Citation Nr: 1321386 Decision Date: 07/03/13 Archive Date: 07/12/13 DOCKET NO. 10-13 809A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Whether new and material evidence was submitted to reopen a claim of entitlement to service connection for major depression (also claimed as a major depressive disorder). 2. Entitlement to service connection for residuals of a right ankle sprain. 3. Entitlement to service connection for right knee tendonitis. 4. Entitlement to service connection for traumatic brain injury (TBI). 5. Entitlement to service connection for leukocytosis. 6. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to January 9, 2009. 7. Entitlement to a total rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Marvin L. Richardson, Agent ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active duty for training in the Army/Air National Guard from January 5 to May 19, 2000 and active duty in the United States Army from January 2003 to July 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from June 2007 and May 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Offices (RO) in Louisville, Kentucky, and Nashville, Tennessee, respectively, that denied a rating in excess of 50 percent for PTSD and service connection for a TBI, and declined to reopen the Veteran's claims for service connection for right knee and ankle disorders, leukocytosis, and a major depressive disorder (major depression). Jurisdiction of the Veteran's case is currently with the VA RO in Cleveland, Ohio. In his April 2010 substantive appeal, the Veteran requested to testify during a hearing at the RO before a Veterans Law Judge ("Board hearing") but, in an October 2010 signed statement, he withdrew his hearing request. The Board is of the opinion that all due process requirements were met regarding the Veteran's hearing request. The record shows that, in August 2008, the Veteran submitted a formal claim for a TDIU that he withdrew in a September 2008 signed statement. Then, in January 2009, he submitted a new formal claim for a TDIU. In a March 2009 rating decision, the RO granted a 100 percent rating for PTSD, effective from January 9, 2009. At that time, the RO indicated that the Veteran's recent TDIU claim was "moot". VA's General Counsel previously concluded that a claim for TDIU may not be considered when, as here, a schedular 100 percent rating is already in effect due to service-connected disability(prior to January 9, 2009). See VAOPGCPREC 6-99; 64 Fed. Reg. 52375 (1999). See also Green v. West, 11 Vet. App. 472, 476 (1998); Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In other words, in the past, the TDIU claim would have been considered moot as of January 9, 2009. However, in November 2009, VA's General Counsel withdrew VAOPGCPREC 6-99 in light of the decision of the United States Court of Appeals for Veterans Claims (court) in Bradley v. Peake, 22 Vet. App. 280 (2008). In Bradley, the court ruled that, although no additional disability compensation through a TDIU may be paid when a total 100 percent schedular disability rating is already in effect, VA may still potentially consider a TDIU claim in such instance in order to determine the Veteran's eligibility for Special Monthly Compensation (SMC) under section 1114(s). Bradley v. Peake, 22 Vet. App. at 292-94. Therefore, in the present decision, the Board will consider whether the Veteran is entitled to a TDIU rating. This consideration will include the entire claim period. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009) (to the effect that a request for a TDIU, whether expressly raised by Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part and parcel of a claim for an initial rating for a disability); Mayhue v. Shinseki, 24 Vet. App. 273 (2011). The RO denied the Veteran's claims for service connection for leukocytosis, right knee tendonitis, and residuals of a right ankle sprain, in September 2005 and June 2007 decisions. Ordinarily new and material evidence would be required to reopen the claims. 38 U.S.C.A. §§ 5108, 7105(c) (West 2002); 38 C.F.R. § 3.156(a)-(b) (2012). However, in December 2007 and March 2008, the RO received copies of additional service treatment records (notably some dated during 2003) that are relevant to the claims and were in existence at the time of the prior decisions. VA has adopted a regulation providing that when such records are received, the prior decisions will be reconsidered without the requirement for new and material evidence. 38 C.F.R. § 3.156(c) (2012). The Board will thus consider the Veteran's claims for service connection for leukocytosis, right knee tendonitis, and residuals of a right ankle sprain, on a de novo basis without the requirement for new and material evidence. In an April 2012 written statement, the Veteran's agent reported that the Veteran permanently relocated to Melbourne, Florida, and requested that his claims file be transferred to the VA RO in St. Petersburg, Florida. This matter is referred to the Agency of Original Jurisdiction (AOJ) for appropriate action. In a November 2012 written statement, the Veteran's agent provided a notice of disagreement (NOD) with the "most recent" RO rating decision regarding the Veteran's request for "P&T Benefits" in addition to his current 100 percent disability rating. This is an apparent reference to the March 2009 rating decision that granted a 100 percent rating for PTSD that was not considered permanent. But see 38 C.F.R. § 20.302 (2012) (to the effect that a NOD must be filed within one year from the date of notice of the rating decision appealed). Thus, the matter of the Veteran's new claim of entitlement to a permanent 100 percent rating for his service-connected PTSD is referred to the AOJ for appropriate action. The issues of whether new and material evidence was submitted to reopen a claim of entitlement to service connection for a major depressive disorder, service connection for a TBI, right knee tendonitis, residuals of a right ankle sprain and leukocytosis, and entitlement to a TDIU, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT Since January 30, 2007, and giving the Veteran all benefit of the doubt, his service-connected PTSD effectively resulted in total social and occupational impairment. CONCLUSION OF LAW Resolving all reasonable doubt in the appellant's favor, since January 30, 2007, the schedular criteria for a rating of 100 percent for his service-connected PTSD are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.125, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION As the Board's decision to grant a 100 percent rating for PTSD since January 30, 2007 herein constitutes a complete grant of the benefits sought on appeal, no further action is required to comply with the Veterans Claims Assistance Act of 2000 and the implementing regulations. The Veteran contends that, prior to January 9, 2009, a rating in excess of the currently assigned 50 percent is warranted for his service-connected PTSD and argues that he was rendered unemployable by it. In written statements in support of his claim, he reports having employment problems due to irritability, impulse control, and PTSD-related symtoms. The Veteran further indicates that his lack of impulse control and unprovoked irritability affected his daily business relationships. In June 2008, he reported that he was diagnosed with PTSD and major depression that caused short term memory loss, depression, suicidal and homicidal ideations, and auditory hallucinations. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). In the case of an increased rating, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). 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, be expected in all instances. 38 C.F.R. § 4.21 (2012). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). The Veteran's statements describing the symptoms of his service-connected PTSD disability are deemed competent. These statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. Under Diagnostic Code 9411, that evaluates PTSD, a 50 percent rating is warranted if the disability is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating contemplates 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 ability 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. Id. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM IV), page 32). A GAF score ranging from 31 to 40 represents some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41 to 50 indicates 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 score of 51 to 60 indicates the examiner's assessment of moderate symptoms (e.g., a flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61 to 70 denotes mild symptoms or some difficulty in social and occupational functioning. Id. While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Rather, GAF scores are but one factor to be considered in conjunction with all the other evidence of record. When it is not possible to separate the effects of a nonservice-connected condition from those of a service- connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); see also 38 C.F.R. § 3.102. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. By way of history, the record reflects that, in a September 2005 rating decision, the RO granted service connection for PTSD that was assigned an initial 50 percent disability rating under Diagnostic Code 9411 On January 30, 2007, the RO received the Veteran's claim for an increased rating for PTSD that was denied in the June 2007 rating decision. The Veteran was notified in writing of the RO's June 2007 determination and his appellate rights and did not appeal. However, on June 29, 2007, the RO received a signed statement from the Veteran, dated March 5, 2007, and requesting an increased rating for his PTSD that he said worsened. He reported that medications prescribed for his disability caused increased depression, mood swings, and changed behavior. The Veteran included copies of discharge instructions provided to him in February 2007 after VA hospitalization for treatment of depression, not otherwise specified (NOS) (duplicative of those previously of record), that describe his prescribed psychiatric medications. In addition, records of VA and non-VA treatment in 2006 include findings suggestive of pertinent psychiatric disability. The Veteran's statement and VA and non-VA treatment records are construed as new and material evidence received during the appeal period after the June 2007 decision. As such, this evidence served to prevent the rating decision from becoming final and required readjudication of the original decision. Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); 38 C.F.R. § 3.156(b) (2012). The claim was essentially readjudicated by the RO in May 2008 and the Veteran perfected an appeal following that decision. Hence, the June 2007 decision is not final and the Veteran's claim arises from this rating determination. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 20.302, 20.1103 (2012). The March 2009 rating decision granted a 100 percent rating for PTSD effective January 9, 2009. The Veteran contends that he is entitled to a higher rating for his service-connected PTSD prior to January 9, 2009. After careful consideration of all the evidence of record, and giving him all benefit of the doubt, the Board concludes that the evidence is in equipoise as to whether the Veteran's service-connected PTSD has effectively rendered him totally impaired and unable to work since January 30, 2007 when he filed his increased rating claim. As such, his claim will be granted. Facts VA and non VA medical records and examination reports, dated from 2006 to 2009, indicate that the Veteran's psychiatric disability was treated with prescribed medications and regular psychiatric interviews for medication management. VA outpatient psychiatry records dated in February 2006 show that the Veteran worked at a Days Inn and was in training. He experienced motor activity. The Veteran liked the quiet environment. His affect was anxious and nervous and he denied auditory and visual hallucinations but felt deceased family members' presence. He denied suicidal ideation but admitted to having road rage at times. The Axis I diagnosis was major depressive disorder, anxiety disorder, NOS, and a need to rule out attention deficit hyperactivity disorder. A GAF score of 58 was assigned. A March 2006 VA outpatient psychiatry record indicates that the Veteran said he was laid off from his job. His wife reported that he twitched in his sleep. The Veteran reported combat-related dreams. He felt calm during the day but felt a strange presence at night. His wife appeared indifferent to his complaints. The Veteran said he kept showing up at his wife's duty station and acting like he was still in service. His wife reported that he stayed in front of the computer for hours. The Veteran said that the computer called him to be on it. She said he was impulsive and he said that he was delusional at times. He denied current auditory and visual hallucinations and suicidal and homicidal ideations. The diagnoses included major depressive disorder, anxiety disorder, and a need to rule out attention deficit hyperactivity and bipolar disorders. August 2006 mental health treatment records from Blanchfield Army Community Hospital (ACH) at Fort Campbell, Kentucky, show that the Veteran had suicidal and homicidal ideations. A September 2006 VA outpatient psychiatry record indicates that the Veteran worked at a bowling center on the Fort Campbell military post and received prescribed medication from a psychiatrist at the Blanchfield ACH. He reported that he got upset at work and was found to be cutting his wrist. The Veteran said that, in July, he had alcohol poisoning, and he and his wife took separate vacations that depressed him. The diagnosis was major depressive (disorder) with psychotic features and bipolar disorder and he was referred to Blanchfield ACH for treatment. When seen at the Blanchfield ACH in October 2006, the Veteran's speech was normal, and his mood was dysthymic, expansive, labile, frustrated, and anxious. His affect was abnormal, exuberant, silly, and showed excessive laughing. He wore a nice looking jacket with six medals of Army campaigns he was in. Grooming was normal. There were no perceptual disturbances and his thought processes were not impaired. No suicidal plans or homicidal ideations were noted. The assessment included bipolar disorder, most recent episode, mixed, and PTSD. VA hospitalized the Veteran for one week in February 2007 for treatment of psychiatric disability. A February 16, 2007 VA outpatient mental health clinic intake record prepared by a social worker shows that the Veteran believed his condition worsened and he had tendencies to hurt himself and other people. He had attention problems and difficulties with his wife, including arguing. The Veteran was unable to work due to becoming angry with customers. His hygiene and grooming deteriorated and he had problems using deodorant and showering daily. The Veteran bowled regularly and went to church but admitted social withdrawal. He was irritable and had poor impulse control. The Veteran always felt angry with a "violent temper" but never followed through with harming another person. The Veteran had sleep difficulty and regular nightmares. He had panic attacks "all the time", and that occurred when he was afraid of being late, when he heard sirens, and had no place to hide. He denied obsessive/compulsive thoughts. The Veteran occasionally heard the voice of a dead relative. He was unable to give examples of what was said but felt the person's presence. The Veteran had constant depression since service. Objectively, the Veteran was dressed appropriately and was fully alert. His behavior was guarded and he believed he was passive and aggressive. His thought content was coherent. The Veteran said his wife told him he was delusional and asked the examiner the definition of delusional thinking. Insight was intact, speech was normal, and thought processes were goal directed. The Veteran's judgment was impaired and his mood was anxious. His affect was blunted and he was oriented, with good concentration and memory. The Axis I diagnosis was major depression and a GAF score of 50 was assigned. According to a VA mental hygiene clinic medication management record, also dated February 16, 2007 and prepared by a physician, the Veteran reported being "chronically suicidal and homicidal" with such thoughts in the past few days. He felt increasingly paranoid and told the examiner that he "can't work". On examination, the Veteran sat uncomfortably close to the examiner and stared into the computer monitor as the clinician typed. The Veteran was alert and oriented, with fluent speech that had an eerie quality of danger inherent in it. His memory was satisfactory and there was no gross cognitive impairment discernible. Mood was mildly to moderately depressed, judgment was poor to fair, and insight was undetermined. Equivocal suicidal and homicidal thoughts were noted. There were no hallucinations but the Veteran admitted to some paranoid feelings. The assessment was recurrent major depression and a borderline personality disorder. The VA clinic physician requested that the Veteran be admitted to the psychiatric service that day due to depression and personality disorder, with chronic homicidal and suicidal ideation, inappropriate behavior (too close in interpersonal space), and bizarre relatedness. When examined by a physician on February 17, 2007, the Veteran complained of depression and needing disability benefits. He appeared dysphoric, but calm and responsive, and felt depressed since service discharge for lack of care for PTSD. He indicated that he was unable to work and needed disability and asked if the hospital could provide 100 percent service connected benefits. He had combat related sleep difficulty and was unable to explain why he could not work, other than stating he was "a mess". On examination, the Veteran was moderately groomed and depressed with clear speech. His thought processes were organized and he denied delusions and hallucinations. He was oriented with intact memory and fair concentration. The Axis I diagnoses were depression, NOS, PTSD by reported history, and a need to rule out malingering for disability. A GAF score of 40 was assigned. A February 20, 2007 mental health inpatient record prepared by a neuropsychiatrist recounts the Veteran's pre-service and service history and indicates that the Veteran was "up-front" regarding his goal to receive a 100 percent disability rating, implying that he was unable to maintain gainful employment in any setting, despite ongoing efforts at retraining via vocational rehabilitation. The examiner noted that "[t]he final matter is currently being examined for adjudication, and this very hospital stay may have been 'used' by the patient to embellish or accentuate his inability to function/interact with people, particularly within a work place". The examiner opined that there was "no true indication that [the Veteran] was not able to benefit from vocational training and future work" and that such disability benefits would "appear to be contraindicated to the general health and well-being of" the Veteran. The Axis I discharge diagnoses included a mood disorder, NOS, and a need to rule-out PTSD. The Veteran's GAF score at admission was 45 and, at discharge, was 70. The record shows that he was observed closely and monitored for signs or symtoms of mood/anxiety disorder but none were found such as to consider the Veteran temporarily or permanently impaired. There was no evidence of underlying thought disorder. The Veteran processed information slowly and interpreted information in a concrete and literal fashion thought more consistent with a longstanding learning disorder that did not render him unemployable or physically or emotionally handicapped. In June 2007, the Veteran underwent VA examination for PTSD. The examiner reviewed the Veteran's medical records and performed a clinical evaluation. The Veteran's February 2007 hospitalization was noted and that the discharge summary suggested there was a strong suggestion of malingering or exaggeration of symtoms for secondary gain. The Veteran reported that he was "out of control" at home and work. He sometimes felt that he might hurt his wife but denied domestic violence, or homicidal thoughts. He was unable to stay still and did not feel that he was able to work. The Veteran had temper tantrums since he was a child. On examination, the Veteran was clean, neatly groomed, and appropriately dressed. He was hyperactive with unremarkable speech. His affect and mood were anxious. The Veteran's attention was intact, and he was oriented. His thought process was rambling and his thought content focused on increasing his disability rating. There were no delusions or hallucinations. The Veteran understood the outcome of his behavior and partially understood that he had a problem. The Veteran reported that sleep difficulty interfered with his daily activity in that he awoke three times during the night due to nightmares and anxiety. He slept on a couch so as not to disturb his wife. There was no inappropriate behavior, obsessive/ritualistic behavior, panic attacks, or homicidal thoughts. The Veteran did have suicidal thoughts of hanging himself while in Florida in May 2007. He did not tell anyone and the thought went away. He denied any current suicidal ideation. His impulse control was fair. The Veteran was able to maintain minimum personal hygiene. His remote memory was normal and his recent and immediate memory was mildly impaired. The Veteran currently worked fulltime as a desk clerk, a job he had less than one year. The Axis I diagnosis was major depressive disorder and a GAF score of 60 was assigned. The VA examiner commented that the Veteran's Axis II diagnoses (personality disorder, NOS with dependent and borderline features) should be considered primary. It was noted that the Veteran's clinical picture was complicated by his cultural background in that some of his presentation may be culturally driven. It was further noted that there was a strong suggestion that the Veteran's presentation was exaggerated by a motive of secondary gain for increased service connection. The Veteran also endorsed at times multiple mental health diagnoses (major depressive disorder, PTSD, bipolar disorder, learning disability, attention deficit disorder, etc.) although he did not consistently endorse symptomatology of all these. The examiner found no credible evidence of bipolar disorder. The Veteran appeared quite distractible and, by his report, was treated for attention deficit disorder as a child that was a possibility. The examiner noted some inconsistencies in two prior VA examination reports regarding his childhood psychiatric history: the Veteran noted that he was almost diagnosed with autism, was treated for attention deficit disorder, and had rages as a child. He also reported that he had some homicidal ideation in service towards non commissioned officers, but the examiner was unable to locate documentation of that, although there was documentation regarding anxiety, poor coping, and some depressive symtoms, including suicidal statements. The Veteran was working full time at present and there was no evidence to suggest that his mental health problems negatively impacted on his current employment. A recent inpatient psychiatric hospitalization was suggestive of exaggeration of mental health symtoms for secondary gain. The examiner concluded that there did not presently appear to be any clear-cut evidence to suggest that the Veteran was unable to work. The VA examiner stated that the Veteran exhibited reduced reliability and productivity due to mental disorder symtoms. The Veteran described a history of loss of anger, with a physical altercation with a customer at work (in 2005) and no episodes of similar incidents noted since that time. He reported being upset when he worked as a janitor at Fort Campbell and engaged in self-mutilating behavior (cut wrists, not hospitalized, scratches only). The Veteran noted additional incidents and appeared to be functioning at the present job relatively well. In July 2007, the Veteran underwent another VA examination for PTSD. The examiner reviewed the Veteran's medical records and performed a clinical evaluation. The Veteran reported weight gain due to prescribed medication for his psychiatric disability. The medication helped manage his insomnia but stress at work was still an issue. The Veteran discussed a history of self-mutilation that occurred as recently as five months earlier (in response to an argument with a customer at work, he said that he took a tweezers and cut his wrist). He denied that this was a suicide attempt and said the self-mutilation episodes occurred once every two or three months since military service. The examiner commented that his account of the frequency and duration of the episodes was quite inconsistent (he reported they occurred once every two to three months but said that the last episode was five months ago). The Veteran reported suicidal ideation while vacation in Florida, as noted in the earlier VA examination report, after conflict with his father. He enrolled in on-line college courses and was studying for a degree in "electrical tech". He felt "fine" about going back to school and did not report any difficulty with academic performance associated with his symtoms. The Veteran was married to his current wife of five years, described their relationship as fine, but reported arguing with her on a daily basis. It was noted that he was inconsistent in describing the frequency of their arguments. While reporting that they had arguments daily, he said that the last argument they had was approximately one week earlier. He was also very vague in describing their arguments and had difficulty citing specific reasons for them (he noted his behavior problems that he acted like a teenager, and that he had tantrums). The Veteran said that he had several friends in his previous job but none in his current job that started the previous day. He denied having any significant friends outside of his immediate family. He bowled once a week and enjoyed going to the gym and talking long walks downtown. The examiner noted that the Veteran provided inconsistent information, reporting that he went to the gym sometimes, and then stating that he had not been in over one year. The Veteran had one suicide attempt in February 2007 for driving recklessly that resulted in his psychiatric hospitalization. It was noted that a review of those hospital records did not reveal any specific documentation of this attempt. There was no history of violence/assaultiveness. The Veteran currently worked as a janitor at a major military base and recently had workplace difficulties associated with poor concentration and restlessness. On examination, the Veteran was clean, neatly groomed, and appropriately dressed. He was hyperactive and restless and his speech was spontaneous and rapid. The Veterna's affect was normal and his mood was good. He was easily distracted and oriented. His thought process showed circumstantiality and he was preoccupied with one or two topics. He understood the outcome of his behavior and partially understood that he had a problem. His current medications helped with his sleep problems and he did not recall when he last had a nightmare. There were no hallucinations, and no inappropriate behavior or obsessive /ritualistic behavior. The Veteran had panic attacks daily that were sparked by storms and power failures, and hearing an explosion. The panic attacks occurred frequently in response to interpersonal conflict and he described symtoms of his heart racing and feeling as if he was going into cardiac arrest. There were no homicidal or suicidal thoughts or episodes of violence, and good impulse control. The Veteran's remote memory was mildly impaired and recent and immediate memory were normal. PTSD symtoms included daily recurrent and intrusive recoolections of combat-related events, a sense of a foreshortened future, irritability or outbursts of anger, concentration difficulty, and hypervigilance. The Veteran displayed irritability, angry outbursts towards his wife, and decreased ability to cope with workplace stress. The VA examiner stated that the Veteran was vague in his descrption of symtoms and provided inconsistent information regarding the frequency of his symtoms. It was noted that the Veteran worked parttime as a custodian. His problems related to occupational functioning included decreased concentration, difficulty following directions, and memory loss. The VA examiner concluded that the Veteran did not meet the criteria for a diagnosis of PTSD. The Axis I diagnosis was an anxiety disorder, NOS (PTSD features), and a GAF score of 60 was assigned. The VA examiner commented that, while the Veteran was diagnosed with PTSD in 2005, his current description of his symtoms was not consistent with a full diagnosis of the disorder. The level of avoidance and emotional numbing described by the Veteran was minimal and insufficient to meet criteria C for PTSD. Also, many of the symtoms endorsed by the Veteran (e.g., social withdrawal) were reportedly present prior to military service and cannot be explained solely by trauma exposure. As to the link between PTSD symtoms and changes in impairment in functional state and quality of life, the VA examiner said this was "very difficult to answer" given the Veteran's "considerable history of psychiatric impairment prior to military service". Given his reported history, it was possible that the Veteran would have developed difficulties with social and occupational functioning without trauma exposure; however, it was very unlikely that his trauma exposure served to increase his reactivity to workplace stressors. Absent specific details regarding his pre service treatment history, any conclusions regarding this issue would be speculative. The Veteran's history of self-mutilation and long-standing emotional reactivity to interpersonal stressors was suggestive of a co-morbid personality diagnosis. Such a clinical condition can lead to difficulties with social and occupational functioning. It was likely that the Veteran's reported trauma exposure worked to exacerbate the level of impairment that resulted from this disorder alone. The VA examiner stated that there was reduced reliability and productivity due to PTSD symtoms, including difficulties with restlessness and poor concentration negatively affecting his ability to engage in customer service positions (losing concentration when counting cash drawer, forgetting information from customers, leaving work station frequently due to heightened stress). There was social impairment shown by few friends, minimal hobbies and reportedly frequent conflicts with his wife over trivial matters. The examiner could not determine the extent to which these impairments were related to the Veteran's reported trauma exposure or pre-existing psychiatric disability. In a February 2008 signed statement, the Veteran said that his mental health was declining and he felt himself becoming more hyperactive, passive, aggressive, and bizarre. Sometimes he felt anxious, depressed, and manic. He felt clear headed and normal at times and confused and delusional at other times. In May 2008, the Veteran underwent VA examination for PTSD. According to the examination report, the examiner reviewed the Veteran's medical records and performed a clinical evaluation. The Veteran reported prior VA treatment for anxiety, depression, and a personality disorder. He gave a history of being taken to the emergency room at Fort Campbell in July 2006 for overconsumption of alcohol and was released later that night. The Veteran treated his psychiatric disorder with prescribed anti-depressant and anti-anxiety medication. The Veteran felt depressed most the day every day of the week. He had sleep problems. The Veteran displayed significant problems with concentration and was unable to stay on track. He described suicidal ideation and endorsed feelings of hopelessness and helplessness. The Veteran indicated that he cried at least twice a week. He described not finding pleasure in the things that used to bring him pleasure. The Veteran heard voices at night but denied them having messages for him. He reported that he saw lightening and heard thunder at night when there was none. He constantly felt that people were about to attack him. The Veteran said he was taking classes at a community college and planned to graduate in May 2008. He was married to his first wife for six years and described their relationship as argumentative due to his irritability. The Veteran had one or two close friends with whom he can talk about personal issues and one or two other friends with whom he socialized. He bowled once a week and liked to watch sports on television. He surfed the Internet for approximately three hours a day. Further, the Veteran said that, in mid-February 2007, he thought of crashing his car, was "in a state of confusion", and was hospitalized by VA in Louisville, Kentucky. He said that, on May 27, 2007, he cried during mass and was tempted to hang himself in church during mass. There was no history of violence or assaultiveness. On examination, the Veteran was clean, neatly groomed, and appropriately and casually dressed. His speech was soft and rapid and his attitude was cooperative, friendly, relaxed, and attentive. The Veteran's affect was full and his mood was anxious and depressed. There was attention disturbance in that he had a short attention span: he was unable to do serial 7s. The Veteran was oriented and his thought process revealed flight of ideas and tangentiality. His thought content was unremarkable, with ruminations and paranoid ideation. There were no delusions. He had auditory hallucinations that were not persistent. The Veteran understood the outcome of behavior and partially understood that he had a problem. He had sleep impairment with difficulty falling asleep and repeated awakenings during the night. There was no inappropriate behavior. The Veteran had obsessive/ritualistic behavior in that the Veteran reported that he obsessively thought of ways to get revenge on persons he felt wronged him. He did not have panic attacks. He had homicidal thoughts in that he thought about wanting to kill his former military chain of command. He said he had not done this because he was physically restrained from doing so in the past. The Veteran thought of suicidal ideation 60 percent of the time. He denied having current thoughts during the present examination. He did not kill himself because of his wife and family. There were no episodes of violence and the Veteran was able to maintain minimum personal hygiene. The Veteran's remote memory was normal and his recent memory was severely impaired. The Veteran had intrusive and distressing recollections about combat-related events for about 20 percent of the day. He had nightmares almost nightly. The Veteran had flashbacks on a daily basis for less than 5 minutes. He tried to avoid training areas of Fort Campbell that was close to his house. The Veteran avoided being in an area that would have sand. He avoided activities outside of the home other than sports because he did not like to be around people. The Veteran had difficulty with sleep, as noted. He was irritable 90 percent of the time. He described a fight response to being startled and always feeling that people were going to attack him. The Veteran was not considered capable of managing his financial affairs. He paid some bills twice and did not pay other ones, and was unable to keep up with it mentally. The Veteran currently performed volunteer work at a gym that he did for the past month. He worked as a bowling alley cashier for two months but was fired because of a "management issue against [him]" and was an assistant at a bowling alley for four months until he moved. His problems related to occupational functioning included being assigned different duties, decreased concentration, difficulty following directions, memory loss, and poor social interaction. The Axis I diagnoses included chronic PTSD and a major depressive disorder with psychotic features. A GAF score of 37 was assigned and the VA examiner commented that the Veteran appeared to have major impairment in social and occupational functioning. The Veteran indicated that he was suicidal 60 percent of the time and endorsed paranoid ideation. As to the link between PTSD symtoms and occupational impairment, functional state, and quality of life, the Veteran reported that his memory problems caused him to lose jobs in the past. He indicated that his irritability, anger, and poor social interactions caused him problems on the job. The Veteran said that these same problems caused marital problems, as well as problems with friends and others. The Veteran indicated that this led to him preferring to be at home, other than bowling and going to the gym. He said that his restless sleep led to his sleeping on the sofa to as to not bother his wife. The VA examiner opined that there was total occupational and social impairment due to PTSD signs and symtoms. The examiner explained that the Veteran had great difficulty in concentrating that was a symptom of depression and PTSD. He had significant difficulty staying on track during the present exam to the degree that it was hard to think of a job that he could do successfully. The Veteran did not like to interact with people and was paranoid of their motives. He was interpersonally very awkward. The Veteran indicated great tension in his marriage and not interacting with anyone other than his wife, with whom he regularly interacted, and his family. In a July 2008 Addendum, the recent VA examiner stated that the Veteran's depression appeared to be long standing in nature and he was not service-connected for it when diagnosed in past VA examinations. The current VA examination indicated the functional impairment was due to PTSD symtoms. As to the Veteran's depressive symtoms, the examiner reported that the Veteran said he felt depressed most of the day each day of the week. He had sleep problems and noticed an unexplained weight gain. The Veteran displayed significant problems with concentration and not being able to stay on track. He had suicidal ideation and endorsed feelings of hopelessness and helplessness. The Veteran indicated that he cried at least twice a week and did not find pleasure in the things that used to bring him pleasure. The Veteran heard voices at night but denied them having messages for him. He saw lightening and heard thunder at night when there was none. He constantly felt that people were about to attack him. The VA examiner again reported that there was total occupational and social impairment due to PTSD signs and symtoms. The Veteran had great difficulty in concentrating that was a symptom of depression and PTSD. He had significant difficulty staying on track during the clinical examination to the degree that it was hard to think of a job that the Veteran could do successfully. He did not like to interact with people and was paranoid of their motives. He was interpersonally very awkward. The Veteran indicated great tension in his marriage and not interacting with anyone other than his wife, with whom he regularly interacted, and his family. The VA examiner commented that the Veteran's problems with concentration, anhedonia, and sleep problems could be due to PTSD or major depressive disorder, or both. It was not possible to delineate at that point, particularly due to the long standing nature of the Veteran's diagnoses of each disorder. According to the examiner, not liking to interact with people can be symptomatic of either disorder but paranoia of others' motives was more commonly seen in PTSD. For these reasons, the functional impact could be related to either diagnosis. The Veteran's GAF score for major depressive disorder was 37, below that for PTSD (GAF = 51) due to the suicidal ideation component being related to major depressive disorder. A June 2008 signed statement from J.S., the Veteran's former employer, indicates that the Veteran was separated that month from his work at a fitness center because he was unable to comply with its basic operation procedures and standards. Several incidents were noted to have occurred during early June 2008 and the Veteran was verbally counseled. According to an accompanying written statement from the Veteran, he did not recall the incidents due to his PTSD and depression that caused short term memory (loss), irritability, depression, and homicidal/suicidal ideations. He heard voices and sounds that were nonexistent. Due to his symtoms he arrived for work late and his condition declined in the past six months. His position at a bowling center was abruptly terminated due to similar incidents. In an August 2008 signed statement, another former employer said that the Veteran worked as a cashier from February to April 2008 and was separated due to issues regarding rudeness from customers and frightening them. September 2008 signed statements from the Veteran's wife and parents are to the effect that he was unable to work due to his psychiatric disability and had become increasingly irrational and prone to violent thoughts. He had constant suicidal ideations. After considering all of the objective medical and other evidence of record, it is the judgment of the Board that the evidence is in equipoise as to whether the schedular criteria for a 100 percent rating are met prior to January 9, 2009. Giving the Veteran the benefit of the doubt, the Board concludes that his psychiatric disability has effectively resulted in total occupational and social impairment. The Board finds that the medical evidence shows the Veteran is unemployable due to the disability at issue. See Mittleider v. West, supra. In fact, in May 2008, the VA examiner particularly noted his combat-related sleep difficulty, intrusive thoughts, suspiciousness, poor impulse control and irritability, auditory and visual hallucinations, and social isolation. That VA examiner assigned a GAF score of 51 (for PTSD), denoting moderate symptoms such as a flat affect and circumstantial speech, occasional panic attacks, or moderate difficulty in social, occupational, or school functioning such as few friends, conflicts with peers or co-workers. Although, June and June 2007 VA examiners assigned GAF scores of 60 (denoting mild symtoms) and suggested that the Veteran provided inconsistent descriptions of his symtoms. However, in view of the foregoing, the Board concludes that the evidence is at least in relative equipoise as to the level of psychiatric disability, and as to whether it is reasonable to conclude that the disability picture is comparable to a 100 percent evaluation. Overall, the current level of disability arguably, but not clearly, approximates the criteria for a 100 percent evaluation. Thus, the Board concludes, with favorable resolution of reasonable doubt, that a 100 percent rating under DC 9411 is warranted, under the regulations currently in effect. 38 C.F.R. § 4.7. The Board notes that the Veteran's psychiatric symptomatology does not precisely mirror the symptoms illustrative of a 100 percent evaluation under Diagnostic Code 9411. For example, there is little or no evidence in the record of gross of impairment in communication; gross inappropriate behavior, disorientation to place; memory loss for names of close relatives, own occupation or own name. However, it is apparent that the Veteran's symptoms, especially his sleep difficulty, irritability, anxiety, social isolation, avoidance behavior, and memory and concentration difficulty, have essentially totally impaired his social and occupational functioning by severely reducing his reliability and productivity. Although the June and July 2007 VA examiners concluded that the Veteran was not totally impaired due to service-connected PTSD, the May 2008 VA examiner particularly noted the Veteran's great difficulty concentrating that was a symptom of depression and PTSD. According to the May 2008 VA examiner, the Veteran had significant difficulty staying on track during the examination to the degree that it was hard to think of a job that he could do successfully. Statements from the Veteran's previous employers note his inability to successfully function in a work environment. In these circumstances, therefore, the Board finds that a 100 percent evaluation is warranted for the service-connected PTSD. See 38 C.F.R. § 4.21 (2012) (not all cases will show all findings specified in the rating criteria, but the rating must in all cases be coordinated with actual functional impairment). The February 2007 VA outpatient clinic records include GAF scores of 58 and the May 2008 VA examiner assigned a GAF score of 51 for PTSD that denotes moderate impairment in social and occupational functioning. See Carpenter v. Brown, supra. But the VA examiners in June and July 2007 considered the Veteran less impaired and assigned GAF scores of 60, reflective of mild social and occupational functioning. Further, the Veteran's psychiatric symptomatology has included irritability, avoidance, anxiety, social isolation, auditory hallucinations, panic attacks, recurrent combat-related nightmares, and intrusive recollections of service-related events. In reaching this decision, the Board recognizes that the Veteran's capability to work was at times attributed to nonservice-connected disorders. Nevertheless, the record also establishes that he has been treated for several years for chronic, debilitating symptoms non-dissociable from the service-connected psychiatric disability that included nightmares and sleep difficulty, social isolation, avoidance, anxiety, and irritability, that, for all intents and purposes, precluded him from gainful employment since January 30, 2007. See e.g., Mauerhan, supra (factors listed in the rating formula are examples of conditions that warrant a particular rating and are used to help differentiate between the different evaluation levels.). From the objective and competent medical evidence of record, it is not unreasonable to conclude that, since he filed his claim in January 2007, the Veteran's service-connected PTSD essentially rendered him unable to work. Resolving reasonable doubt in the Veteran's favor, the Board concludes that, since January 30, 2007, the criteria for the assignment of a 100 percent rating for an acquired psychiatric disorder have been satisfied. In view of the above, the Board finds that the application of the benefit-of-the-doubt doctrine contemplated by 38 U.S.C.A. § 5107(b) is appropriate in this case. As stated, the level of disability, when the benefit of the doubt is given to the Veteran, is approximately commensurate with the 100 percent rating under Diagnostic Code 9411 under current rating criteria. 38 U.S.C.A. §§1155, 5107; 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. As the Board has granted the Veteran a 100 percent schedular evaluation herein, it is not necessary to consider whether he is entitled an extra-schedular rating under 38 C.F.R. § 3.321 (2012). Therefore, for the foregoing reasons, the Board finds that a 100 percent schedular rating is warranted for the Veteran's PTSD for the entire appeal period. ORDER A 100 percent rating for PTSD is granted from January 30, 2007, subject to the laws and regulations governing the award of monetary benefits. REMAND The Veteran also seeks service connection for right knee tendonitis and residuals of a right ankle sprain. Service treatment records, dated in July and August 2003, reflect his complaints of chronic right knee pain with possible internal derangement/medial meniscus tear. In April 2004, the Veteran sustained a right ankle inversion injury. Treatment included crutches and an ankle air cast brace. He was placed on a limited profile from April to July 2004. Records dated in May and June 2004 show that his ankle sprain was resolving. Post service, a December 2004 VA examination report indicates that x-rays of the Veteran's right ankle and knee were normal. The examiner said the Veteran suffered a tendinitis injury of the right knee but appeared to have recovered fully from it. He was still bothered on episodes of high activity but did not show any signs of discomfort on current examination. The Veteran also recovered from his right ankle sprain injury that did not bother him on examination but gave him difficulties when he accidently twisted it. The examiner did not think either of the injuries would be a significant life altering injury. However, more recent VA and non-VA treatment records, dated from 2005 to 2010, include the Veteran's complaints of chronic right knee pain (in December 2005, October 2006, March and November 2008, and March 2009), and right ankle pain (in October 2006 and March 2008). Knee arthralgia was listed among the Veteran's medical problems in January 2012. The March 2009 VA emergency room records indicate that the Veteran was seen for right shin complaints and noted to have knee arthralgia. More recent records show that the Veteran had a normal gait (in April 2009) and walked for exercise up to five times per week (in June 2010). But, VA medical records dated in September and October 2010, indicate that he sprained his right ankle and, in October 2010, was noted to have degenerative joint disease and wanted a new cane Given the Veteran's continued complaints of right ankle and knee pain, and the findings in the service treatment records, the Board is of the opinion that he should be afforded another VA examination to determine the nature and etiology of any right knee and ankle disorder(s) found to be present. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Further, the Veteran seeks service connection for leukocytosis. Leukocytosis is defined as an increase in the number of leukocytes, or white blood cells, in the blood. See Dorland's Medical Illustrated Dictionary, 929 (28th ed. 2007). Leukocytosis is not a disability in and of itself but, rather, a laboratory finding, akin to a finding of elevated cholesterol. Service treatment records do not discuss leukocytosis. However, an October 2004 record from Blanchfield ACH includes a diagnosis of leukocytosis. Given the proximity of this diagnosis to the Veteran's discharge from active service (three months), the Board cannot discount the possibility of a related disorder that had its onset during active service. Thus, in the interest of due process and fairness, the Board believes he should be afforded a VA examination to determine if he has a disorder manifested by leukocytosis that had its onset or is otherwise related to active service. See McLendon, Davidson, supra. The Veteran also seeks service connection for a TBI that was incurred during active service. He has reported a history of exposure to three blasts while serving in Iraq from 2003 to 2004. Service treatment records do not discuss any complaints or diagnosis of, or treatment for, a TBI. A January 2004 Post-Deployment Health Assessment record shows that the Veteran was unable to perform his duties in a combat environment and was referred for mental health evaluation. Results of a magnetic resonance image (MRI) of the Veteran's brain performed by VA in December 2007 were considered unremarkable. November 2008 VA outpatient records, apparently from the VA medical facility in Clarksville, Tennessee, show that the Veteran was sent a letter that advised him of his positive initial Traumatic Brain Injury Screening. He was told that this "did not necessarily mean he had a brain injury", but that a second more detail examination was recommended. It was noted that this will enable more detailed in depth assessment of whether he had a brain injury and if further medical services would be helpful. A December 8, 2008 VA outpatient polytrauma consultation record reflects that the Veteran underwent further evaluation for traumatic brain injury. He had a history of exposure to three different events in which he was approximately 30 to 50 feet from an improvised explosive device. He felt a blast wave but did not have blast-related confusion, loss of consciousness, or immediate post traumatic amnesia. He described symtoms of anxiety and sleep difficulty since those events. The examiner noted the Veteran's treatment for PTSD and associated symtoms. Upon clinical evaluation, the assessment included a history of blast exposure "without evidence of traumatic brain injury". However, according to a May 2, 2012 VA outpatient neurology consult at the Viera, Florida, Community Based Outpatient Clinic (CBOC), the Veteran was a new patient with a history of migraines and balance issues. "Possible TBI?" was noted and an evaluation was requested. The Veteran gave a history of exposure to three blasts from incendiary explosive devices in service. He reported a concussion on one occasion and that he was dazed on the other two incidents. The negative 2007 brain MRI was noted and that the Veteran "had not received a Level II evaluation by the Rehab TBI Clinic". Upon examination, the impression was chronic post-traumatic headaches, status post concussion in 2004, and PTSD. The examining neurologist recommended that the Veteran "may benefit [from] a Level II evaluation by the Rehab TBI Clinic" at the VA medical center (VAMC) in Orlando and deferred to the Veteran's primary care physician to place the referral. VA treatment records do not show that the Veteran has undergone the requested Level II evaluation by the Rehab TBI clinic at the Orlando VAMC and it is unclear if it was performed. Further, the Board believes that the Veteran should be afforded a VA examination to determine the etiology of any TBI found to be present. Id. The May 2008 rating decision declined to reopen the Veteran's claim for service connection for major depression. In January 2009, the RO received the Veteran's NOD with that determination. However, the February 2010 statement of the case (SOC) does not address this issue. Hence, the Board must remand this matter for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). In Rice v. Shinseki, 22 Vet. App. at 447, the court held that a TDIU claim is part of an increased rating claim when such claim is raised by the record. The court further held that when evidence of unemployability is submitted at the same time that the 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 decision, the Veteran has been assigned a total schedular disability rating for the entire appellate period for his PTSD. In Bradley v. Peake, 22 Vet. App. at 294, the court determined that a separate TDIU rating predicated on one disability when considered together with another disability separately rated at 60 percent or more could warrant special monthly compensation under 38 U.S.C.A. § 1114(s). Thus, the court reasoned, it might benefit the Veteran to retain the TDIU rating, even where a 100 percent schedular rating has been granted. In January 2009, the Veteran filed a formal claim for a TDIU that has not yet been adjudicated by the RO. As such, the matter of entitlement to a TDIU for the entire appeal period is referred to the RO for adjudication. Recent medical records regarding the Veteran's treatment at the VAMCs in Nashville, Tennessee, and Orlando, Florida, and at the Viera and Clarksville CBOCs, dated since May 2012, should be obtained. Accordingly, the case is REMANDED for the following action: 1. Issue a statement of the case regarding the matter of whether new and material evidence was submitted to reopen a claim of entitlement to service connection for major depression. If, and only if, the appellant timely perfects an appeal, should this claim should be returned to the Board. 2. Obtain all medical records regarding the Veteran's treatment at the VAMCs in Orlando and Nashville, and the Viera and Clarksville CBOCs, for the period from May 2012 to the present, to specifically include records of a Level II evaluation by the Rehab TBI Clinic at the Orlando VAMC, and from any additional VA and non-VA medical provider identified by him, If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) (West 2002 & Supp. 2012) and 38 C.F.R. § 3.159(e) (2012). 3. Schedule the Veteran for an appropriate VA neurological evaluation performed by physician(s) with expertise to determine the etiology of any TBI found to be present. The claims folder should be made available to and reviewed by the examiner. All indicated tests and studies should be performed, and all clinical findings reported in detail. a. For any TBI diagnosed, the examining physician is requested to render an opinion as to whether it is at least as likely as not (a 50 percent or higher degree of probability) that the disorder had its clinical onset during the Veteran's period of service, or is it otherwise related to such period of service. b. All opinions and conclusions expressed must be supported by a complete rationale. The examiner should reconcile any opinions with the service treatment records, post-service medical evidence, and lay statements of the Veteran, to include his competent reports of symptomatology during and after service. 4. The Veteran should be afforded a VA orthopedic examination performed by a physician with appropriate expertise to determine the etiology of any right knee or right ankle disorder found to be present. The claims folder should be made available to and reviewed by the examiner. All indicated tests and studies should be performed, and all clinical findings reported in detail. a. For any right knee or right ankle disorder diagnosed, the examining physician is requested to render an opinion as to whether it is at least as likely as not (a 50 percent or higher degree of probability) that the disorder had its clinical onset during the Veteran's period of service, or is it otherwise related to such period of service, including the findings noted in the Veteran's service treatment records (including the Veteran's complaints of right knee pain in July and August 2003 and treatment for right ankle sprain from April to June 2004). b. All opinions and conclusions expressed must be supported by a complete rationale. The examiner should reconcile any opinions with the service treatment records, post-service medical evidence, and lay statements of the Veteran, to include his competent reports of symptomatology during and after service. 5. Schedule the Veteran for a VA examination performed by a physician with appropriate expertise to determine the etiology of any disorder manifested by leukocytosis. The claims folder should be made available to and reviewed by the examiner. All indicated tests and studies should be performed, and all clinical findings reported in detail. a. For any disorder manifested by leukocytosis, the examining physician is requested to render an opinion as to whether it is at least as likely as not (a 50 percent or higher degree of probability) that the disorder had its clinical onset during the Veteran's period of active service, or is it otherwise related to such period of service. b. All opinions and conclusions expressed must be supported by a complete rationale. The examiner should reconcile any opinions with the service treatment records, post-service medical evidence, and lay statements of the Veteran, to include his competent reports of symptomatology during and after service. 3. After completion of the above, review the expanded record and readjudicate the issues of entitlement to service connection for a TBI, leukocytosis, a right knee disorder, and residuals of a right ankle sprain, and adjudicate the matter of entitlement to a TDIU. If any of the benefits sought are not granted in full, the Veteran and his agent should be furnished an appropriate supplemental statement of the case (SSOC) that reflects consideration of all evidence received since the October 2010 SSOC, and be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ THOMAS H. O'SHAY Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs