Citation Nr: 1108825 Decision Date: 03/07/11 Archive Date: 03/17/11 DOCKET NO. 06-15 885 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for adenocarcinoma of the colon, to include as secondary to exposure to herbicides. 2. Entitlement to service connection for a respiratory disorder, to include as secondary to exposure to herbicides. 3. Entitlement to service connection for a low back disorder. 4. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to exposure to herbicides. 5. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to exposure to herbicides. 6. Entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to exposure to herbicides. 7. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to exposure to herbicides. 8. Entitlement to service connection for multiple myeloma, to include as secondary to exposure to herbicides. 9. Entitlement to compensation under 38 U.S.C.A. § 1151 for retrograde ejaculation due to VA Medical Center treatment. 10. Entitlement to a compensable evaluation, for the period prior to April 30, 2010, for posttraumatic stress disorder (PTSD). 11. Entitlement to an initial evaluation in excess of 10 percent for the period beginning April 30, 2010, for PTSD. 12. Entitlement to an initial compensable evaluation for bilateral hearing loss. 13. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and Appellant's Spouse ATTORNEY FOR THE BOARD Robert J. Burriesci, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1970 to July 1971, including combat service in the Republic of Vietnam, and his decorations include the Combat Infantryman Badge and Purple Heart Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2004, January 2006, and October 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In January 2011, the Veteran and the Veteran's spouse testified at a video-conference hearing before the undersigned Acting Veterans Law Judge. A transcript of this hearing is associated with the claims folder. The United States Court of Appeals for Veterans Claims (Court) has held that a claim for total disability based on the unemployability of the individual (TDIU) is part of an increased rating claim when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). Specifically, when evidence of unemployability is submitted at the same time that a Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, the Board finds that the Veteran has submitted evidence regarding unemployability in his testimony at the hearing before the undersigned Acting Veterans Law Judge in January 2011. Therefore, TDIU is part of the increased rating claims currently before the Board and must be adjudicated as such. In statements dated in June 2005 and May 2006 and in the Veteran's testimony the Veteran has raised the following issues: entitlement to service connection for a metabolic and digestive disorder, to include as secondary to exposure to herbicides; entitlement to service connection for a heart disorder; entitlement to service connection for a B-12 deficiency; entitlement to service connection for anemia; entitlement to service connection for a liver disorder; entitlement to service connection for tuberculosis; entitlement to service connection for soft tissue sarcoma; entitlement to service connection for a blood disorder; entitlement to service connection for an abdominal disorder; and entitlement to service connection for DNA mutations. As these matters are not currently developed or certified for appellate review, they are referred to the RO for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to service connection for adenocarcinoma of the colon, to include as secondary to exposure to herbicides; entitlement to service connection for peripheral neuropathy of the right upper extremity; entitlement to service connection for peripheral neuropathy of the left upper extremity; entitlement to service connection for peripheral neuropathy of the right lower extremity; entitlement to service connection for peripheral neuropathy of the left lower extremity; entitlement to compensation under 38 U.S.C.A. § 1151 for retrograde ejaculation due to VA Medical Center treatment; and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A low back disorder currently manifested by degenerative disc disease of the lumbar spine is shown as likely as not to be due to injury or disease incurred during the Veteran's period of active service. 2. Since June 11, 2003, the Veteran's PTSD has been manifested by no more than 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. 3. The results of VA audiometric tests conducted in November 2004 show that the Veteran had level I hearing in his right ear and level I hearing in his left ear. 4. The results of VA audiometric tests conducted in March 2010 show that the Veteran had level I hearing in his right ear and level I hearing in his left ear. 5. In January 2011, prior to the promulgation of a decision in the appeal of the issue of entitlement to service connection for a respiratory disorder, to include as secondary to exposure to herbicides, the Board received notification from the appellant that a withdrawal of the appeal of the issue was requested. CONCLUSIONS OF LAW 1. Affording the Veteran the benefit of the doubt, degenerative disc disease of the lumbar spine is due to an injury that was incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 1154(b), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2010). 2. Affording the Veteran the benefit of the doubt, since June 11, 2003, the criteria for a 70 percent rating, but no higher, for PTSD, for the entire period on appeal, are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2010). 3. The criteria for the assignment of an initial compensable evaluation for bilateral hearing loss have not been met for any time period covered by this appeal. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.85, 4.86, Diagnostic Code 6100 (2010). 4. The criteria for withdrawal of a Substantive Appeal in regard to the issue of entitlement to service connection for a respiratory disorder, to include as secondary to exposure to herbicides, have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant 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 claimant 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 claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). 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 Court held that, upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 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 claimant 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. Here, in regard to the Veteran's claims of entitlement to a higher evaluation for PTSD and entitlement to a higher evaluation for bilateral hearing loss, the Veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess, the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, VA's duty to notify in this case has been satisfied. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA treatment records. The Veteran submitted private treatment notes from University of South Alabama, Biloxi Regional Medical Center, Mobile Open MRI, and Spring Hill Memorial Medical Center, and was provided an opportunity to set forth his contentions during the hearing before the undersigned Acting Veterans Law Judge. The Court held in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010) that there are two duties imposed by 38 C.F.R. 3.103(c)(2), (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked-are not impacted by the Veteran's receipt of a VCAA-compliant notice letter. Here, during the hearing, although the AVLJ did not explicitly note the bases of the prior determinations or note the elements that were lacking to substantiate the Veteran's claims, the Veteran's representative demonstrated actually knowledge of this information. The representative's questions specifically elicited responses designed to show that the Veteran's PTSD and bilateral hearing loss disabilities were more severe than currently evaluated. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim.) Accordingly, the Veteran is not shown to be prejudiced on this basis. In addition, the AVLJ sought to identify any pertinent, outstanding evidence that might have been overlooked. The AVLJ specifically asked the Veteran where he received his treatment. Accordingly, the Veteran is not shown to be prejudiced on this basis. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the AVLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2). The appellant was afforded relevant VA medical examinations in January 2004, February 2004, and March 2010. Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In regard to the Veteran's claim of entitlement to service connection for a low back disorder, the Board is granting in full the benefit sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed with respect to this issue. II. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). 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). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604(Fed.Cir.1996). In addition, in cases where a Veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C.A. § 1154(b) and its implementing regulation, 38 C.F.R. § 3.304(d), are applicable. This statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence. If the Veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The Veteran seeks service connection for a low back disorder. The Veteran contends that his low back was injured in service when a beam fell on his back and pinned him to the ground as a result of the explosion. He further contends that his Purple Heart Medal is evidence of the injury to his low back. The Veteran reported that he has had back problems since service. The Veteran's service treatment records do not reveal any complaint, diagnosis, or treatment for any low back disorder. In January 2004 the Veteran was diagnosed with degeneration of the lumbar spine or lumbosacral intervertebral disc. In February 2004 the Veteran reported that a VA physician interpreted X-rays of the lumbar spine to indicate that he had very narrow disc space at L5-S1 with some vertebral bone damage. In February 2004 the Veteran was afforded a VA Compensation and Pension (C&P) spine examination. The Veteran reported that his back was originally injured in service when a large beam fell over his back and legs after an incoming rocket exploded in his bunker. The Veteran reported that he continued to have chronic low back problems since service and that he never sought medical attention for his back. After physical examination the Veteran was diagnosed with degenerative disc disease of the lumbar spine at L5-S1. The examiner stated that there were no specific records dealing with the details of the Veteran's injuries but that he did receive a Purple Heart Medal for his injuries. In March 2004 the Veteran complained of severe pain in the back. In May 2006 a fellow serviceman indicated that the Veteran had been involved in a rocket attack while in service. In April 2008 the Veteran was diagnosed with lumbar spondylosis. A November 2007 X-ray was cited that revealed degenerative disc disease of the L5-S1. In August 2008 the Veteran's lumbosacral spine revealed degenerative disc disease at L5-S1 with no significant disc herniation. There was a disc bulge L1-2 with no evidence of nerve root impingement or compression. There was mild degenerative facet joint disease at L4-5 and L5-S1. There was no stenosis. In October 2008 the Veteran was diagnosed with lumbar spondylosis. The Board finds that entitlement to service connection for degenerative disc disease of the lumbar spine is warranted. The Veteran's service treatment records do not reveal any diagnosis, or treatment for any low back disorder. However, the Veteran's service personnel records reveal that the Veteran was awarded the Purple Heart Medal. The Veteran has credibly reported that he injured back when he was injured in an explosion that resulted in the award of the Purple Heart Medal. In addition, the Veteran has credibly reported that he has had back pain ever since service. As the competent and credible evidence of record reveals that the Veteran injured his back in service, has had back problems since separation from service, and is currently diagnosed with degenerative disc disease of the lumbar spine, affording the Veteran the benefit of the doubt, entitlement to service connection for degenerative disc disease of the lumbar spine is granted. III. Higher Evaluation Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal arises from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A. PTSD In a rating decision dated in June 2004 the Veteran was granted entitlement to service connection for PTSD and assigned an evaluation of noncompensably disabling, effective June 11, 2003, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Subsequently, in May 2010, the evaluation of the Veteran's PTSD was increased to 10 percent disabling, effective April 30, 2010, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran asserts that his PTSD is more disabling than contemplated by the current evaluations. Diagnostic Code 9411 is part of the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130. This formula provides the following ratings for psychiatric disabilities: A 10 percent rating is warranted where the disability is productive of 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 30 percent rating is warranted where the disability is productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted where the disability is productive of 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 warranted where the disability is productive of 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 warranted where the disability is productive of 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. § 4.130. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board further notes that a Global Assessment of Functioning (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. 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; Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. See 38 C.F.R. § 4.126. Age may not be considered as a factor in evaluating a service-connected disability. 38 C.F.R. § 4.19. In February 2004 the Veteran was afforded a VA C&P psychiatric examination. The Veteran reported that he had never received any treatment for PTSD. He stated that he slept very poorly and that in the early years after separation from service he would often go for days without sleeping. He awakened very often at night. The Veteran indicated that the ringing in his ears and back pain trigger intrusive memories. He reported that he experienced nightmares. He stated that he avoided discussion of his experiences in Vietnam. He avoids crowded public situations but his job involves sales. He reported that he no longer engaged in pleasurable activities he previously engaged in and that he spent a great deal of the day working. The Veteran reported poor concentration, hypervigilence, and indicated that when he up at night he is often very watchful of activities in his neighborhood. The Veteran admitted to an exaggerated startle response and indicated that he has caught himself jumping. The Veteran reported that he was irritable and felt that he was more irritable than he would like to be. He admitted to having experienced suicidal ideation but indicated that he has not acted on it due to his religious convictions. The Veteran had essentially no meaningful social relationships. He hardly ever saw his siblings even though they live close by. He admitted some feelings of depression. He had low motivation and had to push himself to get things done. Mental status examination revealed the Veteran to be very neatly and cleanly dressed and demonstrated good personal hygiene. The Veteran was pleasant and cooperative during the examination. He was very articulate and a good historian. He was noted to appear somewhat anxious during the session and spent a great deal of the session sitting on the edge of the chair. He described his mood as dysphoric. His affect was flat and his thought content and process were within normal limits. There was no evidence of delusions or hallucinations. He maintained eye contact throughout the session and no inappropriate behavior was noted. The Veteran admitted to suicidal ideation without current intent. He denied homicidal ideation. He was able to perform the activities of daily living. The Veteran was alert and oriented times four. There was no evidence of gross memory loss or impairment. Speech was linear and coherent and speech production was normal. The Veteran was noted to become very distraught when discussing his experiences in Vietnam. The assessment included that the Veteran met the criteria for PTSD. He had recurrent intrusive memories of Vietnam, avoidance of thinking of Vietnam, diminished interest in activities that he previously enjoyed, and feelings of detachment from others. He had difficulty staying asleep, irritability, difficulty concentrating, hypervigilence, and exaggerated startle response. The Veteran was diagnosed with PTSD, chronic and assigned a GAF score of 55. The examiner summarized that the Veteran reported chronic symptoms of PTSD severe enough to adversely affect his psychosocial functioning and his quality of life. The Veteran was noted to have maintained his own business for 20 years and that he ran the business with his wife. He had no meaningful social relationships outside of the marriage and had given up many of his recreational pursuits. The Veteran reported that he felt he was functioning fairly well. The Veteran had suicidal ideation without intent and received no treatment for his PTSD. He was noted to be alert and oriented and to have no impairment in judgment. The examiner reported that the Veteran's PTSD fell in the moderate range of severity. The Veteran underwent a VA outpatient psychiatric consultation in June 2005. The Veteran reported that he recalled the men dead and with lost limbs, intestines exposed. He stated that he had nightmares three times a week for 20 years and though they had become less frequent he will still have one. He only sleeps 4 to 5 hours each night but it is restful sleep. He and his wife are close companions but he has few friends and spends little time with his siblings and their children. He is not involved in any activities or hobbies. He is easily startled at times and has had some temper problems in the past. He has felt depressed on a consistent basis since returning from Vietnam. He had a hard time concentrating due to tinnitus. The Veteran reported that he had numbness and tingling over the right side of the body and traced it back to the explosion in service or exposure to herbicides. The Veteran had suicidal ideation for 4 to 5 years after returning from Vietnam. Mental status examination revealed that the Veteran was neatly dressed and groomed, was pleasant and cooperative with the examiner, and was oriented to time, place, person, and situation. His speech was normal in rate and volume. He was calm. His thought process was logical and goal directed. He had tight associations. There were no suicidal or homicidal ideations. There were no obsessions or compulsions. There were no hallucinations or illusions. The Veteran had no anxiety and had an average intelligence. He could spell "world" backward. His memory was intact and his judgment and insight were good. The Veteran was diagnosed with PTSD. The Veteran underwent a VA outpatient psychiatric consultation in October 2005. The Veteran reported that the medication has improved his sleep and mood in general. His night sleep was longer and his anxiety was better. He reported feeling paranoid. The Veteran had occasional flashbacks and survival guilt. He had intrusive thoughts about the incident most days and continued hearing a high pitched noise that never stops even when he sleeps. Mental status examination revealed that the Veteran's gait was normal, he was clean, casually dressed, and well groomed, and fully alert and oriented to time, place, person, and situation. His speech was clear, normal in tone, rate, volume, and progression. There was no psychomotor retardation or agitation observed. The Veteran's affect/mood was bright, euthymic/"tired." His thought process was coherent, well organized, and goal directed. He denied suicidal and homicidal ideation. He had no delusions, ideas of reference, or hallucinations/illusions. He had mild anxiety and his intelligence was average. His insight and judgment were fair and he was cognitively intact. The Veteran was diagnosed with PTSD and dysthymic disorder and assigned a GAF score of 45. In January 2006 the Veteran underwent a VA outpatient psychiatric consultation. The Veteran was alert, cooperative, oriented times four, casually dressed, and adequately groomed. His affect was appropriate and his mood was calm and pleasant. His stream and content of thought were normal. His memory and cognition were grossly intact. There was no suicidal or homicidal ideation or plans voiced. His insight and judgment were good. The Veteran was diagnosed with PTSD and assigned a GAF score of 45. In a statement dated in April 2006 the Veteran's spouse reported that the Veteran sleeps with a club, a gun, and a hunter's knife under the bed and a baseball bat to the side of the bed. He was unable to concentrate and gets confused. He was depressed and irritable and at times short tempered. He had trouble staying asleep and falling asleep. He was distrusting of others and at times paranoid. In a statement, received in May 2006, the Veteran's spouse indicated that the Veteran suffered from occupational and social impairment with deficiencies in his work, family relations, judgment, thinking, and mood. She reported that there is a record of his suicidal ideation in his medical file and that this is something to which she could attest. She stated that the Veteran has made reference to suicide as a possible solution to problems. The Veteran's spouse indicated that the Veteran suffered from depression and that it affected his ability to function normally. He gets irritable at times which turns to hitting a wall or throwing something. She has witnessed him telling customers to leave the store. His work efficiency was decreased. She has seen him sit for hours and sometimes days trying to fix minor blemishes that most people would not even notice. He makes a lot of mistakes and forgets basic things like locking the back door of the store and ordering the wrong merchandise. She indicated that he is unable to concentrate on things. She stated that the Veteran forgets the names of relatives, has trouble falling asleep, and does not sleep through the night. In a statement from the Veteran's brother the Veteran was noted to be sometimes weak and very tired and somewhat disoriented. His speech was sometimes slurred. The Veteran was reported to have nightsweats and nightmares. In a statement from the Veteran's sister-in-law, received in May 2006, she described the Veteran as having a high level of anxiety. He was scared to be alone and experienced depression and panic attacks. He repeated sentences. He was obsessed with daily routines. In a VA treatment note dated in April 2008 the Veteran was noted to have a gait within normal limits and to be well groomed and appearing the stated age. He was cooperative with good eye contact and alert and oriented. His speech was mildly increased in rate but otherwise normal. There was no psychomotor agitation or retardation noted. His affect and mood were mildly anxious and described as "pretty good." His thought process was linear, logical without gross impairment. He had no suicidal or homicidal ideation, no delusions, no ideas of reference, and no preoccupations. He had no obsessions, compulsions, hallucinations, or illusions. He denied anxiety and his intelligence was within normal limits. His insight and judgment were good to fair and there was no gross deficit in attention or concentration. The Veteran was diagnosed with PTSD, dysthymic disorder, and history of panic disorder. He was assigned a GAF score of 48. In a July 2008 VA outpatient psychiatry note the Veteran was noted to be alert, cooperative, oriented times four, casually dressed, adequately groomed, affect constricted, mood mildly-moderately anxious, stream and content of thought were normal, memory and cognition were grossly intact, no suicidal or homicidal ideas or plans, insight and judgment good. The Veteran was diagnosed with PTSD and assigned a GAF score of 43. In a treatment note dated in December 2008 the Veteran was noted to be alert, cooperative, oriented times four, casually dressed, adequately groomed, affect constricted, mood mildly anxious, stream and content of thought were normal, memory and cognition were grossly intact, no suicidal or homicidal ideas or plans, insight and judgment good. The Veteran was diagnosed with PTSD and assigned a GAF score of 46. The Veteran underwent a Vet Center outpatient evaluation in January 2009. The Veteran complained of severe depressions, irritability and feelings of rage, sleep disorder with constant flashbacks, severe nightmares, and, in the past, regular night sweats. The Veteran reported a sense of betrayal, mistrust of authority figures and exaggerated startle response. He had intrusive, distressing thoughts of the war on a regular basis. He reported having these symptoms since leaving Vietnam. He has worked steadily for many years. He was noted to have a lack of motivation and avoidance. He worked to avoid intrusive thoughts of his wartime experience. He was frequently isolated and avoided co-workers, family, and many other people in attempts to cope with his job. He reported avoiding the outdoors, tennis, golf, sailing, and various other recreational activities as well as avoiding church, crowds, and many other group activities. The Veteran demonstrated an exaggerated startle response and avoidance when confronted with environmental cues that are reminiscent of Vietnam and other combat zones. The Veteran suffered from sleep disturbance, nightmares, flashbacks, feelings of rage, and alienation. He had an exaggerated startle response, feelings of impending doom, significant survivor guilt, and hypervigilence. He had difficulty concentrating and suffered from long and short term memory deficits. He had recurring, intrusive thoughts about his combat experiences. He remained alienated from other people in most situations, has almost no close friends, and seemed to relate only to other combat Veterans and his wife. He was frightened and startled by loud noise, avoided crowds of people, and continued to isolate himself. The problems were noted to have negatively impacted his occupational and personal life to a profound extent. Although the Veteran had been married for 28 years, he indicated that he is lucky she was still with him as he is so irritable. The Veteran was diagnosed with PTSD. In a statement dated in January 2009 the Veteran was noted to have been treated at the Mobile Vet Center since July 2008. The Veteran was noted to complain of severe depression, irritability, feelings of rage, sleep disorder, constant flashbacks, severe nightmares, and past report of regular night sweats. The Veteran reported a sense of betrayal, mistrust of authority figures and exaggerated startle response. He indicated intrusive, distressing thoughts of the war on a regular basis. The Veteran stated that his PTSD affected his job and that eventually these effects led to self employment. He reported that he worked to avoid intrusive thoughts of his wartime traumatic experiences. He was frequently isolated and avoided co-workers, family, and many other people in an attempt to cope with the job. He reported avoiding the outdoors, tennis, golf, sailing, and various other recreational activities as well as church, crowds, and many other group activities. He demonstrated an exaggerated startle response and avoidance when confronted with environmental cues that are reminiscent of Vietnam and other combat zones. The Veteran was noted to receive both individual and group treatment and that he had sleep disturbance, nightmares, flashbacks, feelings of rage, and alienation. He had an exaggerated startle response, feelings of impending doom, significant survivor guilt, and hypervigilence. He had difficulty concentrating and suffered from long and short-term memory deficits. He had recurring, intrusive thoughts about his combat experiences. He remained alienated from other people including his family in most situations, had almost no friends, and seemed to relate only to other combat Veterans and his wife. He was frightened and startled by loud noises, avoided crowds of people, and continued to isolate himself. These problems were noted to have negatively impacted the Veteran's occupational and personal life to a profound extent. The Veteran's PTSD symptoms were reported to be severe and chronic in nature and cause the Veteran great distress and difficulty in both occupational and family life. In a treatment note dated in June 2009 the Veteran was noted to be alert, cooperative, oriented times four, casually dressed, adequately groomed, affect constricted, mood mildly anxious, stream and content of thought were normal, memory and cognition were grossly intact, no suicidal or homicidal ideas or plans, insight and judgment good. The Veteran was diagnosed with PTSD and assigned a GAF score of 45. In a statement dated in January 2009 the Veteran reported that he had GAF scores of 45 in January 2006, 43 in April and June 2006, 45 in July 2006, 48 in October 2006 and February 2007, 43 in July 2008, and 46 in December 2008. In March 2010 the Veteran was afforded a VA C&P PTSD examination. Examination revealed the Veteran to be clean and casually dressed. He was mildly restless, cooperative, and friendly. His speech was clear and coherent with stuttering. His affect was appropriate and he described his usual mood as a lot of depression with outbursts sometimes. He was oriented to person, time, and place and his attention was intact. His thought process was unremarkable. He thought content was noted to be preoccupied with medical issues with possible paranoia about "cover up." He had no delusions and he was able to understand the outcome of his behavior. He had average intelligence and he understood that he had a problem. The Veteran was noted to have sleep impairment consisting of 2 to 3 hours of sleep a night without medication and 4 or 5 hours of sleep with medication. He had no hallucinations or inappropriate behavior. He interpreted proverbs appropriately. The Veteran had no obsessive or ritualistic behaviors. The Veteran had no panic attacks or homicidal thoughts. He had passive suicidal thoughts without intent. He had good impulse control. He had no episodes of violence. He was able to maintain minimum personal hygiene and had no problem with activities of daily living. His memory was normal for remote, recent, and immediate memory. The Veteran's PTSD symptoms were noted to be recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions, recurrent distressing dreams of the event, intense psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of the traumatic event, physiological reactivity on exposure to internal or external cures that symbolize or resemble an aspect of the traumatic event. The Veteran made efforts to avoid, thoughts, feelings, or conversations associated with the trauma. He had inability to recall an important aspect of the trauma. He had markedly diminished interest or participation in significant activities. He had feelings of detachment or estrangement from others, restricted range of affect, and sense of foreshortened future. He had difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilence, and exaggerated startle response. The Veteran's symptoms were chronic and daily with moderate severity. He reported not liking crowds of people, not having much contact with family, and not going to church since returning from service. The Veteran reported that his daily flashbacks of Vietnam and that his lack of contact with family members and lack of involvement in activities had become more severe since the prior examination. The Veteran was diagnosed with PTSD and assigned a GAF score of 50. The Board finds that entitlement to an evaluation of 70 percent disabling, and no higher, for the Veteran's PTSD is warranted since June 11, 2003, the effective date of service connection. During this entire period, his PTSD was manifested by two incidents of suicidal ideation, no meaningful social relationships outside of his marriage, depression, low motivation, dysphoric mood, sleep difficulties including nightmares, and exaggerated startle. Examiners described the Veteran's PTSD symptoms as moderate to severe and assigned GAF scores predominantly in the mid 40's representing 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 counselor in a statement dated in January 2009 indicated that the Veteran's PTSD symptoms were severe and chronic in nature and cause the Veteran great distress and difficulty in both occupational and family life. The Board acknowledges that the Veteran's spouse has reported that he forgot the names of relatives and has difficulties working. In other lay statements the Veteran has been described as having panic attacks and obsessive rituals. However, the preponderance of the evidence reveals that at no point during the period on appeal did the Veteran's PTSD disability manifest symptoms of 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); or disorientation to time or place. As his symptoms more nearly approximate occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood representing an evaluation of 70 percent disabling, entitlement to an evaluation of 70 percent disabling, and no higher, for PTSD for the entire period on appeal is granted. B. Bilateral Hearing Loss The Veteran asserts that his bilateral hearing loss disability is more disabling than contemplated by the current noncompensable disability rating. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of speech discrimination tests together with the average hearing threshold levels as measured by pure tone audiometry tests in the frequencies 1,000, 2,000, 3,000, and 4,000 cycles per second (hertz). To evaluate the degree of disability for service-connected hearing loss, the rating schedule establishes eleven (11) auditory acuity levels, designated from level I for essentially normal acuity through level XI for profound deafness. 38 C.F.R. § 4.85. Examinations are conducted without the use of hearing aids. 38 C.F.R. § 4.85(a). Disability ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. See Bruce v. West, 11 Vet. App. 405, 409 (1998), quoting Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). In addition, exceptional patterns of hearing impairment exist for VA purposes when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 hertz) is 55 decibels or more. Then, the rating specialist must determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). Exceptional patterns of hearing impairment also exist for VA purposes when the pure tone threshold is 30 decibels or less at 1000 hertz and 70 decibels or more at 2000 hertz. Then, the Roman numeral designation for hearing impairment will be selected from either Table VI or Table VIa, whichever results is the higher numeral, and that numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(b). As the audiological findings reported below demonstrate, the Veteran does not have exceptional patterns of hearing impairment for VA purposes. In June 2004, the RO granted service connection for bilateral hearing loss and assigned the current noncompensable rating under Diagnostic Code 6100, effective June 11, 2003, which was the date the Veteran's claim for service connection was received. The Veteran essentially contends that his hearing loss disability is more disabling than contemplated by a noncompensable evaluation. He contends that his hearing loss puts him at an employment disadvantage and that it lessens his enjoyment of music. In November 2004, the Veteran was afforded a formal VA audiological examination. The Veteran reported that he still heard fine in the range of the human voice but that he had problems trying to hear around the ringing. In addition, the Veteran reported that his wife has stated that he misses things. The authorized audiological evaluation revealed pure tone threshold levels, in decibels, as follows: HERTZ 1000 2000 3000 4000 RIGHT 10 15 65 75 LEFT 10 25 80 75 Pure tone threshold levels averaged 41 decibels for the right ear and 48 decibels for his left ear. Speech audiometry revealed speech recognition ability of 94 percent in his right ear and 94 percent in his left ear. The mechanical application of the Rating Schedule to the March 2004 VA audiometric evaluation shows that the Veteran had level I hearing in his right ear and level I hearing in his left ear, which warrants a noncompensable evaluation under Diagnostic Code 6100. In a statement dated in April 2006 the Veteran's spouse indicated that the Veteran could not hear certain sounds including the sound of the blinker in the car and the beep that the cell phone makes when a call is missed. She stated that when they are out at a restaurant he cannot hear a lot of what she says. She reported that he misses out on conversations when they go out with family members and that he sometimes misunderstands what customers are saying. In a statement from the Veteran's brother the Veteran was noted to be virtually deaf and that he could not hear the birds when they went out hunting. In a statement from the Veteran's sister in law, received in May 2006, the Veteran was noted to have difficulty following conversations. In March 2010, the Veteran was afforded a formal VA audiological examination. The authorized audiological evaluation revealed pure tone threshold levels, in decibels, as follows: HERTZ 1000 2000 3000 4000 RIGHT 20 30 75 80 LEFT 15 30 80 85 Pure tone threshold levels averaged 51 decibels for the right ear and 53 decibels for his left ear. Speech audiometry revealed speech recognition ability of 94 percent in his right ear and 94 percent in his left ear. The examiner noted that the Veteran's hearing loss had significant effects on the Veteran's occupation due to hearing difficulty and that there were no effects on the Veteran's usual daily activities. The mechanical application of the Rating Schedule to the March 2004 VA audiometric evaluation shows that the Veteran had level I hearing in his right ear and level I hearing in his left ear, which warrants a noncompensable evaluation under Diagnostic Code 6100. In light of the foregoing, the Board concludes that the preponderance of the evidence is against a finding that his bilateral hearing loss warrants a compensable schedular evaluation at any point during the period on appeal. In Martinak v. Nicholson, 21 Vet. App. 447 (2007), the Court, noted that VA had revised its hearing examination worksheets to include the effect of the Veteran's hearing loss disability on occupational functioning and daily activities. See Revised Disability Examination Worksheets, Fast Letter 07-10 (Dep't of Veterans Affairs Veterans Apr. 24, 2007); see also 38 C.F.R. § 4.10. The Court also noted, however, that even if an audiologist's description of the functional effects of the Veteran's hearing disability was somehow defective, the Veteran bears the burden of demonstrating any prejudice caused b a deficiency in the examination. The November 2004 C&P examination was conducted before the examination worksheets were revised to include the effects of hearing loss disability on occupational functioning and daily life. The Veteran, as a lay person, is nevertheless competent to submit evidence of how the hearing loss affects his everyday life. See Layno v. Brown, 6 Vet. App. 465, 469-470 (1994) (finding that lay testimony is competent when it regards features or symptoms of injury or illness). The examiner noted in the examination report that the Veteran reported that he still heard fine in the range of the human voice but that he had problems trying to hear around the ringing. In addition, he reported that his wife has stated that he misses things. Thus, the examination report did include information concerning how the Veteran's hearing loss affects his daily functioning. After examination in March 2010, the examiner noted that the Veteran's hearing loss had significant effects on the Veteran's occupation due to hearing difficulty and that there were no effects on the Veteran's usual daily activities. However, the evidence does not show that the Veteran's difficulty hearing his wife and hearing on the telephone has resulted in marked interference with employment. C. Extraschedular Consideration The Board has considered whether the Veteran's claim warrants referral to the Chief Benefits Director of VA's Compensation and Pension Service under 38 C.F.R. § 3.321. The Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. In this case, the Board finds that the rating criteria reasonably describe his disability level and symptomatology, and provide for higher ratings for additional or more severe symptoms than currently shown by the evidence. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. Furthermore, the Board finds no evidence of any unusual or exceptional circumstances, such as marked interference with employment or frequent periods of hospitalization related to the service-connected disabilities at issue that would take the Veteran's case outside the norm so as to warrant an extraschedular rating. The Veteran has not required frequent periods of hospitalization related to any service-connected disability at issue. Therefore, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321 is not warranted. IV. Withdrawal Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A Substantive Appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202. Withdrawal may be made by the appellant or by his authorized representative. 38 C.F.R. § 20.204. In January 2011, the Veteran testified at a hearing before the undersigned Acting Veterans Law Judge; a transcript of that hearing is of record. He indicated his desire to withdraw the issue of entitlement to service connection for a respiratory disorder, to include as secondary to exposure to herbicides. Because the Veteran's statements indicating his desire to withdraw this issue offered during his January 2011 hearing were later reduced to writing and incorporated into the record in the form of a written transcript, the transcript of that hearing has been accepted as his withdrawal of that issue on appeal. See Tomlin v. Brown, 5 Vet. App. 355 (1993). Therefore, the Veteran has withdrawn the appeal of the issue of entitlement to service connection for a respiratory disorder, to include as secondary to exposure to herbicides, and, hence, there remain no allegations of errors of fact or law for appellate consideration regarding that issue. Accordingly, the Board does not have jurisdiction to review the appeal of the issue of entitlement to service connection for a respiratory disorder, to include as secondary to exposure to herbicides, and it is dismissed. ORDER Service connection for degenerative disc disease of the lumbar spine is granted. Effective June 11, 2003, an evaluation of 70 percent for PTSD is granted, subject to the law and regulations governing payment of monetary benefits. An initial compensable evaluation for bilateral hearing loss is denied. The appeal of the issue of entitlement to service connection for a respiratory disorder, to include as secondary to exposure to herbicides, is dismissed. REMAND The Veteran seeks service connection for adenocarcinoma of the colon, to include as secondary to exposure to herbicides; entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to exposure to herbicides; entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to exposure to herbicides; entitlement to service connection for peripheral neuropathy of the right lower extremity, to include as secondary to exposure to herbicides; entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to exposure to herbicides; entitlement to service connection for multiple myeloma, to include as secondary to exposure to herbicides; entitlement to compensation under 38 U.S.C.A. § 1151 for retrograde ejaculation due to VA Medical Center treatment; and entitlement to a TDIU. The Veteran receives VA care and the claims file reveals that the Veteran's complete treatment records have not been associated with the claims file. Specifically, the Veteran has identified treatment at the VA between April 2006 and February 2007 whose records have not been associated with the claims file. VA is required to make reasonable efforts to help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody. See 38 U.S.C.A. § 5103A(b)(1); 38 C.F.R. § 3.159(c)(1). In Bell v. Derwinski, 2 Vet. App. 611 (1992), the Court held that VA has constructive notice of VA generated documents that could reasonably be expected to be part of the record, and that such documents are thus constructively part of the record before the Secretary and the Board, even where they are not actually before the adjudicating body. Thus, attempts must be made to obtain all VA clinical records pertaining to his treatment. The Veteran seeks service connection for adenocarcinoma of the colon, to include as secondary to exposure to herbicides in service. The Veteran argues, in part, that the adenocarcinoma is a soft tissue sarcoma and is therefore presumptively related to the Veteran's exposure to herbicides in service. The Veteran's service treatment records do not reveal any complaint, diagnosis, or treatment for any adenocarcinoma. In a statement dated in February 2004 the Veteran reported that was advised to have one and a half feet of his colon and 30 lymph nodes removed due to colon cancer. He had colon surgery in March 2004. To date the Veteran has not been afforded a VA medical examination regarding the etiology of the Veteran's adenocarcinoma of the colon. As such, the Board finds it necessary to afford the Veteran an examination regarding the etiology of his adenocarcinoma of the colon. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran seeks to service connection for peripheral neuropathy of the upper and lower extremities, to include as secondary to exposure to herbicides in service. The Veteran reports that his peripheral neuropathy, numbness in the extremities, is related to his exposure to herbicides in service. In a statement dated in February 2004 the Veteran reported that a VA physician indicated that he did not believe that the Veteran's peripheral neuropathy was due to the Veteran's exposure to herbicides but rather due to back trauma. In February 2004 the Veteran was afforded a VA C&P neurological examination. The Veteran reported that he had tingling and numbness in both lower extremities extending to the thigh and also in the right hand. He stated that it started at least one year before the examination. He also reported numbness in the right arm. He indicated that he has light numbness all the time but that it will sometimes become more severe. He reported that he had difficulty writing and picking up boxes and that he did not feel as strong as he used to be but that he can still do everything. Physical examination revealed that he was able to take steps on his heels and toes. He was able to do tandem. He had pupils that were equal and reactive to light. His extraocular movements were full. There was no facial asymmetry. On motor examination there were no significant involuntary movements. There was no muscle atrophy. Power was 5/5 in the upper and lower extremities. Deep tendon reflexes were somewhat brisk in the upper extremities to lower extremities. Knee jerks were 2+ and ankle jerks were 2+. Plantars were downgoing. There was no Hoffman or clonus. Muscle tone was normal. Sensory examination revealed some decreased pinprick in the feet but not in any dermatomal pattern. Vibration and position sense was intact. He had some decreased pinprick in the hands on the palmar side. There was no significant spinal tenderness. Straight leg raise test was negative. The examiner diagnosed the Veteran with numbness in the lower extremities and also in the right hand that was nonspecific and questionable for neuropathy. The examiner stated that his numbness in the lower extremities can be associated with his back problem; the neuroconductive study was normal. In a statement dated in June 2005 the Veteran indicated that a VA physician reviewed his X-rays and rendered the opinion that he had chronic peripheral neuropathy manifested by hard gray patches on his peripheral nerves at the L5-S1 area of the spine. The Veteran indicated that he believed that the condition was either caused by his in service back injury or by his exposure to herbicides. In November 2008 the Veteran was noted to have bilateral sensory loss of unknown etiology. In February 2009 the Veteran was reported to have bilateral sensory loss which could be partly related to prior B12 deficiency, and some of his symptoms in the arms may be related to some cervical spine disease. The physician stated that he was doubtful that the Veteran had neuropathy and that a 2006 EMG was unremarkable for a large fiber neuropathy. The evidence of record is unclear as to whether the Veteran is diagnosed with peripheral neuropathy and while the examiner in February 2004 stated that the Veteran's numbness in the lower extremities can be associated with his back problem, the examiner also indicated that the Veteran was questionable for neuropathy. In light of the inadequate VA examination, dated in February 2004, and the additional evidence of record, the Board finds it necessary to afford the Veteran a VA medical examination. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran seeks entitlement to compensation under 38 U.S.C.A. § 1151 for retrograde ejaculation due to VA Medical Center treatment. The Veteran contends that after colon surgery he developed retrograde ejaculation. When a Veteran suffers additional disability or death as the result of training, hospital care, medical or surgical treatment, compensated work therapy, or an examination furnished by the VA, disability compensation shall be awarded in the same manner as if such additional disability or death were service-connected. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361. The provisions of 38 U.S.C.A. § 1151 specify two bases for establishing entitlement. First, entitlement may be established on the basis of a showing of carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of VA providers. Second, entitlement may be established on a showing of an event not reasonably foreseeable. To establish causation, the evidence must show that VA's hospital care, medical or surgical treatment, or examination resulted in additional disability or death. Merely showing that a Veteran received care, treatment, or examination and that the Veteran has an additional disability or died does not establish cause. 38 C.F.R. § 3.361(c)(1). Such VA treatment cannot cause the continuance or natural progress of a disease or injury for which such care was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). In addition to a showing of additional disability or death, there must be evidence showing either that VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or that VA furnished treatment without the informed consent of the Veteran and his representative, in compliance with 38 C.F.R. § 17.32. Minor deviations from the 38 C.F.R. § 17.32 requirements that are immaterial under the circumstances of a case will not defeat a finding of informed consent. Consent may be express or implied as specified under 38 C.F.R. § 17.32(b), as in emergency situations. 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a Veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). A March 2004 treatment note shows that the Veteran consented to risks explained. It was noted that a copy of the surgical consent form was scanned into VISTA. The Veteran underwent a laparoscopic sigmoid colectomy in March 2004. In an August 2004 treatment note the Veteran reported that he has been sterile since his March 2004 surgery. He indicated that he does not ejaculate after intercourse. In September 2004 the Veteran reported that he did not have any problems achieving and maintaining erections and that he had the sensation of orgasm but that no ejaculate is produced. The Veteran has submitted handwritten notes regarding the questions that he asked preoperatively. He indicates that he asked about impotence and sterility as well as lasting complications and was informed that there would be none. In April 2005 the Veteran was noted that a VA physician felt that the Veteran's impotence could be secondary to nerve damage from colon surgery for carcinoma. The note indicated that the physician did not disagree that the time course of the Veteran's complaint seemed to indicate surgery was pertinent to the problem. In a statement submitted by the Veteran's spouse, she indicated that a group of physicians had indicated that the Veteran's retrograde ejaculation would not occur due to the Veteran's colon surgery. She reported that the surgery took much longer than anticipated. She stated that the nurse that kept her informed during the surgery indicated that they were having difficulty finding the tumor. In May 2006 the Veteran indicated that surgeons were switched at the last minute without his approval. The Veteran referenced a September 2004 VA treatment note indicating that a physician had explained how the Veteran's colon surgery caused his retrograde ejaculation. VA has neither afforded the Veteran an examination nor solicited a medical opinion as to whether the Veteran's retrograde ejaculation is a result of carelessness, negligence, lack of proper skill, error in judgment, or a similar instance of fault on the part of VA providers or an event not reasonably foreseeable the onset and/or etiology of his non-small cell carcinoma of the lung. Under 38 U.S.C.A. § 5103A(d)(2), VA must provide a medical examination and/or obtain a medical opinion when there is: (1) competent evidence that the Veteran has a current disability (or persistent or recurrent symptoms of a disability); (2) evidence establishing that he suffered an event, injury or disease in service or has a disease or symptoms of a disease within a specified presumptive period; (3) an indication the current disability or symptoms may be associated with service; and (4) there is not sufficient medical evidence to make a decision. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). As such, the Board finds that the Veteran's claim must be remanded for the Veteran to be afforded a VA examination. Lastly, as noted above, the Board finds that the Veteran has raised an informal claim for a TDIU, which must be remanded for further development and adjudication. A claim for a TDIU is generally not a freestanding claim; rather, it is a claim for an increased rating (a total rating based on individual unemployability) for the underlying disability(ies). The claim may be expressly raised (e.g., by filing a VA Form 21-8940) or "reasonably raised by the record," and the claim may be filed as a component of the initial claim or as a claim for an increase rating for a service-connected disability. The VCAA's duties to notify and assist apply to the latter. If a Veteran asserts entitlement to a TDIU during adjudication of the issue of entitlement to service connection or during the appeal of the initial evaluation assigned, the issue is part of the underlying claim for an increased initial evaluation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Once a Veteran makes a claim for the highest rating possible, and submits evidence of unemployability, an informal claim for a TDIU is raised. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); 38 C.F.R. § 3.155. Here the testimony at the January 2011 hearing reveals that the Veteran has been marginally self employed. He indicated that he has difficulty in this protected work environment due to his disabilities. Since the claim of entitlement to a TDIU is dependent, in part, on the outcome of the Veteran's service connection claims that are being remanded, the Board finds the issues to be inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered). Because the issues are inextricably intertwined, the Board is unable to review the issue of entitlement to a TDIU until the issues of entitlement to service connection are resolved. Id. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). Expedited handling is requested.) 1. Attempt to obtain all VA medical records pertaining to the Veteran, specifically those dated April 2006 to February 2007, those dated since May 2008, and those from the Mobile Vet Center, as well as outstanding records of his treatment at the Biloxi, Mississippi, Mobile, Alabama, and Pensacola, Florida, VA Medical Centers. Any additional pertinent records identified by the Veteran during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the Veteran, and associated with the claims file 2. Thereafter, arrange for the Veteran to undergo an appropriate VA examination to determine the nature, extent, onset and etiology of any adenocarcinoma of the colon found to be present. The claims folder should be made available to and reviewed by the examiner. The examiner should indicate in his/her report whether or not the claims file was reviewed. All indicated studies should be performed, and all findings should be reported in detail. The examiner should render an opinion regarding whether the Veteran's adenocarcinoma of the colon is a soft tissue sarcoma. The examiner should opine as to whether it is at least as likely as not that any adenocarcinoma of the colon is related to or had its onset during service, including the Veteran's presumed exposure to herbicides. The rationale for all opinions expressed should be provided in a legible report. 3. Then afford the Veteran an appropriate VA examination to determine the nature, extent, onset and etiology of any peripheral neuropathy of the upper and lower extremities found to be present. The claims folder should be made available to and reviewed by the examiner. All indicated studies should be performed, and all findings should be reported in detail. The examiner should opine as to whether it is at least as likely as not that any peripheral neuropathy of the upper and lower extremities found to be present is related to or had its onset during service. If not, the examiner should opine as to whether it is at least as likely as not that any peripheral neuropathy of the upper and lower extremities is secondary to or aggravated by the service-connected degenerative disc disease of the L5-S1. The rationale for all opinions should be provided in a report. 4. Thereafter, make arrangements with the appropriate VA medical facility or facilities to obtain a VA medical opinion as to whether it is at least as likely as not that the Veteran's retrograde ejaculation, was proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault of VA in furnishing the hospital care, medical or surgical treatment, or examination, or an event not reasonably foreseeable, in connection with his March 2004 colon surgery. The VA physician must have sufficient expertise in the area of urology to provide a medical opinion as to whether carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault of VA in furnishing the hospital care, medical or surgical treatment, or examination, or an event not reasonably foreseeable, resulted in the Veteran's retrograde ejaculation. The physician should provide, at a minimum, a brief description of his/her qualifications in the area of urology. Reasonable diligence should be exercised in obtaining an opinion from a VA physician who is sufficiently impartial to whether the March 2004, surgery involved use of proper skill, care, and judgment. If the physician finds that an examination of the Veteran is required to provide the requested medical opinion, such an examination must be scheduled. The physician is requested to provide a complete rationale for his or her opinion, as a matter of medical probability, based on his or her clinical experience, medical expertise, and established medical principles. 5. Then, readjudicate the appeal. If the benefits sought on appeal are not granted, issue the Veteran and his representative a supplemental statement of the case and provide them an opportunity to respond. The appellant has the right to submit additional evidence and argument on the 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 Supp. 2010). ______________________________________________ STEVEN D. REISS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs