Citation Nr: 18152126 Decision Date: 11/21/18 Archive Date: 11/20/18 DOCKET NO. 11-25 604 DATE: November 21, 2018 ORDER Entitlement to service connection for a right foot disorder is denied. Entitlement to service connection for a left foot disorder is denied. Entitlement to service connection for bilateral carpal tunnel syndrome is denied. Entitlement to an initial rating in excess of 10 percent for residuals of a stroke to include mild difficulty swallowing is denied. The appeal as to the claim of entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is dismissed. REMANDED Entitlement to service connection for a lung or respiratory disorder is remanded. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) from March 18, 2009 through April 24, 2013, and in excess of 70 percent from April 25, 2013 through May 31, 2016 is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has right foot disability, to include plantar fasciitis or hallux valgus, due to a disease or injury in service, to include performing step-ups during boot camp. 2. The preponderance of the evidence is against finding that the Veteran has left foot disability, to include plantar fasciitis or hallux valgus, due to a disease or injury in service, to include performing step-ups during boot camp. 3. The preponderance of the evidence is against finding that the Veteran has bilateral carpal tunnel syndrome due to a disease or injury in service. 4. Since June 1, 2013, stroke residuals have been manifested by mild difficulty swallowing; other stroke residuals, including urinary incontinence, loss of smell, and loss of taste are separately service-connected or compensated by other service-connected disabilities. 5. On February 26, 2018, prior to the promulgation of a decision on the appeal, the Veteran withdrew the appeal of the issue of entitlement to a TDIU. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right foot disorder have not been met. 38 U.S.C. §§ 1110, 1154(b), 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304(d) (2017). 2. The criteria for entitlement to service connection for a left foot disorder have not been met. 38 U.S.C. §§ 1110, 1154(b), 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304(d) (2017). 3. The criteria for entitlement to service connection for bilateral carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1110, 1154(b), 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304(d) (2017). 4. The criteria for entitlement to an initial rating in excess of 10 percent for residuals of a stroke to include mild difficulty swallowing have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8008 (2017). 5. The criteria for withdrawal of the appeal of the claim for entitlement to a TDIU have been met. 38 U.S.C. § 7105(d)(5) (2012); 38 C.F.R. § 20.204 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1965 to February 1969, including service in the Republic of Vietnam. Awards included the Combat Action Ribbon. This matter comes before the Board of Veterans’ Appeals (Board) from numerous rating decisions. A September 2009 decision denied entitlement to service connection for a right foot disorder, bilateral carpal tunnel syndrome, and a lung disorder. A February 2012 decision denied entitlement to service connection for a left foot disorder. Finally, a July 2013 decision granted service connection for stroke to include mild difficulty swallowing and assigned a 100 percent rating effective November 14, 2012 and a 10 percent rating from June 1, 2013; the Veteran disagreed with the initial 10 percent rating assigned from June 1, 2013. The decision also denied entitlement to a TDIU. In November 2015, the Veteran testified before at a video conference hearing before a Veterans Law Judge; a transcript of the hearing is associated with the claims file. In a September 2018 letter, the Board notified the Veteran that the Veterans Law Judge who presided over the November 2015 hearing was no longer available to prepare a decision on the appeal and offered him the opportunity to appear at another hearing. The Veteran advised VA he did not want another hearing. In January 2016 and September 2017, the Board remanded the issues on appeal for additional development. As a final introductory matter, the issue of entitlement to an increased rating for PTSD requires clarification. A January 2011 decision granted service connection for PTSD and assigned a 30 percent disability rating, effective March 18, 2009. The Veteran disagreed with the initial rating assigned. With his April 2011 notice of disagreement, he circled the paragraph outlining the 50 percent rating criteria for PTSD from the January 2011 decision and stated, “The wife says this is me!” Subsequently, a July 2011 rating decision increased the initial rating for PTSD to 50 percent, effective March 18, 2009. The agency of original jurisdiction (AOJ) advised the Veteran that this “decision represents a favorable resolution of this benefit sought on appeal with an increase to the 50 percent evaluation because you indicated on your notice of disagreement that you met the requirements for the 50 percent evaluation.” In a separate letter issued the same month, the AOJ further notified the Veteran the decision represented a favorable resolution of the benefit sought on appeal and indicated, “If you would like to withdraw your pending appeal at this time, complete and return the enclosed appeal Status Election Form within 60 days.” He did not return the form or otherwise communicate a desire to withdraw his pending appeal. In April 2013, VA received the Veteran’s application for entitlement to a TDIU due to service-connected hypertensive heart disease with coronary artery disease, PTSD, and residuals of a stroke. A January 2014 rating decision increased the assigned rating for PTSD to 70 percent, effective from the date his TDIU claim was received on April 25, 2013. In July 2014, the Veteran expressed disagreement with the 70 percent rating assigned, describing his belief that a 100 percent rating would have been assigned if a VA examination had not been “incomplete.” A September 2016 rating decision increased the rating for PTSD to 100 percent, effective June 1, 2016. In January 2016 and September 2017, the Board had directed the AOJ to issue a statement of the case (SOC) regarding the initial ratings assigned for the Veteran’s PTSD disability. In January 2018, the AOJ issued an SOC regarding the initial 50 and 70 percent ratings for PTSD prior to June 1, 2016, and the Veteran timely appealed in February 2018. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). In addition, service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish direct service connection, there must be: the existence of a present disability; in-service incurrence or aggravation of a disease or injury; and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the case of any veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, campaign, or expedition, the Secretary shall accept as sufficient proof of service connection of any disease or injury alleged to have been incurred in or aggravated by such service, satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Service connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. The reasons for granting or denying service connection in each case shall be recorded in full. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). Service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). 1. Entitlement to service connection for a right foot disorder 2. Entitlement to service connection for a left foot disorder The Veteran contends he has right and left foot disorders that began during military service. In written statements and oral testimony, he asserted that his feet began to hurt doing boot camp after a hard day doing “step-ups” and he asked to go to sick bay. However, his drill instructor hit him three times in the face, then asked him how his feet felt, and sent him back to the Quonset hut. The Veteran reported he never asked to go to sick bay again, but his foot pain continued to the present time. The Veteran’s service treatment records are silent for complains, diagnosis, or treatment for foot problems. On enlistment examination in February 1965 and on separation examination in February 1969, his feet were reported as normal on clinical evaluation. Post-service private treatment records from D. Kraft, M.D., dated from September 1997 to April 2007 and from D. Duncan, M.D., dated from December 2007 to February 2011 are silent for complaints, diagnosis, or treatment for foot problems. The records from Dr. Duncan reflect the Veteran’s reported past surgical history involving the knee, foot, and hand. In September 2008, the Veteran established VA medical care. During his initial primary care visit, he indicated he was a self-employed plumber mainly in the construction industry, but he had not had much work lately. He described a past surgical history of a right foot bunion repair in 1980. A June 2011 primary care nursing note reflects the Veteran’s complaint of right foot pain with certain movements. He described right ankle pain with flexion and extension to the physician. Examination findings included pain with right ankle dorsiflexion and plantar flexion and no specific tender points with palpation. The assessment was ankle pain. A September 2011 primary care note reflects the Veteran’s complaint of pain in the bottom of both feet for about two months, especially in the morning or after sitting. During an October 2011 podiatry consultation, he described pain in his feet for the last several months. The assessment was bilateral plantar fasciitis. Subsequent VA treatment records dating to April 2018 are silent for ongoing problems with plantar fasciitis or complaints, diagnosis, or treatment for other right or left foot problems other than peripheral neuropathy of the lower extremities that developed after the Veteran was diagnosed with diabetes mellitus in February 2012. The Veteran was afforded a VA examination in October 2012. He described a history of having bilateral heel pain, seeking medical treatment a couple months later, and being diagnosed with bilateral plantar fasciitis. Although the Veteran did not assert that he had a right or left foot disability associated with his type II diabetes mellitus, which was diagnosed in February 2012 and later service connected from the date of diagnosis, following an examination and review of the claims file, the examining physician diagnosed bilateral plantar fasciitis and opined it was less likely than not proximately due to or aggravated by his diabetes mellitus. In support of the conclusion, the examiner explained that the diagnosis of bilateral plantar fasciitis preceded the diagnosis of diabetes mellitus, there were no manifestations of foot complications at the time the Veteran was diagnosed with diabetes, and the current sensory neuropathies demonstrated on examination of both feet were associated with demyelination of the sensory nerves due to diabetes. The Veteran was afforded a VA fee-basis examination in May 2016. He reported a history of right foot bunionectomy in 1986. Following a review of the claims file and examination, the diagnosis was bilateral hallux valgus. The examiner opined it was less likely than not that the right or left foot hallux valgus was incurred in or caused by service. The examiner indicated that while the Veteran reported “stepping off a helicopter hard and injuring his foot,” it was less likely than not that the described incident would have caused a hallux valgus deformity, and there was no documentation of an in-service foot injury. In March 2018, the Veteran was afforded another VA fee-basis examination. He reported that in 1965 after basic training, he noticed periodic foot pain, but was not seen in the clinic. He described increased frequency and severity of foot pain since service, being diagnosed with bilateral hallux valgus, and having surgery on the right bunion in 1985. Regarding current symptoms, he reported having dull to sharp, aching pain in both feet periodically after weight-bearing activities, walking, or standing. The diagnosis was bilateral hallux valgus and the examiner indicated the Veteran had no symptoms of plantar fasciitis. Following a review of the electronic claims file, the examiner opined that the Veteran’s hallux valgus disability was less likely than not incurred in or caused by military service. Based on a review of medical literature, the examiner acknowledged that the Veteran’s “footwear in service could have exacerbated an underlying [foot problem].” However, the examiner concluded the reported in-service foot problems were acute because there was no evidence of chronicity of care for either foot after service. Moreover, after the Veteran reportedly underwent a right great toe resection in 1985, there was no evidence of chronicity of care for the right or left foot since that time. Having considered the medical and lay evidence of record, the Board finds that service connection for a right or left foot disorder, including plantar fasciitis or hallux valgus, is not warranted. The Board concludes that while the Veteran has a current diagnosis of bilateral hallux valgus and had bilateral plantar fasciitis during the pendency of the appeal, and the Veteran reported experiencing pain in his feet during boot camp in 1965, the preponderance of the evidence weighs against finding that a right or left foot disability began during service or is otherwise related to an in-service injury or disease. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The May 2016 and March 2018 VA fee-basis examiners opined collectively that the Veteran’s bilateral foot disability was not incurred in or medically related to service because the evidence demonstrated no foot problems in service and a lack of continuity of foot problems after service. The examiners’ opinions are probative and persuasive because they were based on an accurate medical history and provided an explanation that contained clear conclusions supported by the record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). For example, the Board recognizes the Veteran’s account that he did not seek treatment for his feet or other problems during service after being threatened or intimidated by his drill instructor during boot camp. However, the fact remains that even if he experienced pain in his feet during boot camp as he has consistently reported, his feet were examined and determined to be normal four years later at separation examination in 1969. These facts weigh against a finding that any foot pain experienced in 1965 resulted in a chronic foot disability. Also, while the Board acknowledges the Veteran’s status as a combat veteran, he has not identified any foot injury or disease that occurred or began while in engaged in combat. Rather, he has consistently reported that the pain in his feet began during boot camp. Therefore, in the absence of evidence that any foot disability began due to injury or disease incurred during combat, his lay statements alone are insufficient to establish service connection for a right or left foot disability. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). In addition to the Veteran’s normal feet at separation examination, the Board finds the post-service medical evidence weighs against the claim. Nearly two decades of private and VA treatment records reflect a remote surgical history of right foot bunion repair around 1980 or 1985, more than ten years after separation from service, with no further complaints or findings regarding any foot problems until 2011. At that time, he described the onset of his foot pain symptoms to his primary care physician and to a podiatrist as beginning two to three months earlier. In other words, the medical evidence of record, including the Veteran’s lay statements to treatment providers, supports the conclusion that the Veteran did not have ongoing right or left foot problems since boot camp, but instead had a right foot bunion surgically repaired many years after service with no further foot problems until around July 2011, more than 42 years after separation from service. While the absence of evidence does not by itself warrant a negative inference, here given the many years during which the Veteran sought treatment for multiple medical disorders, a notation or reference to right and left foot problems would be expected in these records if the Veteran were experiencing ongoing foot pain since basic training in 1965 as he reported in statements in support of his claim. See Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (citing Fed. R. Evid. 803(7) for the proposition that “the absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded”); see also Kahana v. Shinseki, 24 Vet. App. 428, 438-41 (2011) (Lance, J., concurring) (discussing the distinction between cases in which there is a complete absence of any evidence to corroborate or contradict the testimony, as opposed to cases in which there is evidence that is relevant either because it speaks directly to the issue or allows the Board, as factfinder, to draw a reasonable inference). As such, these records support the findings of the May 2016 and March 2018 VA fee-basis examiners and weigh against any finding of in-service incurrence of a chronic foot disorder, any continuity of symptomatology of foot problems since service, or any medical relationship between the foot pain experienced during boot camp and the right foot bunion that was surgically corrected more than a decade after service or the right and left foot plantar fasciitis and hallux valgus diagnosed more than four decades after separation from service. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim of service connection for right and left foot disabilities, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for bilateral carpal tunnel syndrome The Veteran contends he has a bilateral carpel tunnel syndrome disability that began during military service. In November 2015, he testified that in boot camp he realized his hands were hurting and progressed to where he could hardly use his fingers. He affirmed that he felt numbness in the palms of both hands that began during basic training. The Veteran’s service treatment records are silent for complains, diagnosis, or treatment for problems with his hands or wrists. On enlistment examination in February 1965 and on separation examination in February 1969, his upper extremities and neurologic function were reported as normal on clinical evaluation. Among post-service private treatment records from D. Kraft, M.D., dating since September 1997, the Veteran complained of pain in both hands in September 2001, worse in the right hand, and disclosed a family history of rheumatoid arthritis. X-ray examination of the hands revealed right hand arthritis; the left hand was negative. Dr. Kraft prescribed Celebrex. A December 2007 private treatment record from D. Duncan, M.D., reflects the Veteran’s report of a past surgical history involving his knee, foot, and hand. During a review of systems, he denied any arthritis, myalgias, skeletal problems, or neurological problems. During a February 2008 visit, he complained of stiffness in his right thumb, stating he had been a plumber all his life. Neurological examination was reported as negative. X-ray examination of his right hand the same month revealed degenerative joint disease of the first carpometacarpal joint. In June 2008, he again stated that his hands were hurting. He denied neurological symptoms and neurological examination was negative. The assessment was degenerative joint disease, multiple, primarily right thumb. During a September 2008 VA primary care visit to establish care, the Veteran indicated he was a self-employed plumber mainly in the construction industry, but he had not had much work lately. He described a past surgical history of a right hand tendon repair in 1982. During a review of systems, he endorsed joint pain in his hands. In March 2009, the Veteran presented for an orthopedic consultation to evaluate arthritis primarily in his hands. As an aside, he noted a history of bilateral hand numbness with symptoms present for approximately five years (since 2004). Initially the symptoms were intermittent; however, now his symptoms were near-constant and primarily involving the ulnar three digits of his bilateral hands. The impression included bilateral hand osteoarthritis of most prominent right thumb carpometacarpal joint; bilateral hand numbness, rule out peripheral nerve entrapment. The plan included referral for an EMG/NCS study. During a June 2009 neurological consultation, the Veteran described numbness and tingling in both hands. An EMG/NCS confirmed bilateral carpal tunnel syndrome. He underwent open carpal tunnel release surgery of the right hand in July 2009 and of the left hand in September 2009. The Veteran was afforded a VA examination in October 2012. He described the history of his bilateral carpal tunnel syndrome and release surgeries in 2009. He also described more recent tingling and shots of pain to his hands and feet. The examiner observed that the Veteran had been diagnosed with type II diabetes mellitus in February 2012. Following a review of the claims file and examination, the diagnosis included bilateral carpal tunnel syndrome. Although the Veteran had not claimed that his diabetes either caused or aggravated his carpal tunnel syndrome, the examiner provided an opinion regarding secondary service connection, explaining that diabetes mellitus did not cause or aggravate the Veteran’s carpal tunnel syndrome because it was diagnosed after carpal tunnel syndrome and the Veteran’s primary care physician had detailed that the Veteran had no complications from his diabetes at the time it was diagnosed. During a VA fee-basis examination in May 2016, the Veteran described the onset of bilateral carpal tunnel syndrome occurring in the 1970s from repetitive activity associated with his occupation as a plumber. He stated his symptoms became worse and he had surgery on both wrists in 2009. The diagnosis was bilateral carpal tunnel syndrome. The examining physician reviewed the claims file and opined it was less likely than not that the bilateral carpal tunnel syndrome was incurred in or caused by service. In reviewing the claims file, the examiner observed that service treatment records contained no documentation of carpal tunnel syndrome, lay statements from family members were not pertinent to carpal tunnel syndrome, and the Veteran first complained of bilateral hand numbness in March 2009. The examiner instead opined that the Veteran’s bilateral carpal tunnel syndrome was at least as likely as not the result of post-service repetitive activity related to working in the plumbing industry using his hands for over 20 years. VA requested a supplemental medical opinion to address the Veteran’s lay assertions that he felt pain and numbness in his hands during and since boot camp in 1965. In March 2018, a VA fee-basis examiner review the electronic claims file and opined it was less likely than not that the bilateral carpal tunnel syndrome was incurred in or caused by the Veteran’s military service. In support of the conclusion, the examiner reasoned that while the Veteran may have had symptoms of pain and numbness in service, any such symptoms were acute only because there was no further evidence of such symptoms among post-service treatment records until 2009, many years after service and many years after working as a plumber. Having considered the medical and lay evidence of record, the Board finds that service connection for bilateral carpal tunnel syndrome is not warranted. The Board concludes that while the Veteran has a current diagnosis of bilateral carpal tunnel syndrome and he reported having numbness and pain in his hands during boot camp, the preponderance of the evidence weighs against finding that a carpal tunnel syndrome disability began during service or is otherwise related to an in-service injury or disease. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The May 2016 and March 2018 VA fee-basis examiners opined collectively that the Veteran’s bilateral carpal tunnel syndrome was not incurred in or medically related to service because the evidence demonstrated hand or wrist problems in service and a lack of continuity of such problems after service. The examiners’ opinions are probative and persuasive because they were based on an accurate medical history and provided an explanation that contained clear conclusions supported by the record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this regard, the Board reiterates that even if the Veteran did experience pain and numbness in his hands or wrists during boot camp in 1965 as reported, his upper extremities and neurologic function were normal on separation examination in 1969. These facts weigh against a finding that any hand pain or numbness experienced during boot camp resulted in a chronic disability that progressed to the point that he could barely use his fingers. Also, while the Board acknowledges the Veteran’s status as a combat veteran, he has not identified any hand or wrist injury or disease that occurred or began while in engaged in combat. Rather, he has consistently reported that the numbness and pain in his hands began during boot camp. Therefore, in the absence of evidence that any carpal tunnel syndrome disability began due to injury or disease incurred during combat, his lay statements alone are insufficient to establish service connection for a carpal tunnel syndrome disability. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). In addition to the Veteran’s normal upper extremities and neurologic function at separation examination, the Board finds the post-service medical evidence weighs against the claim. Post-service private and VA treatment records dating since 1997 reflect no complaints or findings attributable to carpal tunnel syndrome until March 2009. At that time, he described the onset of his symptoms beginning about five years earlier, or in 2004. The Board finds these statements regarding the onset of his carpal tunnel syndrome symptoms credible because they were made while seeking treatment. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made for the purposes of medical treatment may be afforded greater probative value because there is a strong motive to tell the truth in order to receive proper care). In summary, the medical evidence of record, including the Veteran’s lay statements to treatment providers, supports the conclusion that the Veteran did not have ongoing carpal tunnel symptoms since boot camp, but instead had developed such symptoms around 2004, more than 35 years after separation from service. As such, these records support the findings of the May 2016 and March 2018 VA fee-basis examiners and weigh against any finding of in-service incurrence of carpal tunnel syndrome, any continuity of symptomatology of hand numbness and pain since service, or any medical relationship between the hand pain and numbness experienced during boot camp and the bilateral carpal tunnel syndrome diagnosed more than 40 years after separation from service. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim of service connection for bilateral carpal tunnel syndrome, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Generally, when an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are also for consideration in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 4. Entitlement to an initial rating in excess of 10 percent for residuals of a stroke to include mild difficulty swallowing The Veteran’s stroke with mild difficulty swallowing was rated 100 percent disabling from November 14, 2012 through May 31, 2013, and has been rated 10 percent disabling since June 1, 2013 pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8008, for thrombosis of brain vessels. Under these criteria, the vascular disability is rated 100 disabling for six months and thereafter is to be rated at a minimum of 10 percent for residuals. By way of history, the medical evidence of records documents that the Veteran underwent a coronary artery bypass graft (CABG) at a private hospital in November 2012 and subsequently suffered a mild cerebrovascular accident (stroke), which resulted in some slurred speech and weakness in his right arm and both hands. He was transferred to the VA medical center where he received acute inpatient rehabilitation therapy. He was discharged one week later. The Board notes that the VA examination reports pertinent to the Veteran’s stroke reference some disorders or manifestations that have been separately service-connected and attributed to his stroke or to other service-connected disabilities. In particular, service connection has been established for the following disabilities associated with his stroke: urinary incontinence, respiratory residuals, loss of smell, and loss of taste. In addition, service connection is in effect for posttraumatic stress disorder (PTSD), for erectile dysfunction associated with PTSD, and for peripheral neuropathy of each upper and each lower extremity secondary to service-connected type II diabetes mellitus. These disabilities are not on appeal. Turning to the evidence, the Veteran was afforded a VA examination in June 2013. He described current symptoms of continued right-sided weakness with slurred speech, which had improved since initial onset. Other signs and symptoms included muscle weakness, mild swallowing difficulties, and urinary incontinence and frequency. Examination findings included the following: normal speech; abnormal gait, requiring use of a cane; less than normal strength (4/5) in the right elbow, wrist, hand, knee, and ankle joints with normal strength in the left-sided joints; and mild muscle weakness in the right upper extremity and right lower extremity, but with no muscle atrophy. As to whether “there was functional impairment of an extremity such that no effective function remains other than that which would be equally served by amputation with prosthesis,” the examiner responded, “Yes.” The examiner described the loss of effective function of the Veteran’s right upper extremity and right lower extremity as “loss of grip and dexterity right hand, 4/5 muscle strength, loss of balance, and some loss of coordination.” In March 2016 correspondence, a private physician, J. Higgins, M.D., described the nature of the Veteran’s heart disease and indicated he was status post cerebrovascular accident with mild right-sided weakness. The Veteran was afforded a VA fee-basis examination in March 2018. He described being unable to move his entire right side and being unable to talk immediately after his November 2012 stroke, adding that his symptoms had improved dramatically, but were still significant. He described current symptoms as weakness with weak grip, short-term memory loss, easy fatigability, periodic dizziness, and decreased taste and smell. He indicated his initial swallowing problems had improved, but he still must take care with eating and drinking. Signs and symptoms of stroke residuals were similar to those reported in the June 2013 examination report, including mild swallowing difficulties, normal speech, and abnormal gait manifested by ataxia with right leg weakness. The examiner indicated the Veteran’s right-sided weakness was more likely than not attributable to his stroke, in most part, and his right-sided instability with standing and walking was attributable to his right-sided diabetic peripheral neuropathy with numbness in tingling of the extremities. Examination findings were similar to those reported in June 2013. However, right wrist and hand strength had diminished to no movement against resistance (3/5), but still without muscle atrophy, and there was moderate weakness in the right upper and right lower extremities. Still, the examiner indicated that right-sided functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner noted depression related to the Veteran’s significant decrease in work and hobby activities due to his stroke; however, it did not result in gross impairment in thought processes or communication. The examiner summarized that the Veteran did not appear to have a speech or major cognitive deficit. He reported short-term memory, taste, and smell loss, as was verified by his spouse during the examination. He continued to have an ataxic gait and self-care issues with dressing and grooming related to his residual right-sided weakness post CVA. In addition, he had depression related to his CVA due to significant decrease in work and hobby activities. VA treatment records since the Veteran’s hospitalization and rehabilitation for his stroke reflect similar symptoms as those documented the VA examination reports, including some ongoing weakness in his right upper and lower extremities, reports of mild memory impairment, and generally clear speech. In May 2016, the Veteran told his primary care provider he still had some right-sided weakness since his stroke, but had been doing better than anyone thought he would. Having considered the medical and lay evidence of record, the Board finds that a rating in excess of 10 percent for stroke with mild difficulty swallowing is not warranted. Since the 10 percent rating was assigned effective June 1, 2013, the Veteran has continued to have mild difficulty swallowing due to his stroke. These findings are consistent with the 10 percent rating currently assigned under Diagnostic Code 8008 for minimum residuals after the six-month period in which the stroke was rated 100 percent disabling. A higher rating is not warranted for difficulty swallowing because the Veteran is not shown to have severe incomplete paralysis of the ninth (glossopharyngeal) cranial nerve. See 38 C.F.R. § 4.124a, Diagnostic Code 8209 (criteria outlining a 20 percent rating for paralysis of the glossopharyngeal nerve). Similarly, in addition to residuals of stroke that are separately service-connected, including urinary incontinence and loss of taste and smell, a separate rating is not warranted for other residuals of stroke because those manifestations are already compensated by other service-connected disabilities including PTSD (memory impairment, sleep disturbance, and depression) and peripheral neuropathy of the right upper and right lower extremities (right-sided weakness, ataxic gait). In this regard, VA is prohibited from evaluating the same disability under various diagnoses. 38 C.F.R. § 4.14. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim for a higher or separate rating than those assigned, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. TDIU 5. Entitlement to a TDIU due to service-connected disabilities The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn by an appellant or by his authorized representative as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. Id. In the present case, the Veteran disagreed with the denial of entitlement to a TDIU. In correspondence received on February 26, 2018, however, he requested to withdraw his current appeal before the Board regarding the TDIU issue. The Board finds that the Veteran’s statements are explicit, unambiguous, and done with a full understanding of the consequences of such action. DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011). Hence, there remain no allegations of errors of fact or law for appellate consideration regarding the issue of entitlement to a TDIU. 38 C.F.R. § 20.204. Thus, the Board does not have jurisdiction to review the appeal of that issue and it is dismissed. REASONS FOR REMAND 1. Entitlement to service connection for a lung or respiratory disorder is remanded. On March 28, 2009, VA received the Veteran’s claim of entitlement to service connection for a lung disorder, to include as due to exposure to herbicide agents during his service in Vietnam and/or due to exposure to asbestos while serving aboard a U.S. naval vessel. The Board remanded the claim for additional development in January 2016 and September 2017. In a May 2018 rating decision, the AOJ granted a separate rating for a respiratory residual of stroke, effective March 29, 2018. Unfortunately, the AOJ has not readjudicated the issue entitlement to service connection for a lung disorder claimed as due to exposure to herbicides and asbestos. The AOJ must issue an SSOC addressing this issue. 2. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) from March 18, 2009 through April 24, 2013, and in excess of 70 percent from April 25, 2013 through May 31, 2016 is remanded. After the Veteran perfected his appeal regarding the initial ratings assigned for PTSD prior to June 1, 2016, he was afforded an additional VA examination and additional, pertinent VA treatment records were associated with the claims file. The AOJ must issue an SSOC addressing the evidence received since the last adjudication in January 2018. The matters are REMANDED for the following action: 1. Readjudicate the issue of entitlement to service connection for a lung disorder, claimed as due to exposure to herbicide agents and/or asbestos, considering the evidence added to the claims file since the August 2016 SSOC. 2. Readjudicate the issue of entitlement to an initial rating in excess of 50 percent for PTSD from March 18, 2009 through April 24, 2013, and in excess of 70 percent from April 25, 2013 through May 31, 2016. Consider the evidence added to the claims file since the January 2018 SOC. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel