Citation Nr: 1620804 Decision Date: 05/24/16 Archive Date: 06/02/16 DOCKET NO. 10-41 797 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a left knee disability, to include as due to an undiagnosed illness and as secondary to service-connected chronic right knee strain. 2. Entitlement to service connection for a bilateral elbow disability, to include as due to an undiagnosed illness. 3. Entitlement to service connection for a pelvic disability, to include as due to an undiagnosed illness. 4. Entitlement to service connection for a kidney disability, to include as due to an undiagnosed illness. 5. Entitlement to service connection for a disability manifested by fatigue/sleep impairment, to include as due to an undiagnosed illness. 6. Entitlement to service connection for a back disability, to include as due to an undiagnosed illness. 7. Entitlement to service connection for a cardiac disability, to include as due to an undiagnosed illness. 8. Entitlement to service connection for rhinitis, to include as due to an undiagnosed illness. 9. Entitlement to service connection for a disability manifested by immune weakness, to include as due to an undiagnosed illness. 10. Entitlement to service connection for residuals of coccidiomycoidosis with a residual lung disease, to include as due to an undiagnosed illness. 11. Entitlement to service connection for a disability manifested by muscle and joint pain (to include fibromyalgia), to include as due to an undiagnosed illness. 12. Entitlement to service connection for a headache disability, to include as due to an undiagnosed illness and as secondary to service-connected posttraumatic stress disorder (PTSD) with depressive disorder. 13. Entitlement to service connection for a disability manifested by chills and fever, to include as due to an undiagnosed illness. 14. Entitlement to service connection for weight gain, to include as due to an undiagnosed illness. 15. Entitlement to service connection for a gastrointestinal disability, to include as due to an undiagnosed illness. 16. Entitlement to an initial rating higher than 10 percent for a chronic right knee strain. 17. Entitlement to an initial rating higher than 20 percent for residuals of status post right shoulder injury. 18. Entitlement to an initial rating higher than 50 percent for PTSD with depressive disorder prior to September 2, 2015. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD B. Elwood, Counsel INTRODUCTION The Veteran served on active duty from March 1995 to January 2002 and from December 2003 to March 2005, which includes service in Southwest Asia. He received the Army Commendation Medal. These matters come before the Board of Veterans' Appeals (Board) from July and September 2008, September and December 2010, and May 2012 decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The RO in Muskogee, Oklahoma currently has jurisdiction over the Veteran's claims. The Veteran testified before a Decision Review Officer (DRO) at an April 2009 hearing at the RO. A transcript of the hearing has been associated with the file. In the September 2010 decision, a DRO assigned a higher (20 percent) initial rating for residuals of status post right shoulder injury, effective from July 6, 2010. In December 2012, the RO assigned a higher (50 percent) initial rating for PTSD with depressive disorder, effective from December 20, 2007. In a June 2013 decision, a DRO assigned an effective date of December 20, 2007 for the grant of an initial 20 percent rating for residuals of status post right shoulder injury. In December 2015, the RO assigned a 100 percent rating for PTSD with depressive disorder, effective from September 2, 2015. As the Veteran was granted the full benefit sought for his service-connected psychiatric disability during the period since September 2, 2015, his appeal for a higher initial rating for this disability during that period will not be addressed by the Board. See AB v. Brown, 6 Vet. App. 35, 38 (1993). See AB v. Brown, 6 Vet. App. 35, 38 (1993). The issues of entitlement to service connection for a left knee disability, a bilateral elbow disability, a pelvic disability, a kidney disability, a disability manifested by fatigue/sleep impairment, a back disability, a cardiac disability, rhinitis, a disability manifested by immune weakness, residuals of coccidiomycoidosis with a residual lung disease, a disability manifested by muscle and joint pain (to include fibromyalgia), a headache disability, a disability manifested by chills and fever, weight gain, and a gastrointestinal disability and entitlement to higher initial ratings for a chronic right knee strain and residuals of status post right shoulder injury are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to September 23, 2011, the Veteran's PTSD with depressive disorder was manifested by anxiety, stress, depression, intrusive thoughts, anger, impaired sleep, hypervigilance, fatigue, a hyperstartle response, feelings of hopelessness and worthlessness, frustration, a restricted/blunted/guarded affect, impaired insight, nightmares, social isolation, distrust of others, emotional detachment, avoidance of others, panic attacks, ruminating thoughts, flashbacks, impaired concentration, irritability, psychomotor agitation, impaired eye contact, loss of appetite, a dysphoric/euthymic mood, and occasional impaired judgment; Global Assessment of Functioning (GAF) scores ranged from 50 to 65 and there were not deficiencies in most of the areas of work, school, family relations, judgment, thinking, or mood. 2. From September 23, 2011 through September 1, 2015, the Veteran's PTSD with depressive disorder was manifested by occupational and social impairment with deficiencies in most areas, such as work, family relations, thinking, and mood; there was not total social and occupational impairment. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 50 percent for PTSD with depressive disorder, prior to September 23, 2011, have not been met. 38 U.S.C.A. §§ 1155 , 5107(b) (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411 (2015). 2. The criteria for an initial 70 percent rating (but no higher) for PTSD with depressive disorder, from September 23, 2011 through September 1, 2015, have been met. 38 U.S.C.A. §§ 1155 , 5107(b); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). The appeal for a higher initial rating for PTSD with depressive disorder arises from the Veteran's disagreement with the initial rating assigned after the grant of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim of 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. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (2003). The United States Court of Appeals for Veterans Claims (Court) has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as initial rating) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128 (2008). Where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements. Id. There has been no allegation of such error in this case. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The Court has held that the provisions of 38 C.F.R. § 3.103(c)(2) (2015) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010) (per curiam). At the Veteran's April 2009 hearing, the DRO identified the issues on appeal at that time (including entitlement to a higher initial rating for PTSD). Information was solicited from the Veteran and his spouse regarding the nature and severity of the service-connected psychiatric disability and the treatment received for the disability. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. Id. at 497. While the DRO did not explicitly suggest the submission of any specific additional evidence, on these facts, such omission was harmless. Following the hearing, additional relevant treatment records were obtained and associated with the file and additional VA psychiatric examinations were conducted to assess the severity of the service-connected psychiatric disability. Also, the Veteran has submitted additional relevant evidence during the claim period. Thus, he has demonstrated actual knowledge of the ability to identify and submit additional relevant evidence. The Veteran's representative indicated during the hearing that the service-connected psychiatric disability was "pretty much covered by existing medical evidence." Under these circumstances, nothing gave rise to the possibility that any existing, relevant evidence had been overlooked. The duties imposed by Bryant were thereby met. VA obtained the Veteran's service treatment records, all pertinent service personnel records, and all of the identified relevant post-service VA treatment records and private medical records. In addition, the Veteran was afforded VA examinations to assess the severity of his service-connected psychiatric disability. Analysis Disability evaluations are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155. Where service connection has been granted and the assignment of an initial evaluation is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA will also consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The schedular criteria for rating psychiatric disabilities incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). See 38 C.F.R. §§ 4.125, 4.130. The Veteran's PTSD is rated under 38 C.F.R. § 4.130, DC 9411 according to the General Rating Formula for Mental Disorders. Under the General Rating Formula, a 50 percent disability rating 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating 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 a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating 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 or place; and memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004); Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The Board has considered the GAF scores assigned during the claim period. The GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267. GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging from 51 to 60 reflect 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). Further, GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well and has some meaningful interpersonal relationships. Id. The GAF score assigned in a case, however, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue. Rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). In this case, medical records dated from December 2006 to March 2008, an April 2008 VA psychiatric examination report, and a January 2008 statement from the Veteran (VA Form 21-4138) include reports of anxiety, stress, depression, intrusive thoughts, anger, difficulty sleeping, hypervigilance, fatigue, a hyperstartle response, feelings of hopelessness and worthlessness, frustration, and sadness. The Veteran experienced anxiety attacks during his job as a police officer and would think about events in Iraq when his job got stressful. He did not experience any nightmares or suicidal ideation and his appetite was good. He was not close with his mother or stepfather and had no contact with his sister, but his relationship with his biological father was improving. He and his wife had been married for 12 years, but there was conflict in their relationship, they argued, and his wife had suggested a brief separation. As for employment, the Veteran was employed as a police officer, but he used up all of his sick time due to physical health problems, he was placed on light duty for a period of time due to medical problems, and his light duty status was changed to temporary disability. However, he loved being a police officer and missed the job. He was capable of performing routine activities of daily living, he socialized within his immediate family, and he participated in occasional social activities outside of his family. Overall, inappropriate behavior was not a significant problem. Examinations revealed that the Veteran's memory was satisfactory, that he was fully oriented, and that his speech was of normal rate and volume. Thought process production was such that he mostly spoke just in response to the examiner's questions and those responses were satisfactory. Continuity of thought was goal directed and relevant, thought content contained no suicidal or homicidal ideation, there were no delusions, ideas of reference, or feelings of unreality, and the Veteran's abstract ability, concentration, and judgment were all satisfactory. His mood was depressed, his range of affect was restricted, he appeared to be somewhat lethargic, and his insight was limited. Diagnoses of anxiety, depression, and depressive disorder not otherwise specified (NOS) were provided and GAF scores ranging from 51 to 61 were provided, indicative of mild to moderate impairment. Medical records dated from April 2008 to October 2009, the report of a June 2008 VA psychiatric examination, and the April 2009 hearing transcript indicate that the Veteran experienced anxiety, nightmares, social isolation, distrust of others, emotional detachment, avoidance, panic attacks several days per week, ruminating thoughts (especially about things at work), a hyperstartle response, flashbacks (often triggered by situations at work), loss of focus, frustration, anger, irritability, depression, sleep disturbance, daytime fatigue, feelings of hopelessness and worthlessness, and an inability to deal with crowds. His relationship with his biological father had improved and he had some limited contact with his sister, but he was not close with his mother or stepfather, he continued to argue with his wife, he would yell and snap at his children, he had no motivation to be with his family, and he was not mentally or socially engaged with his family. The Veteran had been employed as a police officer since September 2005, but experienced periods of leave lasting several months due to health and stress problems, was on light duty for a period of time due to medical problems, and was on short-term medical disability at the time of the June 2008 examination because he had been told by his nurse practitioner to stop working. He returned to work in approximately October 2008, but began to experience more psychiatric symptoms after returning to work. For instance, he experienced reminders of trauma and would get upset when officers were hurt or involved in incidents, he was sensitive to loud noises, and he would occasionally daydream and think about past experiences. Despite the stress at work, he viewed his job as a source of satisfaction in his life, he worried that he would be unable to continue his employment (especially due to medical problems), and he consistently received high performance reviews at work. He was able to manage his own personal hygiene and grooming and was able to perform routine activities of daily living, but strenuous activities contributed to his feeling of fatigue. Leisure activities had not significantly changed since the April 2008 examination and there were no significant problems with inappropriate behavior. Examinations revealed that the Veteran was adequately dressed and groomed. He reported that he experienced problems with short-term memory retention, but his immediate, recent, and remote memory was objectively satisfactory. There was occasional mild psychomotor agitation in gross body movement related to agitation, thought content contained preoccupation with the Veteran's physical health problems and their perceived consequences, his mood was depressed/euthymic, his range of affect was occasionally restricted/blunted, his eye contact was fair/occasionally decreased, he appeared lethargic, and his insight was occasionally only fair. However, he was fully oriented, his speech was of normal rate and volume, thought process production was adequate (but he generally spoke just in response to the examiner's questions), and continuity of thought was relevant and goal-directed. There was no suicidal or homicidal ideation, there were no delusions, hallucinations, ideas of reference, or feelings of unreality, there were no gross cognitive problems, the Veteran's abstract ability and concentration were both satisfactory, and his judgment was adequate A neuropsychologic evaluation which was conducted in August 2008 revealed that the Veteran was mild to moderately depressed and that he displayed relative cognitive impairments in the areas of processing speed, attention, manual labor abilities, and complex visual memory. Average performance was noted in the areas of auditory learning and memory, executive functioning, intellectual functioning, and attention to detail. His relative impairments were consistent with psychomotor slowing and appeared to be attributable to functional etiologies, including sleep difficulties, pain, and depression. He was diagnosed as having depressive disorder NOS/major depression and PTSD and GAF scores ranging from 50 to 65 were assigned, indicative of mild to serious impairment. The Veteran reported during a June 2010 VA psychiatric examination that he experienced anxiety, avoidance behaviors, depression, motivational struggles, sleep difficulties, occasional nightmares, and loss of appetite. He did not speak often with his parents, had little contact with his sister, and was separated from his wife. He still lived in the same house as his wife, but they only remained together for their children. His relationship with his children was "okay." He remained employed as a police officer on a full time basis, but was working in supply since late 2009. He had received 3 reprimands during the previous 6 months related to an inability to perform. He occasionally felt as if he would be unable to work, but he did not lose any time from work related to his mental health. Moreover, the Veteran reported that he spent most of his time at home and did not like to go out. He experienced difficulties with stress that interfered with his ability to maintain grooming and dressing. For instance, he frequently did not shower and was "not motivated to do anything." He did not have any hobbies, preferred to stay alone at home, was usually sleeping and watching television when at home, and took frequent naps during his days off. Examination revealed that the Veteran was alert and fully oriented and adequately groomed. His eye contact was appropriate, his speech was normal in rate and tone (but limited in amount), there was no psychomotor agitation or retardation, his thought process was logical and goal-oriented, and he did not experience any suicidal or homicidal ideation. Also, there was no evidence of a psychotic disorder, the Veteran's memory appeared intact, and his impulse control was appropriate. However, his overall mood appeared dysphoric, his affect was restricted and guarded, and his judgment and insight were limited. A diagnosis of depressive disorder NOS was provided and a GAF score ranging from 50 to 52 was provided, indicative of moderate to serious impairment. Overall, the Veteran's difficulties with depression appeared to be moderate. VA treatment records dated from October 2010 to January 2012 reflect that the Veteran reported that he experienced trouble at work and had stopped working patrols because pain interfered with his ability to work. He also experienced anger at work. He worked at the police station issuing supplies for a period of time, but resigned on September 22, 2011 because he was under investigation for assaulting his stepson. He had separated from his wife and moved in with his girlfriend and her family in July 2011 and he had little interaction with his family. His mood was down much of the time, he had limited interests, and he watched television at home when not at work. He experienced significant anxiety with periods of anxiety and tension throughout the day, several panic attacks per week, anger (including at work), frustration, impaired sleep, restlessness at night, impaired concentration and memory, nightmares, anger, irritability, and intrusive thoughts. As a result of his anger he would yell at his daughter and argue with his wife. He did not experience any suicidal thoughts. Examinations revealed that the Veteran had poor eye contact, a depressed mood, and a constricted affect. He was neatly dressed, his speech was normal, his thoughts were clear and goal directed, he was cognitively intact, he had good insight and judgment, and he did not experience any suicidal thoughts or hallucinations. He was diagnosed as having PTSD and depression NOS and a GAF score of 50 was assigned, indicative of serious impairment. The report of a May 2012 VA psychiatric examination indicates that the Veteran's divorce was finalized and that he had broken up with a woman that he was dating because he experienced struggles connecting with the woman. He had a strained relationship with his daughter and limited contact with his sister, he spoke with his mother a couple of times per year, and he had no contact with his father. He had few friends and lost contact with most of his friends from Iraq. He stopped working as a police officer because he was charged with aggravated assault and resigned rather than get fired. He was enrolled in an online class and was doing "okay" and was able to perform activities of daily living. With respect to psychiatric symptoms, he experienced impaired sleep; nightmares; efforts to avoid thoughts, feelings, or conversations associated with in-service trauma; efforts to avoid activities, places, or people that aroused recollection of the trauma; markedly diminished interest or participation in significant activities; a feeling of detachment or estrangement from others; a restricted range of affect; difficulty falling or staying asleep; and difficulty concentrating. He also experienced a depressed mood, mild memory loss (such as forgetting names, directions, or recent events), a flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Diagnoses of PTSD and depressive disorder NOS were provided. The examiner who conducted the examination concluded that if PTSD was diagnosed alone, the Veteran's GAF score would be 55. His depressive symptoms (which included depressed mood, lack of interest in activities, low motivation, and a flattened affect), if diagnosed alone, would be equivalent to a GAF score of 50. Overall, his psychiatric disability resulted in occupational and social impairment with reduced reliability and productivity. VA treatment records dated from August 2012 to August 2015 reflect that the Veteran's mood was down and that he experienced increasing PTSD symptoms, including more anxiety, panic attacks several times per week, irritability, anger, impaired memory and concentration, depression, intrusive thoughts, social avoidance, anger, impaired sleep, fatigue, poor appetite/overeating, racing thoughts, nightmares, and feelings of hopelessness and frustration. He did not experience any suicidal ideation. He had re-married and was studying sports management in school. He occasionally worked for short periods (e.g., as cab driver), but was unable to work for more than a few months at a time. Examinations revealed that the Veteran had poor eye contact, a depressed mood, and a constricted affect. He was neatly dressed, his speech was normal, his thoughts were clear and goal directed, he was cognitively intact, there were no hallucinations, and his insight and judgment were good. A VA mental health ambulatory care note dated on August 31, 2015 indicates that the Veteran's PTSD symptoms were significant and interfered with daily functioning, impaired his relationships and job functioning, and prevented him from maintaining gainful employment. Diagnoses of PTSD and depression NOS were provided and GAF scores ranging from 45 to 50 were provided, indicative of moderate to serious impairment. The Veteran reported during an October 2015 VA examination that he attended social activities and attended church where he talked with others. He did not have any close friends or any hobbies/interests. He had separated from his third wife and asked for a divorce approximately one month prior to the examination. He was not close with either of his parents, did not have any contact with his sister, and had some limited contact with his children. He was last employed on a permanent basis as a police officer, but had some other employment since that time. For example, he worked in construction with his brother in law, worked in maintenance for one month (he left this job because his job and life circumstances were too stressful and resulted in a panic attack at work), and worked for several months at two other locations (his employment at these locations was terminated because he almost engaged in fights, did not show up for work on time, and was not performing as he should due to impaired concentration). He had last worked in July or August 2015 and reported that he experienced occupational problems due to his psychiatric symptoms. He had been taking online courses for college, but was unable to complete his coursework due to impaired focus. The Veteran was diagnosed as having PTSD and the examiner who conducted the examination concluded that the severity of the disability approximated the criteria for a 70 percent rating under DC 9411. He concluded that the Veteran was not able to maintain a regular work schedule. The Veteran reported that difficulty with paying attention and concentrating had resulted in problems on the job and that this affected his ability to be reliable and productive. He was in heated arguments and near fistfights at 3 of his 4 past jobs since the May 2012 VA examination. Hence, he was not able to work without being distracted by symptoms provoked by interpersonal interactions with others. His occupational and social impairments were almost at the level of having deficiencies in many areas, including family relations, mood, school, and work. Depression affected his ability to function, resulted in an inability to establish and maintain effective relationships, and caused problems with concentration. Information obtained from the Veteran's former employers on "Request for Employment Information in Connection with Claim for Disability Benefits" forms (VA Form 21-4192) dated in November 2015 reveal that he worked for various periods from September 2014 to August 2015 as a salesperson with two companies. He left one of these jobs in May 2015 because he accepted another job offer and abandoned the second job in August 2015. I. Period Prior to September 23, 2011 The above evidence reflects that during the period prior to September 23, 2011, the symptoms of the Veteran's service-connected psychiatric disability more closely approximated the criteria for a 50 percent rating under DC 9411. For example, there is evidence of consistent impairment in the areas of family relations, thinking, and mood in that the Veteran experienced symptoms such as intrusive and ruminating thoughts, impaired concentration, nightmares, anxiety, depression, and irritability. His psychiatric disability impacted his family relationships in that his social interactions with family was limited and his irritability and anger resulted in arguments with his wife and conflict with his children. Also, his affect was impaired and he experienced panic attacks. Nevertheless, despite the fact that the Veteran reportedly experienced some psychiatric symptoms at work (e.g. anxiety attacks and intrusive thoughts), he remained employed on a full basis as a police officer until September 22, 2011. His periods of limited duty status and short term disability during that employment was reportedly due to physical disabilities, he reported that he did not lose any time from work due to psychiatric problems, and he indicated that he enjoyed his work as a police officer and only resigned in September 2011 in order to avoid being fired after he was charged with assault. Thus, no significant impairment of work due to his service-connected psychiatric disability was demonstrated during this period. In addition, the only evidence of impaired judgment during this period is during the June 2010 VA psychiatric examination (where judgment was described as being limited). The Veteran's judgment was otherwise intact on various other occasions during this period and impaired judgment is contemplated by a 50 percent rating under DC 9411. Moreover, the Veteran did not experience any suicidal ideation or obsessed rituals, his speech was not found to be illogical, obscure, or irrelevant, and there was no spatial disorientation. Although there was evidence of panic attacks and depression and he reported during the June 2010 VA examination that stress interfered with his ability to maintain grooming and dressing and that he frequently did not shower, his panic attacks and depression were not so severe so as to affect his ability to function independently, appropriately, and effectively, he maintained the ability to independently perform his activities of daily living , he was able to maintain full time employment until September 22, 2011 without any significant job impairment due to psychiatric symptoms, and clinical evaluations showed the Veteran to be fully oriented and to have appropriate appearance and good hygiene. Despite the fact that GAF scores indicative of serious impairment were occasionally assigned, the majority of the GAF scores assigned during this period are indicative of only moderate impairment and the examiner who conducted the June 2010 VA examination concluded that the Veteran's psychiatric disability was moderately disabling. Thus, overall the Board finds that the Veteran did not have deficiencies in most of the areas specified in the criteria for a 70 percent rating (i.e. work, school, family relations, judgment, thinking, and mood) during the period prior to September 23, 2011. Similarly, his symptoms were not manifested by gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting self or others, an inability to maintain minimal personal hygiene, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Also, the Veteran worked full time until September 22, 2011 despite his psychiatric disability, he resigned in September 2011 to avoid being fired after he was charged with assault, and the evidence does not otherwise indicate deficiencies due solely to his psychiatric disability that would warrant a rating higher than 50 percent during this period. The Veteran's mental evaluations show that he was found to have generally moderate impairment in occupational and social functioning prior to September 23, 2011 as evidenced by the GAFs and assessments of his level of disability. This symptomatology is contemplated by the 50 percent disability rating and the Veteran's symptoms more closely approximated the criteria for that rating during this period. Accordingly, the Board finds that the preponderance of the evidence is against a rating in excess of 50 percent for PTSD with depressive disorder at any time prior to September 23, 2011. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.130, DC 9411. II. Period from September 23, 2011 through September 1, 2015 With respect to the period from September 23, 2011 through September 1, 2015, the symptoms of the Veteran's PTSD with depressive disorder resulted in deficiencies in most of the areas needed for a 70 percent rating under DC 9411. Despite the fact that he was employed in several positions after resigning from the police department in September 2011, he reported that he was unable to maintain employment for more than a few months at a time and left several jobs due to symptoms associated with his psychiatric disability (e.g., panic attacks, irritability/anger, and impaired concentration). He separated from and eventually divorced his second wife, was isolated from and had strained relationships with his family, and would yell at his wife and daughter due to anger. Moreover, his symptoms of impaired concentration and memory, nightmares, intrusive thoughts, memory loss, depression, anxiety, and irritability are reflective of deficiencies in the areas of thinking and mood. Also, the GAF scores assigned during this period are generally indicative of serious impairment. Although the exact onset of the Veteran's more severe symptoms during this period cannot be determined with any certainty, the Board finds that a 70 percent rating is warranted since September 23, 2011, the day following the Veteran's last day of full time employment as a police officer. This is the earliest that it can be factually ascertained that he met the criteria for a 70 percent rating. Hence, resolving reasonable doubt in the Veteran's favor warrants a finding that the criteria for an initial 70 percent rating for the service-connected PTSD with depressive disorder were met from September 23, 2011 through August 1, 2015. An initial rating higher than 70 percent is not warranted at any time during the period from September 23, 2011 through September 1, 2015 because the Veteran continued to work (albeit on an intermittent basis and with impairments due to his psychiatric disability). Despite the fact that the VA mental health ambulatory care note dated on August 31, 2015 indicates that the Veteran's PTSD symptoms prevented him from maintaining gainful employment, the same treatment record reflects that he was working as a cab driver at that time. While he was generally socially isolated, he maintained some social contacts with family and re-married for a period of time. Although he experienced some impaired memory, he did not otherwise demonstrate gross impairment in thought processes or communication, did not experience any delusions or hallucinations, did not exhibit grossly inappropriate behavior, was not in persistent danger of hurting himself or others, and did not experience memory loss for names of close relatives, own occupation, or name. Also, there is no evidence that he lacked the ability to perform activities of daily living and he was not shown to be disoriented to time or place. Thus, he did not exhibit most of the symptoms listed in the examples for a 100 percent disability rating at any time during the period from September 23, 2011 through September 1, 2015 and total social and occupational impairment was not otherwise been demonstrated during this period. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.130, DC 9411. III. Extraschedular Consideration Pursuant to 38 C.F.R. § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). The Board must specifically address whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242, 244 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of a claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). 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. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and 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"). The symptoms associated with the Veteran's psychiatric disability are all contemplated by the appropriate rating criteria as set forth above. Specifically, DC 9411 provides compensation based upon the extent to which all psychiatric symptoms result in social and occupational impairment. The criteria in the general rating formula for mental disorders include both the symptoms listed as symptoms "such as" those listed, along with the overall impairment caused by these symptoms. This broad language in the criteria thus contemplates all of the symptoms even though they are not specifically listed. Thus, referral for consideration of an extraschedular evaluation is not warranted. 38 C.F.R. § 3.321(b)(1) . A veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). In this case, however, there are no symptoms caused by service-connected disability that have not been attributed to and accounted for by a specific service-connected disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed to the combined effect of multiple conditions. IV. Total Disability Rating Based on Individual Unemployability (TDIU) The Court has held that entitlement to a TDIU may be an element of an appeal for a higher initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to a TDIU is raised where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); see Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). In the present case, the Veteran has experienced unemployment during the claim period and he submitted a formal claim for a TDIU (VA Form 21-8940) in September 2015. However, no TDIU claim is before the Board in this case because the disability claimed by the Veteran to cause unemployability (his service-connected psychiatric disability) is rated 100 percent disabling since September 2, 2015. The only other service-connected disabilities are a chronic right knee strain and residuals of status post right shoulder injury. The evidence does not reflect that the Veteran was unemployed and unable to secure and follow substantially gainful employment prior to September 2, 2015. Hence, the issue of entitlement to a TDIU is not before the Board in this instance. 38 C.F.R. § 4.14 (2015); Bradley v. Peake, 22 Vet. App. 280 (2008); Buie v. Shinseki, 24 Vet. App. 242, 250 (2011). ORDER Entitlement to an initial rating higher than 50 percent for PTSD with depressive disorder, prior to September 23, 2011, is denied. Entitlement to an initial 70 percent rating (but no higher), from September 23, 2011 through September 1, 2015, is granted. REMAND VA is obliged to provide an examination or obtain a medical opinion in a claim of service connection when the record contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of disability, the record indicates that the disability or symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. A veteran's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon, 20 Vet. App. at 83.) In this case, the Veteran has reported that he experiences elbow, pelvic, and back, pain. Thus, there is competent evidence of current elbow, pelvic, and back disabilities. Service treatment records include a July 1999 record of treatment for left lateral epicondylitis. In June 2000, the Veteran was treated for left elbow pain which was identified as left lateral epicondylitis secondary to overuse. Also, he was treated in April 2001 for back pain. He has also reported that he injured his right elbow in service. He has reportedly experienced a continuity of elbow, pelvic, and back symptomatology in the years since service. Hence, there is competent evidence of persistent or recurrent symptoms of elbow, back, and pelvic disabilities, competent evidence of elbow, back, and pelvic problems in service, and evidence that the claimed disabilities may be associated with service. Therefore, VA's duty to obtain examinations as to the nature and etiology of any current elbow, pelvic, and back disabilities is triggered. Such examinations are needed to determine whether the Veteran has any current elbow, pelvic, and back disabilities and to obtain medical opinions as to the etiology of any such disabilities. As for the claims of service connection for a left knee disability, a disability manifested by fatigue/sleep impairment, a cardiac disability, rhinitis, a lung disease, a disability manifested by muscle/joint pain, a headache disability, and a gastrointestinal disability, VA examinations were conducted in March 2008 and June, July, and October 2010. The March 2008 and June and July 2010 examination reports include diagnoses of a left knee strain, residuals of coccidiomycoidosis (Valley Fever) with residual pulmonary nodule, muscle pain, joint pain, fatigue, and weakness; undifferentiated spondyloarthropathy; chronic rhinitis; gastroesophageal reflux disease (GERD); diffuse esophageal spasm; hypertensive esophagus; sinus headaches/migraines; and bicuspid aortic valve. The physician who conducted the March 2008 examination indicated that the diagnosed bicuspid aortic valve was a "congenital condition" and that the Veteran did not have any undiagnosed illness due to the Gulf War. The physician who conducted the June 2010 examination opined that the diagnosed disabilities were not likely ("less likely as not") related to a specific exposure event in Southwest Asia. There were no explanations or rationales provided for any of these opinions. With respect to the claimed chronic fatigue, the June 2010 examiner indicated that the Veteran's chronic fatigue was multi-factorial and was attributed primarily to his poor sleep, insomnia, and symptoms in relation to PTSD as well as undifferentiated spondyloarthropathy. This did not constitute a disease or disability pattern in itself. The March 2008 and June 2010 examinations are insufficient because no specific opinion was provided as to whether the diagnosed cardiac disability is a congenital defect or disease (and, if a congenital disease, whether the disease was aggravated in service), no opinion was provided as to the etiology of any other currently diagnosed cardiac disability, no opinion was provided as to whether any fatigue experienced by the Veteran represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia or a medically unexplained chronic multisymptom illness, and the opinions which were provided were not accompanied by any specific explanations or rationales. See Quirin v. Shinseki, 22 Vet. App. 390 (2009); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). In addition, the physician assistant who conducted the July 2010 examination opined that the Veteran's current left knee disability was not caused by or a result of service. She reasoned that a review of the claims file did not show any specific documentation of a left knee injury. He did not report any left knee injury during the April 2009 hearing and he reported during the July 2010 examination that his left knee injury "just came on gradually" shortly after he injured his right knee. There were vague complaints of multiple myalgias and arthralgias (including of the knees) in the Veteran's VA treatment records dating back to 2007, but there was no specific mention of the left knee and no noted history of injury. The examiner who conducted the October 2010 examination concluded that it was conceivable that the Veteran had a left achy knee secondary to a systemic disease and not a mechanical disease. The examiner opined that the Veteran's "left knee condition" was not related to his right knee problem. He had arthralgia of the left knee and possibly some patellofemoral changes which would account for the clicking and the palpable discomfort as the patella and underlying femoral condyle was passively moved. There was no relationship as to cause and effect between the "right knee problem" and the left knee problem. The July and October 2010 opinions are insufficient because they do not reflect consideration of the Veteran's reports of a continuity of left knee symptomatology in the years since service, no rationale was provided for the opinion that the Veteran's left knee problems were not caused by his service-connected right knee disability, and no opinion was provided as to whether the left knee problems were aggravated by the service-connected right knee disability. See Nieves-Rodriguez, 22 Vet. App. at 304; 38 C.F.R. § 3.310 (2015). Hence, a remand is necessary to afford the Veteran new VA examinations to obtain opinions as to the nature and etiology of any current left knee disability, disability manifested by fatigue/sleep impairment, cardiac disability, rhinitis, lung disease, disability manifested by muscle/joint pain, headache disability, and gastrointestinal disability. With respect to the appeal for higher initial ratings for a chronic right knee strain and residuals of status post right shoulder injury, disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45 (2015), pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R § 4.59 (2015). The Veteran was afforded a VA examination in July 2010 to determine the severity of his service-connected right knee and right shoulder disabilities. The ranges of knee and shoulder motions were reported and it was noted that there was objective evidence of painful knee and shoulder motion (there was pain with both flexion and extension of the knee), that there was objective evidence of pain following repetitive motion of the knee and shoulder, and that there were additional limitations after three repetitions of the ranges of shoulder motion (the most important factor being pain). The examiner who conducted the July 2010 examination did not identify at what points in the ranges of knee and shoulder motions, if any, pain and flare ups caused functional impairment or whether any weakened movement, excess fatigability, or incoordination caused any functional impairment. Thus, clarification is required. See Mitchell, 25 Vet. App. at 43-4; 38 C.F.R. §§ 4.40, 4.45, 4.59. Moreover, the VCAA requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). The VCAA's duty to assist includes a duty to help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody. 38 C.F.R. § 3.159(c)(4). The Veteran reported during the April 2009 hearing that he continued to receive relevant treatment from Dr. Nabong. Although some records from this physician have been obtained and associated with the file, they are only dated to January 2008. When VA becomes aware of private treatment records it will specifically notify the Veteran of the records and ask for a release to obtain the records. If the Veteran does not provide the release, VA should ask the Veteran to obtain the records. 38 C.F.R. § 3.159(e)(2). These steps have not been taken with regard to any additional relevant treatment records from Dr. Nabong. Thus, a remand is also necessary to attempt to obtain any additional relevant private treatment records. Updated VA treatment records should also be secured upon remand. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for a knee disability, an elbow disability, a pelvic disability, a kidney disability, a disability manifested by fatigue/sleep impairment, a back disability, a cardiac disability, rhinitis, a disability manifested by immune weakness, residuals of coccidiomycoidosis with a residual lung disease, a disability manifested by muscle and joint pain (to include fibromyalgia), a headache disability, a disability manifested by chills and fever, weight gain, a gastrointestinal disability, and a right shoulder disability, to include the dates of any such treatment. The Veteran shall also specifically be asked to complete authorizations for VA to obtain all records of his treatment for a knee disability, an elbow disability, a pelvic disability, a kidney disability, a disability manifested by fatigue/sleep impairment, a back disability, a cardiac disability, rhinitis, a disability manifested by immune weakness, residuals of coccidiomycoidosis with a residual lung disease, a disability manifested by muscle and joint pain (to include fibromyalgia), a headache disability, a disability manifested by chills and fever, weight gain, a gastrointestinal disability, and a right shoulder disability from Dr. Nabong dated from January 2008 through the present (see page 27 of the April 2009 DRO hearing transcript) and any other sufficiently identified private treatment provider from whom records have not already been obtained. The AOJ shall attempt to obtain records from any private treatment provider for whom a sufficient release is received. All efforts to obtain these records must be documented in the file. If the Veteran fails to furnish any necessary releases for private treatment records, he should be advised to obtain the records and submit them to VA. If any putative records are unavailable, the Veteran should be notified of the identity of the records that are unavailable, the efforts VA has undertaken to obtain such records, and any additional action that may be taken concerning his claims. 2. Obtain and associate with the file all updated records of the Veteran's treatment from the Phoenix VA Health Care System dated from August 2015 through the present and all such relevant records from any other sufficiently identified VA facility. All efforts to obtain these records must be documented in the claims file. Such efforts shall continue until the records are obtained or it is reasonably certain that they do not exist or that further efforts to obtain them would be futile. 3. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to determine the nature and etiology of any current left knee disability. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand along with any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner shall answer all of the following questions: (a) Are any of the Veteran's left knee symptoms that have been present since December 2007 due to a distinct and identifiable disability? (b) If any current left knee symptom is related to a distinct and identifiable left knee disability, is it at least as likely as not (50 percent probability or more) that the current left knee disability had its clinical onset during either period of active service, had its onset in the year immediately following either period of service (in the case of any currently diagnosed arthritis), is related to the Veteran's knee problems in service, or is otherwise the result of a disease or injury in service? (c) If any current left knee symptom is related to a distinct and identifiable left knee disability, is it at least as likely as not (50 percent probability or more) that the current left knee disability was caused or aggravated by the Veteran's service-connected chronic right knee strain? If aggravated, specify the baseline of disability prior to aggravation, and the permanent, measurable increase in disability resulting from the aggravation. (d) If any left knee symptom that has been present since December 2007 is not due to a distinct and identifiable left knee disability, is it at least as likely as not (50 percent probability or more) that the symptom represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms? If so, the examiner should also describe the extent to which the illness has manifested. In formulating the above opinions, the examiner should specifically acknowledge and comment on all left knee disabilities diagnosed/left knee symptoms experienced since December 2007, the Veteran's left knee problems in service, and his reports of a continuity of left knee symptomatology in the years since service. The examiner must provide reasons for each opinion given. 4. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to determine the nature and etiology of any current elbow disability. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand along with any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner shall answer all of the following questions: (a) Are any of the Veteran's elbow symptoms that have been present since April 2009 due to a distinct and identifiable elbow disability? (b) If any current elbow symptom is related to a distinct and identifiable elbow disability, is it at least as likely as not (50 percent probability or more) that the current elbow disability had its onset during either period of active service, had its onset in the year immediately following either period of service (in the case of any currently diagnosed arthritis), is related to the Veteran's elbow problems in service, or is otherwise the result of a disease or injury in service? (c) If any elbow symptom that has been present since April 2009 is not due to a distinct and identifiable elbow disability, is it at least as likely as not (50 percent probability or more) that the symptom represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms? If so, the examiner should also describe the extent to which the illness has manifested. In formulating the above opinions, the examiner should specifically acknowledge and comment on any elbow disabilities diagnosed/elbow symptoms experienced since April 2009, all reports of and instances of treatment for elbow problems in the Veteran's service treatment records, the Veteran's reports of elbow injuries and symptoms in service, and his reports of a continuity of elbow symptomatology in the years since service. The examiner must provide reasons for each opinion given. 5. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to determine the nature and etiology of any current pelvic disability. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand along with any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner shall answer all of the following questions: (a) Are any of the Veteran's pelvic symptoms that have been present since April 2009 due to a distinct and identifiable pelvic disability? (b) If any current pelvic symptom is related to a distinct and identifiable pelvic disability, is it at least as likely as not (50 percent probability or more) that the current pelvic disability had its onset during either period of active service, had its onset in the year immediate following either period of service (in the case of any currently diagnosed arthritis), or is otherwise the result of a disease or injury in service? (c) If any pelvic symptom that has been present since April 2009 is not due to a distinct and identifiable pelvic disability, is it at least as likely as not (50 percent probability or more) that the symptom represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms? If so, the examiner should also describe the extent to which the illness has manifested. In formulating the above opinions, the examiner should specifically acknowledge and comment on any pelvic disabilities diagnosed/pelvic symptoms experienced since April 2009 and the Veteran's reports of a continuity of pelvic symptomatology in the years since service. The examiner must provide reasons for each opinion given. 6. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to determine the nature and etiology of any current disability manifested by fatigue/sleep impairment. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand along with any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner shall answer all of the following questions: (a) Are any of the Veteran's symptoms of fatigue/sleep impairment that have been present since April 2009 due to a distinct and identifiable disability? (b) If any current symptoms of fatigue/sleep impairment are related to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the current disability manifested by fatigue/sleep impairment had its onset during either period of active service, is related to the Veteran's reported fatigue/sleep impairment in service, or is otherwise the result of a disease or injury in service? (c) If any symptom of fatigue/sleep impairment that has been present since April 2009 is not due to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the symptom represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms (such as chronic fatigue syndrome)? If so, the examiner should also describe the extent to which the illness has manifested. In formulating the above opinions, the examiner should specifically acknowledge and comment on any disabilities manifested by fatigue/sleep impairment diagnosed/fatigue and sleep impairment experienced since April 2009, the Veteran's reports of fatigue/sleep impairment in service, and his reports of a continuity of symptomatology in the years since service. The examiner must provide reasons for each opinion given. 7. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to determine the nature and etiology of any current back disability. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand along with any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner shall answer all of the following questions: (a) Are any of the Veteran's back symptoms that have been present since April 2009 due to a distinct and identifiable disability? (b) If any current back symptom is related to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the current back disability had its onset during either period of active service, had its onset in the year immediately following either period of service (in the case of any currently diagnosed arthritis), is related to the Veteran's back problems in service, or is otherwise the result of a disease or injury in service? (c) If any back symptom that has been present since April 2009 is not due to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the symptom represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms? If so, the examiner should also describe the extent to which the illness has manifested. In formulating the above opinions, the examiner should specifically acknowledge and comment on any back disabilities diagnosed/back symptoms experienced since April 2009, all reports of and instances of treatment for back problems in the Veteran's service treatment records, and his reports of a continuity of back symptomatology in the years since service. The examiner must provide reasons for each opinion given. 8. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to determine the nature and etiology of any current cardiac disability. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand along with any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner shall answer all of the following questions: (a) Are any of the Veteran's cardiac symptoms that have been present since December 2007 due to a distinct and identifiable disability? (b) If any current cardiac symptom is related to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the current cardiac disability had its onset during either period of active service or is otherwise the result of a disease or injury in service? (c) If any cardiac symptom that has been present since December 2007 is not due to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the symptom represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms? If so, the examiner should also describe the extent to which the illness has manifested. (d) If any current cardiac disability is a developmental or congenital condition, is the condition a development/congenital defect or disease? If a disease, is it at least as likely as not (50 percent probability or more) that the disease was aggravated (there was an increase in underlying disability) in service? In formulating the above opinions, the examiner should specifically acknowledge and comment on any cardiac disabilities diagnosed/cardiac symptoms experienced since December 2007. The examiner must provide reasons for each opinion given. 9. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to determine the nature and etiology of any current rhinitis. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand along with any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner shall answer all of the following questions: (a) Are any of the Veteran's nasal symptoms that have been present since December 2007 due to a distinct and identifiable disability? (b) If any current nasal symptom is related to a distinct and identifiable disability (e.g., rhinitis), is it at least as likely as not (50 percent probability or more) that the current disability had its onset during either period of active service, is related to the Veteran's reported nasal symptoms in service, or is otherwise the result of a disease or injury in service? (c) If any nasal symptom that has been present since December 2007 is not due to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the symptom represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms? If so, the examiner should also describe the extent to which the illness has manifested. In formulating the above opinions, the examiner should specifically acknowledge and comment on any rhinitis diagnosed/nasal symptoms experienced since December 2007 and the Veteran's reports of rhinitis in service. The examiner must provide reasons for each opinion given. 10. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to determine the nature and etiology of any current lung disease. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand along with any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner shall answer all of the following questions: (a) Are any of the Veteran's lung symptoms that have been present since December 2007 due to a distinct and identifiable disability? (b) If any current lung symptom is related to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the current disability had its onset during either period of active service or is otherwise the result of a disease or injury in service? (c) If any lung symptom that has been present since December 2007 is not due to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the symptom represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms? If so, the examiner should also describe the extent to which the illness has manifested. In formulating the above opinions, the examiner should specifically acknowledge and comment on any lung disease diagnosed/lung symptoms experienced since December 2007. The examiner must provide reasons for each opinion given. 11. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to determine the nature and etiology of any current disability manifested by muscle and joint pain. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand along with any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner shall answer all of the following questions: (a) Are any of the Veteran's symptoms of muscle and joint pain that have been present since December 2007 due to a distinct and identifiable disability? (b) If any current muscle/joint pain is related to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the current disability had its onset during either period of active service, had its onset in the year immediately following either period of service (in the case of any currently diagnosed arthritis), or is otherwise the result of a disease or injury in service? (c) If any muscle/joint pain that has been present since December 2007 is not due to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the symptom represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms (such as fibromyalgia)? If so, the examiner should also describe the extent to which the illness has manifested. (d) Is undifferentiated spondyloarthropathy a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms? In formulating the above opinions, the examiner should specifically acknowledge and comment on any disability manifested by muscle and joint pain diagnosed/muscle/joint pain experienced since December 2007 and the Veteran's reports of symptoms in the years since service. The examiner must provide reasons for each opinion given. 12. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to determine the nature and etiology of any current headaches. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand along with any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner shall answer all of the following questions: (a) Are any of the Veteran's headaches that have been present since December 2007 due to a distinct and identifiable disability? (b) If any current headaches are related to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the current disability had its onset during either period of active service, had its onset in the year immediately following either period of service (in the case of any currently diagnosed organic disease of the nervous system), is related to the Veteran's headaches in service, or is otherwise the result of a disease or injury in service? (c) If any current headaches are related to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the current disability was caused by the Veteran's service-connected PTSD with depressive disorder (to include medications taken for this disability)? (d) Is it at least as likely as not (50 percent probability or more) that the current disability was aggravated by the Veteran's service-connected PTSD with depressive disorder (to include medications taken for this disability)? If aggravated, specify the baseline level of disability prior to aggravation, and the permanent, measurable increase in disability resulting from the aggravation. (e) If any headaches that have been present since December 2007 are not due to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the symptom represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms? If so, the examiner should also describe the extent to which the illness has manifested. In formulating the above opinions, the examiner should specifically acknowledge and comment on any headache disability diagnosed/headaches experienced since December 2007, all reports of instances of treatment for headaches in the Veteran's service treatment records, and his reports of headaches in service and in the years since that time. The examiner must provide reasons for each opinion given. 13. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to determine the nature and etiology of any current gastrointestinal disability. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand along with any records obtained pursuant to this remand, must be sent to the examiner for review. The examiner shall answer all of the following questions: (a) Are any of the Veteran's gastrointestinal symptoms that have been present since December 2007 due to a distinct and identifiable disability? (b) If any current gastrointestinal symptom is related to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the current disability had its onset during either period of active service, is related to the Veteran's gastrointestinal problems in service, or is otherwise the result of a disease or injury in service? (c) If any gastrointestinal symptom that has been present since December 2007 is not due to a distinct and identifiable disability, is it at least as likely as not (50 percent probability or more) that the symptom represents an objective indication of chronic disability resulting from an undiagnosed illness related to the Veteran's service in Southwest Asia or a medically unexplained chronic multisymptom illness which is defined by a cluster of signs or symptoms (such as a functional gastrointestinal disorder as opposed to a structural gastrointestinal disease)? If so, the examiner should also describe the extent to which the illness has manifested. In formulating the above opinions, the examiner should specifically acknowledge and comment on any gastrointestinal disability diagnosed/gastrointestinal symptom experienced since December 2007, all reports of instances of treatment for gastrointestinal problems in the Veteran's service treatment records, and his reports of gastrointestinal problems in the years since service. The examiner must provide reasons for each opinion given. 14. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to evaluate the current severity of his chronic right knee strain. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand and any records obtained pursuant to this remand, must be sent to the examiner for review. The ranges of right knee flexion and extension shall be reported in degrees. The examiner shall also specify whether and to what extent there is any additional loss of knee flexion and/or extension (stated in degrees) due to any weakened movement, excess fatigability, incoordination, flare ups, and/or pain. The examiner shall report if there is ankylosis of the right knee and, if so, the angle at which the knee is held. The examiner shall also report whether there is subluxation or instability of the right knee, and if present, provide an opinion as to its severity (i.e., slight, moderate, or severe). The examiner must provide reasons for any opinion given. 15. After all efforts have been exhausted to obtain and associate with the file any additional treatment records, schedule the Veteran for a VA examination to evaluate the current severity of his residuals of status post right shoulder injury. All indicated tests and studies shall be conducted. All relevant electronic records contained in the VBMS and Virtual VA systems, including a copy of this remand and any records obtained pursuant to this remand, must be sent to the examiner for review. All appropriate ranges of right shoulder motion shall be reported in degrees. The examiner shall also specify whether and to what extent there is any additional loss of right shoulder motion (stated in degrees) due to any weakened movement, excess fatigability, incoordination, flare ups, and/or pain. The examiner shall also report the nature and severity of any ankylosis of the scapulohumeral articulation and any impairment of the humerus, clavicle, and scapula. The examiner must provide reasons for any opinion given. 16. If a full benefit sought on appeal remains denied, the AOJ shall issue a supplemental statement of the case. After the Veteran is given an opportunity to respond, the case shall be returned to the Board. No action is required of the Veteran until he is notified by the AOJ; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claims. 38 C.F.R. § 3.655 (2015). 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). ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs