Citation Nr: 1534551 Decision Date: 08/13/15 Archive Date: 08/20/15 DOCKET NO. 09-38 773 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for a left knee disability. 2. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for a prostate disability. 3. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for a low back disability. 4. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for residuals of shrapnel wounds. 5. Whether new and material evidence has been received to reopen a previously denied a claim of entitlement to service connection for a right ear hearing loss. 6. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for a fungal condition of the mouth and skin. 7. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD), for the period from December 28, 2006, to May 25, 2010. 8. Entitlement to service connection for a left knee disability. 9. Entitlement to service connection for a prostate disability, to include as due to exposure to Agent Orange. 10. Entitlement to service connection for hypertension, to include as secondary to PTSD and coronary artery disease (CAD). 11. Entitlement to service connection for a low back disability. 12. Entitlement to service connection for residuals of shrapnel wounds. 13. Entitlement to service connection for right ear hearing loss. 14. Entitlement to service connection for a fungal condition of the mouth and skin, to include as due to exposure to Agent Orange. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Michael Sanford, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1966 to April 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2008 and April 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. With regard to PTSD, the Veteran has limited the scope of his appeal to whether a rating higher than 50 percent is warranted for the period from December 28, 2006, to May 25, 2010 (the day a 100 percent rating for PTSD was awarded). See April 2015 Statement of Accredited Representative. The issues of entitlement to service connection for a left knee disability, prostate disability, hypertension, low back disability, shrapnel wound residuals, right ear hearing loss, and a fungal disability of the mouth and skin are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A January 2004 rating decision denied the Veteran's claim of entitlement to service connection for a left knee disability, enlarged prostate, low back disability, shrapnel wound residuals, right ear hearing loss, and fungal condition of the mouth and skin. The Veteran did not perfect an appeal of the January 2004 rating decision, and new and material evidence was not received within one year of its issuance. 2. Evidence received more than one year since the January 2004 rating decision relates to unestablished facts necessary to substantiate the claims of entitlement to service connection for a left knee disability, enlarged prostate, low back disability, shrapnel wound residuals, right ear hearing loss, and a fungal condition of the mouth and skin and raises a reasonable possibility of substantiating those claims. 3. For the period from December 28, 2006, to May 25, 2010, the Veteran's PTSD was productive of occupational and social impairment in most areas, such as work, school, family relations, judgment, thinking and mood. CONCLUSIONS OF LAW 1. The January 2004 rating decision that denied service connection for a left knee disability, enlarged prostate, low back disability, shrapnel wound residuals, right ear hearing loss, and a fungal condition of the mouth and skin is final. 38 U.S.C.A. § 7105(c) (West 2014); 38 C.F.R. §§ 3.156(b), 20.302, 20.1103 (2014). 2. Evidence received more than one year since the January 2004 rating decision is new and material, and the claims of entitlement to service connection for a left knee disability, enlarged prostate, low back disability, shrapnel wound residuals, right ear hearing loss, and a fungal condition of the mouth and skin are reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2014). 3. For the period from December 28, 2006, to May 25, 2010, the criteria for a rating of 70 percent, but no higher, for PTSD are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits pursuant to 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. As the decision regarding the claims to reopen is fully favorable, no discussion of the duties to notify and assist is necessary. Regarding the claim for a higher initial rating for PTSD, VA's duty to notify has been satisfied through a notice letter dated April 2009, which fully addressed all notice elements. This letter informed the Veteran of what evidence was required to substantiate his claim for service connection and of the Veteran's and VA's respective duties for obtaining evidence. The Board emphasizes that the Veteran's claim for an initial increased rating for PTSD arises out of the grant of service connection for that disability. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to 'downstream' questions, the claim has been substantiated and there is no need to provide additional VCAA notice or address prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (2003). The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). There has been no such allegation of error in this case. The Board, therefore, finds that all notices required by the Veteran Claims Assistance Act (VCAA) and implementing regulations were furnished to the Veteran and that no useful purpose would be served by delaying appellate review to send out additional VCAA notices. VA must also make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claims, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Service treatment records are associated with the claims file. All post-service treatment records and reports identified by the Veteran related to the claim decided herein have also been obtained. The Veteran has not identified any additional records that should be obtained prior to a Board decision. He was provided with VA examinations to assess the severity of his PTSD in December 2007 and May 2010. The Board finds these examinations are adequate for deciding the issue of entitlement to higher rating for PTSD on appeal, as both involved a review of the Veteran's pertinent medical history, a clinical evaluation of the Veteran, a review of relevant symptomatology related to the given disability. See generally Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Indeed, the Veteran has not argued that those VA examinations are somehow inadequate. In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Analysis A. New and Material Evidence The RO denied entitlement to service connection for a left knee disability, enlarged prostate, low back disability, residuals of a shrapnel wound, right ear hearing loss, and a fungal condition in a January 2004 rating decision. The Veteran was informed of this decision and his appellate rights in a letter dated January 12, 2004. The Veteran did not file a notice of disagreement, or submit new and material evidence within the one year appeal period. Indeed, no evidence was submitted within one year of the issuance of the January 2004 rating decision. Thus, this decision became final. 38 U.S.C.A. § 7105(c) (West 2014); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); 38 C.F.R. §§ 3.104, 3.156(a)-(b), 20.302, 20.1103. Despite the finality of a prior decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). At the time of the January 2004 rating decision, only the Veteran's claim for service connection, his service treatment records (STRs), and service personnel records (SPRs) were considered. No other evidence was of record at that time. Regarding his left knee disability, service connection was denied because there was no evidence that any current left knee disability was related to service. See January 2004 Rating Decision. Subsequently, the Veteran's wife submitted a statement noting that the Veteran was treated for a left knee disability in service. See May 2009 Statement of Veteran's Wife. She further explained that there may not be evidence of the Veteran's left knee problems in his STRs due to the fact that the Veteran was treated by infantry doctors he supported. See id. Crucially, this evidence indicates that the Veteran may have experienced left knee problems during service. This evidence was not of record at the time of the January 2004 rating decision. Consequently, the Veteran's previously-denied claim of entitlement to service connection for a left knee disability is reopened. Regarding a prostate disability, service connection was denied because there was no evidence that any current prostate disability was related to service. See January 2004 Rating Decision. Since that time, in a May 2011 statement signed by the Veteran, a dentist, and his wife, it was asserted that the Veteran suffers from an enlarged prostate, which was caused by his exposure to Agent Orange in Vietnam. Crucially, this evidence, presumed credible for the purpose of reopening, indicates that the Veteran's prostate disability is related to his period of service. This evidence was not of record at the time of the January 2004 rating decision. Consequently, the Veteran's previously-denied claim of entitlement to service connection for a prostate disability is reopened. Regarding his low back disability, service connection was initially denied because there was no evidence that any current low back disability was related to service. See January 2004 Rating Decision. Since the January 2004 rating decision, in a May 2009 statement, the Veteran's wife indicates that he fell during a mortar attack. Further, in a December 2008 statement, P.M. stated that while serving with the Veteran, he observed the Veteran fall down a flight of stairs during a mortar attack. Crucially, these lay statements indicate that the Veteran's current low back disability may have been incurred in service. This evidence was not of record at the time of the January 2004 rating decision. Consequently, the Veteran's previously-denied claim of entitlement to service connection for a low back disability is reopened. Regarding residuals of a shrapnel wound, service connection was initially denied because there was no evidence that such disability was related to service. See January 2004 Rating Decision. Since the January 2004 rating decision, the Board's focus is directed towards the December 2008 statement of P.M., who served with the Veteran in Vietnam. P.M. explained that both he and the Veteran were treated for minor shrapnel wounds in Vietnam. Crucially, P.M.'s statement is evidence that the Veteran suffered a shrapnel wound in service and any residuals may be related to the Veteran's service. Consequently, the Veteran's previously-denied claim of entitlement to service connection for residuals of a shrapnel wound is reopened. Regarding right ear hearing loss, service connection was initially denied because there was no evidence that hearing loss was related to service. See January 2004 Rating Decision. Since the January 2004 rating decision, in a May 2010 VA examination report, the VA examiner concluded that the Veteran's current hearing loss was related to exposure to noise during his military service. Crucially, this opinion is evidence of an etiological link between hearing loss and service. This evidence was not of record at the time of the January 2004 rating decision. Consequently, the Veteran's previously-denied claim of entitlement to service connection for a right ear hearing loss disability is reopened. Regarding a fungal condition of the skin and mouth, service connection was initially denied because there was no evidence that a fungal condition was related to service. See January 2004 Rating Decision. Since the January 2004 rating decision, in a November 2008 statement, the Veteran's wife explained that the Veteran's fungal condition has occurred since the Veteran's period of service and the Veteran, who is a dentist, has treated this fungal condition himself. Crucially, this statement provides some evidence that the Veteran's fungal condition may be related to his period of service. This evidence was not of record at the time of the January 2004 rating decision. Consequently, the Veteran's previously-denied claim of entitlement to service connection for a fungal condition of the mouth and skin is reopened. B. Increased Initial Rating for PTSD Because the Veteran is challenging the initially assigned disability rating, it has been in continuous appellate status since the original assignment of service connection. The evidence to be considered includes all evidence proffered in support of the original claim. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected disability is rated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, pertaining to PTSD. Under that diagnostic code, a 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; 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 work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). The Board notes that effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM and replace them with references to the recently updated Fifth Edition (DSM-5). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. As the RO certified the Veteran's appeal to the Board on May 13, 2015, the claim would normally be governed by the DSM-5. However, insofar as the Veteran has limited his appeal to consideration of a period of time the pre-dates these changes, the Board will continue to utilize the DSM-IV in its analysis. The nomenclature employed in the portion of VA's Schedule for Rating Disabilities ("the Schedule") that addresses service-connected psychiatric disabilities is based upon the DSM-IV. 38 C.F.R. § 4.130. The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. GAF scores included in the record are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The DSM-IV contemplates that the GAF scale will be used to gauge a person's level of functioning at the time of the evaluation (i.e., the current period) because ratings of current functioning will generally reflect the need for treatment or care. While GAF scores are probative of the Veteran's level of impairment, they are not to be viewed outside the context of the entire record. Therefore, they will not be relied upon as the sole basis for an increased disability evaluation. Turning to the evidence of record, the Veteran submitted a statement in January 2006. He reported feeling depressed and not liking to be around people. The Veteran explained that he had a difficult relationship with his previous wife, and that he stopped practicing as a dentist in 2005. He also stated that he divorced his previous wife in 2004. He explained that he remarried, but still experiences periods of depression. The Veteran reported anxiety when he sees news regarding current military operations. The Veteran submitted a psychiatric evaluation from Dr. N.A.Z., D.O., dated July 2007. Dr. N.A.Z. noted that the Veteran was receiving mental health treatment until about 2003 due to an unhappy marriage. The Veteran reported that he since divorced his first wife and married his current wife. The Veteran reported intrusive thoughts and dreams, and increased irritability. He stated that he avoids people. The Veteran explained that he experiences increased nightmares, where he wakes up and yells. The Veteran was noted as having an intense drive and motivation for achieving. He reported leaving his dental practice due to not wanting to be around people anymore. The Veteran was described as outwardly anxious, but easily engaged. There were no homicidal or suicidal ideations. The Veteran's mood was angry, with some components of irritability and dysphoria. There was no evidence of any psychotic processes, including any visual or auditory hallucinations. The Veteran was oriented in all spheres. A GAF score of 65 was recorded. The Veteran was afforded a VA examination in December 2007. There, a diagnosis of PTSD was rendered. The Veteran reported taking medication for his PTSD, but noted that he discontinued those medications due to their effects. The Veteran reported increasing anxiety since 1991. He stated that he began reducing his dental practice around that time. The Veteran explained that he completely ceased his dental practice five years prior due to his anxiety of being around people. The Veteran reported being married for 37 years. He stated that the relationship was troubled because of his emotional distancing and self-isolation. He noted a strained relationship with his adult daughter. He stated that he remarried about two years prior to the examination and reported a good relationship with his current wife. He stated that he gets along adequately with his brother, but has limited tolerance with lengthy visits. He stated that he gets anxious with visitors, including family members. The Veteran noted two good friends, but explained that he spends less time with them. He spends most of his time with his wife or by himself. The Veteran reported going to restaurants and stores, but noted that he does get anxious when he has to interact with people. He stated that he attends church, but does not get involved in church functions. The Veteran reported pleasure in tending land and building a log cabin. The Veteran denied any suicidal or homicidal thoughts. The Veteran reported lessened depression, but low mood 10 to 20 percent of the time. He denied low self-esteem and impaired impulse control. The Veteran had significant insomnia, often related to memories of Vietnam. He reported war-related nightmares. He also reported intrusive memories of the war during the day. The Veteran avoided watching newscasts of military issues and war-related movies, and described a history of emotional distancing and reduced social interactions. He endorsed irritability and anger. Poor concentration was also noted. A GAF score or 60 was assigned. In February 2008, the Veteran submitted a statement detailing his PTSD symptomatology. The Veteran stated that his wife was concerned about the Veteran's alcohol intake. He was also concerned about his stress and anxiety levels. The Veteran's wife stated that the Veteran experiences anxiety attacks more than once per week. The Veteran reported being easily distracted and isolated. The Veteran reported not making important appointments. The Veteran reported low tolerance for tasks. He reported getting angry when things do not go his way. The Veteran reported poor memory and an inability to remember early lifetime events, as well as recent events. The Veteran recounted coworkers constantly reminding him of tasks to be completed. He explained that he often thinks about his time in the military. He also reported sporadic outbursts of anger. Finally, he reported being easily startled by loud noises. A March 2008 VA treatment record notes that the Veteran's mood was dysphoric and his affect was flat. Grooming and hygiene were good. The Veteran was cooperative with the interviewer. The Veteran did not report hallucinations or delusions. Symptoms were: daily depressed mood; daily diminished interest in activities; sleep disturbance more days than not; daily fatigue; and decreased concentration. The Veteran reported consuming alcohol more nights than he intended. It was noted that PTSD symptoms began in 1991 and progressively worsened. He reported that his past marriage failed due to his PTSD symptoms. Another March 2008 VA treatment record notes that the Veteran began experiencing disruptions with his life in 1991. He stated that his first wife and he divorced due to the Veteran's mood problems. He stated that he experiences nightmares, isolation, avoidance of news reports, hypervigilance and sleep disturbances. He denied suicidal and homicidal thoughts. He reported having problems with alcohol abuse. Minimal feelings of helplessness were noted. A GAF of 55 was noted. In April 2008, the Veteran's wife submitted a statement. She explained that the Veteran is very uncomfortable with other people. She stated that he does not do well with large crowds. She stated that while he goes to church, he likes to arrive late and sit in the rear of the church. She stated that he occasionally dines in restaurants, but will only sit near an open door with his back to a wall. She reported that the Veteran maintains only two friends, who he sees no more than once or twice per year. She also noted poor short and long term memory. The Veteran's wife reported managing all of the Veteran's finances due to his inability to keep track of things. She noted that the Veteran is often moody and depressed. She stated that he experiences nightmares more than once per week and acts jumpy at times. She stated that the Veteran is obsessive about checking doors and locks at their home. In a May 2009 Notice of Disagreement, the Veteran's wife stated that the Veteran is anxious and experiences nightmares for periods of time. She stated that he displays irrational behavior and is unable to work. In April 2010, the Veteran testified before a Decision Review Officer (DRO) regarding the severity of his PTSD, describing himself as reclusive and having anxiety around people. He stated that he gets nervous around crowds. The Veteran reported difficulty sleeping and using alcohol to assist with sleep. He noted experiencing nightmares frequently. He displayed a sense of regret for past events. He stated that during the day he watches television. He stated that he spends a lot of time in the woods alone and returns home at night. The Veteran's wife testified that the Veteran thrashes in bed at night. She also stated that he has difficulty staying focused. She stated that the Veteran's short-term memory is severely impaired. She also explained that the Veteran gets along with his grandchildren, but only for finite periods of time. She stated that the Veteran is unable to stay focused. The Veteran testified that he only trusts his wife. He stated that his ex-wife told the Veteran that he changed following his return from Vietnam. He stated that his ex-wife and he divorced due to his behavior. The Veteran received a VA examination in May 2010. There, the Veteran again reported winding down his dental practice in 1991 due to increased anxiety. He ceased his dental practice seven years later. The Veteran reported a positive relationship with his current wife, but noted that she serves a caretaking role. He noted that sometimes they do not get along. The Veteran stated that he is often annoyed. He reported a relationship with his brother, mostly over the phone. He stated that he has limited tolerance with long visits from his brother. The Veteran noted that during visits from family members, he will isolate and withdraw. The Veteran reported that he has one friend, but they see each other infrequently. He stated they talk occasionally on the phone. He noted attending church regularly, but stated that he does not participate in church activities. He stated that he prefers solitary activities. The Veteran reported performing errands with his wife. On mental status examination, the Veteran's affect was very restricted and mood was very dysphoric and anxious with underlying irritability. He stated that he wears dark glasses to hide. There was no impairment of thought processes or communication. There were no hallucinations or delusions. There were no active suicidal or homicidal thoughts, but he did have a great deal of apathy. He was appropriately dressed and groomed, but stated that was only because of his wife's prompting. The Veteran reported poor motivation and forgetfulness. He reported high anxiety. He stated that he worried, was fidgety and avoided groups. He described self-criticism and low self-esteem. Impulse control was poor. Sleep was also poor. The Veteran reported about three to four hours of sleep, leaving him lethargic. He reported taking short naps. Ongoing nightmares were reported. A GAF score of 46 was recorded. Based on the above, a 70 percent rating for PTSD is warranted for the period from December 28, 2006, to May 25, 2010, based on evidence of occupational and social impairment with deficiencies in most areas throughout this period. Specifically, the Veteran reported being unable to maintain his dental practice due to high anxiety and difficulty in adapting to stressful circumstances. Likewise, he reported some difficulty maintaining familial relationships, in that he had a limited tolerance for his brother and his other family members, a poor relationship with his daughter, and a divorce due to his mood problems. The Veteran noted few friends, who he sees infrequently. Collectively, these symptoms reflect an inability to establish and maintain effective relationships. The Veteran also explained that he isolates and has difficulty interacting with crowds, and only maintains his appearance and hygiene due to prompting from his wife. The Veteran also noted that he is often depressed or angry, which affects his ability to function independently, as his wife has taken on a caretaking role towards him. His wife has also indicated that he engages in obsessive rituals, and he has evidence of poor impulse control. Finally, the GAF scores assigned during the period, particularly the score of 46 indicative of 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), are consistent with a 70 percent rating. A rating of 100 percent, however, is not warranted for this period. As discussed above, a 100 percent rating is warranted where PTSD results in total social and occupational impairment. Socially, the Veteran is not totally impaired. Indeed, he does maintain some semblance of a relationship with his brother, as he noted that he will talk to his brother on the phone. He also maintains some relationship with his daughter. The Veteran also maintains a strong, trusting relationship with his current wife. The Veteran also reported having some friends during this period, although he did not interact frequently with those friends. Additionally, there was no evidence of any gross impairment of thought processes or communication, no evidence of any delusions or hallucinations, and no evidence that the Veteran ever considered hurting himself or others. Further, the Veteran did not state that he was ever unable to perform the basic functions of hygiene. Finally, the Veteran did not report any disorientation to time and place. He was not unable to remember his own name, the names of close relatives, or his own occupation. For these reasons, a rating in excess of 70 percent for PTSD is not warranted for the period on appeal. The record does not establish that the rating criteria are inadequate for rating the Veteran's service-connected PTSD. The Veteran's PTSD is manifested by social and occupational impairment due to such symptoms as difficulty in adapting to stressful circumstances, impaired impulse control, an inability to establish and maintain effective relationships, and depression. To the extent the above discussion reflects that the Veteran has some symptoms not specifically referenced by the applicable rating criteria, the Board emphasizes that the General Rating Formula for Mental Disorders specifically allows for consideration of symptoms not mentioned by the rating criteria, as reflected by the phrase "due to such symptoms as" that is included for the 30 percent criteria and higher. Therefore, the Board finds that his PTSD symptoms are contemplated by the applicable rating criteria. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER New and material evidence having been submitted, the claim of entitlement to service connection for a left knee disability is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for an enlarged prostate is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for a low back disability is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for residuals of a shrapnel wound is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for right ear hearing loss is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for a fungal condition of the mouth and skin is reopened. A 70 percent rating, but no higher, for PTSD is granted for the period from December 28, 2006, to May 25, 2010. REMAND Under McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006), in disability compensation (service connection) claims, VA must provide a medical examination 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 VA to make a decision on the claim. Regarding service connection for a fungal condition, a VA examination is required. The Veteran, a dentist, treated himself for a fungal condition of the mouth and skin since service. See November 2008 Statement of Veteran's Wife. This evidence is sufficient to trigger VA's duty to provide an examination to determine the nature and etiology of any fungal disability of the mouth and skin. See McLendon, 20 Vet. App. at 81. Regarding a low back disability, the evidence shows diagnoses of scoliosis, previous lumbar decompression and lumbar spinal stenosis. See December 2009 Private Treatment Record. As discussed above, P.M. explained that he observed the Veteran fall down a flight of stairs in service. See December 2008 Statement of P.M. The Veteran has also explained that he has experienced low back problems since service. See April 2010 Statement of Veteran. This evidence is sufficient to trigger VA's duty to provide the Veteran an examination to determine the nature and etiology of any low back disability. See McLendon, 20 Vet. App. at 81. Regarding right ear hearing loss, a May 2010 VA examination showed that the Veteran did not possess right ear hearing loss for VA purposes. See 38 C.F.R. § 3.385. However, private treatment records from Dr. G.C.Z., M.D., dated February 2010, and D.G.S., M.S., dated March 2008, note that hearing loss testing was performed. Audiogram results from those evaluations are not associated with the Veteran's claims file. Those records are potentially relevant and may show that the Veteran does experience right ear hearing loss for VA purposes. See 38 C.F.R. § 3.385. As such, before adjudication of that issue, all potentially relevant, outstanding private treatment records (including any audiograms conducted) must be obtained. Additionally, given the positive nexus opinion from the May 2010 VA examination, and the fact that more than five years has passed since the Veteran's examination, the Veteran's right ear hearing should be tested to determine if he now meets the criteria in 38 C.F.R. § 3.385. Regarding residuals of a shrapnel wound, as discussed above, in a December 2008 statement, P.M. stated that both he and the Veteran were treated for shrapnel wounds in Vietnam. Likewise, the Veteran himself reported sustaining shrapnel wounds in service. See DRO Hearing Tr. at 27. This evidence is sufficient to trigger VA's duty to provide the Veteran an examination to determine whether the Veteran presently suffers from any residuals due to any shrapnel wound incurred in service. See McLendon, 20 Vet. App. at 81. Regarding a prostate disability, the Veteran, a dentist, has asserted that his prostate disability is related to his conceded exposure to Agent Orange while serving in Vietnam. See May 2011 Statement of Veteran. This evidence is sufficient to trigger VA's duty to provide the Veteran an examination to determine the nature and etiology of any prostate disability. See McLendon, 20 Vet. App. at 81. Regarding service connection for hypertension, a new medical opinion is required. While a March 2015 VA medical opinion explored the relationship between the Veteran's PTSD and his hypertension, no opinion regarding aggravation or any relationship between the Veteran's hypertension and his service-connected CAD was rendered. Indeed, in a November 2008 letter, Dr. P.S., M.D., appears to indicate that an etiological link exists between the Veteran's hypertension and his service-connected CAD. Thus, an addendum opinion is necessary to address the link, if any, between hypertension and service-connected CAD. Regarding service connection for a left knee disability, a VA medical opinion was rendered in March 2015. In that opinion, a VA physician concluded that the Veteran's left knee disability clearly and unmistakably preexisted service and was not aggravated beyond its natural progression by the Veteran's military service. The March 2015 opinion is inadequate. A left knee disability is not listed on the Veteran's service induction examination. Thus, he is presumed sound at entrance. Because the presumption of soundness has attached, VA has the burden of proving by clear and unmistakable evidence that both (1) the Veteran's disease or injury pre-existed service and (2) that such disease or injury was not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). The examiner merely stated that the Veteran's current left knee disability clearly and unmistakably preexisted service without any explanation. Moreover, while the examiner concluded that the Veteran's preexisting left knee disability was not aggravated by service, the examiner did not state that the disability was clearly and unmistakably not aggravated by service. See id. Thus, an addendum opinion addressing these deficiencies is necessary. As the matter is being remanded, updated VA treatment records must also be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain updated VA treatment records dated from July 2011 forward. 2. With any assistance necessary from the Veteran, obtain all outstanding private treatment records (including any audiograms conducted) from Dr. G.C.Z., M.D., and D.G.S., M.S. If any records cannot be obtained after reasonable efforts have been made, notify the Veteran of the attempts made and allow him the opportunity to obtain the records. 3. Return the claims file to the March 2015 VA examiner (or another qualified examiner, if unavailable) for preparation of an addendum opinion. The claims file, including a copy of this remand, must be provided to the examiner in conjunction with the requested opinion. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. The examiner should address the following: a. Is it at least as likely as not (i.e., 50 percent or greater probability) that the Veteran's service-connected CAD status post 3 myocardial infarctions and coronary artery bypass grafts x 3 with scars caused his hypertension? In tendering the above opinion, the examiner must comment on the November 2008 letter of Dr. P.S., which appears to link the Veteran's hypertension with his CAD. b. Is it at least as likely as not (i.e., 50 percent or greater probability) that the Veteran's service-connected CAD status post 3 myocardial infarctions and coronary artery bypass grafts x 3 with scars aggravated (increased beyond the natural progression) his hypertension? c. Is it at least as likely as not (i.e., 50 percent or greater probability) that the Veteran's PTSD aggravated (increased beyond the natural progression) his hypertension? d. Is there is clear and unmistakable (obvious, manifest, and undebatable) evidence that the Veteran's left knee disability preexisted his period of active service? e. If so, the examiner must state whether it is clear and unmistakable (obvious, manifest, and undebatable) that the pre-existing left knee disability WAS NOT aggravated (i.e., permanently worsened) during service or whether it is clear and unmistakable (obvious, manifest, and undebatable) that any increase in service was due to the natural progress of the condition. Please provide a complete explanation for the opinion. f. If it is determined that any current left knee disability did not clearly and unmistakably preexist service, the examiner is further requested to opine as to whether it at least as likely as not (i.e., 50 percent or greater probability) that any currently diagnosed left knee disability is related to the Veteran's service. Comprehensive rationales must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why the opinion cannot be made without resorting to speculation. 4. Then schedule the Veteran for VA examination(s) to determine the nature and etiology of any low back disability, prostate disability, residuals of a shrapnel wound, and fungal condition of the mouth and skin. The examiner(s) should review the entire claims file, including a copy of this remand. Such review should be noted in the examination report. All necessary tests and studies should be conducted. The examiner(s) must respond to the following: a. Is it at least as likely as not (50 percent probability or greater) that any low back disability is related to the Veteran's active service, including a fall down a flight of stairs? b. Is it as least as likely as not (50 percent probability or greater) that any prostate disability is related to the Veteran's active service, including conceded herbicide exposure therein? c. Is it at least as likely as not (50 percent probability or greater) that any shrapnel wound residuals are related to the Veteran's active service? d. Is it at least as likely as not (50 percent probability or greater) that any fungal disability of the mouth and skin is related to the Veteran's active service, including conceded herbicide exposure therein? Comprehensive rationales must be provided for the opinions rendered. If the examiner(s) cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why the opinion cannot be made without resorting to speculation. 5. Schedule the Veteran for a VA audiology examination to determine whether he has a right ear hearing loss disability consistent with 38 C.F.R. § 3.385, if it is not demonstrated in any private records received in response to item 2 above. 6. Thereafter, readjudicate the issues on appeal. If any determination remains unfavorable to the Veteran, both he and his representative should be furnished a Supplemental Statement of the Case and provided an opportunity to respond. 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). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ S. BUSH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs