Citation Nr: 18145809 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 15-21 446 DATE: October 30, 2018 ORDER New and material evidence having been received, the claim of entitlement to service connection for sinusitis, with headaches and watering eyes, is reopened. To that extent only, the appeal is granted. Entitlement to service connection for chronic fatigue syndrome is denied. Entitlement to a separate rating for right knee instability is granted, with a 10 percent rating under Diagnostic Code 5257, effective April 12, 2016. Entitlement to an initial rating in excess of 10 percent for right knee patellofemoral pain syndrome is denied. Entitlement to a rating in excess of 30 percent for chronic constipation is denied. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder is denied. REMANDED Entitlement to service connection for sinusitis, with headaches and watering eyes, is remanded. Entitlement to service connection for sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to posttraumatic stress disorder (PTSD), is remanded. FINDINGS OF FACT 1. A December 2004 rating decision denied service connection for sinusitis. The Veteran did not perfect an appeal. Therefore, that rating decision became final. 2. The evidence received subsequent to the December 2004 final denial of the claim for service connection for sinusitis is new, and is also material because it raises a reasonable possibility of substantiating the claim. 3. At no time during the pendency of the claim does the Veteran have a current diagnosis of chronic fatigue syndrome, and the record does not contain a recent diagnosis of disability prior to the Veteran’s filing of a claim. 4. The Veteran’s service-connected right knee disability is manifested by slight lateral instability. 5. The Veteran’s service-connected right knee disability is manifested by limitation of forward flexion of the knee to no less than 45 degrees. 6. The Veteran is already in receipt of the maximum scheduler evaluation for chronic constipation, and he does not have vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. 7. The Veteran’s symptoms of posttraumatic stress disorder are manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as panic attacks more than once a week; impaired judgment; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. CONCLUSIONS OF LAW 1. As new and material evidence has been received, the criteria to reopen the claim for service connection for sinusitis have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. The criteria for service connection for chronic fatigue syndrome, to include as due to undiagnosed illness or other qualifying chronic disability pursuant to 38 U.S.C. § 1117, are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for entitlement to a separate compensable rating of 10 percent, but no greater, for right knee instability have been met, effective April 12, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 5257. 4. The criteria for entitlement to an initial rating in excess of 10 percent for right knee patellofemoral pain syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 5260. 5. The criteria for entitlement to a rating in excess of 30 percent for chronic constipation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Codes 7319-7346. 6. The criteria for entitlement to a rating in excess of 50 percent for posttraumatic stress disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1987 to August 1991. He is in receipt of the Combat Action Ribbon. The Veteran originally requested a Board hearing, but he withdrew this hearing request in March 2018. 1. Entitlement to service connection for chronic fatigue syndrome The Veteran contends that, since his service in the Persian Gulf, he is always fatigued, tired, and has no energy. As such, he contends that he has chronic fatigue syndrome that is related to his active duty military service. Subject to various conditions, service connection may be granted for a disability due to undiagnosed illness of a Veteran who served in the Southwest Asia Theater of operations during the Persian Gulf War. There must be objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as fatigue, signs or symptoms involving the skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper and lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. The illness must become manifest during either active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more, under the appropriate diagnostic code of 38 C.F.R. Part 4. By history, physical examination, and laboratory tests, the disability cannot be attributed to any known clinical diagnosis. There must be objective signs that are perceptible to an examining physician and other non-medical indicators that are capable of independent verification. There must be a minimum of a six-month period of chronicity. There must be no affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia Theater of operations during the Persian Gulf War. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98 (Aug. 3, 1998). VA and private treatment reports do not show a diagnosis of chronic fatigue syndrome. In October 2015, the Veteran was provided with a VA chronic fatigue syndrome examination. Based upon a review of the record and an in-person examination of the Veteran, the examiner found that the Veteran does not have or has had any findings, signs, and symptoms attributable to chronic fatigue syndrome. The examiner noted that the Veteran had not been previously been diagnosed with chronic fatigue syndrome, and did not meet the criteria for a diagnosis of chronic fatigue syndrome at the time of the examination. The Board has considered the Veteran’s statements regarding his tiredness and fatigue and contentions that such symptoms are related to his military service. While the Veteran is competent to provide statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, he not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). As such, the Veteran’s assertions as to diagnosis of chronic fatigue syndrome, or lack thereof, and etiology of his claimed symptomatology have no probative value. Therefore, based on the foregoing, the Board finds that, at no time during the pendency of the claim does the Veteran have a current diagnosis of chronic fatigue syndrome, and the record does not contain a recent diagnosis of disability prior to the Veteran’s filing of a claim. Consequently, service connection for chronic fatigue syndrome is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for chronic fatigue syndrome. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set for the in the Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.1. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, as is the case here, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where VA’s adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings, different or “staged” ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as “seriously disabled” any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 2. Entitlement to a separate compensable rating for right knee instability 3. Entitlement to an initial rating in excess of 10 percent for right knee patellofemoral pain syndrome VA’s Schedule for Rating Disabilities includes several Diagnostic Codes applicable to evaluating knee and leg disabilities. See 38 C.F.R. § 4.71a. Diagnostic Code 5003 provides that degenerative arthritis that is established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is some limitation of motion of the specific joint or joints involved that is non-compensable (zero percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Under Diagnostic Code 5014, osteomalacia is evaluated as degenerative arthritis, on the basis of limitation of motion of the affected part. Diagnostic Codes 5260 and 5261 are used to rate limitation of flexion and of extension of the knee. Under Diagnostic Code 5260, limitation of flexion of the knee to 45 degrees warrants a 10 percent rating. Limitation of flexion of the knee to 30 degrees warrants a 20 percent rating, and limitation of flexion of the knee to 15 degrees warrants a 30 percent rating. Under Diagnostic Code 5261, limitation of extension of the knee to 5 degrees warrants a zero or non-compensable rating. Limitation of extension of the knee to 10 degrees warrants a 10 percent rating. Limitation of extension of the knee to 15 degrees warrants a 20 percent rating. Limitation of extension of the knee to 20 degrees warrants a 30 percent rating. Limitation of extension of the knee to 30 degrees warrants a 40 percent rating, and limitation of extension of the knee to 45 degrees warrants a 50 percent rating. Normal range of motion of the knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight knee impairment, that is, recurrent subluxation or lateral instability. A 20 percent rating is assigned for a moderate degree of impairment, and a maximum rating of 30 percent is assigned for severe impairment. The words slight, moderate, moderately severe, marked, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence in reaching a decision that is “equitable and just.” 38 C.F.R. § 4.6. Under Diagnostic Code 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, a 10 percent rating is warranted for removal of semilunar cartilage that is symptomatic. In this case, the Veteran’s right knee patellofemoral pain syndrome been rated as 10 percent disabling since April 12, 2016, under Diagnostic Code 5260 for limitation of flexion. The Veteran contends that he is entitled to a higher initial rating. In July 2016, the Veteran underwent a VA examination, which noted diagnosed patellofemoral pain syndrome of the right knee. The Veteran reported painful range of motion, and flare-ups brought on by increased activity, occurring several times per month, and lasting a few days. The Veteran would limit activity during a flare-up, but range of motion was not affected. Upon range of motion testing, right knee flexion was to 125 degrees and extension was to zero degrees. The examiner noted moderate tenderness of medial and lateral patellar facets, and the anterior knee, due to patellofemoral pain syndrome. There was no functional loss or reduced range of motion after repetitive use. The examiner found that pain, weakness, or fatigability or incoordination do not significantly limit functional ability with reported use or during flare-ups. Muscle strength was normal and there was no ankylosis. Joint stability testing was normal. The Veteran had normal gait and no meniscus condition. The Veteran’s condition limited walking to 1.5 miles, repetitive squatting, kneeling, and crawling, and repetitive use of stairs and running. The Veteran was provided another VA examination in November 2016. The Veteran reported flare-ups several times per month, which caused his knees to swell up, especially after being active, and lasted a few days. The Veteran reported he treats his flare-ups with ice, heath, and ibuprofen. The Veteran reported limitations in sitting, standing, lifting, bending, squatting, locomotion, and stairs. Upon range of motion, right knee flexion was to 60 degrees and flexion was to zero degrees. There was no additional loss of function or range of motion after repetitive use. The examiner found moderate tenderness medially and laterally. There was pain with weight bearing and crepitus. The examiner found that additional contributing factors of disability included less movement than normal, swelling, disturbance of locomotion, and interference with sitting and standing. Muscle strength was normal and there was no atrophy. There was no right knee ankylosis or subluxation. Joint stability testing of the right knee did reveal anterior, posterior, medial, and lateral instability of the right knee of 1+ (0-5 millimeters). With regard to limitation of motion, the Board finds that a rating in excess of 10 percent is not warranted for the Veteran’s service-connected patellofemoral pain syndrome of the right knee. There is no lay or medical evidence that the Veteran’s knee pain has been so disabling to result in flexion limited to 30 degrees, or extension limited to 15 degrees, to warrant the next highest rating of 20 percent rating under Diagnostic Codes 5260 or 5261, even during periods of flare-ups. Even with consideration of sections 4.40 and 4.45 and DeLuca, the record presents no basis for assignment of a higher rating under Diagnostic Code 5260 or 5261. Regarding the Veteran’s lateral instability, the Veteran was found to have right knee lateral instability of 1+ (0-5 millimeters), which is the lowest measurement available to the examiner. The Board finds that a separate 10 percent rating under Diagnostic Code 5257 is warranted for slight lateral stability of the right knee, with an effective date of April 12, 2016, the date he was awarded service connection for patellofemoral pain syndrome of the right knee. There is no competent medical evidence of record that indicates symptoms of right knee instability have more nearly approximated moderate recurrent subluxation or lateral instability (the criteria for a 20 percent rating). Therefore, the totality of the evidence shows that the Veteran’s instability is no more than slight in nature. The Board finds that a disability rating in excess of 10 percent is not warranted under Diagnostic Code 5257. 38 C.F.R. §§ 4.3, 4.7. The Board has reviewed the remaining diagnostic codes relating to knee disabilities. As there is no evidence of ankylosis, impairment of the tibia and fibula, or genu recurvatum, evaluation of the right knee under Diagnostic Code 5256, 5262, or 5263, respectively, is not warranted. Moreover, the right knee is not shown to involve any other factors that warrant consideration of any other provisions of VA’s rating schedule. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Entitlement to a rating in excess of 30 percent for chronic constipation The Veteran’s service-connected chronic constipation was rated as 10 percent disabling, effective November 28, 2011 under Diagnostic Code 7319. The Veteran requested an increased rating on January 29, 2015, and the Regional Office (RO) granted an increased rating to 30 percent as of January 29, 2015. The Veteran has appealed that RO decision, contending that his chronic constipation symptoms warrant a rating in excess of 30 percent. Governing regulations provide that there are diseases of the digestive system, particularly with the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title “Diseases of the Digestive System,” do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding. 38 C.F.R. §§ 4.14, 4.113. Ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single evaluation will be assigned under the Diagnostic Code that reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Diagnostic Code 7319 provides ratings for irritable colon syndrome (spastic colitis, mucous colitis, etc.). Moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress, is rated 10 percent disabling. Severe irritable colon syndrome, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, is rated 30 percent disabling. 38 C.F.R. § 4.114. A 30 percent evaluation is the maximum scheduler evaluation available under Diagnostic Code 7319. Under Diagnostic Code 7346, a 10 percent evaluation is warranted for hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent evaluation is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Turning to the evidence of record, in April 2015, the Veteran was provided with a VA intestinal condition examination. The Veteran reported that he now has constipation described as hard stools for about four to five days with dull stomach pain four to five times a week. He takes stool softeners every day, but reports that that these are not effective. He reports that he takes enemas three to four times in a week which is helpful. The examiner noted constant abdominal distress. However, there was no weight loss, malnutrition, serious complications, or neoplasm. The examination report did not note vomiting or anemia. As noted above, a 30 percent rating is maximum scheduler evaluation available under Diagnostic Code 7319. Consequently, an increased evaluation cannot be granted under that diagnostic code. While the Veteran’s constipation is productive of abdominal distress, it is not productive of vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health as contemplated by the higher, 60 percent rating under Diagnostic Code 7346. It was specifically indicated that there were no other serious complication or other general health effects attributable to the intestinal conditions in the April 2015 VA examination. Accordingly, an evaluation in excess of 30 percent is not warranted under Diagnostic Code 7346. Based on the foregoing, the Board finds that the weight of the evidence is against a higher evaluation for the Veteran’s chronic constipation. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. 5. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) The Veteran’s service-connected PTSD was rated as 30 percent disabling from July 26, 2004 and 50 percent disabling from November 28, 2011 under Diagnostic Code (DC) 9411. On January 29, 2015, the Veteran requested an increased rating for PTSD. Under DC 9411, which is governed by a General Rating Formula for Mental Disorders (General Rating Formula), a 50 percent rating is warranted for 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/or difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for 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); and/or inability to establish and maintain effective relationships. A 100 percent rating 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; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name). In July 2014, the Veteran’s wife submitted a letter to the VA indicating that they have been experiencing relationship difficulties due to the Veteran’s mental and physical symptoms. She indicated that the Veteran has difficulty trusting people due to his PTSD. She also stated that the Veteran lost a prior job due to his PTSD. In March 2015, the Veteran’s former military colleague submitted a statement on the Veteran’s behalf. The statement indicated that the Veteran demonstrated psychological changes since his service in the Gulf War. The Veteran has become more suspicious, overly aware of his surroundings, on edge, and has issues with the general public. The colleague opined that the Veteran will required a lifetime of ongoing therapy. The Veteran was provided with a VA mental health examination in May 2015. During a clinical interview, the Veteran reported that he lives with his wife and daughter and prefers to spend his time at home with his dog rather than going out. The Veteran reported visiting his parents every two to three weeks. He reported completing daily tasks such as cutting grass, taking out the trash, and painting the kitchen. The Veteran was currently working a modified full-time schedule as a police officer. He reported he works the night shift, which reduces his interaction with his supervisor and fellow officers. The Veteran reported that his mood is good, but he did feel tired all the time. The Veteran denied suicidal or homicidal ideation. The Veteran reported suffering from anxiety and chronic sleep impairments. The examiner found the Veteran to be alert, attentive, and oriented with proper dress and hygiene. Based on the examination and review of the Veteran’s claims file, the examiner concluded that the Veteran’s psychological symptoms would cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal, routine behavior, self-care, and conversation. In March 2016, the Veteran’s wife submitted a written statement to the VA. She stated that her husband’s symptoms have gotten worse and she left him in February 2016 after a bad argument. She indicated that the Veteran does not participate in family functions, and his two daughters do not talk to him anymore. She stated that the Veteran suffers from nightmares and sleeplessness. Also in March 2016, the Veteran’s immediate supervisor submitted a letter to the VA indicating that the Veteran had been reprimanded at work for his aggressive behavior, which had recently gotten worse, and that his behavior will not be tolerated much longer. Later in March 2016, the Veteran’s friend wrote a statement that the Veteran isolated himself even more than he did in the past, spending more time in his shed instead of interacting with his wife and children. He noted that the Veteran’s wife and youngest daughter had recently moved out of their home due to his inability to control his temper. He also reported that the Veteran had been fired from the Sheriff’s department in the past due to his aggressive interactions with citizens and co-workers. He maintained that the Veteran continued to get complaints at his job with the police department due to his inability to deal with the slightest stress in a non-confrontational way. The Veteran was provided with another VA mental health examination in March 2016. The examiner found the Veteran to be alert, attentive, and oriented, with appropriate dress, good hygiene, and normal speech. The Veteran reported worsening nightmares, sleeplessness, anxiety, and paranoia. The examiner found that, although the Veteran was mildly embellishing symptoms and related functional impairment, the Veteran’s treatment records substantiate the presence of trauma-related symptoms. The VA examiner concluded that the Veteran’s mental health symptoms appear best categorized as mild to moderate and result in moderate impairment in daily functioning. The examiner did note that the Veteran is generally functioning reasonably well in some domains and has some meaningful interpersonal relationships. The examiner noted that although the Veteran is separated from his wife, she accompanied him to his last psychiatric treatment session. The examiner also noted that the Veteran still has interaction with his two daughters, although the relationship is strained. The examiner further noted that the Veteran enjoys his friendships with two former military colleagues. He has maintained a full-time schedule at work, though he avoids interaction with co-workers. Based upon a review of the medical history and the examination, the examiner opined that the Veteran’s PTSD symptoms would cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. VA medical records show that the Veteran is receiving on-going treatment for mental health symptoms. In August 2016, the Veteran reported irritability, hypervigilance, and re-experiencing after Desert Storm. The Veteran’s symptoms have been treated with medication, including Prazosin and Buproprion, and with counseling. Based on the medical and lay evidence of record, the Board finds that a 70 percent rating is not warranted for the Veteran’s PTSD symptoms. The evidence indicates that the Veteran has denied suicidal ideation. The Board notes that while the Veteran had depressive symptoms, the evidence does not establish that the Veteran’s depression or anxiety was affecting the ability to function independently, appropriately, and effectively. Furthermore, the record does not indicate that the Veteran has obsessional rituals, symptoms of spatial disorientation, neglect of personal appearance and hygiene, and/or inability to establish and maintain effective relationships. While the evidence suggests that the Veteran may have experienced anxiety in stressful situations, the evidence does not establish that the Veteran has difficulty in adapting to stressful circumstances. The Board also finds that a 100 percent rating is not warranted. The evidence of record does not show that the Veteran’s symptoms produce total occupational social impairment as to warrant a 100 percent rating. Although the Veteran works a night shift to avoid interaction with his supervisor and colleagues, the Veteran is still able to maintain a modified full-time schedule. The Veteran has been able to maintain relationships, albeit strained, with his wife, two daughters, and two friends from the military. The record also does not establish that the Veteran is in persistent danger of hurting himself or others. There has been no evidence of delusions, gross impairment in thought processes or communication, grossly inappropriate behavior, intermittent inability to perform activities of daily living, or disorientation to time or place. The Veteran’s medical record indicates that the Veteran has denied auditory and visual hallucinations. Furthermore, the record does not show memory loss so severe that the Veteran forgets the names of close relatives, his own occupation, or his name. In reaching this decision, the Board has considered the Veteran’s lay statements and the supporting statements submitted on his behalf. The Board notes that the Veteran is competent to report observations with regard to the severity of his symptomatology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board finds these lay statements to be credible and consistent with the rating now assigned. To the extent he argues his symptomatology is more severe, the Veteran’s statements must be weighed against the other evidence of the record. Here, the specific examination findings of trained health care professionals and documented medical treatment records are of greater probative weight than the more general lay assertions that a rating higher than 50 percent is warranted. Accordingly, the Board finds that the evidence of record weighs against a finding of a disability rating in excess of 50 percent. 38 C.F.R. § 4.130. REASONS FOR REMAND 1. Entitlement to service connection for sinusitis, with headaches and watering eyes, is remanded. 2. Entitlement to service connection for sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD) is remanded. The Veteran contends that his current diagnosis of sleep apnea is secondary to his service-connected PTSD. In June 2015, the VA medical examiner opined that the Veteran’s sleep apnea was more likely related to risk factors including age, weight, neck size, and alcohol use. The examiner concluded that the Veteran’s sleep apnea was not caused by his service-connected PTSD or its medication, and that the sleep apnea was not aggravated beyond its natural progression by PTSD or its treatment. In the July 2016 Appeal to the Board of Veterans Appeals, the Veteran’s attorney contended that the VA examination was inadequate because it did not consider the Veteran’s lay statements, it did not consider medical treatises submitted by the Veteran, and did not consider direct service connection based on the Veteran’s exposure to environmental hazards, including dust, sand, and burn pits while serving in Southwest Asia. In June 2015, the Veteran submitted a medical article entitled “Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort” from the November 2005 edition of SLEEP. He also submitted a medical article entitled “Sleep Disorders and Associated Medical Comorbidities in Active Duty Military Personnel” from the June 2015 edition of SLEEP. These medical articles suggested a connection between the Veteran’s service-connected psychiatric disorder and his diagnosis of sleep apnea. A new VA medical opinion is warranted to consider the medical literature submitted by the Veteran, and to evaluate whether the Veteran’s sleep apnea is directly related to his exposure to environmental hazards in Southwest Asia. Furthermore, the Board cannot make a fully-informed decision on the issue of service connection for sinusitis because no VA examiner has opined whether it is related to service, to include his exposure to enviromental hazards in Southest Asia. 3. Entitlement to service connection for erectile dysfunction, to include as secondary to posttraumatic stress disorder, is remanded. The Veteran contends that his current erectile dysfunction (ED) is related to his service-connected PTSD. In August 2015, a VA medical examiner opined that that the Veteran’s ED is less likely than not proximately due to or the result of PTSD. The examiner reasoned that medical literature does not indicate with “medical certainty” that ED is a result of PTSD. VA’s low standard of proof authorizes VA to resolve a scientific or medical question in the claimant’s favor so long as the evidence for and against that question is in “approximate balance.” See Wise v. Shinseki, 26 Vet. App. 517, 531-32 (2014). Accordingly, the Board finds this VA examiner was utilizing a degree of medical certainty that is inconsistent with VA’s standard of proof in this appeal. Furthermore, this VA medical opinion is inadequate because it does not consider whether the Veteran’s PTSD aggravated his ED beyond its natural progression. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any sleep apnea. (a.) The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including exposure to environment hazards in Southwest Asia, to include sand, dust, and burn pits. (b.) The examiner must opine whether it is at least as likely as not (1) proximately due to service-connected PTSD, or (2) aggravated beyond its natural progression by service-connected PTSD. (c.) The examiner must address and discuss the two medical articles submitted by the Veteran, “Associate of Psychiatric Disorders and Sleep Apnea in a Large Cohort” and “Sleep Disorders and Associated Medical Comorbidities in Active Duty Military Personnel”. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any sinusitis condition, with headaches and watering eyes. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including exposure to environment hazards in Southwest Asia, include sand, dust, and burn pits. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s erectile dysfunction is at least as likely as not related to service connected PTSD, proximately due to service-connected PTSD, or aggravated beyond its natural progression by service-connected PTSD. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Casey, Associate Counsel