Citation Nr: 1338829 Decision Date: 11/25/13 Archive Date: 12/06/13 DOCKET NO. 06-26 709 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for memory loss. 2. Entitlement to service connection for sleep impairment. 3. Entitlement to service connection for a chronic respiratory disorder, claimed as trouble breathing. 4. Entitlement to an initial compensable rating for bilateral hearing loss. 5. Entitlement to an initial rating in excess of 10 percent for vascular hypertension. 6. Entitlement to an initial compensable rating for residuals of a fracture, right middle finger, prior to December 2010. 7. Entitlement to a rating in excess of 10 percent for residuals of a fracture, right middle finger, since December 2010. 8. Entitlement to an initial compensable rating for eczematous dermatitis prior to December 2010. 9. Entitlement to a rating in excess of 10 percent for eczematous dermatitis since December 2010. 10. Entitlement to an initial rating in excess of 30 percent for hypertensive heart disease. 11. Entitlement to an initial rating in excess of 30 percent for migraine headaches. 12. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, attorney ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from February 1997 to February 2000, and from May 2001 to June 2004. This appeal comes before the Board of Veterans' Appeals (Board) from a December 2004 rating decision of the Regional Office (RO) in Atlanta, Georgia. Several procedural matters require clarification. First, in October 2008, the Board remanded this appeal for additional evidentiary development. The Board also denied claims of entitlement to service connection for arthritis of the hands, bilateral shoulder, back, left foot, and visual impairment. The Board's decision with respect to those issues is final. See 38 C.F.R. § 20.1100 (2013). The May 2012 supplemental statement of the case (SSOC) correctly listed the issues remaining on appeal following the Board's October 2008 decision. In a June 2013 SSOC, the low back issue reappeared. In the interim, there was neither an application to reopen the claim nor an adjudication of such an application. The appeal regarding the claim of entitlement to service connection for a back disorder was resolved by a Board decision in October 2008 and the Board no longer has jurisdiction over the matter. The RO's erroneous listing of the issue on an SSOC does not disturb the finality of the Board's decision. The current situation is distinguished from that in Percy v. Shinseki, 23 Vet. App. 37 (2009) where the RO had consistently over an extended period treated an untimely substantive appeal as timely and therefore was deemed to have waived any objection to its timeliness. The RO may not waive the finality of a Board decision, nor may it waive the basic appeal requirements of a prior RO adjudication followed by a notice of disagreement and substantive appeal. Therefore, the back issue is not currently before the Board. Nonetheless, in response to the reappearance of the back disorder issue on the June 2013 SSOC, the Veteran provided written argument on the matter in July 2013. The Board accepts this as an application to reopen the claim of entitlement to service connection for a back disorder and refers that matter to the RO for appropriate action. Next, the Board's October 2008 remand also included a claim of entitlement to service connection for migraine headaches, which was granted in October 2010. As the full benefit sought on appeal has been granted, the appeal of entitlement to service connection for migraine headaches is resolved. The Board will address the appeal of the initial rating for migraine headaches in the Remand below. Further, in May 2012, the RO granted a separate 10 percent rating for vascular hypertension, which had previously been combined with the rating for hypertensive heart disease with a single 30 percent rating. The current appeal thus encompasses both ratings. As the maximum benefit has not been granted with respect to either issue, both remain on appeal. See A.B. v. Brown, 6 Vet. App. 35, 38 (1993). Next, in May 2012, the RO granted 10 percent ratings for skin rash and right middle finger fracture, each effective December 9, 2010. Inasmuch as higher ratings for each disability are available before and after the effective dates of the higher ratings, and as the Veteran is presumed to seek the maximum available benefit for a disability, the Board has characterized these issues as reflected on the title page. Finally, the Board notes that the Veteran specifically appealed the initial rating for "right ear" hearing loss. Service connection for left ear hearing loss had previously been granted. As hearing loss is evaluated based on the level of hearing in each ear, and as each ear is service connected, the Board has characterized the appeal accordingly as bilateral hearing loss. In reviewing this case the Board has not only reviewed the physical claims file, but also the electronic file on the Virtual VA and VBMS electronic filing system to insure a total review of the evidence. The issue of entitlement to a rating in excess of 30 percent for migraine headaches and entitlement to a rating for PTSD in excess of 50 percent are addressed in the REMAND below and is therein REMANDED to the RO. FINDINGS OF FACT 1. Service connection has already been granted by the RO for sleep impairment and memory loss; accordingly, there remains no question of fact or law to be resolved. 2. The Veteran's complaint of dyspnea on exertion has been medically attributed to the service-connected disability of heart disease; there is no other current chronic respiratory disorder. 3. For the entire period of this appeal, the Veteran's bilateral hearing loss was manifested by combinations of audiometric readings and speech recognition scores that support no higher than a 0 percent rating. 4. For the entire period of this appeal, the Veteran's vascular hypertension has been manifested by diastolic pressure that is predominantly less than 110 and systolic pressure that is predominantly less than 200. 5. For the entire period of this appeal, the Veteran's right middle finger fracture residuals have been manifested by painful motion. 6. For the entire period of this appeal, the Veteran's skin rash has been manifested by total body coverage of 5 percent, but less than 20 percent, without requirement of systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of six weeks or more, but not constantly, during the past 12-month period. 7. For the entire period of this appeal, the Veteran's hypertensive heart disease has been manifested by a workload of 7 to 10 METs or higher resulting in dyspnea, fatigue, angina, dizziness, or syncope; there are no episodes of congestive heart failure; there is no left ventricular dysfunction; ejection fraction ranges from 55 to 65 percent. CONCLUSIONS OF LAW 1. There remain no questions of law and fact necessary to a decision by VA regarding entitlement to service connection for memory loss. 38 U.S.C.A. § 511 (West 2002). 2. There remain no questions of law and fact necessary to a decision by VA regarding entitlement to service connection for sleep impairment. 38 U.S.C.A. § 511 (West 2002). 3. A chronic respiratory disorder, claimed as trouble breathing, was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). 4. The criteria for an initial compensable rating for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.85, Diagnostic Code (DC) 6100, 4.86 (2013). 5. The criteria for an initial rating in excess of 10 percent for vascular hypertension have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.104, DC 7101 (2013). 6. Prior to December 9, 2010, the criteria for a 10 percent rating, but no more, for residuals of a fracture, right middle finger, were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.71a, DCs 5226, 5229 (2013). 7. Since December 9, 2010, the criteria for rating in excess of 10 percent for residuals of a fracture, right middle finger, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.71a, DCs 5226, 5229 (2013). 8. Prior to December 9, 2010, the criteria for a 10 percent rating, but no more, for eczematous dermatitis were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.118, DC 7806 (2002-2013). 9. Since December 9, 2010, the criteria for a rating in excess of 10 percent for eczematous dermatitis have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.118, DC 7806 (2002-2013). 10. The criteria for an initial rating in excess of 30 percent for hypertensive heart disease have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.104, DC 7007 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to these claims. Dismissal of Appeals The Board's October 2008 remand included the issues of entitlement to service connection for memory loss and sleep disorder. In October 2010, the RO granted service connection for posttraumatic stress disorder (PTSD). In May 2012, the RO explicitly included sleep impairment and memory loss in the grant of service connection for PTSD and noted that "this is considered to be a full grant of benefits sought on appeal for the issues of service connection for trouble sleeping and memory loss." In the May 2012 SSOC, the RO correctly characterized the issues as having been resolved by this action; however, in a subsequent SSOC, without explanation, the issues were listed again as being on appeal, and the VA Form 8 (certification of appeal) dated August 2013 includes these issues as being recertified to the Board following remand. Unlike the matter of entitlement to service connection for a back disorder, addressed in the Introduction, these issues are not the subject of a final Board decision. Accordingly, the Board finds that specific action is necessary to dismiss the appeals as to these two issues that have been granted in full by the RO. Therefore, the Board finds that service connection for memory loss and sleep impairment has been granted by RO adjudicative action in May 2012. The full benefit sought on appeal has been granted, and there is no longer any question of fact or law for appellate consideration regarding those issues. Accordingly, the Board does not have jurisdiction to review the appeal regarding the claims of entitlement to service connection for memory loss and a sleep disorder, and they are dismissed. Service Connection for a Respiratory Disorder Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). Service connection may be established under 38 C.F.R. § 3.303(b), if a chronic disease or injury is shown in service, and subsequent manifestations of the same chronic disease or injury at any later date, however remote, are shown, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established with certain chronic diseases based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Service connection may also be established for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). This has been interpreted as a three-element test based on nexus: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Finally, service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C.A. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Veteran asserts that he has a disability manifested by breathing problems. An August 2004 VA examination report noted shortness of breath with walking 3 city blocks. The examiner found no pathology to render a diagnosis because of normal findings on pulmonary function testing. In an August 2010 report, the Veteran complained of intermittent episodes of dyspnea which occurred approximately couple of times a week and last for a few minutes. These episodes were associated with chest discomfort or tightness periodically. He denied any cough, hemoptysis, anorexia, or wheezing. While he reported that the symptoms were not related specifically to physical exertion or activity and can occur at rest, he also reported dyspnea with climbing 3 flights of stairs at work and when he has to get in and out of his forklift frequently. He also reported dyspnea with lifting weights for more than an hour. The examiner noted that the Veteran had been given medication that was typically associated with asthma, but noted that it was actually prescribed for a skin condition and not for asthma. Pulmonary function tests were conducted and revealed normal spirometry, normal lung volumes, and mildly reduced DLCO. Chest X-rays were normal. The etiology of the reported dyspnea was unclear. The Veteran reported to a December 2010 examiner that he had dyspnea intermittently with chest pain. He attributed these symptoms to anxiety. He also reported intermittent episodes of chest pain and dyspnea with walking approximately half a mile. These symptoms partially and gradually improved with rest. Chest X-rays were negative. An exercise stress test was normal. The RO requested an opinion to clarify the notation of the August 2010 examiner that the etiology of the Veteran's dyspnea was unclear, and to address VA records that appeared to show treatment from 2005 to 2006 for asthma. A December 2011 opinion was obtained based on a claims file review. The reviewing clinician noted that, from 2005 to 2006, the Veteran received Singulair, which was a medication generally prescribed for asthma, but he received it for chronic pruritus after failing multiple other medications and did not receive this medication for asthma. The clinician found that the Veteran did not have any evidence of asthma, and that no specific pathology was found to render a diagnosis for the Veteran's dyspnea. In a December 2012 VA examination, the only respiratory symptomatology noted was dyspnea on exertion. This was attributed solely to the Veteran's service-connected heart disease. In sum, there is no specific respiratory disorder based on multiple examinations. The Veteran's dyspnea has been related to his service-connected hypertensive heart disease. Unlike the situation with memory loss and sleep impairment, which the RO has specifically acknowledged to be service-connected, there is no such acknowledgement regarding the claimed breathing problems. Therefore, dismissal of this issue is not appropriate. Dyspnea on exertion is not itself a disability, but is a clinical finding. In other words, it is considered to be symptomatology that is associated with a disability, but it does not constitute a distinct diagnosis for which service connection can be granted. Moreover, dyspnea on exertion is explicitly included among the symptomatology considered in assigning a rating under DC 7007, which governs hypertensive heart disease. There is, therefore, no question that it has been considered in assigning the current rating for hypertensive heart disease. Accordingly, no further development or adjudicative action is necessary with respect to the question of service connection for dyspnea on exertion. It is symptomatology that has been directly associated with an already service-connected disability, and which has implicitly been considered in assigning the current rating. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that there is no current underlying chronic respiratory disorder separate and distinct from heart disease. The Veteran does not have asthma and he has not identified any other respiratory diagnosis and the medical evidence does not provide any other respiratory diagnosis. The Board recognizes that the presence of a disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, Congress has specifically limited entitlement to service-connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C.A. § 1110. Hence, where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As there is no current chronic respiratory disorder per se, and as the symptoms of dyspnea on exertion have been attributed to a service-connected disability, the Board finds that the basic criteria for service connection for a respiratory disorder are not met. As such, the appeal is denied. Increased Rating Claims Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3. While a veteran's entire history is reviewed when assigning a disability evaluation, where service connection has already been established and an increase in the rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Hearing Loss In addition to the laws and regulations outlined above, ratings for service-connected hearing loss range from noncompensable (0 percent) to 100 percent for hearing loss. These evaluations are based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination testing together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1,000, 2,000, 3,000 and 4,000 cycles per second. In evaluating service-connected hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). DC 6100 provides a table for rating purposes (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment. The hearing impairment is established by a state licensed audiologist including a controlled speech discrimination and the puretone threshold average, which is the sum of the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. See 38 C.F.R. § 4.85. Table VII is used to determine the percentage evaluation by combining the Roman numeral designations for hearing impairment of each ear. The horizontal row represents the ear having the poorer hearing and the vertical column represents the ear having the better hearing. Under 38 C.F.R. § 4.86(a), when the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz ) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table IV or Table VIa, whichever results in the higher numeral. Each ear is to be evaluated separately. The provisions of 38 C.F.R. § 4.86(b) provide that when the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral. That numeral will then be evaluated to the next higher Roman numeral. In Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007), the Court held that, in addition to providing objective test results, a VA audiological examination report must address the functional effects caused by a hearing disability because an extraschedular evaluation under 38 C.F.R. § 3.321(b) "does not rely exclusively on objective test results to determine whether a referral for an extraschedular rating is warranted." The Court also noted that VA's policy requiring VA audiologists to describe the effect of a hearing disability on occupational functioning and daily activities facilitates extraschedular determinations by requiring VA audiologists to provide such information. Martinak, 21 Vet. App. at 455. Historically, service connection for left ear hearing loss was granted in an October 2000 rating decision with a noncompensable initial rating assigned effective February 21, 2000. The current appeal arises from a claim received at the RO in June 2004. Service connection for right ear hearing loss was granted in a December 2004 rating decision. An initial noncompensatory rating was assigned, effective June 10, 2004. In May 2012, the RO combined the separate ratings for right and left ear hearing loss; however, the rating remained at 0 percent. The report of VA examination in August 2004 reveals pure tone thresholds, in decibels, as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 20 30 30 25 26.25 LEFT 25 35 30 30 30 Speech recognition ability was 100 percent in the right ear and 100 percent in the left ear. Applying these values to Table VI results in level I in the right ear and level I in the left ear. Application to Table VII at 38 C.F.R. § 4.85 produces a 0 percent rating. The report of VA examination in December 2010 reveals pure tone thresholds, in decibels, as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 20 35 35 25 29 LEFT 30 45 40 35 38 Speech recognition ability was 96 percent in the right ear and 94 percent in the left ear. Applying these values to Table VI results in level I in the right ear and level I in the left ear. Application to Table VII at 38 C.F.R. § 4.85 produces a 0 percent rating. The report of VA examination in December 2012 reveals pure tone thresholds, in decibels, as follows: HERTZ 1000 2000 3000 4000 Average RIGHT 35 45 40 40 40 LEFT 35 45 40 40 40 Speech recognition ability was 88 percent in the right ear and 84 percent in the left ear. Applying these values to Table VI results in level I in the right ear and level I in the left ear. Application to Table VII at 38 C.F.R. § 4.85 produces a 0 percent rating. The Board notes that, as each of the audiometric assessments is below 55 decibels, and as in no case is the reading at 1000 Hertz 30 decibels or less with a corresponding reading at 2000 Hertz of 70 or more, the provisions for exceptional patterns of hearing impairment are not applicable. In sum, the audiometry and speech recognition results are consistent with the disability ratings currently assigned. The evidence does not support any higher rating under the rating schedule. To the extent any higher level of compensation is sought, the preponderance of the evidence is against the claim, and hence the benefit-of-the-doubt doctrine does not apply. As such, the appeal is denied. In applying Martinak v. Nicholson, 21 Vet. App. 447 (2007), the Veteran reported to the December 2010 VA examiner that his main complaint was that he could not hear as well. The effect on his occupational and daily functioning was that he cannot hear from a long distance so he has to move closer. He has variously reflected that he turned the television volume up louder than normal, requested that words be repeated, had difficulty hearing at work and did not always hear his supervisor and had been written up for failure to do what he was told, had difficulty hearing at home and school, and asked professors to speak louder. He indicated that his family members complain that the television was too loud and he did not talk on the telephone due to difficulty hearing. Nonetheless, the Board finds that the functional effects of the Veteran's hearing loss disability are adequately addressed by the examination reports, and that these are sufficient for the Board to consider whether referral for an extra-schedular rating is warranted under 38 C.F.R. § 3.321(b). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Only if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology, so is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). Thun v. Peake, 22 Vet. App 111, 115-16 (2008). In this Veteran's case, all of the functional impairment reported involves decreased auditory acuity and speech recognition. The schedular rating criteria specifically provide for ratings based on all levels of hearing loss, including exceptional hearing patterns, and as measured by both audiological testing and speech recognition testing. Speech recognition testing is a schedular rating criterion that recognizes such an inability to understand certain words in conversation. For these reasons, the Board finds that the schedular rating criteria in this case are adequate to rate hearing loss. In the absence of evidence that the schedular rating criteria are inadequate to rate the Veteran's disability, the Board is not required to remand this case to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See also Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Vascular Hypertension The current appeal arises from a claim received at the RO on June 10, 2004. Service connection for hypertensive heart disease was originally granted in a December 2004 rating decision with a combined rating of 30 percent assigned effective June 10, 2004. In May 2012, the RO assigned a separate 10 percent rating for vascular hypertension effective June 10, 2004. Under DC 7101, hypertensive vascular disease (hypertension and isolated systolic hypertension) is assigned a 60 percent rating if diastolic pressure is predominantly 130 or more; a 40 percent rating is assigned if diastolic pressure is predominantly 120 or more; a 20 percent rating is assigned if diastolic pressure is predominantly 110 or more, or systolic pressure is predominantly 200 or more; a 10 percent rating is assigned if diastolic pressure is predominantly 100 or more, or systolic pressure is predominantly 160 or more, or as a minimum evaluation for an individual with a history of diastolic pressure that is predominantly 100 or more who requires continuous medication for control. Thus, in order to warrant the next higher 20 percent rating, the evidence would have to show that diastolic pressure was predominantly 110 or more, or that systolic pressure was predominantly 200 or more. Pertinent to the period on appeal, blood pressure readings are as follows: Date Blood Pressure Date Blood Pressure Jul 04 152/75 Aug 04 154/90 Sep 04 176/94 Sep 04 154/90 Sep 04 155/92 Oct 04 164/86 Oct 04 165/87 May 05 179/80 May 05 185/77 May 05 187/77 Jun 05 177/102 Jun 05 170/90 Jun 05 179/87 Aug 05 169/100 Aug 05 179/92 Jul 06 137/69 Aug 06 177/96 Feb 07 141/97 Jul 07 155/98 Jul 07 150/84 Aug 07 149/86 Mar 09 146/94 Mar 09 151/96 Mar 09 165/103 Mar 09 164/100 Jun 09 155/94 Jun 09 151/82 Jun 09 151/91 Jul 09 134/81 Aug 10 170/100 Aug 10 158/93 Oct 10 150/93 Dec 10 184/106 Dec 10 174/108 Dec 10 187/106 Apr 11 169/95 Dec 12 162/92 Dec 12 160/94 Dec 12 162/94 During the period on appeal, diastolic pressure has not been predominantly 110 or more. Systolic pressure has not been predominantly 200 or more. Thus, the criteria for a rating in excess of 10 percent are not met and are not more nearly approximated than the criteria for a 10 percent rating for any portion of the appeal period. The Board also finds that the schedular rating criteria fully contemplate the Veteran's service-connected vascular hypertension. The criteria specifically provide for ratings based on the presence of elevated blood pressure and the need for medication to control blood pressure. The Board finds that the specific reference to medications for control of blood pressure in the rating schedule means that any expected side effects of such medications are also contemplated. Such factors are explicitly part of the schedular rating criteria. Because the schedular rating criteria are adequate to rate the disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). The weight of the evidence is against a rating in excess of 10 percent for vascular hypertension. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. As such, the appeal is denied. Residuals of Fracture, Right Middle Finger This appeal arises from a claim received at the RO on June 10, 2004. Service connection was granted for right middle finger fracture residuals in a December 2004 rating decision. A 0 percent rating was assigned pursuant to DC 5259, effective June 10, 2004. In May 2012, the RO granted a 10 percent rating, effective December 9, 2010, corresponding to the date of a VA examination report. Under DC 5229, which governs index or long finger limitation of motion, a 10 percent rating is assigned regardless of the handedness of the individual where there is a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. A 0 percent rating is warranted where there is a gap of less than one inch (2.5 cm.) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. Under DC 5226 ankylosis (complete bony fixation) of the long finger warrants a 10 percent rating whether the ankylosis is unfavorable or favorable. When examined in August 2004, the Veteran reported constant pain. On examination, he was able to approximate the proximal transverse crease of the palm. Strength was within normal limits. He was able to tie his shoelaces without difficulty. He could fasten buttons without difficulty. He could pick of a piece of paper and tear it without difficulty. The condition was found not to result in any functional impairment, and he had not missed any work as a result. When examined in August 2005, the Veteran reported constant aching pain in the top part of the middle finger. On examination, he was able to approximate the proximal transverse crease of the palm. Strength was within normal limits. Range of motion of the right middle distal interphalangeal joint was to 70 degrees. Range of motion of the right middle proximal interphalangeal joint was to 110 degrees. Range of motion of the right middle metatarsal-phalangeal joint was to 90 degrees. He was able to tie his shoelaces without difficulty. He could fasten buttons without difficulty. He could pick of a piece of paper and tear it without difficulty. X-rays were normal. The condition was found not to result in any functional impairment, and he had not missed any work as a result. When examined in December 2010, the Veteran reported intermittent episodes of pain, swelling, redness, warmth, and stiffness involving his right hand third digit. He denied any weakness or fatigue. Symptoms occur approximately twice a month lasting for approximately 1 hour. He reported having difficulty buttoning his clothes periodically when he has pain in the third digit but is able to perform his activities of daily living independently. He was able to write without difficulty. He reported having difficulty lifting heavy boxes at work periodically but continues to work through the pain. No special accommodations were made for him at work due to the symptoms. He had not missed any days from work due to the symptoms. The examiner noted diffuse tenderness to palpation was noted involving the right third digit. Motor and sensory examinations were normal. The Veteran was able to write and grip without difficulty. There was no gap noted between the finger and the proximal transverse crease of the palm. Motion of the metacarpal-phalangeal joint was 0 to 90 degrees for 3 repetitions without pain, weakness, fatigue or incoordination on repeated testing. Motion of the proximal interphalangeal joint was 0 to 90 degrees for 3 repetitions with pain throughout range of motion, but no weakness, fatigue or incoordination on repeated testing. Motion of the distal interphalangeal joint was 0 to 60 degrees for 3 repetitions with pain throughout range of motion, but no weakness, fatigue or incoordination on repeated testing. X-rays revealed no acute fractures, subluxations, or dislocations. The joint spaces were well-preserved. There were no osseous erosions. The bone mineralization and bony alignment were within normal limits. There was no abnormal soft tissue swelling, soft tissue calcification, or radiopaque foreign body present. There was neutral ulnar variance. There was no radiographic evidence of acute traumatic injury to the right hand. The X-rays were noted as unremarkable. After a review of all of the evidence, the Board finds that the criteria for a 10 percent rating were met prior to December 9, 2010. The RO noted in the May 2012 rating decision that it was assigning the 10 percent rating based on painful motion of the joint under the provisions of 38 C.F.R. § 4.59. That section provides in pertinent part, it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. The Veteran's painful right middle finger is consistent with a 10 percent rating. Moreover, he has always reported that his right middle finger was painful. Specifically, he reported similar complaints in August 2004 and August 2005. Accordingly, the Board finds that a 10 percent rating is warranted for the entire period on appeal. The Board also notes that there is no higher rating available for limitation of motion or ankylosis of the middle (long) finger. A 20 percent rating is available for amputation of the finger; however, the Veteran has not asserted, and the evidence does not demonstrate, that the disability is the equivalent of an amputation. The Board also finds that the schedular rating criteria fully contemplate the Veteran's service-connected right middle finger fracture residuals. The criteria specifically provide for ratings based on the presence of limited motion, including due to pain and other orthopedic factors. Because the schedular rating criteria are adequate to rate the disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). In sum, while a 10 percent rating is warranted for the entire appeal period, a rating in excess of 10 percent is not warranted for any period. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. As such, the appeal is granted in part. Eczematous Dermatitis The current appeal arises out of a claim received at the RO on June 10, 2004. In a December 2004 rating decision, the RO granted service connection for a skin rash and assigned a 0 percent rating pursuant to DC 7806, effective June 10, 2004. In May 2012, the rating was increased to 10 percent, effective December 9, 2010. The effective date corresponds to a VA examination report. The criteria used to evaluate disabilities of the skin were revised during this appeal, in 2008. The applicability of the 2008 amendment is specified as follows: "This amendment shall apply to all applications for benefits received by VA on or after October 23, 2008. A veteran whom VA rated before such date under diagnostic codes 7800, 7801, 7802, 7803, 7804, or 7805 of 38 CFR 4.118 may request review under these clarified criteria, irrespective of whether his or her disability has worsened since the last review." See 73 Fed. Reg. 54708-01. As the Veteran's claim was received prior to October 23, 2008, and he has not requested that his disabilities be evaluated under the new criteria, the Board will consider only the pre-2008 criteria. The Board first turns to DC 7806, which is the same under both versions of the rating schedule. A 60 percent rating requires that more than 40 percent of the entire body or more than 40 percent of exposed areas are affected, or where constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs was required during the past 12-month period. A 30 percent rating is assignable where 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas are affected, or where systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 10 percent rating is assignable where at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected, or where intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of less than six weeks during the past 12-month period. After a review of all of the evidence, the Board finds that a 10 percent disability rating is warranted during the entire period prior to December 9, 2010. Specifically, in a September 2005 VA examination report, the examiner estimated 5 percent coverage of the entire body. This fully meets the criteria for a 10 percent rating. Other examinations have shown coverage that is less, and others have shown coverage that is greater but this appears to be consistent with the nature of the disability, which is subject to flares and remission of symptoms. It is simply not practical to rate the disability based on each and every flare or remission. The Board finds that the Veteran's skin disability is demonstrated to be capable at any time of flaring to an extent that covers at least 5 percent of his entire body. Resolving all reasonable doubt in his favor, the Board finds that a 10 percent rating is warranted prior to December 9, 2010. Nonetheless, after a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that a rating in excess of 10 percent is not warranted during any portion of the appeal period. Specifically, the September 2004 VA examination reveals complaint of exudation, itching, shedding, and crusting. The Veteran reported that the skin disease involved areas that were exposed to the sun, including the face, neck, and ears; however, on examination, signs of skin disease were found on the bilateral elbows with hyperpigmentation of less than six square inches. There was no ulceration, exfoliation, crusting, tissue loss, induration, inflexibility, hypopigmentation, abnormal texture, or limited motion. Skin lesions covered 0 percent of exposed areas. Total body coverage was 2 percent. He used topical medications and had not lost time from work. There was no functional impairment. The report of VA examination in September 2005 reveals similar complaints to the September 2004 examination. The Veteran reported that he had lost 7 days work in the prior year. The examiner noted signs of skin disease located in the left antecubital foss, and small area of the inner thigh. There was exfoliation, crusting, and hyperpigmentation of more than 6 square inches. There was no ulceration, tissue loss, induration, inflexibility, hypopigmentation, abnormal texture, or limited motion. The skin lesion coverage of exposed areas was 0 percent. The coverage of the entire body was 5 percent. The report of VA examination in December 2010 reveals complaint of persistent and progressively worsening symptoms. He reported noting dry, pruritic patches and reddish bumps affecting his arms, chest, abdomen, face, inner thighs, and the area behind his knees. He reported noting flaking and bleeding after he scratches the lesions. He stated that the symptoms are worse with heat exposure. He had not missed work due to the symptoms. He reported having to scratch frequently which was irritating and had excoriations with occasional bleeding after scratching. There were no eczematous eruptions noted on the face. Eczematous papules and patches were noted involving the chest comprising approximately 10 percent of the chest region, 20 percent of the abdomen, 10 percent of each arm involving bilateral antecubital fossa and mid portion of the arms, 5 percent to 10 percent of each lower extremity, involving bilateral popliteal fossa and mid portion of the legs. There was no evidence of ulceration, exfoliation, crusting, tissue loss, induration, hypopigmentation, or limitation of motion. The dermatitis involved approximately 10 percent of the total body surface area and 0 percent of the exposed areas. A VA dermatology note in May 2012 reveals that the face, neck, and scalp were clear; the back and chest were also clear, there were a few scattered small papules with surrounding hyperpigmentation on the left abdomen, there were collarettes of scale and maceration in the interdigital spaces of the bilateral soles, and the bilateral great toes were dystrophic with hyperkeratosis and subungual debris. The report of VA examination in December 2012 reveals that the disorder was in complete remission. There was no rash. There were no affected areas on any part of the body. There was no scarring or disfigurement of the head, face, or neck. There had been no oral or topical treatments in the prior 12 months. Thus, at no time during the appeal period have the coverage criteria for a 30 percent or higher rating been met because 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas were not affected. Moreover, the Veteran has not asserted that he has required systemic therapy such as corticosteroids or other immunosuppressive drugs a total duration of six weeks or more during the past 12-month period. It does not appear that such therapy has ever been prescribed. The Board has also considered other potential diagnostic codes to determine whether any higher ratings or separate ratings are warranted. DC 7805 applies to limitation of function of the affected part. Here, there has been no suggestion that the Veteran's rash causes limitation of function or impairment of function of any body part. Indeed, the September 2004, September 2004, and December 2010 reports note that there is no limitation of motion. DC 7800 requires involvement of the head, face, or neck. Under the schedule in effect from August 30, 2002, to October 23, 2008, a 30 percent rating required visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or with two or three characteristics of disfigurement. The 8 characteristics of disfigurement are: scar 5 or more inches (13 or more cm.) in length; scar at least one-quarter inch (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). The Veteran has reported that the disorder affects his face and neck; however, such coverage has never been demonstrated on examinations. He has consistently been found to have no coverage of the head, face, and neck, and no disfigurement. While he is competent to describe his symptoms, he has not described any of the characteristics of disfigurement that would warrant a compensable rating under DC 7800. The version of DC 7801 in effect from August 30, 2002, to October 23, 2008 applies to scars, other than head, face, or neck, that are deep or that cause limited motion. In this case, none of the Veteran's symptoms are like or similar to deep scars, and none cause limited motion. DC 7802 provides no more than a 10 percent maximum rating and requires involvement of an area or areas of 144 sq. in. (1 sq ft.) (929 sq. cm.). As it rates on the basis of skin coverage, it is inherently overlapping with DC 7806. Thus, a separate rating would be inappropriate. The version of the DC 7803 in effect from August 30, 2002, to October 23, 2008 applies to scars that are unstable. Here, there is no evidence or assertion of instability of any scars or lesions. Effective August 30, 2002, DC 7804 applied to scars that are superficial and painful on examination. A single 10 percent rating was available. Here, a 10 percent rating is already in effect for the Veteran's rash. The Board finds that the skin rash is more appropriately evaluated under DC 7806 based on the diagnosis and description of symptoms. The Board also finds that the schedular rating criteria fully contemplate the Veteran's service-connected skin rash. The criteria specifically provide for ratings based on the presence of a symptomatic skin condition and include provisions for disfigurement where such symptoms are demonstrated. Because the schedular rating criteria are adequate to rate the disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). In summary of the Board's findings, a 10 percent rating is warranted for the Veteran's rash for the entire period on appeal. However, a rating higher than 10 percent is not warranted for any period. To the extent any higher level of compensation is sought, the preponderance of the evidence is against these claims, and hence the benefit-of-the-doubt doctrine does not apply. Therefore, the appeal is granted in part. Heart Disease Historically, this appeal arises from a claim received at the RO on June 10, 2004. Service connection for hypertensive heart disease was granted in the December 2004 rating decision, with a 30 percent rating assigned pursuant to DC 7007, effective June 10, 2004. Under DC 7007, hypertensive heart disease is assigned a 100 percent rating for chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. A 60 percent rating is assigned for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 30 percent rating is assigned where workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 10 percent rating is assigned where workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that the criteria for a rating in excess of 30 percent have not been met. Specifically, the evidence does not show and the Veteran does not contend that he has experienced episodes of congestive heart failure. A December 2012 VA heart examiner noted that there had been no history of congestive heart failure. Thus, to substantiate a rating in excess of 30 percent, the evidence would have to show that a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or that there is a left ventricular dysfunction with an ejection fraction of 30 to 50 percent. An exercise stress test in December 2010 resulted in a METS value of 13.4. The Veteran's functional capacity was normal. The assessment was normal stress test. An interview-based test in December 2012 showed that between 7 and 10 METS resulted in dyspnea, fatigue, and angina. This was found to be consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, or jogging at 6 miles per hour. An echocardiogram in 2004 showed left ventricular hypertrophy and dilated aortic root with ejection fraction of 65 percent. A February 2011 echocardiogram shows an ejection fraction of 55-60 percent. A December 2012 echocardiogram shows an ejection fraction of 60 percent. Thus, the criteria for a rating of 60 percent are not met. As the rating criteria are successive, the criteria for a 100 percent rating are also not met. The Board has considered whether any other diagnostic code may be appropriate; however, based on findings of no history of myocardial infarction, arrhythmia, ischemic heart disease, valvular disorders, or infections heart disorders, the Board finds no other appropriate diagnostic codes. The Veteran has not asserted that another diagnostic code would be more appropriate. The Board also finds that the schedular rating criteria fully contemplate the Veteran's service-connected hypertensive heart disease. The criteria specifically provide for ratings based on symptoms such as dyspnea on exertion, as well as reduced exercise capacity. Because the schedular rating criteria are adequate to rate the disability, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). In sum, a rating in excess of 30 percent is not warranted for any period. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. As such, the appeal is denied. With respect to all the claims, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability of these disorders according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which these disabilities are evaluated. Moreover, as the examiners have the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinions great probative value. As such, the Board finds these records to be more probative than the Veteran's subjective evidence of complaints of increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (interest in the outcome of a proceeding may affect the credibility of testimony). Duties to Notify and Assist Finally, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and medical or lay 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). When VCAA notice is delinquent or erroneous, the "rule of prejudicial error" applies. See 38 U.S.C.A. § 7261(b)(2) (West 2002). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Because the rating appeals arise from the Veteran's disagreement with the initial evaluations following grants of service connection, no additional notice is required. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for 'downstream' issues following a service connection grant, such as initial rating and effective date claims). The Veteran has not asserted that there is any deficiency regarding the notice provided for the service connection claims. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the service treatment records, post-service VA and private treatment records, and the Veteran's written assertions. In addition, the Veteran was afforded VA examinations to address the manifestations and severity of each of the service-connected disabilities, and was afforded a medical opinion to address the respiratory service connection claim. These examinations were adequate because each was performed by a medical professional based on a review of claims file or solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. The examinations provided pertinent findings regarding the rating schedule and the claimed respiratory disorder. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The Veteran asserts that the August 2010 examination and addendums in September 2010 and December 2011 were inadequate to address his claim for a respiratory disorder. The Board reiterates that the Veteran's dyspnea is acknowledged and the service-connected hypertensive heart disease rating specifically includes dyspnea. The evidence on this issue adequately addresses the claim, and no further development is necessary. Therefore, the available records and medical evidence have been obtained in order to make adequate determinations as to these claims. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). To the extent that the Board is granting in full the benefit sought on appeal with respect to some issues, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and need not be further considered. ORDER The appeal as to service connection for memory loss is dismissed. The appeal as to service connection for sleep impairment is dismissed. Service connection for a chronic respiratory disorder, claimed as trouble breathing, is denied. An initial compensable rating for bilateral hearing loss is denied. An initial rating in excess of 10 percent for vascular hypertension is denied A 10 percent rating, but no more, for residuals of a fracture, right middle finger, prior to December 2010, is granted subject to the laws and regulations governing the award of benefits. A rating in excess of 10 percent for residuals of a fracture, right middle finger, since December 2010 is denied. A 10 percent rating, but no more, for eczematous dermatitis prior to December 2010, is granted subject to the laws and regulations governing the award of benefits. A rating in excess of 10 percent for eczematous dermatitis since December 2010 is denied. An initial rating in excess of 30 percent for hypertensive heart disease is denied. REMAND In an October 2010 rating decision, the RO granted service connection for PTSD and assigned an initial rating of 50 percent, effective August 3, 2009. The RO also granted service connection for migraine headaches and assigned an initial rating of 0 percent, effective June 21, 2004. In correspondence received in May 2011, within 1 year of the October 2010 rating decision, the Veteran expressed disagreement with the initial ratings assigned for PTSD and migraine headaches. To date, a statement of the case has not been prepared on the issue. The RO granted an increased rating for migraine headaches in a June 2013 rating decision. Correspondence received from the Veteran in July 2013, within 1 year of the June 2013 rating decision, expressed disagreement with the 30 percent rating assigned for migraine headaches. To date, a statement of the case has not been prepared on the issue. Accordingly, the claims of entitlement to increased ratings for PTSD and migraine headaches are REMANDED to the RO for the following action: Issue a statement of the case pertaining to the issues of entitlement to increased ratings for migraine headaches and PTSD, and in connection therewith, provide the Veteran with appropriate notice of his appellate rights. The Veteran is reminded that, to vest the Board with jurisdiction over this issue, a timely substantive appeal must be filed after receiving the statement of the case. See 38 C.F.R. § 20.202 (2013). If, and only if, the Veteran perfects the appeal to any issues, the case must be returned to the Board for appellate review. 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 remanded claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs