Citation Nr: 1324343 Decision Date: 07/31/13 Archive Date: 08/07/13 DOCKET NO. 94-12 762 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include major depression, dysthymia, and posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a respiratory disorder, to include as due to an undiagnosed illness. 3. Entitlement to service connection for obstructive sleep apnea and fatigue, to include as due to an undiagnosed illness. 4. Entitlement to service connection for skin disorders, to include as due to an undiagnosed illness. 5. Entitlement to service connection for memory loss, to include as due to undiagnosed illness (previously shown as major depression, panic attacks, night sweats, inability to concentrate, disorientation, memory loss, and irritability). 6. Entitlement to service connection for loss of vision (formerly characterized as eye sight loss), to include as due to an undiagnosed illness. 7. Entitlement to service connection for abnormal weight gain, to include as due to an undiagnosed illness. 8. Entitlement to service connection for residuals of the flu. 9. Entitlement to service connection for otitis externa and otitis media. 10. Entitlement to service connection for hemorrhoids. 11. Entitlement to service connection for a gastrointestinal (GI) disorder. 12. Entitlement to service connection for neck/cervical spine strain. 13. Entitlement to service connection for a head injury. 14. Entitlement to an initial rating in excess of 10 percent for hypertension (HTN). 15. Entitlement to an initial rating for atherosclerotic heart disease (AHD) in excess of 30 percent prior to June 24, 2008, and 60 percent therefrom. 16. Entitlement to an initial rating for mild prostatism in excess of 10 percent prior to June 24, 2008, and 20 percent therefrom. 17. Entitlement to an initial rating for residuals of a left (minor) shoulder injury with traumatic arthritis in excess of 10 percent prior to August 28, 2009, and in excess of 20 percent therefrom. 18. Entitlement to an initial rating for postoperative Dupuytren's contracture of the left (non-dominant) hand, in excess of 0 percent prior to June 24, 2008 and 10 percent therefrom, to include consideration of separate rating(s) for scarring. 19. Entitlement to an initial rating for Dupuytren's contracture of the right (dominant) hand, in excess of 0 percent prior to June 24, 2008, and 10 percent therefrom, to include consideration of separate rating(s) for scarring. 20. Entitlement to a rating in excess of 10 percent for residuals of fracture of the left olecranon process, left (minor) ulnar with traumatic arthritis. 21. Entitlement to an initial rating in excess of 10 percent for postoperative residuals of a left inguinal hernia. 22. Entitlement to a compensable rating for residuals of deformity, fracture of the head of the left (minor) radius. 23. Entitlement to an initial (compensable) rating for residuals of fracture of the right third metatarsal. 24. Entitlement to an initial (compensable) rating for residuals of fracture of the right fifth toe. 25. Entitlement to an initial (compensable) rating for residuals of excision of warts from the soles of the feet. 26. Entitlement to an initial (compensable) rating for residuals of contusion of the left leg. 27. Entitlement to an initial (compensable) rating for residuals of a laceration of the left first digit (minor). 28. Entitlement to an initial (compensable) rating for recurrent left eye pterygium. The issues of entitlement to payment or reimbursement of medical expenses pursuant to 38 U.S.C.A. §§ 1725 and 1728 (West 2002 & Supp. 2011) for medical care rendered at Central Ohio Primary Physicians are the subject of a separate decision. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Hal Smith, Counsel INTRODUCTION The Veteran served on active duty from December 1949 to December 1953 and from July 1987 to December 1991, to include service in Southwest Asia during the Gulf War. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The appeal ensued in 1993. A videoconference hearing was held in February 2001 before the undersigned Veterans Law Judge, sitting in Washington, D.C. A copy of the transcript of that hearing is of record. Initially, it is the noted by the Board that the issues of entitlement to service connection for an acquired psychiatric disorder, obstructive sleep apnea and fatigue, residuals of the flu, a skin disorder, and memory loss were developed by the RO as necessitating the need of the Veteran to submit new and material evidence. It is the Board's opinion, however, that these claims should be considered on a de novo basis. Thus, these issues are characterized as such on the title pages. The Veteran is not prejudiced by this determination. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Specifically, it is noted that the Board reopened and remanded the claim of service connection for a psychiatric disorder in August 2001. Thereafter, the RO mistakenly characterized and considered the issue on the basis of whether new and material evidence had been received sufficient to reopen the claim. As for the claims of service connection for muscle and joint pains, sleep apnea and fatigue, residuals of the flu, a skin disorder, and memory loss, it is noted that the RO (on rating decision in October 2009 and the applicable supplemental statement of the case (SSOC)) has considered these issues on the basis on whether new and material evidence was received to reopen a November 1998 rating decision. It is noted, however, that the Veteran submitted a statement in March 1999, within one year of the issuance of the November 1998 rating decision in which he clearly stated that he wished to appeal the denials. As such, and as indicated above, these issues will be treated on de novo bases. See 38 C.F.R. § 20.302(2012). The issues of entitlement to service connection for an acquired psychiatric disorder, to include major depression, dysthymia, and PTSD; entitlement to obstructive sleep apnea and fatigue; entitlement to service connection for skin disorders; entitlement to service connection for memory loss; entitlement to service connection for loss of vision; and entitlement to service connection for a cervical spine disorder, are addressed in the REMAND portion of this decision, below. Also, the issues of entitlement to an initial (compensable) rating for left eye pterygium and entitlement to separate rating(s) for scarring related to postoperative Dupuytren's contractures of the left and right hands are addressed in the REMAND portion of this decision, below. Each of these issues is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. In a statement dated and received in March 2010, the Veteran indicated that he wished to withdraw his appeal with respect to the claim for entitlement to service connection for a respiratory disorder. 2. There is no medical evidence of a disorder manifested by abnormal weight gain. 3. There is no medical evidence of current diagnosis of chronic residuals of the flu. 4. There is no medical evidence of current diagnoses of chronic otitis externa or otitis media. 5. There is no medical evidence of current diagnosis of chronic hemorrhoids. 6. There is no medical evidence of current diagnosis of a GI disorder. 7. There is no medical evidence of current chronic residuals of a head injury. 8. HTN since the pendency of the appeal is manifested by diastolic pressure predominantly less than 100, systolic pressure predominantly less than 160, and continuous use of medication required for control. 9. Prior to September 15, 2006, AHD manifested with substantiated anginal attacks with ordinary manual labor feasible; and without history of acute coronary occlusion, thrombosis, enlargement of the heart, or congestive heart failure; 5-6 metabolic equivalents (METs) were noted in May 1999. 10. As of September 15, 2006, the Veteran's heart disorder was manifested by estimated METs of 4. Chronic congestive heart failure from that date forward, however, is not demonstrated, nor is workload of 3 METs or less resulting in dyspnea, fatigue, angina, or dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent. 11. For the period prior to June 24, 2008, prostatism was manifested by nighttime voiding frequency of once nightly and no complaints of daytime frequency. 12. For the time period from June 24, 2008, prostatism is manifested by a daytime voiding frequency of every hours and awakening up to 3 times per night for voiding. There is some incontinence due to dribbling but no current use of pads. 13. For the period prior to August 28, 2009, residuals of left shoulder injury with traumatic arthritis were manifested by subjective complaints of pain; degenerative changes on X-ray study. Specific ROM results were not provided on the applicable records. 14. For the period from August 28, 2009, residuals of left shoulder injury with traumatic arthritis are manifested by subjective complaints of pain, degenerative changes on X-ray study, and shoulder motion limited to the shoulder level. 15. For the period prior to September 23, 2003, left and right hand Dupuytren's contracture was manifested by complaints of pain and tingling. There was no evidence of favorable or unfavorable ankylosis of digits. 16. As of September 23, 2003, left and right hand Dupuytren's contracture was manifested by complaints of pain and tingling, and the Veteran was unable to approximate his thumbs to the fingers of each hand. 17. The service-connected left elbow disorder (residuals of fracture of the left olecranon process with arthritis) is manifested by flexion limited to 100 degrees, limitation of extension to -10 degrees and pronation and supination both limited to 50 degrees; limitation of flexion to 100 degrees or extension limited to 75 degrees is not demonstrated. 18. The service-connected postoperative residuals of left inguinal hernia are manifested by occasional pain in the scar area with no recurrence of a hernia. 19. The service-connected residuals of fracture of the head of the left (minor) radius are manifested by a well-healed fracture. 20. The residuals of a fracture of the right third metatarsal are manifested by post-traumatic deformity and degenerative changes of the neck of the third metatarsal, without symptoms. 21. The residuals of a fracture of the right fifth toe are not manifested by changes on x-ray or current symptoms. 22. There are no residuals associated with service-connected excision of warts from the soles of the feet. 23. There are no residuals associated with service-connected residuals of contusion of the left leg. 24. There are no residuals associated with service-connected residuals of a laceration to the left first digit. CONCLUSIONS OF LAW 1. As the Veteran has withdrawn his appeal with respect to the claim for entitlement to service connection for a respiratory disorder, the Board does not have jurisdicition to consider the claim, and it is dismissed. 38 U.S.C.A. § 7105(d) (5) (West 2002 & Supp. 2012); 38 C.F.R. §§ 20.202, 20.204(b) (2012). 2. Abnormal weight gain was not incurred in or aggravated by active military service, and may not be presumed to be due to an undiagnosed illness incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.159, 3.317 (2012). 3. Chronic residuals of the flu were not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 1117, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.159 (2012). 4. Chronic otitis externa and otitis media were not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 1117, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.159 (2012). 5. Chronic hemorrhoids were not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 1117, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.159 (2012). 6. A chronic GI disorder was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 1117, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.159 (2012). 7. Chronic residuals of a head injury were not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131, 1117, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.159 (2012). 8. The criteria for an initial rating in excess of 10 percent for HTN have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.7, 4.104, DC 7101 (1996, 1998, & 2012). 9. The criteria for an initial rating greater than 30 percent for AHD prior to September 15, 2006, have not been met. 38 U.S.C.A. § 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.7, 4.104, DC 7005 (1996, 1998 & 2012). 10. The criteria for an initial rating for AHD of 60 percent, but no more, are met as of September 15, 2006. 38 U.S.C.A. § 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.7, 4.104, DC 7005 (1996, 1998 & 2012). 11. For the time period prior to June 24, 2008, the criteria for an initial rating in excess of 10 percent for prostatism are not met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.115b, 4.20, DC 7527 (2012). 12. For the time period from June 24, 2008, the criteria for an initial rating in excess of 20 percent for prostatism are not met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§3.102, 3.321, 4.115b, 4.20, DC 7527 (2012). 13. For the time period prior to August 28, 2009, the criteria for an initial rating in excess of 10 percent for residuals of left (minor) shoulder injury with traumatic arthritis are not met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.71, 4.20, DCs 5203, 5003, 5200, 5201, 5203(2012). 14. For the time period from August 28, 2009, the criteria for an initial rating in excess of 20 percent for residuals of left (minor)shoulder injury with traumatic arthritis are not met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.71, 4.20, DCs 5203, 5003, 5200, 5201, 5203(2012). 15. The criteria for an initial (compensable) rating for Dupuytren's contracture of the left (non-dominant) hand prior to September 23, 2003, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.7, 4.71, DC 5229 (2012). 16. The criteria for an initial (compensable) rating for Dupuytren's contracture of the right (dominant) hand prior to September 23, 2003, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.7, 4.20, 4.71, DC 5229 (2012). 17. The criteria for an initial rating for Dupuytren's contracture of the left (non-dominant) hand of 10 percent, but no more, are met as of September 23, 2003. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.7, 4.20, 4.71, DC 5229 (2012). 18. The criteria for an initial rating for Dupuytren's contracture of the right (dominant) hand of 10 percent, but no more, are met as of September 23, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.7, 4.20, 4.71, DC 5229 (2012). 19. The criteria for a rating in excess of 10 percent for residuals of fracture of the left olecranon process, left (minor) ulna with traumatic arthritis, based on limitation of flexion, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.7, 4.71, DCs 5206, 5207, 5208, 5211, (2012). 20. The criteria for a rating of 20 percent for residuals of fracture of the left olecranon process, left (minor) ulna with traumatic arthritis, based on limitation of pronation, are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.7, 4.71, DC 5213, (2012). 21. The criteria for an initial evaluation in excess of 10 percent for residuals of a left inguinal hernia have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.114, 4.118, DCs 7338, 7804 (prior to August 30, 2002, as of August 30, 2002, prior to October 23, 2008, 2010). 22. The criteria for the assignment of a compensable disability rating for residuals of deformity, fracture of the head of the left (minor) radius, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.14, 4.27, 4.31, 4.40, 4.45, 4.69, 4.71, 4.71a, DC 5212 (2012). 23. The criteria for an initial compensable evaluation for residuals of excision of warts from the soles of the feet have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.71a, DC 5284 (2012). 24. The criteria for an initial compensable rating for residuals of contusion of the left leg have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.118, DC 7800-7805 (prior to August 30, 2002, as of August 30, 2002, prior to October 23, 2008, 2010). 25. The criteria for an initial compensable rating for residuals of a laceration of the left first digit have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.118, DC 7800-7805 (prior to August 30, 2002, as of August 30, 2002, prior to October 23, 2008, 2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Dismissal Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn at any time before the Board promulgates a decision. 38 C.F.R. § 20.202 (2012). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.2.04 (2012). In a March 2010 statement, the Veteran indicated that he wished to withdraw his appeal of the issue of entitlement to service connection for a respiratory disorder. Hence, there remain no allegations of errors of fact or law for appellate consideration as to that issue. Accordingly, the Board does not have jurisdiction to review the appeal as to that issue and it is dismissed. Duties to Notify and Assist The United States Court of Appeals for Veteran Claims (Court) in Pelegrini v. Principi, 18 Vet. App. 112 (2004), held, in part, that a Veterans Claims Assistance Act of 2000 (VCAA) notice, as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and that VCAA notice consistent with 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant of the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant of the information and evidence that VA will seek to provide; (3) inform the claimant of the information and evidence the claimant is expected to provide. VA satisfied this duty, as to the issues decided herein, by means of letters to the Veteran from the RO dated in March 1997, May 1997, March 2004, June 2004, July 2008, May 2009, and October 2009). By means of these documents, the Veteran was told of the requirements to establish service connection, of the reasons for the denial of his claims and of his and VA's respective duties. In addition to providing the VCAA laws and regulations, additional documents of record, to include the rating decisions of record, the statement of the case and SSOCs have included a summary of the evidence, all other applicable law and regulations, and a discussion of the facts of the case. Such notice sufficiently placed the Veteran on notice of what evidence was necessary, which parties would obtain same, and advised him of his responsibilities if he wanted such evidence to be obtained by VA. Quartuccio v. Principi, 16 Vet. App. 183 (2002). As many of the claims were initially denied prior to the enactment of VCAA, after passage of the VCAA, the RO sent the Veteran the above mentioned VCAA letters which included discussion of the VCAA law and regulations. A VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on a claim for VA benefits. However, the Board finds that any defect with respect to the timing of the VCAA notice requirement was harmless error. After receipt of the content-complying letters, his claims were readjudicated based upon all the evidence of record as evidenced by various SSOCs. There is no indication that the disposition of his claims would have been different had he received pre-AOJ adjudicatory notice pursuant to section 5103(a) and § 3.159(b). Accordingly, any such error is nonprejudicial. See 38 U.S.C. § 7261(b)(2). Also see Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Court held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, to specifically include that a disability rating and an effective date will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, the Veteran was provided with notice of this information in letters dated in July 2008, May 2009, and October 2009. Assistance shall also include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c)(4) (2012). Numerous VA examinations were conducted in regards to the various claims on appeal. These examinations were conducted either to determine the etiology of certain conditions or to determine the severity of already service-connected disorders. The examiners reviewed the claims file and based their decisions on review of the file, the Veteran's medical history, to include as provided by him, and physical examinations. The Board has determined that the evidence of record is sufficient as to he issues decided herein without obtaining additional VA examinations. In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the Veteran in developing the facts is required to comply with the duty to assist as to the issues decided herein. 38 U.S.C.A. §§ 5103 and 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). Service Connection Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303 (2012). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Where there is a chronic disease, as identified under 38 C.F.R. § 3.30(a), shown as such in service or within the presumptive period under § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however, remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2012). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). This rule does not mean that any manifestations in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word "chronic". When the disease entity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2012). Continuous service for 90 days or more during a period of war, or peace time service after December 31, 1946, and post-service development of a presumptive chronic disease such as arthritis to a degree of 10 percent or more within one year from the date of termination of such service, establishes a rebuttable presumption that the disease was incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). The Court has held that, in order to prevail on the issue of service connection, there must be medical evidence of a (1) current disability; (2) medical or, in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Pond v. West, 12 Vet. App. 341, 346 (1999). Undiagnosed Illness In February 1995, VA implemented the Persian Gulf War Veterans' Act by adding 38 C.F.R. § 3.317, which defines qualifying Gulf War service, establishes the presumptive period for service connection, and denotes a broad but non-exclusive list of signs or symptoms which may be representative of undiagnosed illnesses for which compensation may be paid. Objective indications of chronic disability resulting from undiagnosed illness must be manifest to a degree of 10 percent either during active military service in Southwest Asia or no later than December 31, 2016. 38 C.F.R. § 3.317(a) (2012). On December 27, 2001, the President signed into law the "Veterans Education and Benefits Expansion Act of 2001," Pub. L. No. 107-103 (Dec. 27, 2001). This legislation amends various provisions of 38 U.S.C. §§ 1117, 1118, including a complete revision of § 1117(a), which now provides as follows: (1) The Secretary may pay compensation under this subchapter to a Persian Gulf veteran with a qualifying chronic disability that became manifest- (A) during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War; or (B) to a degree of 10 percent or more during the presumptive period prescribed under subsection (b). (2) For purposes of this subsection, the term 'qualifying chronic disability' means a chronic disability resulting from any of the following (or any combination of any of the following): (A) An undiagnosed illness. (B) A medically unexplained chronic multi symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms. (C) Any diagnosed illness that the Secretary determines in regulations prescribed under subsection (d) warrants a presumption of service-connection. Section (c)(1) of 1117 was amended to change some language specific to undiagnosed illness, without substantively changing the provision. A whole new subsection (g) was added to § 1117, as follows: (g) For purposes of this section, signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multi symptom illness include the following: (1) Fatigue. (2) Unexplained rashes or other dermatological signs or symptoms. (3) Headache. (4) Muscle pain. (5) Joint pain. (6) Neurological signs and symptoms. (7) Neuropsychological signs or symptoms. (8) Signs or symptoms involving the upper or lower respiratory system. (9) Sleep disturbances. (10) Gastrointestinal signs or symptoms. (11) Cardiovascular signs or symptoms. (12) Abnormal weight loss. (13) Menstrual disorders. In addition, 38 U.S.C. § 1118(a) was amended to add a paragraph including the signs and symptoms of § 1117(g) as manifestation of an undiagnosed illness. These statutory amendments are effective from March 1, 2002. 38 U.S.C.A. §§ 1117, 1118 (Effective and Applicability Provisions) (West 2002 & Supp. 2011). However, compensation shall not be paid if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the appellant's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the appellant's own willful misconduct or the abuse of alcohol or drugs. 38 U.S.C.A. § 1117 (West 2002 & Supp. 2012); 38 C.F.R. § 3.317 (2012). Reasonable Doubt The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Background Abnormal Weight Gain, Residuals of the Flu, Otitis Externa and Otitis Media, Hemorrhoids, a GI disorder, and Residuals of a Head Injury The service treatment records (STRs) from the Veteran's first period of active service reflect that he weighed in the mid-150s at time of entrance and separation. Many years later, during his second period of active service, he weighed 180 pounds at enlistment and 220 at time of discharge. His weight upon VA exam in November 2008 was 240 pounds. No chronic disorder associated with his weight was noted at any time. There is record of treatment for hemorrhoids prior to entry into the second period of service and a history of hemorrhoids (nonsymptomatic) was noted upon entry of his second period of service. Additional treatment, however, is not indicated, and no chronic hemorrhoidal disorder was noted in the STRs. Hemorrhoids were seen upon VA exam shortly after service in 1992. Review of all STR entries is negative for report of, treatment for, or diagnosis of flu residuals or for residuals of any head injury. Moreover, they are negative for a GI condition. The STRs do show right ear complaints (stopped up) in 1988. Ear wax and resolving otitis externa were noted. He had the same complaint in 1990 and 1991. When examined by VA in 1992, no residuals of the flu were noted. History of otitis externa was noted but no additional diagnosis was indicated. In 1995, irritable bowel syndrome was noted. In 1996, he was treated for gastroesophageal reflux disease (GERD). Review of additional post service records does not reflect that the Veteran has current disorders associated with hemorrhoids, flu residuals, or residuals of a head injury. While GI disorders were noted many years ago, more recent records do not indicate that related problems are ongoing. For example, when examined by VA in 2006, he reported a history of GERD for which he took medication. Also, at that time, hemorrhoids were noted by history. While chronic ear disease was reported by the Veteran, no current disease was indicated, and the condition was reported as stable without current diagnoses of such. Moreover, VA audiometric testing in 2009 did not include complaints of, or diagnosis of, chronic ear disease, to include otitis externa or otitis media. And, upon GW examination by VA in 2009, GI and hemorrhoids were not complained of or diagnosed. Analysis Disability Manifested by Muscle and Joint Pains Upon consideration of the above evidence, the Board finds that the preponderance of the evidence is against the claim of service connection for a disability manifested by muscle and joint pains under the presumptive provisions relating to Persian Gulf claims. In that connection, the Board finds that, to whatever extent the Veteran has at any point suffered from disabilities manifested by problems with muscle or joint pains, these symptoms have been ascribed to known diagnoses. 38 C.F.R. § 3.317(a)(1)(i) (2012). Thus, service connection is precluded under the statutes and regulations that govern claims based upon service in the Persian Gulf. (Those provisions require a qualifying chronic disability as defined above, such as an undiagnosed illness.) Further, the Gulf War examination report dated in August 2009 specifically found that the Veteran's complaints of symptoms of muscle and joint pains were attributable to his multi-joint arthritis. Although the Board does not doubt the sincerity of the Veteran's belief that he has muscle and joint pains due to undiagnosed illnesses related to his service in Southwest Asia, as a lay person without the appropriate medical training or expertise, he is not competent to provide a probative opinion on a complex medical matter such as the diagnosis or etiology of a current disability, undiagnosed illness, or medically unexplained chronic multi-symptom illness. The August 2009 VA examiner clearly took into account the Veteran's complaints and contentions and arrived at medical conclusions contrary to his claim-specifically attributing the Veteran's claimed symptoms to known clinical diagnoses, which are not qualifying illnesses as defined by 38 C.F.R. § 3.317 (2012). The Board relies on the medical treatment providers' opinions in this case as they are based on objective evidence, their medical expertise, and the Veteran's assertions. In short, the Board finds that the Veteran's claimed symptoms of muscle and joint pains have been fully attributed to clinical diagnoses that are not qualifying chronic disabilities under § 1117. Thus, the theory that the Veteran has undiagnosed illnesses or a medically unexplained chronic multi-symptom illness manifested by symptoms that are related to the Veteran's service in Southwest Asia does not have merit. For all the foregoing reasons, the Board finds that the Veteran's claims for service connection for muscle and joint pains must be denied under 38 C.F.R. § 3.317 (2012). The Board notes, however, that in cases where a veteran applies for service connection under 38 C.F.R. § 3.317 but is found to have a disability attributable to a known diagnosis, further consideration under the direct service connection provisions of 38 U.S.C.A. §§ 1110 and 1131 is warranted. See Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Here, however, upon review of the evidence of record, the Board finds that the preponderance of the medical evidence is also against a finding that any current muscle and joint pains are etiologically linked to military service. Absent a medical opinion in the record of a relationship to military service, the Veteran's claim must be denied on a direct basis. As noted above, the Board acknowledges that the Veteran has argued in the alternative that these disorders are of service origin. He is competent to provide testimony concerning factual matters of which he has first-hand knowledge (i.e., experiencing symptoms either in service or after service). See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). However, he is not competent to say that any such symptoms experienced in service were a result of or worsened by any incident in service or were of a chronic nature to which any current disability is attributable. While he reported a history of joint pains (service connection has been established for the joints treated during service) during service, no chronic disorders of other joints were noted. Moreover, as noted above, a VA examiner has reviewed the record and the Veteran and determined that current joint and muscle pains (associated with various joint arthritis) are unrelated to service. The Board concedes that the Veteran has had problems with muscle and joint pains. However, none of the Veteran's treatment providers has provided an opinion that these conditions are related to service. Thus, in this case, when weighing the evidence of record, the Board finds compelling the lack of any evidence etiologically linking the Veteran's current disabilities to service. Furthermore, as a layperson without the appropriate medical training and expertise, the Veteran is simply not competent to provide a probative opinion on a complex medical matter such as the question at issue here of the relationship between any current complaints and service. See Bostain, 11 Vet. App. at 127. Moreover, it is noted that the Veteran submitted numerous copies or excerpts from magazine and/or newspaper articles pertaining to health issues suffered by Persian Gulf veterans. These articles have been considered. However, it is noted that the information submitted by the Veteran is not probative evidence. The information provided is general in nature, and it does not specifically relate to the Veteran's particular case and in particular does not contain any analysis regarding the facts of this case. As such, this information is noted, but it is of little probative value in the instant case. Medical treatise evidence can, in some circumstances, constitute competent medical evidence. See Wallin v. West, 11 Vet. App. 509, 514 (1998); see also 38 C.F.R. § 3.159(a)(1) [competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses]. However, as discussed by the Board above, the Court has held that medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Based on a review of the foregoing evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for muscle and joint pains. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine, but finds that the record does not provide even an approximate balance of negative and positive evidence on the merits. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Abnormal Weight Gain, Residuals of the Flu, Otitis Externa and Otitis Media, Hemorrhoids, A GI Disorder, and Residuals of a Head Injury Regarding the Veteran's claims as listed above, the Board notes that a review of the record does not show that the Veteran is in receipt of competent medical diagnoses of these conditions at the current time. Moreover, the records do not suggest that these conditions have been present or represented a continuing problem for many, many years. While he may have had a chronic ear disease, hemorrhoids, and a GI disorder in the past, he does not have current complaints associated with these conditions and no such disorders are indicated. Similarly, no disorder associated with weight gain has been indicated, and no flu or head injury residuals are indicated in the record. Based on a review of all lay and medical evidence, the Board finds the weight of the evidence to be against the claims for service connection for a chronic disorder (s)manifested by abnormal weight gain, residuals of the flu, otitis externa/otitis media, hemorrhoids, a GI disorder, and residuals of a head injury. The evidence reflects that any of these conditions present in the past resolved and residuals of such are not indicated. See 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 3.102 (2012). Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. §§ 1110, 1131; and see Brammer v. Derwinski, 3 Vet. App. 223 (1992). In Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997), it was observed that 38 U.S.C.A § 1131, as well as other relevant statutes, only permitted payment for disabilities existing on and after the date of application for such disorders. The United States Court of Appeals for the Federal Circuit observed that the structure of these statutes "provided strong evidence of congressional intent to restrict compensation to only presently existing conditions," and VA's interpretation of the law requiring a present disability for a grant of service connection was consistent with the statutory scheme. Degmetich, 104 F.3d at 1332; and see Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998) (holding VA's interpretation of the provisions of 38 U.S.C.A § 1110 to require evidence of a present disability to be consistent with congressional intent); Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (the law limits entitlement for service-related diseases and injuries to cases where the underlying in-service incident has resulted in a disability). Simply put, in the absence of proof of present disability there can be no valid claim. As there is no competent medical evidence of current residuals of the flu, the claim must be denied. Even if the Veteran currently exhibited abnormal weight gain, residuals of the flu, ear disease, hemorrhoids, a GI disorder, or residuals of a head injury, there is still no competent medical evidence which causally relates such conditions to service. Either these conditions were not mentioned during service or there were no residuals of such recorded. Inasmuch as the evidence on file does not tend to show that he currently has chronic disorders manifested by abnormal weight gain, residuals of the flu, ear disease, hemorrhoids, a GI disorder, or residuals of head injury, which may be associated with service, the Board must conclude that no additional development, to include additional medical examinations or medical opinions, is reasonable based upon the facts. See 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2012); Hickson v. West, 12 Vet. App. 247, 253 (1999), Pond v. West, 12 Vet. App. 341, 346 (1999). For the reasons stated above, the Board finds that the preponderance of the evidence is against the claims of service connection for abnormal weight gain, residuals of the flu, ear disease, hemorrhoids, a GI disorder, or residuals of head injury, and they must be denied. As the preponderance of the evidence is against each of these claims, the benefit of the doubt doctrine is not for application in the instant case. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, No. 01- 7006 (Fed. Cir. December 17, 2001). Increased Ratings - In General Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. Part 4 (2012). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole-recorded history, including service treatment records. 38 C.F.R. §§ 4.2, 4.41 (2012). The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59 (2012); DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). Under the laws administered by VA, the Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.3 (2012). For those issues in which a claim for a higher evaluation arises out of the initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the claim and appellate process. See generally, Fenderson v. West, 12 Vet. App. 119 (1999). See also Hart v. Mansfield, 21 Vet. App. 505 (2007). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2012). Entitlement to an Initial Rating in Excess of 10 Percent for HTN and Entitlement to an Initial Rating for AHD in Excess of 30 Percent Prior to June 24, 2008, and 60 Percent Therefrom Background It is noted that service connection for HTN was established upon rating decision in May 1993. A 10 percent rating was assigned. The grant was based on the fact that while HTN was not noted during service, there was a definitive diagnosis of the disorder upon June 1992 VA examination shortly thereafter. Medication was used to control the condition. Blood pressure readings at the 1992 examination included 120/68 when sitting, 120/80 when recumbent, and 120/90 when standing. Private records reflect a blood pressure reading of 138/83 in 1994. When seen for a rash by VA in July 1995, his blood pressure was recorded as 140/80. When seen for psychiatric problems by VA in August 1995, his blood pressure was 140/96. Upon VA examination in July 1997, his blood pressure was recorded as 150/94, and in August 1987, it was 120/80. It was noted that the condition was well controlled on medication. In August 1998, his blood pressure was 130/80 while supine, standing, and sitting. In May 1999, blood pressure readings were recorded as 120/80 and 150/80. In February 2004, it was 157/82. In September 2008, the reading was 120/80 and upon VA exam in November 2008, his blood pressure readings were 142/80 and 140/82. In August 2009 the readings were 14/80, 142/72, and 134/70. Service connection for AHD was established upon rating decision in November 1998 as secondary to service-connected HTN. A separate 30 percent rating was assigned, effective from August 6, 1997, which is the date that a VA examination report showed that the Veteran had coronary artery disease (CAD). At that time, he was noted to have a history of tachy dysrhythmias beginning in January 1998 and supraventricular tachy dysrhythmias which were treated on an emergency basis in January and April 1998. Radiofrequency ablation therapy was performed in April 1998. He was subsequently told that he had mitral stenosis and was currently being evaluated and followed for this on a nonsurgical basis. The Veteran described episodes of positional lightheadedness with recurrent nonexertion and stress related sharp chest pain, as well as dyspnea on exertion. On cardiopulmonary exam, the PMI (point of maximal impulse) was at the fifth left intercostal space at the mid clavicular line. S1 (first heart sound) and S2 (second heart sound) were normal. There were no murmurs, gallops, rubs, clicks, heaves, or thrills. Peripheral pulses included carotid, brachial, radial, femoral, popliteal, and dorsalis pedis and were 2+ symmetric bilaterally and without bruits. He denied cough or expectoration. There was normal mobility to the chest wall and equal excursion of the diaphragms. Palpation and percussion were unremarkable. Auscultation revealed equal breath sounds that were symmetric bilaterally and without adventitious sounds. Echocardiography performed in August 1998, revealed aortic sclerosis without stenosis, very mild mitral regurgitation, as well as tricuspid regurgitation, left ventricular diastolic dysfunction by Doppler interrogation but normal left ventricular systolic function. A radiograph of the chest was unremarkable. Electrocardiographic stress test was performed according to a modified Bruce protocol. The Veteran exercised a total of 12 minutes with a maximum heart rate of 117 beats per minute reaching a 75% maximum, suboptimal heart rate response likely related to beta blockers. He had an adequate stress test which was abnormal as manifested by subjective evidence of ischemia. There were nonspecific symptoms including chest pressure which continued throughout the test and also presented during the stress and recovery periods. He felt lightheaded; however, there were no definite preesyncopal episodes. The examiner's impression was of AHD. The Veteran had reproducible ischemia on an electrocardiographic stress test occurring at a very low work capacity (less than 10 METs. He had ongoing and recurrent exertional dyspnea and positional lightheadedness represented by intermittent episodes of angina occurring at a very low work capacity. Subsequently dated private and VA records show treatment for various conditions, to include, on occasion, his heart disorder. For example, when examined for VA in May 1999, the Veteran reported that he experienced shortness of breath and fatigability. He also experienced lightheadedness and sharp chest pains on exertion. Stress testing displayed no ischemic cardiographic changes or arrhythmias. He was able to achieve 67% of maximal predicted heart rate due to knee pain and dyspnea. An addendum to the stress test reflects that a maximum workload of 5.4 METs was achieved. The diagnosis included AHD with supraventricular tachycardia (by history) treated. When examined by VA on September 15, 2006, the Veteran reported that he was diagnosed with heart disease and cardiac arrhythmia in 1990. He had had an acute myocardial infarction in 2001, at which time he had an angioplasty. He had also been subsequently diagnosed with heart valve problems. He reported occasional chest pain, dizziness, fatigue, and painful breathing. Functional capacity was estimated to be at 4 METs from history. It was noted that he was unable to perform a treadmill stress echocardiogram in the past and he underwent a nuclear stress test recently. There was a mild perfusion defect in the lateral wall, suggesting probably prior mild myocardial infarction. VA records show that the Veteran underwent a heart catheterization in October 2006. The impressions were mild, mostly persistent perfusion abnormality involving the lateral wall. The area was hypokinetic on the gated images. The examiner could not exclude a prior mild infarction in this region. Non-obstructive CAD was noted upon summary. The Veteran underwent additional cardiac examination for VA on August 5, 2009. At that time, his complaints essentially mirrored those as when examined in 2006. The examiner's impression was of CAD. Again, his METs were estimated at 4. Pertinent Laws and Regulations The regulations pertaining to the evaluation of HTN were amended during the pendency of the Veteran's appeal. See 62 Fed. Reg. 65222 (Dec. 11, 1997) (effective Jan. 12, 1998); see also 71 Fed. Reg. 52460 (Sept. 6, 2006) (effective Oct. 6, 2006). The regulations pertaining to the evaluation of CAD amended twice during the pendency of the Veteran's appeal. See 62 Fed. Reg. 652070-01 (Dec. 11, 1997) (to be codified at 38 C.F.R. § 4.104, DCs 7000 to 7123); see also 71 Fed. Reg. 52,459-60 (Sept. 7, 2006); codified at 38 C.F.R. 4.100. The VA General Counsel has held that where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the Veteran had prior to enactment of the new rule. See VAOPGCPREC 7-2003 (Nov. 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C.A. § 5110(g), can be no earlier than the effective date of that change. VA can apply only the earlier version of the regulation for the period prior to the effective date of the change. Hypertensive Vascular Disease Under the regulations in effect prior to January 12, 1998, 38 C.F.R. § 4.104, DC 7101 provided that a 10 percent evaluation was assigned for hypertensive vascular disease (essential arterial hypertension) with a diastolic pressure predominantly 100 or more. A 20 percent evaluation was assigned for hypertensive vascular disease with a diastolic pressure predominantly 110 or more with definite symptoms. A 40 percent evaluation was assigned for hypertensive vascular disease with diastolic pressure predominantly 120 or more and moderately severe symptoms. A 60 percent evaluation, the highest available schedular rating, was assigned for diastolic pressure predominantly 130 or more and severe symptoms. Explanatory Note (1) indicated that for the 40 percent and 60 percent ratings under DC 7101, there should be careful attention to the diagnosis and repeated blood pressure readings. Explanatory Note (2) also noted that when continuous medication is shown necessary for control of HTN with a history of diastolic blood pressure predominantly 100 or more, a minimum of 10 percent will be assigned. See 38 C.F.R. § 4.104, DC 7101 (1996). Effective January 12, 1998, the criteria for evaluating HTN were amended to include consideration of systolic blood pressure readings. In this regard, a 10 percent evaluation is assigned for hypertensive vascular disease (HTN and isolated systolic HTN) with diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum elevation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is assigned for hypertensive vascular disease with diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent evaluation is assigned for hypertensive vascular disease with diastolic pressure predominantly 120 or more, while a 60 percent evaluation, the highest available schedular rating, is assigned for diastolic pressure predominantly 130 or more. Explanatory Note (1) indicated that HTN or isolated systolic HTN must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term HTN means that the diastolic blood pressure is predominantly 90mm, or greater, and isolated systolic HTN means that the systolic blood pressure is predominantly 160mm, or greater with a diastolic blood pressure of less than 90mm. Explanatory Note (2) advised the rater to evaluate HTN due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation. To eliminate the confusion regarding whether or not separate evaluations for HTN and hypertensive heart disease were appropriate, it was proposed to add a new note (3) under DC 7101 stating that HTN will be separately evaluated from hypertensive heart disease and other types of heart disease. See 67 Fed. Reg. 54,396 (August 22, 2002). Effective October 6, 2006, VA amended the Schedule for Rating Disabilities by adding guidelines for evaluating certain respiratory and cardiovascular disorders, including an explanation that HTN will be separately evaluated from hypertensive and other heart diseases. 71 Fed. Reg. 52457-01 (Sept. 6, 2006). This clarification is currently codified at 38 C.F.R. § 4.104, DC 7101 Note (3). It was noted that the provisions of this amendment shall apply to all applications for benefits received by VA on or after the effective date of this final rule. Id. Significantly, however, information in the proposed regulation makes clear that the amendment was simply to clarify existing practice. Given that this amendment clarifies that the criteria of DC's 7005 and 7101 in effect since 1996 have never overlapped, the Board finds no impediment to applying these principles for the entire appeal period. Valvular Heart Disease (Rheumatic Heart Disease) Prior to January 12, 1998, the rating criteria for valvular heart disease set forth at 38 C.F.R. § 4.104, DC 7000, provided as follows: A 30 percent rating is warranted from the termination of an established service episode of rheumatic fever, or, its subsequent recurrence, with cardiac manifestations, during the episode of recurrence, for 3 years, or diastolic murmur with characteristic EKG manifestations or definitely enlarged heart. A 60 percent rating is warranted for rheumatic heart disease with heart definitely enlarged; severe dyspnea on exertion, elevation of systolic blood pressure, or such arrhythmias as paroxysmal auricular fibrillation or flutter or paroxysmal tachycardia; more than light manual labor is precluded. A 100 percent rating is warranted for active rheumatic heart disease, and, with ascertainable cardiac manifestation, for a period of 6 months, or for inactive disease with definite enlargement of the heart confirmed by roentgenogram and clinically; dyspnea on slight exertion; rales, pretibial pitting at end of day or other definite signs of beginning congestive failure; more than sedentary employment is precluded. 38 C.F.R. § 4.104, DC 7000, effective prior to January 12, 1998. Effective January 12, 1998, the rating criteria for DC 7000 was amended as follows: A 30 percent rating is assigned for valvular heart disease with a workload of greater than 5 METs but not greater than 7 METs, results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is assigned for valvular heart disease (including rheumatic heart disease) when there is more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs, results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 percent to 50 percent. A 100 percent rating is for assignment during active infection with valvular heart damage after three months following cessation of therapy for the active infection. Thereafter, with valvular heart disease (documented by findings on physical examination and either echocardiogram, Doppler echocardiogram, or cardiac catheterization) resulting in: Chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina dizziness, or syncope, or; left ventricular dysfunction with an ejection fracture of less than 30 percent. 38 C.F.R. § 3.414, DC 7000. As noted above, the regulations pertaining to the evaluation of CAD were amended twice during the pendency of the Veteran's appeal. See 62 Fed. Reg. 65207-01 (Dec. 11, 1997) (to be codified at 38 C.F.R. § 4.104, DCs 7000 to 7123); see also 71 Fed. Reg. 52,459 -60 (Sept. 7, 2006); codified at 38 C.F.R. 4.100. The VA General Counsel has held that where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the Veteran had prior to enactment of the new rule. See VAOPGCPREC 7-2003 (Nov. 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C.A. § 5110(g), can be no earlier than the effective date of that change. VA can apply only the earlier version of the regulation for the period prior to the effective date of the change. Prior to January 12, 1998, the rating criteria for arteriosclerotic heart disease (i.e. coronary artery disease) set forth at 38 C.F.R. § 4.104, DC 7005, provided as follows: A rating of 30 percent was to be assigned following typical coronary occlusion or thrombosis, or with history of substantiated anginal attack, ordinary manual labor feasible. A rating of 60 percent was to be assigned following typical history of acute coronary occlusion or thrombosis as above, or with history of substantiated repeated anginal attacks, more than light manual labor not feasible. During and for 6 months following acute illness from coronary occlusion or thrombosis, with circulatory shock, etc. arteriosclerotic heart disease was to be rated at 100 percent. Arteriosclerotic heart disease was also to be rated at 100 percent after 6 months, with chronic residual findings of congestive heart failure or angina on moderate exertion or more than sedentary employment precluded. 38 C.F.R. § 4.104, DC 7005, effective prior to January 12, 1998. Effective January 12, 1998, the rating criteria for arteriosclerotic heart disease (i.e. coronary artery disease) DC 7005, was amended as follows: A workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required was to be rated as 10 percent disabling. A workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray was to be rated as 30 percent disabling. More than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent was to be rated as 60 percent disabling. With documented coronary artery disease resulting in: Chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent was to be rated as 100 percent disabling. Note (1): Evaluate cor pulmonale, which is a form of secondary heart disease, as part of the pulmonary condition that causes it. Note (2): One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. Note: If nonservice-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other non-arteriosclerotic heart disease, request a medical opinion as to which condition is causing the current signs and symptoms. The Board has also considered the applicability of 38 C.F.R. § 4.104, DC 7007 relating to hypertensive heart disease. Prior to January 12, 1998, hypertensive heart disease provided: A 30 percent rating was assigned with definite enlargement of the heart, sustained diastolic hypertension of 100 or more, moderate dyspnea on exertion. A 60 percent rating was assigned with marked enlargement of the heart, confirmed by roentgenogram, or the apex beat beyond midclavicular line, sustained diastolic HTN, diastolic 120 or more, which may later have been reduced, dyspnea on exertion, more than light manual labor is precluded. A 100 percent rating was assigned with definite signs of congestive failure, more than sedentary employment precluded. 38 C.F.R. Part 4, DC 7007 (1996). Under the former versions of DCs 7007 and 7101 (effective prior to January 12, 1998), a separate rating was not to be assigned for hypertensive heart disease and HTN. This was because the criteria for rating one condition overlapped with the criteria for the rating the other. See 38 C.F.R. § 4.104, DC 7007 (in effect prior to January 12, 1998) (including "sustained diastolic HTN, diastolic 100 or more, or 120 or more" as rating criteria for hypertensive heart disease). Under those circumstances, the assignment of separate ratings violated the rule against pyramiding. See 38 C.F.R. § 4.14 (2012). Under the amended version, elevated diastolic readings are no longer listed as criteria for rating hypertensive heart disease. See 38 C.F.R. § 4.104, DC 7007 (2012). See also Esteban v. Brown, 6 Vet. App. 259 (1994); Robinette v. Brown, 8 Vet. App. 69 (1995); Akles v. Derwinski, 1 Vet. App. 118 (1991). As already noted, a separate rating for AHD was assigned in this case prior to January 12, 1998. Specifically, upon rating decision in October 1998, a separate 30 percent rating was granted for AHD as secondary to service-connected HTN, effective from August 6, 1997. (In the current case, even though the assignment of a separate rating for AHD prior to January 1998 appears to be in violation of the above summarized DCs, the Board will not question this assignment as the award is long standing. On January 12, 1998, the rating criteria for hypertensive heart disease were revised and are found in 38 C.F.R. § 4.104, DC 7007. The criteria for this DC are the same as the revised criteria for DC 7005. As noted, the regulations for diseases of the heart were amended effective from October 6, 2006. However, a review of the regulations both prior to and after October 6, 2006 reveals that the relevant provisions in DC 7007 remain unchanged. See 71 Fed. Reg. 52,460 (Sept. 6, 2006). As noted earlier, service connection for HTN was awarded in a 1993 rating decision. The RO assigned a 10 percent disabling rating, effective January 1, 1992. The records reflects that a separate 30 percent rating, effective from August 6, 1997, was assigned for AHD as secondary to HTN upon rating decision in November 1998. The Veteran seeks higher ratings. Note: Based on review of the pertinent laws and regulations above, when service connection was also already established for HTN, a separate rating for CAD was not warranted prior to amended regulations in January 1998. However, as the assignment has been long standing, the Board will not address whether such grant was actually proper. Initially, as to whether an initial rating in excess of 10 percent is warranted for HTN, the Board finds that a rating in excess of this award is not warranted at any time throughout the appeal process based on consideration of all pertinent DCs. In order to receive a 10 percent evaluation or higher for this initial period (prior to January, 12, 1998, when amendments went into effect), the evidence must show that the Veteran had diastolic pressure readings that were at least predominately 100 or more. The blood pressure readings dated during this period as reflected above included several diastolic readings in the 80s and at least two in the 90s. Based on these findings, it may be argued that the diastolic pressure was predominantly 100 or more, resulting in the assigned 10 percent rating. Clearly, however, the diastolic blood pressure readings were not 110 or more to warrant a rating in excess of 20 percent. The Board has considered whether a compensable rating could be assigned under an alternate DC, such as DC 7005 (for arteriosclerotic heart disease/coronary artery disease) or DC 7007 (for hypertensive heart disease). At the time in question, there were no additional symptoms (e.g. chest pain, exertional dyspnea), to warrant a rating in excess of the 10 percent assigned, pursuant to 38 C.F.R. § 4.104, DC 7005. Rating of the same "disability" or the same "manifestations" under various diagnoses would result in pyramiding which is prohibited. 38 C.F.R. § 4.14. As already discussed, a separate compensable rating under DC 7005 should not have been allowed prior to the amended regulations which went into effect in January 12, 2008. As indicated above, the grant of the separate rating for AHD in 1997 will not be altered at this late date. At any rate, however, a higher rating is not warranted under DC 7007 as there is no evidence in the record showing that the Veteran had an enlarged heart, sustained diastolic pressure of 100 or more, and significant dyspnea on exertion associated with cardiovascular disability. Based on the forgoing, a rating in excess of 10 percent for HTN is denied for the entire appeal period that is between January 1, 1992, and January 12, 1998. As indicated, the Veteran's HTN is rated as 10 percent disabling, effective January 1, 1992. Blood pressure readings from January 12, 1998, through 2009 have been reviewed and considered in the evaluation of the Veteran's disability. Based on the evidence, the Board finds that the criteria for an evaluation higher than 10 percent are not met for the entire appeal period, that is from January 12, 1998, to the present time. Under the former and revised criteria for rating HTN, an evaluation of 20 percent or higher required a history of diastolic pressure readings that were predominately 110 or higher. 38 C.F.R. § 4.104, DC 7101 (1996, 1998 & 2012). In this case, the Board notes that out of the blood pressure readings obtained between January 12, 1998, and now, none of the Veteran's diastolic pressures obtained have been 110 or higher with definite symptoms. Such findings do not reflect diastolic pressures predominately 110 or higher. His HTN has been described as well controlled on medication. A systolic pressure of predominately 200 or more would merit a higher evaluation under the revised criteria. There are no blood pressure readings with a systolic pressure of 200 or more in the record. Accordingly, an initial evaluation in excess of 10 percent from January 12, 2008, is also not warranted. 38 C.F.R. § 4.104, DC 7101 (1998 & 2012). Under the former criteria set forth at 38 C.F.R. § 4.104, DC 7007 (1998), a 30 percent evaluation was available for definite enlargement of the heart, a sustained diastolic pressure of 100 or more, and moderate dyspnea on exertion associated with cardiovascular disability. The evidence shows that the Veteran has reported dyspnea on exertion and chest pain throughout this appeal period (from 1998), but there has not also been definite enlargement of the heart and sustained diastolic pressure of 100 or more. There simply is no other evidence of heart enlargement in the record. Also, the cumulative blood pressure readings do not reflect a sustained diastolic pressure of 100 or more. As noted earlier, his diastolic blood pressure readings since 1998 have essentially been in the 80s. Accordingly, the criteria for a higher rating of 10 percent for HTN are not met or approximated. See 38 C.F.R. § 4.104, DC 7007 (1998). As to the claim of entitlement to an initial rating for AHD in excess of 30 percent prior to June 24, 2008, and in excess of 60 percent therefrom, it is the Board's conclusion that a rating of 60 percent is warranted as of September 15, 2006, but not earlier, and that a rating in excess of 60 percent is not warranted at any time. In discussion, it is noted that a 60 percent rating is the next higher evaluation for AHD under the former DC 7005, and requires a history of acute coronary occlusion or thrombosis, or a history of substantiated repeated anginal attacks with more than light manual labor not feasible. See 38 C.F.R. § 4.104, DC 7005 (1996). The Board has reviewed the cumulative clinical evidence and finds no evidence of a history of acute coronary occlusion or thrombosis. While there is a history of substantiated anginal attack and dyspnea, there is no medical opinion in the record that states or advises that more than light manual labor was precluded or was not feasible due to the Veteran's CAD. The medical evidence shows that prior to 2006 the Veteran's AHD was manifested by, at worst, a history of a substantiated anginal attack. There were nonspecific symptoms including chest pressure. In the years prior to 2006, he reported some chest pains on exertion, but it was not reported that more than light manual labor was precluded or was not feasible due to AHD. See 38 C.F.R. § 4.104, DC 7005 (1996). Accordingly, the initial 30 percent rating was appropriate. The Board finds, however, that the criteria for a 60 percent disability rating are met in light of the revised rating criteria of DC 7005, as of September 15, 2006. As noted above, amended regulations went into effect in January 1998. As of the September 2006 date, the Veteran's functional capacity was estimated to be 4. Moreover, he experienced the symptoms of dyspnea and angina. Thus, the criteria for an increased rating of 60 percent were met as of that date. Prior to the VA examination on September 15, 2006, the evidence did not demonstrate METs of greater than 3 but not greater than 5 resulting in dyspnea, fatigue, angina, dizziness or syncope and, in fact, the medical evidence shows that the Veteran's metabolic capacity was not specifically provided. There also was no evidence of an ejection fraction of 30 to 50 percent. Rather, the medical evidence showed that the Veteran's AHD was manifested by aortic sclerosis without stenosis, very mild mitral regurgitation, as well as tricuspid regurgitation, left ventricular diastolic dysfunction by Doppler interrogation but normal left ventricular systolic function. A radiograph of the chest was unremarkable. Ejection fractions were not specifically supplied in the available medical records. It is shown that the Veteran had ongoing and recurrent exertional dyspnea and positional lightheadedness represented by intermittent episodes of angina occurring at a very low work capacity. The findings prior to September 15, 2006, are best represented by a 30 percent rating. Accordingly, the 30 percent rating is continued for the entire period prior to September 15, 2006, and the Board assigns a 60 percent disability rating from that date and thereafter. See 38 C.F.R. § 4.104, DC 7005 (1996 & 2012). A higher rating of 100 percent is not warranted under the former or revised criteria set forth at DC 7005. The record does not reflect evidence of acute illness from coronary occlusion or thrombosis with chronic residual findings. See 38 C.F.R. §4.104, DC 7005 (1996). There also is no evidence of chronic congestive heart failure, or a workload of 3 METs or less; or left ventricular dysfunction with an ejection fraction of less than 30 percent. See 38 C.F.R. § 4.104, DC 7005, (2012). Alternately, the Board has considered whether a 60 percent or higher rating may be assigned (prior to September 15, 2006) under DC 7000. Under former DC 7000, a higher rating of 60 percent was possible under this code for rheumatic heart disease with heart definitely enlarged; severe dyspnea on exertion, elevation of systolic blood pressure, or such arrhythmias as paroxysmal auricular fibrillation or flutter or paroxysmal tachycardia; more than light manual labor is precluded. See 38 C.F.R. § 4.104, DC 7000 (1996). In this case, there is no definite heart enlargement shown. While he had some dyspnea, there was no elevation of systolic blood pressure or apparent ongoing arrhythmias or tachycardia. Finally, as was discussed above, the evidence does not show that more than light manual labor was precluded due to the valvular disease. Accordingly, a 60 percent or higher rating, under DC 7000, may not be assigned for the period that is prior to September 15, 2006. The Board has considered whether a 100 percent rating may be assigned for the period beginning September 16, 2006, alternatively under the former or revised versions of DC 7000; but finds that it may not. Applying the former criteria of DC 7000 to the evidence of record beginning September 15, 2006, a 100 percent rating is not proper. The record contains no findings of active rheumatic heart disease. Moreover, it was not indicated that more than sedentary employment was precluded. These findings do not meet the criteria required for a 100 percent rating. However, the Board notes that to warrant a 100 percent rating there must also be evidence of definite enlargement of the heart shown by roentgenogram and clinically. See 38 C.F.R. § 4.104, DC 7000 (1996). Accordingly, the former criteria required for a 100 percent rating are not met. The criteria warranting a 100 percent rating under the revised DC 7000 is identical to those set forth in the revised DC 7005. The Board has already discussed why those criteria are not met in this case. See 38 C.F.R. § 4.104, DC 7000 (2012). Accordingly, the preponderance of the evidence is against a rating in excess of 30 percent for any period of time prior to September 15, 2006, and against a rating higher than 60 percent for any period of time from that date. Hart v. Mansfield, 21 Vet. App. 505 (2007). Final Considerations as to HTN and AHD The Board has considered the Veteran's hearing testimony and his statements in the record and finds that they are credible. Consideration of his statements, as well as the medical evidence has resulted in the Board's conclusion that an initial rating in excess of 10 percent is not warranted for HTN. However, the Board determined that a 60 percent rating, but not more, is warranted for AHD as of September 15, 2006, resulting in a favorable decision to this extent. It was further determined that a rating in excess of 60 percent is not warranted from the September 15, 2006 date. The Board further finds that there is no evidence that the manifestations of the Veteran's service-connected cardiovascular disabilities are unusual or exceptional to demonstrate that the rating schedule is inadequate for determining the proper level of disability. In particular, the Board finds no evidence of any signs or symptoms of the service-connected cardiovascular disabilities which are not encompassed within the rating schedule or within the Veteran's assigned evaluations for HTN or AHD. Therefore, the Board finds that the criteria for submission for an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Thun v. Peake, 22 Vet. App. 111 (2008). The Board has considered the doctrine of reasonable doubt in making the above determinations. As for the claims that were denied, the record does not provide an approximate balance of negative and positive evidence on the merits. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 3.102 (2012); Gilbert, supra. Therefore, the Board is unable to identify a reasonable basis for granting the Veteran's claims further than the extent already indicated. Finally, entitlement to a total disability rating based on individual unemployability (TDIU) is a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the Veteran is already in receipt of a TDIU. Entitlement to an Initial Rating for Mild Prostatism in Excess of 10 Percent Prior to June 24, 2008, and 20 Percent Therefrom Service connection was established for prostatism upon rating decision in May 2003. A 10 percent rating was assigned, effective from January 1, 1992. This grant was based on inservice symptoms which were also present at the time of VA examination in 1992. At the VA exam, the prostate was slightly enlarged, and he was still symptomatic with frequency/dysuria and nocturia (2-3 times). He was placed on medication. The Veteran was assigned an initial 10 percent rating for mild prostatism from January 1, 1992, pursuant to 38 C.F.R. § 4.115b, DC 7527 for prostate gland injuries, infections, hypertrophy, and post-operative residuals. Subsequently dated records, though 2007, essentially reflect treatment for other conditions. When seen by VA in February 2008, the Veteran was evaluated for an elevated prostate specific antigen (PSA) test. Prostate cancer was not indicated. In March 2008, he denied having any voiding symptoms. At the time of the November 2008 exam, the Veteran complained of mild prostatism. He reported increased frequency or urination during the day and night. He urinated about every hour in the daytime hours and 2-3 times per night. He complained of some incontinence, mostly leakage from dribbling. He did not use pads. He had problems with urge incontinence and erectile dysfunction for the past 4 to 5 years. Based on the findings from 2008 as reflected above, the RO, in an October 2009 rating decision, increased the 10 percent rating to 20 percent, effective June 24, 2008. This disorder is rated by analogy to DC 7527 for prostate gland injuries, infections, hypertrophy, and post-operative residuals. Rate as voiding dysfunction or urinary tract infection, whichever is predominant. 38 C.F.R. § 4.115b, DC 7527 (2012). Voiding dysfunction: Rate particular condition as urine leakage, frequency, or obstructed voiding. Continual Urine Leakage, Post Surgical Urinary Diversion, Urinary Incontinence, or Stress Incontinence: Requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day 60% Requiring the wearing of absorbent materials which must be changed 2 to 4 times per day 40% Requiring the wearing of absorbent materials which must be changed less than 2 times per day 20% 38 C.F.R. § 4.115a (2012). Urinary frequency: Daytime voiding interval less than one hour, or; awakening to void five or more times per night 40% Daytime voiding interval between one and two hours, or; awakening to void three to four times per night 20% Daytime voiding interval between two and three hours, or; awakening to void two times per night 10% 38 C.F.R. § 4.115a (2012). After review of the clinical records, it is concluded by the Board that the Veteran's prostatism is accurately reflected by the current ratings. Prior to the findings in 2008, the condition was manifested by nighttime voiding frequency of once nightly and no complaints of daytime frequency. For the time period from June 24, 2008, prostatism is manifested by increased voiding frequency particularly in the daytime (every hour) and awakening up to 3 times per night for voiding. Moreover, he now complained of incontinence. Based on the applicable DC, it is concluded that a 10 percent rating is appropriate for the time period prior to 2008 and that the currently assigned 20 percent rating is appropriate for the period from June 24, 2008. The current ratings best reflect the Veteran's levels of urinary frequency/voiding dysfunction. Finally, it is noted that the Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Thus, the Board is unable to identify a reasonable basis for granting the veteran's claim. Also considered was referral of the case for the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1), but the Board finds no basis for further action on this question as there are no circumstances presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. The Veteran's symptoms are fully contemplated by the rating criteria discussed above. Entitlement to an Initial Rating for Residuals of a Left (Minor) Shoulder Injury With Traumatic Arthritis in Excess of 10 Percent Prior to August 28, 2009, and in Excess of 20 Percent Therefrom Service connection for residuals of a left (minor) shoulder injury with traumatic arthritis was granted upon rating decision in May 1993. At A 10 percent rating was assigned, effective January 1, 1992. (Service connection was already in effect for a left elbow and left forearm condition.) The grant was based on inservice treatment for left shoulder complaints and post service evidence of continuing disability. Specifically, myofascial strain was noted in 1988. In the early 1990s, there was a diagnosis of trapezius strain with chronic left scapular pain. At the time of VA examination in June 1992, the Veteran said that his left shoulder was sore and ached around the left scapula. This pain woke him up at night. He was no longer able to do pushups. The left side of his neck also stiffened up on occasion. There was light decreased sensation in the skin just below and over the left scapula. There was no winging of the left scapula, nor was there any swelling or false motion. X-ray showed a normal appearing left scapula, but there was a diagnosis of arthritis in the shoulder and acromioclavicular joints. The final diagnoses included contusion and sprain of the left shoulder with slight paresthesia and arthritis. In subsequent years, the Veteran was seen on occasion for multiple joint complaints, to include the left shoulder. DDD was noted in 2004. On VA examination in November 2008, the Veteran reported constant pain, described as a 5 on a scale to 10. He reported having intermittent flare-ups of pain to an 8 or a 9. A hot shower relieved his symptoms. Sleeping the wrong way, movement, or weather changes aggravated his pain. On exam, there was tenderness on palpation of the left shoulder. Range of motion (ROM) was flexion to 140 degrees, extension to 30 degrees, abduction to 120 degrees actively, and 160 degrees passively. Adduction was to 40 degrees, internal rotation was to 90 degrees, and external rotation was to 60 degrees. There was no further limitation in ROM with repetitive activity due to weakness, instability, fatigue, or lack of coordination. The diagnosis was residuals of left shoulder injury with traumatic arthritis. Upon additional VA examination in August 2009, abduction of the left shoulder was to 70 degrees with pain. Flexion was to 110 degrees with pain. Extension was to 30 degrees and internal and external rotation were to 70 degrees with pain. There was no tenderness to palpation along the shoulder joints. There was no further limitation in ROM with repetitive activity due to weakness, instability, lack of coordination or endurance. The impression was of left shoulder rotator cuff tears, panlabral tears, and arthritis. In a November 2009 rating action, the 10 percent rating in effect for the left shoulder disorder was increased to 20 percent, effective August 28, 2009, the date of the examination showing decreased ROM. The appeal continues. Normal ROM for the shoulder is 180 degrees of forward elevation and abduction, and 90 degrees of external and internal rotation. See 38 C.F.R. § 4.71a, Plate I (2012). Under 38 U.S.C.A. § 4.71a, DC 5203, a 10 percent evaluation is warranted for nonunion of the clavicle or scapula, without loose movement or malunion of the clavicle or scapula. A 20 percent evaluation is warranted for dislocation of the clavicle or scapula or nonunion of the clavicle or scapula, with loose movement. These evaluations are the same for either the major or minor arm. Under 38 U.S.C.A. § 5202, (impairment of the humerus - minor extremity), a 20 percent evaluation is warranted for recurrent dislocations at the scapulohumeral joint, with frequent episodes and guarding of the arm movements of the minor arm; recurrent dislocations at the scapulohumeral joint with infrequent episodes and guarding of movement only at the shoulder level; or malunion of the humerus with marked deformity of the minor arm or moderate deformity. A 40 percent evaluation is warranted for a fibrous union of the humerus. Nonunion of the humerus warrants a 50 percent evaluation for the minor arm. A loss of the humerus head warrants a 70 percent evaluation for the minor arm. Traumatic arthritis established by X-ray findings is to be evaluated as degenerative arthritis. 38 C.F.R. § 4.71a, DC 5010. Degenerative arthritis established by X-ray findings will be evaluated on the basis of limitation of motion of the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003. Under DC 5201, limitation of motion of the arm (major or minor) at shoulder level warrants a 20 percent evaluation. Limitation of motion of the arm midway between the side and the shoulder warrants a 30 percent evaluation (major) or a 20 percent evaluation (minor). A 40 percent evaluation requires limitation of the major arm to 25 degrees from the side. Limitation of the minor arm to 25 degrees from the side warrants a 30 percent evaluation. Under DC 5200, favorable ankylosis of the scapulohumeral articulation where abduction is to 60 degrees and the veteran may reach his/her mouth and head warrants a 20 percent rating for the minor arm. Ankylosis of the scapulohumeral articulation between favorable and unfavorable warrants a 30 percent rating for the minor arm. Unfavorable ankylosis of the scapulohumeral articulation where abduction is limited to 25 degrees from the side warrants a 40 percent rating for the minor arm. 38 C.F.R. § 4.71a, DC 5200 (2012). The evidence prior to the most recent examination in August 2009 reflects that the currently assigned 10 percent rating best represents the Veteran's left shoulder disability for that time period. Pursuant to DC 5203 for nonunion of the clavicle or scapula, a 10 percent rating is warranted without loose movement or malunion. Subsequently dated records, to include exam in 2008 show some limitation of motion, but when compared to the appropriate DCs above, a rating in excess of the currently assigned 10 percent pursuant to any of the applicable codes is not warranted. There was no recurrent dislocation of the clavicle or scapula with loose movement or recurrent dislocations at the scapulohumeral joint with guarding or the arm movements. DCs 5202 5203. And, limitation of motion that would warrant a 20 percent rating (at shoulder level or midway between the side and shoulder level) is also not shown. DC 5201. It was not until examination on August 28, 2009, that limitation to the shoulder level was indicated as evidenced by limitation of abduction to 70 degrees. This warrants the currently assigned 20 percent rating pursuant to DC 5200 or 5201. As ankylosis between and unfavorable of the scapulohumeral articulation, malunion of the humerus with marked deformity, and limitation of the arm to 25 degrees from the side, is not shown, a rating in excess of 20 percent is not warranted. DCs 5200, 5201, 5202. Thus, it is concluded that the 20 percent rating best represents the left shoulder disability from August 28, 2009. When an evaluation of a disability is based on limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45 (2012). DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy of disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). The Board finds, however, that the functional limitation caused by the Veteran's left shoulder disability is adequately contemplated in the current disability evaluations as reflected above. Finally, it is noted that the Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Thus, the Board is unable to identify a reasonable basis for granting the Veteran's claims. Also considered was referral of the case for the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1), but the Board finds no basis for further action on this question as there are no circumstances presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. The Veteran's symptoms are fully contemplated by the rating criteria discussed above. Entitlement to an Initial Compensable Rating for Postoperative Dupuytren's Contracture of the Left (Non-Dominant) Hand Prior to June 24, 2008, and 10 Percent Therefrom, and Entitlement to an Initial Compensable Rating for Dupuytren's Contracture of the Right (Dominant) Hand Prior to June 24, 2008, And 10 Percent Therefrom Service connection for Dupuytren's contracture of the left (non-dominant) hand was established upon rating decision in May 1993. A noncompensable rating was assigned from January 1, 1992. The grant was based on STRs which showed treatment during the Veteran's second period of service for Dupuytren's contracture of both hands. It was noted, however, that the Veteran had undergone surgery on the right hand prior to his second period of duty (in February 1987). Thus, service connection was denied for the right (dominant) hand as preexisting service and not aggravated therein. Following an August 2001 Board decision that granted service connection for Dupuytren's contracture of the right hand as aggravated by service, an April 2003 rating established service connection, evaluated as noncompensably disabling effective March 1, 1999. An October 2009 rating increased the evaluation for both hands to 10 percent disabling, effective June 24, 2008, the date of receipt of the claim for increased compensation based on individual unemployability. The STRs reflect that the Veteran underwent surgery in September 1988 on the right hand and was doing well postoperatively, maintaining extension and flexion. In October 1988, he was seen for therapy and continued to do well. He underwent surgery on the left hand in March 1989 with no complications. In follow-up visits, excellent results were noted. Additional treatment of the hands during service appears to be on the right hand. Upon VA examination in June 1992, the Veteran gave a history of two surgeries on the right hand and one on the left with some skin grafts. The Veteran complained that his hands were sensitive to the cold and hurt on occasions with use. Holding the steering wheel hurt his hands. Sensation was good on the palms but less on the flexor surface of the fingers. Grasping objects was satisfactory. The examiner's diagnoses included bilateral Dupuytren's contracture with decreased sensation of the fingers. The noncompensable rating assigned upon initial grant of service connection was assigned by analogy to DC 5227 regarding ankylosis of the ring or little finger. Unfavorable or favorable ankylosis of the minor or major ring or little fingers warrants a noncompensable rating under that DC. When examined by VA in September 2003, the Veteran gave a history of Dupuytren's contracture of both hands. He had undergone surgery on both hands (1989 and 1990) with skin grafting to the bilateral 5th digits. He reported increased symptoms of hand pain and "shocky" sensations in the hands and reported that his hand pain alternated between numbness and pain and primarily numbness in the winter. He reported decreased ROM and stated that the grafts had left his digits tight. He said that there was a decrease in motor skills and difficulty when trying to open things. He sometimes dropped utensils while eating. On physical exam of the right hand, there was slight flexion contracture of all of the digits with the fifth digit being primarily affected. He had flexion at the metacarpophalangeal (MP) joints of all fingers to 90 degrees with extension to 15 degrees, flexion at the distal interphalangeal (DIP) joint to 100 degrees with extension to 10 degrees and flexion of the "DIP joints" (though presumably the examiner meant the PIP joints) to 70 degrees and extension to 0 degrees. He was unable to approximate his thumb to all his fingers on the right hand. He had decreased grip strength in the right hand and decreased sensation over the palmar aspect of the hand. scar on the right hand was slightly depressed and hyperpigmented to normal areas of skin. He did not have full ROM at the MP joint. As to the left hand, there were obvious flexion contractures of all the digits with the left fifth digit being most affected. There was decreased ROM of the MP joints with flexion to 70 degrees and extension to 10 degrees. At the PIP joints, flexion was to 100 degrees and extension was to 10 degrees. At the DIP joints, flexion was to 70 degrees with extension to 0 degrees. He was unable to approximate his thumb to all of his fingers on the left hand. He had decreased grip strength in the left hand with decreased sensation over the palmar aspect of the hand. Both hands showed slight edema of the PIP and DIP joints of all of the fingers, bilaterally, and he had decreased grip strength. He was unable to make fists with both hands. The diagnoses were bilateral Dupuytren's contractures, status post skin grafting; bilateral hand degenerative joint disease per x-ray; and mild bilateral carpal tunnel syndrome per EMG with NCVs. Upon additional VA examination of the hands in November 2008, the Veteran reported continued problems associated with his Dupuytren's contracture of both hands. He had problems with contractures and numbness/tingling with loss of sensation "from his diabetes." He believed that the surgeries had resulted in nerve damage. He had decreased ROM and aching. His right hand little finger was still cramped up. The pain itself was aggravated by use. He tended to drop objects and had loss of feeling in his fingertips. It was noted that he also had carpal tunnel syndrome. Upon examination, the hand scars were faint and mingled with the Veteran's hand lines. He still had some flexion contractures of the fingers more prominent of the little fingers bilaterally. He had weak hand grip with 3+/5. Thumb apposition was poor with the Veteran having significant problems in achieving apposition. Both hands showed arthritis upon X-rays. In the October 2009 rating decision, which increased the noncompensable ratings in effect for left and right Dupuytren's contracture of the hands to 10 percent each, the ratings were assigned by analogy pursuant to DC 5223 regarding favorable ankylosis of two digits of one hand. DC 5223 provides that a 10 percent rating is assigned when there is favorable ankylosis of two digits of one hand (either the major or minor hand), and those two digits are the long and ring fingers; the long and little fingers, or the ring and little fingers. Pursuant to DC 5219, a 20 percent rating is assigned for unfavorable ankylosis of the index finger and either the long, ring or little fingers of the minor hand. A 20 percent (minor) and 30 percent (major) rating is assigned to unfavorable ankylosis of the index and long fingers; the index and ring fingers; or the index and little fingers. A 30 percent (minor) or 40 percent (major) rating is assigned for unfavorable ankylosis of the thumb and any finger. It is noted that other diagnostic codes discuss favorable ankylosis of five digits (DC 5220), four digits ((DC 5221), and three digits (DC 5222). Another DC to be considered is DC 5228 regarding limitation of motion of the thumb. Under that code a noncompensable rating is warranted with limitation of the thumb with a gap of less than one inch between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. For a 10 percent rating, there must a gap of one to two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. For a maximum rating of 20 percent, the gap must be more than two inches between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Considering the evidence of record, to include the evidence of limited motion of the fingers, DeLuca considerations regarding functional loss, and 38 C.F.R. § 4.7, the Board finds that that the overall disability picture for Dupuytren's contracture of the left (non-dominant) and right (dominant) hands approximates the increased disability of 10 percent as of VA examination on September 23, 2003. Findings made at that time (like the 2008 exam) showed significant limitation of motion of several fingers but ankylosis is not reported. However, it was noted that the Veteran was unable to approximate his thumb to all of the fingers on both hands. Resolving all reasonable doubt in the Veteran's favor, and considering the fact that he has additional residuals included tingling and numbness, it is concluded that 10 percent ratings for the hands should be awarded as of the date of that exam. This grant is awarded based on application of DC 5229 which is deemed to best represent the Veteran's primary residual (inability to oppose the thumb to the fingers) and because it results in a favorable determination as to his claim. It is noted that prior to that date, significant limitation of motion of the fingers was not demonstrated. Moreover, after the 2003 date, a rating in excess of 10 percent is not warranted for the hands in that a gap of two includes between the thumb pad and fingers is not demonstrated. In summary, a noncompensable rating is warranted as to the applicable dates prior to September 22, 2003, but as of that date and thereafter, 10 percent ratings are warranted for residuals of Dupuytren's contracture of the right and left hands. Consideration of 38 C.F.R. §§ 3.102, 4.7 (2012) was instrumental in this grant. The Veteran's hand symptomatology is fully contemplated by the rating criteria discussed above. As to the hand scarring, the Board has determined that further examination is necessary to clearly set forth pertinent symptomatology. Tender scarring has been noted in the past on physical examination, but additional information is required before the Board may determine if an additional rating or ratings are warranted for symptomatic scars. Accordingly, this portion of these claims is remanded herein. Entitlement to a Rating in Excess of 10 Percent for Residuals of Fracture of the Left Olecranon Process, Left (Minor) Ulna with Traumatic Arthritis Service connection for a healed fracture of the left radius head was established upon rating action in December 1954. A noncompensable rating was assigned. This grant was based on inservice treatment for the condition. In a January 1960 rating, action, the noncompensable rating was confirmed, as VA examination in 1959 showed no significant residuals of the disorder. X-ray examination, in pertinent part, showed slight irregularity of the head of the radius, secondary to old healed fracture. When examined by VA in June 1992, the Veteran reported that it hurt to use the left elbow in that it ached. There was also limitation of motion. On exam, the left elbow had a 36 degree of lack of full extension and flexion to 130 degrees. ROM of the right elbow by comparison was 13 degrees to 135 degrees. Pronation and supination were "okay." The grip on the left was 70 pounds compared to 90 on the right. There was some irregularity of the head of the left radius on rotation. Flexion and extension went smoothly, and there was no swelling in the elbow. There was no deformity, angulation, false motion, or shortening. There was some crepitus on motion in the left elbow. X-ray revealed large ossicles adjacent to the olecranon process with arthritis. In a May 1993 rating decision, a 10 percent rating for the left elbow disorder was granted, effective January 1, 1992, pursuant to DC 5211 regarding impairment of the ulna. Under that code, malunion of the ulna with bad alignment warrants a 10 percent rating (major or minor joint). A 20 percent rating is warranted for nonunion in the lower half. Subsequently dated records over the years reflect that the Veteran's complaints included various joints, to include the elbow, but primarily his complaints were associated with his shoulder. When his elbow was examined by VA in November 2008, he reported intermittent pain of 6 to 7 on a scale to 10. It was aggravated by cold weather and by use. His complaints were alleviated by immobilizing the elbow and with cold or warm compresses. He denied having any flare-ups. He did use a sling to help it. On exam, left elbow ROM was to -10 degrees of extension which increased to 0 degrees passively with significant discomfort. Flexion was to 100 degrees, pronation and supination to 50 degrees actively and passively. There was tenderness to palpation at the tip of the olecranon process and at the lateral epicondyle. X-rays showed degenerative joint disease in the elbow. Based primarily on the findings made at the 2008 examination, the RO, in an October 2009 rating decision, confirmed the 10 percent rating in effect for the service-connected left elbow condition. The listed DC for the 10 percent rating was DC 5206 regarding limitation of flexion of the forearm. Under DC 5206 for limitation of flexion of the forearm, a 0 percent rating is assigned when flexion of the major forearm is limited to 110 degrees; a 10 percent rating is assigned when flexion of the major forearm is limited to 100 degrees; a 20 percent rating is warranted for flexion of the major forearm limited to 90 degrees; a 30 percent rating is warranted for flexion of the major forearm limited to 70 degrees; a 40 percent rating is warranted for flexion of the major forearm limited to 55 degrees; and a 50 percent rating is warranted for flexion of the major forearm limited to 45 degrees. 38 C.F.R. § 4.71a (2012). Under DC 5207 for limitation of extension of the forearm, a 10 percent rating is assigned when extension of the major forearm is limited to 45 or 60 degrees; a 20 percent rating is warranted for extension of the major forearm limited to 75 degrees; a 30 percent rating is warranted for extension of the major forearm limited to 90 degrees; a 40 percent rating is warranted for extension of the major forearm limited to 100 degrees; and a 50 percent rating is warranted for extension of the major forearm limited to 110 degrees. 38 C.F.R. § 4.71a (2012). DC 5208 provides for a 20 percent evaluation where flexion of the forearm is limited to 100 degrees and extension to 45 degrees. 38 C.F.R. § 4.71a, DC 5208. Flexion of the elbow to 145 degrees is considered full and extension to 0 degrees is considered full. See 38 C.F.R. § 4.71, Plate I (2012). After a review of all the evidence in the Veteran's case, the Board finds that a preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for the left elbow based on limitation of flexion. As summarized above, the elbow disability does not manifest left forearm flexion limited to 90 degrees or less, left arm extension limited to 45 degrees or more, the latter of which would warrant assignment of a compensable evaluation for limitation of extension. Moreover, nonunion in the lower half of the ulna is not shown. DC 5211. The medical and lay evidence of record does not support an evaluation in excess of 10 percent for the Veteran's service-connected left elbow disability, under the provisions of DC 5206 or a compensable evaluation under DC 5207. ROM of the left elbow, at worst, was flexion to 100 degrees, and extension to 10 degrees. Pain was not reported. Accordingly, as left elbow flexion was not limited to 90 degrees or less, and extension was not limited to 75 degrees or more, a higher evaluation in excess of 10 percent for the left elbow disability under DCs 5206 or a compensable evaluation under 5207 is not warranted. Under DC 5213, impairment of supination and pronation, a 10 percent rating is warranted for limitation of supination to 30 degrees or less and a compensable evaluation is warranted for loss of supination and pronation (bone fusion). Further, this DC provides for a 20 percent evaluation for the minor upper extremity where there is limitation of pronation with motion lost beyond last quarter of arc, the hand does not approach full pronation or motion lost beyond middle of arc. In the present case, examination has disclosed pronation and supination to 50 degrees. Therefore, a separate rating for bone fusion or limitation of supination is not warranted. With limitation of pronation to 50 degrees, however, the Veteran has motion lost beyond the last quarter of the arc, the hand does not approach full pronation, and a 20 percent rating is warranted. See Yonek v. Shinseki, No. 2012-7120 (Fed. Cir. July 18, 2013). This is the highest rating provided for impairment of supination and pronation of the minor upper extremity. Other DCs pertaining to the elbow have also been considered to evaluate whether a higher evaluation is warranted under an alternate DC. The record does not show evidence of nonunion or impairment of the left arm ulna or radius, or other impairment of the right upper extremity not already considered in this decision. Accordingly, these alternate DCs are not for application. See 38 C.F.R. § 4.71a, DCs 5208, 5209, 5210, 5211, 5212, 5213 (2012). As there is no evidence of immobility in the Veteran's left elbow, a higher initial evaluation is not warranted under DC 5205. The Board has also considered whether a higher disability rating is warranted based on additional functional loss or limitation of motion due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2012); see also DeLuca, supra. Here, the Board notes the Veteran's reported impairment of function, and has considered additional limitations of motion due to pain or other orthopedic factors as limiting motion where the pain begins or where the evidence shows such factors limit functional use. See VAOPGCPREC 9-98 (painful motion is considered limited motion at the point that the pain actually sets in). But the evidence does not show additional limitation of motion due to pain which would entitle the Veteran to an increased rating and no noted additional limitation on motion with repetitive use due to weakness, impaired endurance, or incoordination. The specific clinical measures of ROM, including examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ROM than are general histories or general descriptions of symptoms of pain. A basis for a higher rating or ratings under these provisions is not presented. Further, the Board finds that the Veteran's symptoms are fully contemplated in the ratings assigned, such that a basis for referral of consideration of an extra-schedular rating or ratings is not presented. Entitlement to an Initial Rating in Excess of 10 Percent for Postoperative Residuals of a Left Inguinal Hernia Service connection was established for postoperative residuals of a left inguinal hernia repair upon rating decision in May 1993. A 10 percent rating was assigned, effective January 1, 1992, based on induration and tenderness of the scar on palpation. The grant was based on inservice records that show treatment and surgical repair of the condition in 1991. Subsequent to service, the Veteran was seen in 1992 and 1993 with complaints in the inguinal area. In February 1993, he complained of pain in the area of the scar although it was noted to be well-healed. There was no recurrence of the hernia, but he reported tenderness at the incision, relieved with injection. Questionable nerve entrapment was diagnosed. In March 1993, VA records show he reported improvement after the injections, but he still had some aching pain. The diagnosis was question ilioinguinal nerve entrapment. When examined by VA in 1992, the Veteran reported pain in the left groin area. Examination of the scar showed globular induration underlying the medial aspect of the scar which was described as tender on palpation. The diagnosis was status post left inguinal herniorrhaphy with residuals. Additional VA examination regarding this disability was conducted in November 2008. At that time the Veteran reported a history of surgery for a left inguinal hernia on two occasions. He said that he occasionally experienced pain at the site. There had been no recurrence of the hernia. On exam, a well-healed 2 inch scar that was slightly hypopigmented in the left inguinal hernia area was noted. The scar was 1 mm in width. It was not tender. There was no evidence of hernia reproduction. DC 7338 provides criteria for evaluating an inguinal hernia. 38 C.F.R. § 4.114 (2012). DC 7804 provides criteria for evaluating scars. 38 C.F.R. § 4.118 (2012). Under DC 7338, a 10 percent rating is assigned for a postoperative recurrent inguinal hernia, which is readily reducible and well supported by truss or belt. 38 C.F.R. § 4.114, DC 7338 (2012). A 30 percent rating is assigned for a small, postoperative recurrent, or unoperated irremediable inguinal hernia, which is not well supported by truss, or not readily reducible. A 60 percent rating, which is the maximum rating, is assigned for a large, postoperative, recurrent inguinal hernia, which is not well supported under ordinary conditions and not readily reducible, when considered inoperable. Id. Based on the foregoing evidence, the Board concludes that an increased or separate rating is not warranted for the Veteran's service-connected residuals of a hernia under DC 7338. In order to warrant a 10 percent or 30 percent rating, the Veteran's hernia must be recurrent, or unoperated irremediable. In this case, although the Veteran has a history of surgery to repair an inguinal hernia, there is no evidence of a postoperative recurrent hernia. The Board acknowledges the Veteran's residual and occasional abdominal pain; however, without the presence of a recurrent hernia, an increased or separate rating is not warranted under DC 7338. Turning to the remaining DC, it is noted that DC 7804 is applicable to scars. While this appeal was pending, the applicable rating criteria for skin disorders, 38 C.F.R. § 4.118, were amended effective August 30, 2002. See 67 Fed. Reg. 49,590 (July 31, 2002). Generally, in a claim for an increased rating, where the rating criteria are amended during the course of the appeal, the Board considers both the former and the current schedular criteria because, should an increased rating be warranted under the revised criteria, that award may not be made effective before the effective date of the change. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (overruling Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991) to the extent it held that where a law or regulation changes after a claim has been filed or reopened but before the administrative or judicial appeal process has been concluded, the version more favorable to appellant should apply); see also VAOPGCPREC 7-2003 (Nov. 19, 2003); VAOPGCPREC 3-2000 (April 10, 2000); 38 U.S.C.A. § 5110(g) (West 2002 & Supp. 2012); 38 C.F.R. § 3.114 (2012). Prior to August 30, 2002, scars that were superficial, poorly nourished with repeated ulceration warranted a 10 percent rating under DC 7803 and a 10 percent evaluation was warranted for superficial scars that were tender and painful on objective demonstration under DC 7804. See 38 C.F.R. § 4.118, DCs 7803, 7804 (2002). All other scars under DC 7805 were rated based on limitation of function of the part affected. Id. As of August 30, 2002, under DC 7804, a 10 percent disability rating is assigned for superficial scars that are painful on examination. A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7804 (2007). Otherwise, scars can be rated on the limitation of function of the affected part. 38 C.F.R. § 4.118, DC 7805. The Board notes that the criteria of DCs 7802, 7803, and 7804, as revised in 2002, do not provide a disability rating in excess of 10 percent. 38 C.F.R. § 4.118 (2007). The revised criteria of DC 7805 are essentially the same as the former criteria for DC 7805, both of which provide that scars are to be rated on the limitation of function of the affected part. See 38 C.F.R. § 4.118, DC 7805 (2007). The Board also notes that the evaluation of scars was amended as of October 23, 2008. However, these particular revisions are only applicable to applications for benefits received by VA on or after October 23, 2008. See 73 Fed. Reg. 54,708 (Sept. 23, 2008). Here, VA received the Veteran's claim in 1992. Therefore, only the pre-October 2008 version of the schedular criteria is applicable in this case. As noted above, the Veteran has already been awarded a disability rating of 10 percent for his service-connected residuals of a hernia, which is the maximum schedular evaluation under the former and revised criteria for DC 7802, 7803, and 7804. Therefore, DCs 7802, 7803, and 7804 do not assist him in obtaining a higher evaluation. The Board must consider evaluation of the Veteran's hernia scar under all other potentially appropriate DCs under the former and current criteria. In that case, the evidence of record does not show that a disability evaluation in excess of 10 percent for the Veteran's service-connected residuals of a hernia under the former criteria is warranted. As mentioned above, the scar is approximately 2 inches in length and 2 millimeter wide. The scar(s) is located in the Veteran's umbilical area and not on his head, face, or neck. At no time has it exceeded 12 square inches. Additionally, the November 2008 VA examiner concluded that the scar was not tender. There was no report that there was limitation of ROM associated with it. Thus, a higher rating is not warranted under DC 7800, 7801, and 7805 under the former criteria. See 38 C.F.R. § 4.118, DCs 7800, 7801, 7805 (prior to August 30, 2002). Similarly, a higher disability evaluation in excess of 10 percent is not warranted for the Veteran's service-connected residuals of a hernia under the current criteria. The scar is not located on the head, face, or neck, and there is no evidence showing that it is deep and causes limited motion or limitation of function. As reflected in the 2008 examination report, there is apparently no significant functional disability as a result of his service-connected disability, and the scar has not caused any limitations on his ROM. Therefore, 38 C.F.R. § 4.118, DCs 7800, 7801, and 7805 do not assist the Veteran in obtaining a higher evaluation for his residuals of a hernia. See 38 C.F.R. § 4.118, DCs 7800, 7801, 7805 (as of August 30, 2002). As such, an initial rating in excess of 10 percent for the Veteran's service-connected residuals of a hernia must be denied. The Board notes that the Veteran is appealing the initial assignment of an evaluation following the grant of service connection for residuals of a hernia, and that in such cases, the Board must consider whether staged ratings should be assigned based upon the facts found. Fenderson, supra. In this case, there is no evidence that there have been changes in the Veteran's medical status regarding his service-connected disability. Therefore, his overall service-connected residuals of a hernia have not changed and a uniform rating is warranted. Finally, it is noted that the Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Thus, the Board is unable to identify a reasonable basis for granting the veteran's claim. Also considered was referral of the case for the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1), but the Board finds no basis for further action on this question as there are no circumstances presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. The Veteran's symptoms are wholly contemplated by the rating criteria. Entitlement to a Compensable Rating for Residuals of Deformity, Fracture of the Head of the Left (Minor) Radius Service connection for residuals of fracture of the head of the left radius was established upon rating decision in December 1954. A noncompensable rating was assigned. When the Veteran was examined by VA in 1959, X-ray showed slight irregularity of the head of the radius secondary to a healed fracture. There was deformity of the elbow without impairment of pronation or supination. (As reflected above, service connection is already in effect for residuals fracture of the left olecranon process, left (minor) ulna with traumatic with arthritis.) In May 1993, the RO confirmed the noncompensable rating for the service-connected fracture of the left radius. In October 2009, the RO again confirmed the noncompensable rating in effect for this disorder. The Board points out that manifestations of this disorder have already been summarized above when discussing the service-connected left olecranon process fracture, left ulna, and will not be repeated. Here, the Veteran is in receipt of a noncompensable disability evaluation under DC 5212. Under that code, a rating of 10 percent is warranted where there is malunion of the radius with bad alignment. A rating of 20 percent is warranted where there is nonunion of the radius in the upper half. A rating of 30 percent (20 percent if minor upper extremity) is warranted where there is nonunion in the lower half, with false movement without loss of bone substance or deformity. Finally, a rating of 40 percent (30 percent if minor upper extremity) is warranted where there is nonunion in the lower half, with false movement with loss of bone substance (1 inch/2.5 cms) or more and marked deformity. The provisions of 38 C.F.R. § 4.31 provide that in every instance where the schedule does not provide a zero percent evaluation for the DC, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). The Board has reviewed the relevant evidence of record but finds that the criteria for a compensable rating under DC 5212 are not met. In this respect, the physical examination findings as reported earlier do not show nonunion of the radius. Rather, the findings, and the other x-ray findings of record, show no more than malunion of the radius. Slight irregularity of the head of the radius was identified in a 1959 x-ray. It is described as well-healed. More significantly, however, there has been no false movement, or marked deformity. Hence, a rating in excess of that currently assigned is not warranted. Even though the criteria for a higher rating are not met, the Board cannot ignore that the service-connected left elbow disability results in pain on motion, swelling, stiffness, limited motion, and X-ray evidence of osteoarthritic changes. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2012). However, pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different DCs, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (2012). It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several DCs, and as reflected in this case, he is separately rated for his limited ROM of the left elbow in flexion and pronation as already discussed. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). There are no other DCs pertaining to the elbow that would provide for a compensable rating for residuals of the left radius fracture residuals. Specifically, for example, DC 5210 is not applicable in this case because there is no evidence of nonunion of the radius and ulna with flail false joint. In sum, the preponderance of the evidence is against the claim for an increased disability rating for the service-connected residuals of fracture of the head of the left radius (minor) based on application of DC 5212; there is no doubt to be resolved. 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2012), 38 C.F.R. § 4.3 (2012). As already noted, most of his left elbow complaints are separately rated as residuals of fracture of the left olecranon process of the left ulna with arthritis. Entitlement to an Initial (Compensable) Rating for Residuals of Fracture of the Right Third Metatarsal and Entitlement to an Initial (Compensable) Rating for Residuals of Fracture of the Right Fifth Toe Service connection was established for residuals of fractures of the right third metatarsal and right fifth toe upon rating decision in May 1993. Noncompensable ratings were assigned, effective January 1, 1992. The grants of service connection were based on inservice records which showed that the Veteran suffered injuries (fractures) to these toes after dropping objects on them. June 1992 VA x-ray examination disclosed, in pertinent part, deformity of the third right metatarsal due to an old healed fracture. In September 2006, x-ray examination disclosed posttraumatic changes involving the neck of the third metatarsal of the right foot. When seen by VA in September 2008, the Veteran reported that he did not have symptoms related to these fractures. His only complaints in the toes had to do with numbness and loss of toenails which he said was related to his diabetes. X-rays of the right foot showed prior trauma to the third metatarsal. In all of the VA x-ray reports, hallux valgus deformity with degenerative changes were shown. These findings are unrelated to the service-connected fractures. The Veteran is currently in receipt of noncompensable evaluations for the third and fifth fracture residuals under DC 5283. That DC provides ratings based on the degree of malunion or nonunion of the tarsal or metatarsal bones, to include a 10 percent rating for moderate, a 20 percent rating for moderately severe, and a 30 percent rating for severe malunion/nonunion. Actual loss of use of the foot is rated as 40 percent disabling. 38 C.F.R. § 4.71a, DC 5283 (2012). Evidence of record did not reflect treatment for his 3rd metatarsal or 5th toe disabilities at any time during the pendency of the Veteran's appeal. As noted above, he did undergo a VA foot examination in September 2008 as summarized above. In considering the evidence of record under the laws and regulations set forth above, the Board concludes that the Veteran is not entitled to compensable evaluations for his right metatarsal and toe disability fracture residuals. He has no complaints of toe pain or functional limitation with affected walking ability. The evidence simply does not approximate malunion or nonunion of the metatarsal bones of moderate severity. Evidence of record is also absent any findings of flatfoot, weak foot, claw foot, metatarsalgia, hallux valgus, hallux rigidus, hammer toe, or moderate foot disability related to the toe injury residuals for the assignment of higher or separate ratings under applicable rating criteria. 38 C.F.R. § 4.71a, DC 5276-5284 (2012). Consequently, the assignment of compensable evaluations for the Veteran's right metatarsal and toe disabilities based upon any of these DCs is not warranted. The Board further finds that there is no basis for the assignment of a higher rating based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, supra. In addition, evidence of record reflects that the currently assigned noncompensable ratings properly compensate him for his metatarsal/toe injury residuals in that he reported no current residuals as a result of the fractures. A basis for referral for extra-schedular consideration is not presented, as the disabilities are asymptomatic. Entitlement to an Initial (Compensable) Rating for Residuals of Excision of Warts on the Soles of the Feet Service connection for residuals of excision of warts on the soles of the feet was established upon rating decision in May 1993. A noncompensable rating was assigned, effective from January 1, 1992. The grant was based on inservice treatment for the condition. The noncompensable rating was assigned after consideration of findings made at a VA examination in June 1992. At that time, the Veteran reported that since the excision of the warts, he essentially had no feeling at the bottom of the feet and that he swelled above his socks. The examiner noted that there were white spots of scar where plantar warts were removed from the feet. There was no evidence of recurrence, and skin on the bottom of the feet was soft, although the Veteran reported a numb feeling. X-rays revealed hallux valgus with early minimal arthritis, and deformity of the third right metatarsal due to an old healed fracture as already reported. Subsequently dated records do not reflect additional treatment for warts on the soles of the feet or for residuals associated with their inservice removal. At the time of VA examination in September 2008, the Veteran specifically noted that he had no complaints associated with this condition. This disability has been rated by analogy to DC 5284, other foot injuries. Under that DC, a 10 percent rating is provided for moderate foot injury, 20 percent for moderately severe and 30 percent for severe. While the Veteran has complained of lack of feeing on the bottom of the feet and swelling of the lefts, this has not been attributed to the residuals of wart excision. The Board also notes that diabetes mellitus has been diagnosed and impairment of sensation has been attributed to this disorder. At the most recent examination in 2008, the Veteran advised that he had no complaints as to this disorder. Under these circumstances, the Board must conclude that a basis for a compensable rating is not presented. With no functional impairment shown, the disability does not rise to the level of moderate foot injury. The preponderance of the evidence is against the claim for a compensable evaluation. A basis for referral for extra-schedular consideration is not presented, as the disability is asymptomatic. Entitlement to an Initial (Compensable) Rating for Residuals of Contusion of the Left Leg and Entitlement to an Initial (Compensable) Rating for Residuals of a Laceration of the Left First Digit (Minor) Service connection for residuals of a left leg contusion and for residuals of a laceration of the left first digit (minor) was established in the May 1993 rating action. Noncompensable ratings were assigned for both conditions, effective January 1, 1992. The grants were based on inservice records which showed treatment for a left shin injury and for a laceration to the left first finger. When examined by VA in 1998, although the Veteran reported that the digit was sensitive to the cold, he denied any significant residuals associated with either condition. At the time of VA examination in June 1992, there were no significant complaints associated with these disorders. Review of the claims file reflects that these residuals have always been rated pursuant to DC 7805 which pertains to other scars (including linear scars) and other effects of scars evaluated under DCs 7800, 7801, 7802, and 7804. As noted earlier, the schedular criteria by which skin disorders are rated were revised twice since the Veteran filed his original claim for service connection and subsequently appealed the ratings assigned upon grant of service connection. All pertinent criteria regarding scars was provided earlier in this decision under the discussion of the Veteran's service-connected hernia scar. They will not be repeated here. Applying the criteria to the facts regarding the left leg contusion and left first digit, the Board finds no basis to assign compensable ratings under either the pre-August 2002 or August 2002 criteria because the scars are not deep, unstable, or painful on examination, and do not cause limitation of motion. While there was a report of decreased sensation in the digit in 1992, there was no finding of any loss of function of the left hand due to this decrease in sensory function or any other symptomatology. As well, 10 percent ratings are not warranted because the scars are not on the head, face, or neck, do not cover an area of 144 square inches, and are not unstable or painful. Simply put, because these scars are well-healed and without tenderness or adherence to underlying tissue, they do not meet the criteria for a compensable ratings under the new or old standards. For these reasons and bases, the preponderance of the evidence is against the claims for initial compensable ratings for residuals of left leg contusion or for residuals of a laceration to the first digit of the left (minor) hand. Accordingly, the benefit-of-the-doubt rule is inapplicable, and the claims must be denied. See 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. § 4.3 (2012); Gilbert, supra. A basis for referral for extra-schedular consideration is not presented, as the scars are essentially asymptomatic. ORDER Entitlement to service connection for a respiratory disorder, to include as due to an undiagnosed illness, is denied. Entitlement to service connection for abnormal weight gain is denied. Entitlement to service connection for residuals of the flu is denied. Entitlement to service connection for otitis externa and otitis media is denied. Entitlement to service connection for hemorrhoids is denied. Entitlement to service connection for a GI disorder is denied. Entitlement to service connection for residuals of a head injury is denied. Entitlement to an initial rating in excess of 10 percent for HTN is denied. Entitlement to an initial rating for AHD in excess of 30 percent prior to September 15, 2006 is denied. Entitlement to an initial rating for AHD of 60 percent, but no higher, is warranted from September 15, 2006, subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to an initial rating for mild prostatism in excess of 10 percent prior to June 24, 2008, and 20 percent therefrom, is denied. Entitlement to an initial rating for residuals of a left (minor) shoulder injury with traumatic arthritis in excess of 10 percent prior to August 28, 2009, and in excess of 20 percent therefrom, is denied. Entitlement to an initial compensable rating for postoperative Dupuytren's contracture of the left (non-dominant) hand, prior to September 22, 2003, is denied. Entitlement to an initial rating for Dupuytren's contracture of the left (non-dominant) hand of 10 percent, but no higher, is warranted as of September 23, 2003, subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to an initial compensable rating for Dupuytren's contracture of the right (dominant) hand, prior to August 28, 2003, is denied. Entitlement to an initial rating for Dupuytren's contracture of the right (dominant) hand of 10 percent, but no higher, is warranted as of September 23, 2003, subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to a rating in excess of 10 percent for residuals of fracture of the left olecranon process, left (minor) ulna with traumatic arthritis, based on limitation of flexion, is denied. Entitlement to a separate rating of 20 percent for residuals of fracture of the left olecranon process, left (minor) ulna with traumatic arthritis, based on limitation of pronation, is warranted, subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to an initial rating in excess of 10 percent for postoperative residuals of a left inguinal hernia is denied. Entitlement to a (compensable) rating for residuals of deformity, fracture of the head of the left (minor) radius, is denied. Entitlement to an initial (compensable) rating for residuals of fracture of the right third metatarsal is denied. Entitlement to an initial (compensable) rating for residuals of fracture of the right fifth toe is denied. Entitlement to an initial (compensable) rating for residuals of excision of warts on the soles of the feet is denied. Entitlement to an initial (compensable) rating for residuals of contusion of the left leg is denied. Entitlement to an initial (compensable) rating for residuals of lacerations of the left first digit (minor) is denied. REMAND An Acquired Psychiatric Disorder, Obstructive Sleep Apnea/Fatigue, and Memory Loss Treatment records, VA and private, note different psychiatric diagnoses, including PTSD, major depression, and dysthymia. At the time of Gulf War evaluation in 2005, a sleep study was conducted and obstructive sleep apnea was diagnosed. It was further noted that this condition might have a psychiatric component as it might be due, at least in part, to his depression. Upon examination in August 2009, it was noted that the Veteran had been diagnosed with a history of PTSD and possible depression, and that his memory loss was secondary to his mental health. The Veteran has attributed his current psychiatric problems to events he experienced serving during Operation Desert Storm. As there is conflicting evidence as to whether the Veteran suffers from PTSD or some other acquired psychiatric disorder, the Board finds that a remand is warranted to afford the Veteran a VA examination. Importantly, the Board notes that a veteran generally is not competent to diagnose his mental condition; he is only competent to identify and explain the symptoms that he observes and experiences. Consequently, a claim that identifies a single diagnosis (in this case PTSD) cannot be a claim limited only to that diagnosis, but must rather be considered a claim for any mental disability that may reasonably be encompassed by several factors including the veteran's description of the claim; the symptoms the veteran describes; and the information the veteran submits or VA obtains in support of the claim. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Additionally, the Board notes that VA has recently amended its regulation governing service connection for PTSD by liberalizing the evidentiary standard for establishing the required in-service stressor where the certain requirements are satisfied. Under the revision of the regulation, if a stressor claimed by a veteran is related to the veteran's 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, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed inservice stressor. 75 Fed. Reg. 39852 (July 13, 2010) (codified at 38 C.F.R. § 3.304(f) (2012)). The revised regulation became effective July 13, 2010, and applies in cases like the Veteran's which were appealed to the Board prior to July 13, 2010, but not decided by the Board as of that date. 75 Fed. Reg. 41092 (July 15, 2010) (codified at 38 C.F.R. § 3.304(f) (2012)). On remand, the VA examiner should consider whether the Veteran meets the criteria for entitlement to service connection for PTSD based on the new regulation. As to the claims for service connection for obstructive sleep apnea/fatigue and memory loss, the outcome of the claim for entitlement to service connection for an acquired psychiatric disorder might have an impact upon whether service connection is warranted for these conditions. Thus, the Board concludes that these issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered). Skin Disorders Review of the record reflects that during the Veteran's active duty periods, he had two cysts removed (one in 1951 and another in 1988) and was treated for various skin complaints, to include acne necrotica and acneform folliculitis (in 1988). Shortly before service separation (in November 1991), he was seen for facial skin problems. A history of sun exposure (especially during Desert Storm) was noted. Examination showed small hyperpigmented areas above the left eyebrow and a small erythematous scaly papule of the left infraorbital area. There was a flat and slightly hyperpigmented macule on top of the nose and at the right temple. The veteran's arms showed slightly hyperpigmented flat-topped papulae on the left exterior forearm. No specific diagnoses were indicated. Post service private and VA records show that the Veteran was diagnosed with skin cancer in the mid 1990s. Hair loss was noted upon VA examination in August 1997 compatible with male pattern baldness. The Veteran also reported that he had had white pustules that occurred to the extremities and scalp. These pustules recurred and bled. Actinic keratoses were noted to the face and trunk. VA records in 2008 reflect continued treatment for skin problems. Upon additional VA examination in 2009, it was noted that the Veteran had a history of a skin rash which "sounds" like actinic keratosis "that have been frozen off of his face." A history of skin cancer was also noted. The examiner did not address etiology. As the evidence shows inservice and post service treatment for various skin problems, a VA examination is necessary to secure a medical nexus opinion. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). As to the matter of whether the Veteran is entitled to a separate rating or ratings for scars resulting from the postoperative Dupuytren's contractures of both hands, The Board finds that an updated examination is required in order to determine the extent and severity of any scarring. Eye Disorders, to include Loss of Vision and Service-Connected Left Eye Pterygium (Noncompensable) Initially, it is noted that service connection is in effect for left eye pterygium, rated as noncompensably disabling, effective April 6, 1992. Review of the record reflects that service connection for this eye disorder was established upon rating decision in May 2007. The grant was based, at least in part, upon a STR which showed that the Veteran was treated in August 1991 for a left eye cataract with decreased visual acuity and diagnosed with left eye pterygium. At time of separation, visual acuity was corrected to 20/20 bilaterally for distant vision. Near vision was corrected to 20/20 in the right eye and 20/40 in the left eye. Post service records reflect various vision problems. When examined by VA in December 2008, the Veteran reported decreased vision in the right eye following inservice trauma when thrown from a vehicle, cataract surgery, and vitrectomy surgery. His medical history included diabetes mellitus, HTN, ocular pain, and visual symptoms. His best corrected vision in the right eye was 20/200 and best corrected vision in the left eye was 20/20 near and 20/40 distance. There was visual field loss in the right eye. The diagnoses included bilateral refractive error/presbyopia, history of suspected anterior ischemic optic neuropathy, and optic atrophy, cystoids macular edema, afferent pupillary defect in the right eye, bilateral cataracts, and diabetes mellitus. The examiner noted that he was unable to determine if the right decrease in vision and visual field was secondary to the history of inservice trauma (which as already noted is not corroborated in the record) or from an episode of ischemic optic neuropathy. He further noted that if the decrease in vision was from ischemic optic neuropathy, then the Veteran's hypertensive vascular disease contributed to this decrease in vision. It is noted that service connection is in effect for heart disease and for HTN and that the remand herein includes additional VA examination regarding the etiology of diabetes. A Cervical Spine Disorder The Veteran is service connected for disorders of the left shoulder, elbow, and forearm. In the post service years, he has reported neck pains on many occasions when being seen for left shoulder problems, and he has been diagnosed with DDD in the cervical spine on more than one occasion (e.g., in 2004 and 2009). It is conceivable that this condition is associated with the service-connected left shoulder disorder, but this possibility has not been addressed by an examiner. Additional exam is necessary. It is concluded by the Board that the record as it stands now is currently inadequate for the purpose or rendering a fully informed decision as to the claim of entitlement to service connection for neck/cervical spine strain. Where the record before the Board is inadequate to render a fully informed decision, a remand to the RO is required in order for VA to fulfill its statutory duty to assist the Veteran to develop the facts pertinent to the claim. See Ascherl v. Brown, 4 Vet. App. 371, 377 (1993). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Please do not remove the colored tabs from any volumes of the claims file. 2. The AMC/RO should contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for his psychiatric and associated conditions, sleep apnea/fatigue, skin disorders, vision problems, and cervical spine disorder on appeal. Any records that are not currently included in the claims file should be obtained and added to the file. With any necessary authorization from the Veteran, the AMC should attempt to obtain copies of pertinent treatment records identified by the Veteran that are not currently of record. All efforts to obtain these records must be documented in the claims file. If any records cannot be obtained, it should be so stated, and Veteran is to be informed of such. 3. Following completion of the above, the RO/AMC should schedule the Veteran for a VA mental disorders examination with a VA psychologist or psychiatrist. The examiner should note any acquired psychiatric disability the Veteran suffers from, including PTSD and a disorder manifested by memory loss, as well as any functional impairment caused by the disability, including a full description of the effects of his disability upon his ordinary activities, if any. The VA examiner is asked to render an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any acquired psychiatric disability found had its onset in service or was caused or aggravated by the Veteran's active service. If the Veteran suffers from PTSD, the examiner is asked to render an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that: 1) the Veteran experienced, witnessed, or was confronted by an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, and the Veteran's response to that event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror or that the claimed stressor is related to the Veteran's fear of hostile military or terrorist activity; 2) that the claimed stressor is adequate to support a diagnosis of PTSD; and 3) that the Veteran's symptoms are related to the claimed stressor. For any psychiatric disorder found to be of service origin, the examiner is to opine whether any obstructive sleep apnea/fatigue and/or memory loss is at least as likely as not (a 50 percent or greater probability) due to service, or otherwise related to service, or whether such is proximately due to, aggravated by, or a manifestation of any acquired psychiatric disability. The Veteran's claim folder should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file. All findings should be described in detail and all necessary diagnostic testing performed. 4. The RO/AMC should schedule the Veteran for an appropriate examination in order to determine the presence and, if present, the etiology of any sleep disorder. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. All indicated tests and studies should be undertaken. For any sleep disorder found, the examiner should determine whether it is at least as likely as not (a 50 percent or greater probability) that it is of service onset or otherwise related thereto or whether it is at least as likely as not (a 50 percent or greater probability) a manifestation of or related to an acquired psychiatric disorder, to include whether it is contributing to a psychiatric disorder. The examiner's opinions should be supported by reference to the clinical evidence and by a rationale that is clearly stated. 5. The RO/AMC should schedule the Veteran for a VA skin examination, to determine the nature and etiology of any skin disorder(s) found and to determine the extent and severity of scarring related to the postoperative Dupuytren's contractures of the hands. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. All indicated tests and studies should be undertaken. The examination report should include a complete description of scarring resulting from the postoperative Dupuytren's contractures of the hands. Findings should be reported which comport with the rating criteria for scars. Upon review of the Veteran's medical history and examination, the examiner should determine what skin disorder(s) are present, and whether such are symptom of another disorder (either diagnosed or undiagnosed) or whether such are a diagnosed disease. For all skin disorders, to include basal cell skin cancers, actinic keratosis, and hair loss, the examiner should provide opinions, with supporting rationale, as to whether it is at least as likely as not (a 50 percent or greater probability) that such disability is due to the Veteran's military service. If there is no diagnosed skin disability as such, but rather the skin condition is associated with another disability, to include an undiagnosed disability due to Persian Gulf service, this should be made clear. Finally, if there is no current indication of any skin condition or disability, this should also be made clear. 6. The Veteran should also be provided with an appropriate eye examination. The examiner should review the Veteran's VA claims folder and should state in the text of the examination report that the VA claims folder has been reviewed. The examiner should: (a) clearly recite the Veteran's complaints of eye problems he experiences and has experienced since leaving active service, and clearly state the current eye disorders manifested by the Veteran; (b) clearly state, with the exception of left eye ptygerium and bilateral presbyopia and astigmatism, an opinion whether any such disorder, including anterior ischemic optic neuropathy, optic atrophy, cystoids macular edema, afferent pupillary defect in the right eye, bilateral cataracts, and any other disorder found upon examination, is at least as likely as not (a probability of 50 percent or greater probability) related to the Veteran's active service; (c) clearly state an opinion whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed eye disorder, including anterior ischemic optic neuropathy, optic atrophy, cystoids macular edema, afferent pupillary defect in the right eye, bilateral cataracts, and any other disorder found upon examination, are due to or aggravated (i.e., worsened) beyond the natural progress by the service-connected heart disease, to include HTN, and/or to be determined diabetes. (d) if ischemic optic neuropathy is not found, the examiner should reconcile that finding with the reports of the December 2008 VA examiner. (e) provide a full description of the effects of left eye pterygium (and any other eye disorder found to be of service origin) upon the Veteran's ordinary activities; address the degree of impairment of visual acuity or field loss, pain, rest-requirements, and episodic incapacity due to service-connected left eye pterygium versus the degree due to other disabilities; and address the degree of any paralysis of accommodate due to service-connected left eye pterygium versus the degree due to other disabilities. The examiner's opinions should be supported by reference to the clinical evidence and by a rationale that is clearly stated. 7. The RO should also arrange for an appropriate examination of the Veteran to determine the nature and likely etiology of any cervical spine disability found (to include whether or not any cervical spine disability was caused or aggravated by his service-connected left shoulder disability or some other service-connected disability). The Veteran's claims file must be reviewed by the examiner in conjunction with the examination and the examination report should reflect that such a review was conducted. Based on examination of the Veteran and review of his claims file, the examiner should provide an opinion that responds to the following: (a) Please identify (by medical diagnosis) each current disability of the Veteran's cervical spine. (b) As to any cervical spine disability diagnosed, please indicate what is the most likely etiology for such disability? Specifically, is it at least as likely as not (a 50% or greater probability) that it was incurred on active duty service? The opinion must include comment as to whether the disability picture presented is consistent with the Veteran's accounts that he has had such disability since his discharge from service? (c) Moreover, as to any cervical spine disorder diagnosed, please indicate whether it is at least as likely as not (a 50% or greater probability) that such disorder was caused or aggravated by any of the Veteran's service-connected disabilities, including his left shoulder, left elbow and/or left forearm disabilities? The examiner must explain the rationale for all opinions offered. 8. The Veteran should be also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655 (2012). 9. When the development requested has been completed, and the RO has ensured compliance with the requested actions, this case should again be reviewed by the RO on the basis of the additional evidence. If any benefit sought is not granted, the Veteran and his representative should be furnished a SSOC and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs