Citation Nr: 1331659 Decision Date: 10/02/13 Archive Date: 10/07/13 DOCKET NO. 09-37 122 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for hepatitis A. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for a heart disorder to include paroxysmal supraventricular tachycardia and atrial fibrillation. 4. Entitlement to a higher initial disability rating for tinea versicolor in excess of 60 percent. 5. Entitlement to a higher initial disability rating for right foot arthritis, in excess of 0 percent (noncompensable) for the period prior to August 25, 2009, and in excess of 10 percent for the period on and after August 25, 2009. 6. Entitlement to a higher initial disability rating for left foot injury residuals in excess of 20 percent. 7. Entitlement to a higher initial disability rating for left ankle injury residuals in excess of 10 percent. 8. Entitlement to a higher initial disability rating for left (minor) shoulder injury residuals and acromioclavicular joint separation residuals in excess of 10 percent. 9. Entitlement to a higher initial disability rating for posttraumatic stress disorder (PTSD) in excess of 50 percent. 10. Entitlement to a higher initial disability rating for right (major) shoulder dislocation residuals with degenerative changes in excess of 10 percent. 11. Entitlement to a higher initial disability rating for left (minor) shoulder and chest gunshot wound residuals with retained metal fragments and scar residuals in excess of 10 percent. 12. Entitlement to a higher initial disability rating for thoracolumbar degenerative disc disease and osteoarthritis and sacroiliac joint arthritis in excess of 10 percent. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESSES AT HEARINGS ON APPEAL The Veteran and the Veteran's spouse ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel INTRODUCTION The Veteran is the appellant in the instant appeal. He had active service from December 1965 to November 1967, from May 1968 to June 1980, and from October 1981 to March 1988. The Veteran served in the Republic of Vietnam. He was awarded the Combat Infantryman Badge, the Air Medal, and the Purple Heart with two Oak Leaf Clusters. This matter came before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision of the Roanoke, Virginia, Regional Office (RO) which, in pertinent part, granted service connection for PTSD, and assigned a 50 percent rating for that disability; granted service connection for tinea versicolor, right shoulder (major) dislocation residuals, right foot arthritis, and left ankle injury residuals and assigned noncompensable ratings for those disabilities; effectuated the awards as of August 30, 2005; and denied service connection for hepatitis A. In January 2008, the RO, in pertinent part, established service connection for left (minor) shoulder and chest gunshot wound residuals with a retained metallic fragment and scar residuals and assigned a 10 percent rating for that disability; effectuated that award as of July 21, 2006; established service connection for both left (minor) shoulder injury residuals with acromioclavicular joint separation residuals and thoracolumbar spine degenerative disc disease and osteoarthritis with sacroiliac joint osteoarthritis; assigned noncompensable ratings for those disabilities; effectuated those awards as of August 30, 2005; granted July 15, 2005 as the effective date for the award of service connection for PTSD; and denied service connection for coronary artery disease (CAD) with myocardial infarction residuals, hypertension, and paroxysmal ventricular tachycardia. In October 2008, the RO, in pertinent part, increased the rating for tinea versicolor from noncompensable to 60 percent; increased the rating for left foot injury residuals from noncompensable to 20 percent; and effectuated the awards as of August 30, 2005. In March 2010, the RO, in pertinent part, increased the ratings for thoracolumbar spine degenerative disc disease and osteoarthritis with sacroiliac joint osteoarthritis, right shoulder dislocation residuals with degenerative changes, left shoulder injury residuals with acromioclavicular joint separation residuals, and left ankle injury residuals from noncompensable to 10 percent, and effectuated the awards as of August 30, 2005. In June 2010, the RO, in pertinent part, increased the rating for the Veteran's right foot arthritis from noncompensable to 10 percent and effectuated the award as of August 25, 2005. In September 2011, the RO granted service connection for CAD with myocardial infarction residuals; assigned a 30 percent rating for that disability, and effectuated the award as of July 15, 2005. In October 2012, the Veteran was afforded a Board personal hearing before the undersigned Veterans Law Judge in Washington, DC. A hearing transcript was prepared and incorporated into the record. The Board has reviewed both the physical claims files and the "Virtual VA" file so as to insure a total review of the evidence. The Board has reframed the issue of paroxysmal supraventricular tachycardia as entitlement to service connection for a heart disorder to include paroxysmal supraventricular tachycardia and atrial fibrillation in accordance with the United States Court of Appeals for Veterans Claims' (Court) decision in Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that a claim for benefits for one psychiatric disability also encompassed benefits based on other psychiatric diagnoses and should be considered by the Board to be within the scope of the filed claim). The Veteran has appealed from the initial ratings assigned for service-connected tinea versicolor, right foot arthritis, left foot injury residuals, left ankle injury residuals, left shoulder injury residuals and acromioclavicular joint separation residual, PTSD, thoracolumbar degenerative disc disease and osteoarthritis and sacroiliac joint arthritis, right shoulder injury dislocation residuals with degenerative change, and left shoulder and chest gunshot wound residuals. In Fenderson v. West, 12 Vet. App. 119 (1999), the Court addressed a similar appeal and directed that it was specifically not a claim for an increased disability rating. The Court also directed that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings; therefore, the Board has framed the issues as follows: entitlement to a higher initial rating for tinea versicolor in excess of 60 percent; a higher initial rating for right foot arthritis, in excess of noncompensable for the period prior to August 25, 2009, and in excess of 10 percent for the period on and after August 25, 2009; a higher initial rating for left foot injury residuals in excess of 20 percent; a higher initial rating for left ankle injury residuals in excess of 10 percent; a higher initial rating for left shoulder injury residuals and acromioclavicular joint separation residuals in excess of 10 percent; a higher initial rating for PTSD in excess of 50 percent; a higher initial rating for right shoulder dislocation residuals with degenerative changes in excess of 10 percent; a higher initial rating for left shoulder and chest gunshot wound residuals with a retained metal fragment and scar residuals in excess of 10 percent; and a higher initial rating for thoracolumbar degenerative disc disease and osteoarthritis and sacroiliac joint arthritis in excess of 10 percent. The Board has not dismissed any issue and the law and regulations governing the rating of disabilities are the same regardless of how the issue is styled. The issues of the initial ratings for left shoulder and chest gunshot wound residuals and thoracolumbar spine degenerative disc disease and osteoarthritis and sacroiliac joint arthritis are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. The report of an August 2009 psychiatric examination conducted for VA may be reasonably construed as an informal claim of entitlement to service connection for traumatic brain injury (TBI) residuals to include an amnesic disorder and concussion residuals. The issue has not been adjudicated by the RO. It is not inextricably intertwined with the issue of the initial rating of PTSD given the distinguishable symptomatology arising from PTSD and TBI residuals and because PTSD will still need to be rated under the psychiatric rating criteria regardless of the outcome of a claim for service connection for TBI residuals; therefore, the Board does not have jurisdiction over the issue, and the issue is referred to the RO for appropriate action. FINDINGS OF FACT 1. On June 19, 2012, prior to the promulgation of a decision in this appeal, the Veteran expressly withdrew his appeal from the denial of service connection for hepatitis A. 2. On June 19, 2012, prior to the promulgation of a decision in this appeal, the Veteran expressly withdrew his appeal from the denial of an initial rating in excess of 60 percent for tinea versicolor. 3. On June 19, 2012, prior to the promulgation of a decision in this appeal, the Veteran expressly withdrew his appeal from the denial of an initial rating for right foot arthritis, in excess of noncompensable for the period prior to August 25, 2009, and in excess of 10 percent for the period on and after August 25, 2009. 4. On June 19, 2012, prior to the promulgation of a decision in this appeal, the Veteran expressly withdrew his appeal from the denial of an initial rating in excess of 20 percent for left foot injury residuals. 5. On June 19, 2012, prior to the promulgation of a decision in this appeal, the Veteran expressly withdrew his appeal from the denial of an initial rating in excess of 10 percent for left ankle injury residuals. 6. On June 19, 2012, prior to the promulgation of a decision in this appeal, the Veteran expressly withdrew his appeal from the denial of an initial rating in excess of 10 percent for left shoulder injury residuals and acromioclavicular joint separation residuals. 7. Service connection is currently in effect for CAD with myocardial infarction residuals, tinea versicolor, PTSD, left foot injury residuals, left lower leg and foot post-traumatic paresthesias and aesthesia, Type II diabetes mellitus, right ankle osteoarthritic degenerative changes, left shoulder injury residuals with acromioclavicular joint separation residuals, right shoulder recurrent dislocation residuals with degenerative changes, cervical spine osteoarthritis, thoracolumbar spine degenerative disc disease and osteoarthritis with sacroiliac joint osteoarthritis, left hip degenerative joint disease, left knee reconstruction residuals with osteoarthritis and scar residuals, right leg blast injury residuals with post-traumatic osteoarthritis, left ankle injury residuals, left shoulder and chest gunshot wound residuals with a retained metallic fragment and scar residuals, right foot arthritis, bilateral hearing loss, bilateral ruptured eardrums, and tinnitus. 8. Hypertension was not shown during active service or for many years thereafter. 9. Hypertension is related to service-connected Type II diabetes mellitus and PTSD. 10. A heart disorder was not shown during active service or for many years thereafter. 11. Paroxysmal supraventricular tachycardia and atrial fibrillation are related to the service-connected CAD, Type II diabetes mellitus, and hypertension. 12. PTSD is productive of occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood due to symptoms such as recurrent Vietnam-related nightmares, flashbacks, and intrusive thoughts; hypervigilance including the keeping of multiple weapons about the house; frequent suicidal thoughts; obsessional rituals which interfere with routine activities; difficulty in adapting to stressful circumstances; an impaired ability to make health care choices; and an impaired ability to establish and maintain effective relationships with family and friends. 13. Right (major) shoulder dislocation residuals with degenerative changes are manifested by no more than functional right arm limitation of motion to a point between 45 degrees and shoulder level due to pain; osteoarthritis; Hill-Sachs acromioclavicular joint deformity; and no scapular or clavicular malunion or nonunion. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the substantive appeal from the denial of service connection for hepatitis A have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2013). 2. The criteria for withdrawal of the substantive appeal from the denial of an initial rating in excess of 60 percent for tinea versicolor have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2013). 3. The criteria for withdrawal of the Veteran's substantive appeal from the denial of an initial rating for right foot arthritis, in excess of noncompensable for the period prior to August 25, 2009, and in excess of 10 percent for the period on and after August 25, 2009 have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2013). 4. The criteria for withdrawal of the substantive appeal from the denial of an initial rating in excess of 20 percent for left foot injury residuals have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2013). 5. The criteria for withdrawal of the substantive appeal from the denial of an initial rating in excess of 10 percent for percent for left ankle injury residuals have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2013). 6. The criteria for withdrawal of the substantive appeal from the denial of an initial rating in excess of 10 percent for left shoulder injury residuals and acromioclavicular joint separation residuals have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2013). 7. Resolving reasonable doubt in the Veteran's favor, hypertension was incurred proximately due to or as the result of service-connected Type II diabetes mellitus and PTSD. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310(a), 3.326(a) (2013). 8. Resolving reasonable doubt in the Veteran's favor, paroxysmal supraventricular tachycardia and atrial fibrillation were incurred proximately due to or as the result of the service-connected CAD, hypertension, and Type II diabetes mellitus. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310(a), 3.326(a) (2013). 9. Resolving reasonable doubt in the Veteran's favor, the criteria for an initial 70 percent rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). 10. The criteria for an initial 30 percent rating for right (major) shoulder dislocation residuals with degenerative changes have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003, 5201 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). 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 this decision, the Board grants service connection for hypertension and paroxysmal supraventricular tachycardia and atrial fibrillation; therefore, no further discussion of VA's duties to notify and to assist is necessary as to those issues. In addressing the issues of the initial ratings of PTSD and right shoulder disability, VA has issued several VCAA notices to the Veteran including an August 2006 notice which informed him of the evidence generally needed to support a claim of service connection and the assignment of a rating and effective date for an initial award of service connection, what actions he needed to undertake, and how VA would assist him in developing his claim. The August 2006 VCAA notice was issued to the Veteran prior to the April 2007 rating decision from which the instant appeal arises. The issues were readjudicated in the August 2008 statement of the case (SOC) and the multiple supplemental statements of the case (SSOC); therefore, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Moreover, because this appeal arises in part from the Veteran's disagreement with initial ratings following the grant of service connection for PTSD and right shoulder disability, no additional notice is required regarding this downstream element of the service connection claim for either issue. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Court have similarly held that regarding the downstream element of the initial rating that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (noting that, once an initial VA decision awarding service connection and assigning a disability rating and effective date has been made, 38 U.S.C.A. § 5103(a) notice is no longer required); 38 C.F.R. § 3.159(b)(3) (no VCAA notice required because of filing of NOD). Regarding the duty to assist in this case, VA has secured or attempted to secure all relevant documentation required by the VCAA. The Veteran was afforded multiple VA examinations. The examination reports are of record. He was afforded both a hearing before a VA Decision Review Officer (DRO) and a Board hearing before the undersigned Veterans Law Judge in Washington, DC. Hearing transcripts were prepared and incorporated into the record. All identified and available relevant documentation has been secured and all relevant facts have been developed. There remains no question as to the substantial completeness of the claims. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). For these reasons, the Board finds that the VCAA duties to notify and to assist have been met. Withdrawn Issues 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 in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.202. Withdrawal may be made by a veteran or by his authorized representative. 38 C.F.R. § 20.204. In a June 19, 2012 written statement, the Veteran asserted that he did "not wish to continue my appeal to the Board of Veteran's Appeals for the following disabilities and withdraw my appeal for these disabilities." The enumerated issues included the denial of: service connection for hepatitis A; an initial rating in excess of 60 percent for tinea versicolor; an initial rating for right foot arthritis, in excess of noncompensable for the period prior to August 25, 2009, and in excess of 10 percent for the period on and after August 25, 2009; an initial rating in excess of 20 percent for left foot injury residuals; an initial rating in excess of 10 percent for left ankle injury residuals; and an initial rating in excess of 10 percent for left shoulder injury residuals and acromioclavicular joint separation residuals. Such a written statement constitutes an express withdrawal of the substantive appeal from the denial of the enumerated issues. The Veteran confirmed his desire to withdraw his appeal as to those issues at the October 2012 hearing before the undersigned Veterans Law Judge. For these reasons, the Board finds the Veteran effectively withdrew these issues. 38 C.F.R. § 20.204. As there remains no question of error of fact or law for appellate consideration as to the listed issues, these issues are dismissed. 38 U.S.C.A. § 7104 (West 2002) (the Board is to decide questions of law and fact). Service Connection for Hypertension The Veteran asserts that service connection for hypertension is warranted as the claimed disability was incurred as the result of the result of his service-connected CAD, Type II diabetes mellitus, PTSD, and/or other service-connected disabilities. In the alternative, the Veteran advances that his hypertension was precipitated by his presumed Agent Orange exposure. Service connection may be granted for chronic disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R § 3.303(a). 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). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The provisions of 38 C.F.R. § 3.303(b) are for application in this case as cardiovascular renal disease including hypertension, is a "chronic disease" within the meaning of 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the showing of 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Where a veteran served ninety days or more during a period of war or during peacetime service after December 31, 1946, and cardiovascular renal disease including hypertension becomes manifest to a degree of ten percent within one year of termination of such service, such disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). 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. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). In the case of any veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, campaign, or expedition, the Secretary shall accept as sufficient proof of service connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Service connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. The reasons for granting or denying service-connection in each case shall be recorded in full. 38 U.S.C.A. § 1154(b) (West 2002). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). The Court has clarified that service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service-connected disability has aggravated a nonservice-connected disorder. Allen v. Brown, 7 Vet. App. 439 (1995). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Federal Circuit has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). In his August 2005 claim for service connection, the Veteran advances that hypertension was sustained due to injuries, trauma, and diseases sustained during active service including while he was in the Republic of Vietnam. In his July 2006 Veteran's Application for Compensation or Pension (VA Form 21-526), the Veteran reported that hypertension was initially manifested in 2003. He advanced that hypertension was related to his service-connected PTSD. Service connection is currently in effect for CAD with myocardial infarction residuals, tinea versicolor, PTSD, left foot injury residuals, left lower leg and foot post-traumatic paresthesias and aesthesia, Type II diabetes mellitus, right ankle osteoarthritic degenerative changes, left shoulder injury residuals with acromioclavicular joint separation residuals, right shoulder recurrent dislocation residuals with degenerative changes, cervical spine osteoarthritis, thoracolumbar spine degenerative disc disease and osteoarthritis with sacroiliac joint osteoarthritis, left hip degenerative joint disease, left knee reconstruction residuals with osteoarthritis and scar residuals, right leg blast injury residuals with post-traumatic osteoarthritis, left ankle injury residuals, left shoulder and chest gunshot wound residuals with a retained metallic fragment and scar residuals, right foot arthritis, bilateral hearing loss, bilateral ruptured eardrums, and tinnitus. At a September 2006 examination for compensation purposes conducted for VA, the Veteran reported that he had been initially diagnosed with hypertension in 2003. The Veteran was diagnosed with hypertension. The evidence shows that the Veteran did not have hypertension in service or for many years after service, including no chronic symptoms of hypertension in service or continuous symptoms of hypertension since service separation. The service treatment records make no reference to either hypertension or recurrent elevated blood pressure readings. The Board finds that the evidence is in equipoise on the question of whether hypertension is related to the service-connected Type II diabetes mellitus and PTSD. In a March 2007 written statement, the Veteran asserted that his hypertension was related to either the service-connected PTSD and/or the presumed herbicide exposure while in the Republic of Vietnam. At the October 2012 Board hearing before the undersigned Veterans Law Judge, the Veteran's spouse testified that she was a physician. She opined that hypertension was etiologically related to either service-connected PTSD or the Veteran's presumed herbicide exposure while in the Republic of Vietnam. In a December 2012 written statement, the Veteran's physician-spouse reported that hypertension had been initially diagnosed and treated in 2003. She opined that it was as likely as not that hypertension was related to service-connected Type II diabetes mellitus and PTSD and/or the Veteran's presumed in-service herbicide exposure. The Veteran's spouse submitted several medical articles to support her opinion. The Board finds by the weight of the evidence that hypertension was not shown during active service or for many years thereafter. However, in her testimony and written statement, the Veteran's physician-spouse advances that it was as likely as not that the onset of hypertension was related to the service-connected Type II diabetes mellitus and PTSD. She submitted multiple medical articles in support of her opinion. The Board finds that the private medical opinion is persuasive and supported by the record. For these reasons and upon resolving all reasonable doubt in the Veteran's favor, the Board concludes that service connection for hypertension secondary to the service-connected disabilities is now warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 3.310. Service Connection for a Heart Disorder The Veteran asserts that (secondary) service connection for a heart disorder to include paroxysmal supraventricular tachycardia and atrial fibrillation is warranted as the claimed disability was related to PTSD and other service-connected disabilities. In his July 2006 Veteran's Application for Compensation or Pension (VA Form 21-526), the Veteran related that cardiac arrhythmia was initially manifested in August 2002. He also advanced that cardiac arrhythmia was related to service-connected PTSD. In his March 2007 written statement, the Veteran asserted that his heart disability was related to the service-connected PTSD. After reviewing all the evidence, the Board finds that the evidence is at least in equipoise on the question of whether the paroxysmal supraventricular tachycardia and atrial fibrillation are caused or aggravated by the service-connected disabilities. An August 2002 physical evaluation from H. Wollschläger, M.D., notes that the Veteran was diagnosed with "angina pectoralis, presumably in the scope of a paroxysmal supraventricular tachycardia" and ventricular tachycardia. At a September 2006 examination for compensation purposes conducted for VA, the Veteran reported that he had been initially diagnosed with left anterior fascicular block in the 1980s and cardiac arrhythmia in 2002. On examination, the Veteran's heart was reported to be normal, although the diagnosis was paroxysmal supraventricular tachycardia. An October 2006 VA evaluation resulted in a favorable nexus opinion that related the current paroxysmal atrial fibrillation to the service-connected hypertension and diabetes mellitus. The examining VA physician commented that there was "no obvious reversible cause for [atrial fibrillation], likely related to [hypertension/ diabetes mellitus]." An October 2012 statement from the Veteran's attending VA cardiologist and electrophysiologist notes that the Veteran was being followed "mainly" for paroxysmal atrial fibrillation. The doctor commented that "in relation to his long standing history of atrial fibrillation, in my opinion several factors may be contemplated as possible etiologies, including coronary artery disease, diabetes mellitus, hypertension, vagally-mediated atrial fibrillation, or other unknown etiology." In a December 2012 written statement, the Veteran's physician-spouse opined that the atrial fibrillation was etiological related to service-connected CAD, hypertension, and Type II diabetes mellitus. In support of her opinion, the Veteran's physician-spouse submitted multiple medical articles. The Veteran's attending VA cardiologist/electrophysiologist and his physician-spouse have both opined that the likely etiologies of the heart disorder diagnosed as paroxysmal supraventricular tachycardia and atrial fibrillation included service-connected CAD, Type II diabetes mellitus, and hypertension. The Board finds that the medical opinions are persuasive and supported by the record. For these reasons, and upon resolving all reasonable doubt in the Veteran's favor, the Board concludes that service connection for paroxysmal supraventricular tachycardia and atrial fibrillation secondary to the service-connected disabilities is now warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 3.310. On the theories of direct or presumptive service connection, the Board notes that the Veteran has also put forth a theory of direct service connection. In a March 2007 written statement, the Veteran asserted that his heart disability may be related to the presumed herbicide exposure during service while in the Republic of Vietnam. In this regard, the service treatment records make no reference to paroxysmal supraventricular tachycardia, atrial fibrillation, and irregular heartbeats, and a heart disorder was not shown during active service or for many years thereafter; however, as secondary service connection is being granted in this case, the benefit sought on appeal has been granted. For this reason, the Board does not reach the theory of direct service connection, including the questions of whether presumptive service connection is warranted for a "chronic disease" of cardiovascular disorder under 38 C.F.R. § 3.309(a) and 38 C.F.R. § 3.303(b). PTSD Initial Rating In April 2007, the RO granted service connection for PTSD, assigned an initial 50 percent rating for that disability, and effectuated the award as of August 30, 2005. The evidence at that time included a report of a September 2006 psychiatric examination for compensation purposes conducted for VA that states the Veteran was diagnosed with PTSD secondary to his Vietnam combat experiences. The examiner advanced a Global Assessment of Functioning (GAF) score of 65. The Veteran disagreed with the initial rating. The Veteran contends that PTSD warrants assignment of at least a 70 percent initial evaluation as it is manifested by severe impairment of his daily activities including his ability to make health care decision and severe occupational impairment relieved only through the assistance of understanding supervisors. Disability ratings are determined by comparing a veteran's current symptomatology with the criteria set forth in the Schedule For Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. A 50 percent rating is warranted for PTSD which is productive of occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks occurring more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material or forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. A 100 percent rating requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting herself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: 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 as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). After reviewing all the evidence, the Board finds that PTSD is productive of occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood due to symptoms such as recurrent Vietnam-related nightmares, flashbacks, and intrusive thoughts; hypervigilance including the keeping of multiple weapons about the house; frequent suicidal thoughts; obsessional rituals which interfere with routine activities; difficulty in adapting to stressful circumstances including work; an impaired ability to make health care choices; and an impaired ability to establish and maintain effective relationship which more nearly approximates the criteria for a 70 percent rating. The criteria for an initial rating in excess of 70 percent for PTSD have not been met or more nearly approximated for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326(a), 4.3, 4.7, 4.130, Diagnostic Code 9411. At a September 2006 psychiatric examination conducted for VA, the Veteran complained of constant thoughts of his combat experiences in the Republic of Vietnam; nightmares; anger; irritability; hypervigilance; difficulty remembering names and concentrating; intermittent suicidal thoughts; and social isolation. He reported that he was married and was currently employed as a civilian training specialist with the Army. The Veteran was observed to have an "intense stare;" to be oriented in all spheres; and not to be suicidal, homicidal, or psychotic. On mental status examination, the Veteran exhibited "intense and later sad" mood and affect; goal-directed speech and thought processes; good insight and judgment; good abstraction and reasoning abilities; and no memory deficit. The Veteran was diagnosed with moderate PTSD. A GAF score of 65 was advanced. The examiner commented that the Veteran was "capable of working in a full-time basis from a mental health point of view." A July 2008 VA treatment record states that the Veteran "refuses to have a colonoscopy since he has PTSD and is afraid of losing control." In his August 2009 Appeal to the Board (VA Form 9), the Veteran advanced that a 70 percent initial rating was warranted for PTSD as the disability was manifested by a struggle to go to his employment; an inability to recall instructions at his employment; suicidal feelings; irritability; an "obsessive need to be in control of any life situation;" hypervigilance; impaired impulse control; impaired and excessive sleep; the need to keep a pistol, a machete, a shotgun, a knife, and a hatchet in his bedroom and in his suitcase while traveling; difficulties undergoing invasive medical procedures; survivor's guilt; and impaired concentration and memory. He stated that, while his military-related employment with the Federal Government allowed accommodation of his psychiatric symptoms, his PTSD symptomatology required the use of significant amounts of sick leave and required his supervisors to remove him from a stressful position in contracting to a less demanding job. At an August 2009 psychiatric evaluation conducted for VA, the Veteran complained of recurrent nightmares and intrusive thoughts about Vietnam; associated impaired sleep; intermittent suicidal thoughts; increasing social isolation; hypervigilance; decreasing concentration, memory function, decisiveness, and mental acuity; and amnesic problems. He reported that he frequently forgot procedures and passwords at his employment and his "bosses at work have carried me for the past 5 years." The Veteran indicated that he worked as a civilian training development writer with the Army and was married to his third wife. He was observed to be cooperative; "oriented in all spheres;" and "not acutely suicidal, homicidal, psychotic, manic, hypomanic, obsessive, or compulsive." On mental status examination in August 2009, the Veteran exhibited an appropriately sad and anxious mood and affect; impaired memory function; good abstraction, insight, and judgment; and normal communication skills. The Veteran was diagnosed with severe chronic PTSD, alcohol and cannabis abuse in sustained full remission; and an amnesic disorder secondary to multiple concussions. A GAF score of 55 was advanced. The examiner commented that: the Veteran "remains capable of working on a full time basis;" he would invariably have difficulty interacting with other people in a work setting, if he were not well known and settled into his job;" he "was removed from working with contracts due to the intensity of that work;" "his superiors help to compensate for his memory deficits;" and "he has been able to perform his work well as the result of this." At the March 2010 hearing before a DRO, the Veteran testified that he experienced recurrent Vietnam-related nightmares, flashbacks, and intrusive thoughts; hypervigilance; an "overwhelming sense of dread" which impaired his sleep; and isolation from all beyond his family and service comrades. The Veteran's physician-spouse testified that the Veteran kept multiple weapons in their bedroom and his hypervigilance impaired her life. In a June 2012 written statement, the Veteran advanced that a 70 percent initial rating was warranted for his PTSD as that disability necessitated that he retire from his employment in September 2010 prior to reaching full Social Security Administration retirement age due to his difficulty concentrating and handling and adapting to stressful circumstances and tasks. At the October 2012 Board hearing before the undersigned Veterans Law Judge, the Veteran testified that his PTSD had worsened since his retirement; necessitated that he isolate himself from others; and impaired his relationships with his children. The Veteran's physician-spouse testified that the Veteran's PTSD warranted assignment of a 70 percent rating as it was manifested by "very frequent" suicidal thoughts; memory impairment; and an obsession with being in control which interfered with both his daily activities and his health care decisions including whether to have prescribed cardiac catheterization and a CPAP machine. In a December 2012 written statement, the Veteran's physician-spouse indicated that she had observed that the Veteran's severe PTSD symptoms including Vietnam-related nightmares, flashbacks, and intrusive thoughts; hyperarousal; irritability; an impaired ability to make health care decisions including whether to have a diagnostic colonoscopy, cardiac catheterization, and a CPAP machine; and impaired relationships with his children. In this case, the Board finds that the Veteran's PTSD is productive of occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood due to symptoms including recurrent Vietnam-related nightmares, flashbacks, and intrusive thoughts; hypervigilance including the keeping of multiple weapons about the house; frequent suicidal thoughts; obsessional rituals which interfere with routine activities; difficulty in adapting to stressful circumstances including work; an impaired ability to make health care choices; and an impaired ability to establish and maintain effective relationships with family and friends. The degree of occupational and social impairment, based on PTSD symptoms, more nearly approximates the criteria for a 70 percent rating under Diagnostic Code 9411. The Veteran's impairment was found to be represented by GAF scores of 55 and 65. The GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994). A score of between 51 to 60 reflects moderate difficulty in social, occupational, or school functioning. A score of 61 to 70 indicates the presence of mild symptoms and/or some difficulty in social, occupational, or school functioning, but a generally satisfactory level of functioning. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). The Veteran reported being able to maintain longstanding civilian employment with the Army on a full-time basis with the patience and assistance of his supervisors during the relevant time period. The PTSD symptomatology has been shown to be productive of significant occupational and social impairment most closely approximating the criteria for an initial 70 percent rating. The record does not establish and the Veteran has not advanced that his PTSD disability picture encompasses symptoms causing total occupational and social impairment such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting others, an intermittent inability to perform activities of daily living, disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name at any point during the relevant time period. Given these findings, the Board concludes that the Veteran's service-connected psychiatric disability picture approximates the criteria for an initial 70 percent rating. 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has also evaluated whether the Veteran's appeal should be referred for consideration of an extra-schedular rating for PTSD under 38 C.F.R. § 3.321(b)(1). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extra-schedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. Second, if the schedular rating does not contemplate the appellant's level of disability and symptomatology and is found inadequate, the Board must determine whether the appellant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a appellant's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the appellant's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet App 111 (2008). With respect to the first prong of Thun, the evidence in this appeal does not establish such an exceptional disability picture as to render the schedular rating is inadequate. A comparison between the level of severity and symptomatology of the appellant's PTSD with the established criteria found in 38 C.F.R. § 4.130, Diagnostic Code 9411, reflects that the diagnostic criteria reasonably describes the Veteran's disability level and symptomatology. The diagnostic criteria convey that compensable ratings will be assigned for PTSD which is manifested by various levels of occupational and social impairment. The Veteran's disability picture has been shown to encompass significant occupational and social impairment and symptoms which falls squarely within the diagnostic criteria for a 70 percent rating. The VA Secretary, acting within his authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C.A. § 1155; see 38 U.S.C.A. § 501 (West 2002); 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 psychiatric disorders, there can be no doubt that the VA Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128(1997). See Mauerhan v. Principi, 16 Vet. App. 436, 442 (1992). The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The Federal Circuit has embraced the Mauerhan interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326(Fed. Cir. 2004). PTSD has been shown to be productive of occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood due to symptoms including recurrent Vietnam-related nightmares, flashbacks, and intrusive thoughts; hypervigilance including the keeping of multiple weapons about the house; frequent suicidal thoughts; obsessional rituals which interfere with routine activities; difficulty in adapting to stressful circumstances including work; an impaired ability to make health care choices; and an impaired ability to establish and maintain effective relationships with family and friends; and no delusions or homicidal ideation. All the impairment and symptoms are either explicitly part of the schedular rating criteria or "like or similar to" examples or symptoms in the schedular rating criteria. In addition, the GAF score, which is incorporated into the schedular rating criteria as part of the DSM-IV, assesses the degree of overall occupational and social impairment. For these reasons, the PTSD has not been shown to be productive of an exceptional disability picture; therefore, the Board determines that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not merited. Initial Rating Right Shoulder Dislocation Residuals In April 2007, the RO granted service connection for right (major) shoulder dislocation residuals, assigned an initial noncompensable rating for that disability, and effectuated the award as of August 30, 2005. The evidence at that time included a report of a September 2006 evaluation for compensation purposes conducted for VA that states that the Veteran exhibited "an unremarkable" right shoulder examination and was diagnosed with a right Hill-Sachs acromioclavicular joint deformity. The Veteran disagreed with the initial rating. An August 2009 evaluation for compensation purposes conducted for VA states that the Veteran was right handed, exhibited a full range of right shoulder motion with pain, and radiological findings of degenerative arthritis. The diagnosis was a right shoulder recurrent dislocation with osteoarthritis. In March 2010, the RO recharacterized the service-connected right shoulder disability as right shoulder dislocation residuals with degenerative changes and increased the initial rating for that disability from noncompensable to 10 percent. The Veteran contends that right shoulder dislocation residuals with degenerative changes warrant assignment of at least a 20 percent evaluation as it is manifested by painful right shoulder motion with limitation of right upper extremity to a point between the side and shoulder level. 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, Diagnostic Code 5003. A 20 percent disability evaluation is warranted for limitation of motion of the major arm when motion is possible to the shoulder level. A 30 percent evaluation requires that motion be limited to a point midway between the side and shoulder level. A 40 percent evaluation requires motion be limited to a 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Malunion of the clavicle or the scapula or nonunion of either upper extremity without loose movement warrants a 10 percent evaluation. A 20 percent evaluation requires nonunion with loose movement or dislocation. These disabilities may also be evaluated on the basis of impairment of function of the contiguous joint. 38 C.F.R. § 4.71a, Diagnostic Code 5203. The average normal range of motion of the shoulder is forward elevation (flexion) from 0 to 180 degrees; abduction from 0 to 180 degrees; external rotation from 0 to 90 degrees; and internal rotation from 0 to 90 degrees. When the arm is held at the shoulder level, the shoulder is in 90 degrees of either forward elevation (flexion) or abduction. 38 C.F.R. § 4.71. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59. The evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. 38 C.F.R. § 4.14 (2013). At a September 2006 examination conducted for VA, the Veteran complained of right shoulder pain, weakness, giving way, and recurrent dislocation. On examination of the right shoulder, the Veteran exhibited a range of motion of flexion to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees without pain, subluxation, abnormal or guarding movements, weakness, or tenderness. Contemporaneous X-ray studies of the right shoulder revealed no abnormalities. The Veteran was diagnosed with "Hills-Sachs deformity of the right acromioclavicular joint with dislocation while doing tour duty of Vietnam, now no pathology." In his August 2009 Appeal to the Board (VA Form 9), the Veteran advanced that a 20 percent evaluation was warranted for the right shoulder disability due to pain which limited movement of his right arm to shoulder level. At a September 2009 examination for compensation purposes conducted for VA, the Veteran complained of right shoulder pain, dislocation, tenderness, weakness, stiffness, and fatigability which impaired his ability to lift heavy objects and to sleep. On examination of the right shoulder, the Veteran exhibited a range of motion of flexion to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 90 degrees with pain starting at 0 degrees for all motion. Contemporaneous X-ray studies of the right shoulder revealed findings consistent with degenerative arthritis and calcification of the supraspinous muscle tendon. The Veteran was diagnosed with right shoulder dislocation residuals with osteoarthritis. The examiner commented that "pain has the major functional impact." At the March 2010 DRO hearing, the Veteran testified that his right shoulder dislocated on a weekly basis; he could not raise his right arm to beyond 75 to 80 degrees due to pain; and could not lift heavy objects overhead due to his right shoulder disability. At the October 2012 hearing before the undersigned Veterans Law Judge, the Veteran testified his right shoulder disability was manifested by recurrent dislocation; limitation of motion due to pain; and arthritis. He stated that he avoided using his right upper extremity and acknowledged that he had not experienced right shoulder dislocation for "a couple of years." The undersigned Veterans Law Judge observed that the Veteran could move his right arm to a point "beyond 45 degrees, but not to the shoulder level." The service-connected right shoulder disability has been shown to be manifested by pain, tenderness, and right arm functional limitation of motion to a point "beyond 45 degrees, but not to the shoulder level." Such findings merit assignment of a 30 percent rating under Diagnostic Codes 5003-5201. The evidence of record does not establish, and the Veteran does not allege, that his right arm is either actually or functionally limited to point 25 degrees or less from the side. Therefore, the Board finds that a 30 percent rating, and no higher, is warranted under the provisions of Diagnostic Codes 5003, 5201 at any point during the relevant time period. Hart v. Mansfield, 21 Vet. App. 505 (2007). There is no evidence of right scapular or clavicular malunion or nonunion upon repeated physical and X-ray evaluations as would warrant assignment of a separate evaluation under the provisions of Diagnostic Code 5203. The Board has also evaluated whether the Veteran's claim should be referred for consideration of an extra-schedular rating for right shoulder dislocation residuals with osteoarthritis under 38 C.F.R. § 3.321(b)(1). With respect to the first prong of Thun, the evidence in this instant appeal does not establish such an exceptional disability picture as to render the schedular rating is inadequate. A comparison between the level of severity and symptomatology of the right shoulder disability with the established criteria found in 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5201, reflects that the diagnostic criteria reasonably describes the Veteran's disability level and symptomatology. The diagnostic criteria convey that compensable ratings will be assigned for arthritis and right arm limitation of motion manifested by various levels of actual or functional joint impairment. The Veteran's disability picture has been shown to encompass right arm limitation of motion to a point between 45 degrees and shoulder level which falls squarely within the diagnostic criteria for a 30 percent rating. The functional effects of pain, tenderness, weakness, stiffness, and fatigability have been taken into account and are contemplated in the assigned ratings. See 38 C.F.R. §§ 4.40 , 4.45, 4.59; DeLuca, 8 Vet. App. at 205-06. For this reason, the right shoulder disorder has not been shown to be productive of an exceptional disability picture; therefore, the Board determines that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not merited. ORDER The issues of service connection for hepatitis A; an initial rating in excess of 60 percent for tinea versicolor; an initial rating for right foot arthritis, in excess of noncompensable for the period prior to August 25, 2009, and in excess of 10 percent for the period on and after August 25, 2009; an initial rating in excess of 20 percent for left foot injury residuals; an initial rating in excess of 10 percent for left ankle injury residuals; and an initial rating in excess of 10 percent for left shoulder injury residuals and acromioclavicular joint separation residuals are dismissed. Service connection for hypertension is granted. Service connection for paroxysmal supraventricular tachycardia and atrial fibrillation is granted. An initial 70 percent evaluation for PTSD, and no higher, is granted. An initial 30 percent evaluation for right (major) shoulder dislocation residuals and degenerative changes, and no higher, is granted. REMAND Initial Rating for Left Shoulder and Chest Gunshot Wound Residuals The Veteran asserts that an initial rating in excess of 10 percent is warranted for his service-connected left shoulder and chest gunshot wound residuals. At the October 2012 Board hearing, the Veteran testified that he had been shot in the torso; the bullet had struck his scapula and shattered into three pieces; two of the fragments "worked their way out of my arm and they were fairly large;" and one fragment was retained. In reviewing the record, the Board observes that the evaluations of record do not appear to fully identify the muscle groups affected by the Veteran's gunshot wound residuals. The service treatment records note only that the Veteran sustained a "shrapnel wound of the [left] scapular region." The report of the September 2006 examination for compensation purposes conducted for VA relates that the Veteran exhibited a scar over the left scapula which measured four centimeters by one and one-half centimeters. Contemporaneous X-ray studies of the left shoulder and the chest noted a three millimeter radiopaque foreign body over the inferior portion of the mid-left clavicle. The muscle groups involved were not identified. The December 2012 written statement from the Veteran's physician-spouse indicates that she had examined the Veteran and concluded that the tract of the bullet was from an entry point over the left scapula to a point marked by the retained foreign body and more than likely "penetrated through one or more muscle groups and caused some degree of tissue scarring." The Veteran's physician-spouse, likewise, did not identify the specific muscle groups involved. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. Floyd v. Brown, 9 Vet. App. 88, 93 (1996); Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Therefore, the Board finds that additional VA muscle evaluation would be helpful in resolving the issues raised by the instant appeal. Initial Rating for Thoracolumbar Spine Disability In her December 2012 written statement, the Veteran's physician-spouse indicated that the Veteran's thoracolumbar spine disability had increased in severity over time and encompasses a thoracic vertebral compression fracture. The Veteran was last afforded an evaluation which addressed the thoracolumbar spine in September 2006. In light of the Veteran's physician-spouse competent assertion of worsening of the thoracolumbar spine disability since the last VA examination, the Board finds that an additional examination is required to accurately assess the Veteran's thoracolumbar spine disability picture. Accordingly, the issues of the initial rating for service-connected disability gunshot wound residuals of left shoulder and chest and initial rating for service-connected thoracolumbar back disability (thoracolumbar degenerative disc disease and osteoarthritis and sacroiliac joint arthritis) are REMANDED for the following action: 1. Schedule the Veteran for a VA musculoskeletal examination for compensation purposes in order to assist in determining the current nature and etiology gunshot wound residuals of the left shoulder and chest and thoracolumbar spine disability (which includes the sacroiliac joint). All indicated tests and studies should be accomplished and the findings then reported in detail. The examiner should specifically identify the muscle groups affected by the gunshot wound to the left shoulder and chest. The examiner should further identify the limitation of activity imposed by the Veteran's left shoulder and chest gunshot wound residuals and thoracolumbar spine and sacroiliac joint disabilities with a full description of the effect of the disabilities upon his ordinary activities. The examiner should fully describe any weakened movement, excess fatigability, and incoordination present. Determinations on whether the Veteran exhibits pain with use of his left shoulder and thoracolumbar spine should be noted and described. If feasible, the determinations concerning pain, weakness and fatigability should be portrayed in terms of the degree of additional range of motion loss or ankylosis. If such a determination is not feasible, this should be stated for the record and the reasons provided. The examiner should express an opinion as to the impact of the Veteran's left shoulder and chest gunshot wound residuals and thoracolumbar spine and sacroiliac joint disabilities upon his vocational pursuits. All relevant medical records, including those in the claims folders, should be made available to the examiner for review of pertinent documents therein. The examination report should specifically state that such a review was conducted. A rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 2. Readjudicate the evaluations of left (minor) shoulder and chest gunshot wound residuals and thoracolumbar spine degenerative disc disease and arthritis and sacroiliac joint arthritis. If any benefits sought on appeal remains denied, the Veteran and representative should be provided a SSOC. An appropriate period of time should be allowed for response before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of this claim. See 38 C.F.R. § 3.655 (2012). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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). ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs