Citation Nr: 18153646 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 15-27 054A DATE: November 29, 2018 ORDER Service connection for shin splints is granted. Service connection for a scar on the right forehead is granted. Service connection for residuals of a right foot fracture is denied. Service connection for a bilateral hearing loss disability is denied. An initial rating of 10 percent, and no higher, for hypertension is granted. An initial compensable rating prior to August 28, 2017 is denied, an initial rating of 10 percent from August 28, 2017 to March 28, 2018 is granted, and an initial rating in excess of 10 percent since August 28, 2017 for gastroesophageal reflux disease (GERD) is denied. An initial compensable rating for right fifth finger trigger finger (hereinafter “right fifth finger disability”) is denied. An initial compensable rating for erectile dysfunction (ED) is denied. An initial rating in excess of 10 percent for a right wrist ganglion cyst (hereinafter “right wrist disability”) is denied. An effective date earlier than February 1, 2012 for the grant of service connection for lumbar degenerative joint disease and strain (hereinafter “lumbar spine disability”) is denied. An effective date earlier than February 1, 2012 for the grant of service connection for cervical spine degenerative joint disease and strain (hereinafter “cervical spine disability”) is denied. An effective date earlier than February 1, 2012 for the grant of service connection for bilateral plantar fasciitis with spurs is denied. An effective date earlier than February 1, 2012 for the grant of service connection for obstructive sleep apnea and chronic obstructive pulmonary disease (COPD) is denied. An effective date earlier than February 1, 2012 for the grant of service connection for eczema and pseudofolliculitis barbae (PFB) is denied. REMANDED Entitlement to service connection for Chronic Fatigue Syndrome (CFS) is remanded. Entitlement to service connection for Gulf War Syndrome is remanded. Entitlement to service connection for a dental disability, for compensation purposes, is remanded. Entitlement to an initial rating in excess of 10 percent for lumbar spine disability is remanded. Entitlement to an initial rating in excess of 20 percent for cervical spine disability is remanded. Entitlement to an initial compensable rating for bilateral plantar fasciitis with spurs is remanded. Entitlement to an initial rating in excess of 50 percent for obstructive sleep apnea and COPD is remanded. Entitlement to an initial compensable rating for eczema and PFB remanded. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to additional special monthly compensation (SMC) is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s shin splints were incurred in service. 2. The Veteran’s scar on his right forehead was incurred in service. 3. The Veteran has not been shown to have any current residuals of an in-service right foot fracture at any time since separation from service. 4. The Veteran has not been shown to have a current bilateral hearing loss disability under VA statutes and regulations at any time since separation from service. 5. The Veteran is in receipt of service connection for hypertension, GERD, right fifth finger disability, ED, and right wrist disability effective February 1, 2012, the day following his separation from active service. 6. For the entire initial rating period since February 1, 2012, the Veteran’s hypertension has been manifested by a history of diastolic pressure predominantly 100 or more and requires continuous medication for control; and there is no evidence that his diastolic pressure has been predominantly 110 or more nor that his systolic pressure has been predominantly 200 or more. 7. Prior to August 28, 2017, the Veteran’s GERD was essentially asymptomatic. 8. From August 28, 2017 to March 28, 2018, the Veteran’s GERD was manifested by dysphagia and regurgitation but of less severity required for the next-higher rating of 30 percent. 9. Since August 28, 2017, the Veteran’s GERD has not been manifested by persistently recurrent epigastric distress with dysphagia (difficulty swallowing), pyrosis (heartburn), and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 10. For the entire initial rating period since February 1, 2012, the Veteran’s right fifth finger disability has not been manifested by amputation nor extremely unfavorable ankylosis. 11. For the entire initial rating period since February 1, 2012, the Veteran’s ED has not been manifested by deformity of the penis. 12. For the entire initial rating period since February 1, 2012, the Veteran’s right wrist disability has not been manifested by ankylosis. 13. The Veteran is in receipt of service connection for a lumbar spine disability, cervical spine disability, bilateral plantar fasciitis, obstructive sleep apnea and COPD, and eczema and PFB effective February 1, 2012, the day following the Veteran’s separation from active service. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran’s favor, the criteria the criteria for service connection for shin splints have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303(d) (2018). 2. With resolution of reasonable doubt in the Veteran’s favor, the criteria the criteria for service connection for a scar on the right forehead have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303(d). 3. The criteria for service connection for residuals of a right foot fracture have not been met. 38 U.S.C. §§ 1110, 1131, 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303 (2018). 4. The criteria for service connection for a bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309(a), 3.385 (2018). 5. The criteria for an initial rating of 10 percent, and no higher, for hypertension have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.327, 4.104, Diagnostic Code (DC) 7101 (2018). 6. Prior to August 28, 2017, the criteria for an initial compensable rating for GERD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.327, 4.114, DC 7346 (2018). 7. From August 28, 2017 to March 29, 2018, the criteria for an initial rating of 10 percent for GERD have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.327, 4.114, DC 7346. 8. Since August 28, 2017, the criteria for an initial rating in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.327, 4.114, DC 7346. 9. The criteria for an initial compensable rating for a right fifth finger disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.327, 4.71a, DC 5230 (2018). 10. The criteria for an initial compensable rating for ED have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.327, 4.115b, DC 7522 (2018). 11. The criteria for an initial rating in excess of 10 percent for a right wrist disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.327, 4.71a, DC 5215 (2018). 12. The criteria for an effective date earlier than February 1, 2012 for the grant of service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. § 3.400(b)(2) (2018). 13. The criteria for an effective date earlier than February 1, 2012 for the grant of service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400(b)(2). 14. The criteria for an effective date earlier than February 1, 2012 for the grant of service connection for bilateral plantar fasciitis have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400(b)(2). 15. The criteria for an effective date earlier than February 1, 2012 for the grant of service connection for obstructive sleep apnea and COPD have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400(b)(2). 16. The criteria for an effective date earlier than February 1, 2012 for the grant of service connection for eczema and PFB have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400(b)(2). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1988 to January 2012. Given the decision below for the issues of entitlement to service connection for shin splints and right forehead scar, a detailed explanation of how VA complied with its duties to notify and assist is unnecessary. With regard to the issues of entitlement to service connection for right foot fracture and bilateral hearing loss disability, the requirements of 38 U.S.C. §§ 5103 and 5103A have been met. VA’s duty to notify was satisfied by an October 2011 letter. 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2018). As service connection, an initial rating, and an effective date have been assigned for the issues of higher initial ratings for service-connected hypertension, GERD, right fifth finger disability, ED, and right wrist disability, the notice requirements of 38 U.S.C. § 5103(a) have been met. Next, VA fulfilled its duty to assist the Veteran regarding the issues of entitlement to service connection for right foot fracture and bilateral hearing loss disability and higher initial ratings for service-connected hypertension, GERD, right fifth finger disability, ED, and right wrist disability by obtaining identified and available evidence needed to substantiate a claim to include where warranted by law, and affording the claimant VA examinations, VA medical opinions, and a hearing before the Board. 38 U.S.C. §§ 5103, 5103A. Although the Veteran was not afforded VA examinations for his service-connected right fifth finger and right wrist disabilities during the appeal period, none is required. As will be discussed below, the Board finds that the evidentiary record does not show, nor has the Veteran alleged, that those disabilities have worsened to a degree warranting higher initial ratings. See Waters v. Shinseki, 601 F.3d 1274, 1277 (Fed. Cir. 2010); Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010). Additionally, there is no objective or subjective evidence indicating that there has been a material change in the severity of his remaining service-connected disabilities discussed on the merits below since he was last examined in December 2014 for hypertension, April 2018 for GERD, and August 2017 for ED. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95; 60 Fed. Reg. 43186 (1995). There is no evidence that additional records have yet to be requested. In sum, there is no evidence of any VA error in notifying or assisting him that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the provisions of 38 C.F.R. § 3.303(b) apply only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Service connection can also be established through application of statutory presumptions, including for “chronic diseases,” such as organic diseases of the nervous system which include sensorineural hearing loss, when manifested to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a); see also Cromley v. Brown, 7 Vet. App. 376, 378 (1995) (sensorineural hearing loss). Service connection may be granted on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of qualifying chronic disability, including resulting from undiagnosed illness, that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021 and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117 (2012); 38 C.F.R. § 3.317(a)(1) (2018). A “qualifying chronic disability” for VA purposes is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). In this case, the Board finds that the evidence of record does not show, as discussed below, objective indications of residuals of a right foot fracture or bilateral hearing loss that became manifest either during any service in the Southwest Asia theater of operations or to a degree of 10 percent since separation from service. As a result, the Board finds that service connection on a presumptive basis for a Persian Gulf Veteran does not apply in this case. 1. Shin splints The Veteran contends that he suffers from shin splints that developed in service. The record demonstrates that the Veteran was diagnosed with shin splints during the appeal period, as noted in a December 2013 VA examination report. Next, service treatment records reflect that he was treated in December 2010 for pain in both legs after running. At that time, he reported that he had purchased new shoes, which improved his left leg symptoms, but that his right leg was still bothering him. The December 2013 VA examiner noted that, clinically, the Veteran was suffering from a case of bilateral shin splints and was counseled on various methods to aid in recovery. Thereafter, the Veteran has repeatedly asserted that he has had persistent shin splint-related symptoms since his separation from service. While the December 2013 VA examiner concluded it was less likely than not that the Veteran’s shin splints were incurred in or caused by an in-service injury, the Board finds this opinion lacks probative value because is based on an inaccurate factual history. Specifically, the VA examiner noted review of the claims file and rendered a negative nexus opinion but relied on her own conclusion that the Veteran had no history of an in-service occurrence. In light of the finding above that the element of an in-service occurrence has been met in this case, the Board finds that the December 2013 VA examiner’s opinion regarding the etiology of the Veteran’s shin splints was based on an inaccurate finding of fact thus lacks probative value. In contrast, the Board finds the most probative evidence of record demonstrates that the Veteran’s current bilateral shin splints were incurred in service. As noted above, there is a clinical in-service diagnosis and a post-service diagnosis rendered shortly after the Veteran’s discharge, as well as lay reports from the Veteran of ongoing shin-related pathology. The Board notes that the Veteran is competent to report observable symptoms, such as pain in his shins. See Layno v. Brown, 6 Vet. App. 465 (1994). In sum, the Board finds that the evidence discussed above shows that the Veteran’s shin splints were incurred in service, thus service connection is warranted. See 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(d). 2. Scar on forehead The Veteran contends that he suffered a wound above his right eyelid in service that required stiches and resulted in a scar. During a VA examination in November 2011, a small non-disfiguring scar was observed on the Veteran’s right eyelid. In September 2013, the Veteran submitted a photograph showing a small scar near his right eyelid, consistent with his contentions and the in-service examination report. In addition, he has submitted several lay statements, to include the February 2014 notice of disagreement, reporting that he was hit in the head in service and required stitches, which resulted in scarring. The Board finds these statements both competent and credible. In sum, because the probative lay and medical evidence discussed above demonstrates that the Veteran has a current scar on his right forehead that was incurred in service, his claim for service connection is warranted. See 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(d). 3. Residuals of a right foot fracture The Veteran contends that he suffers from residuals of a right foot fracture incurred in service. The Veteran’s service treatment records indicate that he fractured his right foot in 2009. Thereafter, a November 2011 VA examination report notes a history of “remote fracture” of the right foot. Upon clinical evaluation by a private physician in January 2013, a Disability Benefits Questionnaire (DBQ) noted the Veteran sought treatment for right foot pain, X-rays revealed no abnormalities, and a diagnosis of plantar fasciitis was noted (the Veteran has since been awarded service connection for this disability). On review, the Board finds that the Veteran has not been shown to have any current residuals of an in-service right foot fracture at any time since separation from service. The Board notes that although the Veteran has generally asserted that he is entitled to service connection for residuals of a right foot fracture, and is competent to report symptoms such as pain in his right foot, he is not competent to establish the specific etiology of this symptomatology. See Layno, 6 Vet. App. at 469-70; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The competent and probative medical evidence of record, specifically to include the January 2013 private DBQ, reflects that these symptoms are attributable to the Veteran’s service-connected plantar fasciitis for which he is receiving disability compensation. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability—i.e., a functional impairment of earning capacity—there can be no valid claim, on either a direct or secondary basis. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). Here, while the Board acknowledges that the Veteran fractured his right foot in service, the most probative evidence weighs against his claim of a current disability manifested by fracture residuals that are separate and distinct from his service-connected plantar fasciitis. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against this claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Bilateral hearing loss disability The Veteran contends that he has a bilateral hearing loss disability that was incurred in service. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory thresholds in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Hearing loss does not constitute a disability if it does not meet the threshold requirements for 38 C.F.R. § 3.385. Palczewski v. Nicholson, 21 Vet. App. 174, 179-80 (2007). During a pre-discharge VA examination in December 2011, audiological findings reflected pure tone averages, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 10 10 20 25 LEFT 15 10 10 25 25 Speech audiometry revealed speech recognition ability of 98 percent in the right ear and 100 percent in the left ear. The examiner noted that the Veteran had normal hearing bilaterally. No nexus opinion was provided, as the Veteran’s hearing loss did not rise to the level of disability for VA purposes. In a November 2012 statement, the Veteran’s wife reported that the Veteran had hearing trouble, and that when speaking to the Veteran, one had to repeat oneself constantly. On VA examination in December 2013, audiological findings revealed pure tone averages, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 15 25 25 LEFT 20 15 5 20 25 Speech audiometry revealed speech recognition ability of 100 percent in both ears. The examiner noted that the Veteran had normal hearing bilaterally. An etiology opinion was not indicated. On review, VA outpatient treatment notes do not reflect that the Veteran has ever been seen for hearing loss, and the Veteran has not alleged at any time since the December 2013 VA examination that his hearing has worsened to warrant an additional VA audiological evaluation. Based on the above, the Board finds that service connection cannot be granted because the evidence does not demonstrate that the requirements for a current disability provided in 38 C.F.R. § 3.385 have been met. In short, there is simply no evidence that the thresholds in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz have ever been 40 decibels or greater, or that the thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz have been 26 decibels or greater, for either ear. There is likewise no evidence of speech recognition scores of less than 94 percent. The existence of a current disability is an essential element of a claim for VA disability compensation. See Brammer, 3 Vet. App. at 223. The Board has considered the Veteran’s reports of subjective hearing loss since his service (as well as the March 2003 report of possible hearing loss noted in his service treatment records). Nevertheless, while he is certainly competent to report these symptoms, to the extent that he claims to have had a bilateral hearing loss disability during the pendency of his appeal, the medical evidence of record, specifically to include the December 2013 audiogram and speech recognition results, reflects otherwise, and is more probative than the Veteran’s lay statements. See Layno, 6 Vet. App. at 469-70; Jandreau, 492 F.3d at 1377. In sum, the evidence of record does not establish that the Veteran has had a current bilateral hearing loss disability at any time since separation from service, nor does the weight of the evidence suggest that an organic disease of the nervous system associated with hearing loss manifested in service or within one year of separation from service. See 38 C.F.R. §§ 3.303(b), (d), 3.307(a)(3), 3.309(a); Walker, 708 F.3d at 1331. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against this claim, the doctrine is not for application. Gilbert, 1 Vet. App. at 49. Higher Initial Ratings Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two 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 evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran’s disability should be viewed in relation to its history. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Given the nature of the present claims for higher initial evaluations, the Board has considered all evidence of severity since the effective date for the award of service connection on February 1, 2012. Fenderson v. West, 12 Vet. App. 119 (1999). At the outset, the Board notes that in an October 2012 notice of disagreement, the Veteran expressed disagreement with the assignment of the effective date for the grant of service connection for hypertension, GERD, right fifth finger disability, ED, and right wrist disability. In this case, the Veteran filed his initial claims for service connection for these disorders in October 2011, which was prior to his discharge from active service in January 2012. The RO subsequently granted the claims and assigned an effective date of February 1, 2012, the day following the Veteran’s separation from active service. Under 38 C.F.R. § 3.400(b)(2), that is the earliest effective date allowable by law. 5. Entitlement to an initial compensable rating for hypertension The Veteran contends that his hypertension is more severe than his currently-assigned noncompensable rating. The Board considers whether an initial compensable rating for hypertension is warranted at any time since the date of claim on February 1, 2012. The Veteran’s hypertension is evaluated under DC 7101. See 38 C.F.R. § 4.104. Under DC 7101, a 10 percent rating is warranted when diastolic pressure is predominantly 100 or more; systolic pressure is predominantly 160 or more; or the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent rating is warranted when diastolic pressure is predominantly 110 or more or systolic pressure is predominantly 200 or more. A 40 percent rating is warranted when diastolic pressure is predominantly 120 or more. Finally, a 60 percent rating, the maximum available, is warranted when diastolic blood pressure is predominantly 130 or more. In this case, the Board finds that for the entire initial rating period since February 1, 2012, the evidence of record warrants an initial rating of 10 percent as the Veteran has been shown to have a history of diastolic pressure predominantly 100 or more which has required continuous medication for control. Notably, following a pre-discharge examination in November 2011, an examiner marked “yes” when asked if the Veteran had a history of diastolic blood pressure elevation to predominantly 100 or more. Thereafter, the record shows that the Veteran has required continuous medication to control his hypertension throughout the appeal period. The Board is aware that the most recent VA examination of record, conducted in November 2014, included a negative response regarding whether the Veteran had a history of diastolic blood pressure elevation to predominantly 100 or more. Given the strict wording of the DC, this finding is irrelevant, as it does not change the fact that the Veteran had a previously-demonstrated “history” of elevated diastolic blood pressure. Once that fact is established, the only remaining element is that the Veteran requires continuous medication to control his hypertension. As is noted above, the evidence of record, to include the November 2014 VA examination report, demonstrates that he does require continuous medication for this purpose. Hence, the requirements for a compensable rating have been met, but no higher. Review of the lay and medical evidence of record does not indicate his diastolic pressure has been predominantly 110 or more nor that his systolic pressure has been predominantly 200 or more to justify a rating in excess of 10 percent. Therefore, an initial rating in excess of 10 percent for hypertension is not warranted in this case. See 38 C.F.R. § 4.104, DC 7101. 6. Entitlement to an initial compensable rating prior to March 29, 2018 and in excess of 10 percent thereafter for GERD The Veteran contends that his GERD is more severe than his currently-assigned ratings. In an October 2012 VA rating decision, service connection for GERD was granted and assigned as noncompensable (0 percent) effective from February 1, 2012. During the course of the appeal, in a May 2018 VA rating decision, a 10 percent disability rating was assigned effective from March 29, 2018. Since the 0 and 10 percent disability ratings are not the maximum ratings available prior to March 29, 2018 or thereafter, the issue has been characterized page accordingly. See AB v. Brown, 6 Vet. App. 35 (1993). The Board considers whether an initial compensable rating prior to March 29, 2018 and in excess of 10 percent thereafter for GERD is warranted in this case. The Veteran’s symptoms for GERD are evaluated under DC 7346. See 38 C.F.R. § 4.114. Under DC 7346, a 10 percent rating is warranted for disability manifested by two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is contemplated for persistently recurrent epigastric distress with dysphagia (difficulty swallowing), pyrosis (heartburn), and regurgitation, accompanied by substernal or arm or shoulder pain, causing considerable impairment of health. A 60 percent rating, the maximum available, 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. On VA examination in September 2012, a diagnosis of GERD was noted; however, the examiner indicated that the Veteran’s symptoms were well-controlled with medication. No current symptoms were reported. Additionally, there was no evidence of esophageal stricture, spasm, or an acquired diverticulum of the esophagus. A VA examination conducted in December 2013 likewise showed that the Veteran’s GERD was well-controlled, with no signs or symptoms noted. On VA examination in November 2014, the Veteran reported that he experienced some regurgitation if he did not take his medications. This was the only sign or symptom associated with GERD that was noted by the examiner. On August 28, 2017, the Veteran presented for a GI consultation with symptoms of dysphagia and regurgitation due to GERD. An endoscopy was performed in September 2017, which revealed normal findings. On VA examination in March 2018, the Veteran reported symptoms of dysphagia, pyrosis, reflux, and regurgitation. However, there was no indication of persistently recurrent epigastric distress, substernal arm or shoulder pain, or overall symptoms productive of considerable impairment of health. There was likewise no evidence of vomiting, material weight loss, hematemesis, or melena with moderate anemia. No evidence of esophageal stricture, spasm, or acquired diverticulum was noted. Subsequent VA treatment notes reflect that the Veteran continues to be followed for his GERD, but there is no evidence that his condition has worsened since the March 2018 examination. On review, when applying the facts of this case to the applicable diagnostic criteria, the Board finds that an initial rating of 10 percent is warranted since August 28, 2017, as that is the first date on which it is factually ascertainable that he experienced two or more of the symptoms of less severity listed under the 30 percent criteria. As noted above, on that date he presented for a GI consult with dysphagia and regurgitation, both of which are contemplated under the 30 percent criteria. See 38 C.F.R. § 4.114, DC 7346. For the appeal period from February 1, 2012 to August 27, 2017, the Board finds that the Veteran’s GERD was essentially asymptomatic thus a compensable rating is not warranted. As discussed above, the Veteran participated in three VA examinations during this period which collectively demonstrated, at worst, symptoms of regurgitation. As this is just one of the symptoms listed under the 30 percent criteria, it is insufficient to warrant a compensable rating during the appeal period prior to August 28, 2017. Likewise, the Board finds that an initial rating in excess of 10 percent since August 28, 2017 is not warranted. Again, the Board acknowledges the Veteran’s requests for a higher rating in this case. However, once again, the Board must point out that he has not identified any specific symptoms that would justify a higher rating under DC 7346. Moreover, the March 2018 VA examination report, completed by a medical professional with consideration of the Veteran’s lay reports regarding his symptoms, demonstrates that the criteria for a 30 percent rating have not been met. In short, the evidence of record during this appeal period does not suggest that the Veteran has ever experienced persistently recurrent epigastric distress or substernal or arm or shoulder pain, or that his overall GERD-related symptomatology has caused considerable impairment of health to warrant the next-higher 30 percent rating. See 38 C.F.R. § 4.114, DC 7346. The Board notes that, when evaluating this claim, consideration has been given to other DCs which apply to disorders of the gastric system. See Schafrath, 1 Vet. App. at 589. On review, however, the evidence of record does not indicate findings of obstructions, adhesions, gastritis, colitis, or other symptoms that could warrant a higher initial rating under any other applicable DCs at any time during the entire appeal period. Accordingly, given the Veteran’s symptomatology, the most appropriate DC for rating purposes is DC 7346. 7. Entitlement to an initial compensable rating for right fifth finger disability The Veteran contends that his right fifth finger disability (little finger) is more severe than his currently-assigned noncompensable rating. The Board considers whether an initial compensable rating for right fifth finger disability is warranted at any time since the date of claim on February 1, 2012. The Veteran’s symptoms are rated under DC 5230. See 38 C.F.R. § 4.71a. Under DC 5230, any limitation of motion of the little finger is rated as noncompensable. DC 5227 provides that favorable or unfavorable ankylosis of the ring or little finger must also be rated noncompensable. A compensable rating for a little finger disability requires amputation, or the functional equivalent thereof. See 38 C.F.R. § 4.71a, DC 5156. In this case, as an initial matter, the Board finds that DC 5230 most accurately reflects the Veteran’s disability. Service connection has been granted for only the right fifth finger; thus, the rating criteria for multiple digits are not applicable. After careful review, the Board finds that the evidence does not demonstrate that the criteria for a compensable rating have been met. The most probative evidence does not demonstrate that the Veteran’s right little finger symptoms are functionally equivalent to amputation. On VA examination in November 2011 (prior to his discharge from service), the Veteran reported severe pain (including flare-ups) in his right little finger necessitating cortisone shots. However, there was no evidence of limitation of motion or loss of strength for any of the fingers or the thumb on the right hand. No ankylosis was indicated. The examiner opined that there was not functional impairment such than no effective function remained other than that which would be equally well served by an amputation. Since that time, the Veteran has received ongoing VA treatment for various disabilities, to include his right little finger disability. However, there is no evidence to suggest that his right little finger has materially worsened to the point that it is functionally equivalent to amputation. As discussed above, the record shows that the Veteran’s right little finger is intact, and there is no indication that any of the finger joints are ankylosed. Notably, the Veteran has never alleged that his finger has ever been functionally useless. The Board has considered whether an initial compensable evaluation is warranted for the Veteran’s right little finger based on functional loss due to pain, weakness, excess fatigability, incoordination, and flare-ups. However, in Johnston v. Brown, 10 Vet. App. 80, 85 (1997), the United States Court of Appeals for Veterans Claims (Court) determined that if a claimant is already receiving the maximum disability rating available based on symptomatology that includes limitation of motion, it is not necessary to consider whether 38 C.F.R. § 4.40 and 4.45 are applicable. A noncompensable evaluation is the maximum rating allowable under DC 5230. Accordingly, the aforementioned provisions of 38 C.F.R. § 4.40 and § 4.45 are not applicable. In sum, for the reasons discussed above, the Board finds that an initial compensable rating for right fifth finger disability is not warranted in this case. See 38 C.F.R. § 4.71a, DC 5230. 8. Entitlement to an initial compensable rating for ED The Veteran contends that his ED is more severe than his currently-assigned noncompensable rating. The Board considers whether an initial compensable rating for ED is warranted at any time since the date of claim on February 1, 2012. The symptoms of ED are, in part, contemplated by an award of SMC for the loss of use of a creative organ. See 38 U.S.C. § 1114(k). The Veteran is currently in receipt of SMC for his ED, effective February 1, 2012. A compensable schedular rating for ED may also be assigned when there is associated deformity of the penis, pursuant to 38 C.F.R. § 4.115b, DC 7522. Under that DC, a 20 percent rating is warranted for deformity of the penis with loss of erectile power. The Veteran has reported difficulties performing sexually as a result of his ED; these symptoms are compensated by his award of SMC. However, additional compensation in the form of a compensable schedular rating is not warranted in this case, as the evidence of record does not establish that the Veteran has had a penile deformity associated with ED at any time during the appeal period. Notably, the Veteran underwent a VA male reproductive system examination in August 2017, during which he reported that he was unable to achieve an erection sufficient for penetration and ejaculation without medication. On physical examination, his penis, testes, and epididymis were shown to be normal. No penile deformities of any kind were noted. The Veteran did report testicular pain which he believed was secondary to his ED; however, the examiner attributed this to neuropathy, and not to the Veteran’s ED (the examiner noted that ED “does not cause any pain in the testicular area at all”). The Board notes that the Veteran has filed separate claims for service connection for bilateral testicular pain and prostate problems. These claims are currently pending at the RO and the Board does not have jurisdiction to review them at this time. In sum, for the reasons discussed above, the Board finds that an initial compensable rating for ED is not warranted in this case. See 38 C.F.R. § 4.115b, DC 7522. 9. Entitlement to an initial rating in excess of 10 percent for right wrist disability The Veteran contends that his right wrist disability is more severe than his currently-assigned 10 percent rating. The Board considers whether an initial rating in excess of 10 percent for right wrist disability is warranted at any time since the date of claim on February 1, 2012. As a preliminary matter, the Board notes that the Veteran’s right wrist disability is currently evaluated under DC 5271. 38 C.F.R. § 4.71a. This DC applies to disability of the ankle, and is therefore inappropriate. Rather, the Board finds that DC 5215, which governs wrist disabilities, is the appropriate DC in this case. Id.; see Pernorio v. Derwinski, 2 Vet. App. 625 (1992) (holding that a change in the applicable DC is permissible as long as it is explained). DC 5215 provides that limitation of motion of the major and minor wrist with palmar flexion limited in line with the forearm warrants a 10 percent disability rating. Alternatively, a 10 percent rating may be assigned for limitation of motion of dorsiflexion of the wrist less than 15 degrees. An initial rating in excess of 10 percent is warranted where there is ankylosis of the wrist under DC 5214. 38 C.F.R. § 4.71a. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992). The Veteran was afforded a pre-discharge VA examination for his wrist in November 2011. He reported flare-ups of the right wrist with moderate pain on use. Range of motion testing of the right wrist revealed flexion to 70 degrees, with objective evidence of painful motion beginning at 70 degrees; and dorsiflexion to 70 degrees, with objective evidence of painful motion beginning at 70 degrees. No additional functional loss was noted after repetitive-use testing, and no loss of strength was noted. No ankylosis in the wrist joints was noted. The VA examiner noted that X-rays were negative, and the Veteran’s right wrist disability would not impact his ability to work. The Board notes that the Veteran is already in receipt of the maximum schedular rating under DC 5215, which contemplates the effects of limitation of motion of the wrist. While the Board must consider functional loss factors such as painful motion or limited motion due to pain, weakness, and excess fatigability, because the Veteran is already receiving the highest scheduler rating available for limitation of motion of the wrist under DC 5215, a higher disability rating based on these factors is not available. Johnston, 10 Vet. App. at 84-85. The Board also notes that the Veteran has not been shown to suffer from ankylosis of the right wrist at any point during the appeal period. Therefore, an initial rating in excess of 10 percent for ankylosis of the wrist is not warranted in this case. See 38 C.F.R. § 4.71a, DCs 5214 & 5215. Lastly, with regard to each service-connected disability discussed above, the Board considers the Veteran’s reported history of symptomatology related to his hypertension, GERD, right fifth finger disability, ED, and right wrist disability. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through one’s senses. Layno, 6 Vet. App. at 470. In this case, although the descriptions of his symptoms are competent and credible, they do not show that the criteria for higher initial ratings for these disabilities have been met. Kahana v. Shinseki, 24 Vet. App. 428 (2011). In this case, competent evidence concerning the nature and extent of the Veteran’s disabilities has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran’s subjective reported worsened symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board has also considered the possibility of staged ratings and finds that the proper ratings for hypertension, GERD, right fifth finger disability, ED, and right wrist disability, have been in effect for the appropriate periods on appeal. Accordingly, any additional staged ratings are inapplicable. See Hart, 21 Vet. App. at 505. Earlier Effective Date for the Grant of Service Connection 10. Lumbar spine disability 11. Cervical spine disability 12. Bilateral plantar fasciitis with spurs 13. OSA and COPD 14. Eczema and PFB The statutory and regulatory guidelines for the determination of an effective date of an award of disability compensation are set forth in 38 U.S.C. § 5110 and 38 C.F.R. § 3.400. The effective date of an evaluation and an award of compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefore. See 38 C.F.R. § 3.400. Notably, the provisions of 38 C.F.R. § 3.400(b)(2) allow for assignment of an effective date on the day following separation from active service if a claim is received within one year from separation from service. In this case, the Veteran filed his initial claims for service connection for lumbar spine disability, cervical spine disability, bilateral plantar fasciitis, obstructive sleep apnea and COPD, and eczema and PFB in October 2011, which was prior to his discharge from active service in January 2012. The RO subsequently granted the claims and assigned an effective date of February 1, 2012, the day following the Veteran’s separation from active service. Under 38 C.F.R. § 3.400(b)(2), that is the earliest effective date allowable by law. The pertinent legal authority governing effective dates in this case is clear and specific, and the Board is bound by such authority. The Veteran’s claims for earlier effective dates must be denied. REASONS FOR REMAND 1. Entitlement to service connection for CFS 2. Entitlement to service connection for Gulf War Syndrome The Veteran contends that he has CFS which developed during his deployment to Southwest Asia. Notably, his service treatment records reflect numerous notations of “fatigue” and “tiredness” following his return from deployment. On VA examination in December 2013, it was conceded that the Veteran had symptoms of fatigue and tiredness; however, there was no current diagnosis of CFS and the examiner concluded the Veteran’s fatigue is secondary to multiple conditions including insomnia and hypogonadism while also noting the Veteran’s current diagnoses of GERD and peptic ulcer disease. The Board finds that an additional VA medical opinion is needed to clarify the etiology of the Veteran’s current symptoms of fatigue and tiredness, to include consideration of notation of these symptoms in the Veteran’s service treatment records. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate). The Veteran also contends that he developed Gulf War Syndrome as a result of his deployment in Southwest Asia. In this case, although the Veteran was afforded a VA Gulf War examination in December 2013, the report failed to discuss the vast majority of the Veteran’s documented symptoms over the course of the appeal period. The only symptoms actually discussed pertained to the Veteran’s claimed CFS, which it was determined he did not have. Consequently, the Board finds that the examination was inadequate, and the claim for service connection for Gulf War Syndrome should be remanded for an additional VA examination. See Barr, 21 Vet. App. at 312. 3. Entitlement to service connection for a dental disability, for compensation purposes The Veteran contends that he developed dental problems while in service. The Board notes that, under applicable law, service connection is permitted for dental disability for purpose of outpatient treatment but not compensation, barring loss of substance of body of the maxilla or mandible, or of surrounding soft tissue. See 38 C.F.R. § 4.150, DC 9913 (2018) (provision of VA rating schedule on compensation for dental disability). Moreover, pursuant to 38 C.F.R. § 3.381(b), treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not compensable disabilities. 38 C.F.R. § 3.381(b). The Veteran has submitted private dental records which indicate that he was treated in 2011 (during his period of active duty) for a variety of dental problems, including “gingival recession,” indicating possible soft-tissue loss. To date, however, the Veteran has not been afforded a VA examination to evaluate his condition. Accordingly, an examination is needed to clarify any current dental diagnoses and the etiologies thereof. See 38 C.F.R. § 3.159(c)(4); McClendon v. Nicholson, 20 Vet. App. 79 (2006) (describing the circumstances under which VA has a duty to provide a VA medical examination or opinion). 4. Entitlement to an initial rating in excess of 10 percent for lumbar spine disability 5. Entitlement to an initial rating in excess of 20 percent for cervical spine disability 6. Entitlement to an initial compensable rating for bilateral plantar fasciitis with spurs The Veteran contends that his lumbar and cervical spine disabilities, as well as his bilateral plantar fasciitis with spurs, warrant higher initial ratings. He last underwent a VA examination for these disabilities in November 2011, prior to his discharge from active duty. In light of the Veteran’s reports of worsening symptoms and the lengthy period of time since he was last examined, the Board finds that updated examinations are needed. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered “contemporaneous”). 7. Entitlement to an initial rating in excess of 50 percent for obstructive sleep apnea with COPD The Veteran contends that his service-connected obstructive sleep apnea and COPD warrants a higher initial rating. He last underwent a VA respiratory examination in November 2011, prior to his discharge from active duty. He has not been afforded an examination during the appeal period. The Veteran’s symptoms are currently evaluated under DC 6847, which applies to sleep apnea. See 38 C.F.R. § 4.100. This DC provides that an increased 100 percent rating would be warranted for chronic respiratory failure with carbon dioxide retention or cor pulmonale, or if the Veteran required a tracheotomy. However, because the Veteran is also service-connected for COPD, an alternative evaluation may be available under DC 6604, which specifically applies to that disorder. DC 6604 provides, for example, that an increased 60 percent rating would be warranted for forced expiratory volume in one second (FEV-1) of 40- to 55-percent predicted, or; FEV-1/forced vital capacity (FVC) of 40 to 55 percent, or; diffusion capacity of the lung by the single breath method (DLCO (SB)) of 40- to 55-percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg in (with cardiorespiratory limit). 38 C.F.R. § 4.100, DC 6604. The Board notes that the Veteran has not undergone pulmonary function testing since prior to his discharge from active service. Without the necessary lung function tests, the Board cannot determine the current nature and severity of the Veteran’s respiratory symptoms. Consequently, an updated examination is needed. See Green, 1 Vet. App. at 124; Caffrey, 6 Vet. App. at 381. 8. Entitlement to an initial compensable rating for eczema and PFB The Veteran’s eczema and PFB symptoms are rated as noncompensable under DC 7806. 38 C.F.R. § 4.118 (2018). DC 7806 “draws a clear distinction between ‘systemic therapy’ and ‘topical therapy’ as the operative terms of the diagnostic code.” Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). The Federal Circuit went on to explain that “systemic therapy means ‘treatment pertaining to or affecting the body as a whole,’ whereas topical therapy means ‘treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied.” Id. Thereafter, in Burton v. Wilkie, the Court interpreted Johnson as not intending to limit the factual circumstances by which a topical treatment may become a systemic therapy under DC 7806 to only situations involving large scale topical application. The Court held that one other potential avenue to show a topical corticosteroid is systemic is to determine whether a topical treatment operates by affecting the body as a whole. The Court also held that the Board must determine whether a given treatment is “like” a corticosteroid in deciding whether the treatment constitutes a systemic therapy. The Veteran last underwent a VA skin diseases examination in May 2016. At that time, it was noted that the Veteran’s eczema required the constant or near-constant application of topical corticosteroids, specifically hydrocortisone valerate and triamcinolone cream, and that his PFB required the constant or near-constant application of adapalene gel. On review, the Board finds that the claim must be remanded in order to obtain an additional VA examination and medical opinion that addresses the questions raised by the Court and Federal Circuit decisions discussed above. 9. Entitlement to an initial rating in excess of 50 percent for PTSD The Veteran last underwent a VA examination for his service-connected PTSD in November 2013, at which time he presented with a variety of symptoms including chronic sleep impairment, memory loss, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. Since then, the evidence of record reflects that his symptoms may have worsened, and the Veteran has asserted that he has symptoms associated with his PTSD that have not been considered in his evaluation. The Board notes that the Veteran has filed separate claims for associated psychiatric impairment, which are currently under review at the RO. In light of the above, the Board finds that an additional VA examination is needed to ascertain the current nature and severity of his PTSD symptoms. See Snuffer v. Gober, 10 Vet. App. 400 (1997) (holding that a claimant is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination). 10. Entitlement to additional SMC 11. Entitlement to a TDIU The Veteran contends he is entitled to additional compensation in the form of SMC. Furthermore, the Board notes that he has alleged that his service-connected disabilities prevent him from working. Hence, the issue of entitlement to a TDIU has been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009). As the RO has yet to assign initial ratings for the newly service-connected disabilities adjudicated above, and as the increased rating claims discussed above are being remanded for evidentiary development and could result in the award of additional disability compensation, the Board finds that a decision on the matter of entitlement to additional SMC and/or TDIU would be premature. The matters are REMANDED for the following actions: 1. Provide the Veteran and his representative with notice concerning how to substantiate the claim for a TDIU. 2. Then, return the Veteran’s claims file to the examiner who conducted the December 2013 VA DBQ examinations for CFS and Gulf War so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: Review of service treatment records include numerous notations of fatigue and tiredness following the Veteran’s return from deployment. The examiner must opine as to the following: (a) Indicate whether the Veteran has current diagnoses of CFS and/or Gulf War Syndrome. (b) If so, whether it is at least as likely as not (50 percent or greater probability) that the diagnosis(es) is related to an in-service injury, event, or disease, to include environmental exposures in Southwest Asia. (c) If not, whether it is at least as likely as not that the Veteran’s current symptomatology, to include fatigue and tiredness, are due to an undiagnosed illness or medically unexplained chronic multi-symptom illness resulting from service in Southwest Asia during the Persian Gulf War. If so, the examiner should also comment on the severity of the symptomatology and report all signs and symptoms necessary for evaluating the illness under the rating criteria. (d) If not, whether the Veteran’s current symptomatology, to include fatigue and tiredness, are separate and distinct or part and parcel with any of his service-connected disabilities. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Schedule the Veteran for an examination with an appropriate clinician for his dental disability. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s dental trauma or disease process identified began during active service or is related to an incident of service, to include dental trauma. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 4. Schedule the Veteran for an examination with an appropriate clinician to determine the current severity of his lumbar spine disability. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide all findings, along with a complete rationale for any opinions provided. 5. Schedule the Veteran for an examination with an appropriate clinician to determine the current severity of his cervical spine disability. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide all findings, along with a complete rationale for any opinions provided. 6. Schedule the Veteran for an examination with an appropriate clinician to determine the current severity of his bilateral plantar fasciitis with spurs. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide all findings, along with a complete rationale for any opinions provided. 7. Schedule the Veteran for an examination with an appropriate clinician to determine the current severity of his obstructive sleep apnea with COPD. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide all findings, along with a complete rationale for any opinions provided. 8. Schedule the Veteran for an examination with an appropriate clinician to determine the current severity of his eczema and PFB. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide all findings, along with a complete rationale for any opinions provided, to include as to the following: (a.) Does hydrocortisone valerate operate by affecting the body as a whole in treating the Veteran’s eczema? (b.) Does triamcinolone cream operate by affecting the body as a whole in treating the Veteran’s eczema? (c.) Is adapalene cream like a corticosteroid or other immunosuppressive drugs? If so, does it operate by affecting the body as a whole in treating the Veteran’s PFB? 9. Schedule the Veteran for an examination with an appropriate clinician to determine the current severity of his PTSD. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must provide all findings, along with a complete rationale for any opinions provided. 10. Then, review the examination reports and medical opinions to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the RO must implement corrective procedures. (Continued on the next page)   11. Then, readjudicate the claims, to include additional SMC and TDIU. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. T. Blake Carter Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Minot, Associate Counsel