Citation Nr: 1334229 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 10-01 411 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Anchorage, Alaska THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial rating in excess of 10 percent for right knee strain. 3. Entitlement to an initial rating in excess of 10 percent for left knee strain. 4. Entitlement to an initial rating in excess of 10 percent for right shoulder strain. 5. Entitlement to an initial rating in excess of 10 percent for left shoulder strain. 6. Entitlement to service connection for a gastrointestinal disorder (claimed as parasites and reflux), to include as due to an undiagnosed illness. 7. Entitlement to service connection for a pulmonary disorder (claimed as bronchitis and pneumonia), to include as due to an undiagnosed illness. 8. Entitlement to service connection for bilateral hand disorder, to include as due to an undiagnosed illness. 9. Entitlement to service connection for a cardiovascular disorder (claimed as chest pain), to include as due to an undiagnosed illness. 10. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Colorado Division of Veterans Affairs ATTORNEY FOR THE BOARD T. Mainelli, Counsel INTRODUCTION The Veteran served on active duty from September 2003 to August 2006. He had active service in Iraq and is the recipient of the Combat Action Ribbon (CAR). This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in August 2007, December 2007, and December 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The RO in Anchorage, Alaska, currently holds jurisdiction over the claims. A review of the Virtual VA electronic records storage system as well as the Veterans Benefits Management System (VBMS) reveals no additional evidence or information which is not currently associated with the paper claims folder. The Board further notes that the Veteran has submitted information stored on compact discs which have been converted to printed documents in the claims folder. Regarding the characterization of the service connection claims on appeal, the Board has a duty to identify the benefit being sought on appeal by applying a "sympathetic reading" to a lay person's pleadings with attention focused upon the symptoms and/or symptoms the claimant is attempting to service connect, regardless of the phraseology utilized by the claimant or the RO. Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009). The Veteran initially raised a service connection claim characterized as chest pain, but he reports that a physician has identified him as having a heart valve abnormality. He has been treated for pneumonia, and reports recurrent bouts of bronchitis. The Veteran further reports recurrent gastrointestinal symptoms which may be due to a parasite infection. Therefore, the Board has rephrased the issues to encompass all potential diagnoses for the claimed disorders of various bodily systems. In statements received in January 2009 and January 2010, the Veteran raised the issue of entitlement to residuals of traumatic brain injury (TBI), but has not been adjudicated by the agency of original jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over this claim which is referred to the AOJ for appropriate action. The service connection issues as well as the claim for a 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, D.C. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's PTSD has resulted in, at most, occupational and social impairment with occasional decrease in work efficiency and intermittent ability to perform occasional tasks. 2. For the entire appeal period, the Veteran's right knee strain is manifested by painful, but noncompensable loss of motion, even when considering functional impairment on use; there is no ankylosis, instability or subluxation, dislocated or removed semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 3. For the entire appeal period, the Veteran's left knee strain is manifested by painful, but noncompensable loss of motion, even when considering functional impairment on use; there is no ankylosis, instability or subluxation, dislocated or removed semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 4. For the entire appeal period, the Veteran's right shoulder strain is manifested by painful motion with motion well above shoulder level even with consideration of functional impairment on use, with no evidence of recurrent dislocation at the scapulohumeral joint, malunion of the humerus, or malunion or nonunion of the clavicle or scapula. 5. For the entire appeal period, the Veteran's left shoulder strain is manifested by painful motion with motion well above shoulder level even with consideration of functional impairment on use, with no evidence recurrent dislocation at the scapulohumeral joint, malunion of the humerus, or malunion or nonunion of the clavicle or scapula. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 4.1-4.14, 4.40, 4.45, 4.130, Diagnostic Code (DC) 9411 (2013). 2. The criteria for an initial rating in excess of 10 percent for right knee strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 4.1-4.14, 4.40, 4.45, 4.71a, DCs 5003-10, 5257, 5260, 5261 (2013). 3. The criteria for an initial rating in excess of 10 percent for left knee strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 4.1-4.14, 4.40, 4.45, 4.71a, DCs 5003-10, 5257, 5260, 5261 (2013). 4. The criteria for an initial rating in excess of 10 percent for right shoulder strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 4.1-4.14, 4.40, 4.45, 4.71a, DCs 5003-10, 5201-03 (2013). 5. The criteria for an initial rating in excess of 10 percent for left shoulder strain have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 4.1-4.14, 4.40, 4.45, 4.71a, DCs 5003-10, 5201-03 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations require VA to provide claimants with notice and assistance in substantiating a claim. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not in the record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186 (2002). These notice requirements apply to all elements of a claim, including the degree and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Proper VCAA notice must be provided prior to the initial unfavorable decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). The Board observes that the Veteran has appealed with respect to the propriety of the initially assigned ratings for his PTSD, bilateral knee, and bilateral shoulder disabilities from the original grant of service connection. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the United States Court of Appeals for Veterans Claims (Court) held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claims for service connection for his PTSD, bilateral knee, and bilateral shoulder disabilities was granted and initial ratings were assigned in the rating decisions on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the duty to assist, the Veteran's service treatment records as well as post-service VA treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. In this regard, the Board observes that the record does not contain cardiovascular imaging findings stored in the Veterans Health Information Systems and Technology Architecture (VistA). However, such imaging studies are not relevant to the initial rating claims involving PTSD, bilateral knee, and bilateral shoulder disabilities. Additionally, the Veteran was afforded VA examinations in conjunction with the claims on appeal in March 2007, July 2009 and March 2013. Neither the Veteran nor his representative has alleged that such are inadequate for rating purposes. Moreover, the Board finds that the examinations are adequate in order to evaluate the Veteran's service-connected PTSD, bilateral knee, and bilateral ankle disabilities as they include an interview with the Veteran, a review of the record, and full examinations, addressing the relevant rating criteria. Therefore, the Board finds that the examination reports of record are adequate to adjudicate the Veteran's initial rating claims and no further examination is necessary. For the foregoing reasons, the Board finds that VA has satisfied its duties to inform and assist the Veteran at every stage in this case. As such, the Veteran will not be prejudiced by a decision on the merits of his claims being decided on appeal. II. Analysis The Veteran seeks higher disability ratings for his service-connected PTSD, bilateral knee disability and bilateral shoulder disability. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. A. PTSD The Veteran's service-connected PTSD is evaluated as 30 percent disabling under the criteria of DC 9411. See 38 C.F.R. § 4.130. A 30 percent rating contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occasional tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating contemplates occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms 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 worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The nomenclature employed in the portion of VA's Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "DSM-IV"). 38 C.F.R. § 4.130. DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. Under DSM-IV, GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging between 31 and 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). Symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126(b). The Board notes that the Veteran holds additional psychiatric diagnoses of major depressive disorder (MDD) and alcohol abuse. His alcohol abuse has been described as a means to self-medicate his service-connected PTSD. The Board attributes all signs of psychiatric impairment to service-connected origin. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (holding that VA is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so). Applying the criteria to the facts of this case, the Board finds that the criteria for an initial rating in excess of 30 percent is not warranted for service-connected PTSD for any time during the appeal period. In this respect, the credible lay and medical evidence shows that, for the entire appeal period, the Veteran's service-connected PTSD has resulted in, at most, occupational and social impairment with occasional decrease in work efficiency and intermittent ability to perform occasional tasks. On his initial VA C&P examination in March 2007, the Veteran endorsed a history of sleep impairment, but denied interpersonal relationship difficulties, depression, panic attacks, substance abuse, memory problems, loss of control, homicidal symptoms, anxiety, confusion or suicidal symptoms. On mental status examination, the Veteran had normal mood, affect, judgment and comprehension of commands. There was no obsessive behavior or hallucinations/delusions. His behavior was appropriate. A February 2008 VA clinic record reflected a negative PTSD screening examination, and a depression screen which was suggestive of no depression. The Veteran's only complaint was difficulty with staying or falling asleep. In July 2008, the Veteran underwent an extensive mental health assessment. At that time, the Veteran endorsed PTSD symptoms of re-experiencing stressful events through nightmares, arousal through irritability, temper outbursts, trouble sleeping and hypervigilance, avoidance through not talking about war events, emotional numbness, feeling detached from others and drinking beer to forget. He also endorsed depressive symptoms such as lack of caring, not being sure if he was happy or sad, poor concentration, poor appetite, sleep difficulty, decreased interest in sex and occasional suicidal ideations (SI). He had been married for 2 years, and helped take care of his relatives. He worked 11-14 hours per day performing clerical and groundwater monitoring duties. His recreational activities included working on cars and, rarely, fishing. On mental status examination, the Veteran was described as casually dressed and clean-shaven with normal (nl) grooming. He was polite and cooperative but made rare eye contact. His speech was normal for rate, rhythm, volume and prosody. Mood and affect were flat. His thought process was coherent, rational, relevant and focused. His thought content was focused on the interview questions, repeatedly stating that you can't do anything about something that had already happened. With respect to insight and judgment, the Veteran did not see drinking up to 12-18 beers per night as a problem and was embarrassed about his PTSD symptoms. He had suicidal thoughts, but no plan or strong desire to act on his thoughts. The examiner diagnosed moderate major depressive disorder (MDD), chronic PTSD and alcohol abuse. A GAF score of 45 was assigned. The examiner also offered the following summary: 23 y/o Marine Corp OIF Veteran referred for mental health assessment. Assessment indicates that vet has chronic PTSD and depression and that he is trying to cope by keeping busy nearly all of the time and daily high intake of etoh (12-18 beers every night after work). Avoidant coping has helped vet manage his current fairly high PTSD symptom level but this also helps to maintain his PTSD, keeps him distant from possible sources of support, and interferes with healthy emotional bonding in his primary marital relationship which sounds strained. Vet also reports feeling angered at work which has not interfered with his job so far, primarily because he works alone most of the time. Vet's depression may be secondary to difficulties he counters in daily functioning as a result of PTSD, problems because of numerous other stressors in his life or difficult early history as noted above. In any case, vet would benefit from therapy if he were open to this option. At this point, vet appears to be "on the fence" about therapy. He agreed to be put on the schedule for later openings with the assurance that he can cancel if he changes his mind. An explanation of how PTSD develops and successful treatment options for PTSD were discussed at some length and vet stated that he believed he understood. Vet showed some emotion (sadness, anxiety) at the very end of the session and thanked me for my time. Vet would be a good candidate for [t]he STARR program if he would agree to it. In a statement received in January 2009, the Veteran argued that he demonstrated the examples for a 100 percent schedular rating for PTSD although he conceded that he did not have "total" occupational and social impairment. He argued that he met the example of gross impairment of thought processes due to impaired judgment, irrational thinking and serious memory loss. He described having persistent delusions or hallucinations due to daily flashbacks with nightmares, having reactions to memories caused by the sounds, sights and smells of combat, having a short fuse, wanting to strike others, and driving down the road watching for possible IEDs. He reported being unable to hold a steady job due to being told that he had engaged in inappropriate behavior. He described being in persistent danger of hurting himself or others due to daily suicidal thoughts with recurrent chest pains. His memory impairment had caused him to forget to follow up with a malfunctioning heart valve which had the potential to kill him. With respect to an inability to perform activities of daily living, he describes difficulty in maintaining a semblance of normal life due to panic attacks, anxiety, suicidal thoughts, sleep difficulty. With respect to disorientation to time or place, he described occasions of not remembering his name or location. He lived with an emotional turmoil of anxiety, sleeplessness, flashbacks, survival shame, loud noise response and anger. He had gotten lost going to work. With respect to memory loss for names of close relatives, own occupation or name, the Veteran described memory difficulties which includes forgetting workplace instructions and not remembering having received a notice to report for VA examination. On VA C&P examination in July 2009, the Veteran reported being married since 2006 and characterized his relationship as "all right" noting that both worked a lot. He denied major issues at home other than awaking his spouse due to his nightmares. He denied major outbursts, but commented that he lied a lot to avoid hurting his spouse. He attempted to handle his symptoms alone as they arose. He was attempting to get into a financial position to allow him to go to school. He maintained contact with family members, and helped his disabled mother when able. He saw his brother and best friend once per month, but otherwise stayed to himself. He enjoyed activities such as jumping on a trampoline, taking walks, reading, working on vehicles, helping his in-laws and snowboarding. He described not liking "idle time." He worked full-time as an equipment operator for a construction company, wherein he worked independently of direct supervision and others. He had minor disagreements with his boss. He reported being involved in two fights within the past year due to his fault. He had been intoxicated on one occasion. His worst occasion of violence involved grabbing his friend by the throat and throwing him over the couch. He sometimes drank heavily for periods of time, but could also go periods without drinking. On mental status examination, the Veteran was described as clean, neatly groomed and casually dressed. His psychomotor activity involved hand-wringing. His speech was soft and monotone. His was attitude cooperative, friendly, attentive and guarded. His mood was depressed and numb, and his affect was constricted. His attention was described as easily distracted, losing track of conversations, forgetting what has occurred in the work setting, and becoming aggravated, nervous and jumpy. The Veteran was oriented to person, time and place. Thought process was racing. He had suicidal thoughts but no intent. There were no delusions. He understood the outcome of behavior but had a bravado about handling issues on his own. He understood that he had a problem, but felt capable of handling these problems. He had sleep impairment with early awakening due to nightmares, which occurred nightly. He endorsed visual hallucinations. His inappropriate behavior was described as being insensitive to other people and their feelings. He interpreted proverbs correctly. He demonstrated obsessive behavior such as hating when lids were off of objects noting that the examiner's water cap was not screwed tight. He described panic attacks which occurred 1 to 3 times per week that varied from 1 hour to 2 days in duration. He described being unable to settle down, being edgy and being bothered by everything. He denied suicidal or homicidal thoughts. His impulse control was good with no episodes of violence. He was able to maintain minimal personal hygiene, and there were no problems with activities of daily living. His sexual performance had been decreased. His remote, recent and immediate memory was mildly impaired. The Veteran reported the daily presence of most PTSD symptoms to varying degrees with no relief. Overall, the VA examiner diagnosed chronic PTSD and assigned a GAF score of 50 which represented PTSD symptoms which were transient or mild and decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. It was noted that the Veteran's GAF was based on his working full-time with minor conflicts at work, having a few friends with whom he sporadically maintained relationships, and experiencing suicidal ideations and panic attacks. It was further noted that the Veteran's minimalization of symptoms tended to an impression that his functioning may be worse, but the GAF was assigned based on the information provided by the Veteran. The Veteran was described as having an ideal work environment of primarily having no supervision, and it was opined that the Veteran more likely than not could not tolerate a work situation as part of a team or needing to report for a superior frequently. The following summary was provided: Veteran was somewhat guarded and even contradictory when discussing how PTSD symptoms are impacting his life. He alluded to having violent thoughts of wanting to hurt others, but just 'ignoring' those people. However, he's been in two reported fights within the past year. One fight resulted in Veteran grabbing a friend by the throat and throwing him over a sofa. Veteran also reported lying to his spouse oftentimes about his feelings, as he doesn't want to upset her. However, Veteran appears to want to not appear weak or in need of help moreso than I believe he doesn't want to upset anyone. He stated that he is often inappropriate in not respecting others' feelings. Furthermore, Veteran presented as a young man that wants to have an education, a marriage and a functional lifestyle. He appeared to be struggling to maintain himself (i.e., handle the symptoms of PTSD) in order to continue with his life's goals. Veteran reported attempting to do constructive things to assist himself with his attention/memory issues, physical pain issues, etc., but is unable to participate in any real PTSD therapy, as all that is offered in that region occurs within the business day. Veteran's job does not even have benefits, so he would surely lose his livelihood if he had to attend groups/meetings/appointments on any regular basis.... PTSD is definitely negatively impacting on this Veteran's life at this time.... [Prognosis]. Guarded. Veteran's guardedness makes it difficult to say otherwise. Although he is able to work in his current setting and, although he is taking steps to improve his symptoms (e.g., taking herbs), his minimalizing of symptoms leads this clinician to think that PTSD is more pervasive in his life than Veteran wants to admit. The Veteran underwent an additional VA C&P examination in March 2013. At that time, the Veteran reported working as a behavioral health associate, wherein he had a good relationship with colleagues and his customers. His attendance was good. He described his job situation as "secure" and only being in danger of being promoted. He was also attending college having completed 40 credits with a grade point average (GPA) of 3.2. The Veteran described his marital relationship as "good" and believed that his marriage would last. His hobbies included paid work for working on cars. He averaged 6 to 12 beers per night and became intoxicated to the point of blackouts which were too numerous to count. He described mood symptoms of anxiety which was moderate to severe in degree, and anger and irritability which was moderate. He averaged panic attacks more than once per week accompanied by tachycardia, shakiness, shortness of breath and diaphoresis, which lasted about 60 minutes. His sleep was impaired with daily nightmares. He had occasional verbal outbursts, concentration difficulty ranging from mild to severe, constant hypervigilance and occasional jumpiness. He felt somewhat detached. He avoided social contact but had a few friends and good relationships with family members. He denied suicidal or homicidal ideation. He denied limitations in activities of daily living. On mental status examination, the Veteran was described as neatly dressed in casual attire with good hygiene and grooming. Eye contact was good. Psychomotor activity showed a normal gait, and he sat quietly during the interview. His manner was pleasant, attentive and cooperative. His speech was clear and articulate with normal rate, rhythm and volume. His mood was "neutral" although he experienced anxiety and anger. His affect was pleasant and euthymic. The Veteran's thought processes were clear and coherent with goal-directed answers. His thought content was positive for suppression of combat memories and nightmares, but he denied hallucinations, delusions, ideas of reference, thought insertion, or thought broadcasting. He was oriented to time, place, person and situation. His intelligence was probably in the average range. The Veteran's remote, recent, immediate and delayed recall were intact. His energy was low to normal, and his motivation was high. His judgment was intact, but the Veteran's insight appeared to be a minimization of his PTSD symptoms with self-medication with alcohol. His self-esteem was good but he felt helpless and hopeless sometimes. He had a goal of becoming a surgeon. The examiner diagnosed PTSD and assigned a GAF score of 60 with anxiety, panic attacks, irritability, insomnia and nightmares. The effects of PTSD on the Veteran's occupational and social functioning was described as follows: There is occasional decrease in work efficiency but generally satisfactory functioning (routine behavior, self-care, and conversation normal). The [V]eteran has a few close friends. He is gainfully employed, working full-time and supporting himself. He is attending college and has a GPA of 3.2. He believes his marriage will last. His PTSD symptoms might improve with psychotropic medications but he has been reluctant to seek treatment. Here, the lay and medical evidence demonstrates that the Veteran meets most of the examples supporting a 30 percent rating under DC 9411. For example, the Veteran has demonstrated a depressed mood, weekly panic attacks, chronic sleep impairment and mild memory loss. His speech has consistently been described as normal, and he has demonstrated no personal hygiene abnormalities. The Veteran also demonstrates some examples listed as supporting the 50 percent rating under DC 9411. For example, the Veteran has consistently and credibly described panic attacks that occur more than once per week. He was noted to have a flat affect and constricted affect in July 2008 and July 2009. However, his affect was described as pleasant and euthymic in March 2013. Thus, his affect has not been chronically impaired. The Veteran has also demonstrated some impairment of judgment by describing occasional verbal outbursts and two episodes of unprovoked violence. However, there is no lay or medical evidence regarding the Veteran having legal, financial or health problems caused by lack of judgment. On the other hand, the Veteran does not demonstrate other examples supportive of a 50 percent rating under DC 9411. For example, the mental status examinations have found no impairment of speech. The Veteran has been described as evidencing "mild" memory loss, which is consistent with the criteria for a 30 percent rating. Any difficulty in understanding complex commands, impairment of abstract thinking or disturbance in motivation and mood does not appear significant given the Veteran's demonstrated work history during the appeal period and, more recently, his college coursework with a 3.2 GPA. He has always maintained an effective relationship with his spouse and a few friends, and has shown an ability to maintain effective work relationships by his employability for most of the appeal period. The Veteran also demonstrates some examples listed as supporting the 70 percent rating under DC 9411. He has expressed suicidal ideation, obsessional rituals and impaired impulse control with physical violence. With respect to suicidal ideation, these are passive thoughts without actual intent or plan. His obsessional rituals have been described as wanting caps to be screwed tightly on bottles, but there is no report of rituals which actually interfere with his ability to function in a work or social setting. The reported impulse control with physical violence appears to be limited to two episodes of unprovoked violence. On the other hand, the Veteran's speech has never been described as illogical, obscure or irrelevant. His mental status examinations have shown him to be fully oriented with no neglect of personal hygiene. The Veteran has not reported panic or depression which affects his ability to function independently. His inappropriate behavior is limited to the two episodes of violence and being insensitive to others' feelings. Thus, the Veteran does not manifest many examples listed in the criteria for a 70 percent rating. The Board also considers the GAF scores assigned during the time period, which ranged from 45 to 60. The GAF score of 45 is consistent with psychological, social and occupational impairment intermediate between "major" and "serious" in degree while the GAF score of 60 is consistent with "moderate" severity. As required by Maeurhan, the Board must look at all the factors and evidence identified above to determine whether the Veteran met or more closely approximated the criteria for a rating greater than 30 percent for any time during the appeal period. When considering the evaluation of the examples which may support a higher rating, the frequency, duration and severity of symptoms, the Veteran's capacity for adjustment, and the examiner assessments of the Veteran's psychological, social and occupational functioning (GAF scores), the Board is of the opinion that the Veteran's PTSD has not met or more closely approximated the criteria for a rating in excess of 30 percent for any time during the appeal period. In this respect, the VA clinician in July 2008 who assigned a GAF score of 45 stated that the Veteran's symptoms had not interfered with his job, as he had been working alone. He had been working 11 to 14 hours per day. The VA examiner in July 2009 described the Veteran's PTSD as resulting in transient or mild symptoms with decreased work efficiency and ability to perform tasks only during periods of significant stress. The VA examiner in March 2013 described even better functioning - in a vocation requiring colleague and customer interaction. As addressed below, the Veteran has maintained substantially gainful employment for most of the appeal period and, since 2010, has also been attending college with a 3.2 GPA. Furthermore, from a social point of view, the Veteran has maintained good relations with his spouse and has helped take care of family members. While the Veteran's lack of worker contact in jobs prior to 2010 was described as being beneficial for his psychiatric disability, the Veteran's current employment involves customer and colleague relationships which he describes as good. The Board is aware of the Veteran's reported symptomatology, to include his argument of how he meets the examples supporting the criteria for a 100 percent rating. However, the Board finds that the examples cited by the Veteran are not so pervasive or serious to meet the criteria for a 100 percent rating when viewed in light of the mental status examinations and his social and occupational impairment. The Board is also cognizant of examiner impressions that the Veteran may be underreporting PTSD symptomatology. Taking into account all of these factors as they affect the Veteran's social and occupational impairment, as required by Mauerhan, the Board finds that the evidence establishes that the Veteran's service-connected PTSD has resulted in, at most, occupational and social impairment with occasional decrease in work efficiency and intermittent ability to perform occasional tasks. To the extent that the descriptions by Veteran can be construed as supporting a higher rating still, the Board places greater probative weight to the clinical findings of the VA physicians who have greater expertise and training than the Veteran in evaluating the extent and severity of a psychiatric disability. On these facts, the Board also finds no basis for a staged rating, pursuant to Fenderson. In this respect, the Veteran's psychiatric symptoms and their impact on his social and occupational functioning, if anything, has improved during the appeal period. The most recent assessment of mild symptoms while otherwise functioning well is arguably more consistent with a 10 percent rating. Therefore, the Board finds that the Veteran's PTSD has been no more than 30 percent disabling for any time during the appeal period. There is no reasonable doubt of material fact to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b). The claim for a higher initial rating for PTSD, therefore, is denied. B. Bilateral Knee and Shoulder Disabilities 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 of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). 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 enervation, 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 that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. Furthermore, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. Under DC 5003, degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate DCs, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. Descriptive words such as "slight," "moderate" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. Bilateral knee disability Within 38 C.F.R. § 4.71a, there are multiple DCs that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). The criteria of DC 5256 do not apply as there is no lay or medical evidence of ankylosis. According to DC 5257, a 10 percent rating will be assigned with evidence of slight recurrent subluxation or lateral instability of a knee; a 20 percent rating will be assigned with evidence of moderate recurrent subluxation or lateral instability; and a 30 percent rating will be assigned with evidence of severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. The criteria of DCs 5258 and 5259 do not apply, as there is no history or current evidence of dislocation of semilunar cartilage or history of removal of semilunar cartilage. VA's Office of General Counsel has stated that compensating a claimant for separate functional impairment under DCs 5257 and 5003 does not constitute pyramiding. VAOPGCPREC 23-97 (July 1, 1997). In this opinion, the VA General Counsel held that a Veteran who has arthritis and instability of the knee may be rated separately under DCs 5003 and 5257, provided that a separate rating is based upon additional disability. Subsequently, in VAOPGCPREC 9-98 (Aug. 14, 1998), the VA General Counsel further explained that if a Veteran has a disability rating under DC 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. See also VAOPGCPREC 9-04 (Sept. 17, 2004) (which finds that separate ratings under DC 5260 for limitation of flexion of the leg and DC 5261 for limitation of extension of the leg may be assigned for disability of the same joint). The criteria that focus on limitation of motion of the knee are DCs 5260 and 5261. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, a noncompensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. The criteria of DC 5262 do not apply as there is no history of impairment of the tibia and fibula involving malunion or nonunion. 38 C.F.R. § 4.71a, DC 5262. The criteria of DC 5263 also do not apply as there is no lay or medical evidence of genu recurvatum. 38 C.F.R. § 4.71a, DC 5263. Applying the criteria to the facts of this case, the Board finds that the criteria for initial ratings in excess of 10 percent for service-connected right and left knee strain have not been met for any time during the appeal period. In this respect, the evidence shows that the Veteran's service-connected right and left knee strains are manifested by painful but noncompensable loss of motion, even when considering functional impairment on use; there is no ankylosis, instability or subluxation, dislocated or removed semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. Historically, the Veteran described a history of bilateral knee pain and swelling on his July 2006 separation examination. On his initial VA C&P examination in March 2007, the Veteran described right knee aching and soreness once or twice a week associated with limited range of motion (ROM). He had pain with movement or weight-bearing. His right knee became tight but did not swell. He further described chronic left knee pain which swelled at least once a week, gave-out several times a week, and locked at least once a week. On examination, the Veteran's right and left lower extremities demonstrated 5/5 strength absent atrophy, spasm or other muscle abnormalities. There was no joint swelling, effusion, tenderness or laxity. The right knee demonstrated flexion from 0 to 95 degrees with pain starting at 85 degrees of active motion, and extension from 0 to 95 degrees with pain beginning at 90 degrees and ending at 45 degrees. The left knee demonstrated flexion from 0 to 93 degrees with pain starting at 40 degrees of active motion, and extension from 0 to 93 degrees with pain beginning at 90 degrees and ending at 30 degrees. X-ray examinations were interpreted as unremarkable. The examiner diagnosed a right and left knee strains which had significant effects on the Veteran's occupational functioning due to problems with decreased concentration, decreased mobility, problems with lifting and carrying, lack of stamina, fatigue, decreased strength and lower extremity pain. The effects on daily activities were severe for sports and recreation; moderate for exercise, traveling and driving; and mild for chores and shopping. In pertinent part, a November 2007 VA clinic visitation evaluating the Veteran's complaint of bilateral knee pain was significant only for mild pain with McMurray's test. In a statement received in June 2008, the Veteran described severe, chronic bilateral knee pain which he treated nightly with ice and/or Ben Gay in order to be able to function the next day. On VA C&P examination in March 2013, the Veteran described vague, intermittent bilateral knee pain which worsened with activities such as hiking or playing basketball. The right and left knees demonstrated flexion to 140 degrees and extension to 0 degrees with full strength absent objective evidence of painful motion or additional motion loss with repetitive testing. The Veteran's functional impairment was described as subjective report of pain on movement absent other factors such as less or more movement than normal, weakened movement, excess fatigability, incoordination, swelling, deformity, atrophy of disuse, instability of station, locomotion disturbance or interference with sitting, standing or weightbearing. His anterior, posterior and medial-lateral instability was normal. There was no evidence of patellar subluxation or dislocation. The bilateral knee disabilities did not impact his ability to work. With respect to bilateral knee motion, the Veteran has demonstrated active right knee motion from 0 to 90 degrees (VA C&P examination dated March 2007) and 0-140 degrees (VA C&P examination dated March 2013). The left knee has shown active motion from 0 to 93 degrees (VA C&P examination dated March 2007) and 0-140 degrees (VA C&P examination dated March 2013). The VA clinical records do not further describe limitation of motion in terms of degrees of motion lost. Overall, the clinical findings of record provide highly probative evidence against a compensable rating for the right or left knee disability based upon limitation of motion under DCs 5260 and/or 5261, showing right knee motion of at least 0 to 90 degrees and left knee motion of at least 0 to 93 degrees. The VA clinical records provide no direct evidence in support of the claim, and the Veteran himself has not expressed motion loss in terms of degrees. With respect to bilateral knee instability, VA C&P examination in March 2007 found no evidence of laxity. The VA C&P examination in March 2013 found that anterior, posterior and medial-lateral instability was normal with no evidence of patellar subluxation or dislocation. The available VA clinical records reflect mild pain on McMurray's testing, but do not include any clinical description of right or left knee instability during the appeal period. Overall, the clinical findings of record provide strong evidence against a separate rating based upon instability under DC 5257 for either knee, failing to show any clinical evidence of right or left knee instability or subluxation. At his March 2007 examination, the Veteran described left knee give-way and locking symptoms which occurred on a weekly basis. The Board finds that the clinical findings of VA clinicians of no clinical instability of either knee hold greater probative weight than the Veteran's subjective perceptions, as these examiners possess greater training and expertise than the Veteran in evaluating knee instability or subluxation. The Board also finds no basis to award a rating greater than 10 percent for right and/or left knee disabilities based upon functional loss due to pain, weakness, fatigability, or incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. at 204-08 (1995). In this case, the Veteran describes severe bilateral knee pain which requires which he treats nightly with ice and/or Ben Gay in order to be able to function the next day. He further reports increased pain symptoms on use. The March 2007 VA examiner found that right knee pain began at 45 degrees of extension and 85 degrees of flexion, and left knee pain began at 40 degrees of flexion and 30 degrees of extension. This examiner described functional impairments of decreased concentration, decreased mobility, problems with lifting and carrying, lack of stamina, fatigue, decreased strength and lower extremity pain. The VA examiner in March 2013 found no objective evidence of painful motion or additional limitations of either knee after repetitive testing. Notably, the Veteran has already been assigned separate 10 percent ratings based upon "functional impairment, pain and limited motion of both knees" under DC 5260 despite the fact that he does not manifest compensable motion loss under this diagnostic code. See RO rating decision dated August 2007. The Veteran's pain, while occurring prior to his end ranges of motion and the additional functional impairment described by the March 2007 VA examiner, are not shown to be productive of actual additional motion loss. His strength at all times at VA examinations and in the clinical settings has been described as full (5/5). There are no indications of disuse such as atrophy, skin abnormality or absence of normal callosity. See 38 C.F.R. § 4.40. There are also no indications of swelling, deformity or disturbance of locomotion. See 38 C.F.R. § 4.45. In fact, the Veteran has described his hobbies as snowboarding and jumping on trampolines. On this record, the Board finds that the specific clinical findings by the VA examiners fall well short of meeting, or more nearly approximating, the criteria for compensable motion loss under DCs 5260 and 5261. The Veteran himself does not specifically describe motion loss comparable to flexion limited to 45 degrees or extension limited to 10 degrees. Even with consideration of the functional effects with use, the Board finds that further compensation is not warranted with consideration of the provisions of 38 C.F.R. §§ 4.40 and 4.45. As noted above, there is no lay or medical evidence of ankylosis, dislocated semilunar cartilage, symptomatic removal of semilunar cartilage, impairment of the tibia and fibula or genu recurvatum. As such, the criteria of DCs 5256, 5258, 5259, 5262 and 5263 are not for application. In so holding, the Board has carefully considered the symptomatology and functional limitations voiced by the Veteran. However, the Board has placed greater probative weight to the actual clinical findings of the VA clinicians who have greater expertise and training than the Veteran in evaluating the nature and severity of his bilateral knee disability. There is no doubt of material fact to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b). Bilateral shoulder disability Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from service-connected disorders of the shoulder and arm, to include DC 5200 (ankylosis of scapulohumeral articulation), DC 5201 (limitation of arm motion), DC 5202 (impairment of the humerus), and DC 5203 (impairment of the clavicle or scapula). The criteria of DC 5200 do not apply as there is no lay or medical evidence of ankylosis. 38 C.F.R. § 4.71a, DC 5200. The criteria of DC 5201 provide a 20 percent rating for limitation of major or minor arm motion at shoulder level, or limitation of minor arm motion midway between side and shoulder level. 38 C.F.R. § 4.71, DC 5201. A 30 percent rating is warranted for limitation of major arm motion midway between side and shoulder level. Id. Limitation of arm motion to 25 degrees from side warrants a maximum 40 percent rating for the major arm, and a maximum 30 percent rating for the minor arm. Full range of motion of the shoulder is measured from 0 degrees to 180 degrees in extension, shoulder abduction from 0 to 180 degrees, and external and internal rotation from 0 to 90 degrees. 38 C.F.R. § 4.71a, Plate I. The Veteran reports a history of bilateral shoulder dislocations in service. The criteria of DC 5202 provides for a 20 percent rating for infrequent recurrent dislocation at the scapulohumeral joint with guarding of movement only at shoulder level involving the major or minor arm. 38 C.F.R. § 4.71, DC 5202. A 20 percent rating is also warranted for malunion of the humerus with moderate deformity of the major or minor arm. Id. A higher 30 percent rating is warranted for frequent episodes of recurrent dislocations of the major arm and guarding of all movements. Id. There is no lay or medical evidence of loss of head (flail shoulder) or nonunion (false flail joint). As such, the criteria pertaining to these aspects of disability are not applicable. The criteria of DC 5203 provide a 10 percent rating for the major or minor arm with malunion of the clavicle or scapula, or nonunion without loose movement. 38 C.F.R. § 4.71a, DC 5203. A maximum 20 percent rating is warranted for the major or minor arm with nonunion of the clavicle or scapula with loose movement, or dislocation. Id. Applying the criteria to the facts of this case, the Board finds that the criteria for initial ratings in excess of 10 percent for service-connected right and left shoulder strain have not been met for any time during the appeal period. In this respect, the evidence shows that the Veteran's service-connected bilateral shoulder disabilities are manifested by painful motion with motion well above shoulder level even with consideration of functional impairment on use with no evidence of recurrent dislocation at the scapulohumeral joint, malunion of the humerus, or malunion or nonunion of the clavicle or scapula. Historically, the Veteran described a history of left shoulder pain on his July 2006 separation examination. On his initial VA C&P examination in March 2007, the Veteran described an in-service history of bilateral shoulder dislocations reduced by a medical corpsman. His shoulders hurt once a week with symptoms of pain, stiffness, limited motion and swelling. He had flare-ups of severe disability every 1 to 2 months which lasted hours in duration and caused moderate additional limitation. On examination, the Veteran's upper extremities demonstrated 5/5 strength absent atrophy, spasm or other muscle abnormalities. There was no joint swelling, effusion, tenderness or laxity. The right shoulder demonstrated flexion from 0 to 180 degrees with pain starting at 90 degrees of active motion, abduction from 0-175 degrees, internal rotation from 0 to 90 degrees, and external rotation from 0 to 60 degrees with pain starting at 60 degrees of active motion. The left shoulder demonstrated flexion from 0 to 180 degrees with pain starting at 90 degrees of active motion, abduction from 0-145 degrees with pain starting at 90 degrees active motion, internal rotation from 0 to 90 degrees, and external rotation from 0 to 60 degrees with pain starting at 45 degrees of active motion. X-ray examinations were interpreted as unremarkable. The examiner diagnosed a bilateral shoulder condition which had significant effects on his occupational activities due to decreased concentration, problems with lifting and carrying, lack of stamina, weakness, fatigue, decreased strength and pain. The effects for occupational activities were severe for sports; moderate for exercise and recreation; and mild for chores, shopping, traveling and driving. In pertinent part, a November 2007 VA clinic record evaluating complaint of bilateral shoulder pain noted mild pain with internal and external rotation, 5/5 strength, and negative drop arm test. In a statement received in June 2008, the Veteran described severe bilateral shoulder pain. On VA C&P examination in March 2013, the Veteran described vague bilateral shoulder pain with push-ups or similar activity. The right shoulder demonstrated flexion to 165 degrees and abduction to 170 degrees with no objective evidence of painful motion and full strength. After repetitive testing, there was 170 degrees of flexion and abduction. His left shoulder demonstrated flexion and abduction to 170 degrees with no objective evidence of painful motion or change in motion with repetitive testing. His left shoulder demonstrated full strength. He voiced pain on movement but there was no grimace or change in expression. He was described as having a thick chest with broad, muscular shoulders which were limiting factors. His effort was described as sub-optimal and easily donning his shirt at the conclusion of the examination. There was no localized tenderness, guarding, mechanical symptoms, recurrent dislocation or ankylosis. Hawkins' impingement test, empty-can test, external rotation test, and lift-off subscapularis test were negative. X-ray examination was interpreted as showing minimal changes of the glenohumeral joints. With respect to bilateral shoulder motion, the March 2007 VA C&P examination measured active right shoulder motion from 0 to 180 degrees of flexion, abduction from 0-175 degrees, internal rotation from 0 to 90 degrees, and external rotation from 0 to 60 degrees. The left shoulder demonstrated flexion from 0 to 180 degrees, abduction from 0-145 degrees, internal rotation from 0 to 90 degrees, and external rotation from 0 to 60 degrees. The March 2013 VA C&P examination measured right shoulder flexion to 165 degrees and abduction to 170 degrees, and left shoulder flexion and abduction of 170 degrees. The VA clinical records do not further describe limitation of motion in terms of degrees of motion lost. Overall, the clinical findings of record provide highly probative evidence against a compensable rating for the right or left shoulder disability based upon limitation of motion under DC 5201, showing bilateral shoulder motion well above shoulder level. The VA clinical records provide no direct evidence in support of the claim, and the Veteran himself has not expressed motion loss in terms of degrees. At his March 2007 VA C&P examination, the Veteran reported a history of shoulder dislocations during service. He has not reported an episode of right or left shoulder dislocation during the appeal period. The VA examinations in 2007 and 2013 found no evidence of recurrent dislocation at the scapulohumeral joint, malunion of the humerus, or malunion or nonunion of the clavicle or scapula. Overall, the credible lay and medical evidence during the appeal period reflects no evidence supportive of a compensable rating under DCs 5202 or 5203. The VA examination in March 2013 found no evidence of ankylosis, and the Veteran himself has not alleged ankylosis. As such, the criteria of DC 5200 are not applicable. The Board also finds no basis to award a rating in excess of 10 percent for right and/or left shoulder disabilities based upon functional loss due to pain, weakness, fatigability, or incoordination. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. at 204-08 (1995). In this case, the Veteran describes severe bilateral shoulder pain. He has described weekly flare-ups pain, stiffness, limited motion and swelling with severe flare-ups occurring every 1 to 2 months, which lasted hours in duration, and resulted in "moderate" additional limitation. The March 2007 VA examiner found that right shoulder pain began at 90 degrees of flexion and 60 degrees of external rotation. His left shoulder pain began at 90 degrees of flexion, 90 degrees of abduction and 45 degrees of external rotation. The functional impairments were described as decreased concentration, problems with lifting and carrying, lack of stamina, weakness, fatigue, decreased strength and pain. The VA examiner in March 2013 found no objective evidence of painful motion or additional limitations of either shoulder after repetitive testing. A November 2007 VA clinic record described mild pain with internal and external rotation. The Veteran's 10 percent rating for right shoulder disability has been based upon painful and limited motion under DC 5201-5203 despite the fact that he does not manifest compensable motion loss under this diagnostic code. See RO rating decision dated December 2007. Similarly, the left shoulder disability has been rated as 10 percent disabling under DC 5203 due to painful motion, limited abduction and functional impairment with pain at 90 degrees. See RO rating decision dated August 2007. Notably, the August 2007 RO rating decision contains contradictory findings as the body of the rating decision appears to purport that "[a]n evaluation of 20 percent is assigned" while the decisional award and coding sheets reflect that a 10 percent rating has been assigned. To the extent the RO may have made a "finding" that the criteria for a 20 percent rating had been met, it is not binding upon the Board. See McBurney v. Shinseki, 23 Vet. App. 136, 139-40 (2009). The Veteran's pain, while occurring prior to his end ranges of motion and the additional functional impairment described by the March 2007 VA examiner, are not shown to be productive of actual additional motion loss. His strength at all times at VA examinations and in the clinical settings has been described as full (5/5). There are no indications of disuse such as atrophy of disuse, indications of swelling, deformity or deformity. His flare-ups of pain are infrequent in nature, and brief in duration. Overall, the Board finds that the Veteran's functional use of his shoulders is shown to be well above shoulder level even when considering the factors enumerated by the March 2007 VA examiner. In so finding, the Board finds that the specific clinical findings by the VA examiners fall well short of meeting, or more nearly approximating, the criteria for compensable motion loss under DC 5201. The Veteran himself does not specifically describe motion loss, as opposed to pain, comparable to shoulder level. As such, further compensation is not warranted with consideration of the provisions of 38 C.F.R. §§ 4.40 and 4.45. In so holding, the Board has carefully considered the symptomatology and functional limitations voiced by the Veteran. However, the Board has placed greater probative weight to the actual clinical findings of the VA clinicians who have greater expertise and training than the Veteran in evaluating the nature and severity of his bilateral knee disability. There is no doubt of material fact to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b). C. Other Considerations The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected PTSD, bilateral knee, and bilateral shoulder disabilities; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disabilities is not warranted. The Board has contemplated whether the case should be referred for extra-schedular consideration. In this regard, to accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The provisions of 38 C.F.R. § 3.321(b) state as follows: 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 evaluations 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 evaluation 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. In Thun v. Peake, 22 Vet. App. 111 (2008), the Court specified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. VA's General Counsel has stated that consideration of an extra-schedular rating under 3.321(b)(1) is only warranted where there is evidence that the disability picture presented by the Veteran would, in that average case, produce impairment of earning capacity beyond that reflected in the rating schedule or where evidence shows that the Veteran's service-connected disability affects employability in ways not contemplated by the rating schedule. See VAOPGCPREC 6-96 (Aug. 16, 1996). In Thun, the Court further explained that the actual wages earned by a particular Veteran are not considered relevant in the calculation of the average impairment of earning capacity for a disability, and contemplate that Veterans receiving benefits may experience a greater or lesser impairment of earning capacity than average for their disability. The Thun Court indicated that extraschedular consideration cannot be used to undo the approximate nature of the rating system created by Congress. The Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. However, the Board is not precluded from raising this question, see Floyd v. Brown, 9 Vet. App. 88 (1996), and addressing referral where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). "Because the VA disability rating schedule is designed to consider the disabling effect of disabilities separately, no single DC provision will adequately assess the variety of symptoms involved with multiple service-connected disabilities." Johnson v. Shinseki, 26 Vet. App. 237 (2013) (en banc). Thus, as to the question of "whether [38 C.F.R.] § 3.321(b)(1) requires VA to consider multiple service-connected disabilities on a collective basis" the Court held that it did not. Id. (noting that a concurring opinion in Brambley v. Principi, 17 Vet. App. 20, 27 (2003) that there should have been a determination of "whether the appellant's service-connected disabilities as a whole [sic] entitled [a Veteran] to [an extraschedular rating] under § 3.321(b)(1)" had never been adopted by the Court and concurring opinions are not binding on the Court" (citing Maryland v. Wilson, 519 U.S. 408, 412-13). Stated in other terms, an extraschedular rating may not be assigned for the cumulative impact of the service-connected disabilities herein at issue. The Board is aware of the Veteran's complaints as to the effects of his service-connected PTSD, bilateral knee and bilateral shoulder disabilities have had on his activities of work and daily living. In the Board's opinion, all aspects of this disability are adequately encompassed in the assigned schedular ratings. As instructed in Mauerhan, the Board has considered all of the Veteran's reported psychiatric symptomatology in the assigned 30 percent rating. The Board has also considered whether higher ratings still are warranted based upon the frequency, duration and severity of symptoms, but the criteria for higher ratings are not met. The evaluation of the bilateral knee disability has included consideration of clinical findings such as limitation of motion, instability, subluxation, dislocated or removed semilunar cartilage, impairment of the tibia and fibula, genu recurvatum and ankylosis. The evaluation for the bilateral shoulder disability has involved consideration of clinical findings of limitation of motion, recurrent dislocation, malunion of joints and ankylosis. With respect to both disabilities, the provisions of 38 C.F.R. §§ 4.40 and 4.45 allow for consideration of any additional factors which affect functional use. For all the disabilities considered, VA's Schedule of Ratings provides criteria for higher schedular ratings but the Veteran has not met, or more closely approximated, the criteria for a higher schedular rating. In short, the Board finds that the assigned schedular evaluations for PTSD, bilateral knee disability and bilateral shoulder disability are adequate. As such, there is no basis for extraschedular referral in this case. See Thun, 22 Vet. App. at 114-15. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a TDIU is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In the instant case, the issue of entitlement to a TDIU has been separately appealed and is addressed in the remand section. Therefore, further consideration of such at this time is unnecessary. ORDER An initial rating in excess of 30 percent for PTSD is denied. An initial rating in excess of 10 percent for right knee strain is denied. An initial rating in excess of 10 percent for left knee strain is denied. An initial rating in excess of 10 percent for right shoulder strain is denied. An initial rating in excess of 10 percent for left shoulder strain is denied. REMAND The Board finds that additional development is warranted on the issues of entitlement to service connection for gastrointestinal, pulmonary disorder, bilateral hand, and cardiovascular disorders. Additionally, as the Veteran's claim for TDIU is inextricably intertwined with such claims, it must also be remanded. The Veteran primarily asserts that he manifests a gastrointestinal disorder, a pulmonary disorder, a bilateral hand disorder, and a cardiovascular disorder which first began in service. See Veteran's statement received May 2009. Thus, he seeks to establish service connection on a direct basis. See 38 U.S.C.A. § 1110. However, the Veteran has also alleged that these disabilities may be attributable to an undiagnosed illness based upon his tour of duty in Southwest Asia. See Veteran's statement received May 2009. Thus, he may also be able to establish service connection on a presumptive basis due to undiagnosed illness. See 38 U.S.C.A. § 1117. As will be discussed in more detail below, the Board finds that the Veteran should be afforded VA examinations so as to determine the nature and etiology of his claimed disorders. In this regard, the Board notes that the Veteran has previously been afforded VA examinations in March 2007 and March 2013; however, such examinations do not provide opinions sufficient to decide the issues. Gastrointestinal disorder The Veteran's STRs reflect his treatment for viral gastroenteritis (VGE) in September 2005. A June 2006 private medical record reflects that the Veteran reported a 3-month history of epigastric pain. He was prescribed Nexium based upon an assessment of gastritis. At his July 2006 separation examination, he reported a history of occasional sharp chest pains, but he denied other symptoms such as frequent indigestion or heartburn, trouble with his stomach, liver, intestinal trouble or ulcer. No chronic gastrointestinal disorder was found. Thereafter, VA clinic records reflect that, in January 2007, the Veteran was prescribed Ranitidine for epigastric pain assessed as likely gastritis versus peptic ulcer disease (PUD). The Veteran filed a service connection claim for "stomach (reflux)" and "parasites" in January 2007. On his original VA examination in March 2007, he described daily epigastric, abdominal or sub-sternal symptoms which had been treated with Ranitidine. His symptoms started 4 months previous after returning from the Philippines. In September 2006, his private physician advised him that he may have parasites. The examiner commented that the condition started after active service. A diagnosis of stomach condition of undetermined etiology was provided. Thereafter, VA clinic records in November 2007 reflect that the Veteran was taking over-the-counter (OTC) Tums to treat occasional reflux. In February 2008, the Veteran was prescribed Omeprazole based upon an impression of gastroesophageal reflux disease (GERD). At a March 2013 VA examination, the Veteran reported periodic abdominal pain. Here, the Veteran's private medical records include a June 2006 assessment of gastritis treated with Nexium. This treatment occurred during active service. Post-service, the Veteran has reported continued symptoms of epigastric distress which, more recently, has been diagnosed as GERD treated with Omeprazole. As the record suggests that the currently diagnosed GERD may have first manifested during active service, the Board finds that medical examination and opinion is required in this case. 38 U.S.C.A. § 5103A(d). Pulmonary disorder The Veteran's STRs reflect his treatment for bronchitis in October 2003 and pharyngitis in November 2003. In March 2005, he reported exposure to environmental pesticides, smoke from burning trash or feces, JP8 or other fuels, and industrial pollution during his tour of duty in Iraq from September 2004 to March 2005. At the time of his separation examination in July 2006, he had a history of cough for several weeks and was diagnosed with community acquired pneumonia. A March 2007 VA C&P examination provided a diagnosis of history of pneumonia, resolved. Thereafter, the Veteran reported an increased frequency of colds and flu's. See VA clinic record dated July 2008. At his March 2013 VA C&P examination, the Veteran reported 3 to 4 instances of bronchitis since service separation. The postservice treatment records for recurrent bronchitis after service reported by the Veteran are not associated with the claims folder. The RO should assist the Veteran in associating these records with the claims folder. Additionally, the Board requires medical examination and opinion to determine whether the Veteran manifests chronic bronchitis due to events during active service, to include his exposure to environmental hazards in Southeast Asia. 38 U.S.C.A. § 5103A(d). Bilateral hand disorder The Veteran filed a service connection claim for a bilateral hand condition approximately 4 months after discharge from active service. On his initial VA C&P examination in March 2007, the Veteran described a gradual, spontaneous onset of bilateral hand pain and weakness. The examiner stated that the Veteran's condition began in service, and diagnosed a bilateral hand strain. Post-service, the Veteran has described bilateral hand pain during combat service in Iraq which has increased in severity and frequency since service. See Veteran's statement received in June 2008. He used his hands operating a Humvee-mounted machine gun. Id. The Board finds that the Veteran's report of bilateral hand pain during combat is consistent with his known circumstances in service. See 38 U.S.C.A. § 1154(b) (a combat Veteran's assertions of an event during combat are to be presumed if consistent with the time, place and circumstances of such service). Thus, the Board requires medical examination and opinion to determine whether the Veteran manifests a bilateral hand condition due to events during active service. 38 U.S.C.A. § 5103A(d). Cardiovascular disorder The Veteran reported a history of occasional sharp chest pains on his July 2006 separation examination. On his initial VA examination in March 2007, he described spontaneous episodes of chest pain 1 to 5 times per month sometimes associated with shortness of breath, nausea and clamminess. A March 2007 VA C&P examination provided a diagnosis of history of chest pain of undetermined etiology. A VA C&P examination in March 2013 found no evidence of a current cardiovascular disorder. The Veteran reports being told that he has a malfunctioning heart valve. See Veteran's statement received in June 2008. He asserts that he has provided VA with a copy of a drawing made by a VA examiner of his cardiovascular abnormality, but the claims folder does not include this document. The record reflects that the Veteran underwent electrocardiograph examination at VA in March 2007 with the results stored in VistA. Unfortunately, the actual report is not associated with the claims folder. Similarly, a VA examiner reports that an echocardiogram was performed in November 2010 but those results are also not of record. These records must be obtained prior to any further appellate review. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (holding that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file). On remand, the Board also requires clarifying medical opinion as to the nature and etiology of the Veteran's chest pain complaints. In this respect, the Veteran has described PTSD-related panic attacks manifested by tachycardia, shakiness, shortness of breath and diaphoresis. See VA C&P examination report dated March 2013. He has also described GERD symptoms of epigastric distress and substernal chest pain. See VA C&P examination dated March 2007. Thus, the record suggests that his chest pain may be a symptom of psychiatric and/or gastrointestinal origin. Additionally, the March 2007 VA C&P examination diagnosis of history of chest pain of undetermined etiology calls into question as to whether chest pain may be service-connected as an undiagnosed illness under 38 U.S.C.A. § 1117. Thus, the Board requires clarifying medical opinion. TDIU As the outcome of the Veteran's service connection claims may impact his claim of entitlement to a TDIU, the latter claim is inextricably intertwined with the former claims and adjudication of such issue must be deferred until the agency of original jurisdiction (AOJ) has adjudicated the Veteran's claims for service connection. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). Accordingly, the case is REMANDED for the following action: 1. Associate with the claims folder clinic records of the Veteran's VA treatment since September 2008, to include the results from an EKG performed in March 2007 (reportedly stored in VistA) and the echocardiogram performed in November 2010. 2. Contact the Veteran and request him to identify any pertinent treatment records relating to his claims of service connection for a gastrointestinal disorder, a pulmonary disorder, a bilateral hand disability and a cardiovascular disorder to include: (a) his providers of treatment for his claimed recurrent bronchitis episodes after service and (b) a copy of the reported drawing made by a VA examiner of his cardiovascular abnormality. Thereafter, obtain all identified records. All reasonable attempts should be made to obtain any identified records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C.A. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 3. After all outstanding records have been associated with the claims file, the Veteran should also be afforded appropriate VA examination(s) to determine the current nature and etiology of his claimed gastrointestinal disorder, pulmonary disorder, bilateral hand disorder, and cardiovascular disorder. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. Gastrointestinal disorder The examiner should specifically state whether the Veteran's gastrointestinal symptoms are attributed to a known clinical diagnosis. If diagnosed disorder(s) are established, the examiner should render an opinion as to whether it is at least as likely as not that any such disorder had its onset during any period of the Veteran's active duty service or is otherwise related to such service. In answering this question, the examiner's attention is directed towards the Veteran's June 2006 private treatment for a 3-month history of epigastric pain diagnosed as gastritis and treated with Nexium and his subsequent diagnosis of GERD treated with Omeprazole in November 2007. If the Veteran's gastrointestinal symptoms cannot be ascribed to any known clinical diagnosis, specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. Furthermore, the examiner should clarify whether there is any medical reason to accept or reject the Veteran's report of a parasite infection incurred during active service? The rationale for any opinion offered should be provided. Pulmonary disorder The examiner should specifically state whether the Veteran's pulmonary symptoms are attributed to a known clinical diagnosis. If diagnosed disorder(s) are established, the examiner should render an opinion as to whether it is at least as likely as not that any such disorder had its onset during any period of the Veteran's active duty service or is otherwise related to such service, to include his reported exposures to environmental pesticides, smoke from burning trash or feces, JP8 or other fuels, and industrial pollution during his tour of duty in Iraq from September 2004 to March 2005. In answering this question, the examiner's attention is directed towards the Veteran's report of recurrent bronchitis infections since his discharge from active service. If the Veteran's pulmonary symptoms cannot be ascribed to any known clinical diagnosis, specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. The rationale for any opinion offered should be provided. Bilateral hand disorder The examiner should specifically state whether the Veteran's bilateral hand symptoms are attributed to a known clinical diagnosis. If diagnosed disorder(s) are established, the examiner should render an opinion as to whether it is at least as likely as not that any such disorder had its onset during any period of the Veteran's active duty service or is otherwise related to such service, to include his accepted history of bilateral hand pain while performing machine gun duties in combat and consideration of the diagnosis of bilateral hand strain on VA examination in March 2007. If the Veteran's bilateral hand symptoms cannot be ascribed to any known clinical diagnosis, specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. The rationale for any opinion offered should be provided. Cardiovascular disorder The examiner should specifically state whether the Veteran's cardiovascular symptoms are attributed to a known clinical diagnosis. If diagnosed disorder(s) are established, the examiner should render an opinion as to whether it is at least as likely as not that any such disorder had its onset during any period of the Veteran's active duty service or is otherwise related to such service, to include his report of recurrent chest pain since service and his report of being diagnosed with a heart valve abnormality. If the cardiovascular symptoms cannot be ascribed to any known clinical diagnosis, specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. Furthermore, the examiner should clarify whether there the Veteran's report of recurrent chest pain may be attributable to PTSD-related panic attacks manifested by tachycardia, shakiness, shortness of breath and diaphoresis, or GERD symptoms of epigastric distress and substernal chest pain? The rationale for any opinion offered should be provided. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. His service connection claims should be considered on both a direct basis and due to an undiagnosed illness. If any claim remains denied, the Veteran and his representative should be issued a SSOC. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs