Citation Nr: 0814523 Decision Date: 05/02/08 Archive Date: 05/12/08 DOCKET NO. 06-04 619 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for heart disease, as secondary to the service-connected post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for tinnitus. 4. Entitlement to service connection for hypertension. 5. Entitlement to service connection for erectile dysfunction. 6. Entitlement to an initial evaluation greater than 30 percent for PTSD. 7. Entitlement to a total disability rating for compensation purposes based on individual unemployability due to a service-connected disability (TDIU). REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD L.J. Bakke, Counsel INTRODUCTION The veteran served on active duty from April 1969 to March 1971. His report of discharge at separation shows he was awarded the Combat Action Ribbon. This appeal arises before the Board of Veterans' Appeals (Board) from rating decisions rendered in September 2004 and October 2005 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri in which service connection for bilateral hearing loss, tinnitus, arteriosclerotic cardiovascular disease, hypertension, and erectile dysfunction was denied; in which service connection for PTSD was granted and evaluated as 30 percent disabling; and in which entitlement to TDIU was denied. The issues of service connection for bilateral hearing loss, tinnitus, and hypertension, and of entitlement to TDIU addressed in the REMAND portion of the decision below are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The medical evidence establishes that the veteran's heart disease was aggravated by his service-connected PTSD. 2. A preponderance of the medical evidence does not demonstrate that the veteran is diagnosed with erectile dysfunction. 3. The service connected PTSD is productive of occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a heart condition, as secondary to the service connected PTSD, have been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 3.303, 3.310 (2007). 2. The criteria of entitlement to service connection for erectile dysfunction have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 3.303 (2007). 3. The criteria for an initial evaluation of 70 percent, and no greater, for PTSD have been met from the date of the grant of service connection. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. § 4.1, 4.2, 4.3, 4.6, 4.7, 4.13, 4.130, Diagnostic Code 9411 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). VA must request that the claimant provide any evidence in the claimant's possession that pertains to a claim. 38 C.F.R. § 3.159. The notice requirements apply to all five elements of a service connection claim: 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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In light of the favorable action taken concerning the claim for service connection for a heart condition, as secondary to the service-connected PTSD, discussion of whether VA has met its duties of notification and assistance is not required, and deciding the appeal on that issue at this time is not prejudicial to the veteran. Concerning the claim for service connection for erectile dysfunction and a higher initial evaluation for PTSD, it is noted that the RO provided the appellant pre-adjudication notice concerning the issues of service connection for erectile dysfunction and PTSD in April 2004. The notification substantially complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence; and Pelegrini v. Principi, 18 Vet. App. 112 (2004), requesting the claimant to provide evidence in his or her possession that pertains to the claims. Subsequent additional notice concerning the laws regarding degrees of disability and effective dates was provided in March 2006. The claim for service connection for PTSD was subsequently granted, and an evaluation of 30 percent was initially assigned. The veteran disagreed with the evaluation assigned. In August 2006, in the statement of the case, the RO provided the laws and regulations governing the evaluation of mental disorders and, specifically, provided the rating criteria for ratings from zero to 100 percent. The veteran's claim was subsequently adjudicated in a supplemental statement of the case dated in June 2007. The veteran and his witness-particularly his spouse, who has provided much of the evidence in the current claim- demonstrated their understanding of the criteria required for higher evaluations in subsequent statements to the RO and in testimony provided before a local hearing officer in January 2007. Thus, the duty to notify has been satisfied with respect to VA's duty to notify him of the information and evidence necessary to substantiate the claim. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). VA has obtained service medical records, assisted the veteran in obtaining evidence including private medical records, has accorded the veteran VA examinations, and has afforded the veteran the opportunity to give testimony before the Board, which the veteran declined. He testified before a local RO hearing officer in January 2007. All known and available records relevant to the issues of service connection for erectile dysfunction and a higher initial evaluation for PTSD have been obtained and associated with the veteran's claims file; and the veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the veteran is not prejudiced by a decision on the claim at this time. II. Service Connection Service connection may be established for disability resulting from injury or disease incurred in service. 38 U.S.C.A. § 1110. Service connection connotes many factors, but basically, it means that the facts, as shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service. A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease in service. See Pond v. West, 12 Vet. App. 341 (1999); Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be established on a secondary basis if the claimed disability is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. 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); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Compensation is allowable for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, at 448. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also, 38 C.F.R. § 3.102. When a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Heart Condition The veteran is service-connected for PTSD. Private and VA treatment records show diagnoses of and treatment for coronary artery disease including myocardial infarction and arteriosclerotic cardiovascular disease. Various medical health care professionals have indicated that the veteran's heart condition is at least in part the etiological result of his service-connected neuropsychiatric disorder. In January 2006, Dr. Bakr I. Salem, M.D. F.A.C. P., F.A.C.C. offered his observation that the veteran had suffered from PTSD symptoms for a long period of time. He opined that the combination of toxic stress levels and depression could certainly have been a major contributing factor to the veteran's coronary artery disease. Dr. Roohi S. Desai, M.D., offered a statement in March 2006 noting that the veteran had been treated for depression, cardiac disease, and memory loss-all of which can be an effect of chronic PTSD. The physician observed that extended periods of stress can cause or contribute to depression, anxiety and cardiac disease. Episodes of stress or fear producing "fight or flight" response in humans cause the body to produce additional amounts of cortisal, he explained, which can cause cardiovascular disease. He further stated that invasive procedures, such as cardiac catheterizations and by-pass surgery can cause or contribute to depression and memory loss. In the veteran's case, Dr. Desai opined, his cardiac disease stemmed from his chronic PTSD. VA examination conducted in March 2006 shows a diagnosis of coronary artery disease. The physician opined that it was not at least as likely as not that the veteran's PTSD directly caused his coronary artery disease. Rather, the examiner explained it was more likely than not that the veteran's coronary artery disease was directly caused by a combination of his hypertension, hyperlipidemia, significant smoking history, and positive family history for coronary artery disease. However, the examiner further opined that it was at least as likely as not that the veteran's depression and PTSD may have aggravated his coronary artery disease. The examiner based his opinion on review of the claims file, to include the veteran's extensive psychiatric treatment history, and on evidence in medical literature that psychosocial factors such as depression, stress and anger can have an effect on cardiovascular outcomes. The VA examiner's opinion is consistent with and corroborative of the opinions proffered by Drs. Bakr and Desai. While all three opinions are, in some way, conditional in their use of wording such as "could," "can," or "may," all concur that the veteran's PTSD has, in some way, aggravated his heart condition. Thus the effect of these opinions in the aggregate supports a finding that the veteran's diagnosed coronary artery disease has at least been aggravated by his service-connected PTSD. There are no other opinions against a finding that the veteran's coronary artery disease has been aggravated by his service connected PTSD and, accordingly, Service connection for coronary artery disease is warranted. 38 C.F.R. § 3.102. Erectile Dysfunction In September 2003, private medical records show the veteran complained of loss of libido. In addition, the veteran's spouse has stated that their sex life suffered as a result of his PTSD. However, the medical evidence contains no diagnosis of erectile dysfunction. As the medical evidence contains no diagnosis of erectile dysfunction, the preponderance of the evidence is against service connection for the claimed condition. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("in the absence of proof of a present disability, there can be no valid claim"). Where as here, the determinative issue involves a medical diagnosis and medical opinion of etiology, competent medical evidence is required to support the claim. The veteran and his witness are not competent to offer an opinion as to a medical diagnosis or to causation, consequently his and his wife's statements to the extent that he has erectile dysfunction and that it is related to his service-connected PTSD are not competent medical evidence. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The preponderance of the evidence is against the claim for service connection for erectile dysfunction; there is no doubt to be resolved; and service connection is not warranted. III. Higher Initial Evaluation for PTSD Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2007). Separate diagnostic codes identify the various disabilities. Id. Evaluation of a service-connected disorder requires a review of the veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1 and 4.2. It is necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor, 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply to the veteran's disability, 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. In determining a disability evaluation, the VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons used to support the conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The veteran was service-connected for PTSD in an October 2005 rating decision. The disability was evaluated as 30 percent disabling, effective in April 2004. The veteran appealed the disability assigned. The 30 percent evaluation has been confirmed and continued to the present. The Rating Schedule directs that, in evaluating the severity of mental disorders under the diagnostic criteria, consideration should be given to the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. Ratings shall be based on all the evidence of record as it bears on social and industrial impairment rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. Although social impairment is crucial in determining the level of overall disability, an evaluation may not be assigned solely on the basis of social impairment. 38 C.F.R. §§ 4.126. The veteran's service-connected PTSD is evaluated pursuant to a general rating formula for mental disorders under 38 C.F.R. Part 4. A 30 percent evaluation is afforded for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by continuous medication. A 50 percent rating shall is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating shall be assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating shall be assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance or minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. Part 4, Diagnostic Code 9411. The GAF rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (4th ed.1994). A GAF score of 31 to 40 shows some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, thinking, or mood. A GAF score of 41 to 50 shows serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 reflects moderate symptoms (e.g. flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). A GAF score of 61 to 70 is indicative of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but the individual generally functions pretty well, and has some meaningful relationships. The medical evidence presents a conflicted disability picture, with some medical evidence suggesting that the veteran's neuropsychiatric symptomatology is more attributable to a cognitive disorder that is the residual of his cardiac symptomatology. Other medical evidence asserts that the symptomatology attributable to the PTSD remains present and, if anything, is more disabling, but is unexpressed due to the dementia. Lay witness statements and testimony attest to the continuation and severity of such symptoms as depression, anxiety, anger, memory loss, lassitude, loss of interest, inability to concentrate, night terrors, nightmares, severe sleep disturbances and violent sleep, intrusive thoughts, hyper-arousal, exaggerated startle response, and panic attacks from the time of service connection to the present. Private medical records dated in November and December 2003 reflect that the veteran was suspected to have dementia or a cognitive disorder. But, an April 2004 statement proffered by Steven M. Till, Ph.D. shows a primary diagnosis of major affective disorder, depressed, and a secondary diagnosis of PTSD which the physician described as the more chronic condition. He noted that the veteran had required psychiatric inpatient hospitalizations and intensive hospital-based outpatient care for his conditions, as well as individual psychotherapy and the care of a psychiatrist. The physician opined that the veteran was unable to work due to his emotional state and physical complications related to his excessive emotional state. In a follow-up statement proffered in August 2005, Dr. Till noted he had not seen the veteran since May 2004, but when last seen the veteran presented with slurred speech, lethargy, poor short term memory, poor long term recall, and poor concentration. He reported he had recently experienced depression and panic attacks, and expressed he was having more difficulty coping with his PTSD symptoms. The veteran did not report for his next scheduled appointment. In August 2004, the veteran underwent VA examination and social and industrial survey. The social worker observed the veteran appeared to suffer from PTSD, which may have been latent. The VA examiner did not find the veteran to exhibit sufficient symptomatology to warrant a diagnosis of PTSD. Rather, the report reflects a diagnosis of depressive disorder due to general medical condition. GAF was measured at 60. The examiner specifically observed that the veteran did not subjectively report re-experiencing combat related events in the form of intrusive thoughts, nightmares, or flashbacks. Rather, these symptoms were described by the veteran's spouse. In August 2005, the veteran's treating psychiatrist, Jo-Ellyn M. Ryall, M.D., offered her statement in which she diagnosed generalized anxiety disorder and PTSD, and assigned a GAF of 40. She noted she first began treating the veteran in March 2004. He gave a history of having had increased panic attacks from January of that year. He presented as alert and cooperative but with rapid speech and very anxious mood. He was physically shaking. He denied psychotic symptoms, or homicidal or suicidal ideation. He expressed a generalized anxiety. He was oriented and had good insight. He seemed to exhibit good judgment in following medical orders, with his spouse overseeing them. During treatment, he began to sleep better but continued to experience irritability, avoidance, isolation, lack of attention, and losing chunks of time without realizing what he was doing. Depression increased, and anxiety continued. He was unable to remain cooperative in outpatient treatment. The psychiatrist noted that the veteran's other medical problems had the effect of rendering the veteran unable to work. She observed that the veteran had relied on work to help him cope with his PTSD symptoms. Unable to work, his anxiety was out of bounds. He did not respond well to medication, and medications prescribed for his psychiatric condition had to be balanced with the other medications he was prescribed for his heart condition, and bypass surgery and strokes had increased his memory loss. She remarked that the veteran may not be able to remember his experiences in Vietnam, but this did not mean he no longer had PTSD. In a January 2005 statement proffered by Dr. Salem, the physician stated he had observed the veteran to exhibit symptoms of anxiety, tremulousness, and recurrent bouts of depression with symptoms suggestive of PTSD from 2002 to 2004. In September 2005, the veteran underwent VA examination for PTSD, at which time he was diagnosed with dementia, not otherwise specified and PTSD, described as mild. The examiner noted that the veteran's GAF was 35 overall, but that GAF attributable solely to PTSD would measure 70. VA treatment records show that dementia was again diagnosed in 2006 and 2007. In a March 2006 statement proffered by Dr. Desai, the physician attested to observing the veteran to have suffered from PTSD for a prolonged period of time. The physician amended his statement in January 2007 to describe the veteran's symptoms of PTSD as memory loss, nightmares, hallucinations, and frequent disorientation to place and time. The physician stated he had personally known the veteran for seven years. In January 2007, Dr. Ryall proffered an updated assessment of the veteran's condition, noting that his cognitive functioning had decreased and that his memory was impaired. However, the psychiatrist noted that discontinuation of a medication prescribed for the suspected dementia actually improved the veteran's cognitive condition. He became more aware and less fogged. She noted the spouse's report that she and the veteran had to sleep apart due to the veteran's violent sleep. He had tried to choke her, believing she was an enemy. The psychiatrist described the veteran's mental disorder as involving PTSD with subsequent panic disorder, and cognitive functioning bordering on dementia. She opined him to be completely disabled due to his PTSD and subsequent medical problems including his cardiac disease. Given the differing diagnoses, the veteran was again examined by the VA in April 2007. The examiner interviewed both the veteran and his spouse, acknowledging that the spouse's input was necessary due to unwillingness or inability of the veteran to respond to questions. The examiner observed that the veteran appeared to exhibit problems more in the area of executive function than in the area of actual memory loss. Yet the rate of progress of his condition was not particularly consistent with the dementia he had been diagnosed with, Alzheimer's, or Parkinson's disease. Notwithstanding, the examiner noted, the medical evidence of record presented less variance of opinion about the presence of a cognitive disorder than about its diagnosis or nature. After review of the entire record, examination of the veteran, and clinical testing, the examiner diagnosed PTSD by history and a cognitive disorder, not otherwise specified, in AXIS I, and assigned a GAF of 36. The examiner explained that the GAF of 36 was based on the difficulties the veteran has sustaining regular communication, or responding to functionality, in his environment. GAF based solely on severity of symptoms was measured at 40. The examiner was unable to parse out the GAFs among the veteran's various conditions. However, the examiner noted the veteran had made a satisfactory occupational adjustment and had remained in an apparently satisfactory marriage, despite his PTSD, until his cardiac crisis. In addition, the examiner observed, the veteran appeared to retain considerable regard within his community. The examiner observed that cognitive changes are not infrequent after cardiac events, and noted that the veteran's absolute level of dysfunction appeared to have coincided with the rapid physical deterioration and the development of cognitive disorder. In view of statements proffered by individuals who treated the veteran and who have had the opportunity to observe the veteran closely during the time period under appeal, the Board finds the evidence establishes that the veteran meets the criteria for a 70 percent evaluation, from the time service connection was effectuated, in April 2004. Particularly compelling are the statements proffered by Drs. Ryall and Desai, which corroborate the lay witness testimony of the veteran's spouse and sister, and the January 2007 VA examination report which assigned a GAF of 36-40 but ultimately could not distinguish the level of impairment attributable to the veteran's various mental disorders. If the medical personnel cannot distinguish between the service- connected and nonservice connected symptomatology arising from the veteran's neuropsychiatric disabilities in total, the Board also cannot distinguish it. See Mittleider v. West, 11 Vet. App. 181 (1998). Other symptoms required for a higher, 100 percent evaluation, are not present. Essentially, the veteran has not been found to be totally occupationally and socially impaired. No opinion has attributed the veteran's unemployability solely to his service-connected PTSD. Rather, these opinions have attributed his unemployability to a combination of his neuropsychiatric and general medical disabilities. In addition, while the veteran has been observed to be disoriented, and to have loss of memory for the names of even close relatives and friends, he has not been observed to be totally socially impaired. Rather, the January 2007 VA examination notes that he mows the lawn for his neighbors, with whom he apparently gets along well. He maintains a relationship with his spouse and child, and works on computers, albeit at a diminished capacity. He gets his son ready for school in the morning and was able to set up a voice recognition program in collaboration with his son. Finally, other than an isolated record of difficulty with activities of daily living in 2003, the veteran has not been found to be unable to perform activities of daily living, nor has he been found to be a persistent danger to himself or others. And while he has been observed to have hallucinations, it has not been reported that they are persistent, or that he is persistently delusional. The veteran and his witnesses contend that his service connected PTSD is worse than initially evaluated. The veteran is competent to report his symptoms and complaints. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, neither he nor his witnesses are competent to offer a medical opinion as to extent of his disabilities as there is no evidence of record that they or he has specialized medical knowledge. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The Board has considered whether "staged ratings" may be assigned in the present case. However, the medical evidence shows that a 70 percent evaluation, and no more is warranted for the service-connected PTSD throughout the entire period of time the claim has been pending. Application of an extraschedular evaluation under 38 C.F.R. Section 3.321(b)(1) will not here be considered, as a claim for entitlement to TDIU is the subject of a remand immediately following this decision. ORDER Service connection for coronary artery disease, as secondary to the service-connected PTSD is granted. Service connection for erectile dysfunction is denied. An initial evaluation of 70 percent for PTSD is granted from April 5, 2004, subject to the laws and regulations governing the award of monetary benefits. REMAND The veteran also seeks service connection for bilateral hearing loss, tinnitus, hypertension, and entitlement to TDIU. By this decision, the Board has granted service connection for coronary artery disease and a 70 percent evaluation for PTSD. Remand is therefore required for the RO to readjudicate the claim for TDIU in light of this decision. Concerning the claim for hypertension, it is noted that the veteran is diagnosed with hypertension and coronary artery disease-the later now being service-connected. Remand is therefore required to afford the veteran VA examination to determine the nature and etiology of his diagnosed hypertension. Concerning the claims for bilateral hearing loss and tinnitus, it is observed that the denial of these claims was based on a July 2004 VA opinion that concluded service connection was not warranted in part because the veteran was unable to estimate the onset of his hearing impairment. Additional VA examination was conducted in September 2005, but the results were found to be inconclusive. The record shows that the veteran exhibited memory and cognitive disorder problems at this time and that he continues to do so. The veteran is a recognized combat veteran with a military occupational specialty as a U.S. Marine rifleman (0311). He served in Vietnam and was awarded the Combat Action Ribbon. His service personnel records documents his participation in eight combat operations. He is service connected for PTSD based on findings of combat exposure. His exposure to acoustic trauma is conceded. See 38 U.S.C.A. § 1154(b) (West 2002 and Supp. 2007. See also Pentecost v. Principi, 16 Vet. App. 124 (2002). The July 2004 and September 2005 VA examinations are inadequate and remand is required to determine the nature and etiology of the veteran's hearing impairment. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. Schedule the veteran for examinations with the appropriate specialists to determine the nature, extent, and etiology of his claimed bilateral hearing loss and tinnitus, and hypertension. All indicated tests and studies should be performed. The claims folder, including all newly obtained evidence, and a copy of this remand, must be provided to the examiner in conjunction with the examination. The examiner is to provide opinions as to whether it is at least as likely as not that any diagnosed bilateral hearing loss, tinnitus, and hypertension had their onset during active service or are in any way the result of active service. All opinions expressed must be supported by complete rationale. 2. After completing any and all additional development required, readjudicate the veteran's claims for service connection for bilateral hearing loss, tinnitus, and hypertension, and of entitlement for TDIU. If any of the benefits sought on appeal are not granted, the veteran and his representative should be furnished a supplemental statement of the case (SSOC) and afforded an opportunity for response. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no action until he is so informed. The veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The veteran is advised that failure to appear for scheduled VA examination without good cause could result in the denial of his claims. 38 C.F.R. § 3.655 (2006). See Connolly v. Derwinski, 1 Vet. App. 566, 569 (1991). The Board intimates no opinion as to the ultimate outcome of this case. This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs