Citation Nr: 1304341 Decision Date: 02/07/13 Archive Date: 02/19/13 DOCKET NO. 08-03 489 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for hypertension, to include as secondary to service connected PTSD and/or exposure to herbicides. 3. Entitlement to service connection for an enlarged aorta and aneurysm. 4. Entitlement to service connection for a kidney disability, as due to exposure to herbicides. 5. Entitlement to service connection for a bilateral ear disability other than left ear hearing loss and tinnitus. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from September 1966 to September 1968. This case comes to the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin which denied the Veteran's claim for an increased rating for PTSD as well as his claim for service connection for hypertension. In addition, the Veteran appeals from a June 2009 rating decision which, in pertinent part, denied his claims for service connection for an enlarged aorta and aneurism, a bilateral ear problem and a kidney condition. A review of the Virtual VA claims processing system does not reveal documents pertinent to the claims on appeal. FINDINGS OF FACT 1. The weight of the evidence does not show that the Veteran's PTSD more closely approximates occupational and social impairment with reduced reliability and productivity. 2. The Veteran is presumed to have been exposed to herbicides coincident with service in the Republic of Vietnam. 3. The weight of the evidence does not establish that the Veteran's hypertension was incurred or aggravated by service, to include herbicide exposure, or by his service-connected PTSD. 4. The weight of the evidence does not establish that the Veteran's enlarged aorta and aneurysm were incurred or aggravated by service. 5. The Veteran's current kidney disability is not a disease for which presumptive service connection may be granted due to herbicide exposure, and is not otherwise shown or alleged to have been incurred during service. 6. The Veteran does not have a current diagnosis related to a bilateral ear disability other than hearing loss and tinnitus. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.1--4.10, 4.130, Diagnostic Code (DC) 9411 (2012). 2. The criteria for service connection for hypertension, to include as secondary to service connected PTSD and/or exposure to herbicides, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1116, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 3. The criteria for service connection for an enlarged aorta and aneurysm have not been met. 38 U.S.C.A. §§ 1101, 1110, 1116, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 4. The criteria for service connection for a kidney disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1116, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307 (2012). 5. The criteria for service connection for a bilateral ear disability other than left ear hearing loss and tinnitus have not been met. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, letters dated in February 2007, February 2009 and May 2009, sent prior to the unfavorable decisions issued in April 2007 and June 2009, respectively, advised the Veteran of the evidence and information necessary to substantiate his claim for an increased rating for his PTSD as well as his claims for service connection for hypertension, a heart condition, ear problems and a kidney condition, as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letters advised him of the information and evidence necessary to establish an effective date in accordance with Dingess/Hartman, supra. Relevant to the duty to assist, the Veteran's service treatment records, post-service VA treatment records and Social Security Administration (SSA) records have been obtained and considered. Additionally, the Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran was also afforded multiple VA examinations in conjunction with the claims on appeal, including VA examinations conducted in March 2007, July 2009 and November 2010 to determine the nature and etiology of his claimed disorders. As such examinations were conducted by competent clinicians who considered the Veteran's claims file and medical history in their reports and provided an etiological opinion, complete with the rationale described, the Board finds that such examinations and opinions are adequate to adjudicate the Veteran's claims. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Ardison v. Brown, 6 Vet. App. 405, 407 (1994); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In addition, neither the Veteran nor his representative has alleged that multiple VA psychological examinations conducted are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected PTSD as they include interviews with the Veteran, a review of the record, and full mental and physical examinations, addressing the relevant rating criteria. Moreover, neither the Veteran nor his representative has alleged that his PTSD has worsened in severity since the November 2010 VA examination. Rather, with respect to the PTSD, they argue that the evidence reveals that the Veteran's PTSD has been more severe than the currently assigned 30 percent rating for the duration of the appeal period. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (the passage of time alone, without an allegation of worsening, does not warrant a new examination). Therefore, the Board finds that the examinations of record are adequate to adjudicate the Veteran's claim for an increased rating and no further examinations are necessary. The Board acknowledges that a VA medical examination or opinion was not provided with regard to the issue of entitlement to service connection for a kidney disease. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4) (2012). In deciding to remand the issue for a medical nexus opinion, the Board notes that the Federal Circuit, in a recent decision, upheld the determination that a VA medical examination is not required as a matter of course in virtually every veteran's disability case involving a nexus issue. Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (distinguishing cases where only a conclusory generalized statement is provided by the veteran, in which case an examination may not be required); see also Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010). The Board concludes an examination is not needed with regard to the Veteran's claims for service connection for kidney disease. In so finding, the Board notes that the Veteran has alleged service connection due to herbicide exposure only. In addition, there is no evidence linking the claimed kidney disease to the Veteran's active service. His lay statements of a causal relationship between the claimed kidney disability and his service are found to lack competency and probative value. Such evidence is therefore insufficient to trigger VA's duty to provide an examination. The Board finds that a remand for a VA opinion would not be beneficial in the adjudication of this issue to the extent that it was denied, and is thus not required in this case. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Increased Rating Claim Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. 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. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the Veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, are expected in all instances. 38 C.F.R. § 4.21. PTSD is evaluated under VA's General Rating Formula for Mental Disorders. Under the formula, a 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of an 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 and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, 9411. A 50 percent rating is warranted when there is 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 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. Id. A 70 percent rating is warranted where there is 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; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is 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, 9411. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). On the other hand, if the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Ultimately in Mauerhan, the Court upheld the Board's decision noting that the Board had considered all of the Veteran's psychiatric symptoms, whether listed in the rating criteria or not, and had assigned a rating based on the level of occupational and social impairment. Mauerhan, supra at 444. GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). A GAF of 61 to 70 reflects some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. A GAF of 51 to 60 indicates moderate symptoms, or moderate difficulty in social, occupational, or school functioning. A GAF of 41 to 50 signifies serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 31 to 40 signifies some impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., where a depressed man avoids friends, neglects family, and is not able to work). DSM-IV; 38 C.F.R. §§ 4.125, 4.130. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). Although GAF are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, supra. An assigned GAF, 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). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). A. Schedular Rating A March 2007 VA psychological examination reflected the Veteran's complaints of daily thoughts and nightly bad dreams about Vietnam, ongoing avoidance and numbness, feelings of general disconnection from other people, ongoing heightened physiological arousal in terms of problems with his sleep, irritability and feeling hypervigilant and jumpy. He reported working on an assembly line in a factory and that he maintained an "alright" relationship with his wife, children and grandchildren. Socially, he was fairly limited, but maintained a leadership role in a local veterans' organization and spent his free time working on classic scooters and motorcycles. Significant memory loss or impairment, obsessive or ritualistic behaviors, panic attacks, diagnosable depression or anxiety and impaired impulse control were denied. Although the Veteran stated that his mental health had worsened over the years, he stated that his symptoms had remained fairly stable over time. Mental status examination conducted by the March 2007 VA examiner found the Veteran's eye contact, interaction and speech rate and flow to be within normal limits. He was noted to be oriented to person, place and time. Examination was negative for delusions, hallucinations or impairment to thought process or communication. The examiner noted that the Veteran was unable to describe how his symptoms had changed or worsened over the past year and that he described his symptoms as remaining fairly stable over time. Following this examination, a GAF of 55 was assigned. The examiner noted that the Veteran continued to be successfully employed, that he minimized any mental health problems at work, that he maintained routine responsibilities of self-care and family role functioning and that his social/interpersonal relationships were fairly specific to home, work and the veterans organization while his recreation/leisure pursuits were fairly specific to the home. In a March 2007 statement, the Veteran's wife wrote that she had been married to the Veteran for 38 years. She reported that he woke up at different times during the night and got "upset very fast." A December 2007 VA treatment note reflected the Veteran's reports of sleep difficulties, worry, hyperarousal and isolating behaviors. He described his family relationship as strong and positive and denied suicidal ideations. Although the Veteran reported thoughts of blowing up the building at his job, he stated that he would "cool off" after having these thoughts and indicate that he would not actually follow through with such acts. The provider noted that the Veteran was appropriately dressed and groomed and that he made the appropriate amount of eye contact. Mental status examination found his thoughts to be logical and sequential and that he exhibited a range of affect. A GAF of 68 was assigned. A March 2008 VA psychological examination reflected the Veteran's reports of working for five years in a factory and that he got along with his co-workers but that he had concerns about the labor practices of the company. Socially, he reported being married to his wife for 39 years and that he spent time with his grandchildren. Current symptoms included occasional anger at work and thoughts about how to demolish his factory building, which he attributed to his past work as an engineer and in demolition. Other symptoms included brief periods (a couple of times a week) of depression, anxiety, and panic attacks in which he felt worried and jittery. He also endorsed sleep disturbances, concentration difficulties and nightmares. A history of psychiatric hospitalizations, counseling or the use of medications was denied by the Veteran. Perceptual disturbances, paranoia or memory loss were also denied. Mental status examination conducted by the March 2008 VA examiner found the Veteran's affect to be congruent, appropriate, friendly and engaging and his voice and speech to be within normal limits. Thought processes were found to be generally goal directed but occasionally circumstantial and he was noted to be oriented to person, place or time. The examiner opined that while the Veteran reported occasional flashbacks, these appeared to be fairly eidiotic memories and that he did not avoid talking about Vietnam and was active in a veterans' organization. The examiner noted that the Veteran did not describe any significant changes in his symptoms over the past year. While the Veteran reported experiencing "panic attacks," the examiner noted that these episodes seemed to occur more as brief periods of irritability at work. Examination was negative for a flattened effect, difficulty understanding complex commands, memory impairments, judgment difficulty or difficulty with abstract thinking. Following this examination, a GAF of 55 was assigned. The examiner noted that the Veteran was able to maintain steady employment and function in a work environment that caused occasional distress. An October 2009 private disability evaluation, which was conducted in conjunction with the Veteran's SSA disability claim, noted the Veteran's history of PTSD. The evaluator opined that the Veteran's PTSD "does seem to affect his thinking and memory" but that he would "basically defer" on these issues to VA. A February 2010 VA psychological examination noted that the Veteran was last seen for outpatient mental health treatment in December 2007 and that he was not using any mental health medications. Current symptoms included daily thoughts about service, which were mild to moderate in severity, as well as some short-term memory difficulties, sleep difficulties, and avoidance of others. He described his family relationships as "good" and saw his grandchildren on a daily basis. Socially, he reported attending monthly veterans' group meetings and spent his free time fixing up classic scooters and motorcycles. He reported that he stopped working in May 2009 due to his ongoing heart issues and his objections to the work conditions as provided by his employer. He also reported that his PTSD had been stable over the past two years. A history of violence, assaultiveness or suicide attempts were denied by the Veteran. In addition, obsessive or ritualistic behaviors, panic attacks, depression, anxiety and impaired impulse control were denied. Mental status examination conducted by the February 2010 VA examiner found the Veteran's eye contact, interaction and speech rate and flow to be within normal limits. No impairments of thought process or communication, delusions or hallucinations were demonstrated on examination. The examiner noted that the Veteran's PTSD remained stable, as the Veteran described minimal to no changes in his psychosocial functional status and quality of life since his last examination. The examiner further noted that the Veteran's PTSD was mild to moderately severe due to ongoing symptoms such as persistent re-experiencing, avoidance and increased arousal. Following this examination, a GAF of 55 to 60 was assigned. In a July 2010 substantive appeal, the Veteran wrote that he thought of his Vietnam experiences on a daily basis. He considered himself to be a workaholic and worked two jobs in the past to keep his mind of his service experiences. A November 2010 VA psychiatric examination reflected the Veteran's reports of daily thoughts about Vietnam, nightmares several times per week, continued avoidance symptoms, ongoing hypervigilance and startle, and sleep difficulties with feelings of tiredness during the day. These daily symptoms were mild to moderately severe. The Veteran reported a continued good relationship with his family, that he continued to attend veterans' organization meetings and that he spent his free time repairing scooters and motorcycles. In addition, he reported that he continued to regularly babysit his grandchildren, that he completed all of the housework and that he made the meals. He reported that he had not participated in mental health treatment since his last examination and that he did not take any psychotropic medications. Obsessive or ritualistic behaviors, specific impaired impulse control, a depressed mood, suicidal thoughts and homicidal thoughts were denied by the Veteran. Mental status examination conducted by the November 2010 VA examiner found the Veteran to be talkative, cooperative, friendly and fully oriented with appropriate eye contact. The examiner noted that the Veteran continued to report a daily frequency of these symptoms, which were mild to moderate in severity, and that while the Veteran reported worry about his physical health conditions, he did not describe this to a diagnosable degree in terms of an additional anxiety condition. In addition, the examiner noted that the Veteran did not report any specific changes in symptoms since his last examination. Following this examination, a GAF of 55-60 was assigned. Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, the Board finds that during the appellate period, the Veteran's PTSD was appropriately evaluated as 30 percent disabling. The treatment records, examination reports and his personal statements reflect that his PTSD was stable during the appellate period. The various VA examiners and treatment providers assigned GAF scores between 55 and 68, indicating mild to moderate symptoms, and which are consistent with a 30 percent rating. The Board finds that the preponderance of the medical evidence of record during this period demonstrates that the Veteran's symptoms of PTSD were no more than moderate in degree, and that his disability did not result in occupational and social impairment with reduced reliability and productivity. Although not dispositive, the evidence of record does not show that his psychiatric disability was manifested by 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 or disturbances of motivation. 38 C.F.R. § 4.130, 9411. Moreover, the November 2010 examiner noted that the Veteran's retirement in May 2009 was the result of his physical conditions, not his PSTD. The previous examiners also noted that the Veteran's mental health symptoms were minimized at work. He has maintained positive relationships with his family and is actively involved in a local veterans' organization and leisure pursuits. In addition, the Board notes that although that the Veteran did subjectively complain of "panic attacks" in the March 2008 VA examination, the examiner found that symptoms these were actually brief periods of irritability at work. No short-term memory impairments were found on objective examination despite the Veteran's intermittent subjective reports of memory difficulties. In addition, prior to his retirement in May 2009, the Veteran was able to maintain his employment despite reporting that he was an outspoken critic of the company's policies and work conditions. Given this, and the absence of most other symptoms consistent with a higher 50 percent rating, an assignment of a 50 percent disability rating is not warranted on this basis. The overall disability picture more closely approximated the criteria for a 30 percent rating and thus a higher rating is not warranted during this appellate period. See 38 C.F.R. §§ 4.7, 4.130, 9411. The Board, in reaching these conclusions, has considered the Veteran's and his wife and representatives' contentions and arguments as set forth in written statements. In this regard, this lay testimony is probative, in conjunction with the other evidence of record, particularly the objective medical evidence, in determining the PTSD symptoms and resulting occupational and social impairment. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Board finds that overall, the evidence does not support a rating in excess of 30 percent for PTSD and the claim for that benefit must be denied. 38 C.F.R. §§ 4.3, 4.7. B. Extra-schedular Consideration The Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant'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 "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant'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 extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria found in the rating schedule. The Board finds that the Veteran's PTSD symptomatology is fully addressed by the rating criteria under which the disability is rated. There are no additional symptoms of his PTSD that are not addressed by the rating schedule. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. The Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that 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 Veteran has been retired since May 15, 2009 and he has reported retiring due to his physical disabilities, not his PTSD. Although the Veteran was awarded SSA benefits in October 2009 due, in part, to his anxiety disorders, he indicated in his July 2009 SSA Disability Report that his various physical conditions, including an enlarged heart, limited his ability to work. In addition, he maintained full-time employment in a factory prior to May 15, 2009. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009) (TDIU is a part of an increased rating or initial rating only when there is evidence of unemployability). The claims file reflects that the Veteran did file a claim for TDIU benefits, which was denied in a February 2012 rating decision. The period during which to appeal the denial of the TDIU claim has not yet expired and the Veteran has yet to indicate his intent to appeal the decision. Consequently, the Board finds that no further consideration of such is necessary at this time. III. Service Connection Claims 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 may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; evidence of in-service incurrence or aggravation of a disease or injury; and evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. A disorder also may be service connected if the evidence of record reveals the veteran currently has a disorder that was chronic in service or was seen in service with continuity of symptomatology demonstrated after service. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-97 (1997). In order to establish a showing of chronic disease in service, or within a presumptive period per § 3.307, a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic," is required. 38 C.F.R. § 3.303(b). Subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Id. A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom. Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998), cert. denied, 119 S. Ct. 404 (1998). However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, flat feet, varicose veins), (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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In essence, lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). See also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of a veteran's present condition (e.g., whether a veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumptive period, or whether it can be so identified by lay observation). Savage, 10 Vet. App. 488, 494-97 (1997). See also Barr v. Nicholson, 21 Vet. App. 303 (2007). Diseases associated with exposure to certain herbicide agents used in support of military operations in the Republic of Vietnam during the Vietnam era will be presumed to have been incurred in service. 38 U.S.C.A. § 1116(a)(1); 38 C.F.R. § 3.307(a)(6). This presumption requires exposure to an herbicide agent and manifestation of the disease to a degree of 10 percent or more within the time period specified for each disease. 38 C.F.R. § 3.307(a)(6)(ii). Furthermore, even if a Veteran does not have a disease listed at 38 C.F.R. § 3.309(e), he is presumed to have been exposed to herbicides if he served in Vietnam between January 9, 1962, and May 7, 1975, unless there is affirmative evidence establishing the Veteran was not exposed to any such agent during that service. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The diseases presumptively associated with herbicide exposure include chloracne or other acneform disease consistent with chloracne, Type II diabetes, Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias, multiple myeloma, Non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, Parkinson's disease, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), AL amyloidosis, and soft-tissue sarcoma. 38 C.F.R. § 3.309(e). The term acute and subacute peripheral neuropathy means transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset. 38 C.F.R. § 3.309(e), Note 2; Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). Service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Some chronic diseases are presumed to have been incurred in service, although not otherwise established as such, if manifested to a degree of ten percent or more within one year of the date of separation from service. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.307(a)(3); see 38 U.S.C.A. § 1101(3) and 38 C.F.R. § 3.309(a) (listing applicable chronic diseases, including arthritis, hypertension and calculi of the kidney). This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted on a secondary basis for a disability that is proximately caused or aggravated by a service-connected disability. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). A. Claims for Service Connection for Aorta and Hypertension The Veteran's service treatment records were negative for complaints, treatments or diagnoses related to any enlarged aorta or hypertension disability. A March 2007 VA hypertension examination reflected the Veteran's reports of being diagnosed with hypertension in July 2006 and that he used oral medications to treat his symptoms. Signs or symptoms of organ damage related to hypertension were denied by the Veteran. Following a physical examination and a review of the Veteran's claims file, the examiner opined that the Veteran's hypertension was not caused by or a result of his service-connected PTSD or other service connected conditions. The examiner opined that hypertension was a result of hereditary, diet and environmental causes. In addition, the examiner noted that although stress can cause transient hypertension, it did not cause persistent hypertension. A July 2009 opinion from Dr. K. F., the Veteran's treating VA physician, indicated that her research found that there was no clear evidence connecting PTSD and a thoracic aortic aneurysm. The provider opined that the aneurysm was often seen in connection with the "hardening" or atherosclerosis in the aorta and although it was not known for sure and no research supported it, such atherosclerosis may be worsened with stress of any kind. A second July 2009 opinion from Dr. K. F. indicated that a review of the medical literature found that an aortic aneurysm co-existed with atherosclerosis changes but that atherosclerosis was not thought to be the cause of the aneurysm. Rather, atherosclerosis was thought to be secondary to it. The provider noted that atherosclerosis had risk factors, including depression, and there was no clear correlation with stress or PTSD; there was no research available to clarify such a relationship. The provider opined that it was not her opinion that the Veteran's aortic aneurysm was caused by or aggravated by his PTSD. Competent medical evidence includes statements from a person qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). As the March 2007 VA examiner and the Veteran's treating VA physician are so qualified, the medical opinions constitute competent medical evidence and are highly probative. No other competent medical evidence suggesting a nexus to the Veteran's service and/or service-connected PTSD has been submitted. The Veteran is not entitled to service connection based on the finding of a chronic disease because he was not diagnosed with hypertension in service or within one year of service discharge. The Veteran is also not entitled to service connection on the basis of continuity of symptomatology as the probative evidence of record shows that he did not have continuous symptomatology and the Veteran has not alleged such a continuity for either of these claimed disabilities. 38 C.F.R. § 3.303(b). In addition, neither hypertension nor an enlarged aorta are classified as one of the enumerated diseases associated with herbicide exposure under 38 C.F.R. § 3.309(e). Thus, service connection is not warranted for either disability based on presumed herbicide exposure under 38 C.F.R. § 3.309(e). In the instant case, the Board finds that the questions of whether the Veteran's hypertension and/or enlarged aorta and aneurysm were etiologically related to service and/or service-connected PTSD to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Additionally, in a single-judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation to establish that the appellant suffered from an event, injury or disease in service." Richardson v. Shinseki, No. 08-0357, slip. op. at 4 (Vet. App. May 10, 2010). While the Board recognizes that such single judge decisions carry no precedential weight, they may be relied upon for any persuasiveness or reasoning they contain. See Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992). The Board acknowledges that the Veteran is competent to describe his current cardiac and hypertension symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. 465. However, the Board accords his statements regarding the etiology of his current disabilities to have little probative value as he is not competent to opine on such complex medical questions. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). Moreover, the Veteran has only offered conclusory statements regarding the relationship between his current disabilities and his military service and/or his service-connected PTSD. In contrast, the VA examiner and the Veteran's treating VA physician, took into consideration all the relevant facts in providing their opinions regarding the claimed disorders, specifically to include medical research as to the etiology of aortic aneurysms. Therefore, the Board finds that the Veteran's contentions regarding the etiology of his current enlarged aorta and hypertension are outweighed by the competent and probative VA opinions. In addition, although the Veteran is competent to report that he was experiencing hypertension and/or an enlarged aorta disease, he is not competent to opine on the etiological relationship between these disabilities and service or his service-connected PTSD. Furthermore, there is no competent medical evidence of record which etiologically links the Veteran's either disability to his service or his service-connected PTSD. The preponderance of the evidence is against the award of service connection for hypertension and an enlarged aorta; it follows that the benefit of the doubt doctrine is not applicable in the instant appeals. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). As such, the Veteran's claims are denied. B. Claim Service Connection for a Kidney Disability The Veteran contends that that his kidney disability was the result of his in-service exposure to herbicides; direct service connection has not been alleged. The Veteran's service treatment records were negative for complaints, treatments or diagnoses related to any kidney disorder. An October 2007 VA treatment note listed chronic kidney disease stage III as an active problem. A November 2010 VA treatment note indicated that the Veteran's kidney function was slightly impaired. The Veteran's claimed disability, chronic kidney disease, is not classified as one of the enumerated diseases associated with herbicide exposure under 38 C.F.R. § 3.309(e). Thus, service connection is not warranted for the claimed chronic kidney disease based on presumed herbicide exposure under 38 C.F.R. § 3.309(e). Moreover, there is no evidence that calculi of the kidney was manifested to a compensable degree within the first post-service year, and thus presumptive service connection is also not warranted under 38 C.F.R. § 3.309(a). With respect to the theories of service connection as a result of exposure to herbicides, the Board notes that lay evidence may be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters, supra. In the instant case, the Board finds that the questions of whether the Veteran's kidney disease was etiologically related to exposure to herbicides are complex in nature. See Woehlaert, supra. Although the Veteran was competent to report that he was experiencing kidney disease, he is not competent to opine on the etiological relationship between this disability and exposure to herbicides. Furthermore, there is no competent medical evidence of record which etiologically links the Veteran's kidney disease to his exposure to herbicides. Therefore, the Board finds that service connection is not warranted for a kidney disability. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a kidney disability, as a result of exposure to herbicides. As such, that doctrine is not applicable in the instant appeal, and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. C. Claim Service Connection for a Bilateral Ear Disability The Veteran's service treatment records were negative for complaints, treatments or diagnoses related any ear disabilities other than hearing loss. In an April 2009 statement, the Veteran wrote that has had an ear problem since May 1968 and believed it may have been caused by dampness. A November 2010 VA audiology examination noted that the Veteran's tympananograms to be consistent with normal middle ear function and ear canal volume bilaterally. Following this examination and a review of the Veteran's claims file, no diagnosis other than hearing loss and tinnitus was made. With regard to the Veteran's statements that he currently has a bilateral ear disability, the Board notes that he is competent to report what comes through his senses, such as ringing in the ears and difficulty hearing. See Layno, supra. Additionally, in Jandreau, 492 F. 3d 1372 , the United States Court of Appeals for Federal Circuit determined that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition (noting that sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (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. In the instant case, the Board finds that, while the Veteran is competent to report his symptoms, he is not competent to diagnose an ear disability. In this regard, the Court has held that, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the Veteran is not competent to provide evidence as to more complex medical questions. Woehlaert, supra. Therefore, as diagnosing an ear disability is complex in nature, the Board finds that the Veteran is not competent to diagnose an ear disability. Therefore, the Board finds that the competent and probative evidence fails to reveal a diagnosis of an ear disability other than hearing loss and tinnitus. In the absence of proof of a present disability, there can be no valid claim for service connection. See Brammer v. Brown, 3 Vet. App. 223, 225 (1992); Degmetich v. Brown, 104 F.3d 1328 (1997); McClain v. Nicholson, 21 Vet. App. 319 (2007) (the current disability requirement for a service connection claim is satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim). In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a bilateral ear disability other than hearing loss and tinnitus. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Entitlement to a rating in excess of 30 percent for PTSD is denied. Entitlement to service connection for hypertension, to include as secondary to service connected PTSD and/or exposure to herbicides, is denied. Entitlement to service connection for an enlarged aorta and aneurysm is denied. Entitlement to service connection for a kidney disability, as due to exposure to herbicides is denied. Entitlement to service connection for a bilateral ear disability other than left ear hearing loss and tinnitus is denied. ____________________________________________ DELYVONNE M. WHITEHEAD Acting Veterans Law Judge, Board of Veterans' Appeals epartment of Veterans Affairs