Citation Nr: 1753874 Decision Date: 11/24/17 Archive Date: 12/01/17 DOCKET NO. 09-28 045A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for cardiovascular disease. 3. Entitlement to service connection for dermatitis of the neck and anterior axillae. 4. Entitlement to service connection for chronic cough. 5. Entitlement to an initial rating in excess of 70 percent for PTSD. 6. Entitlement to a total disability rating based on individual unemployability (TDIU). WITNESSES AT HEARING ON APPEAL Appellant and L.H. ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran had honorable active duty service from April 1970 to December 1971. He is in receipt of the Combat Infantryman Badge, which denotes his participation in combat. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), which denied the claims for service connection and granted service connection for PTSD, assigning a 30 percent rating effective July 18, 2008. The rating assigned for PTSD was increased to 70 percent effective July 18, 2008, in a February 2017 rating decision. The Veteran testified at a personal hearing before the undersigned Veterans Law Judge in March 2012. A transcript is of record. The case was previously before the Board in October 2012 and March 2016 and was remanded for additional development. Concerning the claim for a TDIU listed on the cover page, a TDIU may be part of an increased disability rating claim when such claim is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran has argued for a 100 percent rating for PTSD and records from the Social Security Administration indicate benefits were granted, in part, based on psychiatric disability. Accordingly, the evidence reasonably raises a claim of entitlement to a TDIU. Thus, that issue has been added to cover page. The issues of entitlement to service connection for hypertension and cardiovascular disease, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A current diagnosis of dermatitis of the neck and anterior axillae is not shown by the evidence of record. 2. The competent and probative evidence of record does not establish that the Veteran's chronic cough, which has been attributed to a diagnosis of chronic bronchitis, had onset in service or is causally related to service. 3. The Veteran's PTSD has not been manifested by total social impairment. CONCLUSIONS OF LAW 1. The requirements for establishing service connection for dermatitis of the neck and anterior axillae have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017). 2. The requirements for establishing service connection for chronic cough have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 3. The criteria for an initial rating in excess of 70 percent have not been met for PTSD. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board notes that actions requested in the prior remands have been undertaken. In this regard, additional VA treatment records were obtained as were records from the Social Security Administration (SSA) were obtained, and VA examinations were provided. A Formal Finding of Lack of Information Required to Obtain the January 2014 Supplemental Statement of the Case was prepared. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed.Cir.2013) (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b)). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). A Veteran who had active military service in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307 (a)(6)(iii) (2017). The Veteran's exposure to herbicide agents has been conceded in this case. A presumption of service connection exists if a Veteran is diagnosed with certain enumerated diseases associated with exposure to certain herbicide agents. See 38 U.S.C. § 1116 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). Dermatitis is not a condition listed as being associated with exposure to herbicide agents. Notwithstanding the regulations governing presumptive service connection based on herbicide exposure, service connection may also be established with proof of actual direct causation. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Service connection may be established on a secondary basis for a disability which is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran essentially contends that he developed a chronic cough as a result of service, and that he has dermatitis of the neck and anterior axillae as a result of his conceded exposure to herbicides during service. He has also raised an assertion that his claimed skin condition is secondary to PTSD. As an initial matter, the Board notes that the Veteran has been diagnosed during the course of the appeal with chronic bronchitis, and that his chronic cough has been attributed to this diagnosis. Accordingly, the first criterion for establishing service connection has been met for this claim. The question becomes whether this condition is related to service. Service treatment records are devoid of reference to complaint of, or treatment for, either cough or bronchitis, either acute or chronic. The first reference to chronic cough following service was during an August 2005 VA Agent Orange Registry Examination, when the Veteran expressed concern for recurrent cough and was diagnosed with chronic cough of uncertain etiology. VA treatment records dated after that examination contain assessments of acute asthmatic bronchitis (January 2012); acute bronchitis (May 2014); and asthma/chronic obstructive pulmonary disease (COPD) exacerbation (September 2014). Pulmonary Function Testing (PFT) in April 2012 showed no obstruction, borderline restriction, no response to bronchodilators, and normal diffusion capacity. Subsequent PFT dated in October 2014 and January 2017 showed no obstruction, no bronchodilator response, no restriction, and normal diffusion capacity. Chest x-rays taken in January 2012, June 2014, September 2014, and January 2017 contain impressions of no radiographic evidence for acute cardiopulmonary disease. The Veteran was diagnosed with chronic bronchitis during a January 2017 VA respiratory conditions Disability Benefits Questionnaire (DBQ). The preponderance of the evidence is against the claim for service connection for chronic cough. There is no indication that the Veteran had problems involving cough or bronchitis during service; the post-service evidence does not establish the Veteran was seen with problems involving cough prior to August 2005, which is approximately 34 years following his discharge from service, despite his assertion during the January 2017 VA examination that he had had intermitted cough since 1970's; and the January 2017 VA examiner provided an opinion that the condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. This opinion was supported by detailed rationale, namely that VA treatment records are silent for evaluation of cough from August 2005 until January 2012; that there is no objective evidence to support a diagnosis of asthma because there was no evidence of bronchodilator responsiveness on PFT and treatment records are silent for evaluation or diagnosis of asthma by pulmonary specialist; and that the diagnosis of chronic bronchitis was noted in 2014, more than 42 years after separation from military service. As such, it is afforded high probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). While the Veteran believes that his chronic cough is related to service, as a lay person, the Veteran has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis and etiology of chronic cough are matters not capable of lay observation, and require medical expertise to determine. Accordingly, the Veteran's opinion as to the diagnosis or etiology of his chronic cough is not competent medical evidence. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to his current disability is also a matter that also requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's own opinion regarding the etiology of his chronic cough is not competent medical evidence. The Board finds the opinion of the VA examiner to be significantly more probative than the Veteran's lay assertions. The preponderance of the evidence is also against the claims for service connection for dermatitis of the neck and anterior axillae. A current disability is the cornerstone of a claim for VA disability compensation and in the absence of proof of a present disability, there can be no valid claim. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). The post-service medical evidence does not document that the Veteran has been diagnosed with dermatitis of the neck and anterior axillae. The Board acknowledges that the Veteran was diagnosed with probable contact dermatitis of the neck and anterior axillae during the August 2005 VA Agent Orange Registry Examination; however, review of the medical evidence of record dated since the Veteran filed his claim for service connection in 2007 does not reveal that the Veteran has been treated for or diagnosed with dermatitis of the neck and anterior axillae. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim."). Therefore, without competent evidence of a current diagnosis of dermatitis of the neck and anterior axillae, service connection is not warranted on a direct or secondary basis. See 38 C.F.R. §§ 3.303, 3.310. While the Veteran contends he suffers from dermatitis of the neck and anterior axillae, as a lay person he is not competent to diagnose such disabilities as such matters require medical testing and expertise to determine. See Jandreau, 492 F.3d at 1376-77. The Board finds the medical evidence of record to be significantly more probative than the Veteran's lay assertions. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the probative evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert, 1 Vet. App. at 55-56. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service connection was established for PTSD in the December 2008 rating decision that is the subject of this appeal. An initial rating of 30 percent was assigned effective July 18, 2008, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. The rating was increased to 70 percent, also effective July 18, 2008, in a February 2017 rating decision. Pursuant to the General Rating Formula for Mental Disorders, a 70 percent evaluation contemplates occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activity; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). A 100 percent evaluation is warranted where there is total occupational and social impairment, due to symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting 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 name. Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. 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 on the basis of social impairment. 38 C.F.R. § 4.126(b). The record also contains Global Assessment of Functioning (GAF) scores assigned by clinicians, which reflect the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240 (1995). Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by replacing references to DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition (DSM-IV) with the fifth edition of the DSM (DSM-5). See 38 C.F.R. § 4.125, amended by 79 Fed. Reg. 45099 (effective Aug. 4, 2014). Although DSM-5 does not use GAF scores to assess functioning, the DSM-IV was in effect at the time the GAF scores were assigned. Thus, the Board will consider the GAF scores of record in evaluating the Veteran's occupational and social functioning. However, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is not determinative of the VA disability rating to be assigned. See Carpenter v. Brown, 8 Vet. App. 240 (1995). The percentage evaluation is based on all of the evidence that bears on occupational and social impairment. Id; see also 38 C.F.R. § 4.126. The Veteran originally asserted that he was entitled to an initial rating in excess of 30 percent because he met the criteria for a 70 percent evaluation, and specifically cited the criteria to support a 70 percent rating without elaborating on symptoms specific to him. He later asserted he was entitled to an initial 100 percent rating, again specifically citing the criteria to support a 100 percent rating without elaborating on symptoms specific to him. The Veteran testified in March 2012 that he could not sleep at nighttime; sometimes worried about things; panicked; was depressed; had problems managing anger; nightmares and flashbacks. The Veteran denied thoughts of suicide and violence, to include road rage, and although he indicated that he showered later in the day than before, did not indicate he did not shower and was nicely dressed for his hearing. L.H. testified that she had observed him becoming more anxious and that he had impaired sleep. The medical evidence in this case consists of VA treatment records, records obtained from the Social Security Administration, and several VA examination reports. The Board again notes that it has reviewed all the evidence in the record and that although it has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales, 218 F.3d at 1380-81 and Timberlake, 14 Vet. App. at 128-30. Upon review of the record, the Board finds that the preponderance of the evidence does not support the assignment of an initial rating in excess of 70 percent for PTSD at any time during the period of the appeal. The Board acknowledges the fact that the Veteran has been assigned three GAF scores of 50, one GAF score of 58, and one GAF score of 70. In pertinent part, a GAF score of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job) while scores ranging from 51 to 60 represent moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers) and scores ranging from 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. The Board notes that GAF scores consistent with the 100 percent rating criteria would be below 31. In this regard, a GAF score of 11 to 20 indicates that there is some danger of hurting oneself or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement), or an occasional failure to maintain minimal personal hygiene, or gross impairment in communication; and a GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). The Board has considered the assignment of the GAF scores in conjunction with the subjective symptoms reported by the Veteran and with the objective evidence of record as reflected in VA treatment records, records obtained from the Social Security Administration, and the VA examination reports. The evidence of record, however, does not reveal that the Veteran had gross impairment in thought processes or communication; or persistent delusions or hallucinations. Rather, VA treatment records reveal that thoughts were logical, coherent and goal-directed; that speech was fluent, spontaneous, and of normal rate, tone, volume and rhythm; and that the Veteran consistently denied hallucinations and delusions. Moreover, the Veteran's speech was noted to be within normal limits during the October 2008 VA examination, thought processes were appropriate, and there was no delusion or hallucination observed; the November 2012 VA examiner indicated the absence of circumstantial, circumlocutory or stereotyped speech, speech intermittently illogical obscure or irrelevant, gross impairment in thought processes or communication, and persistent delusions or hallucinations; a January 2013 clinical interview and mental status examination conducted by the Social Security Administration indicates that the Veteran's stream of mental activity and speech was within normal limits, that his thought was generally organized and appropriate to the interview, and that there was no history of hallucination; and the January 2017 VA examiner indicated that speech was of normal rate and volume and that the Veteran denied hallucinations. The evidence of record also does not reveal that the Veteran had disorientation to time or place; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); memory loss for names of close relatives, own occupation, or own name; or that he exhibited grossly inappropriate behavior or was in persistent danger of hurting others. Rather, the Veteran was noted to be oriented within normal limits with appropriate behavior during the October 2008 VA examination; the November 2012 VA examiner noted the absence of spatial disorientation, disorientation to time or place, and grossly inappropriate behavior; the January 2013 Social Security clinical interview and mental status examination reported that the Veteran was fully oriented to person, place, date and situation; and the January 2017 VA examiner reported that he was pleasant and cooperative. The Veteran was also consistently reported to be oriented when seeking even non-mental health VA treatment and calm and cooperative during mental status assessment when receiving VA treatment. In addition, the Veteran has also been able to perform activities of daily living, as evidenced by VA treatment records, which consistently indicate he is independent with activities such as bathing, dressing, grooming, toileting, feeding and ambulation. In addition, the October 2008 VA examiner reported that the Veteran does not have difficulty performing activities of daily living; the November 2012 VA examiner noted the absence of intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; the January 2013 Social Security assessment indicated that the Veteran was able to perform activities of daily living, including toileting, bathing, grooming, cooking, cleaning, finances, transportation, and shopping; and the January 2017 VA examiner indicated that the Veteran had normal routine behavior and self-care. The Veteran was also consistently described as appropriately dressed when seeking VA treatment and was reported to have appropriate appearance and hygiene during the October 2008 VA examination, was noted to have the absence of neglect of personal appearance and hygiene during the November 2012 VA examination, presented as neatly groomed during the January 2013 Social Security clinical evaluation, was noted to be nicely dressed at his March 2012 Board hearing, and was noted to be well groomed at the time of the January 2017 VA examination. In addition, only slight impairment in immediate memory was noted during the January 2013 Social Security assessment, with remote and recent memory being intact at that time and memory being normal during VA examinations and VA treatment, even non-mental health treatment, prior to and since January 2013. Finally, although the Veteran has reported problems with irritability and being easy to anger since initiating his claim, and he also reported getting into arguments with superiors while working as a welder during a period of the appeal, homicidal ideation has been notably absent during VA examination and VA treatment and he specifically denied thoughts of violence at his March 2012 Board hearing. The Board acknowledges that the Veteran has reported social isolation and lack of desire to seek contact with anyone and that he has been divorced from his only wife for a lengthy period of time; however, the Veteran has consistently reported having a girlfriend and although they do not live together, they appear to spend a considerable amount of time together and she occasionally accompanies him to VA treatment. In addition, he has reported having a good relationship with his three children; having the support from friends following his mother's 2015 death; having two friends who were Vietnam veterans during the January 2017 VA examination; and being able to leave the house to go to the store. The Veteran has also attended group therapy through VA, which began in December 2012. For the reasons set forth above, the Board finds that the preponderance of the evidence is against the claim for an initial rating in excess of 70 percent for the Veteran's PTSD. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b) (2012); Ortiz, 274 F.3d at 1364; Gilbert, 1 Vet. App. at 55-56. ORDER Service connection for dermatitis of the neck and anterior axillae is denied. Service connection for chronic cough is denied. An initial rating in excess of 70 percent for PTSD is denied. REMAND The Veteran has raised the issue of hypertension as secondary to his service-connected PTSD. An addendum opinion is needed from the VA examiner who conducted the January 2017 VA examination to address this contention. Additionally, a January 2013 EKG noted sinus tachycardia, although EKG was noted to otherwise be normal. As the significance of this finding has not been addressed, a new VA examination is warranted. Finally, a claim for TDIU has been reasonably raised by the record. On remand, the Veteran should be afforded appropriate notice under the Veterans Claims Assistance Act (VCAA) concerning claims for a TDIU. The Veteran should also be asked to fully complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability on remand. Accordingly, the case is REMANDED for the following action: 1. Issue a VCAA notice letter to the Veteran concerning a claim for a TDIU. Additionally, ask him to fully complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. 2. Schedule the Veteran for a VA heart examination to determine whether the Veteran suffers from a current heart disability. In addition, an opinion on whether the Veteran's hypertension is secondary to his PTSD should also be requested. The claims file must be reviewed in conjunction with the examination. All indicated tests should be conducted and the results reported. If the tests are deemed unnecessary or contraindicated the examiner should state such and indicate why the testing is not being conducted. Following review of the claims file and examination of the Veteran, the examiner should respond to the following: a. The examiner should indicate whether the Veteran suffers from ischemic heart disease or other heart disability. In rendering this opinion, the examiner should address the significance of the January 2013 EKG noting sinus tachycardia, and indicate why this is/is not an indicator of current heart disability. b. If the Veteran suffers from a diagnosed heart disorder other than ischemic heart disease, the examiner should provide an opinion as to whether such condition is cause by or worsened beyond normal progression by the service-connected PTSD. c. The examiner should provide an opinion as to whether the Veteran's hypertension is cause by or worsened beyond normal progression by the service-connected PTSD. d. If the examiner concludes that a heart condition and/or hypertension have been worsened beyond normal progression by service-connected PTSD, the examiner should attempt to quantify the degree of worsening of the hypertension that is due to PTSD. A rationale for all opinions expressed should be provided. 3. After undertaking the development above and any additional development deemed necessary, the Veteran's remanded claims should be adjudicated. If the benefits sought on appeal remain denied, the appellant should be furnished a supplemental statement of the case and be given an appropriate period to respond thereto before the case is returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter 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. §§ 5109B, 7112 (2012). ______________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs