Citation Nr: 18148079 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 17-52 000 DATE: November 6, 2018 ORDER Entitlement to service connection for peripheral artery disease (PAD) is granted. Entitlement to service connection for stroke is granted. A rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is denied. A compensable rating for bilateral hearing loss disability is denied. An initial rating of 20 percent, but no higher, for right lower extremity sciatic nerve radiculopathy is granted. An initial rating of 20 percent, but no higher, for right lower extremity femoral nerve radiculopathy is granted. REMANDED Entitlement to a rating in excess of 60 percent for ischemic heart disease (IHD) is remanded. Entitlement to service connection for right total shoulder replacement status post rotator cuff tear is remanded. Entitlement to service connection for right knee patellofemoral pain syndrome is remanded. Entitlement to service connection for a respiratory disability, to include acute respiratory failure and chronic obstructive pulmonary disease (COPD) is remanded. Entitlement to special monthly compensation based on aid and attendance/housebound is remanded. FINDINGS OF FACT 1. The medical evidence of record indicates that Veteran’s PAD was caused by the same disease process as his service-connected IHD. 2. The medical evidence of record indicates that Veteran’s stroke was caused by the same disease process as his service-connected IHD. 3. The Veteran’s PTSD is characterized by anger, anxiety, some memory loss, obsessional rituals such as clearing the house multiple times per night, flashbacks, depression, isolation and inability to tolerate crowds, but not by grossly inappropriate behavior, neglect of personal hygiene or suicidal ideation. 4. The Veteran’s bilateral hearing loss disability has not been manifested by a Level I hearing loss in his right ear and a Level II hearing loss in his left ear. 5. The Veteran’s right lower extremity radiculopathy is characterized by moderate incomplete paralysis of the sciatic and femoral nerves, and moderate constant pain, paresthesias and numbness. CONCLUSIONS OF LAW 1. The criteria for service connection for peripheral artery disease (PAD) have been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 2. The criteria for service connection for stroke have been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 3. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411 (2017). 4. The criteria for a compensable rating for bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code (DC) 6100 (2017). 5. The criteria for an initial rating of 20 percent, but no higher, for right lower extremity sciatic nerve radiculopathy are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.14, 4.123, 4.124, 4.124a, Diagnostic Code (DC) 8520 (2017). 6. The criteria for an initial rating of 20 percent, but no higher, for right lower extremity femoral nerve radiculopathy are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.14, 4.123, 4.124, 4.124a, Diagnostic Code (DC) 8520 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1965 to October 1965, from February 1969 to September 1969 and from November 1972 to October 1989. The Veteran served in the Republic of Vietnam. This matter came before the Board of Veterans Appeals (Board) on appeal from a June 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Evidence in the record suggests that the Veteran has been diagnosed with multiple respiratory conditions; therefore, the Board will broadly construe the issue of service connection for acute respiratory failure as a claim for service connection for a respiratory disability, to include respiratory failure and chronic obstructive pulmonary disease (COPD). Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (holding that the Board must consider any disability that “may reasonably be encompassed by” the description of the claim and symptoms and other submitted information). An August 2018 rating decision granted a claim for a temporary 100 percent evaluation due to coronary artery bypass graft surgery, increasing the rating for IHD from 60 to 100 percent from April 4, 2018 to August 1, 2018. Because higher ratings for this disability are assignable during other portions of the relevant period and the Veteran is presumed to seek the maximum available benefit, the issue remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Service Connection 1. Entitlement to service connection for peripheral artery disease (PAD) is granted. 2. Entitlement to service connection for stroke is granted. The Veteran contends that his PAD and stroke were caused by his service-connected IHD. The Board concludes that, resolving reasonable doubt in the Veteran’s favor, he has current diagnoses of PAD and stroke caused by the same disease process as his service-connected IHD. Service connection is therefore warranted. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a). The July 2017 VA examiner found that the Veteran had a diagnosis of PAD and noted his 2009 stroke. The examiner opined that the Veteran’s PAD and stroke were not directly caused by the IHD. However, the examiner made a specific finding that the PAD and stroke were caused by the same disease process as the service-connected ischemic heart disease. The examiner further stated that all three diseases were chronic and developed slowly and were caused by the buildup for cholesterol and plaque in the arteries. In the brain, the examiner stated that this occluded the arteries and caused a stroke. Given the July 2017 examiner’s clear finding that PAD and stroke resulted from the same disease process as the already service connected ischemic heart disease, there is simply no basis on which the Board can dissociate their causation from that of the service-connected disability. Resolving reasonable doubt in the Veteran’s favor, the Board therefore finds that service connection is warranted. 38 U.S.C. § 5107 (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Individual disabilities are assigned separate diagnostic codes. See U.S.C. §1155; 38 C.F.R. § 4.1. When there is a question as to which of two evaluations applies, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for the rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. Ratings are assigned according to the manifestation of symptoms, but the use of the term “such as” in the General Rating Formula demonstrates that the symptoms after the phrase 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 rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). See also Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (explaining that symptoms that could give rise to a given rating are those in like kind, i.e., of similar duration, severity, and frequency, to those in the non-exhaustive lists). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 39 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to a rating in excess of 70 percent for post-traumatic stress disorder (PTSD) is denied. The Veteran contends that he is entitled to a higher rating for his PTSD. The Board concludes that a rating above 70 percent is not warranted. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. For the entire period on appeal, the Veteran has been rated under Diagnostic Code (DC) 9411 for PTSD, which is evaluated under the General Rating Formula for Mental Disorders. Under the DC, the criteria for a 70 percent rating are 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. The criteria for a 100 percent rating are 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 of 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. 38 C.F.R. § 4.130, DC 9411. Veteran’s Center treatment records (VCRs) document treatment for PTSD. November 2014 VCRs note the Veteran’s sleeping problems, and nightmares about fire fights and having to kill. The Veteran reported getting angry about little things and that he had some memory loss. December 2014 VCRs noted that the Veteran had to pull over for 5 minutes while driving to the doctor because he forgot where he was going. He also reported getting angry and frustrated at a nurse he thought had attitude toward him. He reported feeling that he should avoid people and traveling due to his anger and memory loss. He did not report suicidal or homicidal ideation. Additional December 2014 VCRs note that the Veteran had problems with memory loss and had left the water running and the stove on. The Veteran reported feeling anxious and stressed and that he was isolating himself. A VA examination was provided in July 2017. The examiner noted that the Veteran was not currently receiving psychiatric treatment. The examiner found symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic/depression, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty with work and social relationships, difficulty adapting to stressful circumstances, obsessional rituals, and persistent delusions/hallucinations. The examiner noted that the Veteran was tearful at times and angered easily. He also noted that the Veteran reported problems staying asleep and that he had nightmares. The Veteran also reported isolation and that he could not tolerate crowds. The examiner noted that the Veteran was hypervigilant, easily startled and clears the house several times at night. The examiner also noted flashbacks. The examiner found that the Veteran did not have grossly inappropriate behavior or neglect of hygiene, and noted that the Veteran was appropriately groomed, arrived promptly and made good eye contact when talking. The Veteran did not report any suicidal or homicidal ideation or intent. The Board finds that the preponderance of the evidence is against an evaluation above 70 percent for the period on appeal. The medical evidence of record does not support the conclusion that the Veteran’s overall disability picture more nearly approximates the frequency, severity, or duration of psychiatric symptoms required for a 100 percent disability evaluation based on total occupational and social impairment. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. That is, the competent evidence of record does not show that the Veteran experiences: gross impairment in thought processes or communication, 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 or memory loss for names of close relatives, own occupation or own name. The Board finds that the evidence of record indicates that the Veteran’s PTSD has been characterized by isolation, chronic sleep impairment, nightmares, memory loss of a severity involving forgetting a destination or forgetting to turn off water or a stove, hypervigilance, anger, obsessional rituals such as clearing the house multiple times per night, and isolation. The record also indicates that he has difficulty handling stress and near-continuous panic or depression. All of these symptoms are contemplated by the 70 percent rating already assigned. While the July 2017 VA examiner found that the Veteran experienced delusions and hallucinations, the record does not contain evidence of the other symptoms associated with a 100 percent rating. The evidence does not indicate that the Veteran’s memory loss is of a severity equivalent to forgetting names of close relatives or his own name or occupation as contemplated by a 100 percent rating. The record also does not indicate a history of suicidal or homicidal ideation or harm to himself or others or a neglect of person hygiene. The July 2017 examiner found that the Veteran’s grooming was appropriate and that he did not have grossly inappropriate behavior. The Board therefore finds that the evidence shows that the Veteran’s overall disability picture disability picture more nearly approximates the severity warranting a 70 percent rating. The Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran’s disability in his favor. The Board finds that the Veteran’s overall picture more nearly approximates that of a 70 percent disability rating, and his symptoms do not more nearly reflect the frequency, severity, and duration of symptoms associated with the 100 percent rating. A rating in excess of 70 percent is therefore not warranted. 4. Entitlement to a compensable rating for bilateral hearing loss disability is denied. The Veteran contends that he is entitled to a higher rating for his bilateral hearing loss. The Board concludes that the criteria for a compensable rating have not been met as the evidence indicates that he Veteran’s hearing loss is manifested by Level I hearing acuity in the right ear and Level II hearing acuity in the left ear. Evaluations for defective hearing are based upon organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests, along with the average hearing threshold level as measured by puretone audiometric tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz. 38 C.F.R. § 4.85, Tables VI, VII. To evaluate the degree of disability for service-connected bilateral hearing loss, the rating schedule establishes eleven auditory acuity levels, designated from level I for essentially normal acuity, through level XI for profound deafness. Table VI is used to determine the Roman numeric designation, based on test results consisting of puretone thresholds and Maryland CNC test speech discrimination scores. The numeric designations are then applied to Table VII to determine the appropriate rating for hearing impairment. Id. Where there is an exceptional pattern of hearing impairment, a rating based on puretone thresholds alone may be assigned (Table VIA). This alternative method for rating hearing loss disability may be applied if the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz are all at 55 decibels or higher, or if the puretone threshold at 1000 Hertz is 30 or less and at 2000 Hertz is 70 or more. 38 C.F.R. § 4.86. Each ear is to be evaluated separately under this part of the regulations. Ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). At the June 2015 VA audiological examination for compensation purposes, puretone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 20 30 35 35 LEFT 15 35 60 65 65 The average puretone threshold from 1000 to 4000 Hertz was 30 decibels in the right ear and 56.25 decibels in the left ear. Speech audiometry revealed speech recognition ability of 94 percent in the right ear and of 84 percent in the left ear. The Veteran was diagnosed with bilateral sensorineural hearing loss. The examiner noted the Veteran’s reports of difficulty hearing and understanding people. Applying the foregoing medical evidence to the rating criteria, the Veteran’s right ear is assigned a Level I designation and the left ear is assigned a Level II designation under Table VI. These categories correspond with a noncompensable disability rating under Table VII. 3 8 C.F.R. § 4.85, Diagnostic Code 6100. The Veteran’s hearing loss did not meet the criteria for an exceptional pattern of hearing loss in either ear. 38 C.F.R. § 4.86 (a)(b). Accordingly, the Board will not use Table VIA in its analysis. The January 2013 private audiometric results cannot be used because while the provider conducted speech recognition testing, the report does not indicate the testing was the Maryland CNC speech recognition test required under the regulations. 38 C.F.R. § 4.85. However, the Board notes that the results from the examination were equivalent to the VA examination of record. Puretone testing showed an average of 30 decibels in the right ear and 46.25 decibels in the left ear, and the speech discrimination scores were 96 percent in the right ear and 84 percent in the left ear. As in the VA examination, the right ear was Level I and the left ear was Level II. The Board acknowledges the Veteran’s complaints of difficulty hearing clearly and problems understanding other people and notes his contentions that the 2015 VA examiner was biased against his claim. However, 2015 VA audiologist described the functional effects caused by the Veteran’s hearing disability. Martinak v. Nicholson, 21 Vet. App. 447, 455-56 (2007). The Veteran reported to the VA examiner in 2015 that he had difficulty hearing and understanding people and those reports were noted in the report. Regardless of whether this satisfies the requirement in Martinak, the Veteran must demonstrate prejudice due to any examination deficiency, which he has not done in the instant case. Id. As noted above, the VA examination results were equivalent to the results of the January 2013 private testing. The Veteran is competent to report his difficulty hearing. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); and 38 C.F.R. § 3.159 (a)(2) (2017). Nevertheless, as a layperson, without the appropriate medical training and expertise, his statements are not competent evidence to provide a probative opinion on a medical matter, especially the severity of his bilateral hearing loss disability in terms of the applicable rating criteria. Rather, this necessarily requires appropriate medical findings regarding the extent and nature of his bilateral hearing loss, including audiometric testing for puretone thresholds. As indicated above, rating a hearing loss disability involves the mechanical application of rating criteria to the results of specified audiometric studies. The probative medical evidence does not show the Veteran’s hearing loss has ever reached a disability rating in excess of 0 percent disabling during the appeal period. Considering the results of the VA examinations, entitlement to a compensable for bilateral hearing loss must be denied. 5. Entitlement to a rating in excess of 10 percent for right lower extremity sciatic nerve radiculopathy is granted. The Veteran contends that he is entitled to a higher rating for his right lower extremity sciatic nerve radiculopathy. The Board concludes that the medical evidence of record indicates that the Veteran has moderate right lower extremity sciatic nerve radiculopathy and that a rating of 20 percent, but no higher, is therefore warranted. 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8520. For the entire period on appeal, the Veteran’s sciatic radiculopathy has been rated under DC 8520 for disabilities of the sciatic nerve. Under the DC, a 10 percent rating is warranted for mild incomplete paralysis. A 20 percent rating is warranted for moderate incomplete paralysis. A 40 percent rating is warranted for moderately severe incomplete paralysis. A 60 percent rating under DC 8520 is warranted where there is severe incomplete paralysis of the sciatic nerve with marked muscular atrophy. The maximum rating of 80 percent will be assigned where there is complete paralysis of the sciatic nerve, where the foot dangles and drops, there is no active movement possible of muscles blow the knee, and flexion of the knee is weakened or (very rarely) lost. The Veteran’s private and VA treatment records are silent for treatment of right lower extremity sciatic radiculopathy. A June 2015 VA examination found that the Veteran had radicular symptoms of moderate right lower extremity constant pain, paresthesias and numbness. The examiner found that the Veteran had sciatic nerve involvement and that his lower right extremity radiculopathy was moderate in severity. The Board finds that the medical evidence of record indicates that the Veteran’s sciatic nerve radiculopathy is moderate in severity, as both the symptoms and the overall disability have been assessed as moderate. As noted above, under DC 8520, a rating of 20 percent is warranted for moderate incomplete paralysis of the sciatic nerve. Therefore, criteria for a rating of 20 percent under DC 8620 for the Veteran’s right lower extremity sciatic radiculopathy have been met and an increased rating of 20 percent, but no higher, for the Veteran’s right lower extremity sciatic radiculopathy is granted. To warrant a rating of 40 percent, the evidence would have to show that the Veteran’s sciatic radiculopathy was moderately severe. As the Veteran’s symptoms of constant pain, paresthesias and numbness were found to be moderate in severity upon examination and the Veteran’s radiculopathy was found to be moderate in severity, a rating of 40 percent is not warranted. All potentially applicable DCs have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against a rating in excess of 20 percent for right lower extremity sciatic radiculopathy. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. 6. Entitlement to a rating in excess of 10 percent for right lower extremity femoral nerve radiculopathy is granted. The Veteran contends that he is entitled to a higher rating for his right lower extremity femoral nerve radiculopathy. The Board concludes that the medical evidence of record indicates that the Veteran has moderate right lower extremity femoral nerve radiculopathy and that a rating of 20 percent, but no higher, is therefore warranted. For the entire period on appeal, the Veteran’s femoral radiculopathy has been rated under DC 8526 for disabilities of the femoral nerve. Under the DC, a 10 percent rating is warranted for mild incomplete paralysis. A 20 percent rating is warranted for moderate incomplete paralysis. A 30 percent rating is warranted for severe incomplete paralysis. The maximum rating of 40 percent is warranted where there is complete paralysis of the femoral nerve with paralysis of quadriceps extensor muscles. The Veteran’s private and VA treatment records are silent for treatment of right lower extremity femoral radiculopathy. A June 2015 VA examination found that the Veteran had radicular symptoms of moderate right lower extremity constant pain, paresthesias and numbness. The examiner found that the Veteran had femoral nerve involvement and that his lower right extremity radiculopathy was moderate in severity. The Board finds that the medical evidence of record indicates that the Veteran’s sciatic nerve radiculopathy is moderate in severity, as both the symptoms and the overall disability have been assessed as moderate. As noted above, under DC 8526, a rating of 20 percent is warranted for moderate incomplete paralysis of the femoral nerve. Therefore, criteria for a rating of 20 percent under DC 8526 for the Veteran’s lower right extremity femoral radiculopathy have been met and an increased rating of 20 percent, but no higher, for the Veteran’s right lower extremity femoral radiculopathy is granted. To warrant a rating of 40 percent, the evidence would have to show that the Veteran’s sciatic radiculopathy was moderately severe. As the Veteran’s symptoms of constant pain, paresthesias and numbness were found to be moderate in severity upon examination and the Veteran’s radiculopathy was found to be moderate in severity, a rating of 40 percent is not warranted. All potentially applicable DCs have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against a rating in excess of 20 percent for right lower extremity femoral radiculopathy. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. REASONS FOR REMAND 1. Entitlement to a rating in excess of 60 percent for ischemic heart disease (IHD) The RO last adjudicated the issue of an increased rating for IHD in an September 2017 Statement of the Case (SOC). Since that time, private treatment records from the Fayetteville VA Medical Center (VAMC) have been added to the record. A waiver of AOJ review was submitted for records submitted in April 2018. However, since that date additional private treatment records pertaining to treatment for ischemic heart disease and an August 2018 VA examination were added to the record. A waiver of AOJ review has not been submitted for these records. The Board notes that the AOJ did grant a temporary total rating due to coronary bypass graft surgery in its August 2018 rating decision, however in that decision the AOJ explicitly stated that the appeal for an increased rating was still pending and would be addressed in a separate decision and did not issue a Supplemental Statement of the case (SSOC). As evidence relevant to the issue on appeal was added to the file and the issue of an increased rating for the entire period has yet to be adjudicated by the AOJ, remand is necessary for the AOJ to consider the new evidence of record and issue an SSOC. 2. Entitlement to service connection for right total shoulder replacement status post rotator cuff tear is remanded. A June 2015 VA examination found that the Veteran’s right shoulder disability was not related to service. As a rationale, the examiner stated that there was no evidence of injuries to the shoulder in service. However, the Board’s review indicates that the Veteran’s service treatment records do contain evidence of shoulder injuries. July 1978 service treatment records a complaint of right shoulder pain after carrying a flag during a parade. The provider noted a history of a dislocated shoulder. The records note trauma to the right shoulder and that the Veteran was in a splint for 5 days. June 1985 service treatment records note a right shoulder injury during a softball game. January 1986 service treatment records note complaints of sharp, constant pain with movement extending from the right shoulder to the right hand. The Board therefore finds the examiner’s opinion to be inadequate as it is based upon an inaccurate medical history. A new examination and opinion—based on full review of the record and supported by stated rationale—is needed to fairly resolve the issue on appeal. See 38 U.S.C. § 5103A (West 2014); 38 C.F.R. § 3.159 (2017). 3. Entitlement to service connection for right knee patellofemoral pain syndrome is remanded. A June 2015 VA examination found that the Veteran’s right knee disability was not related to service. As a rationale, the examiner stated that the Veteran only had one right knee injury in 1985 after playing ball but that the x-ray and examination were normal and that the separation examinations were normal. However, the Board’s finds that the examiner mischaracterized the Veteran’s service medical history. First, the April 1985 service treatment records of the right knee injury during a softball game note that the right knee x-ray showed minimal degenerative joint disease and the Veteran was diagnosed with degenerative right knee joint disease. Second, in addition to the April 1985 right knee injury, the service treatment records contain multiple right knee injuries. October 1980 service treatment records document a diagnosis of right knee sprain. An x-ray was performed which showed mild osteophyte spurring in the right knee and the provider found “probably patellar tendonitis.” May 1981 service treatment records note leg pain going up to the right knee. October 1987 service treatment records note severe pain in the right knee lasting for 5 days with swelling and stiffness. The provider diagnosed patellar tendonitis and mild patellar edema, right knee. The Board therefore finds the examiner’s opinion to be inadequate as it mischaracterizes the Veteran’s 1985 right knee injury and fails to consider multiple additional right knee injuries in service. A new examination and opinion—based on full review of the record and supported by stated rationale—is needed to fairly resolve the issue on appeal. See 38 U.S.C. § 5103A (West 2014); 38 C.F.R. § 3.159 (2017). 4. Entitlement to service connection for a respiratory disability, to include acute respiratory failure and chronic obstructive pulmonary disease (COPD) is remanded. The Veteran has not yet been afforded a VA examination regarding this issue. September 2015 private treatment records document a hospitalization for acute respiratory failure. Service treatment records contain July 1979 records of acute bronchitis, June 1980 records diagnosing bronchitis and noting a PPD conversion, and July 1989 records of hospitalization for chest congestion and cough, which note a history of PPD conversion and a diagnosis of upper respiratory infection. Remand for a VA examination is therefore required. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 5. Entitlement to special monthly compensation (SMC) based on aid and attendance/housebound is remanded. As service connection for stroke and PAD has been granted herein, the issue of entitlement to SMC must also be remanded pending the RO’s assignment of ratings for those disabilities. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when the adjudication of one issue could have “significant impact” on the other issue). The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from March 2015 to the Present. 2. Ask the Veteran to complete a VA Form 21-4142 for all private providers who treat him for his disabilities. Make two requests for the authorized records from all identified providers, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current right shoulder disability. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current right shoulder disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of his symptoms. Attention is requested to July 1978, January 1986 and April 1985 service treatment records of right shoulder complaints. 4. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current right knee disability. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current right knee disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of his symptoms. Attention is requested to October 1980, May 1981, and April 1985 service treatment records of right knee complaints and October 1987 service treatment records documenting a diagnosis of patellar tendonitis and mild patellar edema, right knee. 5. Schedule the Veteran for an appropriate VA examination, to determine the etiology of any current respiratory disability, to include acute respiratory failure and COPD. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current respiratory disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran’s active service. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran’s statements regarding the onset and persistence of his symptoms. 6. If upon completion of the above action the appeal remains denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Arnold, Associate Counsel