Citation Nr: 1300787 Decision Date: 01/09/13 Archive Date: 01/16/13 DOCKET NO. 10-07 274 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for a skin condition, diagnosed as tinea cruris. 2. Entitlement to service connection for a sinus condition. 3. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 4. Entitlement to a rating in excess of 20 percent for diabetes mellitus with erectile dysfunction. 5. Entitlement to service connection for a disability of the hands, to include carpal tunnel syndrome (CTS) and osteoarthritis, to include as secondary to service-connected diabetes mellitus. 6. Entitlement to service connection for peripheral neuropathy in the bilateral lower extremities, to include as secondary to service-connected diabetes mellitus. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD L. A. Rein, Counsel INTRODUCTION The Veteran had active service from June 1969 to December 1970. These matters come to the Board of Veterans' Appeals (Board) on appeal from August 2008 and March 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In September 2012, the Veteran and his spouse testified during a videoconference hearing before the undersigned Veterans Law Judge; a transcript of that hearing is of record. Because the Veteran has disagreed with the initial rating assigned following the grant of service connection for PTSD, the Board has characterized this issue in light of Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). The issues of entitlement to service connection for a skin condition, entitlement to a rating in excess of 20 percent for diabetes mellitus with erectile dysfunction, entitlement to service connection for a disability of the hands, to include carpal tunnel syndrome and osteoarthritis, to include as secondary to service-connected diabetes mellitus, and entitlement to service connection for peripheral neuropathy in the bilateral lower extremities, to include as secondary to service-connected diabetes mellitus 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. The evidence is in equipoise as to whether the Veteran's sinus condition began in service. 2. From the March 2, 2009, effective date of the grant of service connection, the Veteran's PTSD was manifested, primarily, by depression, chronic sleep disturbance and insomnia, nightmares, flashbacks, irritability and anger, avoidance behaviors, exaggerated startle response, difficulty concentrating, feelings of detachment, decreased energy and interest in activities, hypervigilance, passive suicidal thoughts and restlessness. These symptoms are reflective of no more than occupational and social impairment with reduced reliability and productivity. Occupational and social impairment with deficiencies in most areas and inability to establish and maintain effective relationships is not demonstrated. CONCLUSIONS OF LAW 1. With resolution of all reasonable doubt in the Veteran's favor, the criteria for service connection for a sinus condition have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. With resolution of all reasonable doubt in the Veteran's favor, the criteria for an initial 50 percent rating for PTSD, but no higher, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.20, 4.130, 4.132, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA have been codified, as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim, as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice 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. VA's notice requirements apply to all five elements of a service connection claim: Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, a January 2008 letter and a September 2009 letter provided notice to the Veteran of the evidence and information needed to substantiate his claims for service connection for a sinus disorder and a psychiatric disorder. These letters also informed the Veteran of what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The letters further requested that the Veteran submit any additional information or evidence in his possession that pertained to his claims. After issuance of the above letters, and proving the Veteran and his representative additional opportunity to respond, the RO readjudicated each issue decided herein in an April 2012 statement of the case and supplemental statement of the case. Hence, the Veteran is not shown to be prejudiced by the timing of VCAA-compliant notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006). See also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in a statement of the SOC or SSOC, is sufficient to cure a timing defect). In addition, it is noted that 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, once service connection was granted there was no further duty to notify. Additionally, the record also reflects that VA has complied with the duty to assist. Pertinent medical evidence of record includes the Veteran's service treatment records, VA medical records, private medical records, Social Security Administration records, and the reports of VA examinations. Also of record and considered in connection with the appeal is the transcript of the September 2012 Board hearing, as well as various written statements provided by the Veteran, his family and friends, as well as by his representative, on his behalf. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO, the appellant has been notified and made aware of the evidence needed to substantiate the claims herein decided, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with any claim(s). Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the appellant or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters herein decided, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Service connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). That determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d) (2012). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing a service connection claim. See 38 C.F.R. § 3.303(b) (2012). Continuity of symptomatology may be established if a claimant can demonstrate (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. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). Service treatment records are negative for complaints, findings or diagnosis of any sinus condition in service. A January 1983 VA medical record reflects that the Veteran complained of chronic nasal obstruction and drainage "since Vietnam." The impression was deviated nasal septum with chronic sinusitis, question of allergic. An April 1983 VA medical record reflects that the Veteran underwent septoplasty for a deviated nasal septum. A February 1984 VA allergy consultation report reflects that the Veteran reported nasal symptoms and sore throat for ten to seventeen years. The diagnosis was chronic rhinitis, allergy probably significant, questionable food. An August 1987 private medical record notes findings of allergic drainage. An October 1987 VA medical record notes that a radiographic report of the paranasal sinuses when compared with those from January 1983 demonstrates ethmoid and frontal haziness indicative of sinusitis. A January 1997 private medical record reflects that the Veteran had persistent postnasal drip and sore throat. He underwent a nasal endoscopy. The assessment was chronic rhinitis and vacuum sinusitis with vasomotor rhinitis suspected as the mechanism of the Veteran's chronic problem. In the Veteran's November 2007 claim for VA benefits, he asserted that while in Vietnam he became sick with respiratory problems and that he continued to have problems. He also stated that in his first year after discharge from service, he was treated for many respiratory diagnoses, but was not specific. In a November 2008 VA mental health record, the Veteran reported that he had sinusitis since Vietnam and that his symptoms started during his second part of duty. He stated that he got sick with the same symptoms that he currently has now, specifically constant drainage in the back of his throat, coughing up greenish-yellowish mucus every morning, and blowing his nose every morning. In August 2009 letters, the Veteran's uncle and a family friend stated that they were aware of the Veteran's respiratory problems after he returned from Vietnam. A February 2012 VA larynx and pharynx examination report reflects that the Veteran has been diagnosed with vasomotor rhinitis. The Veteran reported chronic sinusitis that began in 1970. He has had recurrent sinus infections associated with recurrent headaches, sinus congestion, and coughing. The examiner noted that a sinus CT from September 2008 was normal, no sinusitis. During the September 2012 Board hearing, the Veteran testified that he started having sinus type problems in Vietnam. He indicated that he was treated in Vietnam and within one year after discharge from service for the same complaints. In this case, the Veteran reports that he had the same problems in service and was treated by a medic although there is no record of such treatment. There is no reason to doubt the Veteran's credibility with respect to having symptoms in service, for which he received treatment by a medic, and reports of symptoms shortly after his discharge which continued thereafter. The Board also finds it significant, that in January 1983, while seeking VA medical treatment, he reported that he had chronic nasal obstruction and drainage "since Vietnam." This statement is significant and given a lot of weight and credibility because it was made during the course of seeking medical treatment, years before he submitted a claim for VA benefits, when there was no incentive - financial or otherwise - to fabricate information for personal gain. See, e.g., Struck v. Brown, 9 Vet. App. 145, 155-56 (1996). See also Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (finding that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). His reports are also competent and probative. While post service VA medical records are negative for complaints, findings or diagnosis of a sinus condition until 1983, the Veteran reports that he continued to suffer with such symptoms during Vietnam and continuing thereafter, which the Board also finds credible. Moreover, statements provided by his Uncle and friend support his contentions of having sinus symptoms since his discharge from service. Although the Veteran was afforded a VA examination in February 2012, no opinion as to a relationship between the Veteran's sinus condition and his service was provided. However, both rhinitis, which was diagnosed by the VA examiner and in the VA medical records, and chronic sinusitis, for which he received treatment in February 2010 and which is listed as a current problem on the Veteran's VA health care problem list, at least as likely as not began in service. This conclusion is based on the Veteran's credible reports of symptoms in service and thereafter, which were ultimately diagnosed as rhinitis and sinusitis. Upon considering the totality of the evidence, including the Veteran's credible assertions of sinus problems in Vietnam with continuous symptomatology since service, the diagnosis of sinusitis in 1983 and most recently vasomotor rhinitis on VA examination in February 2012, and the nature of the disability, the Board finds that the evidence is at least equipoise on the question of a nexus, based on continuity of symptomatology, between the current respiratory disorder and service. Therefore, by resolving all reasonable doubt in the Veteran's favor, the claim of service connection for a sinus condition is granted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. III. Increased rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign an evaluation 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. 38 C.F.R. § 4.126(a) (2012). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Veteran's PTSD has been assigned an initial 30 percent rating since the March 2, 2009 effective date for the grant of service connection pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. A General Rating formula for evaluating psychiatric impairment other than eating disorders contains the actual rating criteria for evaluating the Veteran's disability. Pursuant to the General Rating formula, a 30 percent rating is warranted when there is occupation and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactory, 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, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating requires 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 per 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 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 work like setting); inability to establish and maintain effective relationships. A rating of 100 percent is warranted 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. A November 2008 VA mental health record notes that the Veteran gets angry from the frustration of being ill, feeling bad, and unable to enjoy his life. He indicated that his memory was getting bad. He also reported nightmares on a weekly basis, hitting his wife in his sleep, few friends, a loner, and occasional flashbacks. Screening for depression was positive. The Veteran was seen in February 2009, at which time his medication was adjusted and a GAF score of 55 was assigned. An April 2009 VA medical record reflects that although the Veteran had been on a variety of antidepressants, he was not feeling any better on any of them. The diagnosis was major depression, recurrent and PTSD. A GAF score of 61 was assigned. A December 2009 VA PTSD examination report reflects that the Veteran had PTSD symptoms consisting of painful nightmares recalling his combat experience, episodes of becoming extremely agitated in his sleep and actually hitting his wife during those periods. He also suffers distress when exposed to stimuli which remind him of his combat experiences. He avoids situation that he knows will cause him difficulties such as crowds or seeing movies about combat. He has a loss of interests in previously pleasurable activities. He feels emotionally walled off, numb, and detached. He is quite socially withdrawn. He described feelings of depression and sadness with decreased mood, difficulty with concentration and focus, frequent awakenings, feelings of hopelessness and helplessness and passive suicidal ideations. He has difficulty with anger, irritability and being short-tempered. He startles easily. He is not currently receiving any psychiatric care. He has been married for 20 years. He goes to church, but described discomfort with social interactions and lack of interest. On mental status examination, the Veteran was alert, oriented and cooperative. His mood is obviously depressed and he became tearful and distraught describing his experiences in Vietnam. His thoughts are clear and goal oriented except when interrupted by his emotional distress. There is no evidence of delusions or hallucinations. His cognitive abilities, including capacity for abstraction, memory, and judgment are tested and intact. His grooming and hygiene were appropriate. Speech and communication were appropriate. There was no panic, paranoia or obsessional rituals. There is ongoing hypervigilance. The Veteran described some suicidal ideation, but no current suicidal plan or intent. The diagnosis was PTSD and major depression and a GAF score of 50 was assigned. The examiner noted that the Veteran's symptoms of depression appeared to be a result of both his significant PTSD as well as being demoralized and depressed by his physical difficulties. The Veteran also described difficulty with irritability causing friction at home, as well as in the work place and currently described almost complete social isolation as a result of his PTSD and major depression. A March 2012 VA PTSD examination report reflects that the Veteran does not obtain any mental health services currently. The examiner noted that there were very little mental health records associated with the claims file. The Veteran has been married since 1981 and reports that they have a good relationship. He attends church three times a week, if he is not too physically ill. The Veteran's PTSD symptoms were described as intrusive memories of Vietnam, nightmares, diminished interest in normal activities, detachment from others, restricted affect, sleep disturbance, concentration problems, and hyper-vigilance. These symptoms occur on a daily basis. The Veteran also has depression caused by his physical problems and manifested by feelings of sadness and worthlessness, diminished pleasure, irritability, and low energy. Intensity of problems is moderate to severe with impaired social relationships, judgment, mood, and range of activities. The Veteran demonstrates reduced reliability and productivity in his occupational and social functioning because of flattened affect, impaired concentration, impaired judgment, disturbances of motivation and mood, and difficulty establishing and maintaining effective relationships. His employment problems seem primarily related to his physical difficulties, and while his PTSD and depression would interfere with employment, it would not preclude it. The Veteran's PTSD and depression cause a moderate impairment of the Veteran's concentration, thought organization, social comfort, ability to cooperate and communicate with others, ability to deal with conflict, frustration tolerance, and mood stability. The diagnosis was PTSD, chronic, and adjustment disorder with depressed mood. A GAF score of 55 was assigned for depression because of excessive guilt, worry, and irritability and a GAF score of 51 was assigned for PTSD because of no friends and low social tolerance. During the September 2012 Board hearing, the Veteran testified that he wakes in the middle of the night with bad dreams, is easily startled, has a short temper with outbursts, nightmares, does not like to socialize, avoids crowds, has some thoughts of suicide and of hurting others if they get in his way or are some sort of threat. The Board has considered all the evidence of record in light of the criteria noted above, and finds that by resolving all reasonable doubt in favor of the Veteran, an initial 50 percent disability rating is warranted from the March 2, 2009, effective date of the grant of service connection. In granting an initial 50 percent for the Veteran's PTSD, the Board has considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for PTSD. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In this regard, since the March 2, 2009 effective date of the grant of service connection, the Veteran's PTSD symptoms were manifested, primarily, by: chronic sleep disturbance, nightmares, irritability and anger, depression, avoidance behaviors, restricted affect, hypervigilance, difficulty concentrating, feelings of detachment, impaired judgment, passive thoughts of suicide and exaggerated startle response. The Board finds that this symptomatology more nearly reflects occupational and social impairment with reduced reliability and productivity, the criteria for a 50 percent disability rating. The Board emphasizes that since the March 2, 2009 effective date of the grant of service connection, the evidence does not show symptoms such as 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 work like setting); or an inability to establish and maintain effective relationships or more severe symptomatology such as to warrant at least the next higher 70 percent rating. The Veteran's passive suicidal thoughts, disturbances of mood, and impaired judgment were considered in assigning the 50 percent evaluation. The evidence does not show that there are deficiencies in most areas with symptoms such as those described immediately above such that the criteria for a higher evaluation are approximated. According to the Fourth Edition of the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF score is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). The GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a) . The Board finds that collectively, the GAF scores assigned are consistent with an initial 50 percent rating. In this case, the Veteran has been assigned GAF scores of 50, 51, 55, and 61 for his service-connected PTSD since the month prior to filing his claim. According to DSM-IV, GAF scores between 41 and 50 indicate 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, and inability to keep a job). A GAF of 51-60 denotes moderate symptoms (e.g. flat affect, circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). In this case, the reported symptomatology is consistent with no more than moderate symptoms or moderate difficulty in social, occupational, or school functioning. In this regard, although the Veteran has reported passive thoughts of suicide, he has no intentions, further he has a good relationship with his wife and interacts with other family members, thus demonstrating that he does not manifest an inability to establish and maintain effective relationships, attends church, was appropriately groomed, and was not found to have obsessional rituals. In sum, the evidence demonstrates that the symptoms and degree of social and industrial impairment from the disability since the initial grant of service connection do not more nearly approximate the criteria for a 70 percent rating. Moreover, the evidence does not show total social and occupational impairment, as the Veteran has been able to maintain a relationship with his wife and as neither he nor the examiners or clinicians have indicated that he is totally disabled as a result of his service-connected psychiatric disorder. The statements of the Veteran and the hearing testimony of the Veteran's wife have been considered and are found credible, competent and probative. They support the assignment of a 50 percent evaluation, however, the evidence as a whole does not show that the criteria for a higher evaluation are met or approximated. While the Board has applied the benefit-of-the-doubt doctrine in determining that the criteria for an initial 50 percent rating since the March 2, 2009 effective date of the grant of service connection have been met, the Board finds that the preponderance of the evidence is against the assignment of any higher ratings; hence, there is no basis for staged ratings of the Veteran's PTSD, pursuant to Fenderson. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The Court of Appeals for Veterans Claims has clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App 111, 115-16 (2008). First, the RO or the Board must 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 Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional 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. The symptoms report by the Veteran are specifically contemplated in the pertinent rating criteria and are therefore adequate to evaluate the Veteran's disability. Accordingly, referral for consideration of extraschedular rating is not warranted. ORDER Entitlement to service connection for a sinus condition is granted. An initial 50 percent rating for PTSD, but no higher, is granted, subject to the laws and regulations governing the award of monetary benefits. REMAND Initially, the Board notes that during the September 2012 hearing before the undersigned, the Veteran indicated that his diabetes symptoms are more severe than reflected in the current 20 percent disability rating assigned. Specifically, he asserted that he has a restricted diet and activities. Therefore, to ensure that the record reflects the current severity of the Veteran's diabetes mellitus with erectile dysfunction, the Board finds that a contemporaneous examination, with findings responsive to the applicable rating criteria, is needed to properly evaluate the disability. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). See also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one) and Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered contemporaneous"). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (2012). The Court has held that when aggravation of a nonservice-connected condition is proximately due to or the result of a service-connected condition the veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995); see also 38 C.F.R. § 3.310(b) . With regards to the Veteran's claim for a skin condition, the Veteran contends that he was treated for a rash in the groin area during service in the Republic of Vietnam. A February 2012 VA diabetes examination report reflects that the VA examiner indicated that the Veteran had a skin condition that was at least as likely as not due to the Veteran's diabetes mellitus. However, the VA examiner did not identify the skin condition related to the Veteran's diabetes mellitus in that report or in a February 2012 skin disease examination. The February 2012 skin disease examination merely noted that the Veteran had a diagnosis of tinea crurus with no discussion of etiology. The Board finds that the VA examination reports fail to clearly identify what, if any, skin condition is related to the Veteran's service-connected diabetes mellitus or whether any diagnosed skin condition is related to service, to include tinea crurus. On remand, the Veteran should again be examined and provided with notice as to how to substantiate his claim on a secondary basis. With regards to the Veteran's claims for service connection for a hand disability, to include CTS and osteoarthritis, VA medical records show that the Veteran has been diagnosed with both of these disabilities. Specifically, he was diagnosed with CTS and underwent release surgery in 2001, which a February 2012 VA examiner noted appeared successful. A December 2009 VA examination report reflects that a VA examiner opined that the Veteran's CTS was not related to or aggravated by the Veteran's service-connected diabetes mellitus. The February 2012 VA examiner concluded that the Veteran's current hand pain was from another source. He was found to have ulnar nerve entrapment after undergoing diagnostic testing. VA medical records show that the Veteran is also diagnosed with osteoarthritis of the hands. The VA examiner opined that neither the Veteran's remote carpal tunnel syndrome nor his current ulnar nerve entrapments are due to the Veteran's stint as a stenographer in the military in 1970. He noted that the Veteran worked heavy labor since leaving the service, both in construction and as a farmer. He is extremely muscular and also is morbidly obese. All of these are risk factors for entrapment. However, the February 2012 VA examiner did not address the etiology of the Veteran's diagnosed osteoarthritis of the hands, nor whether any of these diagnosed disabilities were secondary to the Veteran's service-connected diabetes mellitus. Hence, the Board finds that the VA examination is inadequate. With regards to the Veteran's claim for service connection for peripheral neuropathy of the bilateral lower extremities, an April 2009 VA examination report addendum reflects that the examiner clearly opined that the Veteran has peripheral neuropathy (paresthesias and dysthesias left lower extremity). A November 2009 VA medical record notes that the Veteran was prescribed medication for neuropathic pain. A January 2010 VA neurology examination report reflects an impression of possible small fiber neuropathy, etiology from underlying poorly controlled diabetes mellitus. However, a February 2012 VA examination report reflects that the VA examiner concluded that there was no evidence of generalized peripheral neuropathy of any extremity. The Board finds that the evidence of record is replete with conflicting findings. In light of the above, the Board finds that the medical evidence currently of record is insufficient to make a decision on the claims for service connection for a skin disability, a hand disability, to include CTS and osteoarthritis, and peripheral neuropathy, on a direct or secondary basis, and that an additional VA examination based on a full review of the record is needed to resolve these claims. See 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Lastly, during the September 2012 Board hearing, the Veteran asserted that he had received VA treatment for his diabetes mellitus in June 2012. VA treatment records associated with the claims file are dated through August 2011. Therefore, the RO should obtain and associate with the claims file all outstanding VA records dated from August 2011 to the present. See Dunn v. West, 11 Vet. App. 462 (1998); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following actions: 1. Obtain all outstanding VA medical records dating from August 2011. If no further treatment records exist, the claims file should be documented accordingly. 2. Inform the Veteran as to how he can substantiate his claim for service connection for a skin rash as secondary to his service-connected diabetes mellitus pursuant to 38 C.F.R. § 3.159. 3. Then, schedule the Veteran for an appropriate VA examination to determine the current severity of his service-connected diabetes mellitus disability. The entire claims file must be provided to the examiner, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. All indicated tests should be accomplished and all clinical findings reported in detail. The examiner should render findings responsive to the criteria for rating diabetes mellitus, to include whether the condition requires insulin, restricted diet, and/or regulation of activities (avoidance of strenuous occupational and recreational activities). If regulation of activities is necessary, please state whether this is due solely to diabetes mellitus. The examiner should also state whether the Veteran has been hospitalized for episodes of ketoacidosis or hypoglycemic reactions; whether he requires visits to his diabetic care provider either weekly or twice per month; whether he has complications and, if so, the severity thereof; and whether he has had a progressive loss of weight and strength due solely to the service-connected diabetes disability. A complete explanation must be given for all opinions and conclusions. 4. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any skin disease, to include tinea crurus. The entire claims file must be provided to the examiner, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. All indicated tests should be accomplished and all clinical findings reported in detail. The examiner is requested to identify all diagnosed skin disease disabilities and opine whether it is at least as likely as not (i.e. there is a 50 percent or greater probability) that any skin disability, including tinea cruris, began in or is related to the Veteran's active service. Also, as the February 2012 VA examiner indicated that there was a skin disability secondary to diabetes mellitus, the examiner should opine whether it is at least as likely as not (i.e. there is a 50 percent or greater probability) that any diagnosed skin disability, to include tinea cruris, (a) was caused, or (b) are aggravated (worsened) beyond the natural progress by the Veteran's service-connected diabetes mellitus disability. If aggravation is found, the examiner should address the following medical issues: (1) the baseline manifestations of the Veteran's skin disability (ies) found prior to aggravation; and (2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected diabetes mellitus disability. The Veteran has contended that the onset of his rash in the groin area was in service. It should be noted that he is competent to attest to factual matters of which he had first-hand knowledge. In providing the opinions requested above, the examiner must consider the Veteran's statements regarding the onset of his skin disease, in addition to his statements regarding the continuity of symptomatology. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant's report of in-service injury and instead relied on the absence of evidence in the service treatment records to provide a negative opinion).. A complete explanation must be given for all opinions and conclusions. 5. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any hand disability, to include CTS, osteoarthritis, and ulnar nerve entrapment, as well as peripheral neuropathy of the bilateral lower extremities. The entire claims file must be provided to the examiner, and the examination report should reflect consideration of the Veteran's documented medical history and assertions. All indicated tests should be accomplished and all clinical findings reported in detail. The examiner is requested to identify all bilateral hand disabilities and whether the Veteran has a diagnosis of peripheral neuropathy of the bilateral lower extremities. Thereafter, the VA examiner is requested to opine whether the Veteran has a current hand disability, including CTS, ulnar nerve entrapment and osteoarthritis, and peripheral neuropathy of the bilateral lower extremities that is at least as likely as not (i.e. there is a 50 percent or greater probability) related to the Veteran's active service, to include presumed agent orange exposure therein. Further, the examiner should opine whether it is at least as likely as not (i.e. there is a 50 percent or greater probability) that any diagnosed hand disability, to include CTS, osteoarthritis, and ulnar nerve entrapment and any diagnosed peripheral neuropathy of the bilateral lower extremities (a) were caused, or (b) are aggravated (worsened) beyond the natural progress by the Veteran's service-connected diabetes mellitus disability. If aggravation is found, the examiner should address the following medical issues: (1) the baseline manifestations of the Veteran's hand disability (ies) and peripheral neuropathy found prior to aggravation; and (2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected diabetes mellitus disability. With regards to the Veteran's claim for service connection for peripheral neuropathy of the bilateral lower extremities, the examiner's attention is directed to the following evidence. An April 2009 VA examination report addendum reflects that the examiner clearly opined that the Veteran has peripheral neuropathy (paresthesias and dysthesias left lower extremity). A November 2009 VA medical record notes that the Veteran was prescribed medication for neuropathic pain. A January 2010 VA neurology examination report reflects an impression of possible small fiber neuropathy, etiology from underlying poorly controlled diabetes mellitus. However, a February 2012 VA examination report reflects that the VA examiner concluded that there was no evidence of generalized peripheral neuropathy of any extremity. The Veteran has contended that the onset of his hand symptoms was in service. It should be noted that he is competent to attest to factual matters of which he had first-hand knowledge. In providing the opinions requested above, the examiner must consider the Veteran's statements regarding the onset of his hand conditions, in addition to his statements regarding the continuity of symptomatology. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant's report of in-service injury and instead relied on the absence of evidence in the service treatment records to provide a negative opinion).. A complete explanation must be given for all opinions and conclusions. 6. After ensuring the examination reports are adequate, readjudicate the claims. If any benefit sought on appeal remains denied, the Veteran should be issued a supplemental statement of the case (SSOC) and given a reasonable opportunity to respond before the case is returned to the Board. 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 Supp. 2012). ______________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs