Citation Nr: 1322102 Decision Date: 07/10/13 Archive Date: 07/18/13 DOCKET NO. 08-33 944A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for hearing loss. 2. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for headaches. 4. Entitlement to service connection for a scalp laceration. 5. Entitlement to service connection for an aphthous ulcer. 6. Entitlement to service connection for bilateral orchitis. 7. Entitlement to service connection for residuals of warts. 8. Entitlement to service connection for tinea pedis. 9. Entitlement to service connection for bilateral pes planus with plantar fasciitis. 10. Entitlement to service connection for sleep apnea. 11. Entitlement to service connection for epididymitis. 12. Entitlement to service connection for urinary frequency. 13. Entitlement to service connection for a left ankle disorder. 14. Entitlement to service connection for hypertension. 15. Entitlement to service connection for a disability manifested by dizziness. 16. Entitlement to service connection for narcolepsy. 17. Entitlement to an initial compensable rating for a left knee scar. 18. Entitlement to an initial compensable rating for bilateral inguinal hernia repair scars. 19. Entitlement to an initial compensable rating for a ventral hernia scar. 20. Entitlement to an initial compensable rating for erectile dysfunction. 21. Entitlement to an initial rating in excess of 10 percent for psoriasis. ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from June 1985 to June 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in August 2007, and September 2008, issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. In February 2013, the Board remanded the claims for additional development. The issues of entitlement to service connection for an acquired psychiatric disorder, to include, PTSD, apthous ulcer, bilateral orchitis, residuals of warts, tinea pedis, bilateral pes planus with plantar fasciitis, sleep apnea, epididymitis, and dizziness, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The evidence of record indicates that the Veteran has bilateral hearing loss that is related to active duty service. 2. The evidence of record does not show that the Veteran has a left ankle disability, a scalp laceration, urinary frequency, headaches, hypertension, or narcolepsy, that is related to active duty service. 3. The Veteran's service-connected left knee scars are not shown to be productive of deep scars or scars that cause limited motion, superficial scars that do not cause limited motion with an area or areas of 144 square inches, superficial and unstable scars, or superficial scars that are painful on examination. 4. The Veteran's service-connected hernia scars are not shown to be productive of deep scars or scars that cause limited motion, superficial scars that do not cause limited motion with an area or areas of 144 square inches, superficial and unstable scars, or superficial scars that are painful on examination. 5. The Veteran's service-connected ventral herniorrhapy scars are not shown to be productive of deep scars or scars that cause limited motion, superficial scars that do not cause limited motion with an area or areas of 144 square inches, superficial and unstable scars, or superficial scars that are painful on examination. 6. The Veteran does not have penile deformity. 7. The Veteran's psoriasis is not shown to be productive of symptoms covering 20 to 40 percent of the entire body, or 20 to 40 percent of exposed areas affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. CONCLUSIONS OF LAW 1. Service connection for bilateral hearing loss is granted. 38 U.S.C.A. §§ 1110, 1131, 5108 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.385 (2012). 2. Headaches, a left ankle disability, a scalp laceration, urinary frequency, hypertension, and narcolepsy, were not incurred in, and are not otherwise due to, the Veteran's active duty service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 3. The criteria for an initial compensable evaluation for service-connected left knee scars have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805 (2008). 4. The criteria for an initial compensable evaluation for service-connected hernia scars have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805 (2008). 5. The criteria for an initial compensable evaluation for service-connected ventral herniorrhaphy scars have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.118, Diagnostic Codes 7801, 7802, 7803, 7804, 7805 (2008). 6. The criteria for an initial compensable evaluation for service-connected erectile dysfunction have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.20, 4.31, 4.115b, Diagnostic Code 7522 (2012). 7. The schedular criteria for an initial evaluation in excess of 10 percent for service-connected psoriasis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.118, Diagnostic Code 7816 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection The Veteran asserts that service connection is warranted for bilateral hearing loss, a left ankle disability, a scalp laceration, headaches, hypertension, and narcolepsy. In general, service connection may be established for a disability resulting from an injury suffered or disease contracted in the line of duty, or for aggravation of a pre- existing injury or disease in the line of duty. 38 U.S.C.A. §§ 1110, 1131. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Service connection may also be granted for arthritis, hypertension, or an organic disease of the nervous system, such as a sensorineural hearing loss, when it is manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). It is appropriate to consider high frequency sensorineural hearing loss as an organic disease of the nervous system and, therefore, subject to presumptive service connection. See Memorandum, Characterization of High Frequency Sensorineural Hearing Loss, Under Secretary for Health, October 4, 1995; 38 C.F.R. § 3.309(a) (2012). Applicable regulations provide that impaired hearing shall be considered a disability when the auditory thresholds in any of the frequencies of 500, 1,000, 2,000, 3,000, and 4,000 Hz are 40 decibels or greater; the thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores are 94 percent or less. 38 C.F.R. § 3.385 (2012). 38 C.F.R § 3.385 does not preclude service connection for a current hearing loss disability where hearing was within normal limits on audiometric testing at separation from service. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Rather, when audiometric test results at a veteran's separation from service do not meet the requirements of 38 C.F.R. § 3.385, a veteran may nevertheless establish service connection for current hearing disability by submitting medical evidence that the current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155 (1993). Where the requirements for hearing loss disability pursuant to 38 C.F.R. § 3.385 are not met until several years after separation from service, the record must include evidence of exposure to disease or injury in service that would adversely affect the auditory system and post-service test results meeting the criteria of 38 C.F.R. § 3.385. Hensley, 5 Vet. App at 155. If the record shows (a) acoustic trauma due to significant noise exposure in service and audiometric test results reflect an upward shift in tested thresholds while in service, though still not meeting the requirements for "disability" under 38 C.F.R. § 3.385, and (b) post service audiometric testing produces findings which meet the requirements of 38 C.F.R. § 3.385; then the rating authorities must consider whether there is a medically sound basis to attribute the post service findings to the injury in service, or whether these findings are more properly attributable to intervening causes. Id. at 159. The U.S. Court of Appeals for the Federal Circuit has recently held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic 38 C.F.R. § 3.309(a). Walker v. Shinseki, No. 10-2634, 2013 WL 628429 (Fed. Cir. May 25, 2011). The Veteran's discharges (DD Form 214s) list his military occupation specialties as "commander, manpower-personnel, squadron section," aerospace control & warning systems craftsman," and "F-15/F-16 tactical aircraft maintenance journeyman." His performance reports (AF Form 909s) indicate that he had technical and operations duties (discussed in greater detail, infra). A. Hearing Loss The Veteran's service treatment records include an August 2001 examination report shows that the Veteran's left ear had a decibel loss of 60 at 4,000 Hz. The report notes mild to severe high frequency hearing loss AU (both ears). The post-service medical evidence consists of VA (to include TriCare) and non-VA reports, dated between 2006 and 2013. This evidence includes a QTC examination report, dated in November 2010, which shows that the Veteran reported a 20-year history of hearing loss related to "loud combat and jet aircraft noise exposure during military service." He reported a post-service history of five years as a jet mechanic with use of hearing protection, eight years as a mobile radar operator with use of hearing protection, and helicopter operations duty office for three months with use of hearing protection. He did not report any exposure to loud noise outside of military service. He reported sustaining five or six head traumas during service. The diagnosis was bilateral sensorineural hearing loss. The report contains audiometric findings (air conduction) that revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 30 30 25 25 LEFT 25 30 25 30 25 The report contains audiometric findings (bone conduction) that revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 30 30 30 LEFT 20 20 30 30 30 The examiner stated that an air conduction study is better than a bone conduction study to determine the claimant's hearing loss. The examiner concluded that the Veteran bilateral sensorineural hearing loss was more than likely due to acoustic trauma during active military duty. The examiner noted that the objective factors are that audiometric testing revealed hearing loss of severity, of a configuration and type associated with noise-induced hearing loss. The examiner further explained that the Veteran had a significant shift and decrease in his hearing sensitivity during his active duty from the time of his enlistment exam. The Board finds that service connection is warranted. During service, the Veteran is shown to have had left ear hearing loss as defined at 38 C.F.R. § 3.385, and he was described as having mild to severe high frequency hearing loss AU (both ears). Furthermore, the November 2010 QTC examiner concluded that his bilateral sensorineural hearing loss was related to his service, explaining that the Veteran's hearing loss was of a severity, configuration and type associated with noise-induced hearing loss, and that he had a significant shift and decrease in his hearing sensitivity during his active duty. In this regard, although the Veteran's air conduction studies do not show that he has hearing loss in either ear as defined at 38 C.F.R. § 3.385, his test results are within one decibel of meeting that criteria, bilaterally. Furthermore, his bone conduction test results show that he does meet the criteria hearing loss in both ears, as defined at 38 C.F.R. § 3.385. To the extent that the examiner stated that air conduction study is better than a bone conduction study to determine the claimant's hearing loss, the applicable regulation does not require that only air conduction studies may be used. Id. The Board therefore finds that the evidence is at least in equipoise, and that affording the Veteran the benefit of all doubt, that service connection for bilateral hearing loss is warranted. As the Board has granted the claim in full, any failure of VA in its duty to assist could be no more than harmless error, and the Veterans Claims Assistance Act of 2000 need not be further discussed. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). B. Left Ankle The Veteran's service treatment records show that he received treatment for bilateral ankle pain in April 1996. A separation examination report is not of record. The post-service medical evidence consists of VA (to include TriCare) and non-VA reports, dated between 2006 and 2013. This evidence includes a March 2007 QTC examination report, which shows that the left ankle had signs of tenderness, but that there was no deformity. The report contains a diagnosis of DJD (degenerative joint disease) of the ankles, and notes that X-rays showed degenerative changes. The associated X-ray report, dated in March 2007, contains an impression noting "No abnormalities noted," it does not contain a finding of arthritis/DJD. VA progress notes, dated in June and December of 2012, state that he has no arthritis other than OA (osteoarthritis) of the knee. The Board finds that the claim must be denied. The Veteran was treated for left ankle symptoms in 1996. However, there is no record of subsequent treatment during his remaining period of service, a period of about ten years. Therefore, a chronic left ankle condition is not shown during service. See 38 C.F.R. § 3.303(a), (b). In addition, the Board finds that the preponderance of the evidence shows that the Veteran does not currently have a left ankle disability. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (under 38 U.S.C.A. §§ 1110 and 1131, an appellant must submit proof of a presently existing disability resulting from service in order to merit an award of compensation). In particular, despite the notation of arthritis in the February 2007 QTC examination report, the associated X-ray report shows that the Veteran does not have left ankle arthritis, nor is there any other X-ray evidence to show left ankle arthritis as required by VA regulations. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012); VAGCOPPREC 9-98, 63 Fed. Reg. 56,704 (1998). Therefore, service connection for left ankle arthritis is not warranted on any basis, to include on a presumptive basis. See 38 C.F.R. §§ 3.303, 3.307, 3.309. The only other evidence of a left ankle disability are notations of left ankle "arthralgia" in the VA progress notes. This is essentially a notation of ankle pain. However, VA generally does not grant service connection for symptoms, such as pain. which have not been associated with trauma or a disease process. See Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). See also Gilpin, supra. There is simply no competent or credible lay or medical evidence to show that the Veteran has a left ankle disability that is related to his service. In summary, the evidence does not show that the Veteran has a left ankle disability, and the Board finds that the preponderance of the evidence is against the claim, and that the claim must be denied. C. Scalp Laceration The Veteran's service treatment records show that he was treated for a laceration of the scalp in July 1986. In August 1994, he was treated after he was hit on head with phone receiver. The report notes that there was no laceration to the head. He later reported a history of associated headaches in June 2002. A TriCare report, dated in December 2005, shows that the Veteran claimed to have sustained a laceration to his scalp. However, the examiner stated that on examination, a laceration was not found. The relevant assessment was "contusion with intact skin surface - head occipital." The post-service medical evidence consists of VA (to include TriCare) and non-VA reports, dated between 2006 and 2013. This evidence includes a February 2007 QTC examination report, which shows that the Veteran reported a 11/2-year history of a scalp laceration after being hit in the head. In the diagnosis portion of the report, the examiner stated that a diagnosis is not possible because no scar could be located. The Board finds that the claim must be denied. The Veteran was treated for a scalp laceration in 1986. There is no other evidence of a scalp scar during his remaining period of service. He was hit on the head in 1994, however, there were no findings of a scalp scar. Therefore, the claimed condition is not shown during service. See 38 C.F.R. § 3.303(a), (b). In addition, the Board finds that the preponderance of the evidence shows that the Veteran does not currently have a scalp scar, or residuals of a scalp laceration. Gilpin. In particular, the February 2007 QTC report shows that the examiner could not locate a scalp scar, and that there was no relevant diagnosis. Finally, there is no competent medical evidence to show that the Veteran has a scalp laceration that is related to his service. In summary, the evidence does not show that the Veteran has a scalp laceration/scar, and the Board finds that the preponderance of the evidence is against the claim, and that the claim must be denied. D. Urinary Frequency With regard to the claim for urinary frequency, the Veteran's "report of medical history" upon entrance into service, dated in September 1984, shows that he reported a history of frequent urination. However, the associated examination report shows that his G-U (genitourinary) system was clinically evaluated as normal. A "report of medical history," dated in July 1992, shows that the Veteran reported a history of frequent urination all of his life, which had not been treated or diagnosed. The associated examination report shows that his G-U (genitourinary) system was clinically evaluated as normal. See also August 2001 examination report (same). The post-service medical evidence consists of VA (to include TriCare) and non-VA reports, dated between 2006 and 2013. This evidence includes a February 2007 QTC examination report which shows that the Veteran reported a 14-year history of frequent urination, i.e., about 12 times per day at hourly intervals, and twice per nights at 3-hour intervals. There were no problems starting urination, and no problems with urinary incontinence. He indicated that he was not receiving any treatment for these symptoms. In the diagnosis portion of the report, the examiner stated, "[T]here is no diagnosis because there is no pathology to render a diagnosis." Private treatment reports from Advanced Urology, Inc., dated between November 2007 and 2008, show that the Veteran reported difficulty with urinary frequency and urgency, with nocturia times two to three, and daily frequency every two hours. He reported urgency on urination, a decrease in size and force of stream, with splitting, and he felt that he did not empty completely. He reported constant suprapubic pressure that increased during intercourse. A January 2008 report from AU notes bladder outlet obstructive symptoms and urinary frequency. A February 2008 VA progress note contains a notation of prostatitis NOS (not otherwise specified). A June 2008 VA progress note contains a notation of "chronic frequency/BPH (benign prostatic hypertrophy)." A July 2008 VA progress note shows treatment for complaints of a more-than 10-year history of urinary frequency, and urge incontinence. He was noted to have been placed on terazosin, which had helped. The assessment was frequency and urgency. The "problem list" in a March 2010 VA progress note shows that the disorders listed included urinary obstruction. A May 2010 VA progress note shows that the Veteran complained of an overactive bladder that was well-controlled on tolterodine tartrate and tamsulosin. The report notes detrusor overactivity. A number of VA progress notes contain notations of "hypertonic of bladder," and neurogenic bladder. See e.g., VA progress note, dated in February 2011. The Board finds that the claim must be denied. The Veteran was noted to complain of urinary frequency on three occasions during his 20 years of service. However, he reported that he had had urinary frequency prior to service, he was not diagnosed with a urinary condition during service, there is no evidence of urinary tract pathology, and the Board finds that a chronic urinary disorder is not shown during service. See 38 C.F.R. § 3.303(a), (b). The February 2007 QTC examination report shows that the examiner determined that there was no diagnosed condition at that time. Although urinary obstruction and a bladder disorder are shown after separation from service, and after the post-service QTC report, the Veteran is not shown to have been diagnosed with a disorder listed at 38 C.F.R. § 3.309(a) in association with this claim, and the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic 38 C.F.R. § 3.309(a) . Walker. Finally, there is no competent medical evidence to show that the Veteran has urinary frequency that is related to his service. In summary, the evidence does not show that the Veteran has urinary frequency that is related to his service, and the Board finds that the preponderance of the evidence is against the claim, and that the claim must be denied. E. Headaches With regard to the claim for headaches, the Veteran's service treatment records show that he was treated after he was hit on head with phone receiver in August 1994. In June 2002, he reported a history of associated headaches. In November 2002, and May 2003, the Veteran was treated for complaints of "head pain" with a related history of a motor vehicle accident in November 2002. A private treatment report dated in September 2004, from R.J.R., M.D., shows that the Veteran denied having headaches. In February 2005, he was treated for complaints of a sore throat, and a headache. A January 2006 report shows that he denied having headaches. A separation examination report is not of record. The post-service medical evidence consists of VA (to include TriCare) and non-VA reports, dated between 2006 and 2013. A February 2007 QTC examination report contains a diagnosis of chronic tension headaches. A June 2008 VA progress note contains a notation of migraines. A December 2008 VA progress note shows that the Veteran reported a ten-year history of headaches, and overall, a number of VA progress notes contain notations of migraines. The Board finds that the claim must be denied. The Veteran was noted to complain of headaches on several occasions during his 20 years of service. However, he was not diagnosed with a chronic headache condition during service, and the Board finds that a chronic headache disorder is not shown during service. See 38 C.F.R. § 3.303(a), (b). Although headaches are shown after separation from service, the Veteran is not shown to have been diagnosed with a disorder listed at 38 C.F.R. § 3.309(a) in association with this claim, and the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic 38 C.F.R. § 3.309(a) . Walker. Finally, there is no competent medical evidence to show that the Veteran has headaches that are related to his service. In summary, the evidence does not show that the Veteran has headaches that are related to his service, and the Board finds that the preponderance of the evidence is against the claim, and that the claim must be denied. F. Hypertension The Veteran's service treatment records contain a notation of hypertension in a September 2005 private treatment report. A January 2006 TriCare report notes that there was no history of diagnosed essential hypertension. A separation examination report is not of record. The post-service medical evidence consists of VA (to include TriCare) and non-VA reports, dated between 2006 and 2013. This evidence includes a February 2007 QTC examination report which shows that the Veteran reported that he had a two-year history of hypertension, and that he was not currently receiving any treatment for this condition. The diagnosis portion of the report shows that the examiner concluded, "[T]here is no diagnosis because there is no pathology to render a diagnosis. There is no finding of hypertensive heart disease." A July 2007 VA progress note shows that the Veteran reported a family history of hypertension, however, hypertension was not noted. A private treatment report, from Family Practice, dated in September 2007, indicates that the Veteran does not have hypertension. The Board finds that the claim must be denied. Although there is one notation of hypertension (in September 2005), this appears to be "by history" only, as there were no supporting blood pressure findings, and no evidence of use of medication, and as there is no previously-dated evidence of hypertension. In fact, the Veteran was not treated for hypertension during service. Therefore, the claimed condition is not shown during service. See 38 C.F.R. § 3.303(a), (b). In addition, the Board finds that the preponderance of the evidence shows that the Veteran does not currently have hypertension. Gilpin. In particular, the February 2007 QTC report shows that the examiner determined that the Veteran does not have hypertension. Finally, there is no competent medical evidence to show that the Veteran has hypertension that is related to his service. In summary, the evidence does not show that the Veteran has hypertension, and the Board finds that the preponderance of the evidence is against the claim, and that the claim must be denied. G. Narcolepsy With regard to the claim for narcolepsy, service treatment reports do not show any relevant complaints or diagnoses. The post-service medical evidence consists of VA (to include TriCare) and non-VA reports, dated between 2006 and 2013. A February 2007 QTC examination report shows that the Veteran reported a one-year history of narcolepsy; alternatively characterized as a history of 48 attacks over the last two years, averaging two attacks per month. He stated that he was not currently receiving any treatment for this condition. In the diagnosis portion of the report, the examiner stated, "[T]here is no diagnosis because there is no pathology to render a diagnosis. The claimant does not suffer from a seizure disorder." VA progress notes dated thereafter include a number of notations of narcolepsy. See e.g., VA progress reports, dated in September and December of 2009, March 2010. However, a June 2009 sleep study shows that narcolepsy was not found. A September 2007 private treatment report notes possible narcolepsy. A December 2012 VA progress note states that the Veteran has vasovagal syncope, not narcolepsy. VA progress notes, dated in June 2011 and January 2013, indicate that the Veteran does not have narcolepsy. Citing August 2009 VA neurological consultation report (which notes that the Veteran's history is most consistent with vasovagal/situational syncope "occurring exclusively in setting of fear when seeing blood or micturation/intercourse"). The Board finds that the claim must be denied. The Veteran is not shown to have received treatment for narcolepsy during service. The Board therefore finds that narcolepsy is not shown during service. See 38 C.F.R. § 3.303(a). In addition, while there are a number of post-service findings which indicate that the Veteran does not currently have narcolepsy, there are also a number of notations of narcolepsy. In any event, even assuming arguendo that narcolepsy is currently shown, the Veteran is not shown to have been diagnosed with a disorder listed at 38 C.F.R. § 3.309(a) in association with this claim, and the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic 38 C.F.R. § 3.309(a). Walker. Finally, there is no competent medical evidence to show that the Veteran has narcolepsy that is related to his service. In summary, the evidence does not show that the Veteran has narcolepsy that is related to his service, and the Board finds that the preponderance of the evidence is against the claim, and that the claim must be denied. H. Conclusion With respect to the Veteran's own contentions, a layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997). See also Bostain v. West, 11 Vet. App. 124, 127 (1998) citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992) (a layperson without the appropriate medical training and expertise is not competent to provide a probative opinion on a medical matter, to include a diagnosis of a specific disability and a determination of the origins of a specific disorder). Lay testimony is competent, however, to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, the service treatment records and the post-service medical records have been discussed. The Board has determined that the Veteran does not have a scalp laceration, a left ankle disability, or hypertension, and that service connection is not warranted for any of the claimed disabilities. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, whether the Veteran has a left ankle disability, a scalp laceration, headaches, hypertension, or narcolepsy, due to his service, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The Board has determined that the service and post-service medical evidence outweighs the Veteran's contentions, to the effect that he has the claimed conditions that are related to his service. Accordingly, the Board finds that the preponderance of the evidence is against the claims, and that the claims must be denied. II. Increased Ratings The Veteran asserts that he is entitled to a compensable/increased rating for his service-connected left knee scar, hernia scars, ventral hernia scars, erectile dysfunction, and psoriasis. Disability evaluations are determined by comparing the veteran's symptomatology with the criteria set forth in the VA's Schedule for Ratings Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § Part 4. 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). The Court has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. It is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207 -08 (1994). As a general matter, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). As a layperson the Veteran is only competent to report observable symptoms, but not the clinical findings which are applied to VA's Rating Schedule. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Bruce v. West, 11 Vet. App. 405, 410-11 (1998). When there is a question as to which of two evaluations to apply, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7 (2012). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3 (2012). In August 2007, the RO granted service connection for left knee scars, "residual scars, status post ventral herniorrhaphy," "residual scars, status post bilateral hernia repair," and erectile dysfunction, evaluated as noncompensable (0 percent disabling). The RO also granted service connection for psoriasis, evaluated as 10 percent disabling. The Veteran has appealed the issue of entitlement to initial compensable evaluations, and an initial evaluation in excess of 10 percent for psoriasis. The Veteran is appealing the original assignments of disability evaluations following awards of service connection. In such cases, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). A. Scars, Left Knee, Hernia, and Ventral Herniorrhaphy In 2008, the Secretary of the VA amended that portion of the Schedule for Rating Disabilities pertaining to scars. As set forth in the Federal Register, the revised criteria apply to all applications for benefits received by VA on or after the effective date of October 23, 2008. See 73 Fed. Reg. 54,710 (Sept. 23, 2008). Here, the Veteran's claim was received at the RO in November 2006. Thus, the new regulations are not applicable. Under Diagnostic Code 7801, scars, other than head, face, or neck, that are deep or that cause limited motion: area or areas exceeding 6 square inches (39 sq. cm.), warrant a 10 percent rating. Under Diagnostic Code 7802, a 10 percent rating is warranted for: scars, other than head, face, or neck, that are superficial and that do not cause limited motion: Area or areas of 144 square inches (929 sq. cm.) or greater. Under 38 C.F.R. § 4.118, Diagnostic Code 7803, a 10 percent rating is warranted for superficial and unstable scars. Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): A superficial scar is one not associated with underlying soft tissue damage. Under 38 C.F.R. § 4.118, Diagnostic Code 7804, a 10 percent rating for superficial scars that are painful on examination. Note (1): A superficial scar is one not associated with underlying soft tissue damage. Note (2): In this case, a 10-percent evaluation will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable evaluation. (See Sec. 4.68 of this part on the amputation rule.). Under 38 C.F.R. § 4.118, Diagnostic Code 7805, other scars are rated on limitation of function of the affected part. The notes pertaining to these regulations (re-numbered) are shown below: (1) Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with § 4.25 of this part. (2) A deep scar is one associated with underlying soft tissue damage. (3) A superficial scar is one not associated with underlying soft tissue damage. (4) An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 1. Left Knee As for the history of the disability in issue, see 38 C.F.R. § 4.1 (2012), the Veteran's service treatment reports show that he began receiving treatment for left knee symptoms in early 2001. In May 2001, he underwent an arthroscopy and removal of a loose body. The diagnoses were chondral defect of patella, and loose body. He later underwent a second surgery. In September 2005, the Veteran was noted to have a lateral meniscal tear of the left knee. The only relevant evidence is a February 2007 QTC examination report, which shows that on examination, the Veteran's left knee had a scar measuring 14 centimeters (cm.) x 1 cm. There was another scar measuring 0.2 cm. x 0.2 cm. For both scars, there was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, abnormal texture, inflammation or edema. The Board finds that the claim must be denied. The evidence is insufficient to show that the Veteran's left knee scars are productive of deep scars or scars that cause limited motion, superficial scars that do not cause limited motion with an area or areas of 144 square inches, "superficial and unstable scars," or "superficial scars that are painful on examination." Accordingly, an initial compensable evaluation is not warranted pursuant to Diagnostic Codes 7801, 7802, 7803, 7804, or 7805. 2. Inguinal Hernia Scars As for the history of the disability in issue, see 38 C.F.R. § 4.1, the Veteran's service treatment reports show that in April 2006, he underwent a repair of left and right inguinal hernia. The postoperative diagnoses were direct and indirect right inguinal hernia with herniation of properitoneal fat through the internal ring, and larger size direct hernia with herniation of properitoneal fat through the internal ring with some degree of weakening of the inguinal floor. An August 2001 examination report notes a 6-inch hernia repair scar WHNS (well-healed, no sequalae). The only relevant post-service medical evidence is a February 2007 QTC examination report, which shows that on examination, the Veteran had a right groin scar measuring 10 cm. x 1 cm., and a left groin scar measuring 10 cm. x 1 cm. For both scars, there was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, abnormal texture, inflammation or edema. The Board finds that the claim must be denied. The evidence is insufficient to show that the Veteran's inguinal hernia scars are productive of deep scars or scars that cause limited motion, superficial scars that do not cause limited motion with an area or areas of 144 square inches, "superficial and unstable scars," or "superficial scars that are painful on examination." Accordingly, an initial compensable evaluation is not warranted pursuant to Diagnostic Codes 7801, 7802, 7803, 7804, or 7805. 3. Scars, Status Post Ventral Herniorrhaphy As for the history of the disability in issue, see 38 C.F.R. § 4.1, the Veteran's service treatment reports show that in May 2001, he underwent a ventral herniorrhaphy. The postoperative diagnosis was ventral hernia. The only relevant post-service medical evidence is a February 2007 QTC examination report, which shows that on examination, the Veteran had a scar on his abdomen that was 7 cm. x 2 cm. There was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, abnormal texture, inflammation or edema. The Board finds that the claim must be denied. The evidence is insufficient to show that the Veteran's residual scars, status post ventral herniorrhaphy, are productive of deep scars or scars that cause limited motion, superficial scars that do not cause limited motion with an area or areas of 144 square inches, "superficial and unstable scars," or "superficial scars that are painful on examination." Accordingly, an initial compensable evaluation is not warranted pursuant to Diagnostic Codes 7801, 7802, 7803, 7804, or 7805. B. Erectile Dysfunction As for the history of the disability in issue, see 38 C.F.R. § 4.1, the Veteran's service treatment reports include a private treatment report which shows that in September 2004, he was found to have erectile dysfunction. See also April 2005 TriCare report (same). A March 2005 private treatment report notes use of Viagra with moderate success, low-normal testosterone, and use of Testim. The impression was hypogonadism. An October 2005 TriCare report notes low testosterone. There is no specific disability rating for erectile dysfunction, and the RO has evaluated the Veteran's erectile dysfunction as deformity of the penis with loss of erectile power under 38 C.F.R. § 4.115b, Diagnostic Code 7522. The Board can find no other diagnostic code provision that would be more appropriate in rating the Veteran's disability. There is no evidence that he has had removal of half or more of his penis, or that glans have been removed, such that would warrant consideration under Diagnostic Codes 7520 or 7521, respectively. Therefore, Diagnostic Code 7522 is most appropriate to rate this disability. Pursuant to Diagnostic Code 7522, two distinct elements are required for a compensable, 20 percent, disability rating: penile deformity and loss of erectile power. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). The Board finds that the claim must be denied. The evidence shows that the Veteran has repeatedly reported experiencing impotence. However, there is no evidence to show that the Veteran has penile deformity. In this regard, a February 2007 QTC examination report shows that the Veteran reported a three-year history of erectile dysfunction that was caused by medication and hormonal imbalance, specifically, low testosterone. An examination of the penis and testicles was normal. The relevant diagnosis was hypogonadism with erectile dysfunction. VA progress notes include notations of erectile dysfunction, and/or use of Cialis. See e.g., VA progress notes, dated in January and August of 2008. A January 2009 VA progress note shows that the Veteran was using Cialis which was "'working okay' but not great." The Board therefore finds that he is properly evaluated at the noncompensable level for erectile dysfunction. See 38 C.F.R. § 4.31 (2012). Furthermore, the record shows that he has already been awarded special monthly compensation under 38 U.S.C. § 1114, subsection (k), 38 C.F.R. § 3.350(a), due to loss of use of a creative organ, so he is already being compensated for loss of use. In any event, a compensable rating is not warranted under Diagnostic Code 7522. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. 38 U.S.C.A. § 5107(b) . C. Psoriasis As for the history of the disability in issue, see 38 C.F.R. § 4.1, the Veteran's service treatment reports show that he was noted to have psoriasis on multiple occasions, beginning in at least 2002, treated with use of topical medications. A March 2005 TriCare report notes that the Veteran had skin symptoms on his lower extremities, buttocks, trunk, and upper extremities. A June 2005 report notes the presence of skin symptoms on the body, scalp, and face. A May 2006 TriCare report notes psoriasis, folliculitis, and punctuate keratitis. The Veteran's psoriasis has been evaluated under 38 C.F.R. § 4.118, DC 7816. Under DC 7816 (2008), a 10 percent rating is assigned for psoriasis covering at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent of exposed areas affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent is assigned for psoriasis covering 20 to 40 percent of the entire body, or 20 to 40 percent of exposed areas affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Id. A QTC examination report, dated in February 2007, shows that the Veteran reported a two-year history of skin symptoms that included constant ulcer formation, itching, shedding, and crusting. His symptoms involved areas that are exposed to the sun, including the head, face, and neck. Over the past 12 months, he stated that he had used corticosteroids and UV (ultraviolet) light. The functional impairment was described as having to cover up to not bring embarrassment upon self. On examination, there was psoriasis, with 1-2 cm. dry patches of the arms, with abnormal texture of more than six square inches. There was no ulceration, exfoliation, crusting, tissue loss, induration, inflexibility, hypopigmentation, hyperpigmentation, or limitation of motion. Skin lesion was 0 (zero) percent of exposed areas. There was coverage of 9 percent of the whole body. The skin lesions were not associated with systemic disease, and did not manifest in connection with a nervous condition. There were no nodules, lumps, or cysts present. The relevant diagnosis was psoriasis. The objective factors were patchy dry rash. Overall, VA progress notes show a number of treatments for skin symptoms, with several notations that his psoriasis was less than 3 percent of his BSA (body surface area) (June 2011), about 5 percent BSA (October 2008), 5 percent BSA (December 2011, June and December of 2012), and less than 10 percent BSA (March and April of 2010). These reports note the use of a number of different topical crèmes, and that he had symptoms on areas that included his knees, ankles, and buttocks, bilateral elbows, trunk, and BLE (bilateral lower extremities). The Board finds that the claim must be denied. The evidence is insufficient to show that the Veteran's psoriasis is productive of symptoms covering 20 to 40 percent of the entire body, or 20 to 40 percent of exposed areas affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. Accordingly, an initial evaluation in excess of 10 percent is not warranted pursuant to Diagnostic Code 7816. D. Conclusion In reaching these decisions, the Board has considered the doctrine of reasonable doubt. However, the preponderance of the evidence is against the claims, and the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, the claims for a compensable/increased evaluations must be denied. In deciding the Veteran's increased/compensable initial evaluation claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119, 126 (1999), and Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. As noted above, the Board does not find evidence that the Veteran's evaluations should be increased for any other separate period based on the facts found during the whole appeal period. The evidence of record supports the conclusion that the Veteran is not entitled to increased compensation during any time within the appeal period. The Board therefore finds that the evidence is insufficient to show that the Veteran had a worsening of the disabilities on appeal such that an increased initial evaluation is warranted. Consideration has also been given to whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1) (2012); Thun, 22 Vet. App. at 116. The schedular evaluations in this case are not inadequate. When comparing the Veteran's disability pictures with the symptoms contemplated by the Rating Schedule, the Board finds that manifestations of the service-connected scars, and psoriasis, disabilities are congruent with the disability pictures represented by the disability ratings assigned herein. The criteria for the ratings assigned herein more than reasonably describe the Veteran's disability levels and symptomatology. The Veteran is shown to have scars, which do not require treatment or medication, and psoriasis, which requires the use of medication. As the Board finds that the Veteran's disability pictures are contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. In reaching this decision, the Board has considered the written testimony of the Veteran. The Board points out that, although a lay person is competent to testify only as to observable symptoms, see Falzone v. Brown, 8 Vet. App. 398, 403 (1995), a layperson is not, however, competent to provide evidence that the observable symptoms are manifestations of chronic pathology or diagnosed disability, unless such a relationship is one to which a lay person's observation is competent. See Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). In this case, the Board has determined that the medical evidence is more probative of the issues, and that it outweighs the lay statements. Accordingly, the Veteran's claims must be denied. Finally, although the Veteran has submitted evidence of medical disability, and made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). III. Duties to Notify and Assist The Board finds that the duties to notify have been fulfilled by information provided to the Veteran in letters from the RO dated in January 2007, and January 2008. 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Those letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claims, and identified the Veteran's duties in obtaining information and evidence to substantiate his claims. 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess/Hartman v. Nicholson, 20 Vet. App. 473 (2006); Mayfield v. Nicholson, 20 Vet. App. 537 (2006); Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). With regard to the claims for initial increased/compensable evaluations, the Board notes that the January 2007 VCAA notice was issued in association with the Veteran's underlying service connection claims, and that these claims were granted in August 2007. In such a case, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled; no additional § 5103(a) notice is required. Dingess v. Nicholson, 19 Vet. App. 473, 491 (2006). The RO also provided assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available service medical reports, and post-service records relevant to the issues on appeal have been obtained and are associated with the Veteran's claims files. The RO has obtained the Veteran's VA and non-VA medical records. With regard to the claims for service connection, the Veteran has been afforded examinations, however, etiological opinions have not been obtained. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifest during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. The Board has determined that the Veteran does not have a left ankle disability, hypertension, or a scalp laceration. Therefore, the first McLendon criterion is not satisfied as to these claims. The Veteran's service treatment reports do not show any relevant complaints, treatment, or findings, providing evidence against the claims (hypertension, urinary frequency, narcolepsy). Therefore, the second McLendon criterion is not satisfied as to these claims. With regard to the third McLendon criterion, there is no competent evidence to show that any of the claimed conditions are related to service. Therefore, etiological opinions need not be obtained. McLendon; see also 38 C.F.R. § 3.159(c)(4) (2012); Wells v. Principi, 327 F. 3d 1339, 1341 (Fed. Cir. 2002). The Veteran and his representative have not argued that any error or deficiency in the accomplishment of the duty to notify has prejudiced him in the adjudication of his appeal. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (burden of showing that an error is harmful or prejudicial falls upon the party attacking the agency determination). In view of the above, the Board finds that the notice requirements pertinent to the issues on appeal have been met. In summary, the Board finds that the available medical evidence is sufficient for an adequate determination of the claims on appeal. There has been substantial compliance with all pertinent VA laws and regulations and to move forward with these claims does not cause any prejudice to the Veteran. [Continued on Next Page] ORDER Service connection for bilateral hearing loss is granted. Service connection for a left ankle disability, a scalp laceration, urinary frequency, headaches, hypertension, and narcolepsy, is denied. An initial compensable evaluation for service-connected left knee scars is denied. An initial compensable evaluation for service-connected hernia scars is denied. An initial compensable evaluation for service-connected ventral herniorrhaphy scars is denied. An initial compensable evaluation for service-connected erectile dysfunction is denied. An initial evaluation in excess of 10 percent for service-connected psoriasis is denied. REMAND With regard to the claims for an acquired psychiatric disorder, to include PTSD, bilateral orchitis, epididymitis, residuals of warts, tinea pedis, bilateral pes planus, sleep apnea, and dizziness, the Board finds that additional evidentiary development is necessary before a decision can be reached on the merits of the Veteran's claims. With regard to the claim for PTSD, although his reports are somewhat inconsistent, on multiple occasions the Veteran has reported that he participated in combat, and/or that he served in Afghanistan (to include stating that he was there for one, or two, weeks), and/or in Kuwait. See e.g., November 2010 QTC audiological examination report (combat); VA progress notes, dated in November 2008 (reporting service in Kuwait, as well as service in Afghanistan for two weeks), and March 2009 (reporting participation in combat, and service in Afghanistan in 2001); November 2008 VA polytrauma consultation reports (from two different physicians); January 2013 VA progress note; cf. May 2008, March, June and September of 2011, and December 2012 VA progress notes (no report of service in either Afghanistan, or Kuwait), report from Dr. H, dated in November 2009 (same). The Veteran's discharges (DD Form 214s) list his military occupation specialties as "commander, manpower-personnel, squadron section," aerospace control & warning systems craftsman," and "F-15/F-16 tactical aircraft maintenance journeyman. His performance reports (AF Form 909s) show duties as a repair and reclamation specialist, a track correlation technician, a data entry technician, a NCOIC (non-commissioned officer in charge) operations scheduling, a NCOIC operations plans, a NCOIC Combined Operations Air Center (ADSI operator), NCOIC tactical digital information link (TADIL) plans, air defense planner, air defense systems integrator and global command and control systems operator, and self-inspection monitor. They indicate service in Saudi Arabia between 1998 and 2001. The Veteran's personnel records do not show that he has received awards or decorations which establish combat service, or service in either Afghanistan or Kuwait, nor is there any objective evidence currently in the claims file which establishes participation in combat or service in Afghanistan or Kuwait while on temporary duty (TDY). The regulations governing PTSD have been amended, effective July 13, 2010. 75 Fed. Reg. 39843 -52 (July 13, 2010). Specifically, this amendment eliminates the requirement for corroborating that the claimed in-service stressor occurred if a stressor claimed by a veteran is related to his/her fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor-provided that the claimed stressor is consistent with the places, types, and circumstances of the veteran's service. Id. Given this amendment, the question of whether the Veteran served in Afghanistan is relevant to the PTSD claim. In addition, the Veteran's currently unverified claims of participation in combat, and service in Kuwait are highly relevant, and may affect his credibility. In summary, the Veteran's service treatment reports, and personnel records, do not show either participation in combat, or service in either Afghanistan or Kuwait. On remand, the Veteran should be contacted and requested to provide additional details of his participation in combat, and his service in Afghanistan and Kuwait, followed by an attempt to verify these claims. Upon completion of this development, the RO/AMC should determine if participation in combat is established, or if the claimed service in Afghanistan is verified, followed by a credibility determination. Thereafter, as discussed below, the Veteran should be afforded a psychiatric examination, to include an etiological opinion. The Veteran's service treatment records show the following (cited treatments may not be a comprehensive summary of all treatment): With regard to the claim for an acquired psychiatric disorder, to include PTSD, the Veteran's service treatment reports show that he was noted to have marital problems (May 2006), an Axis I diagnosis of partner relational problem (January 2005), a diagnosis of "adult maltreatment (perpetrator)" (January and June of 2006), and a history of depression and insomnia (October 2000). As for the post-service medical evidence, a March 2007 QTC examination report contains an Axis I diagnosis of "dysthymia (chronic depression)." A May 2007 report from the Valley Medical Group notes dysthymic disorder. A report from R.G.H., dated in May 2010, Psy.D., contains Axis I diagnoses of panic disorder with agoraphobia, PTSD, and major depressive disorder without psychotic features, and indicates that some symptoms are related to his service. See also Dr. H's November 2009 report (associating PTSD with the Veteran's service). VA progress notes, dated in 2008, note depression and PTSD. With regard to the claim for an apthous ulcer, the Veteran's service treatment reports show that he was noted to have an apthous ulcer (May 2006). As for the post-service medical evidence, there are a number of findings of apthous ulcer. See e.g., September 2009 VA progress report. With regard to the claim for bilateral orchitis, the Veteran's service treatment reports show that he was noted to have bilateral orchitis (September 2004 and January 2005). A March 2007 QTC examination report contains an Axis I diagnosis of chronic bilateral orchitis. VA progress notes, dated in May and June of 2008, note complaints of testicular pain, with a notation of possible epididymitis in May 2008. With regard to the claim for epididymitis, the Veteran's service treatment reports show that he was treated for epididymitis (May to June of 1986, and April 2005); he received complaints of testicular pain that had existed for over a year (December 2005), and complaints of testicular pain (December 2002, August and September of 2004, and April 2005). VA progress notes, dated in May and June of 2008, note complaints of testicular pain, with a notation of a history of treatment for possible epididymitis in May 2008. With regard to the claim for residuals of warts, the Veteran's service treatment reports show that received treatment for warts of the hands (June through August of 1997). As for the post-service medical evidence, there are notations of viral warts. See e.g., December 2009 VA progress report. VA progress notes, dated in 2010, show treatment for warts on the feet. With regard to the claim for tinea pedis, the Veteran's service treatment reports show that there are findings of onychomycosis (October 2005, May 2006), dermaphytosis of the nails (April 2006), and tinea pedis (January 2005). As for the post-service medical evidence, a December 2008 VA progress note shows treatment for tinea pedis. With regard to the claim for bilateral pes planus, the Veteran's entrance examination report shows that he was noted to have pes planus. His service treatment reports show that there are notations of pedis planus (March 1998), bilateral pes planovalgus (May 1998), and pes planus (July 1992, March 1999, and January and February of 2005). As for the post-service medical evidence, VA progress notes, dated in November 2007, and June and August of 2008, note bilateral pes planus. There are also a number of findings of plantar fasciitis. With regard to the claim for sleep apnea, the Veteran's service treatment reports show that there is a notation of snoring (March 2006), and of apnea (May 2006). As for the post-service evidence there are several finding of disordered breathing consistent with upper airways resistance syndrome, with 0 (zero) obstructive sleep apneas (October 2006), as well as a number of findings of sleep apnea. See e.g., September 2009 VA progress report. With regard to the claim for dizziness, the Veteran's service treatment reports show that the Veteran was treated for complaints in December 1992 and May 1993, with diagnoses of probable flu, and pharyngitis in April 2006. In September 2005, he was noted to have sustained a nasal injury after getting dizzy and falling off of a toilet. He reported a history of multiple episodes of "near syncope" when having bowel movements. The findings included concussion. See Lompoc Healthcare District reports, dated in September 2005. There is a notation of fainting spells (September 2005) (Alta Orthopedics report). Post-service treatment reports include VA progress notes, dated in November and December of 2008, which show complaints of dizziness. A May 2009 VA progress note associates the Veteran's syncope and lightheadedness as a vasovagal response to the sight of blood. An August 2009 VA progress note shows that the Veteran complained of a history of spells, and that he stated that all episodes were triggered either by urination or by seeing blood. The report notes vasovagal/situations syncope occurring exclusively in a setting of fear when seeing blood or micturition/intercourse. There are also notations of Eustachian tube dysfunction. See e.g., June 2008 VA progress note. VA will provide a medical examination or obtain a medical opinion if the record, including lay or medical evidence, contains competent evidence of a disability that may be associated with an event, injury, or disease that occurred in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon, 20 Vet. App. at 83. Under the circumstances, the Veteran should be afforded VA examinations to determine whether or not he has an acquired psychiatric disorder, to include, PTSD, apthous ulcer, bilateral orchitis, residuals of warts, tinea pedis, bilateral pes planus with plantar fasciitis, sleep apnea, epididymitis, and/or a disability manifesting dizziness, that are etiologically related to service. The appellant is hereby notified that it is the appellant's responsibility to report for the examinations and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158 and 3.655 (2012). Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran provide additional details of his service in Afghanistan and Kuwait, as well as his participation in combat, to include dates and locations. 2. Following the development discussed in the first paragraph of this remand, forward the Veteran's responses, as well as his personnel records, to the U.S. Army and Joint Services Records Research Center (JSRRC) and request them to provide any available information which might corroborate the Veteran's claimed service in Afghanistan and Kuwait, and participation in combat. 3. After the development requested in the first two paragraphs has been completed, the RO/AMC should determine if participation in combat is established, or if the claimed service in Afghanistan is verified, followed by a credibility determination. 4. Schedule the Veteran for a VA psychiatric examination to determine his correct diagnosis(es), to include whether he has PTSD under the criteria as set forth in DSM-IV. The claims file should be provided to the examiner in connection with the examination, and the examiner should indicate that the Veteran's C-file has been reviewed. All necessary studies or tests, including appropriate psychological testing and evaluation, is to be accomplished. The examiner should be notified of the results of the RO/AMC's credibility determination. If PTSD is found, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., whether there is a 50 percent or greater likelihood) that his PTSD was caused by his service. If PTSD is diagnosed, the examiner must state the stressor(s) relied upon to support the diagnosis. If an acquired psychiatric disorder other than PTSD is found, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., whether there is a 50 percent or greater likelihood) that the Veteran's acquired psychiatric disorder (other than PTSD) was manifested during service. The report of examination should include the complete rationale for all opinions expressed. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 5. The Veteran should be scheduled for an examination of his mouth, in order to ascertain the nature and etiology of any apthous ulcer found. The claims folder and a copy of this REMAND should be reviewed by the examiner, and the examiner must annotate the examination report that the claims file was in fact made available for review in conjunction with the examination. The examiner should state whether it is at least as likely as not (i.e., a likelihood of 50 percent or greater) that any diagnosed apthous ulcer is a chronic condition that was manifested by the Veteran's service. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 6. The Veteran should be scheduled for a genitourinary examination, in order to ascertain the nature and etiology of any orchitis, and/or epididymitis, found. The claims folder and a copy of this REMAND should be reviewed by the examiner, and the examiner must annotate the examination report that the claims file was in fact made available for review in conjunction with the examination. The examiner should state whether it is at least as likely as not (i.e., a likelihood of 50 percent or greater) that any diagnosed orchitis, and/or epididymitis, is a chronic condition that was manifested by the Veteran's service. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 7. The Veteran should be scheduled for an examination of his skin, in order to ascertain the nature and etiology of any residuals of warts, and/or tinea pedis, found. The claims folder and a copy of this REMAND should be reviewed by the examiner, and the examiner must annotate the examination report that the claims file was in fact made available for review in conjunction with the examination. The examiner should state whether it is at least as likely as not (i.e., a likelihood of 50 percent or greater) that any diagnosed residuals of warts, and/or tinea pedis, is a chronic condition that was manifested by the Veteran's service. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 8. The RO should schedule the Veteran for an examination of his feet, in order to ascertain whether his preexisting pes planus was aggravated by his service, or whether any plantar fasciitis is related to service or a service-connected disability. The claims folder and a copy of this REMAND should be reviewed by the examiner, and the examiner must annotate the examination report that the claims file was in fact made available for review in conjunction with the examination. a) The examiner should express an opinion as to whether it is at least as likely as not (i.e., a likelihood of 50 percent or greater) that the Veteran's preexisting bilateral pes planus was aggravated during service. b) If, and only if, the examiner determines that the Veteran's bilateral pes planus underwent aggravation during service, the examiner must provide an opinion as to the baseline level of severity of the Veteran's bilateral pes planus (i.e., pathology, nature, frequency, and degree of severity of symptoms) existing prior to the onset of aggravation, and the level of severity of the disability after aggravation occurred. If any of the increase in severity of the left foot pes planus, or the right foot pes planus, is due to natural progress, the examiner should indicate the degree of disability due to natural progression. c) The examiner should express an opinion as to whether it is at least as likely as not (i.e., a likelihood of 50 percent or greater) that the Veteran's plantar fasciitis had its onset during service, or was caused or aggravated by the Veteran's pes planus. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 9. The Veteran should be scheduled for an examination in order to ascertain the nature and etiology of any sleep apnea found. The claims folder and a copy of this REMAND should be reviewed by the examiner, and the examiner must annotate the examination report that the claims file was in fact made available for review in conjunction with the examination. The examiner should state whether it is at least as likely as not (i.e., a likelihood of 50 percent or greater) that any diagnosed sleep apnea is a chronic condition that was manifested by the Veteran's service. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 10. The Veteran should be scheduled for a neurological examination, in order to ascertain the nature and etiology of any dizziness found. The claims folder and a copy of this REMAND should be reviewed by the examiner, and the examiner must annotate the examination report that the claims file was in fact made available for review in conjunction with the examination. The examiner should state whether it is at least as likely as not (i.e., a likelihood of 50 percent or greater) that any dizziness is a symptom of a diagnosed chronic condition that was manifested by the Veteran's service. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 11. To help avoid future remand, the RO/AMC must ensure that all requested action has been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 12. 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. If any of the benefits sought on appeal remains denied, the Veteran and his representative 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. 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). ______________________________________________ JONATHAN A. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs