problem. He reviewed several magnetic resonance angiography (MRA) studies. He said the Veteran was totally occluded in the abdominal aorta. He felt the Veteran would benefit from an aorto-bi-femoral iliac bypass graft. The January 2004 operative report was also provided. The Veteran was afforded a VA contract examination in June 2008. His weight was recorded as 168 pounds. The Veteran reported he had been diagnosed with hypothyroidism in February 2003 (he was on active duty at this time) and continued to be treated for the diagnosis. He said he suffered from fatigability, sleepiness, depression, tremor, and slowness of thought. He also said he was intolerant to cold weather and would get numbness in his hands. The examiner said that laboratory studies for thyroid-stimulating hormone (TSH), triiodothyronine (T3), and levothyroxine (T4) uptake were all abnormal; however, the examiner failed to comment on the results and the significance of any abnormality. More importantly, the attached laboratory results showed the Veteran's values to be within the designated normal range. The examiner said that the Veteran's heart had a regular rate and rhythm. A diagnosis of hypothyroidism was provided. The examiner said this was consistent with the Veteran's history and treatment. The examiner also provided a diagnosis of arteriosclerosis with peripheral arterial disease surgery. He said the final diagnosis was arteriosclerosis, status post aortic bi-femoral grafting with residual scar. The Veteran was granted service connection for hypothyroidism in September 2008. The grant was made on the basis of the hypothyroidism manifesting itself to a compensable degree within one year after the period of active duty that ended in July 2003. Although hypothyroidism was the disability identified, the AOJ assigned a 10 percent disability rating based on rating criteria used to evaluate a disability involving hyperthyroidism. See 38 C.F.R. § 4.119, Diagnostic Code 7900 (2011). The Veteran submitted his notice of disagreement (NOD) in October 2008. He noted that the rating decision had applied the wrong criteria to evaluate his disability. He said that the medical evidence showed that he had repeated visits for muscular weakness, mental disturbance, and weight gain, fatigability, constipation, and mental sluggishness that required continuous medication for treatment. The Veteran was afforded an informal conference with a decision review officer (DRO) in December 2008. The error in the rating criteria was noted and it was agreed the Veteran would have a new VA examination. The Veteran was afforded a VA examination in January 2009. Unfortunately, the examination was used to evaluate the Veteran's hypothyroidism and his arteriosclerosis disabilities together rather than provide findings specific to his hypothyroidism. The examiner listed the Veteran's recitation of symptoms to include fatigue, bouts of lightheadedness, dizziness, and intolerance to cold. The Veteran also related that he would feel hot at times when his wife was comfortable at room temperature. The Veteran also said he had a lot of depression. The Veteran had taken Zoloft but was off the medication for the last several months. He took Xanax to help him sleep. The examiner addressed the Veteran's fatigue by noting the Veteran continued to smoke and had several positives for underlying sleep apnea including heavy snoring and being unrefreshed on awakening. He said there was no outright neurologic presentation on examination. The Veteran reported that he still helped out in his daughter's yard and did his own yard work. He said he would ache a lot and seem to be tired and "poop out quickly." The examiner said the Veteran was able to perform self care and engage in the activities as noted. The Veteran said he had tried to part-time work as a janitor but could not keep up with the walking. The examiner recorded the Veteran's weight as 177 pounds. He said the Veteran was generally healthy and in no apparent distress. He said the Veteran had a normal heart rate and rhythm with no murmurs, rubs, or gallops. The examiner stated that there was no outward evidence of myxedema or other hypothyroid symptoms. The examiner provided a diagnosis of hypothyroidism. The agency of original jurisdiction (AOJ) issued a statement of the case (SOC) in March 2009. The appropriate rating criteria were used to evaluate the Veteran's disability for hypothyroidism. His 10 percent rating was confirmed and continued. The Veteran perfected his appeal in May 2009. He also submitted private medical records in support of his claim. Some of the evidence was duplicative of previously submitted items such as the January 2004 sleep study and records from Dr. Cain. The other records were from Dr. Borrill. Although there were some duplicative entries, there were additional treatment reports from January 2008 to March 2009. The Veteran was seen for complaints regarding his hypothyroidism in March 2009. He reported having both a cold and heat intolerance. The Veteran said he had had an excessive weight gain in the last five years. His weight was recorded as 175 pounds. He reported having severe constipation along with severe bleeding of his hemorrhoids. The Veteran reported having extreme fatigue and not having energy to do anything. He also reported severe episodes of anxiety and felt like his heart skipped a beat at times. The Veteran claimed that he had severe muscle weakness and that he had gained well over 50 pounds in the last five years since being diagnosed with hypothyroidism. The Veteran further stated that he had dizziness along with a hard time thinking and depression. There was no comment by Dr. Morrill as to the symptoms expressed by the Veteran. The physical examination noted that the Veteran was oriented and developed, nourished and not in distress. The Veteran was said to have a normal rate, regular rhythm and normal heart sounds. There was no evidence of gallop and friction rub and no murmur. There were normal breath sounds. There was no evidence of edema of the extremities. Dr. Morrill said the Veteran displayed a normal affect and exhibited a depressed mood and anxiousness. The Veteran and his wife testified at a Board hearing in October 2009. The Veteran said that he had cold intolerance and had what he described as "cold flashes." He also said he experienced fatigue to the point where he was put on medication. The Veteran further testified that he had constipation and that he had bleeding hemorrhoids as a result. He said he had decreased mental acuity and problems remembering things. The Veteran's wife testified that he experienced bouts of depression and fatigability. She said he was in his recliner and tired all of the time. She also said he had a problem with constipation and hemorrhoids. She further testified that the Veteran had gained 40 pounds in the last few years because he used to weigh about 135 pounds. The Veteran reported that he took medication once a day for his hypothyroidism. He said he was seen by a psychologist for his depression and was put on Xanax for treatment. The Veteran said his psychologist said that part of his depression was due to his thyroid. He said he was being treated by Dr. Morrill and that he had sent all of the records to VA. The Veteran said he had been diagnosed with hypertension and diabetes and was on medication for his hypertension. The Veteran's wife said he had severe anxiety attacks where he had to go to the emergency room. The Veteran did not identify the psychologist who was treating him or say that he would provide the records of such treatment. The Board remanded the case for additional development in March 2011. The AOJ wrote to the Veteran in March 2011. He was asked to identify sources of additional treatment records for VA to obtain or to provide such evidence to the AOJ. The Veteran responded in April 2011. He provided treatment records from Dr. Morrill for the period from February 2010 to February 2011. The records consist of duplicate and additional laboratory results and clinical visits. The clinical visits do not show any specific treatment for hypothyroidism. Rather, the entries relate to treatment for an upper respiratory infection (URI), diabetes mellitus, lung mass, and essential hypertension in February 2010; hypertension , diabetes, and sinus congestion in June 2010; diabetes and dermatophytosis of the foot in September 2010; acute bronchitis in December 2010, and acute bronchitis, anxiety and insomnia in February 2011. The records show the Veteran was still taking Synthroid for his hypothyroidism. The Veteran's weight was recorded as 175 pounds in February 2010; 175 pounds in June 2010; 171 pounds in September 2010; 173 pounds in December 2010; and, 165 pounds in February 2011. The Veteran was reported as oriented and as having a normal mood and affect with most entries. There were no cardiac abnormalities noted and he was said to have a normal heart rate and rhythm. There was no swelling of the extremities to include with the special foot examination in September 2010. The Veteran did report feeling depressed and having little interest or pleasure in doing things in the past two weeks at his visit in June 2010. In February 2011 the Veteran was alert and oriented and was said to be in no distress. His speech and behavior were said to be normal. His mood was reported as anxious. His cognition and memory were normal. The Veteran was afforded a VA examination in April 2011. The Veteran's claims folder was unavailable at that time. The examiner noted that the Veteran brought some of his private medical records to the examination for review. The examiner noted that he had been requested to evaluate the Veteran for hyperthyroidism. The examiner stated that this was in error - the veteran had never been diagnosed with hyperthyroidism and was, in fact, service connected for hypothyroidism. This was diagnosed in March or April 2003. The Veteran reported being treated with Synthroid since his diagnosis. He took a dose every day. The examiner noted that the most recent reported laboratory test for TSH was within the normal range in September 2010. It was also noted to be normal in January 2009 (results from the VA examination at that time). The examiner stated that this meant the Synthroid was very effective in controlling the Veteran's hypothyroidism. The Veteran complained of some degree of fatigability but this was not a major problem. The Veteran also said he had occasional constipation. The examiner said the Veteran did not have significant mental sluggishness and did not have cold intolerance. The examiner further stated there was no generalized or focal weakness. He said there was no history suggesting the presence of any cardiovascular disease. He added that the Veteran had no history of dementia or significant slow thought process or bradycardia. The examiner said the Veteran had a rather long history of depression and anxiety. He said the Veteran reported the depression and anxiety pre-dated the diagnosis of hypothyroidism and had not changed significantly since treatment with Synthroid. The Veteran currently took Xanax intermittently for anxiety and Zoloft for his depression. The Veteran reported having some difficulty in sleeping through the night. The examiner said the Veteran was noted to have some mild generalized weakness and muscle aching and difficulty with his thought process at the time he was diagnosed in 2003. However, the symptoms had improved since the Veteran started taking Synthroid. The examiner also noted that the Veteran had diabetes mellitus, hyperlipidemia and mild hypertension. He noted the medications that Veteran was taking for the respective conditions. The Veteran was noted to continue to smoke a pack of cigarettes a day. He walked for exercise, did some yard work, and cared for his own personal needs. On physical examination the Veteran was said to weigh 175 pounds. The examiner said the Veteran was oriented and alert with a normal mental status. The Veteran moved freely and was said to walk normally. The Veteran skin was said to be normal. The Veteran had a regular heart rate with no murmurs. Motor examination was said to show normal strength throughout, 5/5, with no atrophy. Reflexes were normal throughout both upper extremities and at the knees, with trace reflexes at the ankles. The examiner said that pain, temperature, touch, position and vibratory senses were normal on the sensory examination. The diagnosis was hypothyroidism, which was said to be effectively being treated with Synthroid. The examiner said the Veteran had no specific symptomatology of hypothyroidism. The second diagnosis was depression and anxiety that were long-standing and treated with medications. The examiner opined that the depression and anxiety were not secondary to the Veteran's hypothyroidism. The examiner was provided the Veteran's claims folder for review in July 2011. He submitted an addendum to his examination report at that time. He said that his diagnosis and discussion from his report stands. He said the Veteran had hypothyroidism that was being effectively treated with Synthroid. He repeated that the Veteran had no specific symptomatology of hypothyroidism and that his depression and anxiety were longstanding and unrelated to the hypothyroidism. II. Analysis Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2011). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2011). The Veteran's claim for a higher evaluation for his disability of hypothyroidism is an original claim that was placed in appellate status by a notice of disagreement (NOD) expressing disagreement with an initial rating award. As such, separate ratings can be assigned for separate periods of time based on the facts found--a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Diagnostic Code 7903 provides ratings for hypothyroidism. Hypothyroidism with fatigability, or; continuous medication required for control, is rated 10 percent disabling. A 30 percent rating is warranted for hypothyroidism with fatigability, constipation, and mental sluggishness. A 60 percent rating is for consideration for hypothyroidism with muscular weakness, mental disturbance, and weight gain. Finally a 100 percent rating is assigned for hypothyroidism with cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness is rated 100 percent disabling. 38 C.F.R. § 4.119 (2011). The Board notes that the United States Court of Appeals for Veterans Claims (Court) has addressed the specific application of the rating criteria for Diagnostic Code 7903. In that regard, the Court has said that the all of the symptoms listed for a particular disability rating were not required to be demonstrated in order to establish entitlement to a higher disability rating. See Tatum v. Shinseki, 23 Vet. App. 152, 155, (2009). The Court noted that symptoms that meet some of the rating criteria should be considered in light of 38 C.F.R. § 4.7 (2011) and resolved based on the evidence of record. The Court also stated that unlike the diabetes mellitus rating criteria addressed in Camacho v. Nicholson, 21 Vet. App. 360 (2007), the rating criteria for Diagnostic Code 7903 are not successive. Tatum, 23 Vet. App. at 155. A claimant could potentially establish all of the criteria required for a 30 percent or 60 percent rating without establishing any of the criteria for a lesser disability rating. Id. at 156. The Court also went on to acknowledge the difficulty in assessing the subjective reporting of symptoms by a claimant. In particular, the veteran in Tatum contended that she suffered from constipation. The Court recognized that the "...credibility of a person's assertion of such a personal affliction is a key consideration with regard to a finding that the person does or does not suffer from such affliction." Id. The Court directed that the Board must discuss such contentions and the credibility of the claimant. The Veteran had a specific visit with Dr. Morrill where he made complaints related to his hypothyroidism in March 2009. At that time the Veteran endorsed all of the symptoms listed in the rating criteria. He said he had cold intolerance, heat intolerance, and excessive weight gain in the last five years, severe constipation with rectal bleeding, severe dry skin with flaking, and extreme fatigue. He also said he had severe muscle weakness and fatigue and that he had gained well over 50 pounds in the past few years since being diagnosed with hypothyroidism. He further reported having dizziness along with a hard time thinking and depression. The symptoms were worse if he did not take his medication. It is important to note that the Veteran had not ever presented for a clinical evaluation with the above list of symptoms at any time prior to this date, either with Dr. Morill or Dr. Foote, and has not at any time subsequent to March 2009. Moreover, the treatment entry from Dr. Morrill did not provide any assessment or finding to support the claimed symptoms. He was given diagnoses of; inter alia, unspecified hypothyroidism, internal and external hemorrhoids without mention of complication. The latter characterization is from the actual entry. At the outset the Board finds that the Veteran's statements regarding his weight gain in the last five years lack any credibility. It is well established that an individual may provide competent lay evidence of matters within their personal knowledge and experience or regarding symptoms capable of lay observation. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Charles v. Principi, 16 Vet. App. 370, 374 (2002). However, the objective evidence of record demonstrates that the Veteran weighed 172 pounds in October 2003. He was diagnosed with hypothyroidism and placed on medication for his hypothyroidism at that time. He had a weight loss of 17 pounds over the next several months leading up to, and including his vascular disease surgery in January 2004. He weighed 155 pounds at that point. He then slowly regained his weight and has not weighed more than 176 pounds - as reflected in records from Dr. Foote in December 2004, more than four years prior to the submission of the Veteran's current claim. The Veteran's most recent weight in April 2011 was 175. The objective evidence, as shown by the multiple weights provided in the records from Dr. Foote, Dr. Morrill, and the VA examination reports, unequivocally establish that the Veteran has not had a weight gain of 40 or 50 pounds at any time in more than 20 years, and a weight gain of less than 10 pounds during the pendency of this appeal from January 2008 to the present. The Veteran has reported subjective symptoms of mental sluggishness, fatigue, constipation to the point of causing problems with hemorrhoids, cold intolerance, heat intolerance, and being tired. He has not stated subjective symptoms of bradycardia. The objective medical evidence of record establishes, as stated by the VA examiner of April 2011, longstanding treatment for anxiety and depression. The Veteran's separate treatment by a psychiatrist and a psychologist are documented in numerous entries in the records from Dr. Foote. The depression is noted by Dr. Cain in his records regarding vascular surgery in January 2004. The records from Dr. Morrill also note anxiety and depression. However, there is no medical evidence of record to relate either diagnosis to the Veteran's service-connected hypothyroidism. The April 2011 VA examiner, upon review of the claims folder, noted the longstanding treatment for the psychiatric disorders and stated that they were unrelated to the Veteran's hypothyroidism. The Veteran has made statements, specific statements, that he has mental sluggishness. He made this contention in his notice of disagreement (NOD) of October 2008 and a similar statement in the record with Dr. Morill of March 2009. However, the multiple private treatment records before the current claim, but more importantly, during the pendency of the current appeal do not show evidence of mental sluggishness. The Veteran is predominantly described as alert and oriented with normal mood and affect. He is also found to be alert and oriented at the time of his VA examinations with no objective finding of any mental impairment that is related to his hypothyroidism. The Veteran has not consented to either provide his private psychiatric/psychological records or to authorize VA to obtain the records in support of his claim. In light of the specific medical opinion that finds no connection between his depression and anxiety and his service-connected hypothyroidism, and the lack of any other medical evidence to establish such a link, the Board finds the objective medical evidence outweighs the Veteran's lay assessments. Thus, the Board finds the evidence supports a conclusion that the Veteran does not suffer from mental sluggishness or mental disturbance that is related to his hypothyroidism. The Veteran has submitted statements and testified that he suffers from fatigability. As noted, he said he had severe muscular weakness in March 2009. He testified that he felt that he did not have the same stamina as before and would tire easily. The medical entries for the period of the appeal do not demonstrate complaints of fatigability. The Veteran was evaluated for a number of medical complaints, especially in the period 2010 and 2011. His fatigability was not reported. It was related essentially only at the time of the entry from March 2009. Moreover, on examination, there is no objective evidence of muscular weakness; either in the private records or on VA examination. In addition, there is objective evidence of record to establish mild obstructive sleep apnea syndrome as per the report from January 2004. The Veteran has also alleged that he suffers from constipation, in fact severe constipation at the time of his clinical visit in March 2009. He has testified and made statements that his constipation causes him problems with his hemorrhoids. However, he has not received treatment for his claimed constipation based on the medical records he submitted. He included a printout of prescriptions from a pharmacy that covered a period up to February 2008. It did not include hemorrhoid treatments. There was a note in Dr. Morill's records that the Veteran was prescribed a cream for hemorrhoids in December 2007. However, there is no objective evidence to show complaints of constipation. Moreover, the records from Dr. Morill show that the Veteran was carefully evaluated for complaints associated with pain in the abdomen in July 2007 and January 2008. The ultrasound, CT scan and colonoscopy results made no reference to problems associated with constipation. The concern was for problems related to the surgery on the Veteran's aorta. The objective medical evidence of record does not document treatment for constipation as related to the Veteran's hypothyroidism. Nor is there any medical evidence to link his self-described symptoms to his service-connected hypothyroidism. The Veteran's recitation of symptoms, as set forth in the rating criteria, is not sufficient to justify a higher rating. Such an application of the rating criteria would negate the need for any objective evaluation of the contentions of a claimant and dictate a mechanical awarding of benefits based entirely on subjective reporting of symptoms that happen to mirror the rating criteria required for a particular disability rating. The Court requires VA to assess such subjective assertions and evaluate them in light of the evidence of record. See generally Tatum, supra. In summary, the evidence establishes that the Veteran's hypothyroidism has been well-controlled by continuous medication, as evidenced by the several laboratory reports showing his TSH and other markers within normal limits, and has been manifested by subjective complaints throughout the appeal. Considering both the lay and medical evidence of record, as summarized above, the Board finds that a rating of 30 percent is not justified for hypothyroidism, at any time during the pendency of the appeal, based on the of the evidence in this case. The Veteran does not suffer from fatigability, or constipation, or mental sluggishness. He requires medication for control of his hypothyroidism. In keeping with the guidance of the Court in Tatum, the Board also finds that the evidence of record does not establish that the Veteran suffers from muscular weakness, or mental disturbance or weight gain to warrant the assignment of 60 percent at any time during the appeal. Finally, the evidence does not establish that the Veteran has cold intolerance, or muscular weakness, or cardiovascular involvement, or mental disturbance, or bradycardia, or sleepiness that is related to his hypothyroidism and would support a 100 percent rating at any time. See 38 C.F.R. §§ 4.7, 4.10, 4.119, Diagnostic Code 7903. In short, the most recent VA assessment is the best description-the Veteran's hypothyroidism has been controlled, which in turn means that he has not suffered from the symptoms that would allow for a higher rating. The Veteran is retired from his federal service employment and the Army National Guard. He has not stated that his hypothyroidism keeps him from obtaining and sustaining substantially gainful employment and there is no other evidence of record to indicate the same. Thus, no claim of entitlement to a total disability evaluation based on individual unemployability (TDIU) has been reasonably raised by the evidence. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Board is unable to identify a reasonable basis for granting a disability evaluation in excess of 10 percent for hypothyroidism at any time during the period of the appeal. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2011). The Board has also considered whether the Veteran's hypothyroidism is so exceptional as to require consideration of an extraschedular rating. In Thun v. Peake, the Court held that determining whether a claimant is entitled to an extraschedular rating is a three-step inquiry. 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (Fed. Cir. 2009). The first step is to determine whether the "evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate." Id. If the adjudicator determines that this is so, the second step of the inquiry requires the adjudicator to "determine whether the claimant's exceptional disability picture exhibits other related factors," such as marked interference with employment or frequent periods of hospitalization. Id. at 116. Finally, if the first two steps of the inquiry have been satisfied, the third step requires the adjudicator to refer the claim to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether an extraschedular rating is warranted. Id. In this case, the schedular criteria are adequate to address the Veteran's level of disability for his hypothyroidism. The criteria have specific symptoms that are required. The evidence of record establishes that the Veteran's hypothyroidism is controlled by his medications. As discussed above, the evidence does not support the existence of the other claimed symptoms. His 10 percent rating is an accurate reflection of his level of impairment at this time. The rating criteria are clearly adequate to evaluate this Veteran's hypothyroidism disability. The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp 2011)), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2011), provides that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. See 73 Fed. Reg. 23353-56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the veteran to provide any evidence in the veteran's possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1).) The Court issued a decision in March 2006 in the case of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Veteran was provided such notice in October 2008. VA's General Counsel has held that VCAA notice is not required for downstream issues. VAOPGCPREC 8-2003. In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess, 19 Vet. App. at 490. In this case, the Veteran's claim for service connection for hypothyroidism was granted and an effective date and disability rating was assigned in the rating decision on appeal. As such, no additional notice is required because the purpose that the notice is intended to serve has been fulfilled. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate his claim. All available evidence pertaining to the Veteran's claim has been obtained. The evidence includes his claims folder, which includes his STRs, VA examination reports, a contract examination report and private treatment records submitted by the Veteran. The Veteran identified no additional source of evidence in his current claim, specifically records related to his psychiatric treatment. The Veteran and his spouse testified at a Board hearing. The Board remanded the case for additional development. The Veteran submitted argument in September 2011 wherein he took issue with the results of the VA examination of April 2011 and subsequent addendum of July 2011. He felt that the examiner was incorrect in stating that the Veteran did not have specific symptoms of hypothyroidism. He also said that the VA examiner did not have the appropriate expertise in endocrinology as requested by the Board in its remand of March 2011. The Veteran has not provided any specific evidence to support his contention in regard to the examiner. Thus, the Board does not find merit in the Veteran's contention. As noted, the Veteran was afforded VA examinations. The examinations were adequate upon which to base a determination as they fully address the Veteran's symptoms and the medical evidence of record in assessing the Veteran's status as well as the impact of the Veteran's hypothyroidism on his social and occupational functioning. See 38 C.F.R. § 3.326 (2011), Barr v. Nicholson, 21 Vet. App. 303, 311 (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). The April 2011 examination, in particular, was very thorough in noting the Veteran's subjective symptoms and providing objective findings. Moreover, the examiner provided informed opinions, albeit without the claims folder in the first instance. However, he affirmed his findings and opinions upon his review of the claims folder. The Board finds that VA has complied, to the extent required, with the duty-to-assist requirements found at 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c)-(e). ORDER Entitlement to a disability rating in excess of 10 percent for service-connected hypothyroidism is denied. _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs