Citation Nr: 1631840	
Decision Date: 08/10/16    Archive Date: 08/23/16

DOCKET NO.  15-20 204	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in St. Petersburg, Florida


THE ISSUES

1.  Entitlement to an initial evaluation in excess of 10 percent for degenerative arthritis of the cervical spine.

2.  Entitlement to an initial compensable evaluation for bilateral hearing loss.

3.  Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), depressive disorder, and sleep disorder.

4.  Entitlement to service connection for nerve damage to the bilateral upper extremities, claimed as flash freeze of the hands.

5.  Entitlement to service connection for a skin rash, claimed as severe bites.

6.  Entitlement to service connection for prostatitis.

7.  Entitlement to service connection for sleep apnea.

8.  Entitlement to service connection for a right shoulder disability.

9.  Entitlement to service connection for a left shoulder disability.

10.  Entitlement to service connection for residuals of a traumatic brain injury (TBI), claimed as a concussion, to include headaches.

11.  Entitlement to service connection for irritable bowel syndrome (IBS).

12.  Entitlement to service connection for an esophageal disability, to include gastroesophageal reflux disease (GERD).

13.  Entitlement to service connection for a heart disability.

14.  Entitlement to service connection for a benign lung nodule.

15.  Entitlement to service connection for damage to the voice box.

16.  Entitlement to service connection for bilateral paralysis of the eyes.

17.  Entitlement to service connection for lumps in the mouth.


REPRESENTATION

Veteran represented by:	The American Legion


WITNESSES AT HEARING ON APPEAL

The Veteran, his case manager, and his acquaintance



ATTORNEY FOR THE BOARD

J. Gallagher, Associate Counsel


INTRODUCTION

The Veteran served on active duty from September 1976 to September 1979.

This appeal is before the Board of Veterans' Appeals (Board) from September 2014 and January 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee.  Jurisdiction has since been transferred to the RO in St. Petersburg, Florida.

In November 2015, the Veteran testified during a hearing at his RO.  In March 2016, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge via videoconference.  Transcripts of both hearings are included in the claims file.

In a May 2015 statement of the case, the RO last adjudicated the claims subject to this decision ("May 2015 issues").  The Veteran has a pending appeal on another set of issues which were last adjudicated in an April 2016 statement of the case ("April 2016 issues").  In his May 2016 substantive appeal, the Veteran requested a hearing before the Board for the April 2016 issues, and they are thus not before the Board until such a hearing occurs.  Some of the April 2016 issues, however, overlap with the May 2015 issues now before the Board.  The Veteran provided testimony as to these overlapping issues at his March 2016 hearing before the Board, and are thus ready to be decided.  Specifically, the Veteran's claims for service connection for an acquired psychiatric disorder, for a left shoulder disability, and for dizziness secondary to a TBI have already been certified and subject to hearing testimony and are thus decided below.  Additionally, while the Veteran's claim for total disability rating based on individual unemployability (TDIU) is part and parcel of his increased ratings claims, see Rice v. Shinseki, 22 Vet. App. 447, 453 (2009), he raised the issue in conjunction with his separate appeal stream.  The Board thus finds it inextricably intertwined with his other issues, and it is not decided herein.

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015).  38 U.S.C.A. § 7107(a)(2) (West 2014).

The issue of entitlement to service connection for nerve damage to the bilateral upper extremities is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ).


FINDINGS OF FACT

1.  Degenerative arthritis of the cervical spine is productive of forward flexion limited to less than 30 degrees but not less than 15 degrees or the functional equivalent thereof, and is not productive of ankylosis, incapacitating episodes, or the functional equivalent thereof.

2.  The Veteran manifested, at worst, Level I hearing loss in each ear. 

3.  An acquired psychiatric disorder is not related to service and did not manifest within one year of separation from service.

4.  Prostatitis is not related to service.

5.  Current skin disabilities are not related to service.

6.  There was no in-service event, injury, or disease which could be related to the Veteran's current sleep apnea.

7.  There are no allegations of errors of fact or law for appellate consideration with regard to service connection for a right shoulder disability.

8.  A left shoulder disability is not related to service or a service-connected disability.

9.  Symptoms claimed as residuals of a TBI are not related to service.

10.  IBS clearly and unmistakably existed prior to service and was not aggravated during service.

11.  An esophageal disability or GERD is not related to service.

12.  The Veteran was not exposed to herbicides, and a heart disability is not otherwise related to service.

13.  A benign lung nodule is related to in-service asbestos exposure.

14.  A voice box disability is not related to service or to a service-connected disability.

15.  There was no in-service event, injury, or disease which could be related to an eye disability.

16.  A mouth disability was caused by tobacco use.


CONCLUSIONS OF LAW

1.  The criteria for an initial evaluation of 20 percent, but not in excess thereof, for degenerative arthritis of the cervical spine have been met.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2015).

2.  The criteria for an initial compensable rating for bilateral hearing loss have not been met.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.85, 4.86, Diagnostic Code 6100 (2015).

3.  The criteria for service connection for an acquired psychiatric disability, to include PTSD, depressive disorder, and sleep disorder have not been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 4.125 (2015).

4.  The criteria for service connection for a skin rash, claimed as severe bites, have not been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015).

5.  The criteria for service connection for prostatitis have not been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015).

6.  The criteria for service connection for sleep apnea have not been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015).

7.  The criteria for dismissal of the appeal for the issue of entitlement to service connection for a right shoulder disability have been met.  38 U.S.C.A. § 7105(d)(5) (West 2014).

8.  The criteria for service connection for a left shoulder disability have not been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015).

9.  The criteria for service connection for residuals of a TBI, claimed as a concussion, to include headaches, have not been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015).

10.  The criteria for service connection for IBS have not been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2015).

11.  The criteria for service connection for an esophageal disability, to include GERD, have not been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015).

12.  The criteria for service connection for a heart disability have not been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015).

13.  The criteria for service connection for a benign lung nodule have been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015).

14.  The criteria for service connection for damage to the voice box have not been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015).

15.  The criteria for service connection for bilateral paralysis of the eyes have not been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015).

16.  The criteria for service connection for lumps in the mouth have not been met.  38 U.S.C.A. §§ 1101, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.300, 3.303 (2015).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Duties to Notify and Assist
		
Under applicable criteria, VA has certain notice and assistance obligations to claimants.  See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a).  In the present case, required notice was provided by letter dated October 2013.  See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015).  

As to VA's duty to assist, all necessary development has been accomplished.  See Bernard v. Brown, 4 Vet. App. 384 (1993).  The Veteran's service treatment records and have been obtained.  VA medical records have been obtained to the extent that they are still in existence, as have relevant private medical records identified by the Veteran.  

The Veteran was provided multiple VA examinations, including examinations of his cervical spine in November 2014, of his hearing loss in April 2014, of his mental health in July 2014, August 2015, and December 2015, of his skin in November 2014, of his prostatitis in November 2014 and December 2015, of his headaches in January 2015, and of his IBS and GERD in June 2014.  The Board finds that these examinations and their associated reports were adequate.  Along with the other evidence of record, they provided sufficient information to decide the appeal and a sound basis for a decision on the Veteran's claims.  The examination reports were based on examination of the Veteran by examiners with appropriate expertise who thoroughly reviewed the claims file.  38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303 (2007).  

With regard to the remaining decided issues, the Veteran has not been provided with a VA examination.  VA has a duty to provide a medical examination where there is (1) competent evidence of a current disability or symptoms thereof; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability is associated with service; and (4) insufficient competent medical evidence to decide the claim.  McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i).  As discussed in more detail below, with respect to sleep apnea, a heart disability, and an eye disability, the Board finds that the evidence does not establish that a relevant event, injury, or disease occurred in service, and an examination is not required.  With respect to voice box damage and lumps in the mouth, the Board finds that there is sufficient competent medical evidence in the Veteran's treatment records to decide the claims.

With respect to the claim of entitlement to service connection for a lung nodule, because the claim is being granted in full, VA's duties to notify and assist are deemed fully satisfied and there is no prejudice to the Veteran in proceeding to decide the issue on appeal.  See 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156, 3.159.
	
Therefore, VA has satisfied its duties to notify and assist, additional development efforts would serve no useful purpose, and there is no prejudice to the Veteran in adjudicating this appeal.  See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994).

Increased Ratings

Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity.  38 U.S.C.A. § 1155; 38 C.F.R. Part 4.  An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment.  38 C.F.R. § 4.10.  

In addition, when assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming  these factors are not already contemplated by the governing rating criteria.  DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59.

When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating.  38 C.F.R. § 4.7.  After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran.  38 C.F.R. § 4.3.  The Veteran's entire history is to be considered when making disability evaluations.  See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995).


Cervical Spine

The Veteran claims an initial evaluation in excess of 10 percent for degenerative arthritis of the cervical spine.

The Veteran is currently in receipt of a 10 percent disability rating for his service-connected cervical spine disability under 38 C.F.R. § 4.71a, Diagnostic Code 5242, degenerative arthritis of the cervical spine.  Spinal disabilities are evaluated either upon application of the General Rating Formula for Diseases and Injuries of the Spine ("General Formula"), or as intervertebral disc syndrome (IVDS) under the Formula for Rating IVDS Based on Incapacitating Episodes ("IVDS Formula"), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25.  See VBA Training Letter 02-04 (October 24, 2002).  

Under the General Formula, a 10 percent rating is assigned for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or spinal contour; or vertebral body fracture with loss of 50 percent or more of the height.  The next higher rating of 20 percent is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, combined range of motion of the cervical spine not greater than 170 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour.  A 30 percent is assignable for forward flexion of the cervical spine 15 degrees or less, or favorable ankylosis of the entire cervical spine.  A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine, and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine.  Also under the General Formula, any associated objective neurologic abnormalities are to be evaluated separately under an appropriate diagnostic code.  

Under the IVDS Formula, ratings are based on evidence of incapacitating episodes, defined as periods of acute signs and symptoms that require bed rest prescribed by a physician and treatment by a physician.  The next higher rating of 20 percent is warranted for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the last 12 months.  A 40 percent rating is warranted for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months.  A 60 percent rating is warranted for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months.

Diagnostic Code 5242 further directs that degenerative arthritis of the spine may alternatively be rated under 38 C.F.R. § 4.71a, Diagnostic Code 5003, on the basis of limitation of motion.  When limitation of motion is noncompensable, a 10 percent rating is for application for each major joint.  In the absence of limitation of motion, a maximum schedular 20 percent rating is assigned for degenerative arthritis of two or more major joints or two or more minor joint groups, with occasional incapacitating episodes.  Since some limitation of motion is noted, and the Veteran is already in receipt of a 10 percent rating based on limitation of motion, these criteria are not applicable in granting the Veteran a higher evaluation.

VA treatment records include a March 2013 MRI showing mild degenerative changes with no significant spinal canal or foraminal stenosis.  In April 2013 the Veteran reported neck pain and numbness in his hands.  His physician found evidence of neck discomfort with right rotation and extension.  An MRI revealed very mild degenerative disc disease and was otherwise unremarkable with no canal stenosis or cord compression seen.

In a November 2013 statement, the Veteran's girlfriend stated that he has constant pain in his neck.

VA treatment records reflect that in October 2014 the Veteran was enrolled in an outpatient chronic pain rehabilitation program.  Examination of his cervical spine by his physical therapist revealed forward flexion limited to 20 degrees, extension limited to 5 degrees, right lateral rotation limited to 25 degrees, left lateral flexion limited to 30 degrees, and bilateral rotation limited to 50 degrees.  At his November 2014 discharge from the program, forward flexion was limited to 25 degrees and extension was limited to 20 degrees.  There was no change from the October 2014 measurements of lateral flexion and lateral rotation.  

The Veteran underwent a VA examination in November 2014.  He reported constant neck pain and denied flare-ups.  On examination, forward flexion and extension were to 35 degrees with pain thereat.  Right lateral flexion and left lateral flexion were to 40 degrees with pain thereat.  Right lateral rotation and left lateral rotation were to 65 degrees with pain thereat.  Repetitive testing did not result in further reduction of the range of motion, but it did result in additional functional loss with contributing factors of less movement, incoordination, and pain on movement.  The Veteran exhibited localized tenderness/pain on palpation, muscle spasms not resulting in abnormal gait or spinal contour, and guarding not resulting in abnormal gait or spinal contour.  Muscle strength was normal with no atrophy.  Reflexes of the biceps and triceps were normal, and reflexes of the brachioradialis were hypoactive.  Sensory tests of the shoulders and forearms were normal, but there was diffused decreased sensation to light touch and pinprick in short glove distributions of both hands, which the examiner attributed to nonservice-connected carpal tunnel syndrome.  There was no radiculopathy or ankylosis.  There was no IVDS and the Veteran did not use any assistive devices.  Arthritis was documented in December 2012 x-rays.  The examiner diagnosed degenerative arthritis of the spine, and noted that the disability impacted the Veteran's ability to work due to pain and limited range of motion.  In a December 2014 addendum the examiner could not report further loss of range of motion due to neck flare-ups without resorting to mere speculation as this would require examination of the Veteran during a flare-up.  (The Board notes that the Veteran denied flare-ups.)

At his March 2016 hearing before the Board, the Veteran reported that he cannot turn his head due to pain, specifically when turning his head fast to the left.

The Board finds that the evidence warrants a 20 percent evaluation for degenerative arthritis of the cervical spine.  While the range of motion as measured in the November 2014 examination warrants only a 10 percent rating, the 20 and 25 degree forward flexion measurements by the Veteran's treating physical therapist warrant the higher rating.  Affording the Veteran the benefit of the doubt, the Board finds that the measurements of active range of motion by the Veteran's treating physical therapist are more reliable than the measurements taken in a VA examination setting.  An increased rating of 20 percent is therefore warranted.

The Board further finds that a rating in excess of 20 percent is not warranted.  Higher ratings are warranted for forward flexion limited to 15 degrees or less, ankylosis, incapacitating episodes, or the functional equivalent thereof.  The Board finds no evidence of such manifestations.  There is no indication of ankylosis and there is no medical record of any incapacitating episodes.  The Veteran's flexion has never been measured at less than 20 degrees, and his statements regarding neck pain speak to rotation, not flexion.  As to functional equivalence, he denies flare-ups, and though there is evidence that he uses a cane there is no indication that such a device would help support his neck.  See DeLuca, 8 Vet. App. at 204-07.  For these reasons, the Board finds that the evidence weighs against an initial evaluation in excess of 20 percent for degenerative arthritis of the cervical spine.

Hearing Loss

The Veteran claims an initial compensable evaluation for bilateral hearing loss.  In evaluating service-connected hearing loss, disability ratings are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed.  Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992).  An examination for hearing impairment for VA purposes must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test.  38 C.F.R. § 4.85.  Evaluations of bilateral hearing loss range from noncompensable to 100 percent based on an organic impairment of hearing acuity, as measured by controlled speech discrimination tests and puretone audiometric tests in the frequencies of 1000, 2000, 3000 and 4000 cycles per second.  The rating schedule establishes 11 auditory acuity Levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness.

VA audiological evaluations are conducted using a controlled speech discrimination test together with the results of puretone audiometry tests.  The vertical line in Table VI (printed in 38 C.F.R. § 4.85) represents nine categories of the percentage of discrimination based on a controlled speech discrimination test.  The horizontal columns in Table VI represent 9 categories of decibel loss based on the puretone audiometry test.  The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the puretone decibel loss.  The percentage evaluation is found from Table VII in 38 C.F.R. § 4.85 by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate for the numeric designation for the level for the ear having the poorer hearing acuity.  For example, if the better ear had a numeric designation of Level "V" and the poorer ear had a numeric designation of Level "VII" the percentage evaluation is 30 percent.  See 38 C.F.R. § 4.85.

Regulations also provide that in cases of exceptional hearing loss, i.e., when the puretone threshold at each of the four specified frequencies (1000, 2000, 3000 and 4000 hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIa, whichever results in the higher numeral.  Each ear will be evaluated separately.  38 C.F.R. § 4.86(a).  The provisions of 38 C.F.R. § 4.86(b) further provide that when the puretone threshold is 30 decibels or less at 1000 hertz and 70 decibels or more at 2000, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or VIa, whichever results in the higher numeral.  That numeral will then be evaluated to the next higher Roman numeral.

The Veteran underwent a VA examination in April 2014.  He reported difficulty communicating with his wife due to his hearing.  Audiometry results revealed pure tone thresholds, in decibels, as follows:




HERTZ



1000
2000
3000
4000
Average
RIGHT
20
10
35
40
26
LEFT
25
25
45
50
36

Speech discrimination scores were 94 percent in both ears.  The examiner diagnosed bilateral sensorineural hearing loss.

At his March 2016 hearing before the Board, the Veteran reported that his hearing had worsened.  He had trouble understanding voices.

The Board finds that a review of the audiological testing of record reveals that the disability is not severe enough to warrant a compensable rating.  The April 2014 VA examination revealed a right ear speech recognition score of 94 percent and an average decibel level of 26, which results in a numeric value of I. The Veteran's left ear speech recognition score of 94, when combined with the average decibel level of 26, results in a numeric value of I. When those values are applied to Table VII, it is apparent that the noncompensable evaluation is accurate and appropriately reflects the Veteran's bilateral hearing loss under the provisions of 38 C.F.R. § 4.85.  Moreover, none of the record audiological findings qualify as an exceptional pattern of hearing, as the Veteran at no point had puretone thresholds of 55 decibels or more at each of the frequencies of 1,000, 2,000, 3,000 and 4,000 hertz or a puretone threshold of 30 decibels or less at 1,000 hertz and 70 decibels or more at 2,000 hertz.  For these reasons, the Board finds that the evidence weighs against an initial compensable evaluation for bilateral hearing loss.

The Board recognizes that the Veteran reported worsening hearing loss at his March 2016 hearing.  A new examination, however, is not warranted.  The April 2014 VA examination was both relatively recent and indicated hearing at Level I in both ears.  Compensable ratings are not warranted unless hearing worsens to Level IV in at least one ear.  The Veteran's description of his hearing loss, however, is little different than the description of his hearing loss in April 2014, and does not reflect so drastic a worsening.  The Board thus finds that a new examination is not warranted.

Extraschedular Consideration

The Board has considered whether an extraschedular evaluation is warranted for the Veteran's issues on appeal.  In exceptional cases an extraschedular rating may be provided.  38 C.F.R. § 3.321.  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 the 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).

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").  When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating.  Id. 

Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairments caused by the Veteran's service connected disabilities, including pain, tenderness, muscle spasm, guarding, painful limited motion, and difficulty hearing, are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required.  

The Veteran has not expressly raised the matter of entitlement to an extraschedular rating.  His contentions have been limited to those discussed above, i.e., that his cervical spine and hearing loss disabilities are more severe than is reflected by the assigned ratings.  As was explained in the merits decision above in denying higher ratings, the criteria for higher schedular ratings were considered, but the ratings assigned were upheld because the rating criteria are adequate.  In view of the circumstances, the Board finds that the rating schedule is adequate, even in regard to the collective and combined effect of all of the Veteran's service connected disabilities, and that referral for extraschedular consideration is not warranted under the circumstances of this case.  Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014).

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service.  38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a).  Service connection requires:  (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995).  Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).

Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310(a).  Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability.  38 C.F.R. § 3.310(b).

When determining service connection, a presumption of soundness ordinarily applies.  38 C.F.R. § 3.304(b).  Pursuant to such presumption, a Veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service.  Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Horn v. Shinseki, 25 Vet. App. 231, 234 (2012).  Only such conditions as are recorded in examination reports are to be considered as noted.  The burden falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the disability was both preexisting and not aggravated by service.  The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition.  38 U.S.C.A. § 1153; Wagner, 370 F.3d at 1096.  

Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service.  See 38 U.S.C.A. § 1153; 38 C.F.R. §§ 3.304, 3.306(b).  A pre-existing disease or injury will be presumed to have been aggravated by service only if the evidence shows that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability.  See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a).   Furthermore, temporary or intermittent flare-ups of a pre-existing condition during service are not sufficient to be considered aggravation of the condition, unless the underlying condition, as contrasted to symptoms, worsens.  See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991).

For certain chronic diseases, such as arthritis and psychosis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service.  38 C.F.R. §§ 3.307(a)(3), 3.309(a).  When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time.  When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a).  38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Notwithstanding any other provision of law, for claims filed after June 9, 1998, a Veteran's disability or death shall not be considered service-connected on the basis that it resulted from injury or disease attributable to the Veteran's use of tobacco products during service.  38 U.S.C.A. § 1103(a); 38 C.F.R. § 3.300(a).  This provision does not preclude the establishment of service connection for a disability or death from a disease or injury which is otherwise shown to have been incurred or aggravated in military, naval, or air service or which became manifest to a requisite degree of disability during any applicable presumptive period.  38 U.S.C.A. § 1103(b); 38 C.F.R. § 3.300(b).

In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied.  38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).  When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant.

Acquired Psychiatric Disability

The Veteran claims service connection for an acquired psychiatric disability, to include PTSD, a depressive disorder, and a sleep disorder.  Specifically, in his January 2013 clam, the Veteran stated that he suffered from PTSD due to in-service sexual harassment.

Service connection for PTSD requires:  (1) a diagnosis of the disorder made in accordance with the criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM-5); (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) a link established by medical evidence, between current symptoms and an in-service stressor.  38 C.F.R. §§ 3.304(f), 4.125(a).

There are special considerations for PTSD claims predicated on a personal assault.  The pertinent regulation, 38 C.F.R. § 3.304(f)(5), provides that PTSD based on a personal assault in service permits evidence from sources other than a veteran's service records which may corroborate his or her account of the stressor incident.  Examples of such evidence include, but are not limited to:  records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy.  38 C.F.R. § 3.304(f)(5).  VBA's Adjudication Procedure Manual, M21-1MR, also identifies alternative sources for developing evidence of personal assault, including private medical records, civilian police reports, reports from crisis intervention centers, testimonial statements from confidants such as family members, roommates, fellow service members, or clergy, and personal diaries or journals.  M21-1MR, Part IV, Subpart ii, 1.D.17.n.

Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources.  Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to:  a request for a transfer to another military duty assignment; deterioration in work performance, substance abuse, episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes.  38 C.F.R. § 3.304(f)(5).

Service treatment records reflect that in March 1978 the Veteran was diagnosed with anxiety.  Specifically, the Veteran reported back pain that had lasted for a month and a half, and his physician determined that the pain was due to anxiety.  Additionally, in October 1978, while being treated for abdominal cramping and rectal bleeding, the Veteran reported that onset was related to a time of increased emotional stress.  There is no indication of further mental health treatment, and no abnormality was noted at the Veteran's June 1979 separation examination.

VA treatment records indicate that in September 1994 the Veteran was treated for stress-related chest pain.  He reported that he had anxiety due to his unhappiness with his current life situation.  He presented as anxious and agitated.  He reported stress doe to projects he was involved in and had been for many years that put him at great risk, but he was guarded about the nature of these projects.  He was diagnosed with generalized anxiety disorder.  He scheduled further therapy sessions but did not report to them.

VA treatment records further reflect that in July and September of 2011 the Veteran reported anxiety and panic attacks brought on by significant financial and legal stressors that have occurred in the prior few years.  He was diagnosed with generalized anxiety disorder, rule out depressive disorder.  At a November 2011 consultation with a psychologist, he first reference military stressors.  He reported three traumatic experiences - almost being run over by a tank, having a friend run over by a tank, and having a friend blown up - but did not go into further detail.  In December 2011 he was diagnosed with depressive disorder, anxiety disorder, and alcohol abuse.  He reported a life-threatening stressor during military training - being almost run over by a tank - but stated that the incident was no longer substantially distressing, though he occasionally had related anxiety-provoking dreams about it.  The Veteran's social worker noted salient symptoms of anxiety and depression outside the context of past traumatic incidents.  He reported current stressors of a legal and financial nature, including getting swindled out of money by a business partner and being falsely accused of physical assault by a girlfriend.  In January 2012, he reported feelings of frustration with being assigned new providers.  He reported infrequent alcohol consumption, which his psychiatrist noted was inconsistent with prior reports.  In March 2012, the Veteran reported that he had served three years in prison for fraud, though he stated that he was working undercover for a federal agency but they refused to have his record expunged.  He stated his belief that it was a conspiracy against him by the people he helped send to prison, and he asked his psychologist if he was delusional or not.  In May 2012, the Veteran confronted his wife and separated from her.  He informed his psychologist that his panic attacks disappeared following the confrontation, and at a later appointment speculated that his anxiety attacks were the result of her attempting to poison him.  In June 2012 his psychiatrist explored the possibility of a bipolar disorder, but assigned instead an additional rule-out diagnosis of intermittent explosive disorder.  The Veteran's military experiences were not discussed.  At an August 2012 session with a new psychologist, the Veteran reported childhood and adult traumas and stressors, but nothing about his military service.  He referred to ongoing legal proceedings related to his wife's attempt to poison him.  He was diagnosed with depressive disorder.  In December 2012 he reported a reoccurring dream that he was about to be run over by a tank.  His psychologist assessed that his dream was not distressing to him, and they both agreed to focus treatment elsewhere.  There was no discussion of military experiences at a January 2013 session.

In a January 2013 statement, the Veteran reported that while in service his unit experienced on a daily basis absence without official leave, desertion, rape, physical abuse, attempted murder, drug abuse, alcoholism, suicides, and training casualties.  In a separate January 2013 statement he reported that his PTSD including flashbacks prevented him from working.

VA treatment records reflect that in February and March of 2013 the Veteran's therapy sessions were not focused on his military experiences.  In March 2013, the Veteran reported that people continually lie to him, using as an example that his neurologist told him that he had diabetes while his primary care physician told him he did not.  In April 2013 he was unable to articulate an instance in which people acted towards him with kindness.  Later in April 2013, he reported experiencing his tank nightmare two to three times per night.  Therapy continued to focus on his dreams in May 2013.  In June 2013 he was referred to a sleep psychologist and prescribed medication.  In a July 2013 report, the sleep psychologist noted that the Veteran reported that his nightmares were abated by the medication and that he had cut back his alcohol consumption.  At the session, the Veteran was less concerned with his nightmares than with his inability to stay asleep.  In September 2013, he reported that his worst nightmares originated from watching a tank accident which resulted in the death of several soldiers.  His psychiatrist added a rule-out diagnosis of PTSD, but removed that diagnosis at a session later in the month.

The Veteran underwent a VA PTSD clinic evaluation in October 2013.  He denied having experienced military sexual trauma.  He reported nine stressors as follows:  (1) He witnessed a fellow soldier commit suicide by slitting his wrists.  (2) He witnessed a fellow soldier commit suicide by gunshot.  When pressed, he said he did not witness the suicide but saw the bloodstain afterwards.  (3) While in training, two intoxicated soldiers fired into a command post wounding or killing seven people.  (4) Fell in Alaska when his hands froze after getting caught in the air wash from a helicopter.  (5) A local Alaskan tried to kill one of his fellow soldiers.  (6) A hard landing caused him to be stranded on the side of a mountain in Alaska for five days.  (7) He endured a hard landing in a helicopter in Florida.  (8) A fellow soldier was run over by a tank and killed.  (9) He was almost run over with a tank.  He further reported that he could not describe all of his stressors because he had performed work for the government that was "very classified."  The psychologist noted that the high intensity and frequency of symptoms brings to question if secondary gain is involved in his reported symptoms.  The psychologist gave a provisional diagnosis of antisocial personality disorder.  At a follow-up appointment later in the month, the Veteran reported that he had been sexually assaulted by a provider while in the military.  He subsequently began PTSD group therapy.

In a November 2013 statement, the Veteran claimed that his PTSD was due to two incidents.  The first incident occurred sometime in 1978 when the Veteran underwent a colonoscopy.  While performing the procedure, the physician placed his crotch near the Veteran's face and fondled the Veteran's genitals.  The second incident occurred sometime in 1979, when an acting first sergeant whose name the Veteran could not recall invoked three separate instances of sexual harassment.  The Veteran stated that he reported these instances and was subsequently physically assaulted by the sergeant.  In addition, the Veteran reported that he was exposed to multiple incidents on a constant basis, including sexual harassment, suicide attempts, attempted murder of a fellow soldier in Alaska, fellow soldier run over by a tank and killed while on maneuvers, hard landings of helicopters in Florida and Alaska, being stranded on a mountainside for several days in February in Alaska, coming within inches of being run over by a tank while on maneuvers in Florida, racism, knocking over a 3-foot high red ant hill and being bitten, and repeated tear gas attacks while sleeping in a field.

In a November 2013 statement, the Veteran's girlfriend stated that he has violent and recurring nightmares of traumatic events from active duty and has anger management issues, difficulty getting along with others, trust issues, feelings of worthlessness, difficulty concentrating, and flashbacks.

VA treatment records reflect that in November 2013 the Veteran reported remembering past events and being distressed since starting treatment at the PTSD clinic.  His diagnoses were unspecified depressive disorder, a provisional diagnosis of antisocial personality disorder, and a rule-out diagnosis of PTSD.  He continued anger management group therapy.  At a December 2013 individual therapy session, he stated his frustration with his VA treatment, stating that he had been given the "runaround."  

In January 2014, the Veteran underwent psychological testing at the VA PTSD clinic.  Included in the tests was the Structured Inventory of Malingering Symptomatology (SIMS), on which the Veteran scored a 35.  The report explains that this score is significantly above the recommended cutoff score for suspected malingering of 19.  Specifically, the Veteran endorsed an elevated frequency of symptoms that are highly atypical in patients with genuine psychiatric or cognitive disorders, raising suspicion of over-reporting and exaggeration of symptoms.  His responses reflected a pattern of significant exaggeration of psychotic, neurological, amnestic, and affective symptoms.  Interpretation of other clinical information and tests should be approached with a high degree of caution.  Similarly, his validity scores on the trauma symptom inventory (TSI) reflected a high endorsement of atypical symptoms, invalidating the profile and often indicative of symptom exaggeration.  Scores on other tests were similarly found invalid.  For these reasons, the report declined to diagnose the Veteran with PTSD, as his self-report of symptoms is considered unreliable due to significant over-endorsement of various psychiatric symptoms including psychotic thinking.  The report concluded that the Veteran most likely meets the criteria for alcohol use disorder and major depressive disorder with psychotic features, though it was noted to be difficult to tell the severity or extent of these diagnoses given the exaggerated presentation.  The Veteran was subsequently assigned rule-out diagnoses of bipolar I with psychotic features, major depressive disorder with psychotic features, paranoid schizophrenia, and paranoid personality disorder.  In February 2014, his psychologist noted a longstanding history of perceived persecution, grandiose delusions, and considerable interpersonal conflict.  

In a March 2014 statement, the Veteran described a process of being referred among 7 different treatment providers over a period of more than two years.  He was diagnosed with PTSD but not treated during this period.

VA treatment records indicate that in March 2014 his psychologist attempted to refine his diagnoses.  He noted that the Veteran's past reports of frequent and severe head injuries should be ruled out as a possible contributing factor to his clinical picture.  He was diagnosed with persistent depressive disorder, relationship distress with intimate partner, history of bipolar I with psychotic features in partial remission, rule-out paranoid schizophrenia, rule-out intermittent explosive disorder, mild alcohol use disorder, moderate nicotine abuse disorder, and rule-out PTSD.  In April 2014, therapy focused on his anger, irritability, and isolation, as well as suspected underlying depression.  He reported worsening nightmares in May 2014.  In July 2014 his therapy focused on his relationship difficulties.

The Veteran underwent a VA examination in July 2014.  He reported being arrested over 20 times, including being sentenced for three years, but claimed never to have broken the law.  When asked, he stated that he could not talk about his alleged offense, except to say that it happened when he was on active duty.  He reported current consumption of a gallon per week of bourbon.  He stated that he tried cocaine in the 1980s but quit.  He reported three stressors: (1) being almost run over by a tank a few days before a fellow soldier was run over by a tank and killed; (2) a vague statement of horrific things involving the deaths of soldiers; and (3) a statement about his colonoscopy incident, described above, and an alleged gang rape of a female employee at the officers club.  The Veteran stated that he witnessed the officers joking around with her, but that the actual rape occurred after he left the club.  The examiner found that these incidents did not qualify as stressors to support a diagnosis of PTSD under DSM-5.  The examiner further found that the Veteran's symptoms did not meet the intrusion or avoidance criteria (B and C) to support a diagnosis of PTSD, though they did meet criteria D and E.  Additionally, psychological testing results were invalid due to over-reporting and exaggerating of symptoms.  In a detailed explanation, the examiner articulated why the Veteran was more appropriately diagnosed with persistent depressive disorder with anxious distress as well as an alcohol use disorder.  The examiner opined that it was less likely than not that the Veteran's mental health disability were the result of an in-service event.  This opinion was based on the rationale that the only marker to corroborate the Veteran's account of an in-service assault was his report of anxiety when he was treated for back pain.  The examiner explained that the Veteran's current disability was the result of a myriad of current and post-service psychosocial stressors, including medical conditions and failed relationships, and that there is no treatment history to tie the single reference of in-service anxiety to his current symptoms.

VA treatment records indicate that in July 2014 the Veteran indicated that he felt that the sexual assault he reports experiencing in the past has not been addressed by his therapists.  He further indicated that he feels that his records were tampered with in order to protect higher ranking officials.  His psychiatrist continued her prior diagnoses of depressive disorder and anxiety disorder.  At a subsequent session, the Veteran indicated that he worked as a secret government contractor from 1979 to 1999.  At treatment in August and September of 2014 he did not discuss his military stressors.

In an August 2014 letter, the Veteran's treating VA psychiatrist stated that he was currently being treated for his diagnoses of major depressive disorder and anxiety disorder to address symptoms of depression, anxiety, and anger/irritability.

In a September 2014 statement, the Veteran stated that while in service, he was exposed to (1) one suicide and one attempted suicide of fellow trainees during basic training; (2) being physically assaulted by two Mexicans; (3) being spat at by a civilian in the Dallas airport; (4) a live fire accident in North Carolina; (5) a live fire accident death in Georgia; (6) a Jeep accident in Georgia; (7) a member of his unit being run over by a tank and killed; (8) suffering dysentery in Florida (9) going three days with very little sleep and coming within inches of being run over by a tank in Florida; (10) being advanced into helicopter live fire in Georgia; (11) the assault of a fellow soldier due to his religious beliefs; (12) the assault of a fellow soldier due to his race; (13) witnessing a conversation in which one soldier said he wished to shoot his lieutenant because of his race; (14) a racially motivated attempted murder by stabbing in Alaska; (15) being snapped at by Vietnam veterans; (16) witnessing flashbacks by Vietnam veterans; (17) witnessing a fellow soldier collapse from heat exhaustion; (18) witnessing a fellow soldier vomiting in his protective mask; (19) receiving a concussion in Georgia form multiple artillery simulators thrown at his position with gas while he was sleeping; (20) knocking over a 3-foot tall ant hill in Georgia; (21) a hard landing in a helicopter in Florida in which the door gunner was injured; (22) widespread narcotic use, including one overdose resulting in permanent coma; (23) a hard landing in a helicopter in Alaska; (24) being stranded on a mountain in February for 5 days in Alaska; (25) getting caught in a rotor wash in Alaska which resulted in a flash freeze of both hands; (26) the accidental discharge of a weapon during an attempt to subdue a unit member threatening suicide; (27) an attempted sexual assault on the Veteran by his doctor; (28) attempted murder of a transvestite in the barracks by a fellow soldier; (29) his sergeant consistently showing the entire company films of his wife having sex with multiple partners; and (30) the brutal rape of a civilian woman at the officers' club in Georgia, which was subsequently covered up leading to the suicide of the victim.

The Veteran gave detailed information of some of these stressors in separate September 2014 statements.  Those descriptions are as follows:  (1) In January 1977, he was in El Paso waiting to return via bus, when he was jumped by two adults.  He was rescued by two fellow soldiers, but had been knocked unconscious, suffering a swollen face, broken glasses, and a black eye.  He refused medical attention.  (2) In February 1978, he was sent to a mountainside summer camp in Alaska.  A hard landing due to weather caused injuries, and he was stranded for five days.  While there, a racial fight broke out between two fellow soldiers, culminating in one stabbing the other multiple times with a bayonet.  The Veteran witnessed the altercation and was forced to clean up the blood.  The attacker was subsequently convicted of attempted murder.  (3) In April 1979, the Veteran was asleep under a jeep while on maneuvers.  The opposing force attacked his position with artillery simulators.  The Veteran was knocked out and hit his head.  (4) In the summer of 1979, the Veteran was involved in exercises with an armored battalion.  The Veteran witnessed a fellow soldier thrown off a tank, run over, and killed.  (5) Within the last four months prior to separation, he was in the officers' club when he witnessed the sexual assault of a civilian employee.  After he left the club, she was raped.  The rape was subsequently covered up and the victim committed suicide.  The Veteran said that he was cleared of wrongdoing.  (6) At an unknown time, the Veteran reported that his doctor fondled his genitals and stuck his crotch in his face, showing his erection through his pants.  This happened during a colonoscopy.  (7) At an unknown time, the Veteran's acting first sergeant showed stag films of his wife with other men as a form of entertainment to the company for a period of three weeks.  (8) At an unknown time, the Veteran's acting first sergeant harassed a fellow soldier for being a virgin for religious reasons.  The sergeant then harassed the Veteran for standing up for the soldier.  (9) At an unknown time, the Veteran was marching when a fellow soldier suffered heat exhaustion and vomited while wearing a gas mask, almost choking to death.  The Veteran helped carry the victim for the rest of the march.  There were no medics available because the Veteran had witnessed a fellow soldier "butt-stroked" by a weapon, and that soldier was taken away by the medics.

In a separate September 2014 statement, the Veteran's girlfriend stated that the Veteran suffers severe nightmare which cause him to yell, scream, act out, and defecate in bed.

In another September 2014 statement the Veteran disputed the adequacy of his July 2014 VA examination.  He stated that he did not feel the examination was an accurate reflection of his condition because he was on an excessive amount of medication for nightmares and sleep disorders.  He also stated he was physically ill and depressed, and suffered from memory issues which made it difficult for him to report his symptoms.  In a November 2014 statement, the Veteran stated that he was unable to comprehend the psychological test questions on the computer, and that he was never asked about his stressors.  In a separate November 2014 statement, the Veteran reported being tested for memory issues, inability to focus, and confusion due to his PTSD.  He stated that he could no longer read or spell.  In a January 2015 statement, he further elaborated that because of these difficulties he was unable to read the questions when psychologically tested at his VA examination.

VA treatment records reflect that in October 2014 the Veteran underwent neuropsychological testing.  He initially reported that he had been suicidal since 1978, but upon further inquiry denied current suicidal intent.  He demonstrated impairments in processing speed and executive functioning, specifically mildly impaired encoding of verbal information, semantic generativity, and processing speed.  He also demonstrated weaknesses in attentional control, working memory ability, phonemic generativity, and cognitive control/flexibility.  The neuropsychologist found that none of his performance indicated severe impairment and he did not meet the criteria for dementia, but the symptoms were consistent with cognitive sequelae of chronic pain and may be exacerbated by PTSD or sleep apnea.

VA treatment records reflect that in October and November of 2014, the Veteran participated in an outpatient chronic pain rehabilitation program, which had a significant psychiatric treatment component.  He listed his left shoulder as his primary pain concern.  The focus of his therapy within this program was how his symptoms were related to his chronic pain.  At an October 2014 session with his VA treating psychologist during this period, the Veteran reported a "flashback ... meltdown" but otherwise did not mention his service.  In November 2014, the psychologist noted that the Veteran's current stressors consisted of somatic issues and financial pressures.  In discharge from the program, when asked what he hoped to receive from his treatment, he stated he was seeking answers regarding his flashbacks.  After discharge from the program, the Veteran spoke with his psychologist over the phone and expressed frustration that he had been through four assaults in service and no one at VA had asked him about them.

In a November 2014 statement, the Veteran reported that medication for his sleep disorder and nightmares caused dizziness, depression, hearing voices, and suicidal ideation.  

VA treatment records reflect that in a December 2014 telephone conversation with his treating psychologist, the Veteran reported that his symptoms were in part the result of an assault that he had not reported to VA yet.  In the report of a second December 2014 telephone contact, his psychologist noted that the Veteran's perception that all of his mental health care providers had diagnosed him with PTSD persisted.  When confronted with evidence to the contrary, the Veteran called into question the evaluating providers and the nature of the test results and introduced additional reports of traumatic events.  The psychologist noted that the Veteran continued to demonstrate guardedness during interviews, inconsistency in his self-report, grandiosity, and perceptions of differential if not prosecutorial treatment.  The psychologist specifically noted that the nature of reported traumatic events appears to be ever-expanding in nature.

In a December 2014 statement, the Veteran reported that in 1978 he was assaulted with a bayonet in the middle of the night.  The soldier who assaulted him was the same soldier who was subsequently convicted of attempted murder for stabbing another soldier with the same bayonet.  The Veteran gave the names of two other soldiers who witnessed his stabbing.

The Veteran's social worker from a county vet center submitted a December 2014 letter, in which she states that the Veteran's account of his own sexual trauma and traumatic deaths of other persons during his military experience appear to have led to several years of symptoms related to posttraumatic stress.  The Veteran reported moderate to severe problems with anxiety, mood/depression, sleep disturbance, somatic issues, and disturbing recollections.  He further reported financial distress and a risk of homelessness within 30 days.  

VA treatment records indicate that in January 2015, the Veteran's treating psychologist was informed by his otolaryngologist that the Veteran refused a dental appliance, stating that his doctor told him he was schizophrenic and did not need it.  He further cancelled his sleep apnea surgery, giving contradictory explanations.  He stated that he was a hypochondriac and did not need to have anything done.  He also stated that he was told he had a 50 percent chance of dying in his sleep due to his sleep apnea.

In a January 2015 statement, the Veteran attached a service performance evaluation from December 1977.  The evaluation was exceptionally positive, but the Veteran contends that the evaluation was a fraud.  Specifically, the Veteran contends that the evaluation states that he was involved in a missile exercise in 1977, yet he was involved in live fire in 1978.  It is not clear why the Veteran believes such a falsification would occur or what relevance it has to his claimed PTSD.  The Board notes that the evaluation contains the Veteran's signature.

A friend of the Veteran submitted an April 2015 statement.  The friend explained that he knew the Veteran since 2005, but since 2009 his personality began to change.  His temper shortened and he started complaining about unexplainable aches and pains.  His mental sharpness deteriorated to the point that his business failed.  The friend hired him, but he was unable to perform his duties.  The friend accompanied the Veteran to his July 2014 VA examination.  When the Veteran emerged, he went straight to the restroom and became violently ill.  The Veteran then told the friend that he was unable to concentrate because of several things that happened in service.

VA treatment records reflect that the Veteran was treated in April 2015.  His psychiatrist found that he was minimally cooperative with significant external blame and locus of control, disparaging other caregivers.  He was diagnosed with persistent depressive disorder with posttraumatic stress elements related to military sexual trauma, rule out PTSD.

The Veteran underwent a VA examination in August 2015.  He reported memory difficulties, getting things backwards, and in inability to be around people.  He denied having any criminal history.  The examiner diagnosed schizoaffective disorder.  The examiner opined that the Veteran's disability was less likely than not related to any incident in service.  This opinion was based on the rationale that the Veteran's condition is not posttraumatic in nature, but is rather a mood disturbance with evidence of delusional thinking, which the evidence indicates arose many years after separation from service.

In an October 2015 statement, the Veteran's landlord reported that he only sleeps for an hour and half at a time.

In another October 2015 statement, a fellow soldier stated that while he was stationed in Alaska a helicopter went down hard and stranded a platoon on a mountainside.  The soldier, who was not present for this event, could not confirm whether the Veteran was one of those aboard.

At a November 2015 RO hearing, the Veteran reported he was sexually assaulted while receiving a colonoscopy without anesthesia while in service.  He stated that he tried to report the assault, but was advised to forget about it.  He reported that rape was commonplace in his unit.  Additionally, he reported the stressor of finding out that the woman he saw in the officers' club in service was raped.  He stated that the assault occurred after he left the club.  He recounted seeing a soldier killed by a tank, but did not know his name.  He further stated that when he took the computer portion of his VA examination, he had taken 10 sleeping pills and became violently ill.  He reported panic attacks, fear of crowds, lack of friends, and fear of hostile military or terrorist activity.  Additionally, the Veteran's friend who submitted the abovementioned April 2015 statement gave testimony consistent with that statement.  Other friends gave testimony establishing the Veteran's mental decline in recent years, and stating that the factual accounts he had given them had been consistent.

In November 2015, VA confirmed that a soldier who served with the Veteran was killed in a training accident after being thrown from a tank in July 1978.

The Veteran underwent another VA examination in December 2015.  The examiner diagnosed an unspecified depressive disorder and an unspecified anxiety disorder.  The examiner opined that it was less likely than not that these disorders were related to service.  This opinion was based on the rationale that he did not have evident psychiatric symptoms either prior to or during his active duty, it is unclear clinically when his symptoms first developed, and it is evident that he appeared to function at a relatively high level occupationally and psychosocially prior to 2009.  In an addendum to the opinion, the examiner noted that VA had corroborated the fact that the Veteran was in the same unit as a soldier who had been killed during a training exercise in July 1978.  The examiner found that this did not change his opinion, because the Veteran did not consistently connect this death with his disorders, and such a connection would be inconsistent with his clinical history.  The examiner noted that in addition to this incident, the Veteran has claimed multiple unlikely and unverifiable active duty stressor events which reasonably raise questions about his self-reporting.

At his March 2016 hearing before the Board, the Veteran reported witnessing his friend being run over by a tank and being stranded on a mountainside in Alaska after a helicopter hard landing.

The Board finds that the evidence weighs against a finding that the Veteran's acquired psychiatric disability is related to service or manifested within one year of separation from service.  Specifically, the Board finds that the evidence establishes that the Veteran's disability manifested decades after separation from service.  Despite isolated reports of anxiety and emotional stress in the Veteran's service treatment records, his post-service treatment records and statements from his friends establish that he had no significant mental health problems prior to 2009.  As such, the Board finds credible the opinions of the VA examiners, specifically their finding that the Veteran's in-service stressor reports are not to be relied upon.  Objective psychological testing indicated a high level of exaggeration and over-reporting on the part of the Veteran.  While VA has confirmed one death the Veteran reported to have witnessed, his reports of witnessing it are inconsistent.  Specifically, earlier reports only mention the death occurring several days after the Veteran himself was almost run over.  Only later reports place the Veteran at the scene of the death.  Furthermore, the Board finds the Veteran's description of his stressors to lack believability and suggestive of delusions.  Earlier treatment records dismissed in-service stressors in favor of current legal and financial difficulties.  Later reports continually add new traumatic events.  His reports of traumatic events are inconsistent, unbelievable, and as his psychologist aptly described, ever-expanding.  These stressor accounts are further undermined by his reports of top-secret government work, his fast transition from suspicion to certainty that his wife tried to poison him, and his accounts of requesting a prison sentence as part of his undercover work with the Department of Justice.  The Board agrees with the VA examiners and the Veteran's treating psychiatrists that the accounts of these events are unreliable.  To the extent that any of the Veteran's mental health caregivers indicate that his disabilities are related to service, such an opinion is no more credible than the unreliable factual accounts on which they are based.  For these reasons, the Board finds that the evidence weighs against a finding that the Veteran's acquired psychiatric disability is related to service or manifested within one year of separation from service, and service connection is therefore denied.  

Skin Rash

The Veteran claims service connection for a skin rash, claimed as severe bites.  Specifically, in a January 2013 statement the Veteran explained that he suffered skin issues due to multiple red ant bites that resulted in anaphylactic shock and hospitalization.  

Service treatment records reflect that in August 1977 the Veteran was treated for an irregular rash in the groin area.  He was diagnosed with probable tinea cruris.  There is no indication of any further treatment for skin symptoms, and no abnormality was noted at the Veteran's June 1979 separation examination.

VA treatment records reflect that in March 2012 the Veteran was diagnosed with seborrheic keratosis of the lower legs and eczema of the right ankle.  In May 2012 he was diagnosed with actinic keratosis of the right temple and sebaceous hyperplasia of the right chin.  He reported a rash in July 2013.  His dermatologist found an erythematous scaly macular rash involving his buttocks and diagnosed tinea corporis.  In April 2014 he was diagnosed with an erythematous hyperkeratotic lesion of the nose.

In a November 2014 statement, the Veteran stated that his skin trouble was also due to exposure to asbestos, tear gas, and smoke grenades.  He stated that in service he was exposed to tear gas in training five to ten times per month over a period of two years, including four trips to the gas house.  He also reported firing a live missile in 1979, receiving a face full of smoke.  In a December 2014 statement, he stated that he was exposed to asbestos at Fort Bragg, Fort Bliss, and Fort Stewart.

The Veteran underwent a VA examination in November 2014.  He reported being covered by fire ants in 1979 during an all-night forest march.  He stated that he had bumps on his body ever since.  The examiner diagnosed actinic keratosis of the right temple and sebaceous hyperplasia on the right chin.  The examiner further noted scattered small hyperkeratotic lesions in the nose, temple and right eye area, as well as scattered small white popular lesions involving the lower legs, face, arms, and hands.  In a December 2014 addendum, the examiner opined that the Veteran's current skin conditions are less likely than not related to his in-service report of groin rash.  This opinion was based on the rationale that his current skin conditions were separate conditions from groin rash and diagnosed more than 40 years later.

VA treatment records reflect that in December 2014 the Veteran was treated for erythematous hyperkeratotic lesions involving the face.

The Board finds that the evidence weighs against a finding that his current skin rash is related to service.  The VA examiner's opinion is highly probative.  It explains how the isolated instance of jock itch in the Veteran's service treatment records was an acute condition unrelated to the Veteran's current skin conditions.  The Board recognizes that the Veteran has claimed that his skin conditions are due to his exposure to asbestos, tear gas, smoke grenades, and fire ants.  As discussed above, however, the Board does not find the Veteran's accounts reliable, and there is no corroborating evidence of such exposure or a relationship with the Veteran's current skin difficulties.  For these reasons, the Board finds that the evidence weighs against a finding that his current skin rash is related to service, and service connection is therefore denied. 

Prostatitis

The Veteran claims service connection for prostatitis.

Service treatment records reflect that in September 1978 the Veteran was treated for probable prostatitis.  There was no subsequent treatment for the condition, and no such abnormality was noted at the Veteran's June 1979 separation examination. 

VA treatment records reflect that in July 2011 the Veteran's physician noted a history of prostatitis or urinary tract infections.

The Veteran underwent a VA examination in November 2014.  He reported being diagnosed with acute prostatitis in 1978 while in the field and prescribed oral antibiotics.  He reported subsequent similar episodes in November 1979, in 1995, and in 1998.  On examination, his prostate was slightly enlarged, appropriate for the Veteran's age, with no overt nodules.  The examiner diagnosed recurrent prostatitis.  In a December 2014 addendum, the examiner opined that any current prostatitis is unrelated to the Veteran's in-service prostatitis.  This opinion was based on the rationale that the Veteran's infections were discrete, episodic events with complete resolution of symptoms after each episode. 

At his November 2015 RO hearing, the Veteran reported that when diagnosed with prostatitis in service, he was told that it could be caused by dysentery or stomach issues.

The Veteran underwent another VA examination in December 2015.  The examiner noted the Veteran's history of prostatitis but found no current disease.  Specifically, he noted four discrete episodes of prostatitis, with the most recent occurring 8 months prior to examination, although the urine culture was negative.  The examiner opined that any current prostatitis is less likely than not related to the Veteran's in-service prostatitis.  This opinion was based on the rationale that there is no evidence of chronic prostatitis, but rather individual episodes.

The Board finds that the evidence weighs against a finding that any current prostatitis is related to the prostatitis the Veteran experienced in service.  The VA examiners' opinions are highly probative, as they explain that the Veteran's four to five episodes of prostatitis were isolated, separated by years, and completely resolved in the interim.  There is no medical evidence in the record indicating a chronic condition.  Although the Veteran claims that the episodes of prostatitis are related or caused by stomach issues, the Board finds the opinions of the VA examiners more probative due to their medical expertise.  For these reasons, the Board finds that the evidence weighs against a finding that any current prostatitis is related to the prostatitis the Veteran experienced in service, and service connection is therefore denied.

Sleep Apnea

The Veteran claims service connection for sleep apnea.  In a January 2013 statement, the Veteran reported that in 1979 he started sleepwalking, talking and screaming in his sleep, and experiencing severe nightmares. 

Service treatment records do not reflect any symptoms of or treatment for any sleep disorder, and no such abnormality was noted at the Veteran's June 1979 separation examination.

VA treatment records reflect that in June 2013 the Veteran underwent a sleep study and was diagnosed with obstructive sleep apnea without associated severe oxygen desaturation.  He was prescribed a continuous positive airway pressure (CPAP) machine.  

In a November 2013 statement, the Veteran's girlfriend stated that he has severe sleep apnea and wakes frequently gasping for breath.

In a September 2014 statement, the Veteran's girlfriend stated that his sleep apnea caused him to be up and down all night.

In an October 2014 statement, the Veteran reported that he suffered a sleep disorder while on active duty and continually since being discharged.  He stated that in addition to sleep apnea, he experiences sleepwalking, snoring, flashbacks, nightmares, and crying out.

In a December 2014 statement, the Veteran reported that his sleep apnea caused him to snore, sleepwalk, and yell and scream.  He stated that it was so bad in service that no one would sleep in the same room as him, and he was going to be referred for a medical discharge.  He further stated that his sleep problems began after he was personally assaulted with a bayonet while sleeping.

VA treatment records reflect that in January 2015 the Veteran was scheduled for surgery to address his sleep apnea, but he cancelled it.  The reasons for the cancellation were unclear.  He reported that he was told by a doctor that there was a 50 percent chance that he would die in his sleep because of his sleep apnea.

At his November 2015 RO hearing, the Veteran reported that in service he snored, walked, yelled, cried, and laughed in his sleep.  He reported treating the condition with over-the-counter sleep medication because he was afraid of reporting it and getting discharged for mental health reasons.  He stated that he was unable to tolerate the CPAP machine because he was stabbed in the neck in service, and he can no longer stand to have anything over his face.  He further stated that he was instructed not to use his CPAP machine until he was treated for PTSD.

The Veteran underwent a VA examination in December 2015.  The examiner diagnosed the Veteran with obstructive sleep apnea resulting in persistent daytime hypersomnolence.  The examiner opined that it was less likely than not that the Veteran's sleep apnea was aggravated by any mental health disability.  The Board notes that this opinion is not relevant, as the Veteran does not have a service-connected mental health disability.

At his March 2016 hearing before the Board, the Veteran reported that he had always had trouble snoring and stoppages in breathing, including in service.  Additionally, he reported problems with sleepwalking.

As an initial matter, the Board notes that the Veteran's reports of sleepwalking, talking and screaming in his sleep, and having severe nightmares have been addressed in his claim for an acquired psychiatric disorder.  The Veteran has given no explanation and there is no evidence otherwise in the record connecting these symptoms to obstructive sleep apnea, a respiratory condition.

The Board finds that the evidence weighs against a finding of an in-service event, injury, or disease which could be related to the Veteran's current sleep apnea.  The Board recognizes that the Veteran has stated that he suffered snoring and stoppages of breathing in service.  He further stated that his sleep difficulties began after a fellow soldier attempted to stab him in his sleep with a bayonet.  The Board does not find either of these reports credible.  Furthermore, the Board notes that while a fellow soldier has given statements supporting the Veteran's other claims, that soldier has not stated anything regarding the Veteran's account that his snoring habits were widely known throughout his unit.  For these reasons, the Board finds that the evidence weighs against a finding of an in-service event, injury, or disease which could be related to the Veteran's current sleep apnea, and service connection is therefore denied.

The Board notes that a VA examiner has offered an opinion on the now-moot issue of service connection secondary to an acquired psychiatric disorder.  Despite the lack of a direct service connection opinion, there is no need to remand for the VA examiner to provide such an opinion.  The question of whether there was an in-service event, injury, or disease in service underlying the Veteran's claim is a factual determination and not a medical question, and the Board's finding is determinative.  

Right Shoulder

While a bilateral shoulder disability was certified to the Board, all of the evidence, including the Veteran's own statements, indicates that the only issue on appeal is a left shoulder disability.  

The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed.  38 U.S.C.A. § 7105(d)(5).  The Board finds no allegations of errors of fact or law for appellate consideration with regard to service connection for a right shoulder disability.  Accordingly, the Board does not have jurisdiction to review this claim and it is dismissed.
 
Left Shoulder

The Veteran claims service connection for a shoulder disability.  In a January 2013 statement, he reported that his shoulder injury is related to his neck injury.

Service treatment records do not reflect any symptoms of or treatment for any disability of the shoulders, and no such abnormality was noted at the Veteran's June 1979 separation examination.

VA treatment records reflect that in October 2014 the Veteran was enrolled in an outpatient chronic pain rehabilitation program.  At that time he reported that he had always had left shoulder pain.  Flexion of the left shoulder was limited to 101 degrees.  Extension of the left shoulder was limited to 50 degrees.  Abduction of the left shoulder was limited to 90 degrees.  Range of motion of the right shoulder was within normal limits.

In a November 2014 statement, the Veteran reported that his left shoulder pain had been diagnosed as rucksack syndrome due to marching with a full rucksack in service.  He reported limited use of his left arm.

At his November 2015 RO hearing, the Veteran stated that he injured his left shoulder in a helicopter hard landing in Alaska while in service.  He further stated that when he first began treatment for his back and shoulder, he was told that they could treat his lower back or shoulder, but not both, so he chose his back.  He reported that his recent x-ray showed a torn rotator cuff.

The Veteran underwent a VA examination in December 2015.  The examiner diagnosed rotator cuff tendonitis of the left shoulder.  The examiner opined that it was less likely than not that the Veteran's tendonitis was caused by carrying a rucksack in service.  This opinion was based on the rationale that there is no evidence in medical literature, consensus in the medical community, or evidence in this specific case supporting a causal or aggravation relationship between carrying a backpack and the Veteran's disability.  Additionally, there is no evidence of continuity from service.

At his March 2016 hearing before the Board, the Veteran again stated that he had hurt his left shoulder in a hard helicopter landing while serving in Alaska.  
The Board finds that the evidence weighs against a finding that a left shoulder disability is related to service or to a service-connected disability.  The VA examiner's opinion is highly probative, in that it explains the current medical consensus that carrying a rucksack in service is not a likely cause of rotator cuff tendonitis arising decades later.  Furthermore, the Board does not find probative the Veteran's statement that his shoulder disability is related to his degenerative arthritis of the cervical spine.  The Veteran has neither explained the mechanism by which cervical spine arthritis could cause or aggravate rotator cuff tendonitis nor provided any medical evidence supporting such a relationship.  For these reasons, the Board finds that the evidence weighs against a finding that a left shoulder disability is related to service or to a service-connected disability, and service connection is therefore denied.

TBI

The Veteran claims service connection for TBI residuals, to include headaches.  Specifically, in a January 2013 statement the Veteran reported suffering a severe concussion in 1979.

Service treatment records do not reflect any symptoms of or treatment for any TBI, and no related abnormality was noted at the Veteran's June 1979 separation examination.

VA treatment records reflect that an April 2014 CT scan of the head showed no acute intracranial process.  The Veteran reported headaches in June 2014, though his physician believed that they were related to his neck pain.

In a September 2014 statement, the Veteran reported suffering a concussion in Georgia form multiple artillery simulators thrown at his position with gas while he was sleeping.  In a second statement, he elaborated, explaining that in April 1979, he was asleep under a jeep while on maneuvers.  The opposing force attacked his position with artillery simulators.  The Veteran was knocked out and hit his head, suffering a concussion.  

In a November 2014 statement, the Veteran reported having been involved in an auto accident prior to service.  He then stated that since his 1979 head injury he has suffered dizziness, headaches, disorientation, and difficulty with comprehension.

VA treatment records reflect that in December 2014 the Veteran reported dizziness to his ophthalmologist, who found no ocular etiology.

The Veteran underwent a VA examination for headaches in January 2015.  He reported pain in the right occipital area since service, associated with daily bilateral frontal headaches.  The examiner found that his symptoms were not characteristic of migraine headaches, and he was diagnosed with tension headaches.  The examiner opined that it was less likely than not that his headaches were related to service.  This opinion was based on the rationale that the only notes of headaches in service treatment records were related to acute prostatitis and fever, and there was no further documentation of headaches until recent VA treatment. 

VA treatment records reflect that in May 2015 his ophthalmologist found no vestibulopathy evident to explain his dizziness.

At his March 2016 hearing before the Board the Veteran reported ear problems, earaches, and constant headaches due to his TBI.  He stated that all of these started after the hard landing in Alaska.

VA treatment records reflect that in an April 2016 communication to his neurologist, his audiologist stated that the Veteran had normal peripheral and central horizontal semi-circular canal vestibular function bilaterally.

The Board finds that the evidence weighs against a finding of TBI residuals related to service.  Specifically, the Board finds no credible evidence of any in-service TBI, nor is there any other indication that the Veteran's current symptoms are related to service.  The Veteran's service treatment records show no indication of any head injury in service, and the Board finds this absence more probative than the Veteran's own accounts for credibility reasons discussed above.  Furthermore, the Board finds probative the VA examiner's explanation of why the Veteran's current tension headaches are unrelated to the headaches referred to in his service treatment records.  For these reasons, the Board finds that the evidence weighs against a finding of TBI residuals related to service, and service connection is therefore denied.

IBS and GERD 

The Veteran claims service connection for IBS and for an esophageal disability, to include GERD.  

Service treatment records include a pre-service record of treatment for gastrointestinal issues.  An April 1977 letter indicated that he was hospitalized for a week in January and February of 1975 and diagnosed with lactase deficiency and a spastic and irritable colon.  In June 1975, his gastroenterologist diagnosed bowel irritability with associated severe lactose intolerance and lactase deficiency.  No abnormalities were noted on his August 1976 induction examination.  In service, the Veteran was treated for colitis in March 1977.  In April 1977 his prior history was noted and he was placed on a lactose-free diet.  He was diagnosed with a spastic colon and lactose intolerance.  In June 1977 he was diagnosed with irritable colon syndrome.  Subsequently, the Veteran was treated for blood in his stool and abdominal pain in July 1978.  He was diagnosed with spastic colitis.  He was then treated for stomach problems in August 1978 and diagnosed with possible diverticulosis or ulcerative colitis.  In October 1978 he reported abdominal cramping and rectal bleeding followed by constipation.  He was noted to have a history of alternating constipation and diarrhea.  No abnormalities, however, were noted at his June 1979 separation examination.

VA treatment records reflect that in July 2011 the Veteran was diagnosed with longstanding GERD.  His physician noted that his GERD medication caused constipation and diarrhea.  Because diarrhea was accompanied by occasional rectal bleeding, the physician referred for a colonoscopy to check for colitis.  At an August 2011 gastroenterology consultation he was diagnosed with GERD, IBS, lactose intolerance, and anxiety.  A December 2011 colonoscopy found a normal colon.  Random biopsies were normal.  In December 2012, the Veteran again reported occasional rectal bleeding.

In a January 2013 statement the Veteran reported contracting dysentery while on maneuvers around the time of his 1979 concussion.  He stated that he started passing blood, was hospitalized, and given a colonoscopy.  He reported that to this day he suffers IBS and continues to pass blood rectally.

VA treatment records reflect that in July 2013 the Veteran reported hoarseness.  His physician noted his history of severe reflux, and that the Veteran continued to smoke and drink in noncompliance with recommended behavioral modifications.  

In a November 2013 statement, the Veteran's girlfriend stated that he bleeds into the toilet when defecating, and that he has frequent stomach issues, including vomiting in his sleep.

The Veteran underwent a VA examination in June 2014.  He reported dysentery while stationed in Florida for training in 1978.  He further stated that he started vomiting in his sleep from reflux due to a colonoscopy in Georgia.  He reported that he currently continues to have diarrhea and constipation with intermittent blood in his stools.  The examiner opined that the Veteran's GERD and IBS, which clearly and unmistakable existed prior to service, were not aggravated by service.  This opinion was based on a rationale of a normal upper gastrointestinal noted in service treatment records dated September 1978 and in VA treatment records dated December 2011.

In a November 2014 statement, the Veteran reported drinking water from a contaminated water tanker in 1978 or 1979, causing him to contract dysentery that led to IBS.  He said since that time he has suffered bloating, cramps, chronic diarrhea, and fluctuating weight.

VA treatment records reflect that in April 2015 the Veteran underwent an upper endoscopy and colonoscopy for reported rectal bleeding and severe reflux.  The procedure revealed esophagitis, an abnormal structure, antral gastritis with erosions/ulcerations, diverticulosis, and internal and external hemorrhoids with inflammation.  He was referred to private specialists to diagnose the abnormal structure.

Private treatment records reflect that in June 2015 the Veteran underwent an esophagogastroduodenoscopy.  The procedure revealed the prior diagnosed abnormal structure to be a 2-centimeter submucosal mass which was diagnosed as an esophageal duplication cyst, which the Veteran's physician stated was not likely related to his GERD symptoms.  The Veteran declined the physician's medication recommendations.

The Veteran underwent a VA examination for disabilities of the rectum and anus in September 2015.  The examiner diagnosed rectal bleeding due to large external hemorrhoids.  The examiner opined that such hemorrhoids arose in service, and the Veteran was subsequently granted service connection for hemorrhoids.

At his November 2015 RO hearing, the Veteran reported that his dysentery began after drinking water from a water tanker in service.  He stated that after all the guys were drinking from the tanker, someone showed up telling them all to stop drinking because it was contaminated.  After he developed prostatitis, he was told that he would suffer it and the digestive problems for the rest of his life.

At his March 2016 hearing before the Board, the Veteran stated that he suffered IBS prior to service, but that it intensified after he drank the contaminated water at Eglin Air Force Base.

Because IBS was not noted in the Veteran's August 1976 induction examination, the Veteran is presumed sound on entry absent clear and unmistakable evidence of a prior disability and no aggravation.  The Board, however, finds clear and unmistakable evidence that the Veteran's IBS pre-existed service and was not aggravated by service.  The record evidence establishes that the Veteran had been hospitalized for a week and treated for IBS in early 1975, prior to his induction in September 1976.  The Veteran's reports that his IBS began when he drank contaminated water at Eglin Air Force Base are unreliable both because his service personnel records do not indicate service at Eglin Air Force Base and because such statements clearly contradict the records establishing his hospitalization prior to service.  As to aggravation, the Veteran's disability prior to service required hospitalization for a week, and there is no indication in the record that the disability ever reached such severity again.  The symptoms in service reflect at worst temporary, intermittent flare-ups of the underlying condition.  The Board notes that prior to service and as the record indicates unbeknownst to the mess hall, the Veteran had been diagnosed with severe lactose intolerance.  Symptoms attributable to the Veteran's failure to follow his prescribed dietary restrictions cannot alone be considered a worsening of the underlying disease.  Furthermore, the Board notes that to the extent that the Veteran's IBS results in rectal bleeding, that symptom is already service-connected as a manifestation of the Veteran's hemorrhoids.  For these reasons, the Board finds clear and unmistakable evidence that the Veteran's IBS pre-existed service and was not aggravated by service, and service connection is therefore denied.

The Board further finds that the evidence weighs against a finding that GERD is related to service.  There is no indication in the record that the Veteran's GERD symptoms began during or prior to service and as IBS is not service-connected, service connection on a secondary basis is not available.  To the extent that GERD represents an aggravation of IBS, there is no evidence that such aggravation began during or prior to service, as all evidence of reflux is from decades later.  Furthermore, as to the Veteran's contentions that his GERD is the result of drinking contaminated water at Eglin Air Force Base, the Veteran has not explained the basis for such a relationship, there is no medical evidence in the record to support it, and there is no indication apart from the Veteran's statements that he ever served at Eglin Air Force Base.  For these reasons, the Board finds that the evidence weighs against a finding that GERD is related to service, and service connection is therefore denied.

Heart

The Veteran claims service connection for a heart disability.

For certain diseases with a relationship to herbicide exposure, such as ischemic heart disease, a presumption of service connection arises if the disease manifests to a degree of 10 percent or more following service in the Republic of Vietnam any time during the period from January 9, 1962 to May 7, 1975.  38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309(e).  Service in the Republic of Vietnam includes service in the brown water offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam.  38 C.F.R. § 3.313.  Absent a presumption based on service in Vietnam, a veteran may establish service connection on a direct basis if the evidence shows that current ischemic heart disease was, in fact, caused by exposure to Agent Orange or some other incident of service.  See Combee v. Brown, F.3d at 1039 (Fed. Cir. 1994).

Service treatment records do not reflect any symptoms of or treatment for any disability of the heart, and no such abnormality was noted at the Veteran's June 1979 separation examination.

VA treatment records reflect that in March 1994 the Veteran reported intermittent tightness and pain in his chest.  He was initially diagnosed with angina.  He described tightness with onset three weeks prior, elicited by activity, radiating to both arms, and relieved by lying down to rest.  He was noted to have familial risk factors for coronary artery disease.  X-rays showed no congestive heart failure or infiltrate.  After a normal echocardiogram and normal cardiac catheterization, the Veteran was diagnosed with atypical chest pain, discharged without medication, and instructed to follow-up.  He sought further treatment in September 1994, at which time he reported that he was told his pain was stress-related.  

VA treatment records further reflect that in May 2011 the Veteran reported intermittent substernal chest tightness, shortness of breath, and a feeling of impending doom.  A private cardiac workup one year prior was negative.  He was diagnosed with chest discomfort likely from anxiety attacks.  In April 2012 the Veteran reported nonradiating continuous chest pain for the past 12 hours, with chest pressure episodic for the prior 8 months and increasing in frequency.  Echocardiogram was normal.  It was unclear whether the atypical chest pain was related to anxiety, GERD, or tobacco use.  A November 2014 chest x-ray showed no acute cardiopulmonary disease.

In a November 2014 statement, the Veteran reported pains in chest and shortness of breath.  He stated that he had been hospitalized for five days in intensive care after suffering a heart attack.

VA treatment records reflect that at a November 2014 cardiology consultation, the Veteran reported a history of chest pain.  He was diagnosed with labile hypertension but refused medication.  In January 2015 the Veteran reported chest pain.  An echocardiogram was within normal limits. In October 2015, his cardiac surgeon stated that if the Veteran was exposed to Agent Orange, such could be a cause for his papillary fibroelastoma.  

At his November 2015 RO hearing, the Veteran reported he had been diagnosed with something on his aorta valve and that his doctor told him that the only way one can get this defect is through exposure to Agent Orange.

At his March 2016 hearing before the Board, the Veteran reported that he had been diagnosed with a papillary fibroelastoma.  He stated that his doctors told him that there had only been five cases at the VA medical center over the past 20 years, and all had been related to exposure to Agent Orange.  

VA treatment records reflect that in April 2016 the Veteran was seen for a follow-up for his aortic valve fibroelastoma.  His heart was otherwise normal, he had no neurological symptoms, and his cardiologist did not believe that his chest pain was related to the condition.  The cardiologist noted that the condition could become critical if the Veteran developed neurological symptoms, and that most of the literature suggests excision.  The Veteran had postponed surgery several times due to concerns about recovery periods.

The Board finds that the evidence weighs against a finding that the Veteran was exposed to herbicides or that his heart disability is otherwise related to service.  As an initial matter, there is no evidence in the record relating any heart disability to service other than the Veteran's statements that he was exposed to herbicides.  The Board notes that the Veteran's cardiologist stated that his papillary fibroelastoma could have been caused by exposure to Agent Orange.  Even if such a relationship between exposure to herbicides and papillary fibroelastoma could be established, the Veteran has not credibly established exposure to herbicides.  Specifically, the Veteran did not serve in Vietnam or indeed anywhere outside the United States.  His claimed exposure occurred at Eglin Air Force Base, but his service personnel records do not indicate that he ever served there or attended Ranger school.  As discussed elsewhere in this decision, the Board does not find the Veteran's statements reliable, particularly when they conflict with the conspicuous absence of documentation.  For these reasons, the Board finds that the evidence weighs against a finding that the Veteran was exposed to herbicides or that his heart disability is otherwise related to service.  Service connection is therefore denied.

Lung Nodule

The Veteran claims service connection for a lung nodule.  Specifically, in his January 2013 claim, he claimed a spot on his left lung.

There is no specific statutory guidance with regard to asbestos-related claims, nor has the Secretary promulgated any regulations in regard to such claims.  However, VA has issued a circular on asbestos-related diseases.  DVB Circular 21- 88-8, Asbestos-Related Diseases (May 11, 1988) (DVB Circular) provides guidelines for considering compensation claims based on exposure to asbestos.  The DVB circular was subsumed verbatim as § 7.21 of Adjudication Procedure Manual, M21-1, Part VI. (This has now been reclassified in a revision to the Manual at M21-1, IV.ii.2.C).  See also VAOPGCPREC 4-00. 

The guidelines provide that the latency period for asbestos-related diseases varies from 10-45 years or more between first exposure and development of disease.  It is noted that an asbestos-related disease can develop from brief exposure to asbestos or as a bystander.  VA must analyze an appellant's claim to entitlement to service connection for asbestosis or asbestos-related disabilities under the administrative protocols under these guidelines.  Ennis v. Brown, 4 Vet. App, 523, 527 (1993); McGinty v. Brown, 4 Vet. App. 428, 432 (1993).  

Service treatment records do not reflect any symptoms of or treatment for any disability of the lungs beyond acute upper respiratory infections, and no such abnormality was noted at the Veteran's June 1979 separation examination.

VA treatment records reflect that in December 2012 the Veteran requested that his lung nodule be checked.  His physician advised him to quit smoking tobacco and scheduled a January 2013 CT scan, which revealed a 3-4 millimeter nodule in the base of the right lung with no significant changes in the past year.  There were no new nodules.  Similarly, a March 2014 CT scan showed a stable 4 millimeter nodule in the right lung base for over two years, likely benign.

In a November 2014 statement, the Veteran stated that this disability was due to exposure to asbestos, tear gas, and smoke grenades.  He stated that in service he was exposed to tear gas in training five to ten times per month over a period of two years, including four trips to the gas house.  He also reported firing a live missile in 1979, receiving a face full of smoke.  In a December 2014 statement, he stated that he was exposed to asbestos at Fort Bragg, Fort Bliss, and Fort Stewart.

VA treatment records reflect that in May 2015 the Veteran underwent another CT scan, which revealed a stable 4 millimeter noncalcified pulmonary nodule, determined to be benign.

At his March 2016 hearing before the Board, the Veteran stated that his lung nodule was the result of exposure to asbestos.

The Board finds that the evidence is in equipoise as to whether in-service asbestos exposure caused the Veteran's lung nodule.  Specifically, the Board notes that the Veteran's specialty, short-range missile crewman, is analogous to missile technician, which is currently considered by VA to indicate probable exposure to asbestos.  See M21-1, IV.ii.1.I.3.c.  Furthermore, benign tumors of the lung are considered diseases with known relationships to asbestos exposure.  See M21-1, IV.ii.2.C.2.b.  For these reasons, the Board finds that the evidence is in equipoise as to whether in-service asbestos exposure caused the Veteran's lung nodule and service connection is therefore granted.

Voice Box

The Veteran claims service connection for damage to his voice box.

Service treatment records do not reflect any symptoms of or treatment for any disability of the voice box, and no such abnormality was noted at the Veteran's June 1979 separation examination.

VA treatment records reflect that in November 1999 the Veteran was referred to an otolaryngologist for evaluation of a vocal fold lesion.  The Veteran developed severe ear pain and was found to have a questionable laryngeal mass.  He underwent a suspension microdirect laryngoscopy with biopsy and esophagoscapy, which revealed leukoplakia of the true vocal folds bilaterally.  In December 1999 he was diagnosed with hyperkeratosis of the posterior right true vocal folds.  He continued follow-up treatment in the subsequent years.

VA treatment records reflect that in March 2012 the Veteran reported having lost his voice.  He was diagnosed with laryngitis.  His physician noted both his history of vocal cord thickening and his current treatment for acute bronchitis.  In July 2013 he reported hoarseness.  His physician noted his history of severe reflux, and that the Veteran continued to smoke and drink in noncompliance with recommended behavioral modifications.  The physician attributed the hoarseness to an episode of alcohol consumption.  The Veteran consulted a speech pathologist in March 2014 in relation to his mouth lesions, but denied changes to voice or voice complaints.  The pathologist diagnosed mild dysphonia characterized by hoarseness consistent with significant history of tobacco use.  In June 2014 the Veteran reported ear pain and was diagnosed with an irregular left true vocal cord.  In October 2014, the Veteran reported that his dysphagia worsens with GERD flare ups, about once weekly.  On examination, he was diagnosed with irregular left true vocal cord and interarytenoid pachydermia likely secondary to uncontrolled GERD and chronic smoking.   

The Board finds that the evidence weighs against a finding that the Veteran's voice box disability is related to service.  The evidence establishes disabilities which the Veteran's otolaryngologist attributed to GERD and chronic tobacco use.  Service connection is not available for disabilities caused by tobacco use, and secondary service connection is not available as the Board herein denies service connection for GERD.  There is no evidence in the record of direct service connection not based on tobacco use.  For these reasons, the Board finds that the evidence weighs against a finding that the Veteran's voice box disability is related to service, and service connection is therefore denied.

Eyes

The Veteran claims service connection for paralysis in both eyes.

Service treatment records do not reflect any symptoms of or treatment for any disability of the eyes, and no such abnormality was noted at the Veteran's June 1979 separation examination.

VA treatment records reflect that at a December 2013 appointment the Veteran reported no significant ophthalmological history.  He was diagnosed with refractive error and early cataracts, not visually significant.

In a November 2014 statement, the Veteran explained that his eye disability was the result of his TBI.

VA treatment records reflect that in December 2014, the Veteran reported dizziness but denied diplopia.  His ophthalmologist found that the dizziness had no ocular etiology.  In February 2015, the Veteran was referred to an ophthalmological surgeon for residuals of his reported TBI.  He reported longstanding constant eye strain, an effort to see, and a rare, brief shadow on the left side of his vision occurring about once per month.  The surgeon found that eyes were healthy, and diagnosed left hyperphoria.  In a March 2015 note, the surgeon stated that hyperphoria was possibly due to skew or longstanding traumatic or congenital misalignment that has decompensated.  In May 2015 his ophthalmologist found no vestibulopathy evident to explain his dizziness.

At his March 2016 hearing before the Board, the Veteran reported that he got hit in the eye during basic training.  In a statement submitted subsequent to the hearing, the Veteran clarified that he had been treated immediately after separation from service for the inability to close one eye without closing the other.  He stated that he was sent for an outside consultation for suspected multiple scleroses because of this symptom.

The Board finds that the evidence weighs against a finding of an in-service event, injury, or disease that could be related to an eye disability.  The only evidence of such an in-service event is the Veteran's statements that he got hit in the eye and that he suffered a TBI.  The Board does not find these statements credible.  The statement that the Veteran was hit in the eye is unsupported by service treatment records, and no supporting details have been offered.  The Veteran did not describe how he got hit in the eye, if he was hit in both eyes, or if being hit in one eye caused a bilateral eye disability.  As discussed above, the Board likewise does not find credible the Veteran's statements regarding his claimed TBI.  For these reasons, the Board finds that the evidence weighs against a finding of an in-service event, injury, or disease that could be related to an eye disability, and service connection is therefore denied.

Mouth

The Veteran claims service connection for lumps in the mouth.

Service treatment records do not reflect any symptoms of or treatment for any disability of the mouth, and no such abnormality was noted at the Veteran's June 1979 separation examination.

VA treatment records reflect that in May 2013 the Veteran asked to be checked for throat cancer.  On examination, his oral cavity was moist and no lesions were noted.  In February 2014, he reported lumps inside his mouth.  His physician found a 5-6 millimeter soft nontender circular mass on the right lower vestibule of the mouth.  He was referred to an otolaryngologist, to whom the Veteran in March 2014 reported intermittent lower lip lesions for the past 10 years.  He reported a firm nontender lesion that gets bigger then goes away.  He was diagnosed with fibrotic lip lesions and instructed to return if they failed to resolve.  He was also diagnosed with a left commissure leukoplakia and recommended a biopsy, which he declined.  Finally, he was advised to quit tobacco.

In a November 2014 statement, the Veteran stated that this disability was due to exposure to asbestos, tear gas, and smoke grenades.  He stated that in service he was exposed to tear gas in training five to ten times per month over a period of two years, including four trips to the gas house.  He also reported firing a live missile in 1979, receiving a face full of smoke.  In a December 2014 statement, he stated that he was exposed to asbestos at Fort Bragg, Fort Bliss, and Fort Stewart.

At his March 2016 hearing before the Board, the Veteran stated that his mouth disability arose when he was covered with fire ants while in service.  He further stated that he was told that they were related to exposure to Agent Orange.  The Veteran stated his belief that he was exposed to Agent Orange after drinking from a stream near Eglin Air Force Base in 1978.  A fellow soldier testified that there was a water shortage at Eglin Air Force Base and that water purification tablets were distributed.

The Board finds that the evidence weighs against a finding that the Veteran's mouth disability is not associated with tobacco use.  His physician diagnosed a leukoplakia and advised him to quit smoking tobacco.  An oral leukoplakia is by definition mainly associated with tobacco use.  See Dorland's Illustrated Medical Dictionary 1030 (32nd ed. 2012).  The Board recognizes that the Veteran has put forth other theories, including contaminated water, Agent Orange, and a fire ant attack, but none of these theories are supported by any medical expertise.  For these reasons, the Board finds that the evidence weighs against a finding that the Veteran's mouth disability is not associated with tobacco use, and service connection must therefore be denied.


ORDER

An initial evaluation of 20 percent, but not in excess thereof, for degenerative arthritis of the cervical spine is granted, subject to the laws and regulations governing the payment of VA benefits.

An initial compensable evaluation for bilateral hearing loss is denied.

Service connection for an acquired psychiatric disability, to include PTSD, depressive disorder, and sleep disorder, is denied.

Service connection for a skin rash, claimed as severe bites, is denied.

Service connection for prostatitis is denied.

Service connection for sleep apnea is denied.

The appeal on the issue of entitlement to service connection for a right shoulder disability is dismissed.

Service connection for a left shoulder disability is denied.

Service connection for residuals of a TBI, claimed as a concussion, to include headaches, is denied.

Service connection for IBS is denied.

Service connection for an esophageal disability, to include GERD, is denied.

Service connection for a heart disability is denied.

Service connection for a benign lung nodule is granted.

Service connection for damage to the voice box is denied.

Service connection for lumps in the mouth is denied.


REMAND

The Veteran claims disability for nerve damage to the bilateral upper extremities caused by exposure to cold in the hands.

Service treatment records do not reflect any symptoms of or treatment for any disability of the hands, and no such abnormality was noted at the Veteran's June 1979 separation examination.

VA treatment records reflect that in December 2012 the Veteran reported paresthesia in his hands.  His physician found nothing abnormal on examination and referred him for x-rays and neurological testing.

In a January 2013 statement, the Veteran reported that he had current numbness in his arms and hands due to freezing both hands while on active duty in Alaska.  He reported that the condition had steadily worsened since service.

VA treatment records reflect that in February 2013 the Veteran reported to his neurologist that he suffered an episode of "flash cold" exposure while in service.  X-rays of the hands revealed no significant or acute bony abnormality.  Nerve conduction tests were consistent with bilateral moderate carpal tunnel syndrome.  In April 2013 his orthopedist diagnosed numbness of the bilateral upper extremities, questionably related to either cold injury or mild compressive neuropathy.  In June 2013 the Veteran had a left carpal tunnel release procedure performed, with the same procedure performed on the right in November 2013.

In a November 2013 statement, the Veteran's girlfriend stated that he has constant pain in his hands and often loses his grip and drops things, no matter how light.

VA treatment records reflect that in September 2014 the Veteran reported continuous pain and numbness in his hands which had progressively worsened over the years since being exposed to severe cold weather in Alaska.  His neurologist diagnosed pain of undetermined origin.

In a September 2014 statement, the Veteran reported that he got caught in a rotor wash in Alaska which resulted in a flash freeze of both hands.

VA treatment records reflect that at a December 2014 neurology consultation, the Veteran reported hand and finger pain due to his in-service hand freeze.  Specifically, he reported right hand pain travelling from wrist up to forearm, worse with any type of movement.  His neurologist found that the symptoms were not likely cervical radiculopathy based on imaging review and diagnosed tendonitis versus carpal tunnel syndrome.  At a January 2015 follow-up with his orthopedist for his prior carpal tunnel release procedures, the orthopedist questioned whether remaining symptoms were due to fibromyalgia. 

At his November 2015 RO hearing, the Veteran reported that when serving in Alaska he put his hands into the airstream of a helicopter's rotors, which caused excruciating cold.  He further stated that his gastroenterologist recognized his white scales on his hands as a residual of frostbite.  

At his March 2016 hearing before the Board, the Veteran reported nerve damage in his hands due to in-service frostbite.

VA treatment records reflect that in April 2016, the Veteran was treated by a neurologist.  In a May 2016 addendum, the neurologist opined that the Veteran's neuropathic symptoms in his upper extremities can be related both to his reported exposure to frostbite and his cervical degenerative disease.

The Board finds that the Veteran's statements regarding frostbite in service are not credible because they are not supported by his service treatment records.  Nevertheless, the Board finds that a VA examination is necessary to address the conflicting medical evidence in the record as to whether his hand numbness is related to his degenerative arthritis of the cervical spine.  Specifically, the December 2014 VA neurologist discounted the possibility of radiculopathy based on a review of imaging.  In contrast, the May 2016 opinion of another VA neurologist stated that the Veteran's numbness "can" be related to his cervical spine disability.  Because neither the nature nor the likelihood of such relationship was explained in the May 2016 opinion, it is not adequate to support an award of service connection.  Because the opinion indicates the possibility of such a relationship, however, remand is necessary for a VA examination.

Accordingly, the case is REMANDED for the following action:

(Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c).  Expedited handling is requested.)

1.  Obtain and associate with the claims file any additional medical evidence that may have come into existence but has not been associated with the record.  

2.  Schedule the Veteran for a VA examination for his hand numbness.  The claims file must be reviewed by the examiner.  

Following a review of the claims file and any clinical examination results, the examiner should diagnose any neurological or radiculopathy disabilities of the upper extremities suffered by the Veteran.  For each disability diagnosed, the examiner should offer an opinion as to whether it is at least as likely as not (i.e. 50 percent probability or more) that such disability is related to the Veteran's degenerative arthritis of the cervical spine.     

All opinions are to be accompanied by a rationale consistent with the evidence of record.  A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested.  If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so.  In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question.

3.  After completing the above, and any other development deemed necessary, readjudicate the appeal.  If the benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board.

The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board 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).



______________________________________________
JONATHAN B. KRAMER
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs