Citation Nr: 1330291 Decision Date: 09/20/13 Archive Date: 09/25/13 DOCKET NO. 08-24 642 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disability, claimed as depression and anxiety, to include as secondary to service-connected disabilities. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II. 3. Entitlement to service connection for sleep apnea, to include as secondary to service-connected diabetes mellitus, type II. 4. Entitlement to service connection for a vision impairment, to include as secondary to service-connected diabetes mellitus, type II. 5. Entitlement to an evaluation in excess of 20 percent for service-connected diabetes mellitus, type II. 6. Entitlement to an initial evaluation in excess of 10 percent for right upper extremity peripheral neuropathy. 7. Entitlement to an initial evaluation in excess of 10 percent for left upper extremity peripheral neuropathy. 8. Entitlement to an initial evaluation in excess of 10 percent for right lower extremity peripheral neuropathy. 9. Entitlement to an initial evaluation in excess of 10 percent for left lower extremity peripheral neuropathy. 10. Entitlement to a finding of total disability based on individual unemployability due to service-connected disabilities (TDIU), prior to February 3, 2011. ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from February 1969 to February 1971. These matters come before the Board of Veterans' Appeals (Board) from March 2007 (hypertension, depression), August 2008 (sleep apnea, vision impairment, and peripheral neuropathy), December 2008 (TDIU), and March 2009 (diabetes) rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO) in San Juan, Puerto Rico. These matters were previously before the Board in July 2012 and were remanded for development. They have now returned to the Board for further appellate consideration. The issues of entitlement to service connection for an acquired psychiatric disability (claimed as depression and anxiety), hypertension, sleep apnea, and a vision disability, all to include as secondary to service-connected disabilities, and the claim for TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the rating period on appeal, the evidence of record is against a finding that the Veteran's diabetes mellitus type II requires any regulation of activities. 2. Throughout the rating period on appeal, the Veteran's peripheral neuropathy of the right upper extremity has resulted in a disability analogous to no more than mild incomplete paralysis a peripheral nerve. 3. Throughout the rating period on appeal, the Veteran's peripheral neuropathy of the left upper extremity has resulted in a disability analogous to no more than mild incomplete paralysis a peripheral nerve. 4. Throughout the rating period on appeal, the Veteran's peripheral neuropathy of the right lower extremity has resulted in a disability analogous to no more than mild incomplete paralysis a peripheral nerve. 5. Throughout the rating period on appeal, the Veteran's peripheral neuropathy of the left lower extremity has resulted in a disability analogous to no more than mild incomplete paralysis a peripheral nerve. CONCLUSIONS OF LAW 1. The criteria for entitlement to an evaluation in excess of 20 percent for diabetes mellitus type II, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.119, Diagnostic Code 7913 (2013). 2. The criteria for an initial rating in excess of 10 percent for right upper extremity peripheral neuropathy have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2013). 3. The criteria for an initial rating in excess of 10 percent for left upper extremity peripheral neuropathy have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2013). 4. The criteria for an initial rating in excess of 10 percent for peripheral neuropathy of the neuropathy, right lower extremity, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Codes 8520 (2013). 5. The criteria for an initial rating in excess of 20 percent for peripheral neuropathy, left lower extremity, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Codes 8520 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided in September 2008 and March 2011. The claims were readjudicated, most recently in a February 2013 supplemental statement of the case. Mayfield, 444 F.3d at 1333. VA has a duty to assist the appellant in the development of the claims. The claims file includes service treatment records (STRs), VA and private medical records, Social Security Administration (SSA) records, and the statements of the Veteran in support of the claims. The evidence includes paper documents, electronic documents, and documents which have been translated into English. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations are adequate, as they include physical examinations, and interviews with the Veteran regarding his symptoms and treatment. The reports of the examinations contain findings necessary to evaluate the Veteran's service-connected disabilities under the applicable diagnostic code rating criteria. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c) (4). The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Ratings - in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Rating Diabetes Mellitus Under Diagnostic Code 7913, a 20 percent evaluation is warranted for diabetes mellitus requiring insulin and restricted diet or an oral hypoglycemic agent and restricted diet. A 40 percent evaluation is warranted for diabetes requiring insulin, restricted diet, and regulation of activities. A 60 percent evaluation is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if evaluated separately. Diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated, warrants a 100 percent evaluation. See 38 C.F.R. § 4.119. Complications of diabetes mellitus are to be evaluated separately unless they are part of the criteria used to support a 100 percent rating. Noncompensable complications are considered part of the diabetic process under DC 7913. Note 1 following 38 C.F.R. § 4.119. Rating Peripheral Neuropathy of the Lower Extremities Under Diagnostic Code 8520, a 10 percent rating is assigned for mild incomplete paralysis of the sciatic nerve; a 20 percent rating is assigned for moderate incomplete paralysis of the sciatic nerve; a 40 percent rating is assigned for moderately severe incomplete paralysis; a 60 percent rating is assigned for severe incomplete paralysis, with marked muscular atrophy; and an 80 percent rating is assigned for complete paralysis of the sciatic nerve, where the foot dangles and drops, and there is no active movement possible of muscles below the knee, flexion of knee weakened, or very rarely, lost. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. See 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." Neither the Rating Schedule nor the regulations provide definitions for words such as "mild," "moderate," "moderately severe," and "severe." Rather than applying a mechanical formula, the Board must instead evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Rating Peripheral neuropathy of the upper extremities Under Diagnostic Code 8515, a 10 percent rating is assigned for mild incomplete paralysis of the median nerve for both the major and minor extremity; moderate incomplete paralysis of the median nerve warrants the assignment of a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity; severe incomplete paralysis warrants the assignment of a 40 percent rating for the minor extremity and a 50 percent rating for the major extremity. Complete paralysis of the median nerve warrants the assignment of a 60 percent rating for the minor extremity and a 70 percent rating for the major extremity. Complete paralysis of the median nerve contemplates such symptoms as the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; and pain with trophic disturbances. Analysis The Board has reviewed all of the evidence in the Veteran's claim file, with an emphasis on the medical evidence pertinent to the claims on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Entitlement to an evaluation in excess of 20 percent for service-connected diabetes mellitus, type II The Veteran is service-connected for diabetes mellitus, evaluated as 20 percent disabling, effective from May 31, 2006. In a January 2009 statement, the Veteran requested an increased rating and stated that he "just started using insulin" for his diabetes. Historically, a January 2007 VA examination report reflects that the Veteran had "no history of use of Insulin." It was noted that he was currently taking Rosiglitazone and Metformin orally. It was further noted that he was following a restricted diet of no sweets, low fat, and low sodium. The report reflects that there was "no restriction of activities on account of diabetes." A November 2007 VA examination for eye purposes reflects that the Veteran had diabetes and was on pills and diet. The report is negative for any medical restriction on activities. An October 2008 VA record reflects that the Veteran's diabetes was uncontrolled and that he was to discontinue Glyburide, and was to start insulin. The report is negative for any medical restriction on activities. In order to receive a rating higher than 20 percent, the evidence, at a minimum, would have to reflect that the Veteran required insulin, restricted diet, and regulation of activities. The definition of "regulation of activities" in the criteria for a 100 percent rating, i.e., "the avoidance of strenuous occupational and recreational activities," applies to the "regulation of activities" criterion for a 40 percent rating under DC 7913. Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). A regulation of activities contemplates a regulation or restriction by medical professionals. See Comacho, Id. The record, as noted above and below, does not reflect that the Veteran has a regulation of activities due to his diabetes mellitus. A February 2009 VA examination report reflects that the Veteran was instructed to follow a restricted or special diet. However, it also reflects that he was not restricted in his ability to perform strenuous activities. A February 2012 VA record reflects that the Veteran was to follow a low salt/fat diabetic diet and to do daily exercises. A May 2012 VA record reflects that the Veteran was to keep a low sweet diet and to exercise as tolerated. The report is negative for any medical restriction on activities. The Board acknowledges the Veteran's statement that he is now on insulin; however, this alone does not warrant a higher rating. The change from oral medications to insulin does not change the Veteran's evaluation under DC 7913. A 20 percent evaluation under DC 7913 is warranted for mellitus requiring insulin and restricted diet or an oral hypoglycemic agent and restricted diet. In sum, there is no competent clinical evidence of record that the Veteran has a regulation of activities due to his service-connected diabetes; to the contrary, the clinical records reflect that he should exercise. Any statement by the Veteran that he has been medically restricted in his activities is less than credible when considered with the record as a whole. Because of the successive nature of the rating criteria of DC 7913, the evaluation for each higher disability rating includes the criteria of each lower disability rating; thus, each of the three criteria listed in the 40 percent rating must be met in order to warrant such a rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). Thus, because the Veteran does not have a regulation of activities, an evaluation in excess of 20 percent is not warranted for any portion of the rating period on appeal. The Board has also considered Note 1 to DC 7913. The Veteran has a diagnosis of erectile dysfunction for which he is service-connected, and separately evaluated, and a diagnoses of bilateral lower extremity atheromatous disease for which he is service-connected and separately compensated. Those evaluations are not on appeal. The Veteran is also service-connected for peripheral neuropathy, as is discussed in further detail below. The Board finds that in examining the entire record, a rating in excess of 20 percent rating is not warranted for the Veteran's diabetes mellitus for any period on appeal. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Entitlement to an initial evaluation in excess of 10 percent for right upper extremity peripheral neuropathy; Entitlement to an initial evaluation in excess of 10 percent for left upper extremity peripheral neuropathy; Entitlement to an initial evaluation in excess of 10 percent for right lower extremity peripheral neuropathy; Entitlement to an initial evaluation in excess of 10 percent for left lower extremity peripheral neuropathy The Veteran's peripheral neuropathies are evaluated as 10 percent disabling for each extremity effective from September 2007. An October 2008 VA clinical record reflects that the Veteran had decreased dorsalis pedis and tibialis post pulses bilaterally. A June 2008 VA examination report reflects that the Veteran reported symptoms of numbness, paresthesia, and pain. He reported it felt like "ant crawling" and cramps in the legs. Upon clinical examination, the sensory function report reflected decreased vibration, decreased pain, sensation, and decreased sensory to light touch. The Veteran's reflexes were 2+ for the triceps, biceps, brachioradialis, abdominal , knee, ankle, and plantar. His finger jerks were 2+. There was no muscle atrophy present. There was no abnormal muscle tone or bulk. There were no tremors, tics, or other abnormal movements. There was no function of any joint affected by the nerve disorder. The Veteran's gait and balance were normal. The clinician opined that the Veteran had symptoms and signs compatible with mild sensory peripheral neuropathy in the upper and lower extremities. There was nerve dysfunction, but no paralysis. There was no significant effect on occupation. A February 2009 VA diabetes examination report reflects that the Veteran had peripheral neuropathic symptoms of the plantar area of both feet and the lower extremities. He had pin-prick and vibration sensation decrease in both upper and lower extremities in the distal areas. The Veteran reported swelling of the lower extremities, and feelings of "ant crawling," "pins and needles," and cramps. A February 2009 VA clinical record reflects that the Veteran reported that he had been in very poor control of his diabetes until approximately one year earlier when he changed primary care facilities. He reported that in the past six to eight months, he started to be more in control of his blood sugars "and feels much better." The effect on occupation was "significant" in that he had decreased manual dexterity, problems with lifting and carrying, decreased strength, lower extremity pain. It was noted that he cannot stand up for too much time due to lower extremity discomfort and pain. The report reflects that his symptoms had a moderate affect on chores, mild on shopping, exercise, recreation, traveling, feeding, dressing, and driving, and no affect on bathing, toileting, and grooming. They prevented sports. It was noted that he was currently employed as a self-employed businessman. An October 2009 VA examination report reflects that the Veteran reported that his lower extremities have feelings of "ant crawling," "pins and needles," and cramps. The Veteran's reflexes were 2+ for the triceps, biceps, brachioradialis, abdominal , knee, ankle, and plantar. His finger jerks were 2+. There was no muscle atrophy present. There was no abnormal muscle tone or bulk. There were no tremors, tics, or other abnormal movements. There was no function of any joint affected by the nerve disorder. Upon clinical examination, the sensory function report reflects decreased vibration, decreased pain, sensation and decreased sensory to light touch. The Veteran's reflexes were 2+ for the triceps, biceps, brachioradialis, abdominal , knee, ankle, and plantar. His finger jerks were 2+. There was no muscle atrophy present. There was no abnormal muscle tone or bulk. There were no tremors, tics, or other abnormal movements. There was no function of any joint affected by the nerve disorder. The Veteran's gait and balance were normal. The October 2009 VA clinician opined that the Veteran had secondary diabetic peripheral neuropathy with similar subjective and objective sensory symptoms and signs as previously noted, now with greater pain in the lower extremities, requiring a higher dose of Gabapentin but still no motor deficient and reflexes remained normal. He had neuritis, but no paralysis or neuralgia. The Veteran's disability had a moderate effect on chores, shopping, and exercise. It had a mild effect on recreation and traveling. It had no effect on feeding, bathing, dressing, toileting, and grooming. SSA records reflect that the Veteran reported that his legs feel as if they are on fire. The SSA records also reflect that a report from Dr. O.R. revealed that the Veteran had lower extremity numbness and weakness, and muscle power in the upper and lower extremities of 4/5. He had back pain. He had diminished reflexes, tender hands and wrists, and muscle power in the hands was 4 out of 5. The record reflects that the Veteran reported that neuropathy causes a loss of sensation in his feet, legs, and hands. An MRI record dated in October 2009 reflects that the Veteran had degenerative intervertebral changes with evidence of small underlying chromic disc protrusion. The SSA records reflect a primary diagnosis of degenerative disk disease at the lumbar spine and a secondary diagnosis of major depression. With regard to the lower extremities, a rating in excess of 10 percent would be warranted if the Veteran had moderate or moderately severe incomplete paralysis of the sciatic nerve or complete paralysis the nerve. With regard to the upper extremities, a rating in excess of 10 percent would be warranted if the Veteran had moderate or severe incomplete paralysis, or complete paralysis, of the median nerve. The evidence, as noted above, is against such a finding. The June 2008 examiner noted that the Veteran's peripheral neuropathy was "mild sensory" neuropathy with no paralysis and no effect on occupation. In addition, the Veteran has normal reflexes and normal muscle tone, with no joint affected, no paralysis, and normal gait. (See October 2009 VA examination report.) There was no muscle atrophy which would be indicative of less than normal use. The Board has considered the SSA records, but finds that even those clinical findings do not rise to the level of moderate, based on their muscle power level of 4/5. In addition, the Veteran's peripheral neuropathies were not listed as a primary or secondary diagnosis for his grant of disability benefits. The Board finds that in examining the entire record, a rating in excess of 10 percent rating for each extremity's peripheral neuropathy is not warranted for any period on appeal. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extraschedular Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In evaluating the Veteran's service-connected disabilities, the Board has attributed all potentially service-connected symptoms to one service-connected condition or another. See Mittleider v. West, 11 Vet. App. 181 (1998). The discussion above reflects that the symptoms of the Veteran's diabetes and neuropathy disabilities are contemplated by the applicable rating criteria. The rating criteria reasonably describe the Veteran's diabetes disability level and symptomatology and they allow for a rating based on the treatments necessary to control the Veteran's diabetes. With regard to peripheral neuropathy, the rating criteria allow for symptoms, both subjective and objective, to be considered regardless of whether they are specifically listed, as they are considered under the broad terms of mild, moderate, moderately severe, and severe. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule; hence, referral for an extraschedular rating is unnecessary at this time. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to an evaluation in excess of 20 percent for service-connected diabetes mellitus, type II is denied. Entitlement to an initial evaluation in excess of 10 percent for right upper extremity peripheral neuropathy is denied. Entitlement to an initial evaluation in excess of 10 percent for left upper extremity peripheral neuropathy is denied. Entitlement to an initial evaluation in excess of 10 percent for right lower extremity peripheral neuropathy is denied. Entitlement to an initial evaluation in excess of 10 percent for left lower extremity peripheral neuropathy is denied. REMAND Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II The Veteran contends that his nonservice-connected hypertension is caused by, or aggravated by, his service-connected diabetes mellitus. The Veteran avers that he was first diagnosed with hypertension in June 2005; however, a January 2005 VA record reflects that the Veteran already had a history of hypertension. A January 2007 VA examination report is of record. It reflects that the Veteran was pending confirmation for diabetes mellitus. It was also stated that the Veteran has hypertension, which had been incidentally found in a routine examination by his private physician more than five years earlier (thus, in approximately 2002), and for which he was taking medication. It was noted that the Veteran had changed the medication three years earlier, or in approximately January 2004, and had changed it again when he began treatment at the VAMC in 2005. In sum, the clinical evidence reflects that the Veteran had a diagnosis of hypertension for several years prior to his diagnosis of diabetes. As part of the January 2007 VA examination, the Veteran had laboratory work, with the results that his BUN was 29.5 and his creatine was 1.1. The January 2007 VA clinician stated, in pertinent part, as follows: "Hypertension in this veteran is not due to Diabetes Mellitus because Hypertension predates Diabetes. Hypertension is not aggravated by Diabetes Mellitus because there is no evidence of renal disease. Hence, Hypertensive Heart Disease is not related to Diabetes Mellitus." Subsequent to the 2007 examination and opinion, a VA clinical record in January 2008 reflects a diagnosis of "hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified." However, a February 2009 VA examination report is also of record. The report reflects that laboratory work, to include with regard to renal function, was performed. The examiner stated that the Veteran did not have a diagnosis of kidney disease. He also stated that the Veteran's hypertension was not a complication of diabetes because the Veteran's hypertension predates diabetes. The clinician further stated that the Veteran's hypertension is not worsened or increased by the Veteran's diabetes. Subsequent to the February 2009 VA examination report, VA clinical records in February 2012 and May 2012 reflect that the Veteran had "renal insufficiency: stable." In sum, the clinical evidence reflects that the Veteran's hypertension predated his diabetes. However, with regard to whether his nonservice-connected hypertension is aggravated by his service-connected diabetes, the Board finds that a supplemental clinical opinion, which considers whether the Veteran has a kidney disability, and if so, whether it represents an aggravation of his hypertension by his diabetes, is necessary. If so, the clinician should also state the degree of aggravation. Entitlement to service connection for a vision impairment, to include as secondary to service-connected diabetes mellitus, type II The Veteran contends that he has vision impairment secondary to his service-connected diabetes. The claims file includes an August 2012 VA examination report. The examiner opined that the Veteran's possible early dry-age related macular degeneration senile cataracts, blepharitis, suspect low tension glaucoma suspect, and lid retraction of the left eye are not related to diabetes mellitus or active military service. The examiner stated, in pertinent part, as follows: "The Veteran does not have diabetic retinopathy. Fundus exam reveals hypertensive retinopathy grade II, not causing decrease in visual acuity and not associated to diabetes mellitus." As noted above, the Board is remanding the issue of entitlement to service connection for hypertension to obtain a clinical opinion as to whether it is aggravated by the Veteran's diabetes mellitus. Thus, the issue of entitlement to service connection for an eye disability (i.e. hypertensive retinopathy) is inextricably intertwined with whether the Veteran is entitlement to service-connection for hypertension. Entitlement to service connection for sleep apnea, to include as secondary to service-connected diabetes mellitus, type II A November 2007 VA examination report reflects that the Veteran reported an onset of sleep apnea in 2002. The examiner stated that the Veteran's sleep apnea is not caused by or a result of diabetes mellitus. The examiner further stated that there "is no evidence in medical literature of any etiologic relation between diabetes mellitus and obstructive sleep apnea." Unfortunately, the examiner failed to state whether the Veteran's diabetes mellitus aggravates the Veteran's sleep apnea, and if so, to what degree. Thus, a supplemental opinion to address such is warranted. Entitlement to service connection for an acquired psychiatric disability, claimed as depression and anxiety, to include as secondary to service-connected disabilities The Veteran's STRs include an October 1968 pre-induction report of medical history which appears to reflect that the Veteran reported that he had frequent nightmares, excessive worry, and nervous trouble. This document should be translated by VA from Spanish into English, and thereafter considered by a VA examiner, as discussed below. A June 13, 2005 VA report reflects that the Veteran reported insomnia for four months, that some times he wanted to cry for no apparent reasons. A June 13, 2005 VA psychiatry report reflects that the Veteran reported that he was being evaluated by a psychiatrist for the first time. He reported that since one year earlier he had been irritable, feeling sad, with anhedonia, loss of energy, and feelings of worthless and hopelessness. He also reported problems sleeping for seven months. The Veteran reported a history of head trauma with loss of consciousness. He was diagnosed with major depressive disorder without psychotic features. The Veteran had not yet been diagnosed with diabetes as of this examination. A December 2006 VA examination report is of record. It reflects that the Veteran had a history of head trauma in January 2005. The report reflects that the Veteran reported that his psychiatric symptoms began one a half years earlier (or in approximately June 2005) with trouble sleeping with frequent waking. The Veteran was diagnosed with dyssomnia, not otherwise specified. No other mental disability was found. The examiner opined that the Veteran had no psychiatric complaints findings, or treatment in service or for 35 years after service. She also noted that the Veteran sought psychiatric care in 2005, 35 years after separation from service and after he had an episode of head trauma with loss of consciousness in January 2005. She noted that the Veteran had a diagnosis of diabetes mellitus in February 2006, seven months after he sought psychiatric care. A private record from Dr. M. D.S. reflects that the Veteran has a diagnosis of mood disorder induced by physical conditions. A September 2009 letter from Dr. J.V.S. reflects the following statement: "This is to inform that the [the Veteran] is currently under psychotherapy and pharmacological treatment monthly. [The Veteran] is going through an emotional crisis because of his condition of diabetes." An April 2012 psychiatric progress note reflects that the Veteran had a cognitive deficit that can be "due to partially treated apnea." The Axis I diagnosis was "Mental Disorder due to other Medical Condition [Sleep Disorder] 300.9 Depression Not Otherwise Specified, Cognitive Deficit Not Otherwise Specified Primary Sleep Disorder [Apnea and/or Narcolepsy] " An August 2012 VA examination report reflects that the Veteran has signs and symptoms compatible with cognitive disorder. The examiner noted that the Veteran's psychiatric disorder is a cognitive disorder that is not due to, caused by, or related to service, diabetes, or other service-connected disabilities. The examiner noted that the Veteran had a history of head trauma with loss of consciousness in January 2005, and that one of the strongest links with cognitive disorder is head trauma. The examiner also noted that the Veteran was diagnosed with diabetes mellitus in February 2006, seven months after his psychiatric condition began. The examiner, stated, in pertinent part, as follows: Regarding aggravation beyond the natural course of cognitive disorder, it is my opinion that veteran's cognitive disorder has evolved accordingly to other individuals without any of [the Veteran's] medical condition. Veteran's first sign and symptoms began in 2005 untill [sic] actual full bloom, condition took several years to appeared as today. The examiner noted that the Veteran was diagnosed with diabetes mellitus in February 2006, seven months after his psychiatric condition began; however, the Veteran contends that he was diagnosed with diabetes in June 2005. The Board finds that VA should attempt to obtain all VA clinical records from June 2005 to February 2006, which are not associated with the claims file, to include laboratory results. The Board also finds that VA should attempt to obtain all records from the head trauma sustained in January 2005. Finally, the Board finds that because the issue of entitlement to service connection for sleep apnea is being remanded, the issue of an acquired psychiatric disability, to include as secondary to a service-connected disability should also be remanded. In this regard, the Board notes that a VA clinician stated that the Veteran had a cognitive deficit that can be "due to partially treated apnea." Entitlement to TDIU prior to February 3, 2011 The claim for TDIU is inextricably intertwined with the pending service connection claims that are being remanded. The Board must defer adjudication of the TDIU issue until the intertwined issues are decided. See Harris v. Derwinski, 1 Vet. App. 180 (1991). . Accordingly, the case is REMANDED for the following action: 1. Request the appellant to complete and return a provided VA Form 21-4142, Authorization and Consent to Release Information, for all treatment and/or examinations for a head trauma in January 2005, and for hypertension prior to June 2005. After obtaining a completed VA Form 21-4142, VA should attempt to obtain such records, to include VA records from June 2005 to February 2006, to include laboratory results, not already associated with the claims file. 2. Obtain a translation, from Spanish to English, of the Veteran's October 1968 pre-induction report of medical history. 3. Obtain a supplemental opinion as to whether the Veteran has a kidney disability, and if so, whether it represents an aggravation of his hypertension by his diabetes. If the clinician finds that it is as likely as not that the Veteran's diabetes chronically aggravates his hypertension, the clinician should state, if possible, the degree of aggravation. The clinician should provide a thorough rationale for his/her opinions. 4. Obtain a supplemental opinion from the November 2007 VA clinician, or another appropriate clinician if that clinician is unavailable, as to whether the Veteran's service-connected diabetes mellitus chronically aggravates his sleep apnea. If the clinician finds that it is as likely as not that the Veteran's diabetes aggravates his sleep apnea, the clinician should state, if possible, the degree of aggravation. The clinician should provide a thorough rationale for his/her opinions. 5. Obtain a supplemental opinion from the August 2012 VA clinician, or another appropriate clinician if she is unavailable. The clinician should consider the entire claims file, to include a.) the translated October 1968 pre-induction report of medical history and b.) any additional records, if received, which reflect the onset date of the Veteran's diabetes. The clinician should state whether the above noted documents alter the August 2012 VA opinion, and provide a rationale. 6. Thereafter, after completing any further development deemed necessary, readjudicate the claims for service connection and for TDIU, considering all evidence received since the most recent supplemental statement of the case. If a benefit sought is not granted, issue a supplemental statement of the case and afford the appellant and his representative, if any, an appropriate opportunity to respond. The case should be returned to the Board, as warranted The appellant has the right to submit additional evidence and argument on the 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). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs