Citation Nr: 18154793 Decision Date: 11/30/18 Archive Date: 11/30/18 DOCKET NO. 17-37 888 DATE: November 30, 2018 ORDER Entitlement to service connection for a left knee disorder is denied. Entitlement to service connection for erectile dysfunction is granted. Entitlement to service connection for cystalgia is denied. Entitlement to an initial rating greater than 10 percent for tinnitus is denied. Entitlement to an initial 10 percent rating for hypertension, and no more, is granted, subject to the laws and regulations governing the award of monetary benefits. REMANDED Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for bronchitis is remanded. Entitlement to service connection for chronic obstructive pulmonary disease is remanded. Entitlement to service connection for asthma is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for hypothyroidism is remanded. Entitlement to service connection for right lower extremity sciatica is remanded. Entitlement to a rating greater than 20 percent for lumbar degenerative disc disease is remanded. Entitlement to an initial rating greater than 50 percent for posttraumatic stress disorder is remanded. Entitlement to a total disability rating based on individual unemployability is remanded. REFERRED On his October 2014 VA Form 21-526EZ, Fully Developed Claim, the Veteran claimed entitlement to service connection for cephalgia. This matter is referred to the Agency of Original Jurisdiction (AOJ) for appropriate action. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s current left knee disorder is related to active service or events therein; and there is no evidence that left knee arthritis was manifested to a compensable degree within one year following discharge from active service. 2. Medical evidence indicates the Veteran’s erectile dysfunction is caused by his use of antihypertensive medications. 3. The preponderance of the evidence is against finding that the Veteran currently has cystalgia that is related to active service or events therein. 4. The Veteran is currently assigned the maximum schedular rating for tinnitus. 5. The disability picture pertaining to the Veteran’s hypertension more nearly approximates a history of diastolic pressure predominantly 100 or more requiring continuous medication for control. CONCLUSIONS OF LAW 1. A left knee disorder was neither incurred nor aggravated during active service, and left knee arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309(a). 2. Erectile dysfunction is secondary to service-connected hypertension. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310(a). 3. Cystalgia was not incurred or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 4. The criteria for an initial rating greater than 10 percent for tinnitus are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.87, Diagnostic Code 6260. 5. The criteria for an initial 10 percent rating, and no more, for hypertension are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.104, Diagnostic Code 7101. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1976 to February 1998. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Certain chronic diseases will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Service connection may also be granted on a secondary basis for a disability that is proximately due to a service-connected condition. 38 C.F.R. § 3.310(a). Entitlement to service connection for a left knee disorder In April 2015, VA denied entitlement to service connection for a left knee disorder. The Veteran disagreed and perfected this appeal. Service treatment records are negative for complaints or findings related to the left knee. On retirement examination in December 1997, the Veteran’s lower extremities were reported as normal on clinical evaluation. On the associated report of medical history, he denied having or having had a “trick” or locked knee. A September 2014 report from a private chiropractor, Dr. Y., indicates the Veteran had a well-documented military medical history of chronic left knee pain for which he had multiple clinical contacts with military medical personnel and that his left knee pain and dysfunction have persisted without hiatus to the present. Following an examination the diagnosis was well advanced degenerative joint disease of the left knee complicated by lateral instability. Dr. Y. further stated that “[d]iagnosis and treatment of this condition which persists to the present during active duty military service should qualify same for service connection.” The Veteran underwent a VA examination in February 2015. The diagnoses were listed as degenerative joint disease (patellar spurs) and patellofemoral syndrome. The Veteran did not report a specific injury or onset date and did not report receiving any treatment. The examiner did not link a left knee disorder to service. As set forth, the Veteran clearly has a current left knee disability. The Board acknowledges the private chiropractic report which indicates the Veteran was seen during service and that the condition continued thereafter. There is no indication, however, that Dr. Y. reviewed the Veteran’s service treatment records. The Board notes that while service treatment records document complaints related to the right knee, they are negative for the left knee. The Board also does not find the statement regarding any continuity of pathology to be objectively supported given the normal clinical examination at separation and the Veteran’s affirmative denial of knee issues at that time. It is well to note that the alleged “well-documented” history of inservice treatment is not corroborated by the objective evidence of record. Accordingly, Dr. Y.’s opinion is not found probative on this issue. In summary, there is no evidence of a chronic left knee disorder during service or for many years thereafter, and the record does not contain probative evidence relating the current left knee disorder to active service or events therein. There is also no evidence of left knee arthritis manifested to a compensable degree within one year following discharge. The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. 38 C.F.R. § 3.102. The claim is denied. Entitlement to service connection for erectile dysfunction In April 2015, VA denied entitlement to service connection for erectile dysfunction. The Veteran disagreed and perfected this appeal. The Veteran is service-connected for hypertension and a September 2014 statement from Dr. Y. indicates that since being medicated for this disorder, the Veteran has suffered from progressive erectile dysfunction. Diagnosis was iatrogenic erectile dysfunction secondary to antihypertensive medications. On review, the record does not contain probative evidence to the contrary and hence, secondary service connection for erectile dysfunction is warranted. 38 C.F.R. § 3.310. Entitlement to service connection for cystalgia In April 2015, VA denied entitlement to service connection for cystalgia (pain in the bladder). The Veteran disagreed and perfected this appeal. Service treatment records are negative for any complaints or findings of cystalgia. Review of the record does not show a current diagnosis of cystalgia or indicate that any such disorder is related to active service or events therein. The preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. 38 C.F.R. § 3.102. The claim is denied. The Board notes that on review of the October 2014 VA Form 21-526EZ, it appears the Veteran was seeking compensation for “cephalgia” rather than “cystalgia.” As noted above, that issue is referred to the Regional Office for appropriate consideration. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Entitlement to an initial rating greater than 10 percent for tinnitus In April 2015, VA granted entitlement to service connection for tinnitus and assigned a 10 percent rating. The Veteran disagreed with the evaluation and perfected this appeal. In his notice of disagreement, he argued that a 10 percent rating was warranted for each ear. A 10 percent evaluation is assigned for recurrent tinnitus. 38 C.F.R. § 4.87, Diagnostic Code 6260. Only a single evaluation may be assigned, whether the sound is perceived in one ear, both ears, or in the head. Id. at Note (2). The Veteran is currently assigned the maximum schedular rating under the assigned diagnostic code. The Veteran’s functional complaints (i.e. ringing in the ears impacting hearing) are contemplated by the rating schedule and referral for extraschedular consideration is not warranted. See 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008); aff’d Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The claim is denied. Entitlement to an initial compensable rating for hypertension In April 2015, VA granted entitlement to service connection for hypertension and assigned a noncompensable rating. The Veteran disagreed with the evaluation and perfected this appeal. A 10 percent rating is assigned for hypertension when diastolic pressure is predominantly 100 or more, or; systolic pressure predominantly 160 or more, or it is the minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code 7101. A 20 percent rating is assigned when diastolic pressure is predominantly 110 or more, or; systolic pressure predominantly 200 or more. Id. A September 2014 statement from Dr. Y. indicates the Veteran remains hypertensive. Specific blood pressure readings were not provided. A review of service treatment records shows the Veteran underwent serial blood pressure checks in January 1998. Blood pressures were recorded as 148/98, 146/100, 138/96, 146/98, 136/92, 136/98, 142/102, 148/102, 153/85, and 162/90. The Veteran underwent a VA hypertension examination in February 2015. He reported being diagnosed with hypertension during service and he takes Micardis and Maxzide. Current blood pressure readings were recorded as 148/90, 143/86, and 135/84. On review, the evidence does not show current diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more. The Veteran, however, requires continuous medication for control and as set forth, several diastolic pressures over 100 were noted during service. Resolving reasonable doubt in his favor, a history of diastolic pressure predominantly 100 or more is established and the criteria for an initial 10 percent rating are more nearly approximated. There is no evidence of diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. Hence, the criteria for a 20 percent rating are not met. REASONS FOR REMAND In October 2014, the Veteran indicated he had no more medical evidence. Review of the September 2014 chiropractic report, however, suggests there may be records at a local VA facility. The Veteran should be asked to identify dates and locations of any relevant VA treatment. Additionally, he should be asked to identify any relevant private medical treatment. 38 C.F.R. § 3.159(c)(1), (2). Entitlement to service connection for a right knee disorder In April 2015, VA denied entitlement to service connection for a right knee disorder. The Veteran disagreed and perfected this appeal. Service treatment records show the Veteran was seen in May 1979 with complaints of right knee pain. Physical examination showed peripatellar edema and pain, and he was placed on a profile. At his retirement examination in December 1997, the appellant’s lower extremities were reported as normal on clinical evaluation. The September 2014 report from Dr. Y. indicates the Veteran has a well-documented military medical history of chronic right knee pain for which he has multiple clinical contacts with military medical personnel and that his right knee pain and dysfunction have persisted without hiatus to the present. The diagnosis was well advanced degenerative joint disease of the right knee complicated by lateral instability. Dr. Y. further stated that “[d]iagnosis and treatment of this condition which persists to the present during active duty military service should qualify same for service connection.” The Veteran underwent a VA examination in February 2015. The diagnoses were listed as degenerative joint disease (patellar spurs) and patellofemoral syndrome. The Veteran did not report a specific injury or onset date and did not report receiving any treatment. A medical opinion was not provided. On review, the Veteran was seen for right knee complaints during service and he has a current right knee disability. The statement from Dr. Y. suggests a medical nexus. Given the foregoing the Board finds that an additional examination and opinion are needed. 38 C.F.R. § 3.159(c)(4). Entitlement to service connection for a cervical spine disorder In April 2015, VA denied entitlement to service connection for a cervical spine disorder. The Veteran disagreed and perfected this appeal. A September 2014 statement from Dr. Y. indicates that the Veteran has degenerative joint disease and spondylosis of the cervical and cervicothoracic regions, and that it was more likely than not directly and casually related to the low back injury and involvement of the thoracic region and chronic and constant adaptation and compensation for altered gait and weight shifting. Dr. Y. further stated it was more likely than not directly and causally related to military service. The appellant is service connected for lumbar degenerative disc disease. The Board acknowledges the opinion from Dr. Y., but notes that service treatment records are negative for complaints or findings related to the cervical spine. Additionally, on VA back examination in February 2015, the Veteran did not exhibit an abnormal gait. Considering Dr. Y.’s statement and the fact that the appellant is service connected for a low back disorder, however, a VA examination and opinion are needed. 38 C.F.R. § 3.159(c)(4). Entitlement to service connection for bilateral hearing loss Service treatment records show the Veteran underwent frequent audiograms as he was routinely exposed to hazardous noise. Results during service are inconsistent. For example, audiometry in January 1990 showed the Veteran had a hearing loss disability for VA purposes on the left under 38 C.F.R. § 3.385. At his December 1997 retirement examination a hearing loss disability for VA purposes was not shown. In his September 2014 report, Dr. Y. stated that testing revealed that the Veteran had a bilateral hearing loss under normal conditions of 60 percent in each ear, which was more likely than not directly related to inservice acoustic trauma. The report further notes that the Veteran was asked to obtain a confirmatory puretone audiogram and that once performed, he would send a copy and Dr. Y. would publish an addendum. On review, it is unclear whether the Veteran ever obtained the audiogram as requested. On VA examination in February 2015, the examiner stated that puretone test results were not valid for rating purposes (not indicative of organic hearing loss). The audiologist noted that in speaking to the Veteran, they could communicate with ease at normal tones. Once in the booth, the Veteran replied he “could barely hear [the examiner]”, yet his speech recognition thresholds were at 35 dB bilaterally. The examiner also indicated that the use of speech discrimination scores was not appropriate for the Veteran. The audiologist was unable to render a diagnosis of hearing loss as the test results were not valid. While the evidence of record does not show a current hearing loss disability for VA purposes under 38 C.F.R. § 3.385, the Board finds that the Veteran should be offered an opportunity to submit any confirmatory audiogram conducted by Dr. Y or an associate. Additionally, another attempt should be made to obtain valid test results on VA examination. The Veteran is reminded that he has a duty to cooperate with the examination. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (noting that the duty to assist is not a one-way street). Entitlement to service connection for bronchitis, chronic obstructive pulmonary disease, and asthma In April 2015, VA denied entitlement to service connection for bronchitis, chronic obstructive pulmonary disease, and asthma. The Veteran disagreed and perfected this appeal. Service treatment records are negative for any evidence of a chronic respiratory disorder. At his retirement examination in December 1997, the Veteran’s lungs were described as normal on clinical evaluation. In his September 2014 report, Dr. Y, stated that during military service in Desert Storm, the Veteran was exposed to contaminated and toxic air from burn pits, and he developed respiratory difficulties which intensified over the years. Dr. Y stated that auscultation of the lung fields was consistent with chronic obstructive pulmonary disease and bronchial asthma, which Dr. Y. stated was more likely than not directly and causally related to military service. The Veteran’s DD Form 214 shows he was awarded the Southwest Asia Service Medal and the Kuwait Liberation medal and he is a Persian Gulf veteran. 38 C.F.R. § 3.317(e). His reports of exposure to burn pits is arguably consistent with his service. On review, the record does not contain objective testing confirming the listed diagnoses and additional examination and opinion is needed. 38 C.F.R. § 3.159(c)(4). The Board further notes that signs or symptoms involving the respiratory system can be manifestations of undiagnosed illness or medically unexplained chronic multi symptom illness. 38 C.F.R. § 3.317(b)(8). Entitlement to service connection for sleep apnea In April 2015, VA denied entitlement to service connection for sleep apnea. The Veteran disagreed and perfected this appeal. In September 2014, Dr. Y. stated the Veteran suffers from heavy snoring and cessation of breathing while sleeping. The presumptive diagnosis was sleep apnea although the Veteran needed to have a confirmatory lab study. Dr. Y. further stated that sleep apnea was more likely than not related to service connectable chronic obstructive pulmonary disease and bronchial asthma. He also stated that it was directly and causally related to military service. The service treatment records do not show complaints or findings related to sleep apnea and the record does not show a confirmed diagnosis of sleep apnea. Considering Dr. Y.’s report, however, the Board finds that a VA examination is warranted. 38 C.F.R. § 3.159(c)(4). Entitlement to service connection for hypothyroidism In April 2015, VA denied entitlement to service connection for hypothyroidism. The Veteran disagreed and perfected this appeal. In September 2014, Dr. Y. stated that the Veteran was diagnosed with a goiter during service and his goiter and thyroid were surgically removed causing a surgical hypothyroidism. Service treatment records show the Veteran underwent a computed tomography scan of the neck in January 1998 to rule out a mass. The impressions included a constellation of findings compatible with a multinodular goiter with substernal extension. There is no indication that the Veteran underwent surgical removal of the thyroid during service. The Veteran should be contacted and asked to identify or otherwise provide any medical records pertaining to the alleged inservice surgical removal of the thyroid. Additionally, a VA examination is needed. 38 C.F.R. § 3.159(c)(4). Entitlement to service connection for right lower extremity sciatica In April 2015, VA denied entitlement to service connection for right sciatic pain. The Veteran disagreed and perfected this appeal. In his September 2014 report, Dr. Y. states that the Veteran has developed right sciatic radicular pain. The diagnosis was discogenic right sciatic radicular pain that was more likely than not directly and causally related as a progression to the Veteran’s low back condition. A February 2015 VA back examination yielded a finding that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. Considering the inconsistent findings, the Board finds additional examination is needed. 38 C.F.R. § 3.159(c)(4). Entitlement to a rating greater than 20 percent for lumbar degenerative disc disease In April 2015, VA increased the rating for lumbar degenerative disc disease to 20 percent effective October 1, 2014. The Veteran disagreed with the rating and perfected this appeal. The September 2014 report from Dr. Y. indicates the Veteran’s lumbar spine flexion was limited to 20 degrees. On VA examination in February 2015, forward flexion was to 60 degrees. The Veteran reportedly was, however, “unable” to perform repetitive use testing due to severe pain, and the examiner stated she was unable to express additional limitation due to pain, weakness, etc. in terms of degrees because the claimant was unable to replicate the estimated limitation at time of examination. The examiner stated that submaximal effort was exhibited on examination. On review, the findings on the private examination report versus the VA examination are inconsistent. Further, in Sharp v. Shulkin, 29 Vet. App. 26 (2017), the United States Court of Appeals for Veterans Claims (Court) held that examiners must offer opinions with respect to the additional limitation of motion during flare-ups based on estimates derived from information procured from relevant sources, including a Veteran’s lay statements. Accordingly, the Board finds a current examination is needed. 38 C.F.R. § 3.327. Entitlement to an initial rating greater than 50 percent for posttraumatic stress disorder In April 2015, VA granted entitlement to service connection for posttraumatic stress disorder and assigned a 50 percent rating effective October 1, 2014. The Veteran disagreed with the evaluation and perfected this appeal. In September 2014, the Veteran underwent a private psychological evaluation. Following interview and psychiatric testing, the psychologist concluded that the Veteran suffered serious impairment in social and occupational functioning The Veteran underwent a VA examination in February 2015 and the examiner summarized the Veteran’s level of disability as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation. In his VA Form 9, the Veteran argued that his private examiner was more competent because the report was based on a lengthy interview and psychiatric testing. He argued that essentially VA did “nothing.” Considering the inconsistent findings, the Veteran’s arguments, and the length of time since examination, the Board finds that a current examination is warranted. 38 C.F.R. § 3.327. Entitlement to a total disability rating based on individual unemployability The issue of entitlement to a total disability rating based on individual unemployability is inextricably intertwined with the issues remanded herein and as such, the adjudication of this issue must be deferred. Harris v Derwinski, 1 Vet. App. 80 (1991). It is also unclear whether the Veteran is currently employed. Hence, he should be asked to provide his employment history. The matters are REMANDED for the following action: 1. Contact the Veteran and ask him to identify relevant VA or private treatment, to include pertaining to any audiograms or thyroid surgery. Specifically, the Veteran should: (a) Identify dates and locations of VA treatment. All VA records should be obtained. If the AOJ cannot locate any Federal records requested herein, it must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The AOJ must then: (i) notify the claimant of the specific records that it is unable to obtain; (ii) explain the efforts VA has made to obtain that evidence; and (iii) describe any further action it will take with respect to the claim. The claimant must then be given an opportunity to respond. (b) Complete a VA Form 21-4142 for any relevant private medical treatment, to include all records of treatment by Dr. Y. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. (c) Identify where and when the appellant allegedly underwent thyroid surgery while on active duty. 2. Contact the Veteran and ask him to complete a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. 3. Thereafter, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right knee disorder. The VBMS and Virtual VA/Legacy folders must be available for review. The examiner must opine whether any diagnosed right knee disorder is at least as likely as not related to active service or events therein, to include findings of right knee peripatellar edema and pain. In making this determination, the examiner must consider and discuss as necessary the September 2014 private report from Dr. Y. If the examiner finds that the appellant’s complaints represent malingering that should be explained. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 4. After completion of directives one and two, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any cervical spine disorder. The VBMS and Virtual VA/Legacy folders must be available for review. The examiner must opine whether any diagnosed cervical spine disorder is proximately due to or aggravated by lumbar degenerative disc disease. In making this determination, the examiner must consider and discuss as necessary the September 2014 private report from Dr. Y. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. If the examiner finds that the appellant’s complaints represent malingering that should be explained. 5. After completing directives one and two, schedule the Veteran for an examination by an audiologist to determine the nature and etiology of any hearing loss. The VBMS and Virtual VA/Legacy folders must be available for review. If the Veteran is shown to have a hearing loss disability for VA purposes, the examiner must opine whether it is at least as likely as not related to active service or events therein. In making this determination, the examiner should consider and discuss as necessary the September 2014 private report from Dr. Y. If the examiner finds that the appellant’s complaints represent malingering that should be explained. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 6. After completing directives one and two, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed respiratory disorder to include bronchitis, chronic obstructive pulmonary disease and asthma. The VBMS and Virtual VA/Legacy folders must be available for review. If the Veteran is shown to have a respiratory disorder, to include bronchitis, asthma, and/or chronic obstructive pulmonary disease, the examiner must opine whether it is at least as likely as not that the disorder is related to active service or events therein, to include exposure to burn pits. In making this determination, the examiner must consider and discuss as necessary the September 2014 private report from Dr. Y. If the Veteran’s respiratory complaints are not related to a known clinical diagnosis, the examiner must indicate whether they are due to an undiagnosed illness or medically unexplained chronic multi symptom illness. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. If the examiner finds that the appellant’s complaints represent malingering that should be explained. 7. After completing directives one and two schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of claimed sleep apnea. The VBMS and Virtual VA/Legacy folders must be available for review. If the Veteran is shown to have a confirmed diagnosis of sleep apnea, the examiner must opine whether it is at least as likely as not related to active service or proximately due to or aggravated by any service-connected disability. In making this determination, the examiner should consider and discuss as necessary the September 2014 private report from Dr. Y. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. If the examiner finds that the appellant’s complaints represent malingering that should be explained. 8. After completing directives one and two schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of hypothyroidism. The VBMS and Virtual VA/Legacy folders must be available for review. The examiner must opine whether any diagnosed hypothyroidism is at least as likely as not related to active service or events therein, to include findings compatible with a multinodular goiter with substernal extension. See January 1998 CT scan. In making this determination, the examiner should consider and discuss as necessary the September 2014 private report from Dr. Y. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. If the examiner finds that the appellant’s complaints represent malingering that should be explained. 9. After completing directives one and two, schedule the Veteran for an examination of the current severity of his lumbar degenerative disc disease. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner must identify all symptoms and functional impairments due to lumbar degenerative disc disease alone and discuss the effect of the Veteran’s disability on any occupational functioning and activities of daily living. The examiner is also to indicate whether the Veteran has right lower extremity sciatica or radiculopathy related to lumbar degenerative disc disease. In making this determination, the examiner must consider and discuss as necessary the September 2014 report from Dr. Y. If it is not possible to provide all information requested herein, to include a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). If the examiner finds that the appellant’s complaints represent malingering that should be explained. 10. After completing directives one and two schedule the Veteran for an examination by an appropriate clinician to determine the current severity of the appellant’s posttraumatic stress disorder. The examiner must provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to service-connected posttraumatic stress disorder alone. The examiner is also asked to attempt to reconcile the findings in the September 2014 private psychological evaluation and the February 2015 VA examination. A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. If the examiner finds that the appellant’s complaints represent malingering that should be explained. DEREK R. BROWN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Carsten, Counsel