Citation Nr: 1326535 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 05-32 749 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to a disability rating in excess of 10 percent for Grave's disease with iatrogenic hypoparathyroidism, hypothyroidism, and hypokalemia. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Sherrard, Counsel INTRODUCTION The Veteran, who is the Appellant in this case, had active service from March 1982 to June 1995. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a February 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii. Jurisdiction over the Veteran's claims file was subsequently transferred to the Reno, Nevada RO. The Board remanded this claim for further development in March 2013. As discussed below, the development requested has been completed, and the claim is now appropriate for appellate review. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. FINDING OF FACT Throughout the rating period on appeal, the Veteran's Grave's disease has manifested hypothyroidism, with symptoms of muscular weakness, mental disturbance, weight gain, and fatigability. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for an increased evaluation of 60 percent for Grave's disease with iatrogenic hypoparathyroidism, hypothyroidism, and hypokalemia have been met for the entire rating period on appeal. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.119, Diagnostic Code 7903 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. 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 required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). As is the case here, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. at 469; 38 C.F.R. § 3.159(a)(2). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In this case, the Veteran is in receipt of a 10 percent disability rating for Grave's disease for the entire rating period on appeal. He filed a claim for an increased rating in July 1998. He avers that his Grave's disease symptoms, which include weakness and joint and muscle aching, warrant a disability rating higher than 10 percent. The Veteran's Grave's disease has been evaluated under Diagnostic Code 7905, which addresses hypoparathyroidism. Under this Diagnostic Code, a 10 percent rating is warranted when continuous medication is required for control. A 60 percent rating is warranted when there is marked neuromuscular excitability, or; paresthesias (of arms, legs, or circumoral area) plus either cataract or evidence of increased intracranial pressure. A 100 percent rating is warranted when there is marked neuromuscular excitability (such as convulsions, muscular spasms (tetany), or laryngeal stridor) plus either cataract or evidence of increased intracranial pressure (such as papilledema). 38 C.F.R. § 4.119, Diagnostic Code 7905 (2012). Another potentially applicable diagnostic code is Diagnostic Code 7903, for hypothyroidism. Under this Diagnostic Code, a 10 percent rating is assigned when there is hypothyroidism with fatigability, or; when continuous medication is required for control. Hypothyroidism with fatigability, constipation, and mental sluggishness is rated as 30 percent disabling. Hypothyroidism with muscular weakness, mental disturbance, and weight gain is rated 60 percent disabling. Hypothyroidism with cold intolerance; muscular weakness; cardiovascular involvement; mental disturbance, to include dementia, slowing of thought, and depression; bradycardia (less than 60 beats per minute); and sleepiness is rated as 100 percent disabling. 38 C.F.R. § 4.119, Diagnostic Code 7903 (2012). Turning to the evidence of record, VA treatment notes from July 1997 indicate that the Veteran had complaints of feeling weak and tired, joint pain, and tingling in his arms and hands. A bilateral median motor nerve conduction study was normal, however. A November 1997 treatment note indicates that the Veteran's hypothyroidism was fully controlled with Levothyroxine replacement. The VA clinician increased the dose of Levothyroxine. In January 1998, the Veteran had an increased TSH level despite the increased dose of medication. He continued to report feeling tired and fatigued. Examination of the heart was normal. The VA clinician also noted a history of hyperparathyroidism. After increasing the medication dose again, the TSH level was normal in February 1998. In December 1997, the Veteran reported memory loss, lack of sleep, and joint and muscle pain. The VA clinician assessed rule out amnestic dementia, and referred the Veteran for neuropsychiatric testing and a sleep class. In April 1998, the Veteran reported failing a quiz and stated that, since the beginning of the weekend, he had been unable to retain information. He said he could read a book, close it, and be unable to answer any questions about it. He also reported decreased ability to concentrate in May 1998. The Veteran underwent neuropsychiatric testing in April and May 1998, which showed that his general memory was in the average range for his age group, although the general memory measure was a composite of divergent scores. Specifically, there was a deficit in using verbal methods to encode and retrieve information, and the Veteran's Attention Index was lower than other areas of memory functioning. The doctor listed a number of factors that could contribute to lower scores in Verbal IQ and Verbal Memory, including deficits with left hemispheric functioning, vascular problems in that region, head trauma, ingestion of or exposure to unknown substances with possible toxic effects, and/or high degree of anxiety. The doctor diagnosed anxiety disorder, cognitive disorder, and PTSD, stating that the unknown effects of the factors contributing to Gulf War Syndrome could not be ruled out as affecting both the Veteran's cognitive and emotional presentation. In September and December 1998, the Veteran reported intermittent joint pain and arthralgias, as well as fleeting episodes of numbness over different parts of his body. Examination of the heart was normal. The VA clinician assessed polyarticular arthralgias and myalgias, and prescribed continued anti-inflammatory medication. The clinician also diagnosed paresthesias from the head to the groin, etiology uncertain. The Veteran was afforded a VA examination in May 1999. He reported that he was easily tired when going up steps and walking, and that he sometimes forgot things. On physical examination, there were no heart palpitations or neurologic symptoms. The Veteran reported heartburn for which he took medication. He was also taking thyroid medication. He denied any cold intolerance, but reported constipation. He stated that his weight fluctuated. There was no muscle weakness on examination, and no tremor or myxedema. The VA examiner assessed post-operative thyroidectomy for Grave's disease with iatrogenic hypoparathyroidism, clinically euthyroid (state of having normal thyroid gland function). VA treatment notes from June 1999 indicate the Veteran reported calf and thigh pain and numbness, as well as calf weakness, which occurred every four to five months. The VA clinician assessed possible neuropathy of unknown etiology or myopathy. In August 1999, it was noted that the Veteran had gained about 20 pounds in the past several months, and a VA clinician assessed hypothyroidism with weight gain. VA treatment notes from 1997 to 1999 consistently show normal examination of the heart and no cardiovascular problems, with the exception of a diagnosis of possible hypertension in March 1999. Subsequent VA treatment records indicate an ongoing diagnosis of hypertension. In November 1999 and January 2000, the Veteran reported numbness of his entire leg and buttock area, as well as muscle fatigue. He further stated that his hands felt tight, and he had achiness in the left thigh. A January 2000 nerve conduction study and EMG of all the extremities, including the paraspinals, was normal. In March 2000, the Veteran presented to the emergency department because he was unable to walk. He reported an exacerbation of lower extremity muscle spasms, stating that he had experienced these spasms for years. Testing revealed that he was hypokalemic and he was given potassium replacement, which resolved his symptoms. The following day, a VA clinician assessed questionable hypokalemia and periodic paralysis, and referred the Veteran to endocrinology to determine whether he had periodic paralysis secondary to hypokalemia, although he had a total thyroidectomy. In June 2000, the Veteran again presented to the emergency department complaining of difficulty walking for six days. He stated he was unable to life both legs. His spouse reported that the difficulty walking "comes and goes" over the past several years. A June 2000 VA treatment note indicates complaints of chronic extremity pain and episodic paralysis associated with potassium replacement. Recent potassium levels were noted to be normal. A separate June 2000 VA treatment note indicates that the Veteran denied constipation. In July 2000, the Veteran reported an injury at work when he experienced low back pain and his legs gave out while he was holding on to a table. Since then, he stated he had pain in his back and thighs and weakness to both legs. He went to the neurology clinic the following day, where it was noted that he had a history of attacks of weakness, almost to the point of paralysis, associated with severe low back pain and pain radiating down the thigh. He also had occasional tingling in his hands and feet, but no numbness. Currently, he reported an increase in the frequency of these "drop attacks" over the past year, and especially over the past month. The Veteran stated that the first attack occurred in 1991, when he dropped to the ground secondary to paralysis and weakness; at the time, his potassium levels were found to be depleted. Since then, he stated he had similar attacks over the years. His brother was having similar symptoms and was diagnosed with thyroiditis in 1994. The Veteran was then tested and also found to have thyroiditis. The VA neurologist assessed "drop attacks" involving weakness of the lower extremities greater than the upper extremities with severe low back and leg pain. The doctor noted that the Veteran had been diagnosed with hypokalemia on two occasions in the past, and stated that hypokalemic periodic paralysis must be considered, but did not seem to explain all of his attacks, as he had normal potassium levels with some attacks. The doctor further stated that the attacks could be secondary to iatrogenic hyperthyroidism, but there was no evidence of thyrotoxicosis on examination. Further, the pattern of pain suggested involvement of the spinal cord with radiculopathy, but the Veteran denied bladder or bowel involvement, had adequate strength on examination, and the most recent MRI study showed no spinal cord involvement. Moreover, a disorder of proximal muscle weakness (e.g., steroid-induced, metabolic, Guillain-Barre Syndrome) was considered, but there was no evidence for these, especially since weakness was not ascending and deep tendon reflexes were intact. As there was no increase in symptoms with exertion or relief with rest, myasthenia was not likely. Thus, the neurologist concluded that the etiology of the paralysis attacks was unclear at the time, and suggested waiting for the results of an endocrine evaluation. The following day, in July 2000, the Veteran saw an endocrinologist, who found very low TSH levels and normal FT4 levels. Thus, the endocrinologist concluded that the symptoms were suggestive of a hyperthyroid state, and recommended decreasing the Veteran's thyroid medications in order to decrease the FT4 levels and increase TSH levels. A week later, the Veteran again reported to the emergency department with complaints of an inability to stand up. Although he had good sensation in his legs, his muscles could not hold him up. The VA clinician assessed hypokalemia, probable periodic paralysis, and hypothyroidism. He was given potassium supplementation. In August 2000, it was noted that, since starting potassium supplementation, he had not had any attacks of paralysis associated with hypokalemia. In September 2000, the Veteran again saw the VA neurologist for follow-up, who assessed hypokalemic periodic paralysis associated with a hyperthyroid iatrogenic component. The neurologist was unable to determine why the Veteran had chronically low potassium levels, but stated he should have them monitored, as well as his TSH and FT4 levels. A November 2000 VA treatment note indicates the Veteran had no recent paralysis attacks and continued to take potassium supplements. In January 2001, he was treated for rectal bleeding, but denied constipation. A February 2001 letter from a VA staff physician indicates that the Veteran had been diagnosed with hypokalemia with periodic paralysis, and that this condition was sometimes associated with hyperthyroidism. In July 2001, it was noted that, although he had preliminary muscle weakness, he had experienced no attacks of paralysis since beginning potassium supplements the year prior. In December 2001, the Veteran experienced an episode of weakness secondary to hypokalemia. He had difficulty standing or walking. He stated these episodes occurred once or twice a month when his potassium was low, but that the episodes occurred much more frequently before he started taking potassium supplements. The VA clinician assessed hypokalemia and increased the Veteran's potassium dosage. In March 2002, the Veteran reported continued intermittent body aches, pointing to arthralgias and myalgias. A VA psychiatric treatment note from October 2002 indicates the Veteran was diagnosed with depression and insomnia, reporting tiredness upon awakening. He also stated that he was not able to keep a job due to occasional, temporary paralysis associated with hypokalemia that made him unable to go to work for days at a time. He stated that a neurological work up had been negative, however. He also reported that he had recently been diagnosed with the same heart condition from which several of his siblings had died. In November 2002, the Veteran was hospitalized for increasing agitation, depression, and suicidal ideation. Cardiovascular and gastrointestinal examinations were normal, and the Veteran denied having any heart problems. His discharge diagnosis was major depression. In December 2002, the Veteran stated that he lost his memory at times and did not know where he was. At times, when he was driving, he could forget where he was and needed to stop and look around. In March 2003, the Veteran reported continued intermittent weakness and reported that he had gained a lot of weight. He also reported feeling tired. The VA clinician assessed depression and weight gain that was possibly due to hypothyroidism. An April 2003 psychiatric treatment note continued the diagnosis of depression. A July 2003 VA treatment note indicates that an eye examination did not reveal any cataracts. Treatment notes from this time period also indicate a history of periodic paralysis and hypothyroidism, but do not reflect any ongoing episodes. The Veteran continued to take thyroid supplements to regulate his TSH level. In August and September 2003, the Veteran reported recent weakness and pain from the lower back to the legs. It was noted that previous X-ray and MRI studies had shown degenerative disc disease and degenerative joint disease of the lumbar spine, and very mild spondylolisthesis. A follow-up MRI study showed little change from previous studies. Testing further revealed states of hyperkalemia and hypokalemia, and his potassium supplement was adjusted several times. Eventually, the VA clinician assessed hypothyroidism, hyperkalemia resolved, noting that his potassium supplements were maintaining adequate potassium levels. A separate September 2003 VA treatment note indicates the Veteran chronically complained of decreased cognitive functioning, stating that he had difficulty remembering and comprehending things. He stated that this problem began in 1993. The VA PTSD counselor assessed major depressive disorder, rule out PTSD, and rule out organic brain syndrome. The diagnosis of depression was continued in treatment notes from 2004 and 2005, along with PTSD. In February 2004, the Veteran reported daily, generalized, whole body weakness. He also reported daily pain in his thighs. Neurological examination was normal. The VA clinician assessed generalized weakness of unclear etiology, noting that it was not likely rheumatologic, myasthenia gravis, or statin induced. Further, the clinician noted that it was unclear if it was hypokalemic periodic paralysis, as the Veteran was often hyperkalemic, although he reported low potassium levels in the past. An April 2005 VA treatment note indicates the Veteran reported that his condition had not changed, in that he still had episodic generalized weakness. In fact, he reported weakness in his legs that day. On examination, strength was normal in the lower extremities. The VA clinician assessed a history of hypokalemic periodic paralysis, unchanged from previous examinations. In August 2005, incipient senile cataracts were found in both eyes on examination. The Veteran was afforded another VA examination in September 2005. The VA examiner noted that the Veteran continued to take Synthroid and that continuous medication was required for hypothyroidism. The examiner also noted a diagnosis of hypoparathyroidism for which continuous potassium supplements were necessary. Symptoms associated with the hypoparathyroidism included weakness and pain in the muscles from hypokalemia. Currently, the Veteran reported thinning hair, hives, increased appetite, and loss of taste. A blood test was conducted, and the VA examiner concluded that the disease was active and would impact the Veteran's occupation due to decreased concentration, lack of stamina, and weakness or fatigue. With regard to daily activities, the Grave's disease would prevent sports, have severe effects on recreation and exercise, moderate effects on chores, shopping, and traveling, and no effects on feeding, bathing, dressing, toileting, or grooming. The VA examiner noted that the main problem was fatigue. In February 2008, the Veteran was hospitalized for chest pain and shortness of breath. A cardiovascular work-up, which included an electrocardiogram, was negative. He was discharged with a diagnosis of atypical chest pain. At a February 2009 eye examination, trace cataracts were noted. A July 2009 VA treatment note indicates that the Veteran was diagnosed with dysthymia related to his medical problems. The Veteran saw an endocrinologist in July 2009, who noted that the Veteran continued to take thyroid medication. The Veteran denied cold intolerance, weight gain, and constipation. However, he reported fatigue. Cardiovascular examination was normal. In September 2009, the Veteran had another endocrinology consultation for electrolyte abnormalities, postablative hypothyroidism, and hyperparathyroidism. It was noted that his most recent episode of hypokalemia was in June 2009, when he was admitted to the hospital for generalized weakness. He continued to take thyroid medication. He denied having cold intolerance or weight gain, but reported fatigue. Cardiovascular examination was normal. He denied constipation. It was noted that his chronic/recurrent hypokalemia was resolved, and that he continued to take potassium supplements. In addition, the VA endocrinologist noted that the hyperparathyroidism (that was most likely due to vitamin D deficiency) was resolved. An October 2009 EMG study of the lower extremities was negative. Thus, it was noted that there was no electrodiagnostic evidence of a lumbosacral radiculopathy on either side, although it was clarified that electrodiagnostic studies could not rule out radiculopathy, especially if the symptoms were mainly sensory. A November 2009 VA treatment note indicates complaints of low back pain with radiation to the legs. A March 2010 depression screen was positive, cardiovascular examination was normal, and the Veteran denied constipation. In June 2010, the Veteran reported ongoing difficulty sleeping due to anxiety. The Veteran was afforded a VA examination in July 2010. He reported fatigability, weakness, depression, paresthesias, dizziness, excessive thirst, excess sweating, pain, in the muscles and joints, and vomiting. He stated that his muscle and joint pain was occasional. He also reported dementia and slowing of thought, as well as fluctuating weight. He had lost six pounds in the last year, but gained four pounds back. After reviewing the Veteran's claims file and medical records, the VA examiner assessed post surgical Grave's disease with resultant intermittent hypoparathyroidism and unclear hypokalemia resulting in periodic paralysis, noting that the Veteran was currently in a clinically euthyroid state. It was noted that the Veteran had retired in 1997 due to age or duration of work. The VA examiner opined that the Grave's disease would prevent sports, have severe effects on exercise and recreation, moderate effects on chores, shopping, and travelling, mild effects on bathing, dressing, and grooming, and no effects on feeding or toileting. Further, the VA examiner concluded that most of the Veteran's claimed symptoms - including fatigability, mental sluggishness, dementia, and/or sleepiness - were more likely than not related to his chronic multi-health conditions, the most prominent being PTSD. Trace cataracts were again noted in August 2010. In September 2010, the Veteran had another endocrinology appointment, at which he denied cold intolerance and weight gain, but reported fatigue and joint pain. Cardiovascular examination was normal. The endocrinologist assessed post surgical hypothyroidism, biochemically euthyroid. The doctor also noted that his hypokalemia had resolved, but assessed hyperparathyroidism most likely due to vitamin D deficiency. The Veteran was afforded a VA examination in July 2012. He reported that the most recent hospitalization for weakness secondary to hypokalemia was in 2010. The VA examiner noted that continuous medication was required for control of the thyroid condition. The examiner stated that the Veteran did not have any current findings, signs, or symptoms attributable to a hyperthyroid condition or to a hyperparathyroid or hypoparathyroid condition. With regard to his hypothyroidism, the Veteran reported muscle aches, but not fatigability. He further reported diarrhea, but not constipation. Further, his anxiety and PTSD sometimes interfered with his sleep, causing him to feel mentally sluggish the following day. He denied any unexplained weight change, but reported heat and cold intolerance. He denied bradycardia, but stated he experienced tachycardia which he attributed to PTSD. The Veteran stated that he had muscle weakness that did not improved when he was euthyroid. He denied any history of neuromuscular excitability. Examination of the eyes was marked as normal, despite the prior findings of cataracts. The VA examiner concluded that the Veteran's thyroid condition did not affect his ability to work. The July 2012 VA examiner assessed hypothyroidism secondary to a thyroidectomy for Grave's disease, noting that the laboratory studies indicated that he was not euthyroid on his current treatment regimen. His TSH results since 2011 demonstrated wide variations, which could be secondary to poor adherence to treatment program, poor bioavailability of his thyroid replacement medication, or a combination of the above. Examination was negative for neuromuscular excitability, as was his history, although he experienced muscular weakness which he attributed to hypokalemia. Further, the Veteran's history was significant for fatigability, diarrhea, and mental sluggishness. The VA examiner stated it was difficult to determine whether these symptoms were secondary to his thyroid condition or his other medical conditions and/or treatments. However, it was possible that fatigability and mental sluggishness be related to an undertreated thyroid condition. However, the Veteran did not report that his symptoms correlated to insufficient thyroid replacement. Rather, he attributed his fatigability and muscle weakness to hypokalemia, and his mental sluggishness to PTSD. By his history and record, his hypokalemia symptoms preceded his thyroid condition. Therefore, the examiner concluded that his thyroid condition did not cause his hypokalemia, nor did his hypokalemia cause his thyroid condition. The Veteran did not describe chronic problems with cold intolerance, unexplained weight change, or bradycardia, and was unaware of any cardiovascular sequelae secondary to hypothyroidism. The VA examiner further assessed transient hypoparathyroidism, resolved, with no current diagnosis, noting that the July 2012 parathyroid hormone level was normal. Further, the VA examiner noted that hypokalemia associated with muscle weakness was not present currently, as potassium level was normal. VA treatment notes from July 2012 indicate the Veteran continued to take potassium supplements. He also presented with a feeling that he might stumble and fall when walking. The VA clinician determined that his symptoms were consistent with inadequate thyroid medication replacement and increased his dosage. The Veteran was afforded VA ophthalmologic examination in May 2013. The examiner noted that the Veteran had been diagnosed with cataracts in July 2003, and that he had undergone a cataract extraction with implantation of an intraocular lens in the left eye in May 2012, and the same procedure in the right eye in November 2012. The examiner noted that the Veteran developed cataracts after becoming hypothyroid, and that there was no documentation that his cataracts were related to his Grave's disease or his hypothyroidism. Further, the VA examiner was unaware of Grave's disease or hypothyroidism causing or being a risk factor for cataracts. After conducting a thorough eye examination, the VA examiner opined that to say that the Veteran's cataracts were related to his Grave's or iatrogenic hypothyroidism would be speculation just because they were first noted after having a partial thyroidectomy and becoming hypothyroid. A separate VA opinion was obtained in May 2013 on the question of marked neuromuscular excitability, paresthesias, or increased intracranial pressure. After reviewing the claims file, the VA examiner stated that there was no evidence of marked neuromuscular excitability or paresthesias secondary to Grave's disease, as the Veteran's Grave's disease was treated with a thyroidectomy in 1995. The examiner noted that laboratory studies did not show any evidence of hypocalcemia until April 2012, when he was diagnosed with pancreatitis. Pancreatitis, in turn, likely resulted in numerous metabolic abnormalities, including hypocalcemia, which can result in tetany, papilledema, seizures, hypotension, cataracts, dental abnormalities, renal abnormality, dry puffy skin, brittle hair, skeletal abnormalities, and extrapyramidal abnormalities including Parkinsonism and dementia. The examiner further noted that laboratory findings from September 2011 to March 2012 demonstrated normal calcium levels and thus did not support any laboratory evidence suggesting marked neuromuscular excitability or paresthesias resulting from hypocalcemia. The VA examiner also noted normal phosphorus and magnesium levels during the same period. The normal calcium, phosphorus, and magnesium levels did not suggest a diagnosis of hypoparathyroidism, and, thus, there was no evidence of marked neuromuscular excitability or paresthesias secondary to hypoparathyroidism, as there was no laboratory evidence of hypoparathyroidism. Further, review of the Veteran's medical records did not reveal any descriptions of neuromuscular excitability or paresthesias associated with undertreatment or overtreatment of his iatrogenic hypothyroidism. Next, the May 2013 VA examiner acknowledged that the claims file indicated periods of symptomatic hypokalemia prior to 2011, with symptoms of weakness and joint and muscle aching secondary to hypokalemia. However, he concluded that there was no evidence of marked neuromuscular excitability or paresthesias secondary to hypokalemia as laboratory studies had been negative for hypokalemia since 2011; indeed, the Veteran had normal potassium levels from September 2011 to April 2013, and his current medication list did not include any evidence of treatment with supplemental potassium. Based on the lay and medical evidence of record, the Board finds that the evidence is at least in equipoise as to whether a higher, 60 percent, disability rating is warranted for hypothyroidism under Diagnostic Code 7903. As noted above, a 30 percent disability rating is assigned under Diagnostic Code 7903 when there is fatigability, constipation, and mental sluggishness. A 60 percent rating is assigned when there is muscular weakness, mental disturbance, and weight gain. 38 C.F.R. § 4.119. Looking at the criteria for a 30 percent disability rating first, in this case, although the Veteran reported constipation on several occasions, he has overwhelmingly denied constipation throughout VA treatment notes. However, his fatigability and mental sluggishness have not been ruled out as being attributable to his hypothyroidism. Indeed, the July 2012 VA examiner stated it was possible that fatigability and mental sluggishness could be related to an undertreated thyroid condition. VA treatment notes from the same month indicate that the Veteran's condition was, in fact, determined to be undertreated, and his medication was adjusted accordingly. Next, looking at the criteria for a 60 percent disability rating, in this case, VA treatment notes throughout most of the rating period on appeal indicate a diagnosis of hypokalemia with muscle weakness and joint pain, especially prior to 2011, with the Veteran reporting to the July 2012 VA examiner that his most recent hospitalization for a hypokalemic episode was in 2010. VA treatment notes indicate that, even after beginning potassium supplementation in 2000, the Veteran continued to experience hypokalemic episodes associated with muscle weakness until 2010. As noted above, July 2012 VA treatment notes also indicate that the Veteran expressed a fear of falling when walking, although it is uncertain whether this symptom was associated with hypokalemia or attributable to something else, as he was not diagnosed with hypokalemia at the time. With regard to mental disturbance, which includes slowing of thought and depression, the Veteran's mental sluggishness has not been ruled out as a symptom attributable to his hypothyroidism, as noted above. Further, VA treatment notes throughout the rating period on appeal indicate a diagnosis of depression or dysthymia, separate and apart from his PTSD diagnosis. Indeed, some VA treatment notes indicate a diagnosis of dysthymia secondary to medical conditions. Thus, it is unclear whether his depression is attributable to his PTSD or to his thyroid condition. Given the Board's finding and the fact that the Veteran has had TDIU since 2005, further investigation of this issue is simply not warranted. Finally, while more recent VA treatment notes do not suggest weight gain secondary to hypothyroidism (as the Veteran has reported that his weight fluctuates), he has been diagnosed with weight gain secondary to his thyroid condition during the rating period on appeal. Resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence is at least in relative equipoise as to whether a 60 percent disability rating for hypothyroidism is warranted under Diagnostic Code 7903 for the entire rating period on appeal. 38 C.F.R. § 4.119. In this regard, the Board finds it is simply impossible, based on detailed review of this extensive record, to distinguish between the Veteran's service connected problems and his non-service connected problems (if any). His problems have been consistent thought-out many years and there is simply no indication of exaggeration. The Board finds that the weight of the evidence is against a grant of an even higher, 100 percent, disability rating under Diagnostic Code 7903. As noted above, a 100 percent disability rating is assigned when there is cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance, bradycardia, and sleepiness. Although the Veteran has reported cold intolerance on one or two occasions, VA treatment notes indicate he has consistently denied this symptom throughout the rating period on appeal. Further, although the Veteran has had hypokalemia associated with muscle weakness in the past, this symptom has been fairly well-controlled since 2010 with potassium supplementation. In fact, the 2013 VA examiner indicated that the Veteran's potassium levels were normal even without supplementation. There is no evidence of cardiovascular involvement or bradycardia, and there has been no diagnosis of dementia. Further, although the Veteran has reported sleepiness, he has consistently attributed this symptom to his PTSD and nightmares associated with it. Therefore, the Board finds that the Veteran's disability picture does not more nearly approximate the rating criteria for a 100 percent disability rating under Diagnostic Code 7903. Id. Further, the overwhelming preponderance of the evidence demonstrates that the Veteran's disability picture is adequately reflected by the 60 percent disability rating assigned herein. Indeed, it is important for Veteran to also understand that without some problems associated with his thyroid there would be no basis for the 60 percent disability rating. In this regard, as stated above, it is important to note that some of his symptoms, such as fatigability and mental sluggishness, are only questionably related to his thyroid condition, and others, such as muscular weakness and weight gain, have been absent in more recent years. However, reasonable doubt has been afforded in attributing them to his hypothyroidism. Without affording such reasonable doubt, the Veteran's condition would not even meet the requirements of the next higher, 30 percent, evaluation, let alone the 60 percent disability rating assigned herein. Without consideration of the problems he has cited, the 60 percent evaluation could not be justified. The problems he has cited are the basis for the 60 percent evaluation, as the objective medical evidence would, to some degree, provide evidence against a higher evaluation. The Board has considered whether other applicable diagnostic codes would warrant an even higher evaluation for his service-connected hypothyroidism. As noted above, Diagnostic Code 7905 (under which the Veteran's disability has historically been evaluated) addresses hypoparathyroidism. The next higher, 60 percent, disability rating is assigned when there is marked neuromuscular excitability, or paresthesias plus either cataract or evidence of increased intracranial pressure. A 100 percent disability rating is assigned when there is marked neuromuscular excitability, or laryngeal stridor plus either cataract or evidence of increased intracranial pressure. As discussed above, the 2013 VA examiner stated that hypoparathyroidism was absent, and there was no evidence of neuromuscular excitability or paresthesias. The 2013 VA ophthalmological examiner stated that he could not state that the Veteran's cataracts were due to hypothyroidism without resort to speculation. Further, the record is devoid of evidence of increased intracranial pressure or laryngeal stridor. Thus, the criteria for a higher disability rating under Diagnostic Code 7905 have not been met, and the weight of the evidence is against such a finding. 38 C.F.R. § 4.119. The Board has also considered Diagnostic Code 7904, which addresses hyperparathyroidism, as this diagnosis was mentioned several times in the Veteran's VA treatment notes. A 100 percent disability rating is assigned under this code when there is generalized decalcification of bones, kidney stones, gastrointestinal symptoms, and weakness. Here, there is no evidence of decalcification of bones or kidney stones. Further, with the exception of a few episodes of diarrhea, the evidence does not demonstrate gastrointestinal symptoms. Thus, the criteria for a disability rating in excess of 60 percent have not been met under Diagnostic Code 7904. Id. The Board finds that there are no other potentially applicable diagnostic codes. The evidence has not demonstrated diagnoses of hyperthyroidism, or toxic or non-toxic adenoma of the thyroid gland, so Diagnostic Codes 7900 through 7902 do not apply. In addition to the foregoing, the Board has considered whether referral for an extraschedular evaluation is warranted for the Veteran's thyroid disability. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Veteran's thyroid disability has manifested episodes of hypokalemia with muscle weakness and joint pain, fatigue, mental sluggishness, and weight gain, and has required continuous medication for control. The schedular criteria for rating the thyroid disability (38 C.F.R. § 4.119, Diagnostic Code 7903) specifically provide for ratings based on these symptoms. In this case, comparing the Veteran's disability level and symptomatology of the thyroid to the rating schedule, the degree of disability of the thyroid throughout the entire period under consideration is contemplated by the rating schedule and the assigned rating is, therefore, adequate. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the thyroid disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353 -356 (April 30, 2008). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment and earning capacity, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (2009). In a timely September 2002 letter, the Veteran was informed of the evidence necessary to establish an increased evaluation for Grave's disease. In accordance with the requirements of VCAA, the VA letter informed the Veteran what evidence and information he was responsible for obtaining and the evidence that was considered VA's responsibility to obtain. A November 2005 notice letter advised the Veteran of the specific requirements for establishing an increased rating claim, and a March 2006 letter advised him as to how VA determines disability ratings and effective dates. The March 2006 letter further advised the Veteran that VA used a published schedule for rating disabilities that determined the rating assigned and that evidence considered in determining the disability rating included the nature and symptoms of the condition, the severity and duration of the symptoms, and the impact of the condition and symptoms on employment. The Board finds that any lack of timeliness in notice is nonprejudicial to the Veteran, as he was provided with ample opportunities to submit additional evidence following receipt of proper notice. The Veteran has been afforded an adequate examination on the issue of an increased rating for his service-connected thyroid condition. VA provided the Veteran with examinations in May 1999, September 2005, July 2010, July 2012, and May 2013. The Veteran's history was taken, and complete examinations were conducted, to include laboratory tests. Conclusions reached and diagnoses given were consistent with the examination reports. Further, the May 2013 VA examination complied with the Board's March 2013 remand directives. For these reasons, the Board finds that the Veteran has been afforded an adequate examination on the issue of an increased rating for his service-connected thyroid condition. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence, including affording a VA examination. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, VA examination reports, and the Veteran's statements. Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER An increased 60 percent disability rating for Grave's disease with iatrogenic hypoparathyroidism, hypothyroidism, and hypokalemia is granted for the entire rating period on appeal, subject to the rules governing payment of monetary benefits. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs