Citation Nr: 1314286 Decision Date: 05/01/13 Archive Date: 05/15/13 DOCKET NO. 07-10 224 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for sleep apnea, including as secondary to service-connected diabetes mellitus, congestive heart failure, hypertension, or retained metallic foreign body in the lung. 2. Entitlement to a rating higher than 20 percent for shell fragment wound of the right shoulder. 3. Entitlement to a rating higher than 30 percent for posttraumatic stress disorder (PTSD). 4. Entitlement to an initial compensable rating for pseudoaneurysm and arteriovenous fistula of the right iliac artery. 5. Entitlement to a total disability rating based on unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Fleming, Counsel INTRODUCTION The Veteran had active service from June 1963 to June 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2006 and January 2008 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, and August 2009 and August 2010 rating decisions from the RO in Houston, Texas. As the appeal of the Veteran's claim for an initial compensable rating for pseudoaneurysm and arteriovenous fistula of the right iliac artery emanates from his disagreement with the initial noncompensable rating assigned following the grant of service connection, the Board has characterized the claim as one for a higher initial rating, in accordance with Fenderson v. West, 12 Vet. App. 119, 126 (1999). On multiple occasions during the appellate period, the Veteran requested a hearing before a Veterans Law Judge in connection with these claims; however, pursuant to the Board's request for clarification, his representative submitted a statement in December 2012 indicating that the Veteran did not want the hearing. Accordingly, the Board finds that the request for a hearing has been withdrawn and will proceed to adjudicate the claims. 38 C.F.R. § 20.704(d) (2012). The Board further notes that the Veteran, in a May 2011 statement, indicated that he is unable to work due to his service-connected disabilities. The United States Court of Appeals for Veterans Claims (Court) has held that a request for a TDIU, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather is part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue whether a TDIU is warranted as a result of that disability. Id. As such, the Board has added the issue of entitlement to a TDIU, as noted above. The decision below addresses the Veteran's claims for increased ratings for his service-connected shell fragment wound of the right shoulder and PTSD. The Veteran's remaining claims 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. Additionally, in the May 2011 statement to VA, the Veteran indicated that he wished to file claims for service connection for peripheral neuropathy of the bilateral upper and lower extremities. As these claims have not been adjudicated by the RO, they are not before the Board; hence, they are referred to the agency of original jurisdiction (AOJ) for appropriate action. FINDINGS OF FACT 1. The Veteran's shell fragment wound of the right shoulder required debridement and prolonged hospitalization for treatment and has resulted in consistent findings of weakness and loss of muscle substance, most nearly approximating moderately severe disability of Muscle Group II. 2. For the entirety of the appeal period, the Veteran's PTSD has been manifested by depressed mood, anxiety, social impairment, and chronic nightmares and sleep impairment that approximate occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 30 percent for shell fragment wound of the right shoulder have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.40, 4.45, 4.56, 4.59, 4.73, Diagnostic Code 5302 (2012). 2. The criteria for a disability rating higher than 30 percent for the Veteran's service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist At the outset, the Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). In this case, the Board finds that all notification and development action needed to arrive at a decision on the claims decided herein has been accomplished. In this respect, through June 2006 and August 2007 notice letters, the Veteran received notice of the information and evidence needed to substantiate the claims on appeal. Thereafter, the Veteran was afforded the opportunity to respond. Hence, the Board finds that the Veteran has been afforded ample opportunity to submit information and/or evidence needed to substantiate his claims. The Board also finds that the June 2006 and August 2007 notice letters satisfy the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). In the letters, the RO also notified the Veteran that VA was required to make reasonable efforts to obtain medical records, employment records, or records from other Federal agencies. The RO also requested that the Veteran identify any medical providers from whom he wanted the RO to obtain and consider evidence. 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. See Pelegrini v. Principi, 18 Vet. App. 112, 121 (2004). See also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (codified at 38 C.F.R. § 3.159) (removing the prior requirement that VA specifically ask the claimant to provide any pertinent evidence in his possession). These requirements were met by the aforementioned June 2006 and August 2007 notice letters. In addition, the Veteran was provided notice regarding an award of an effective date and rating criteria in the June 2006 and August 2007 letters. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Board does not now have such issues before it. Consequently, a remand for additional notification on these questions is not necessary. Nothing about the evidence or any response to the RO's notification suggests that the case must be re-adjudicated ab initio to satisfy the requirements of the VCAA. The Board also points out that there is no indication that any additional action is needed to comply with the duty to assist in connection with the claims decided herein. The Veteran underwent VA examination in May 2007, August 2007, April 2008, and June 2010; reports of those examinations are of record. In that connection, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA examinations obtained in this case are adequate, as they are predicated on consideration of all of the pertinent evidence of record, to include the statements of the Veteran and his representative, and document that the examiners conducted full physical and psychological examination of the Veteran. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the claims decided herein has been met. 38 C.F.R. § 3.159(c)(4). In addition, records of the Veteran's private and VA medical treatment have been associated with the file, as have his service treatment records. The Veteran has further been given the opportunity to submit evidence, and he and his representative have provided written argument in support of his claims. Otherwise, neither the Veteran nor his representative has identified, and the record does not indicate, existing records pertinent to the claims decided herein that need to be obtained. Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. II. Analysis Disability evaluations are determined by comparing a Veteran's present symptoms with criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where entitlement to compensation has already been established, VA must address the evidence concerning the state of the disability from the time period one year before the claim for an increase was filed until VA makes a final decision on the claim. The Court has held that consideration of the appropriateness of a staged rating (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). A. Shell Fragment Wound of the Right Shoulder For rating purposes, the skeletal muscles of the body are divided into 23 muscle groups in five anatomical regions, including six muscle groups in the shoulder. See 38 C.F.R. § 4.55(b). When considering the extent of the Veteran's disability, the Board must consider three aspects of the injury, (1) the type of injury; (2) the treatment history and complaints related to the injury; and (3) the current objective findings. Based on the findings related to these three aspects, the disability will be rated as one which is "slight," "moderate," "moderately severe," or "severe." For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). Moderate disability is characterized by a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. History and complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objective findings of entrance and exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). Moderately severe disability of muscles is characterized by a through and through or deep penetrating wound by a small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. History and complaint characteristic of moderately severe muscle injury includes service department records or other evidence showing hospitalization for a prolonged period for treatment of wound. A showing of moderately severe muscle disability should include a record of consistent complaints of cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c) and, if present, evidence of inability to keep up with work requirements. Objective findings characteristic of moderately severe muscle disability include entrance and (if present) exit scars indicating the track of the missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side are also indicative of moderately severe muscle disability. Tests of strength and endurance compared with the sound side should demonstrate positive evidence of impairment. 38 C.F.R. § 4.56(d)(3). Severe disability of muscles is characterized by a through and through or deep penetrating wound due to high-velocity missile, or large multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. History and complaint characteristic of severe disability of muscle includes service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. Objective findings characteristic of severe muscle disability include ragged, depressed, and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) Visible or measurable atrophy; (E) Adaptive contraction of an opposing group of muscles; (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; and (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d)(4). The Veteran's shell fragment wound of the right shoulder is rated under 38 C.F.R. § 4.73, Diagnostic Code 5203, applicable to Muscle Group II, which encompasses various muscle groups in the upper arm. The Veteran is right handed, and the shell fragment wound of the right shoulder affects his dominant arm. Under Diagnostic Code 5203, a 20 percent rating is warranted for moderate disability, a 30 percent rating is warranted for moderately severe disability, and a 40 percent rating is warranted for severe disability, each of the dominant arm. In this case, the service treatment records reflect that the Veteran sustained a shell fragment wound to the right shoulder, as well as multiple other shell fragment wounds, in combat due to an exploding land mine. His right shoulder wound was debrided and a fragment removed, although multiple metallic fragments were retained. The Veteran underwent surgery during service to treat a secondary hemorrhage and to repair an aneurysm of the right subclavian artery. On the July 2006 VA examination, the Veteran complained of constant pain in the shoulder, as well as stiffness and numbness, with increased pain on reaching above the level of the shoulder. The examiner found the Veteran to have normal muscle strength, with no loss of muscle function or range of motion of the shoulder. The examiner did not comment as to whether the Veteran experienced any tissue loss in the right shoulder. The diagnosis was remote right shoulder muscle group II injury with residual healed scars. On the April 2008 orthopedic VA examination, the Veteran complained of constant aching in his shoulder that was decreased following a December 2007 steroid injection. He also stated that he experienced brief sharp pains upon sudden or strenuous movements and overhead reaching. No lack of endurance was reported. The examiner noted a mild pain at the end of abduction of the right shoulder but otherwise normal range of motion. The examiner diagnosed the Veteran with residuals of a shell fragment wound of the right shoulder with mild degenerative joint disease of the shoulder. Similarly, on VA examination of the Veteran's musculature conducted on the same date, the Veteran complained of a constant aching in his shoulder that was relieved by steroid injection and increased with sudden or strenuous movements. The examiner noted, however, that the Veteran performed sudden movements of the shoulder during the examination without evidence of increased pain. Physical examination revealed an entry wound only, and the examiner noted that the Veteran experienced tissue loss of muscle group II, without nerve or bone damage. Muscle strength was normal, with no muscle herniation or loss of muscle function n noted. The diagnosis was the same. The Veteran again underwent VA examination of his right shoulder in June 2010. At that time, the examiner noted that the wound was not a through-and-through injury, with no initial infection, but resulted in a right subclavian artery aneurysm that was repaired while the Veteran was still in service. The Veteran reported at that time that he experienced no pain, weakness, decreased coordination, or increased fatigability of the shoulder. Physical examination revealed tissue loss to the right pectoralis major muscle, but no nerve, bone, or tendon damage was noted. Review of the Veteran's treatment records reflects that he has complained of pain in his right shoulder on an ongoing basis. In December 2007, he was seen for complaints of pain and tenderness in the shoulder when raising his arm above shoulder level. He received a cortisone injection to treat the pain. He again complained of right shoulder pain in September 2009; at that time, his right pectoralis muscle was noted to be deficient, with spasm, tenderness, and weakness to the muscles on the right. He was again seen for complaints of right shoulder pain in August 2010; at that time, he stated that his right shoulder pain moved down into his chest and caused him to wake up with pain and stiffness in his right arm if he slept on it. He was again noted to have loss of pectoralis muscle tissue, as well as tenderness and spasm in the trapezius and supraspinatus muscles. Deltoid muscle weakness was noted on the right. The examiner diagnosed the Veteran with chronic right shoulder pain due to pectoralis muscle injury. Based on the above, the Board finds that the shell fragment wound of the right shoulder warrants a 30 percent rating under Diagnostic Code 5302. This is so because the Veteran's symptoms, as described on multiple VA examinations and by his treatment providers, most nearly approximate moderately severe disability. In that connection, the Board notes that the Veteran has displayed consistent complaints of cardinal signs and symptoms of muscle disability, such as pain and weakness in the affected muscle, as well as objective findings specifically noted in the criteria characteristic of moderately severe muscle injury, such as loss of muscle tissue and weakness in the affected muscle group. These findings were specifically noted by the Veteran's VA treatment providers in September 2009 and August 2010, as well as by his VA examiners. In addition, the Board notes that the Veteran underwent debridement of the injury in service and required a prolonged period for treatment of the wound, including a surgery to correct a traumatic aneurysm brought about by the injury, while he was on active duty. He has consistently complained of pain in the right shoulder and arm and has been noted to display weakness, tenderness to palpation, and muscle spasm in the affected area. These findings are consistent with a 30 percent disability rating under Diagnostic Code 5302. The Board, however, does not find that, at any time during the appellate period, the Veteran has displayed signs or symptoms of a severe muscle disability. To that end, the Board finds that the initial in-service injury did not result in shattered bone, open comminuted fracture, prolonged infection, or sloughing of soft parts. Further, there is no indication that the Veteran has ragged, depressed, or adherent scars, soft flabby muscles in the wound area, or severe impairment of strength, endurance, or coordinated movements. There has been no showing that the Veteran has adhesion of scars with epithelial sealing over bone, diminished muscle excitability, visible muscular atrophy, or any other symptoms to warrant the assignment of a 40 percent disability rating under Diagnostic Code 5302. B. Posttraumatic Stress Disorder In the January 2008 rating decision, the Veteran's PTSD was evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Under the General Rating Formula For Mental Disorders, to include anxiety and depressive disorders and PTSD, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is assignable where 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency 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. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency 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). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2012). Relevant evidence of record consists of the Veteran's ongoing treatment with VA treatment providers, as well as report of VA psychological examinations conducted in May 2007, August 2007, and June 2010. Report of the May 2007 examination reflects the Veteran's complaint that his primary symptom of PTSD was his recurrent nightmares, although he stated that he was managing to "function fairly well" in spite of his symptomatology. He also stated that he avoided news of combat, as well as combat-related movies. He reported having a good relationship with his daughter but stated that he had very few friends outside of his immediate family. The examiner noted that the Veteran had limited leisure activities and few social interactions. His overall functioning was found to be mildly to moderately impaired. The Veteran reported that he was unemployed but attributed this to his physical disabilities, not his PTSD. The Veteran reported that he had problems sleeping due to his nightmares, as well as ongoing anxiety. He further complained of problems with memory, but objective testing revealed no memory deficits. He also reported symptoms of mild irritability, cognitive deficits, and social withdrawal. The examiner diagnosed the Veteran with PTSD and assigned a Global Assessment of Functioning (GAF) score of 50. The examiner opined that he experienced mild symptoms and found him to experience intermittent periods of inability to perform occupational therapy along with an occasional decrease in work efficiency. He found the Veteran to have generally satisfactory function. Report of the August 2007 VA examination reflects the Veteran's ongoing complaints of experiencing nightmares several times a week. The examiner specifically found the Veteran's symptoms to be mild in severity and again noted that he was functioning "fairly well in spite of his symptoms." The Veteran complained of avoidance of combat-related news items, as well as irritability, although the examiner noted that the Veteran maintained relationships with his neighbors in the domiciliary where he lived. He reported having a good relationship with his immediate family, including his siblings, daughter, and granddaughter, but stated that his socializing was limited to family members and his domiciliary neighbors. The examiner again found the Veteran to display "fairly good performance" in activities of daily living, as well as "fair to good social and interpersonal relationships." No delusions, suicidal or homicidal thoughts, or impairment of thought processes or communication were noted. The Veteran reported occasional panic attacks and intermittent depressed mood, as well as anxiety symptoms. The examiner found the Veteran's symptoms to be "mild to moderate" and again assigned a GAF score of 50. The examiner stated that the Veteran displayed reduced reliability and productivity due to his symptoms of PTSD and recommended that his PTSD be rated as 50 percent disabling. Report of the June 2010 VA examination reflects that the Veteran reported having a good relationship with his daughter and other family members but stated that he does not socialize outside his family. Psychological examination found the Veteran to display no abnormalities of speech, psychomotor activity, orientation, or thought process or content, but he was noted to have a constricted affect. The Veteran complained of disrupted sleep and nightmares occurring nearly every night. The examiner noted that this broken sleep likely contributes to the Veteran's increased irritability and decreased concentration. No panic attacks, delusions, or suicidal or homicidal thoughts were noted, although the Veteran did state that he experienced some irritability. The examiner also noted that the Veteran employed avoidance tactics regarding news or information about combat and often felt detached or estranged from others. The Veteran complained of irritability in interpersonal interactions, social withdrawal, and loss of interest in leisure activities. The examiner noted, however, that the Veteran's symptoms appeared to be "in the mild range" and assigned him a GAF score of 65. The examiner also noted the Veteran's report that his PTSD symptoms had interfered with job performance in the past and opined that his symptomatology resulted in occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Report of the Veteran's ongoing treatment with VA treatment providers reflects that he has been seen by mental health treatment providers on a regular basis for the entirety of the appeal period. In December 2006 he was discharged from an inpatient PTSD treatment program; at that time, he was noted to display a restricted affect but to engage in some socialization. In January 2008 he underwent a psychiatric assessment, at which time he reported that he was in close contact with his mother and his siblings and had a good relationship with his daughter and grandchildren. He specifically stated that he was able to make and maintain close relationships with others. He reported experiencing ongoing nightmares but denied suicidal or homicidal ideation. He stated that he was depressed at the time but was able to carry out his activities of daily living. At a June 2009 treatment visit, the Veteran complained of problems sleeping and was noted to be somewhat depressed and anxious. He was assigned a GAF score of 65. At a subsequent June 2010 treatment visit, the Veteran reported that his symptoms had improved, with less depression. He did report ongoing nightmares and insomnia but reported that he was "coping well." His GAF score was 66. Upon review of the evidence of record, the Board finds that a disability rating higher than 30 percent for the Veteran's service-connected PTSD is not warranted. In so concluding, the Board finds persuasive the June 2010 VA examiner's report, in which the examiner noted that the Veteran experienced chronic nightmares and sleep impairment, as well as irritability and isolation, but that his symptoms were "in the mild range." The examiner noted that the Veteran consistently reported having a strong relationship with family members, including his siblings, daughter, and grandchildren. Similarly, although the August 2007 examiner stated that the Veteran displayed reduced reliability and productivity due to his symptoms of PTSD, he also specifically found the Veteran's symptoms to be mild and noted that he was functioning "fairly well in spite of his symptoms." At that time the examiner also noted that the Veteran maintained relationships with his neighbors in the domiciliary where he lived and had a good relationship with his immediate family. The examiner found the Veteran to display "fairly good performance" in activities of daily living, as well as "fair to good social and interpersonal relationships." The Board further notes that at no time has the Veteran been found to experience panic attacks more than once per week, difficulty in orientation, understanding complex commands, or impaired judgment, speech, memory, or abstract thinking. These findings are echoed in the Veteran's ongoing VAMC treatment, notes from which document the Veteran's ongoing complaints of nightmares and isolation but document that he continues to have good relationships with his family and only mild PTSD symptoms. The Board notes that these documented symptoms more closely align with the criteria for a 30 percent disability rating, discussed above. Further, the Board does not find that a rating greater than 50 percent for PTSD is warranted. Here, the medical evidence does not reflect deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); or an inability to establish and maintain effective relationships. To the contrary, none of these symptoms has been noted at any time during the appellate period. The Board has also has considered but does not find that the Veteran's acquired psychiatric disability causes total social and occupational impairment; thus it does not more nearly approximate a 100 percent disability rating under 38 C.F.R. § 4.130. In that connection, the Board acknowledges that the Veteran has not, at any time during the appellate period, reported suicidal thoughts; no delusions, hallucinations, or grossly inappropriate behavior has been noted. Similarly, the Veteran has been shown to be oriented and to be able to perform activities of daily living. Thus, the Board finds that a rating of 100 percent is not warranted under Diagnostic Code 9411. In its analysis, the Board has considered the GAF scores assigned to the Veteran. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." It does not otherwise include impairment in functioning due to physical (or environmental) limitations. There is no question that 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). Regardless, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, they must be considered in light of the actual symptoms of the Veteran's disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). In this case, the Board acknowledges that the Veteran has assigned GAF scores ranging from 50 to 66. Here, the Board finds that the Veteran's GAF score of 65, assigned at the June 2010 VA examination, coincides with both his stated symptoms and with the rating of 30 percent assigned under the General Rating Formula For Mental Disorders. In this case, the Board notes that the DSM-IV identifies scores in the range of 61-70 as "mild symptoms" such as depressed mood and mild insomnia with some difficulty in social, occupational, or school functioning but with the ability to maintain some meaningful interpersonal relationships. Scores in the range of 51-60 are identified as "moderate symptoms" such as flat affect or moderate difficulty in social, occupation, or school functioning. In this case, the Veteran has stated that he has a good relationship with his family, and has not been found to have moderate difficulty in social or occupational functioning. To the contrary, his symptoms have been described by multiple VA examiners and treatment providers as "mild." The Board finds, further, that the GAF score of 50 assigned to the Veteran by the 2007 VA examiner does not coincide with the symptoms documented at either the May 2007 or the August 2007 examination, or with the Veteran's ongoing treatment records or the findings of the June 2010 VA examiner. In this case, the Veteran has been found to have mild symptoms of PTSD, including sleep impairment, irritability, and isolation, but has also been found to have "generally satisfactory functioning" and a good relationship with many family members. In so finding, the Board reiterates that the Veteran's assigned GAF score is not dispositive of the evaluation and must be considered in light of the actual symptoms of his disorder. In this case, the Board has found that the Veteran's symptomatology during the appellate period, as discussed above, is appropriately compensated by the 30 percent rating currently assigned. The Board has taken into consideration the frequency, severity, and duration of the Veteran's symptoms of PTSD. In this case, the Board finds that, for the entirety of the appellate period, the Veteran's reported symptoms are most akin to the criteria for the 30 percent rating currently assigned. The Board notes that in accordance with Hart, supra, staged ratings have been considered, but because there is no indication that the Veteran's disability was more disabling than warranted by the 30 rating currently assigned at any point during the claim period, a staged rating is not warranted. C. Extra-Schedular Evaluation The above determination is based on consideration of the applicable provisions of VA' s rating schedule. The Board finds that at no time have the disabilities under consideration been shown to be so exceptional or unusual as to warrant the referral for consideration of any higher ratings on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). Here, there is an absence of evidence of marked interference with employment (i.e., beyond that contemplated in the assigned evaluation), frequent periods of hospitalization, or evidence that the Veteran's service-connected shell fragment wound of the right shoulder or PTSD-without consideration of other disabilities-has rendered impractical the application of the regular schedular standards. The Veteran himself has stated, at multiple VA examinations, that he is unable to work due primarily not his PTSD or right shoulder problems, but to his cardiac disorders. Additionally, the Board notes that a claim for entitlement to a TDIU is herein remanded. Furthermore, all of the Veteran's symptoms of his PTSD and shell fragment wound of the right shoulder have been considered and are specifically contemplated by the criteria discussed above. See Mittleider v. West, 11 Vet. App. 181 (1998). Thus, the criteria for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). It bears emphasis that the schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2012). Thus, based on the record before it, the Board does not find that the medical evidence demonstrates any unusual disability with respect to the claims that is not contemplated by the rating schedule. The very symptoms the Veteran experiences are all addressed by the rating schedule. Thun v. Peake, 22 Vet. App. 111 (2008). As a result, the Board concludes that a remand for referral of the rating issue to the VA Central Office for consideration of extra-schedular evaluation is not warranted. For all the foregoing reasons, the Board finds that a disability rating of 30 percent for shell fragment wound of the right shoulder is warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.40, 4.45, 4.56, 4.59, 4.73, Diagnostic Code 5302 (2012). The Board further finds that a disability rating higher than 30 percent for PTSD is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.130, Diagnostic Code 9411 (2012). This is so for the entirety of the appellate period. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the Veteran's claims for ratings higher than those assigned herein, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to a rating of 30 percent for shell fragment wound of the right shoulder is granted. Entitlement to a rating higher than 30 percent for posttraumatic stress disorder is denied. REMAND The Board finds that further evidentiary development is necessary before a decision can be reached on the merits of the Veteran's claim for service connection for sleep apnea, as well as his claim for an initial compensable rating for pseudoaneurysm and arteriovenous fistula of the right iliac artery. The Board notes, as an initial matter, the enactment of the VCAA in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty. See 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection on a secondary basis is warranted when it is shown that disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2012). The Court has held that this includes disabilities aggravated or made chronically worse by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Regarding his service connection claim, the Veteran has contended that he has sleep apnea secondary to his service-connected diabetes mellitus, heart disorder, hypertension, or retained shell fragment in the lung. In addition, in his October 2011 VA Form 9, the Veteran stated that symptoms of his sleep apnea "had its original manifestation during [his] military service." The RO denied the Veteran's claim on the basis that the medical evidence of record weighed against a finding of a link between his current sleep apnea disability and his service but did not address his claim on a secondary basis. Relevant medical evidence consists of the Veteran's service treatment records, as well as his post-service treatment at both private and VA facilities. The Veteran's service records are silent as to any complaints of sleep apnea or any other complaints regarding sleep. Post-service VA treatment records indicate that the Veteran was hospitalized for substance abuse problems in 1995; at that time, he reported that he had difficulty sleeping only when he was using drugs. VA psychiatric treatment records reflect that the Veteran was noted on multiple occasions to complain of sleep problems due to nightmares, which were attributed to his PTSD. The first indication in the Veteran's medical record of a diagnosis f sleep apnea appears in a November 2009 VA treatment note in which the treating physician noted that the Veteran reported that he had been prescribed a CPAP machine to treat sleep apnea. Later VA treatment records dated in February and July 2010 reflect that the Veteran carried a diagnosis of sleep apnea as of that time, but no etiological opinions were offered in relation to the diagnosis. Pursuant to the Veteran's claim, the Board obtained VHA opinions in June 2012 and August 2012 concerning the Veteran's sleep apnea; at that time, the somnologist who provided the expert opinion stated that it is less likely than not that the Veteran's sleep apnea has been caused or aggravated by service-connected disability. The examiner, however, failed to offer an opinion as to whether the Veteran's sleep apnea is etiologically linked directly to service. Once VA undertakes to provide an examination or obtain an opinion when developing a claim for service connection, even if not statutorily obligated to do so, it must provide an adequate one. See Woehlaert v. Nicholson, 21 Vet. App. 456, 464 (2007), citing Barr, 21 Vet. App. at 311; see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence . . . is essential for a proper appellate decision"). Although the VHA expert offered adequate opinions as to the Veteran's claim of service connection for sleep apnea on a secondary basis, the Board notes that none of the VHA examiners has provided an adequately reasoned opinion as to whether the Veteran's currently diagnosed sleep apnea is directly related to service. Because the VHA opinions do not provide a medical nexus opinion with an explanation concerning a direct relationship between the Veteran's current sleep apnea and service, the VHA medical opinions obtained to date are inadequate. See 38 C.F.R. § 4.2 (2012) (providing that where an examination report does not contain sufficient detail, it is inadequate for evaluation purposes); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that a medical examination report must contain clear conclusions with supporting data and a reasoned medical explanation connecting the two); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). Accordingly, remand is required. In light of the above considerations, the Board concludes that additional medical examination and opinion are needed. Under these circumstances, evidentiary development is needed to fully and fairly evaluate the Veteran's claim of service connection for sleep apnea. 38 U.S.C.A. § 5103A (West 2012). Specifically, the AOJ must arrange for the Veteran to undergo VA examination by a qualified professional, who must review the Veteran's claims file and his assertions and offer a well-reasoned etiological opinion as to whether the Veteran's current sleep apnea is directly linked to his time on active duty. The Veteran's contention, as set forth in his October 2011 VA Form 9, that his sleep apnea first manifested in service, must be discussed in the context of any negative opinion. Regarding the Veteran's claim for an increased rating for his service-connected pseudoaneurysm and arteriovenous fistula of the right iliac artery, the Board notes that the disorder has been rated under 38 C.F.R. § 4.104, Diagnostic Code 7113 (2012), governing traumatic arteriovenous fistulas. Under that Diagnostic Code, traumatic arteriovenous fistula causing edema or stasis dermatitis of the lower extremity warrants a 30 percent disability rating. Traumatic arteriovenous fistula causing edema, stasis dermatitis, and either ulceration or cellulitis of the lower extremity, but without cardiac involvement, warrants a 50 percent disability rating. Traumatic arteriovenous fistula without heart failure but with enlarged heart, wide pulse pressure, and tachycardia warrants a 60 percent disability rating. Traumatic arteriovenous fistula with high output heart failure warrants a 100 percent disability rating. 38 C.F.R. § 4.104, Diagnostic Code 7113. In addition, however, the Board acknowledges that there is an additional Diagnostic Code that may be applicable in the Veteran's case. In that connection, Diagnostic Code 7111, governing aneurysms of a large artery, provides that a 100 percent rating is assigned if the aneurysm is symptomatic, or; for an indefinite period from the date of hospital admission for surgical correction. Following surgery, a 100 percent rating is assigned for ischemic limb pain at rest, and; either deep ischemic ulcers or an ankle/brachial index of 0.4 or less. A 60 percent rating requires claudication on walking less than 25 yards on a level grade at 2 miles per hour, and; either persistent coldness of the extremity or ankle/brachial index of 0.5 or less. Claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour, and; tropic changes (thin skin, absence of hair, dystrophic nails) or ankle/brachial index of 0.7 or less warrants a 40 percent rating. A claudication on walking more than 100 yards, and diminished peripheral pulses or ankle/brachial index of 0.9 or less warrants a 20 percent rating. 38 C.F.R. § 4.104, Diagnostic Code 7111 (2012). In this case, VA treatment records reflect that the Veteran underwent surgery in May 2009 to treat his pseudoaneurysm and arteriovenous fistula of the iliac artery. Follow-up visits in February and June 2010 reflect that he was able to walk without trouble and was recovering well, with only some numbness around the incision area down to the knee. Similarly, private treatment records dated in August 2009 reflect the Veteran's complaint of edema and pain in his legs, but no clubbing, cyanosis, or peripheral edema was noted in his lower extremities bilaterally. Report of the July 2009 VA examination reflects that the Veteran was found to have a pseudoaneurysm and arteriovenous fistula of the right iliac artery as an incidental finding during a heart catheterization. He underwent surgery to repair the pseudoaneurysm and fistula in May 2009. Physical examination revealed that the Veteran was able to walk one-quarter mile, stopping due to shortness of breath. No claudication was noted on walking, and the Veteran was noted to have "bounding pulses" in the dorsalis pedis and posterior tibial arteries. His extremities were noted to be normal in color and temperature. No Reynaud's phenomenon, varicose veins, or any edema or post-phlebitic syndrome was present. The examiner did note that the May 2009 repair surgery appeared not to have been successful, with additional surgery planned at a later date. The Veteran again underwent VA examination in June 2010. At that time, the examiner noted the course of the disorder to have been stable since onset, with no ulceration, gangrene, edema, or coldness resulting. The Veteran complained of some pain in his right hip and leg, but no edema, Reynaud's phenomenon, or varicose veins were found. The Veteran's dorsalis pedis and posterior tibial pulses were noted to be normal, with ankle/brachial indexes of 1.0 bilaterally. The examiner noted no evidence of swelling, warmth, cellulitis, dermatitis, or ulceration of the right lower extremity. The examiner diagnosed the Veteran with pseudoaneurysm of the right external iliac artery with an arteriovenous fistula. Here, the Veteran's pseudoaneurysm and arteriovenous fistula of the right iliac artery has been rated as noncompensably disabling under Diagnostic Code 7113, governing traumatic arteriovenous fistulas. As noted above, however, the Board finds that Diagnostic Code 7111, governing aneurysms of a large artery, may also be applicable in the Veteran's case. There is no clarity in the record as to whether the pseudoaneurysm experienced by the Veteran is comparable to an aneurysm, and thus governed by Diagnostic Code 7111, or if the two disorders are separate and distinct, rendering application of that Diagnostic Code inappropriate. In so finding, the Board notes that medical questions such as these cannot be answered by the Board. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (the Board is prohibited from exercising its own independent judgment to resolve medical questions). Rather, these questions must be addressed by an appropriately qualified physician. See Charles v. Principi, 16 Vet. App. 370 (2002); see also 38 C.F.R. § 3.159(c)(4) (2012) (a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim). Because the VA examinations do not provide a clear discussion as to whether the Veteran's pseudoaneurysm should be considered as analogous to an aneurysm for purposes of the rating criteria, the examinations obtained to date are inadequate. See 38 C.F.R. § 4.2 (2012) (providing that where an examination report does not contain sufficient detail, it is inadequate for evaluation purposes); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that a medical examination report must contain clear conclusions with supporting data and a reasoned medical explanation connecting the two); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). Accordingly, remand is required. In light of the above considerations, the Board concludes that a medical examination and opinion are needed. Under these circumstances, evidentiary development is needed to fully and fairly evaluate the Veteran's claim for an initial compensable rating for his service-connected pseudoaneurysm and arteriovenous fistula of the right iliac artery. 38 U.S.C.A. § 5103A (West 2012). Specifically, the AOJ must arrange for the Veteran to undergo VA examination by a qualified professional, who must review the Veteran's claims file and offer a well-reasoned discussion as to whether the Veteran's pseudoaneurysm should be considered as analogous to a true aneurysm for purposes of rating under Diagnostic Code 7111. In addition, the examiner must discuss the Veteran's residual symptomatology of pseudoaneurysm and arteriovenous fistula of the right iliac artery in the context of the symptoms set forth in both Diagnostic Code 7113, governing traumatic arteriovenous fistulas, and Diagnostic Code 7111, governing aneurysms of a large artery. In re-adjudicating the Veteran's claim for increase, the AOJ must take particular care in considering whether Diagnostic Code 7111, governing aneurysms, is for application in this instance. If the AOJ determines that the Veteran's pseudoaneurysm should be evaluated under Diagnostic Code 7111, the Board calls the AOJ's attention to the procedural requirements set forth therein, including the initial 100 percent disability rating following surgical repair of the aneurysm and the necessity of a follow-up VA examination and possible rating reduction following that initial period. 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. In this case, the Veteran has stated on multiple occasions, including in a May 2011 written statement to VA, that he was no longer able to work due to his service-connected disabilities. The Board finds that the issue of TDIU has been reasonably raised by the record and is, thus, properly before the Board by virtue of his increased-rating claims pursuant to Rice. The Veteran, however, has not received notice pursuant to the VCAA as it pertains to his claim for a TDIU. If, as here, the record has a procedural defect with respect to the notice required under the VCAA, this may not be cured by the Board. See Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). The Board therefore must remand the case to the agency of original jurisdiction because the record does not show that the Veteran was provided adequate notice under the VCAA and the Board is without authority to do so. Further, the Board notes that the RO has not addressed the issue of whether the Veteran is unemployable due solely to service-connected disabilities. Therefore, the question of whether the Veteran is entitled to a TDIU must be returned to the AOJ for adjudication. In particular, on remand the AOJ must obtain a medical opinion addressing the effect of all of the Veteran's service-connected disabilities, when considered together, on his unemployability. Accordingly, on remand, an opinion regarding the effect of all of the disabilities together on employability must be obtained. That opinion must consider this specific Veteran's educational and occupational experience. See 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). In view of the foregoing, the case is REMANDED for the following action: 1. The Veteran must be sent a letter requesting that he provide sufficient information and, if necessary, authorization to enable VA to obtain any additional pertinent evidence not currently of record. The AOJ must explain the type of evidence VA will attempt to obtain as well as the type of evidence that is the Veteran's ultimate responsibility to submit. The letter must particularly notify the Veteran of the information and evidence necessary to substantiate entitlement to a TDIU rating, as well as service connection claim on the basis of secondary service connection. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439, 448 (1995). 2. After securing any additional records, the Veteran must be scheduled for examination with a qualified medical professional or professionals. He must be notified that failure to report to any scheduled examination, without good cause, could result in a denial of his claims. See 38 C.F.R. § 3.655(b) (2012). The entire claims file, including a copy of this remand, must be made available to and reviewed by the examiner(s). All appropriate tests and studies must be accomplished, and all clinical findings must be reported in detail. Sleep apnea-The VA examination is necessary to determine the etiology of any current sleep apnea shown to be present. The VA examiner must review the Veteran's claims file and medical history, examine the Veteran, and provide an opinion as to whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that the Veteran's currently diagnosed sleep apnea is directly traceable to his period of military service. The Veteran's contentions that his sleep apnea first manifested in service must be discussed in the context of any negative opinion. The examiner must thoroughly review the Veteran's claims file, to include a copy of this remand. A well reasoned opinion must be provided with a detailed explanation for all conclusions reached by the reviewer. Citations to the record or relevant medical principles should be included as necessary to explain the opinion(s), and a complete rationale must be given for all opinions and conclusions expressed. Pseudoaneurysm and Arteriovenous Fistula of the Right Iliac Artery-The examiner must provide a detailed assessment of the current severity of the Veteran's service-connected pseudoaneurysm and arteriovenous fistula of the right iliac artery. The examiner must make all findings necessary to apply the rating criteria, paying particular attention to assessing the current severity of the Veteran's symptoms. The examiner must further discuss, in detail, whether the Veteran's pseudoaneurysm and arteriovenous fistula of the right iliac artery is analogous to an aneurysm of a large artery for purposes of evaluation under the criteria set forth in Diagnostic Code 7111. If the examiner finds the pseudoaneurysm and arteriovenous fistula of the right iliac artery not to be analogous to an aneurysm of a large artery, he or she must provide a detailed explanation as to why the two conditions are not analogous. If any additional testing is required to make such a determination, such testing should be conducted. The examiner must set forth all examination findings, along with the complete rationale for the opinions expressed. TDIU-The examiner must elicit from the Veteran, and record for clinical purposes, a full work and educational history. Based on the review of the claims file, the examiner must provide an opinion as to whether the Veteran is unable to obtain or retain employment due only to his service-connected disabilities, consistent with his education and occupational experience, irrespective of age and any nonservice-connected disorders. A full explanation for all opinions expressed must be provided. If an opinion cannot be provided without resort to speculation, it must be noted in the examination report, and a full explanation provided for that conclusion. The Board notes that the opinion regarding the Veteran's employability must be provided based on the effects of the Veteran's service-connected disabilities together, not based on the effects of each disability singularly. The Veteran's service-connected disabilities are as follows: coronary artery disease, congestive heart failure, status post pacemaker; PTSD; shell fragment wound of the right shoulder; diabetes mellitus with erectile dysfunction and bilateral toenail onychomycosis; tinnitus; hypertension; bilateral lower extremity diabetic dermopathy; right shoulder traumatic arthritis of the glenohumeral and acromioclavicular joints with impingement; retained metallic foreign body of the right upper lobe of the lung; residuals of resection of aneurysm of the right axillary artery; shell fragment wound scars of the right groin, knee, and upper leg; and pseudoaneurysm and arteriovenous fistula of the right iliac artery. 3. After completing the requested actions and any additional notification and/or development deemed warranted, the claims on appeal must be adjudicated in light of all pertinent evidence and legal authority. In particular, the AOJ must pay close attention to whether the Veteran's pseudoaneurysm and arteriovenous fistula of the right iliac artery should be evaluated under Diagnostic Code 7111. If such analysis is found to be necessary, the AOJ must ensure that all procedural requirements set forth in that Diagnostic Code are followed. If any benefit sought is not granted, the Veteran must be furnished a supplemental statement of the case (SSOC) and afforded the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. Thereafter, the case should be returned to the Board for further appellate review, if in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is notified. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims remanded by the Board 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). ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs