Citation Nr: 1753312 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 13-28 677A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for prostatitis. 3. Entitlement to service connection for a low back disability, to include degenerative disc disease and arthritis. 4. Entitlement to service connection for eczematoid dermatitis and xerosis. 5. Entitlement to service connection for a right hip disability. 6. Whether new and material evidence has been received to reopen a previously denied claim of entitlement to service connection for a melanoma. 7. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD E. Alexander Neff, Associate Counsel INTRODUCTION The Veteran served on active duty in the Army from December 1968 to September 1971, including service in the Republic of Vietnam from April 1970 to March 1971. His awards and decorations included: a Vietnam Service Medal with a Bronze Star; a Republic of Vietnam Campaign Medal; and an Armed Forced Expeditionary Medal (Korea). The Board sincerely thanks him for his service to his country. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2011 and December 2011 rating decisions by the Waco, Texas Department of Veterans Affairs (VA) Regional Office (RO). The June 2011 rating decision denied service connection for low back, right hip, prostatitis, and skin disability. The June 2011 rating decision also denied reopening his claim for entitlement to service connection for melanoma secondary to herbicide agent exposure. The December 2011 rating decision denied bilateral hearing loss. In the October 2013 VA Form 9, the Veteran indicated that he wanted a Travel Board hearing. In March 2015, the Veteran requested a Video Conference hearing in lieu of a Travel Board hearing. In an October 2015 correspondence the Veteran withdrew his request for a Board hearing. The issues of prostatitis, low back disability, eczematoid dermatitis and xerosis, and melanoma are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The evidence is in equipoise as to whether the Veteran's bilateral hearing loss is related to service. 2. In December 2013, prior to the promulgation of a decision in the appeal, the RO received notification from the Veteran that he did not intend to pursue his service connection claim for right hip. 3. Prior to September 30, 2011, the Veteran's PTSD did not manifest as occupational and social impairment with reduced reliability and productivity or even more severe symptoms. 4. From September 30, 2011, the Veteran's PTSD was manifested by total occupational and social impairment. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran's favor, the criteria for service connection for bilateral hearing loss have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2017). 2. The criteria for withdrawal of an appeal by the Veteran have been met with respect to the claim for service connection for a right hip disorder. 38 U.S.C.A. § 7105 (b)(2), (d)(5); 38 C.F.R. § 20.204. 3. Prior to September 30, 2011, the criteria for a disability rating in excess of 30 percent for service-connected PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, and 4.130, Diagnostic Code 9411. 4. From September 30, 2011, the criteria for a 100 percent schedular rating for PTSD are met. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, and 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Legal Criteria The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim being decided. II. Service Connection: Bilateral Hearing Loss Establishing service connection generally requires medical or, in certain circumstances, lay evidence of: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet.App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A veteran is entitled to service connection for a disability resulting from a disease or injury incurred or aggravated during active service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection also is permissible for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). In each case where a veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of such veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303 (b). The theory of continuity of symptomatology under 38 C.F.R. § 3.303 (b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Sensorineural hearing loss, a chronic disease, may be presumed to have been incurred during service if it becomes disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101 , 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The determination of whether a veteran has a service-connectable hearing loss is governed by 38 C.F.R. § 3.385, which states that hearing loss will be considered to be a "disability" when the threshold level in any of the frequencies 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; or the thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores are less than 94 percent. 38 C.F.R. § 3.385. The absence of in service evidence of hearing loss, including one meeting the requirements of 38 C.F.R. § 3.385 , is not always fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The Hensley case also provides that 38 C.F.R. § 3.385 does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service if there is sufficient evidence to demonstrate a relationship between a Veteran's in-service exposure to loud noise and his current disability. When there is an approximate balance of positive and negative evidence regarding any issue material to a determination, the benefit of the doubt is afforded to the claimant. 38 U.S.C.A. § 5107(b). The February 2011 examiner found that the Veteran's tinnitus was as likely as not caused by a result of noise exposure in service. The examiner also found that the Veteran's tinnitus was as likely as not symptom associated with the Veteran's hearing loss. The Board notes that the August 2011 opinion provider, upon review of the evidence, opined that the Veteran's current hearing loss was not related to service. The Veteran has complained of hearing loss and tinnitus since leaving Vietnam, and finds that he is competent to report lay symptoms of hearing loss. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Thus, resolving all reasonable doubt in the Veteran's favor, the Board finds that the evidence is in at least equipoise that the Veteran's bilateral hearing loss is related to service. As such, service connection for bilateral hearing loss is warranted. III. Service Connection: Right Hip 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. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by an appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran in a December 2013 correspondence advised that he did not intend to pursue a claim for right hip. He advised that he intended his December 2011 notice of disagreement be for a left hip disability, and that his statement that he sought to appeal the decision for right hip was in error. The Veteran was advised of the denial of his claim for left hip on August 3, 2010. He did not file a timely notice of disagreement for this claim within one year, and as such it became final. As such, the Board has no jurisdiction over a claim for left hip in lieu of a claim for right hip. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal for a right hip disability and it is dismissed. IV. Increased Rating: PTSD A. Higher Ratings The present appeal involves the Veteran's claim that the severity of his service-connected PTSD warrants a higher disability rating. Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from a disability. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Where, as here, the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Moreover, adjudication of a claim for a higher initial disability rating should include specific consideration of whether staged ratings are appropriate. See Fenderson v. West, 12 Vet. App, 119 (1999). The Global Assessment of Functioning (GAF) Scale is used to report the clinician's judgment of the individual's overall level of functioning. The GAF Scale is to be rated with respect only to psychological, social and occupational functioning. See American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders 44 (4th ed. 1994). The Board notes that the GAF scale was removed from the more recent DSM-5 for several reasons, including its conceptual lack of clarity, and questionable psychometrics in routine practice. See DSM-5, Introduction, The Multiaxial System (2013). GAF scores range from 1-100 with the higher numbers representing higher levels of functioning. A GAF score of 41 to 50 is defined as denoting serious symptoms or any serious impairment in social, occupational, or school functioning. GAF scores from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupation, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupation, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well with some meaningful relationships. The Board notes that it has reviewed all of the evidence in the record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims being decided. B. Rating Criteria PTSD is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent evaluation is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms in the General Rating Formula for Mental Disorders is not intended to constitute an exhaustive list, but rather provides examples of the type and degree of symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Furthermore, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. C. Factual Background In January 2011, the Veteran filed to reopen his claim for entitlement to service connection for PTSD. In June 2011, the claim was granted and a 30 percent rating was assigned, effective January 28, 2011. In the February 2011 VA examination, the Veteran reported that he would frequently get angry and would "just go off." Thus, as a precaution, he would try to keep to himself. He would frequently isolate himself. He avoided news related to war as it would cause recollections of service. He could not sleep in the same bed as his wife, because she reported that he "beat her up" in the middle of the night due to his dreams. He found it difficult to concentrate on anything for very long. He was hypervigilant, did not sit with his back to the door, and did not like to have others behind him. He had been married for 32 years and had three children. He reported a "great" and supportive relationship with his wife. He had a great relationship with his children, and okay relationships with his siblings. He had no social relationships outside of his family. His reported leisure activities were: pacing the floor, watching television, and going out to his back yard. He took care of a couple of the rooms in his house, and reported that he kept them spotless. There was no history of suicide attempt. He had a past history of assaultiveness, but denied any recent fighting. He was noted to have PTSD symptoms of: persistent re-experiencing of traumatic events; persistent avoidance of stimuli associated with trauma and numbing of general responsiveness; and persistent symptoms of increased arousal. These symptoms were chronic, and their severity was noted as daily to weekly, moderate to severe, and varying in time frame. The Veteran's sleep difficulties also appeared to be attributable to his reported chronic pain symptoms. The examiner found that the Veteran had: frequent intrusive memories of his experiences in Vietnam; frequent dreams about his experiences in Vietnam that resulted in sleep difficulties; isolative behaviors and decreased socialization; hypervigilance; avoidance of media and entertainment related to war; loss of interest in previously pleasurable activities; frequent irritability. The examiner opined that the Veteran's reported irritability, anxiety, hypervigilance, concentration problems, and intrusive memories would likely lead to occasional decrease in work efficiency and/or intermittent periods of inability to perform occupational tasks if he were currently employed. The Veteran's mood was neutral with an appropriate affect. His attention was intact, and he was fully oriented. His thought process and content were unremarkable. He did not experience delusions or hallucinations. He understood the outcomes of his behavior, and understood he had a problem. He did not have: inappropriate behavior, obsessive/ritualistic behavior; panic attacks; homicidal or suicidal thoughts; episodes of violence; or problems with activities of daily living. His impulse control was fair, and he did not have problems with activities of daily living. His remote, recent, and immediate memory were grossly intact. He was given a GAF score of 60. In a September 30, 2011 report of general information, the Veteran's representative reported that the Veteran had moderate to severe memory loss and attention issues. In a January 2012 VA medical record, the Veteran reported that he was forgetful about names, dates, and topics of conversation. Over the last two years he has been forgetful, off and on, with names and dates over the last 20 years. He reported that he was able "to get by" until a few years ago. His wife reported that his long-term memory was good, and that his short-term memory was "really bad." Many times he did not remember what he is doing. She would tell him about a medical appointments, and he would repeatedly ask about same. He would forget times, dates, appointments, objects, and sometimes names of family members. His forgetfulness worsened over the last year. He experienced nightmares and insomnia. He would sleep a few hours at night, and his sleep was not refreshing. Upon examination, the Veteran was able to name objects. His was able to immediately recall 3/3 objects; however, after five minutes he could not recall any. He was able to spell "world," but his ability to spell same in reverse was impaired. He could repeat only two letters out of five. His speech was normal, and it was noted that he was apprehensive with dysphoria. The clinician found that he had a mild degree of cognitive impairment. A CT scan of his head showed generalized atrophy. His blood work was unremarkable for any reversible cause of dementia. He was diagnosed with memory loss, that was noted as probably amnestic-type, mild cognitive impairment, and early Alzheimer's dementia. In a May 2012 VA medical record, the Veteran complained of continuing: depression, anxiety, irritability, insomnia, nightmares, flashbacks, hypervigilance, hyperarousal, and avoidance. He had daily anxiety attacks. His wife reported that he was very angry and irritable, and often yelled and threw things. The Veteran denied current symptoms of euphoria, psychosis, active suicidal ideation, intent or plan, or homicidal ideation. He did report that when he was angry he wanted to "spank people." His mood was depressed, and had an affect that was appropriate to speech content and his stated mood. His thought processes were goal directed, future-oriented, and coherent. There was no evidence of delusional thinking. The Veteran denied hallucinations. There was no evidence of obsessive thinking/compulsive behavior during the interview. Regarding insight, he was noted as aware of and understood his current mental health condition. Regarding judgment, he presented with realistic choices, plans, and goals. He was given a GAF score of 60. In a July 2012 VA medical record, the Veteran's wife was present, and it was noted that she did most of the talking for the Veteran. She noted that his mood and sleep were improved, but he still had constant nightmares. The Veteran reported that he continued to have problems with depression, anxiety, irritability, insomnia, nightmares, flashbacks, hypervigilance, hyperarousal, and avoidance. He denied current symptoms of euphoria, psychosis, active suicidal ideation, intent or plan, or homicidal ideation. His mood was depressed, and he had an affect that was appropriate to speech content and his stated mood. His thought processes were goal directed, future-oriented, and coherent. There was no evidence of delusional thinking. The Veteran denied hallucinations. There was no evidence of obsessive thinking/compulsive behavior during the interview. Regarding insight, he was noted as aware of and understood his current mental health condition. Regarding judgment, he presented with realistic choices, plans, and goals. He was given a GAF score of 60. In a September 2012 VA medical record the Veteran and his wife reported that mentally he was feeling a lot better. It was reported that he currently felt the best he had felt on his current medications in a long time. He reported continuing problems with: depression, anxiety, irritability, insomnia, nightmares, flashbacks, hypervigilance, hyperarousal, and avoidance. He denied current symptoms of euphoria, psychosis, active suicidal ideation, intent or plan, or homicidal ideation. His mood was depressed, and he had an affect that was appropriate to speech content and his stated mood. His thought processes were goal directed, future-oriented, and coherent. There was no evidence of delusional thinking. The Veteran denied hallucinations. There was no evidence of obsessive thinking/compulsive behavior during the interview. Regarding insight, he was noted as aware of and understood his current mental health condition. Regarding judgment, he presented with realistic choices, plans, and goals. He was given a GAF score of 60. In a December 2012 VA medical record, the Veteran reported continued problems with: depression, anxiety, irritability, insomnia, nightmares, flashbacks, hypervigilance, hyperarousal, and avoidance. He denied current symptoms of euphoria, psychosis, active suicidal ideation, intent or plan, or homicidal ideation. He reported that he was tolerating current medications well and denied any side effects. His mood was depressed, and had an affect that was appropriate to his speech content and stated mood. His thought processes were goal directed, future-oriented, and coherent. There was no evidence of delusional thinking. The Veteran denied hallucinations. There was no evidence of obsessive thinking/compulsive behavior during the interview. Regarding insight, he was noted as aware of and understood his current mental health condition. Regarding judgment, he presented with realistic choices, plans, and goals. He was given a GAF score of 60. In an April 2013 VA examination for aid and attendance, the Veteran was noted to have a current diagnosis of dementia. He needed assistance with bathing/hygiene secondary to his pain/arthritis. His wife managed his medications and finances, and she accompanied him for all appointments. It was noted that his dementia generally limited activities. In a July 2013 VA medical record, the Veteran was noted as forgetful about names, dates, and appointments. It was noted that he may have an episode of forgetfulness in the middle of conversation; however, with things that he was interested in he remembered better. In these situations, he was able to grasp very quickly rather than experience a delay in comprehension. Regardless, his recall mechanism was impaired. He was able to do immediate register and recall, but could not after a five minute delay. He was able to name objects. He appeared to be depressed, very apprehensive, and apathetic. He did not have any localizing neurologic deficits. He was found to have high intellectual functioning with mild dementia. His grasp was reasonably good, but his retrieval mechanism was not as good. He was assessed with mild dementia and affective disorder. In an April 2013 VA medical record, it was noted that the Veteran had a poverty of thought. He did not have suicidal or homicidal intent/ideation. He did not have hallucinations or delusions. His mood was noted as "it's okay right now" with a stable affect. His judgment, insight, and motivation were poor. In a November 2013 VA medical record, the Veteran's wife was noted to do most of the talking. It was noted that the medications the Veteran was taken could cause dementia. He was assessed with PTSD and dementia not otherwise specified. It was noted that the Veteran had a poverty of thought. He did not have suicidal or homicidal intent/ideation. He did not have hallucinations or delusions. His mood was noted as "okay right now" with a stable affect. His judgment, insight, and memory were poor. This month, it was also noted that the Veteran used THC. In an April 2014 VA medical record, the Veteran was accompanied by his wife. He was noted as having a very negative attitude about life. His wife reported that he did not want to do anything. He had nightmares and restless legs at night. He was noted as alert, awake, and with an intellectual impairment. He was forgetting his grandchildren. He was assessed with mild dementia, affective disorder, and PTSD with nightmares. In a June 2014 medical record, the Veteran was noted as taking medication for Alzheimer's and nightmares. During the examination, his wife did most of the talking. It was noted that reducing his Valium was met with strong resistance by the Veteran and his wife. Reportedly, even a slight reduction in valium caused uncontrollable outbursts of anger. It was noted that the Veteran and his wife lived with his step-daughter and step-grandson. His wife reported that the Veteran's memory had worsened. He continued to have bouts of anger, had poor sleep, and a negative attitude. He was noted to have a prosody of thought process. He did not have current suicidal or homicidal ideation. He did not have hallucinations or paranoid delusions. His mood was "I don't know" and he had a stable affect. His judgment, insight, and motivation were poor. It was noted that he had not worked since 2008. In a December 2014 VA medical record, it was noted that during the examination, the Veteran's wife did most of the talking. The Veteran's wife advised that the Veteran did some yardwork in the summer, as well as some housework. She reported that the Veteran would get "pissed off" easily. The Veteran was assessed with PTSD and dementia not otherwise specified. His thought process was linear, logical, and goal-oriented. He did not have current suicidal or homicidal ideation. His mood was "not too good" and had an irritable affect. His judgment, insight, and motivation were poor. In another record from this month, the Veteran was noted to have memory issues for many years, and is on medication. His memory was not that much worse or better. He was noted to have also have chronic affective disorder with anxiety/PTSD. He was assessed with memory loss, chronic affective disorder, and PTSD. In a September 2015 VA medical record, the Veteran's wife reported that the Veteran was "piddling around the house [...] watching the news [...] helping me in the yard a little bit [....]" In was noted that the Veteran's wife did most of the talking. The Veteran was assessed with PTSD and dementia not otherwise specified. His thought process was linear, logical, and goal-oriented. He did not have current suicidal or homicidal ideation. He did not have hallucinations, or paranoid delusions. His mood was "I'm okay today but that don't mean I won't have a bad day later [...]" with a stable affect. His judgment, insight, and motivation were poor. In a March 2016 private report medical testing, the Veteran was noted to have a history of reported cognitive difficulties for approximately 20 years, with a reported further decline over the last 10 years. It was noted that he was diagnosed with "mild cognitive impairment, early Alzheimer's dementia," by a VA clinician, and a January 2016 VA medical record suggested that the Veteran's cognitive complaints may be related to mood disturbance (including PTSD) as well as the side effects of his medications. His cognitive difficulties reportedly interfered with is ability to manage most of his instrumental activities of daily living. These included: managing medications, appointments, and finances, as well as driving to some extent. The Veteran was noted to exhibit some difficulty understanding complicated test instructions, and occasionally required the repetition and/or clarify instructions. On a verbal learning and memory task, he benefited from multiple repetitions of information. Although his short-delayed recall was within expectation, he demonstrated inefficiency with delayed recall. Across all memory tasks (verbal and nonverbal) he did not benefit from cueing, and his free recall was generally better than recognition. He demonstrated areas of inefficiency in attention, information processing speed, phonemic fluency, and mental flexibility. He had significant difficulty on a task of novel problem solving. The private clinician noted that the Veteran experienced a significant degree of anxiety, to the extent that his functioning is likely impaired. He has a propensity to experience his anxiety somatically, such as racing heart, sweaty palms, rapid breathing, and dizziness. Responses indicated that he was likely volatile in response to frustration and that this judgment in such situations may be poor. The quality of his mood state could change rapidly, and he was noted to possibly be prone to lash out at those he viewed as the source of his frustration. He was more likely than others to display physical displays of anger, such as breaking objects or engaging in physical altercations. His level of somatic concerns and severe anxiety probably rendered him incapable of performing even minimal role expectations. Interpersonally, the Veteran could be distant in personal relationships and may not appear to place a high premium on close, lasting relationships. He possibly saw himself as independent, practical, and less preoccupied by the opinions of others as most people. The clinician opined, given the Veteran's self-reported history of cognitive difficulties over at least the past 20 years, there was reason to suspect that at least some of his current cognitive complaints were related to chronic mental health difficulties superimposed in addition to premorbid areas of borderline functioning. The clinician found that the Veteran had been experiencing a significant degree of psychological distress, consistent with PTSD. It was noted that the Veteran's difficulties with attention, concentration, and processing speed (which could "clearly impact" learning and memory) were often observed in individuals with PTSD, and may present as a part of the sequelae of same. In addition to mood disturbance, it was also likely that the Veteran's medication's side effects contributed to the Veteran's cognitive complaints. Many of the medications he was recently been prescribed, including hydrocodone, cyclobenreprine, amitriptyline, and diazepam had known cognitive side-effects. Neuroimaging revealed evidence of vascular changes, which could have contributed to some of the Veteran's reductions in attention and processing speed. Based on the assessment, the clinician opined that an underlying neurodegenerative process would be the least likely suspected etiology of the Veteran's cognitive difficulties. In a January 2017 private opinion, the Veteran reported ongoing symptoms of depression and anxiety. He was nervous all the time, irritable, and short tempered. He had symptoms of depression, to include sadness, anhedonia, and feeling s of worthlessness. He remained self-reliant regarding basic care and household chores, and stated he was able to drive without assistance. He required assistance with managing his medications, appointments/scheduling, and finances. He reported an increase in mood disturbances since he was last seen in March 2016. He additionally reported extremely high amounts of rumination, magnification-style thinking, and helplessness compared to other pain patients. The clinician noted that the Veteran's cognition declined from low average to borderline since March 2016. There was evidence of inefficiencies in attention, information processing speed, delayed memory for verbal information, and aspect of executive functioning. During diagnostic testing, the Veteran had significant difficulty with a novel problem solving task. It was noted that he became frustrated with this task, and it may have impacted his performance. The etiology of his cognitive difficulties was suspected to be related to mood disturbance, the side effects of medication, marijuana use, and other variables including difficulties with sleep, fatigue, and pain. He was fully oriented and alert. His mood was poor and his affect was labile. His thought process was mildly perseverative, but was easily redirected. There was no evidence of disorganized thought, hallucinations, delusions, or loose associations. He denied suicidal and homicidal ideation. D. Analysis As an initial matter, the Board observes that the Veteran's neurocognitive symptoms have been attributed to a number of different etiologies. The March 2016 and January 2017 private medical records suggest that these symptoms have a relationship to his PTSD disability. The Board finds that these medical records are competent, credible, and probative regarding the Veteran's overall disability picture. Giving the Veteran the benefit of the doubt,, the Board shall consider these symptoms in its analysis of his PTSD disability. See Mittleider v. West, 11 Vet. App. 181 (1998). Prior to September 30, 2011, the Veteran was shown to have short and long term memory that was grossly intact. He reported good to great relationships with his close family members. He had a neutral affect. Although he was frequently irritable, it was not associated with periods of violence. He also denied any recent assaultiveness or panic attacks. His assigned GAF scores, including a GAF of 60 on his February 2011 VA examination, further suggested mild to moderate symptoms. As such, a rating in excess of 30 percent prior to September 30, 2011, is not warranted. The Veteran's representative called VA with the Veteran on September 30, 2011. The VA employee who took the call noted that "the Veteran suffers from moderate to severe memory loss and attention issues. He can verify his ID, but will have his wife speak with VSR who calls." From this point forward, the Veteran was shown to have gradually increasing cognitive impairment, wherein he forgot times, dates, appointment, objects, and sometimes the names of his grandchildren. He would forget what he was talking about, but would quickly recall. He was noted to have some limitation of activities, and required assistance with managing his medications and finances. He had impaired judgment and a very negative mood. He had difficulty with novel tasks. He had daily anxiety attacks, and was irritable/angry. The Veteran was shown to have daily anxiety attacks and some difficulty managing medications, appointments, and finances. The Veteran was noted to forget the names of family members in January 2012. Other records reflect that he was forgetting his grandchildren. As early as July 2012, medical records noted that the Veteran's wife was doing most of the communicating for the Veteran at his appointments. Affording the Veteran the benefit of the doubt, since September 30, 2011 he has experienced the type of gross impairment in thought processes and communication that more nearly approximate the criteria for a 100 percent rating. In March 2016, the private clinician found that the Veteran was experiencing a significant degree of psychological distress, consistent with PTSD. He had cognitive difficulties that interfered with is ability to manage most of his instrumental activities of daily living, including: managing medications, appointments, and finances, as well as driving to some extent. He had difficulties with his attention, information processing speed, phonemic fluency, and mental flexibility. He had significant difficulty with novel problem solving. He experienced a significant degree of anxiety and his mood could change rapidly. It was opined that he was possibly prone to lash out at those he viewed as the source of his frustration, and more 1ikely than others to display physical displays of anger. His level of somatic concerns and severe anxiety were opined to probably render him incapable of performing even minimal role expectations. The Board observes that the record shows that there are potentially outstanding VA mental health records created in 2016 and 2017 that address his current symptoms. In February 2017 the Veteran submitted a request for additional VA medical evidence to be associated with his claims file; a March 2016 private opinion cited to a January 2016 VA record not within the claims file; and a January 2017 private medical opinion suggested that the Veteran continued to undergo VA psychiatric treatment. However, given the full grant awarded in this decision for this period of time, the Board finds lack of further development for these records results in no prejudice to the Veteran. In summation, prior to September 30, 2011, a rating in excess of 30 percent is not warranted; from September 30, 2011, a total schedular 100 percent rating is warranted. The question of entitlement to TDIU based solely on PTSD symptomatology is moot for the period during which a schedular 100 percent evaluation is assigned for PTSD. Prior to that time, the Veteran's PTSD has been rated below 60 percent, which does not meet the threshold minimum schedular rating requirement for a TDIU rating under 38 C.F.R. § 4.16(a) and the preponderance of the evidence does not reflect that a TDIU rating is warranted under 38 C.F.R. § 4.16(b). ORDER Service connection for bilateral hearing loss is granted. The claim for entitlement to service connection for a right hip disability is dismissed as withdrawn. Prior to September 30, 2011, a rating in excess of 30 percent for PTSD is denied. From September 30, 2011, a total schedular rating of 100 percent for PTSD is granted, subject to the laws and regulations governing monetary awards. REMAND As an initial matter, the Board acknowledges that the Veteran has significant cognitive deficits that greatly impair his short term and long term memory. As such, the RO should take this fact into account when developing the Veteran's remanded claims. In February 2017, the Veteran requested VA medical records from January 1, 1990 to the present to from the Austin, Texas outpatient clinic and the Temple, Texas VA Medical Center. He additionally requested VA medical records from September 8, 1971 to December 1, 1998 from the Audie Murphy Memorial VA Hospital. The Board observes that these records have not been associated with the record, and there is no indication that these records, notwithstanding Audie Murphy records from 1972 to 1973, have been sought. The Board observes that the most current VA records within in the file are from September 2015. As such, further development is necessary for the proper adjudication of the Veteran's claims for prostatitis, low back disability, eczematoid dermatitis and xerosis, and melanoma. The Board further notes that the Veteran has not undergone a VA examination for his claimed prostate condition. For the following reasons the Board finds that an examination is necessary to decide the claim. See 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board observes that in service the Veteran complained of burning urination, dysuria and urinary frequency. These symptoms were related to as possibly secondary to sexual encounters or as urethritis. In a September 1999 VA medical record, it was noted that Veteran had a many year history of urinary urgency and frequency. In an April 2000 VA medical record, the Veteran complained of increased urinary frequency, urgency, and burning. The post-service record indicates that the Veteran has either experienced or was considered to possibly have a chronic prostatitis condition. Notably, the Veteran has experienced similar genitourinary symptoms in service and more recently. As such, the Board finds that the low threshold has been met for triggering the Secretary's duty to assist by providing a medical examination to address the question of whether the Veteran has a prostate disorder related to his military service. Accordingly, the case is REMANDED for the following action: 1. Please provide the Veteran with the proper authorizations so that he may provide dates of treatment, as well as the names and addresses of all medical care providers who treated him for prostatitis, low back disability, eczematoid dermatitis and xerosis, and melanoma. Please also provide him with the opportunity to submit additional records in support of his claims. 2. Please obtain any VA treatment records since the Veteran's separation from service, that have not already been associated with the claims file to specifically include: a. records from January 1, 1990 to the present to from the Austin, Texas VA outpatient clinic and the Temple, Texas VA Medical Center; and b. records from September 8, 1971 to December 1, 1998, from the Audie Murphy Memorial VA Hospital (it appears records from 1972 to 1973 are already in the virtual file). If any additional records are not available, or the search for any such records otherwise yields negative results, that fact should be clearly documented in the claims file. 3. After completion of directives 1 and 2, please arrange for the Veteran to be scheduled for a VA examination, to determine whether it is at least as likely as not (a 50 percent or greater probability) that he has a current genitourinary disorder, to include prostatitis, that is related to service. The examiner is requested to consider and discuss as necessary a September 1999 VA medical record where it was noted that Veteran had a many year history of urinary urgency and frequency with a normal urinalysis. The claims file should be made available to and reviewed by the examiner. All indicated tests and studies should be undertaken The examiner is advised that the Veteran has a cognitive deficits that greatly impair his short term and long term memory. As such, the examiner is requested to take this into account when providing an opinion. 4. Finally, please readjudicate the claims. If any claim remains denied, issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or 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). ______________________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs