Citation Nr: 1337670 Decision Date: 11/19/13 Archive Date: 12/06/13 DOCKET NO. 09-07 852 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for a nose bleed disorder. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for peripheral vascular disease (PVD) of the bilateral upper extremities. 4. Entitlement to a higher initial rating for service connected diabetes mellitus, Type II, currently rated as 20 percent disabling. 5. Entitlement to a higher initial rating for service connected peripheral neuropathy and radiculopathy of the left lower extremity, currently rated as 10 percent disabling prior to January 31, 2012 and 20 percent disabling thereafter. 6. Entitlement to a higher initial rating for service connected peripheral neuropathy of the right lower extremity, currently rated as 10 percent disabling. 7. Entitlement to a higher initial rating for service connected onychomycosis, currently rated as noncompensable. 8. Entitlement to a higher initial rating for service connected hypertension, currently rated as noncompensable. 9. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. ATTORNEY FOR THE BOARD C. D. Simpson, Counsel INTRODUCTION The Veteran had active duty service from August 1962 to November 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2006 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA) in San Diego, California, which denied service connection for a nose bleed disorder, tinnitus, PVD, prostate disorder, posttraumatic stress disorder (PTSD), and a low back disability. It assigned initial ratings for diabetes, peripheral neuropathy of the lower extremities, and onychomycosis. The Veteran also appealed a January 2009 RO decision that awarded service connection for hypertension with an initial noncompensable rating. In February 2009, the RO awarded service connection for prostate cancer. As the rating action results in a full grant of the benefit sought (i.e. service connection), this issue is no longer on appeal. The Veteran was afforded an August 2009 RO hearing. The hearing transcript is associated with claims folder. In August 2012, the RO recognized radiculopathy, in addition to peripheral neuropathy, of the left lower extremity and awarded a 20 percent rating beginning January 31, 2012. As higher schedular ratings are available, the issue remains on appeal. This decision also awarded service connection for posttraumatic stress disorder (PTSD) and a low back disability. As the rating action results in a full grant of the benefit sought for these issues (i.e. service connection), they are no longer on appeal. In his January 2013 substantive appeal for hypertension, the Veteran requested a RO hearing. He withdrew his request in April 2013. Review of the record shows that the Veteran has not been gainfully employed throughout the claims period and he asserts it is due to service connected disabilities. Entitlement to TDIU is raised as part of the initial rating claims, and it is included on appeal as set forth on the title page above. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A review of the Virtual VA paperless claims processing system shows that updated VA treatment records are of record. The RO considered these updated VA treatment records in the August 2012 Supplemental Statement of the Case (SSOC) and the April 2013 SSOC for hypertension. The issues of service connection for nose bleeds and a higher initial rating for hypertension is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, his current tinnitus is attributable to in-service noise exposure. 2. Current peripheral vascular disease in either upper extremity has not been demonstrated at anytime during the claims period. 3. The Veteran has not had physician indicated regulation of activities due to diabetes mellitus, Type II. 4. The Veteran's peripheral neuropathy and radiculopathy of the left lower extremity has been manifested by incomplete paralysis of the nerve with primarily sensory disturbances and slight loss of strength and reflexes; skin changes, muscle atrophy, motor loss, or paralysis have not been shown on clinical examination. Beginning January 31, 2012, neurological impairment was clinically characterized as moderate. 5. The Veteran's peripheral neuropathy of the right lower extremity has been manifested by incomplete paralysis of the nerve with primarily sensory disturbances and slight loss of strength and reflexes; skin changes, muscle atrophy, motor loss, or paralysis have not been shown on clinical examination. 6. Throughout the initial rating period on appeal, onychomycosis on the toes of both feet is productive of a fungal infection of less than 5 percent of the total body area. 7. Beginning March 24, 2006, the Veteran's combined disability rating is 80 percent, with posttraumatic stress disorder (PTSD) rated as 50 percent disabling, meeting the schedular TDIU criteria throughout the entire claims period. 8. The Veteran is not gainfully employed and his service-connected PTSD, in addition to various additional service connected disabilities, precludes him from obtaining and retaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for tinnitus have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303 (2013). 2. The criteria for service connection for peripheral vascular disease of the upper extremities have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303 (2013). 3. The criteria for an initial rating in excess of 20 percent for service connected diabetes mellitus, Type II have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.119, Diagnostic Code 7913 (2013). 4. The criteria for higher initial rating of 10 percent prior to January 31, 2012 and 20 percent thereafter for left lower extremity peripheral neuropathy and radiculopathy have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.123, 4.124, 4.124a, Diagnostic Codes 8520, 8521 (2013). 5. The criteria for an initial rating in excess of 10 percent for right lower extremity peripheral neuropathy have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.123, 4.124, 4.124a, Diagnostic Code 8521 (2013). 6. The criteria for a compensable rating for onychomycosis on the toes of both feet have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.118, Diagnostic Codes 7806, 7820 (2013). 7. The criteria for entitlement to TDIU are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). In light of the fully favorable determination for tinnitus and TDIU, no further discussion of compliance with VA's duty to notify and assist is necessary for these issues. Proper VCAA notice must inform the claimant of any information and evidence not of 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. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2013); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Pelegrini, the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). For the issues of higher initial ratings for diabetes, peripheral neuropathy of the lower extremities, and onychomycosis, the appeal arises from disagreement with the initial ratings following the grants of service connection. The courts have held that once service connection is granted, the claim is substantiated. Additional VCAA notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Nevertheless, the record indicates that the Veteran was provided with adequate VCAA notice in September 2006. Specifically, the RO notified the Veteran of information and evidence necessary to substantiate his service connection claims, including notice of disability ratings and effective dates. He was notified of the information and evidence that VA would seek to provide and the information and evidence that he was expected to provide. In June 2008 and March 2009, he received additional information about how to substantiate increased rating claims. The duty to notify has been met. The Board further concludes that the duty to assist has also been met. The Veteran's service treatment records, VA treatment records, private medical records, and Social Security Administration (SSA) records have been obtained. He was afforded appropriate VA examinations, and relevant opinions have been obtained from the examiners after a review of the claims folder. There is no indication that his service connected disabilities have materially increased in severity since his most recent VA examinations in December 2010 for diabetes, peripheral neuropathy, and onychomycosis and in January 2012, which included a neurological assessment for lower extremity radiculopathy. The Court has held that the provisions of 38 C.F.R. § 3.103(c)(2) (2013) impose two distinct duties on VA employees in conducting hearings: The duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam); See also 77 Fed. Reg. 23128-01 (April 18, 2012). At the August 2009 RO hearing, the Decision Review Officer (DRO) identified the issues on appeal. The Veteran provided testimony as to all treatment received for his claimed disabilities and, thereby, demonstrated actual knowledge of the ability to submit additional relevant evidence. Based in part upon his hearing testimony, VA obtained updated medical records and furnished updated VA examinations. The duties imposed by Bryant were thereby met. There is no indication that there is any relevant evidence outstanding in these claims, and the Board will proceed with consideration of the Veteran's appeal. II. Service connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (2013). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A disability may be service connected if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2013). Moreover, in general, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310(b) (2013). The Board notes that there has been an amendment to the provisions of 38 C.F.R. § 3.310 during the pendency of the Veteran's claim. See 71 Fed. Reg. 52744 -47 (Sept. 7, 2006) (codified at 38 C.F.R. § 3.310 (2013)). However, as service connection is not being granted on the basis of aggravation further discussion of the amendments would serve no useful purpose. The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). Although the Veteran is competent in certain situations to identify a simple condition such joint pain or dyspnea, he is not competent to provide evidence as to more complex medical questions. Id.; see also Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. Layno v. Brown, 6 Vet. App. 465, 469 (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). (i) Tinnitus There were no complaints or findings of tinnitus in the service treatment records (STRs). Service personnel records confirm that the Veteran worked in auxiliary equipment repair and served in Vietnam. He is competent to report his recollections of in-service acoustic trauma. Given his Vietnam service, the Board considers his reports of in-service acoustic trauma credible. The August 2006 VA examination report shows that Veteran denied any post service noise exposure. The examiner diagnosed tinnitus, but concluded that the date of onset was unknown based upon review of prior records. In contrast, January 2009 VA primary care treatment records reflect that the examiner believed the Veteran's tinnitus was likely related to noise exposure since inner ear pathology was not found. At the August 2009 RO hearing, the Veteran reported that tinnitus started in Vietnam when he was constantly exposed to gunfire. In summary, the record contains credible evidence of in-service acoustic trauma and current disability. The remaining issue is a nexus. At the hearing, the Veteran asserted tinnitus began in service and recounted in-service incidents of acoustic trauma. VA treatment records from January 2009 suggest that the Veteran's tinnitus is likely related to acoustic trauma. The evidence does not otherwise suggest that the Veteran had any post service acoustic trauma. Resolving all doubt in the Veteran's favor, the Board finds the above cited evidence sufficient to show a nexus to in-service acoustic trauma and service connection for tinnitus is granted. See 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. at 55-57. (ii) Peripheral vascular disease (PVD) of both upper extremities For background purposes, the June and September 2006 claims do not specifically mention peripheral vascular disease (PVD). Rather, the Veteran described symptoms of hand weakness and swelling and identified peripheral neuropathy as a claimed disability. In the appealed December 2006 decision, the RO characterized the issues as separate service connection claims for peripheral neuropathy of the upper extremities, which was granted, and PVD of the upper extremities, which was denied. The Veteran timely appealed. STRs are negative for any vascular disorder of the upper extremities. The Veteran's September 1969 Report of Medical History does not suggest that he had any vascular disorder. Accordingly, his contemporaneous clinical examination for separation reflects that his vascular system was clinically examined and found to be normal. The Veteran was afforded a comprehensive VA diabetes examination in June 2006. He reported having tingling and numbness in his fingers. However, the examiner noted the objective findings were uncertain, given the Veteran's varying response. Clinical examination also showed that peripheral arteries were intact and there was no evidence of peripheral edema. In response to diabetic complications, the examiner responded that the Veteran had no known PVD and vascular disorder was not listed as a diagnosis. Rather, the examiner diagnosed peripheral neuropathy for the Veteran's upper extremity symptoms. Review of private and VA treatment records throughout the claims period do not show any PVD diagnosis for the upper extremities. VA diabetes examination from May 2009 reflected that the Veteran had upper extremity peripheral neuropathy secondary to diabetes. Neurological examination of the upper extremities showed that his hands were warm with excellent pulsations. He did not have any noticeable skin disorder. The examiner continued the peripheral neuropathy diagnosis and did not list PVD as a diabetic complication. At the August 2009 RO hearing, the Veteran described having sensory disturbances in his upper extremities. He reported that his physician had diagnosed peripheral neuropathy. He was unsure if his physician had also diagnosed PVD. The Veteran had another VA diabetes examination in December 2010. He continued to have neurological symptoms in his hands. No evidence of any diabetic related skin disorder (diabetic dermopathy) was observed. He had normal radial pulses. The examiner continued to the peripheral neuropathy diagnosis and did not list PVD as a diabetic complication. The most recent VA treatment records from 2012 and 2013 are similarly negative for findings or diagnosis of PVD for the upper extremities. The Veteran contends service connection is warranted for PVD of the upper extremities. Although he is competent to describe observable symptoms, he has not been shown to be a medical professional and is not competent to diagnose PVD or its cause. See Jandreau, 492 F.3d at 1376, 1377 (layperson competent to identify simple conditions such a broken leg, but not complex conditions such as cancer). His lay reports self diagnosing PVD have no probative value. Id. Meanwhile, the competent medical evidence indicates that PVD has not been present at anytime during the claims period. See June 2006, May 2009, and December 2010 VA diabetes examination reports; see generally VA treatment records from 2007-2013. Without probative evidence of current diagnosis, service connection for PVD of the bilateral upper extremities is denied. Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); McLain v. Nicholson, 21 Vet. App. 319 (2007). III. Increased ratings Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). Because the Veteran is challenging the initially assigned disability ratings, it has been in continuous appellate status since the original assignment of service connection. The evidence to be considered includes all evidence proffered in support of the original claim. Fenderson v. West, 12 Vet. App. 119 (1999). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (i) Diabetes, currently 20 percent disabling Diabetes mellitus is evaluated under 38 C.F.R. § 4.119, Diagnostic Code (DC) 7913 (2013). Under DC 7913, a 20 percent rating is assigned when there is evidence that the Veteran's diabetes requires the use of insulin or oral hypoglycemic agent, and a restricted diet. A 40 percent evaluation is assigned for diabetes that requires insulin, a restricted diet, and regulation of activities. A 60 percent rating is assigned when there is also evidence of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider plus complications that would not be compensable if separately evaluated. Id. "Regulation of activities" has been defined as the situation where the Veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996) (defining "regulation of activities," as used by VA in Diagnostic Code 7913). In order to show "regulation of activities" there must be medical evidence that it is necessary for a claimant to avoid strenuous occupational and recreational activities. Camacho v. Nicholson, 21 Vet. App. 360, 365 (2007). The United States Court of Appeals for the Federal Circuit has specifically affirmed that for disability rating criteria, such as DC 7913, written in the conjunctive, a veteran must demonstrate all of the required elements in order to be entitled to that higher evaluation and 38 C.F.R. § 4.7 cannot be used to circumvent the need to demonstrate all required criteria. Middleton v. Shinseki, 727 F.3d 1172 (Fed. Cir. 2013). In addition, a note following the rating criteria indicates that compensable complications from diabetes mellitus are evaluated separately unless they are part of the criteria used to support a 100 percent evaluation. Noncompensable complications are considered part of the diabetic process under DC 7913. The Veteran had a June 2006 VA diabetes examination. He reported being diagnosed with diabetes in 1996. He had not had ketoacidosis, hyperglycemic reaction, or hospitalizations. He was not on insulin, nor did he have any restriction on his activities. However, he was on a restrictive diet and placed on Glipizide 5 milligrams (mg) and Metformin 850 mg. The examiner identified diabetic complications of peripheral neuropathy, onychomycosis, and erectile dysfunction. He maintained the diabetes mellitus, Type II diagnosis. VA primary care treatment records from July 2007 show that the Veteran met his blood glucose (A1C) goals on Metformin 1000 mg and Glipizide 7.5 mg regimen. Private medical records also dated in July 2007 reflect that the Veteran checked his blood sugar once a day. He walked about twice per week for exercise and watched his diet. Blood glucose (A1C) was 6.6 percent. The examiner commented that there was significant diabetic improvement and control. She encouraged the Veteran to exercise more. Private medical records from April 2008 show that the Veteran's diabetes was assessed as fairly well controlled and he was encouraged to exercise. In June 2008, the Veteran underwent another VA diabetes examination with review of the claims folder. He again denied ketoacidosis, hyperglycemic reaction, or hospitalizations for diabetes. He continued to have a restricted diet and continued Metformin 1000 mg and Glipizide 7.5 mg regimen. His weight was stable. He denied any restriction of activity due to diabetes. He walked for exercise, but was limited in doing so due to knee and back pain. He sought medical attention for diabetes management on a six month basis. The examiner continued the established diabetes diagnosis. In June 2008, the Veteran also reported his diabetes was uncontrolled based upon recent at home blood sugar readings. Private medical records from July 2008 reflect that the Veteran had increasing blood sugars over the past few months. He did not believe the recent increase in Glipizide to 10mg had been effective. The examiner assessed deteriorating blood glucose control. He commented that it may be related to stress over the recent prostate cancer diagnosis. Also, he noted that blood sugar control tends to deteriorate over time. He suggested increasing Glipizide to 15 mg. VA treatment records from January 2009 showed that fasting serum glucose (FSG) was slightly high, but blood sugar glucose (A1c) was 6.7 percent. The examiner continued the Metformin 1000 mg and Glipizide 10 mg regimen. He noted to consider insulin as the next step. VA reexamined the Veteran for diabetes in May 2009. He reported that he restricted some activities due to peripheral neuropathy. The clinical findings were relatively unchanged from June 2008, although he had started seeking medical attention four times per year. The examiner reaffirmed the prior diabetes diagnosis. He commented that the Veteran was essentially the same as he was a few years ago, except for slightly advanced neuropathy. VA treatment records dated in June 2009 reflect that the Veteran's diabetes was poorly controlled and added Pioglitazone medication for diabetic control. At the August 2009 RO hearing, the Veteran reported that while he was not on insulin, his medications had increased. He participated in hydrotherapy since he could not exercise due to back pain. When queried about regulation in activities, he stated that he had bladder problems. VA treatment records from October 2009 show that the Veteran's diabetes control was stable. He checked his blood sugars twice a week. In March 2010, VA treatment records show that the Veteran continued the Metformin 1000 mg, Glipizide 10 mg, and Pioglitazone 15mg medication regimen. The Veteran was found to have elevated blood sugar glucose (A1c). Pioglitazone was increased to 30 mg per day. In July 2010 the examiner determined that the current medication regimen was insufficient and added insulin (Glargine) every evening. VA treatment records from August 2010 show that the Veteran did not have hypoglycemia problems. He had not made any dietary changes and was unable to exercise due to arthritis. The examiner commented that the Veteran had improved blood sugar control with newly added insulin. She told the Veteran to check his blood sugar before driving. VA treatment records from November 2010 show that the Veteran had improved diabetes control. He was carefully watching his diet and participating in exercise classes. VA notes from January and March 2011 reflect similar findings. VA reexamined the Veteran for diabetes in December 2010. He had quarterly medical follow up for diabetes management. He checked his glucose at home and it ranged between 130 and 180. He avoided red meat and carbohydrates, but did not have a calorie restriction. He denied any diabetic complication restricting his activities. The examiner diagnosed diabetes with peripheral neuropathy complication. VA notes from January and March 2011 reflect that the Veteran was encouraged to continue his diet and exercise to further improve his glycemic control. VA treatment records from December 2011 show that the Veteran had low fasting blood sugars. He had stopped taking Glipizide and Pioglitazone. He used Prazosine as needed. He continued to have a dietary regimen. The examiner assessed morning hypoglycemia asymptomatic episodes. In January 2012, VA treatment records show that the Veteran's diabetes was not well controlled citing high blood sugar readings. However, the Veteran had a stable weight and denied any recent dietary changes. He was given increased insulin medication. He returned to the clinic the following month. His blood sugar had decreased. He detailed his home glucose monitor report and stated that he walked once a week. The examiner assessed the Veteran as doing fairly well and instructed him to titrate his insulin as needed. VA treatment records from April 2012 show that the Veteran had significantly varying blood sugars due to diet and insulin dosing. The examiner recommended a fixed insulin dose and consistent diet. The goal was to taper off insulin. VA treatment records from February 2013 reflect that the Veteran's blood sugar was at goal. He had restarted insulin and Metformin. He was encouraged to work on his diet and exercise. The Veteran contends a rating in excess of 20 percent is warranted. As noted above, each separate element of insulin, restricted diet, and regulation of activities must be met for a 40 percent rating. Middleton, 727 F.3d 1172; 38 C.F.R. § 4.119 DC 7913. The Veteran has demonstrated a restricted diet and beginning in July 2010, insulin use. The remaining issue is whether the Veteran has met the regulation of activities element. This element must be demonstrated through medical evidence. Camacho, 21 Vet. App. 365; 61 Fed. Reg. 20,440, 20, 446 (May 7, 1996). As the Veteran is not shown to be a medical professional, he is not competent to report on this matter and to the extent he asserts self regulation of activities, such reports have no probative value in the context of the applicable rating criteria. Id.; Layno, 6 Vet. App. at 469. VA examination reports from June 2006, June 2008, May 2009, and December 2010 show that the Veteran did not have any restriction on activities due to diabetes. Moreover, various treatment records reflect that either treating clinicians encouraged the Veteran to exercise or that he had reported exercising. (See Private medical records dated July 2007 and April 2008; VA treatment records from November 2010, January and March 2011, January 2012, and February 2013). At best, the August 2010 clinician suggested that the Veteran check his blood sugar prior to driving. However, he has never been instructed by a clinician not to drive or specifically not to participate in any activity. Given the evidence above, medically indicated regulation of activities has not been shown to meet the regulation of activities element for a 40 percent rating under DC 7913. Camacho, 21 Vet. App. 365; Middleton, 727 F.3d 1172; 38 C.F.R. § 4.119 DC 7913. A rating in excess of 20 percent for service connected diabetes is denied. Id. (ii) Peripheral neuropathy of the lower extremities The Veteran is service connected for bilateral lower extremity peripheral neuropathy, with each extremity separately rated. He is currently assigned a 10 percent initial rating prior to January 31, 2012, and a 20 percent rating thereafter under Diagnostic Codes (DC) 8521-8520 for the left lower extremity, which is also inclusive of sciatic nerve impairment due to radiculopathy. 38 C.F.R. § 4.124a, DCs 8520, 8521. A 10 percent initial rating is assigned for peripheral neuropathy of the right lower extremity. 38 C.F.R. § 4.124a, DC 8521. Disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. Id. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, atrophic changes, or sensory disturbances. 38 C.F.R. § 4.120. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. 38 C.F.R. § 4.124 (2013). DC 8520 provides an 80 percent rating for complete paralysis of the sciatic nerve, contemplated by foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. A 60 percent rating is warranted for severe incomplete paralysis with marked muscle atrophy. Ratings of 10 percent, 20 percent and 40 percent are assignable for incomplete paralysis that is mild, moderate or moderately severe in degree, respectively. 38 C.F.R. § 4.124a, DC 8520. Under DC 8521, a 10 percent rating is for mild incomplete paralysis of the peroneal nerve. A 20 percent rating is warranted where there is moderate incomplete paralysis. A 30 percent rating is assigned for severe incomplete paralysis, and a 40 percent rating is for application where there is severe complete paralysis of the external popliteal nerve manifested by foot drop and slight droop of first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of foot lost, adduction weakened; anesthesia covers entire dorsum of foot and toes. 38 C.F.R. § 4.124a, DC 8521. The words "moderate" and "severe" are not defined in 38 C.F.R. §§ 4.120-4.124a. As noted, in applying the schedular criteria for rating peripheral nerve disabilities, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The Veteran underwent a VA diabetes examination in June 2006. He reported having tingling and numbness in his legs. Clinical examination confirmed decreased sensory perception to pinprick and touch in his feet and toes. However, proprioception was normal. The examiner diagnosed peripheral neuropathy in both legs secondary to diabetes. VA primary care treatment records from July 2007 show that he had sensation intact to light touch. He exhibited full deep tendon reflexes at the ankle and patella. In May 2008, the Veteran visited the VA neurology clinic to address headache complaints. He exhibited full motor strength in all tested movements and had intact sensation for his lower extremities. Reflexes were normal. He had no gait or ambulatory difficulty. VA reexamined the Veteran for diabetes in June 2008. He reported experiencing intermittent numbness in his lower extremities. Neurological examination showed normal light touch with minimal decreased pinprick in both lower extremities. The examiner declined to diagnose peripheral neuropathy based upon the recent negative EMG study. A September 2008 VA neurology clinic note reflects that the Veteran had problems maintaining balance due to proprioception. Given the negative indication from diagnostic testing, vascular causes were ruled out and the Veteran was referred back to his primary care physician. At his October 2008 VA primary care visit, the Veteran complained about foot numbness, particularly in the morning. Clinical examination showed diminished monofilament to the shins. VA primary care clinic records from January 2009 reflect that the Veteran had 4/5 strength in hip flexion, knee flexion, and knee extension bilaterally. The examiner noted that the Veteran's low back pain may also have a neuropathic component. VA neurology clinic records from January 2009 include an EMG study. The findings were normal. While generalized large fiber sensorimotor polyneuropathy was definitely excluded, a small fiber neuropathy was possible. The examiner commented that there was no change since June 2008 and there was no neurophysiologic evidence of chronic lumbosacral radiculopathy. In March 2009, VA primary care notes show that the Veteran complained about intermittent numbness and tingling in both lower extremities with the right leg being greater than the left leg. Clinical examination showed symmetric deep tendon reflexes. The Veteran was afforded a May 2009 VA diabetes examination. He reported restricting his activities due to peripheral neuropathy of the lower extremities. Clinical examination showed a "stocking-like" decrease in sensation bilaterally over the toes and feet to approximately three inches above the malleoli. He had 1+ pretibial edema. He also had loss of vibratory sensation and proprioception in both legs. The examiner continued the peripheral neuropathy diagnosis and noted loss of proprioception and vibratory sensation of the feet and ankles. He described the lower extremity neuropathy as "slightly advanced." VA treatment records from August 2009 reflect that the Veteran had uncontrolled low back pain. He also complained about painful numbness and electrical sensations in his legs. He was diagnosed with radiculopathy. At the August 2009 hearing, the Veteran reported that his lower extremity neuropathy was increasing in severity. He cited that the episodes of numbness and tingling had become more frequent to where it occurred on a daily basis. He stated that he had lost his balance and avoided walking where possible. In October 2009 VA notes, the examiner found hyperesthesia on the Veteran's feet and legs. He further commented that weakness was not found and skin remained intact. Dorsal pedis and posterior tibialis pulses were intact. The Veteran had normal monofilament sensation, but it elicited excess tingling. The examiner diagnosed hyperesthesia neuropathy and recommended capsaicin cream. At the March 2010 VA visit, the Veteran reported that the capsaicin cream helped alleviate his neuropathic foot pain. VA treatment records from July, August, and October 2010 reflect that the Veteran's peripheral neuropathy was assessed as stable. The Veteran had a December 2010 VA diabetes examination. He reported having numbness and tingling in his feet. He did not take any medication for it. Clinical examination showed full strength for both lower extremities. He had full reflexes for the knee and 1+ reflex for the ankles bilaterally. He had decreased sensation to pinprick in stocking and glove distribution. The examiner assessed peripheral neuropathy. In January 2011, VA endocrine clinic records showed that the Veteran complained about worsening peripheral neuropathy. He described having constant numb, tingling sensations. Clinical examination showed decreased fine pinpoint sensations in both feet. Pressure and gross sensation was intact. The examiner assessed worsening peripheral neuropathy and recommended medication. The Veteran revisited the VA endocrine clinic in April 2011. He endorsed worsening peripheral neuropathy symptoms, described as numbness and tingling. Limited clinical examination was negative for foot ulcers. In the addendum, the examiner noted that the Veteran had difficulty with neuropathic medication. He recommended daily foot examinations. VA treatment records from December 2011, January 2012, February 2012, and April 2012 reflect that the Veteran's peripheral neuropathy was assessed as stable. In January 2012, the Veteran underwent a neurology examination as part of VA lumbar spine examination. He demonstrated 4/5 strength in both lower extremities. Muscle atrophy was not found. He had full reflexes. Light touch sensation was decreased in his left thigh, knee, calf, and ankle. It was normal for his right leg and left upper anterior thigh and feet. Straight leg raise test was positive for his left leg and negative for his right leg. The examiner characterized the Veteran as not having constant or intermittent pain. However, he assessed moderate parethesias and numbness in the left leg due to sciatic nerve involvement. He noted that the Veteran regularly used a cane. The Veteran contends higher initial ratings are warranted for peripheral neuropathy of the lower extremities. As detailed below, the Board does not find higher initial ratings are not warranted for either extremity. 38 C.F.R. § 4.124a, DCs 8520, 8521. For both legs, the symptoms demonstrated throughout the appeals period include pain, sensory disturbances and occasional hypo reflexes and slight (4/5) motor weakness. (See VA examination reports from June 2006, June 2008, May 2009, December 2010, and January 2012; VA treatment records from May 2008, September 2008, January 2009, March 2009, October 2009, March 2010, January 2011, April 2011, December 2011, January 2012, and February 2012). The symptoms for either lower extremity do not include muscle atrophy, weakness beyond scaled 4/5 strength, skin changes, significant loss of reflexes, or paralysis. The January 2012 VA examiner specifically characterized the left lower extremity disability as moderate. For these reasons, the criteria for a "severe" or "moderately severe" neurological disability are not met for either lower extremity at anytime during the appeals period and rating in excess of 20 percent is not warranted. See id.; 38 C.F.R. §§ 4.123, 4.124, 4.124a, DC 8520, 8521. The evidence shows the first report of an increase in disability occurred in May 2009. Prior to May 2009, the Veteran's primary symptom was intermittent sensory disturbance. Notably, January 2009 VA primary care notes do not even list peripheral neuropathy as a current problem. Rather, his lower extremity complaints are characterized as a radicular component to his low back pain. At that time, he describes radicular radiation of low back pain, but radiculopathy was excluded on EMG testing. The additional evidence prior to May 2009 does not otherwise suggest ongoing neurological symptoms beyond sensory disturbances. For these reasons, an initial rating in excess of 10 percent for "mild" peripheral neuropathy of the right lower extremity and radiculopathy/ peripheral neuropathy of the left lower extremity are not approximated prior to the first report of increase in May 2009. 38 C.F.R. §§ 4.124a, DC 8520, 8521. The May 2009 VA examination report suggests that the Veteran's lower extremity neuropathy had slightly increased with the additional of proprioception problems and loss of vibratory sense. The Veteran provided a similar report at the August 2009 hearing, specifically citing his ambulatory limitations due to loss of proprioception. However, at the hearing, he also reported a restriction in activities due to low back pain and in August 2010 identified arthritis, rather than peripheral neuropathy, as his obstacle to exercise. In December 2010, he denied any diabetic complication restricting his activities. (See December 2010 VA diabetes examination report). Notably, October 2009 VA clinical findings do not show weakness, skin changes, or significant loss of reflexes. Reports from July, August, and October 2010 reflect a stable assessment of neuropathic symptoms. These reports conflict with his August 2009 lay assertion that peripheral neuropathy symptoms were productive of ambulatory impairment or additional impairment in activities of daily living. While clinical findings from December 2010 show sensory disturbances and hypo ankle reflexes, the Veteran continued to exhibit full motor strength without atrophic changes. In sum, the reports after August 2009 reflect that the Veteran did not have additional non-sensory impairments, such as loss of motor strength, skin problems, atrophic changes, or significant loss of reflexes. Several reports from 2010 show his symptoms had stabilized. As noted above, his 2009 lay reports of ambulatory difficulties posing additional impairment in activities of daily living conflict with additional evidence of record. For these reasons, the Board declines to assign a rating in excess of 10 percent based upon the 2009 reports of increased disability alone. See id. The Veteran's January and April 2011 reports also indicate that the level of sensory disturbance had again increased. He then described his sensory disturbances as constant. Subsequent findings from April 2011 assessed his neuropathy as stable. (See VA treatment records from December 2011, January, February, and April 2012). The first objective finding of additional non-sensory impairment was at the January 2012 VA examination, which showed slight loss of motor strength (4/5) in both legs. However, he had full reflexes. Muscle atrophy or noticeable skin change was not observed. Moreover, the sensory impairment found in January 2012 was normal for the upper anterior thigh, right knee, right ankle, and both feet. Again, despite the Veteran's assertions of increased disability, the subsequent clinical findings and assessments above do not approximate moderate incomplete paralysis for the left leg prior to January 31, 2012 or for the right leg at anytime. 38 C.F.R. §§ 3.102, 4.7, 4.123, 4.124, 4.124a, DC 8520, 8521. In summary, the Board declines to assign a 20 percent rating for the left leg prior to January 31, 2012 or a rating in excess of 10 percent rating for the right leg. Id. The claims for higher initial ratings for the left and right lower extremities are denied. (iii) Onychomycosis The Veteran is service connected for onychomycosis in both feet as secondary to diabetes. It is currently rated as noncompensable under DC 7806-7820. 38 C.F.R. § 4.118. He contends a compensable rating is warranted. DC 7820 states that infections of the skin are to be rated as disfigurement of the head, neck, or face (DC 7800), scars (DCs 7801-7805), or dermatitis (DC 7806), depending on the predominant disability. See 38 C.F.R. § 4.20 (2013) (when an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology, are closely analogous). As the Veteran's predominant disability manifests itself as a skin infection of the feet, the disorder is evaluated under 38 C.F.R. § 4.118, DC 7806. In relevant part, DC 7806 provides a noncompensable evaluation for dermatitis or eczema involving less than 5 percent of the entire body, or less than 5 percent of exposed areas affected, and no more than topical therapy was required during the prior 12-month period. A 10 percent disability evaluation is assigned if there is dermatitis or eczema of at least 5 percent of the entire body, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent of the exposed affected areas, or intermittent systemic therapy, such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the prior 12-month period. See 38 C.F.R. § 4.118, DC 7806 (2013). The June 2006 VA diabetes examination report shows that the Veteran had onychomycosis on the first, third, and fifth nails of both feet. The examiner diagnosed bilateral onychomycosis due to diabetes mellitus, Type II. At the June 2008 VA diabetes examination, the Veteran reported having fungal infection in his toenails. He denied any functional impairment. Clinical examination showed bilateral onychomycoses involving less than one percent of total body area and no exposed areas. VA treatment records from November 2008 show onychomycosis without skin breaks. The May 2009 VA diabetes examination report reflected continued onychomycosis on the first, third, and fifth nails of both feet. The examiner characterized it as stable. At the August 2009 hearing, the Veteran reported that his onychomycosis had increased in severity. He continued to use topical powder treatment. The Veteran had a VA annual diabetic foot screen in October 2009. The examiner did not find skin changes. She noted that sensation was intact to monofilament testing, and pulses were palpable. The December 2010 VA diabetes examination report showed that the Veteran had onychomycosis since the 1980s. He had tried topical medication without improvement. He denied any function impairment from it. Clinical examination again showed bilateral onychomycoses involving less than one percent of total body area and no exposed areas. VA treatment records from December 2011 reflect that the Veteran has "some" onychomycosis bilaterally. In short, the record does not show that the Veteran had onychomycosis over at least 5 percent of his entire body or at least 5 percent of an exposed area at anytime during the claims period. Thus, the criteria for a compensable disability evaluation under DC 7806 are not approximated. 38 C.F.R. § 4.118, DC 7806-7820. A compensable rating for onychomycosis is denied. Id. Extraschedular considerations The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board finds that the severity of the Veteran's service-connected diabetes mellitus, Type II, peripheral neuropathy and radiculopathy of the left lower extremity, peripheral neuropathy of the right lower extremity, and onychomycosis are fully contemplated by the applicable rating criteria, whether considered separately or in the context of additional service connected disabilities. Mittleider v. West, 11 Vet. App. 181 (1998). The symptoms are productive of high blood sugar, neurological disturbances of the lower extremities, and fungal infections in both feet. There is no indication that these disabilities markedly interferes with the Veteran's industrial capacity or that they require frequent inpatient care. The degree of disability exhibited for these disabilities is contemplated by the rating schedule. Thus, the Board finds that the threshold test is not met for referral for extraschedular consideration for the Veteran's increased rating claim. 38 C.F.R. § 4.16(b); Thun v. Peake, 22 Vet. App. 111 (2008). (iv) Total disability based upon individual unemployability (TDIU) A request for a TDIU whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Id. The Veteran submitted VA Form 21-8940 (Application for TDIU) in March 2009. He asserted that he was disabled since May 2000 when he left his last full time job. His occupation was in human resources. From June 2006 to March 2009, he worked ten hours per week at his church. In July 2009, the church pastor essentially stated that the church provided a sheltered work environment to accommodate his disabilities. Given the above, the issue of TDIU is part of the appeal for higher initial ratings. Rice, 22 Vet. App. at 453-54. Total disability ratings for compensation may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The claims period dates to March 24, 2006, when the Veteran filed his initial service connection claims. From March 24, 2006, the Veteran is service connected for the following disabilities: posttraumatic stress disorder (PTSD), 50 percent disabling; heart disease, 30 percent disabling; diabetes mellitus, Type II, 20 percent disabling; low back disability, bilateral upper and lower extremity peripheral neuropathy, 10 percent disabling with each extremity separately rated. His combined rating was 80 percent. He meets the schedular TDIU criteria from the beginning of the claims period. 38 C.F.R. § 4.16(a). In determining whether the Veteran is unemployable, consideration may be given to his education, training, and special work experience, but not to his age or to impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 1.419; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Here, the Veteran is shown to have a college education and occupational experience in human resources and marketing. (March 2009 TDIU claim; August 2011 VA PTSD examination report). He has not been gainfully employed throughout entire claims period. Id. The question is whether his service connected disabilities preclude gainful employment consistent with his educational and occupational background. 38 C.F.R. § 4.16(a). The May 2009 VA examiner opined that the Veteran was capable of part-time sedentary work. However, he did not consider the Veteran's service connected PTSD which is rated 50 percent prior to June 11, 2007 and 70 percent thereafter. Thus, the May 2009 opinion is less probative. The Veteran submitted numerous September 2006 lay statements from his family. They attested that he had significant PTSD related psychiatric problems that interfered with occupational functioning. Similarly, the July 2009 pastor statement indicates that the Veteran requires significant disability accommodation and is unable to participate in competitive employment. Most tellingly, the Veteran's treating VA psychiatrist submitted an October 2008 letter in support of the Veteran's SSA disability claim. He reported that the Veteran's PTSD related behavior problems led to his January 2006 resignation from his longtime job. The Veteran was unable to resume gainful employment. The treating VA psychiatrist believed the Veteran was unemployable due to his deteriorating psychiatric and physical health. Resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran's service connected disabilities from March 24, 2006 precluded gainful employment throughout the claims period based upon the reports recited above. 38 C.F.R. §§ 3.102, 4.16(a). TDIU is granted. Id. ORDER Service connection for tinnitus is granted. Service connection for peripheral vascular disease of the upper extremities is denied. Entitlement to a rating in excess of 20 percent for diabetes mellitus, Type II is denied. Entitlement to a higher initial rating for peripheral neuropathy and radiculopathy of the left lower extremity is denied. Entitlement to a higher initial rating for peripheral neuropathy of the right lower extremity is denied. Entitlement to a higher initial rating for onychomycosis is denied. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU) is granted. REMAND Nose bleeds A VA examination is necessary for the claimed nose bleed disorder. Service treatment records from June 1966 reflect that the Veteran sought medical attention for frequent nose bleeds. Private medical records from September 2005 show that the Veteran complained about nosebleeds. The May 2009 VA examination report reflects that the Veteran had short duration nose bleeds approximately 5 or 6 times per month. A VA examination is necessary as instructed below. Hypertension The Veteran submitted a January 2013 statement contending that his hypertension was worse. He submitted numerous blood pressure readings taken at home from February 2012 to January 2013, which were appreciably higher than clinical readings shown in VA treatment records. The most recent VA treatment records, dated on March 13, 2013 and March 15, 2013 reflect that for VA purposes, he had normal blood pressure readings. Additional development is needed to reconcile clinical reports and the Veteran's assertions as instructed below. Accordingly, the case is REMANDED for the following action: 1. Ensure that a complete copy of all 2012 VA treatment records for hypertension are associated with the record and obtain any newly generated records since April 2013. 2. After associating newly generated VA treatment with the claims file, schedule the Veteran for a VA examination to evaluate his claimed nose bleed disorder. The claims folder and any pertinent documents in Virtual VA/ VBMS efolders must be made available and reviewed by the examiner. A clinical interview and examination with any necessary medical testing must be conducted. The examiner is asked to opine on whether the reported nose bleed disorder is as likely as not (probability of 50 percent or greater) related to service. The examiner must consider the June 1966 service treatment records reflecting nose bleed complaints. A complete rationale for the opinion must be given. The Veteran is competent to report his observable symptoms and relate his medical history. If the examiner rejects the Veteran's reports, he or she must explain why and cannot rely solely on the absence of contemporaneous medical treatment to do so. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. 3. After associating newly generated VA treatment with the claims file, schedule the Veteran for a VA examination to ascertain the nature and severity of his current hypertension. The claims folder and any pertinent documents in the Virtual VA/ VBMS efolders must be made available and reviewed by the examiner. A clinical interview and examination with any necessary medical testing must be conducted. The examiner should specifically comment on whether the Veteran currently has diastolic pressure predominantly 100, 110, 120, 130, or more; systolic pressure predominantly 160, 200, or more; and/or a history of diastolic pressure predominately 100 or more requiring continuous use of medication for control. The examiner must comment on the discrepancy in blood pressure readings taken at home by the Veteran as he reported in January 2013 and contemporaneous 2012 and 2013 VA clinical readings. 4. After completing all development required to adjudicate the Veteran's claims, re-adjudicate these issues. If the benefit sought remains denied, the Veteran should be provided a supplemental statement of the case and given an opportunity to respond before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ Thomas H. O'Shay Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs