Citation Nr: 1122329 Decision Date: 06/09/11 Archive Date: 06/20/11 DOCKET NO. 07-34 398 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for post-traumatic stress disorder (PTSD). 2. Entitlement to a compensable rating for scar residuals of a shell fragment wound to the right thigh. 3. Entitlement to service connection for tinea versicolor, to include as secondary to herbicide exposure. 4. Entitlement to service connection for a liver disability to include elevated liver enzymes, to include as secondary to herbicide exposure. 5. Entitlement to service connection for hypertension, to include as secondary to herbicide exposure. 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from November 1967 to November 1970, including combat service in the Republic of Vietnam, and his decorations include the Combat Medical Badge and the Purple Heart Medal. This matter comes to the Board of Veterans Appeals (Board) from September 2006 and September 2008 rating decisions of the Nashville, Tennessee, Department of Veterans Affairs (VA) Regional Office (RO). Because the Veteran explicitly contends that he is entitled to a TDIU rating, since the evidence shows that he is unemployed, and given that the examiner who performed the December 2008 VA psychiatric examination stated that he may be unemployable due to his PTSD, the Board finds that a remand is warranted to address the claim of entitlement to a TDIU rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (where there is evidence of unemployability raised by the record during a rating appeal period, the TDIU is an element of an initial rating or increased rating). As such, the Board has included this issue on the title page. The Veteran's claims seeking an initial evaluation in excess of 70 percent for PTSD, to service connection for hypertension and liver disability, and to a TDIU are addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Since April 15, 2008, the Veteran's PTSD causes, at least, occupational and social impairment, with deficiencies in most areas. 2. The Veteran's scar residuals of a shell fragment wound to the right thigh are symptomatic and cause pain. 3. Tinea versicolor had its onset in service. CONCLUSIONS OF LAW 1. The criteria for at least an initial 70 percent rating for PTSD, effective August 15, 2008, are met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2010). 2. The criteria for a 10 percent rating for scar residuals of a shell fragment wound to the right thigh are met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7801 (2007). 3. Tinea versicolor was incurred in service. 38 U.S.C.A. §§ 1101, 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide. 38 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the Veteran with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of the claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). RO letters dated June 2006, May 2008, and November 2008 informed the Veteran of all three elements required by 38 C.F.R. § 3.159(b), as stated above. The letters also notified the Veteran that that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded, in compliance with Dingess. Regarding the duty to assist, VA also fulfilled its duty to obtain all relevant evidence with respect to the issue on appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran's service treatment records and post-service medical records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication that any additional evidence, relevant to the issue decided herein, is available and not part of the claims file. The Veteran was also afforded VA examinations for his higher rating claims The examinations are adequate as the examiner reviewed the pertinent history, examined the Veteran provided findings in sufficient detail, and provided rationale. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Ratings Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. However, if VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the claim has been pending. In Hart v. Mansfield, 21 Vet. App. 505 (2007), the United States Court of Appeals for Veterans Claims (Court) found no basis for drawing a distinction between initial ratings and increased rating claims for applying staged ratings. Accordingly, it was held that ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Also, before proceeding with its analysis of the Veteran's claim, the Board finds that some discussion of Fenderson v. West, 12 Vet. App 119 (1999) is warranted. In that case, the Court emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case (such as this one) in which a Veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim-a practice known as "staged rating." See also Hart. PTSD The Veteran has been assigned a 50 percent rating for PTSD, effective August 15, 2008. The regulations for mental disorders are found in 38 C.F.R. §§ 4.125-4.130. The Board notes that PTSD which is evaluated under Diagnostic Code 9411 is rated according to the General Rating Formula for Mental Disorders. A 50 percent rating is provided for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is provided 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is provided for total occupational and social impairment, due to such symptoms as: Gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. §§ 4.125-4.130. The Board further notes that a 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 (4th ed. 1994). The Board notes that an examiner's classification of the level of psychiatric impairment, by a GAF score, is to be considered but is not determinative of the percentage rating to be assigned. VAOPGCPREC 10-95. Global Assessment of Function (GAF) scores ranging between 81 and 90 reflect absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging between 61 to 70 reflect 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 generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more 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). Scores ranging from 41 to 50 reflect 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). See 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV, for rating purposes]. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e. g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130. In July 2006, the Veteran was afforded a VA PTSD examination. Mental status examination revealed that the Veteran exhibited poor eye contact. He had fair concentration. His speech was normal. His affect was appropriate. His mood was depressed. His thought processes did not reflect delusions or hallucinations, but he had a history of probable hallucinations fur to alcohol withdrawal. He denied suicidal or homicidal ideation. He was alert and oriented times three. He had good recent and remote memory. His concentration was fair and his fund or knowledge was good. He had insight into his problems. The diagnosis was alcohol dependence in partial remission; PTSD. His GAF was 45. Thereafter, the Veteran attended group psychotherapy sessions as well as anger management therapy. His VA records dated prior to the 2006 VA examination and after that time are generally consistent with the examinations findings, although a lower GAF of 40 was recorded. In August 2008, the Veteran was afforded another VA examination. He presented with average grooming and hygiene. He arrived on time and was anxious, but cooperative. The Veteran stated that he had been divorced once and was currently separated from his second wife due to past alcohol use. He had 3 adult children and 4 grandchildren with whom he had a good relationship. The Veteran was living with his sister which was a good living arrangement. Currently, the Veteran was sober, according to his treating psychologists, and participating in the appropriate alcohol programs. Mental status examination revealed that the Veteran was alert and oriented in all spheres. His speech was low in rate and tone with normal articulation. Is mood was anxious and affect was moderately restricted. The Veteran did not present with psychomotor agitation or retardation. His thought process was goal-directed and concrete. The Veteran reported that he occasionally had auditory hallucination when he felt his worse, but the symptoms were rare. There was no indication of disorganized thinking or delusions during the conversation. He did not present with unusual features of memory or cognition. The Veteran reported that his sleep was notably poor which was one of his chief complaints. His judgment and personal insight appeared fair and his impulse control was fair to poor. He denied suicidal and homicidal ideation, plan, or intent. Memory was average. His fund of knowledge was low average. He reported avoidant behavior. He also exhibited low average attentional abilities. He was unable to complete serial 7's, but was able to answer basic arithmetic problems and could spell the word "world" forward and backwards. The Veteran was a concrete thinker who was unable to provide abstract interpretations of proverbs or point out similarities between categorically related objects. His abstract social judgment appeared to be generally adequate and he behaved in a generally norm manner. The Veteran reported feeling socially isolated. He was jumpy and overreacted to noise. He also reported feeling anxious and worried. The Veteran reported having numerous symptoms related to combat and of feeling guilty about telling soldiers that he knew would die that they would make it home, in his duties as a combat medic. He suffered from nightmares, depression, and survivor guilt. The Veteran felt numb as to death and was unable to cry when his mother died. He reported restricted affect, poor eye contact, and a watchful and guarded demeanor. The Veteran was basically able to care for himself. The diagnosis was chronic PTSD. The GAF was 60, but the examiner noted that the Veteran had a serious level of overall impairment. In December 2008, the Veteran was afforded another PTSD examination. At that time, the Veteran indicated that he had lost all of his jobs due to his alcohol abuse. The examiner noted that the Veteran's subjective complaints had not changed. The examiner noted that the Veteran was still attending Alcoholic Anonymous and maintain sobriety. His GAF was 55. The examiner noted that the Veteran had taken positive steps to improve his life by maintaining sobriety. The examiner further indicated that the alcohol problems were related to his PTSD. The examiner indicated that his current symptoms, including social isolation may make it very likely made it difficult for him to sustain gainful employment. The Board finds that the criteria for at least a 70 percent rating are warranted. The Veteran has occupational and social impairment, with deficiencies in most areas. He is not employed and has been granted pension. In the past, his alcohol abuse, as noted to be due to PTSD, caused work impediments. However, the Board accepts that there is occupational impairment due to PTSD, as pointed out by the VA examiner in December 2008. The Veteran also has cognitive impairments, depression, occasional hallucinations, impaired impulse control, and a myriad of subjective PTSD symptoms attributable to his combat service. Scar Residuals of a Shell Fragment Wound to the Right Thigh In September 2007, the Veteran was afforded a scar examination. The examiner noted that the Veteran had a shell fragment wound with no pain. However, he described stiffness and pain in the area, but the Veteran thought that they were due to arthritis. Physical examination revealed that the scar was located appropriately above the right knee, laterally, and up across the distal part of the lateral surface of the right thigh. Palpation revealed that underlying structures were mildly loose. There was no elevation of the scar. There was mild depression of the scar with the lower extremity in extension which disappeared with flexion. There was induration which was more pronounced around the scar by palpating in comparison with the counterpart that measured approximately 2 centimeters in width along the scar. The scar was atrophic in appearance with no keloid formation. There was mild hyperpigmentation noted along and surrounding the scar. Otherwise, it was healed and non-tender with moderate disfiguration in the area. The maximum width was .5 centimeters. The length was 8.5 centimeters. There was no tenderness to palpation, but there was adherence to underlying tissue with soft tissue damage. There was no loss of function or skin ulceration or breakdown. The diagnosis was scar in lateral aspect of the right thigh, distal part, from shrapnel fragment wound with minimal residuals concerning the scar itself. The Veteran has been assigned a noncompensable rating under Diagnostic Code 7805. Under the rating schedule, disfigurement of the head, face, or neck is rated under Diagnostic Code 7800. The Veteran's scar is located on his leg. Scars, other than head, face, or neck, that are superficial and that do not cause limited motion warrant a 10 percent rating for area or areas of 144 square inches (929 sq. cm.) or greater. A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802. A 10 percent rating may be assigned for scars which are superficial and unstable. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7803. A 10 percent rating is assigned for scars which are superficial and painful on examination. 38 C.F.R. § 4.118, Diagnostic Code 7804. Scars may also be rated based on limitation of function of the affected part. 38 C.F.R. § 4.118, Diagnostic Code 7805. In this case, the Veteran's scar is deep since there is underlying tissue damage; it is not superficial. In addition, it is not productive of limitation of function of the right thigh. Scars, other than on the head, face, or neck, that are deep or that cause limited motion are assigned a 40 percent evaluation for an area or areas exceeding 144 square inches; a 30 percent evaluation for an area or areas exceeding 72 square inches; a 20 percent evaluation is assigned for an area or areas exceeding 12 square inches (77 sq. cm.); and a 10 percent evaluation for an area or areas exceeding 6 square inches. 38 C.F.R. § 4.118, Diagnostic Code 7801. Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, are separately rated and combined in accordance with 38 C.F.R. § 4.25. Id. at Note (1). A deep scar is one associated with underlying soft tissue damage. Id. at Note (2). Although the Veteran's scar is less than 6 square inches, it is also disfiguring, there is mild depression, it is hyperpigmented, and there is induration. There is no exact diagnostic code that reflects the Veteran's symptoms. The Board notes that the assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. I n reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the Veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995); Pernorio v. Derwinski, 2 Vet. App. 625 (1992). The Board finds that in light of the medical history, the current diagnosis, and demonstrated symptomatology, the Veteran's scar more nearly approximates the criteria for a 10 percent rating under Diagnostic Code 7801 as the scar is deep and productive of other symptoms. A higher rating is not warranted since it is not nearly large enough. During the pendency of this appeal, VA amended the rating schedule governing ratings of skin, 38 C.F.R. § 4.118, effective October 23, 2008. See 73 Fed. Reg. 54708-54712 (September 23, 2008). This amendment applies to all applications for benefits received by VA on or after October 23, 2008. Id. As the Veteran's claim for an increase was received prior to that date, his claim is not subject to the amended regulation. In sum, a higher rating of 10 percent is warranted under Diagnostic Code 7801 for the appeal period. The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected scar disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's scar with the established criteria found in the rating schedule shows that the rating criteria reasonably describes the Veteran's disability levels and symptomatology, as discussed above. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). The second and third elements may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The service treatment records reflect that in February and May 1970, the Veteran was treated for tinea versicolor, noted to have been contracted in Vietnam. The skin problem was also described as being a rash. On his July 1970 physical examination at separation, the Veteran was noted to have tinea versicolor. Post-service VA records reflect that the Veteran was diagnosed in August 2003 as having tinea versicolor. Subsequent records reflect treatment for skin rashes. In sum, the Veteran had tinea versicolor during service. After service, he reports that he continued to have skin rashes. He is competent to report skin rashes. The Veteran is competent to testify as to both the incurrence and continuity of symptomatology and the lack of corroboration does not, by itself render lay evidence incredible. See e.g., Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Veteran's credible statements constitute continuity of symptomatology. There is a post-service diagnosis of tinea versicolor and evidence post-dating that diagnosis not only showed further skin rashes, but that "tinea versicolor" remained on the Veteran's medical list of disabilities. Thus, service connection is warranted on a direct basis. As such, there is no need to consider presumptive service connection due to herbicide exposure. ORDER Subject to the law and regulations governing payment of monetary benefits, effective August 15, 2008, a 70 percent rating for PTSD is granted. Subject to the law and regulations governing payment of monetary benefits, a 10 percent rating for scar residuals of a shell fragment wound to the right thigh is granted. Service connection for tinea versicolor is granted. REMAND As to his PTSD claim, the Board has granted entitlement to an initial 70 percent rating. The Board observes, however, that in a February 2009 statement, the Veteran reported that the psychiatric disability had worsened and that he was unable to work due to the condition, which is consistent with the statement offered by the examiner who prepared the most recent VA psychiatric examination report, which is dated in December 2008. As such, the Board has no discretion and must remand the Veteran's claim for an initial evaluation in excess of 70 percent for PTSD, to include the TDIU aspect of that claim. Rice. As to his hypertension claim, the Board notes that the evidence shows that the Veteran has hypertension and it is unclear whether that disease was caused or aggravated by his PTSD. Finally, because the medical evidence indicates that the Veteran has used alcohol to treat his psychiatric disability, and because it is unclear whether he has a liver disability, related to either herbicide exposure or to his PTSD, the Board finds that this claim must be remanded for further development. Accordingly, this matter is REMANDED for the following actions: 1. Associate any pertinent, outstanding records with the claims folder. 2. Afford the Veteran a VA psychiatric examination to determine the extent and severity of his PTSD. The claims folder should be made available to and reviewed by the examiner. All indicated tests should be performed. The examiner should report all pertinent findings and estimate the Veteran's Global Assessment of Functional (GAF) Scale score. The examiner must also opine as to whether it is at least as likely as not that the Veteran is unable to secure or follow a substantially gainful occupation due to his PTSD. In doing so, the examiner must acknowledge and discuss the findings and conclusions set forth in the December 2008 VA psychiatric examination report. If the examiner is of the opinion that due to his PTSD, or due to the cumulative impact of each of his service-connected disabilities, the Veteran is not unemployable, the examiner should suggest the type or types of employment in which the Veteran would be capable of engaging with his current service-connected disabilities, given his current skill set and educational background. The examiner should set forth a complete rationale for all findings and conclusions in a legible report. 3. Afford the Veteran an appropriate VA examination to determine whether he has a liver disability. The examiner must opine as to whether it is at least as likely as not that the Veteran has a liver disability that is related to or had its onset in service, to include his in-service herbicide exposure. Thereafter, the examiner must state whether it is at least as likely as not that any liver disorder found to be present is related to alcohol use related to the Veteran's service-connected PTSD. All findings and conclusions should be set forth in a legible report. 4. Then adjudicate whether the Veteran's psychiatric disability warrants an evaluation in excess of 70 percent; adjudicate whether a TDIU is warranted; and thereafter readjudicate the remaining issues on appeal. If the benefits sought on appeal are not granted, the RO must issue a supplemental statement of the case and the veteran should be given an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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 2002 & Supp. 2010). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs