Citation Nr: 1302954 Decision Date: 01/28/13 Archive Date: 02/05/13 DOCKET NO. 10-04 795 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a right wrist disability. 2. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD). 3. Entitlement to an initial rating in excess of 10 percent for hepatitis C. 4. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Gregory D. Keenum, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Scott Walker, Counsel INTRODUCTION The Veteran served on active duty from May 1967 to February 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2009 and July 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Veteran testified before the undersigned during a Board videoconference hearing held in February 2011. A copy of the hearing transcript has been associated with the record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to service connection for a right wrist disability is REMANDED to the RO via the Appeals Management Center in Washington, D.C. FINDINGS OF FACT 1. The Veteran's PTSD is manifested by occupational and social impairment, though not total impairment, with deficiencies in most areas such as work and family relations, occasional suicidal ideation (with no plan or attempt), depression, impaired impulse control (such as unprovoked irritability with periods of violence), neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work-like setting), and the inability to establish and maintain effective relationships. 2. The Veteran's hepatitis C is shown to be productive of no more than intermittent or daily symptoms of fatigue. Dietary restriction and continuous medication are not required. There are no associated symptoms of malaise, nausea, vomiting, anorexia, abdominal pain, weight loss, or incapacitating episodes requiring bed rest or treatment by a physician. 3. The Veteran is currently service-connected for the following disabilities: PTSD, for which he has a 70 percent disability rating, and hepatitis C, for which he has a 10 percent disability rating; these awards, in combination, represent a 70 percent disability rating. 4. The Veteran meets the schedular requirements of 38 C.F.R. § 4.16(a) for the rating of his disabilities. 5. The competent and credible evidence establishes that the Veteran's service-connected disabilities preclude him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an initial rating in excess of 10 percent for hepatitis C have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.114, Diagnostic Code 7354 (2012). 3. The criteria for entitlement to a TDIU rating are met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 3.340, 3.341, 4.16, 4.25 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The Veteran's TDIU claim is granted in this decision. Therefore, any deficiency with regard to notice or development for the issue of entitlement to TDIU is harmless and non-prejudicial. With regard to the Veteran's increased rating claims, proper notice from VA must inform the claimant, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ), of any information and any 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. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Neither the Veteran nor his representative has alleged prejudice with respect to notice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. VA's duty to notify has been satisfied. The Veteran was notified in February 2009 of the criteria for establishing service connection and an increased rating, the evidence required, and his and VA's respective duties for obtaining evidence. That letter addressed all notice elements and predated the initial adjudication in April 2009. He also was notified of how VA determines disability ratings and effective dates if service connection is awarded. Nothing more is required. The Veteran is challenging the initial rating assigned following the grant of service connection for hepatitis C. In cases where service connection has been granted and an initial disability rating has been assigned, the typical service connection claim has been substantiated, thereby rendering notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Thus, because the notice that the Veteran was provided before service connection was granted was legally sufficient, VA's duty to notify has been satisfied. As for the duty to assist, the Veteran's service medical records have been obtained. Pertinent post-service medical records have been obtained, to the extent available. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The Board finds that no additional evidence, which may aid the Veteran's claim or might be pertinent to the claim, has been submitted, identified, or remains outstanding, and the duty to assist requirement has been satisfied. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. 38 C.F.R. § 3.159(c)(4) (2012); Green v. Derwinski, 1 Vet. App. 121 (1991). Here, the Veteran was most recently afforded VA examinations to address his claims in March and June 2009. When VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The VA examination reports are adequate to decide the claims addressed, as the examination reports included a thorough review of the file, and examination findings relevant to the issues. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any error is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005). Increased Ratings Disability ratings are based upon the average impairment of earning capacity as contemplated by the schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). In order to rate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589 (2002). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, the reasonable doubt shall be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a staged rating. Fenderson v. West, 12 Vet. App 119 (1999). The Court has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evidence of record does not establish additional, distinct time periods where the Veteran's service-connected disabilities have resulted in symptoms that warrant different/additional staged ratings. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2012). However, the rating of the same disability or the same manifestations under various diagnoses is not allowed. 38 C.F.R. § 4.14 (2012). A claimant may not be compensated twice for the same symptomatology as such a result would overcompensate the claimant for the actual impairment of his earning capacity. Brady v. Brown, 4 Vet. App. 203 (1993); 38 U.S.C.A. § 1155 (West 2002). That would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14 (2012). If a Veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Assignment of a particular Diagnostic Code is completely dependent on the facts of a particular case. Butts v. Brown, 5 Vet. App. 532 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Where there is a question as to which of two ratings shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). PTSD The Veteran is service connected for PTSD, and his disability has been assigned an evaluation of 70 percent pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, General Rating Formula for Mental Disorders (2012). The General Rating Formula for Mental Disorders provides a 70 percent rating for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: Suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is provided for total occupational and social impairment, due to such symptoms as: Gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2012). The use of the term such as in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. The use of the phrase such symptoms as, followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) rating is a scale indicating the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266 (1996); Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association (4th ed. 1994). With regard to GAF scores, scores ranging from 51 to 60 indicate moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 indicate some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). 38 C.F.R. §§ 4.129, 4.130 (2012); Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association (4th ed. 1994). At the time of a VA psychiatric examination conducted in November 2007, the Veteran indicated that he was compliant with his psychiatric medications. Though they did not fully alleviate PTSD symptomatology, his sleep had improved. A review of the record indicated that the Veteran carried a GAF score of 45 since September 2007. Symptoms noted in VA outpatient treatment included intrusive images, flashbacks, nightmares, feeling distant, outbursts of anger, irritability, difficulty being around family members, difficulty attending social functions, slow work, and making mistakes. The Veteran reported other symptoms, such as hypervigilance and exaggerated startle response, and a low tolerance to loud noise. As for employment, he noted that he was on disability from the Social Security Administration (SSA), and that he had not worked since 1994. During the interview, the Veteran was alert and oriented. He was neatly, casually dressed with fair grooming and hygiene. Eye contact was limited and speech was pressured at times. His mood was depressed, and he was at times tearful and agitated. Attention and concentration were limited at times, though memory appeared grossly intact. No suicidal or homicidal ideation was reported. He endorsed auditory hallucinations, though no visual hallucinations were noted. Insight and judgment were fair, thoughts were logical and goal-oriented, and there was no evidence of looseness of association or flight of ideas. The Veteran indicated that he had been sober for 12-18 months. He was assigned a GAF score of 45. The Veteran was afforded an additional VA psychiatric examination in March 2009. At that time, the Veteran indicated that he was still married, and that their relationship was "OK." He further stated that he had no friends, and had not had a friend in 20 years. He was not using alcohol or any other substances. As for hygiene, he indicated that he bathed and changed clothes approximately once per week. On examination, psychomotor activity was unremarkable, and speech was spontaneous, clear, and coherent. During the examination, the Veteran's attitude was cooperative and friendly, and his affect was flat. He was oriented to person, place, and time. His thought process was slow, and his thought content was unremarkable. Judgment was intact, and intelligence was average. No delusions or hallucinations were reported. There was no inappropriate behavior observed, nor were there obsessive, ritualistic behavior. He did not report panic attacks or homicidal thoughts, though suicidal thoughts were acknowledged, triggered by loss of loved ones, with no plan. Impulse control was good, and there were no episodes of violence. There were no problems with grooming. PTSD symptoms included persistent avoidance of stimuli associated with his in-service trauma, feelings of detachment and estrangement from others, sleep disturbance with nightmares, exaggerated startle response, diminished interest in activities, and sensitivity to loud noise. It was noted that the Veteran retired in 1993 due to his mental problems. The Veteran reported that he had problems on the job, including arguments with his bosses and coworkers. He noted that his fuse was not as short at present, but that he still got angry and became verbally abusive, at times breaking things. The examiner indicated that total occupational and social impairment was not present. He was assigned a GAF score of 45. While the Board has also reviewed the Veteran's VA outpatient treatment reports of record, to include notes from his group counseling sessions, there are no additional reports indicating symptoms of greater severity within the appellate period than the examination reports discussed above. During the Veteran's February 2011 Board hearing, he testified that he had difficulty sleeping at night, and when he did, he experienced nightmares. He noted that he had a very hard time concentrating. With regard to friends, he testified that he did not want friends, as he could not bear it when they left. He also stated that loud noise caused a great deal of emotional disturbance. He indicated that he was extremely irritable with those he came in contact with, mostly family. The Board finds that the preponderance of the evidence is against the assignment of a 100 percent rating. Regarding GAF scores of record, the Veteran has consistently been assigned a rating of 45 during the appellate period, indicative of serious symptoms, to include serious impairment in social and occupational functioning. Symptoms which support his 70 percent rating include, but are not limited to, occupational and social impairment, with deficiencies in most areas such as work and family relations, occasional suicidal ideation (with no plan or attempt), depression, impaired impulse control (such as unprovoked irritability with periods of violence), neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work-like setting), and the inability to establish and maintain effective relationships. However, there was no evidence that the Veteran demonstrated total occupational and social impairment as a result of his PTSD, as specifically indicated by the March 2009 VA examiner. According to the most recent VA examination report, total occupational and social impairment was not present. Further, the record does not contain evidence of gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. In fact, the only symptom typically associated with a 100 percent rating which was endorsed by the Veteran included the intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), as the Veteran reported that many weeks he showered and changed clothes only one time. However, when he reported to for the interview, the Veteran was dressed appropriately, and the examiner noted that he was not incapable of adequate grooming. Therefore, while the Veteran's PTSD is indicative of serious symptomatology, those symptoms are contemplated in his current rating of 70 percent. While the Board does not doubt the severity of his psychiatric disorder, the criteria for a 100 percent rating are not met because total occupational and social impairment due to PTSD is not shown. The preponderance of the evidence is against the claim for increased rating and the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hepatitis C The Veteran's service-connected hepatitis C is rated 10 percent under Diagnostic Code 7354, used for rating hepatitis C. 38 C.F.R. § 4.114 (2012). Historically, he was rated under DC 7345, which is assigned for chronic liver disease without cirrhosis, including hepatitis B, chronic active hepatitis, autoimmune hepatitis, hemochromatosis, drug-induced hepatitis, but excluding bile duct disorders and hepatitis C. The Board notes that not only does the rating schedule expressly provide that hepatitis C be rated under Diagnostic Code 7354, but Diagnostic Code 7345 explicitly excludes hepatitis C. Notwithstanding those explicit provisions as to the diagnostic code under which to rate hepatitis C, the rating criteria under each Diagnostic Code are essentially identical. Under Diagnostic Code 7354, a 10 percent is warranted when the Veteran has serologic evidence of hepatitis C infection and the following signs and symptoms due to that infection: intermittent fatigue, malaise, and anorexia or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12 month period. A 20 percent rating is warranted when symptoms include daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms described above) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. 38 C.F.R. § 4.114 (2012). An incapacitating episode is a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. 38 C.F.R. § 4.114, Diagnostic Code 7354, Note 2 (2012). The term substantial weight loss means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer; and the term minor weight loss means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. The term inability to gain weight means that there has been substantial weight loss with inability to regain it despite appropriate therapy. Baseline weight means the average weight for the two-year- period preceding onset of the disease. 38 C.F.R. § 4.112 (2012). The Veteran was first afforded a VA examination to address his claim for hepatitis C in July 2004. At that time, the Veteran denied having a problem with vomiting or diarrhea. He reported a variable appetite, and he complained of easy fatigability. On examination, the examiner identified fullness in the right upper quadrant, though a definite liver boarder was not identified. After testing, the Veteran was diagnosed with a fatty liver and colonic diverticulosis, in addition to hepatitis C. An additional VA examination was provided in June 2009. He complained of chronic fatigue, and noted that he felt exhausted by the morning with limited activity. He further noted pruritis in his arms and legs. He did not recall a history of jaundice. The Board has reviewed the Veteran's voluminous VA outpatient record, however there is no evidence that his hepatitis C has manifest more severely during the appellate period than demonstrated by the two VA examinations of record. During his Board hearing in February 2011, he testified that hepatitis C made him tired, and affected his sex life. Based upon its review of the evidence of record, the Board finds there is no basis for a disability rating in excess of 10 percent for hepatitis C. The evidence shows that the Veteran's hepatitis C objectively manifests as chronic fatigue. However, there is no evidence of record indicating that it otherwise causes malaise or anorexia. Under Diagnostic Code 7354, the assignment of a 20 percent rating for hepatitis C requires a showing of those symptoms on a daily basis and a need for dietary restriction or continuous medication, or incapacitating episodes having a total duration of at least two weeks during the past 12-month period. In this case, the Veteran reports, and physicians note, fatigue, but no malaise or anorexia. Moreover, there is no indication that the Veteran has been prescribed medication for hepatitis C during the course of the appeal. With respect to a higher rating based on the frequency and extent of incapacitating episodes, defined as a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician, the Board notes that there is no indication, from the Veteran or any medical provider, that an incapacitating episode was experienced since the Veteran filed his claim for service connection. Further, VA treatment records and examination reports, dated during the course of this appeal, do not show that the Veteran's fatigue involved regular visits to a physician and none of them show prescribed bed rest. Therefore, the evidence does not show doctor-prescribed bed rest due to incapacitating episodes. As a result, the Board finds that the Veteran's symptoms do not more nearly approximate the criteria for a rating in excess of 10 percent under Diagnostic Code 7354. 38 C.F.R. § 4.114 (2012). The Board has also considered rating the Veteran under closely related codes. Higher ratings are provided for residuals of liver injury (Diagnostic Code 7311), cirrhosis of the liver (Diagnostic Code 7312), malignant neoplasms of the digestive system (Diagnostic Code 7343), and benign neoplasms, exclusive of skin growths (Diagnostic Code 7344). 38 C.F.R. § 4.114. However, absent clinical documentation of such findings, the Veteran is not entitled to a higher rating for his service-connected liver disorder under any of those Diagnostic Codes as those disabilities are not shown. Therefore, a higher rating for the Veteran's service-connected hepatitis C is not available at this time. The Board finds that the preponderance of the evidence is against the claim for increased rating and the claim is denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Conclusion In reaching the above conclusions, the Board has also not overlooked the Veteran's statements regarding the severity of his service-connected disabilities. The Veteran is competent to report on factual matters of which he has first-hand knowledge, such experiencing fatigue, and severe psychiatric symptoms. Washington v. Nicholson, 19 Vet. App. 362 (2005). However, while the Board may consider the Veteran's subjective statements regarding the severity of his disabilities, the Board notes that with respect to the Rating Schedule, the criteria set forth therein generally require medical expertise which the Veteran has not been shown to have and the types of findings are not readily observable by a layperson. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Furthermore, the Board finds the objective medical findings and opinions provided by the VA examiners of record are afforded the greater probative weight. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the Board as adjudicator. Guerrieri v. Brown, 4 Vet. App. 467 (1993). The above determinations are based upon consideration of applicable rating provisions. There is no showing that either of the Veteran's disabilities have demonstrated so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluation on an extra-schedular basis. 38 C.F.R. § 3.321(b)(1) (2012). The symptoms of each disability have been accurately compensated by the schedular criteria. Further, the Board points out that his disability ratings encompass a degree of occupational impairment relative to those ratings. Also, as discussed in more detail below, the Board is awarding a TDIU, which encompasses both disabilities currently on appeal. Without sufficient evidence showing that the Veteran's disability picture is not contemplated by the rating schedule, referral for a determination of whether the Veteran's disability picture warrants the assignment of an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). In light of the foregoing, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 70 percent for PTSD, or a 10 percent rating for hepatitis C. Therefore, the claims for increase are denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to a TDIU A total disability rating may be assigned where the schedular rating is less than total, when the disabled person is 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, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2012). Substantially gainful employment must be reviewed in a practical manner, and mere theoretical ability to engage in substantial gainful employment is not a sufficient basis to deny benefits. The test is whether a particular job is realistically within the physical and mental capabilities of the claimant. Moore v. Derwinski, 1 Vet. App. 356 (1991), Timmerman v. Weinberger, 510 F.2d 439 (8th Cir. 1975): A veteran's service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, the reasonable doubt will be resolved in favor of the Veteran. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102 (2012). The Veteran satisfies the percentage requirements noted above. The Veteran is service-connected for PTSD, rated 70 percent, and hepatitis C, rated 10 percent disability. His combined rating is 70 percent. 38 C.F.R. § 4.25, Table I (2012). The Veteran contends that he is entitled to a TDIU rating, as his service-connected disabilities, particularly his PTSD, render him unemployable. Therefore, the Board must address whether any service-connected impairment of mind or body is present that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340(a)(1), 4.15 (2012). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. 38 C.F.R. §4.16(a) (2012). On his February 2008 Application for Increased Compensation Based on Unemployability, the Veteran indicated that he had no education or training, and that he became too disabled to work as of September 1992. He further noted that he earned no money during the prior year. The Veteran last worked full-time in January 1990. His employer at that time was an auto parts store. Turning to medical evidence of record, a VA outpatient report dated in July 2001 indicated that the Veteran was participating in occupational therapy. The Veteran reported that he would like to stop drinking and smoking, and indicated that he had difficulty completing the work load for his last employer. In October 2002, he reported that he was not currently working on account of his psychiatric symptomatology. In November 2005, the Veteran's primary VA psychiatric provider authored a statement in support of his TDIU claim. It was noted that the Veteran had been a member of the PTSD residential program for two months, and that his GAF of 45 was indicative of serious symptomatology. It was further noted that with a GAF score in that range, the Veteran was simply unable to work. The examiner explained that PTSD was a disorder which can be treated to help veterans better cope and manage, but that PTSD was a debilitating condition that could not be cured. It was explained that the occupational impairment demonstrated by a GAF of 45 was clinically significant, and that the Veteran had a very difficult time carrying out simple tasks and social activities, such as going to the grocery store. To make matters worse, his PTSD symptomatology was increasing. The examiner stated that the Veteran's symptoms had an extremely detrimental impact on the overall quality of his life, stripping from him the clear psychological benefits that are derived from being gainfully employed, and that the chances of the Veteran ever working again were permanently eliminated. Following his November 2007 VA psychiatric examination, it was noted that his PTSD symptoms interfered significantly with occupational functioning. Following his March 2009 examination, the examiner indicated that PTSD did not cause total occupational impairment. However, the Board again notes that is not the standard when determining whether a service-connected disability impedes gainful employment. Instead, the test is whether a particular job is realistically within the physical and mental capabilities of the claimant. Moore v. Derwinski, 1 Vet. App. 356 (1991). The March 2009 examiner noted that, when the Veteran did work, he had a history of work-related problems and conflicts. Taking the medical evidence of record into account, and the Veteran's hearing testimony, the Board finds that Veteran is not capable of performing the physical and mental acts required by employment. Therefore, the Board must determine whether currently-service-connected disabilities alone, to include PTSD, render the Veteran unemployable. Here, the Board is precluded from rendering its own medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). After a review of the claims file, the Board finds that the most probative medical evidence establishes that the Veteran would be unable to work solely due to his service-connected disabilities. The Board again notes that the evaluation of March 2009, which noted that total work deficiency was not present, confirmed that the Veteran's social and occupational functioning was drastically hindered by his psychiatric disability. Looking again to the standard of whether a particular job is realistically within the physical and mental capabilities of the claimant, the Board finds that determination does not bar a TDIU grant, and that the Veteran's service-connected disabilities, alone, and specifically his PTSD, are sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). The Veteran has no formal education or special training. Even assuming the Veteran were able to find a sedentary job for which he could be trained, the Veteran would still face significant workplace hurdles, such as heightened startle response and outbursts of anger, and deficiencies in mental capacity with regard to his ability to quickly process information. At the very least, a reasonable doubt arises as to his employability, which must be resolved in favor of the Veteran. 38 C.F.R. § 3.102 (2012). The Board finds that the Veteran is not currently able to engage in substantial employment due to impairment caused by service-connected disabilities. Medical evidence demonstrates that he is generally incapable of adequate social interaction, and lacks the inability to perform the tasks required by substantial employment. The Board concludes that a total rating for compensation purposes based on individual unemployability due to service-connected disabilities is warranted. Reasonable doubt has been resolved in favor of the Veteran in making this decision. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder is denied. Entitlement to an initial rating in excess of 10 percent for hepatitis C is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted. REMAND Although the Board regrets any further delay in adjudicating the Veteran's remaining claim, pursuant to the duty to assist, the issue of entitlement to service connection for a right wrist disability must be remanded for further development. In support of his claim, the Veteran testified that artillery rounds landed close to his position during service, and that he was blown into a trench line, causing his right wrist to bend back, almost to his forearm. The Board notes that his service treatment records document treatment for a right wrist injury on several occasions in October 1968. It was noted that the Veteran extended his right wrist when trying to catch himself. On examination, there was pain on flexion and dorsiflexion, each limiting range of motion, and on the exterior of the wrist. There was also tenderness over the area and localized swelling. X-rays were negative for a fracture, and the assessment was a traumatized dorsal ganglion. The Board notes that the Veteran is competent in this regard to report observable symptomatology, such as wrist pain. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Further, the circumstances of his service are consistent with his claim, as he was a machine gunner. Finally, the Board finds that, while a complex diagnosis of the wrist is not possible for a layperson, wrist pain is a condition which is simple to identify. Therefore, the Veteran is competent to report that he experienced wrist pain during his tour of duty, and that his right wrist symptoms are similar to those experienced during his period of active service. Moreover, the record contains current complaints of right wrist discomfort. In June 2008, X-rays indicated that there was mild periarticular demineralization seen at the wrist, with small soft tissue calcification which was possibly related to a remote injury. His wrist was again symptomatic to the extent that an X-ray was ordered in February 2009. At the time, X-rays demonstrated normal bony alignment with some calcification of soft tissue, and splints were ordered. It does not appear that any further testing was done to determine whether any further right wrist disability was present, and an etiological opinion was not provided. VA must provide a medical examination in a service connection claim when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, there is evidence of current treatment for a right wrist disability, and there is competent evidence showing a continuity of symptomatology from the Veteran's period of service, when a right wrist injury was shown, to the present. However, the record lacks an etiological opinion to determine whether any current right wrist injury is related to his period of active service. Pursuant to VA's duty to assist, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). Taking into account the Veteran's complaints of record, in addition to his competent lay statements, his claim for service connection should be remanded for a VA examination so as to determine whether any current right wrist disorder is etiologically-related to his period of active service. Accordingly, the case is REMANDED for the following actions: This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested. 1. Schedule the Veteran for a VA orthopedic examination to assess the severity and etiology of any currently-diagnosed right wrist disability. The examiner must review the claims file and must note that review in the report. The examiner should review, note, and discuss the Veteran's statements in support of his claim, and prior VA medical evidence of record, and in-service reports of right wrist treatment with accompanying reported history. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current right wrist disability is etiologically-related to the Veteran's period of active duty service and his complaints of and treatment for right wrist problems during service. The term at least as likely as not does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. The rationale for the requested opinions should be provided. 2. Then readjudicate the claim. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. The appellant has the right to submit additional evidence and argument on the matter or 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 or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ HARVEY ROBERTS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs