Citation Nr: 18155049 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 15-19 334 DATE: December 4, 2018 ORDER Entitlement to service connection for a traumatic brain injury (TBI) is denied. Entitlement to an initial rating in excess of 10 percent for tinnitus is denied. Entitlement to an initial rating in excess of 50 percent for sleep apnea with CPAP is denied. For the period of appeal prior to September 29, 2015, entitlement to a rating in excess of 30 percent anxiety disorder is denied. For the period of appeal from September 29, 2015, entitlement to a rating of 70 percent for anxiety disorder is granted. Entitlement to a total disability rating based on individual unemployability by reason of service-connected disability (TDIU) is granted. REMANDED Entitlement to service connection for a disability of the toes, to include as due to an undiagnosed Gulf War illness, is remanded. Entitlement to service connection for a neck disability, to include as due to an undiagnosed Gulf War illness, is remanded. Entitlement to service connection for a right ankle disability, to include as due to an undiagnosed Gulf War illness, is remanded. Entitlement to service connection for a left ear disability, to include as due to an undiagnosed Gulf War illness, is remanded. Entitlement to service connection for an abdominal condition other than gastroesophageal reflux disease (GERD), to include as due to an undiagnosed Gulf War illness, is remanded. Entitlement to service connection for rosacea, to include as due to an undiagnosed Gulf War illness, is remanded. Entitlement to service connection for a heart condition, to include arial septal defect, is remanded. Entitlement to service connection for anisometropia, right eye amblyopia, and right eye hyperopic astigmatism (“eye disability other than vitreous floaters with photophobia”) is remanded. Entitlement to an initial rating in excess of 10 percent for degenerative disc disease of the lumbar and thoracic spine (“back disability”) is remanded. Entitlement to an initial rating in excess of 10 percent for right foot plantar fasciitis is remanded. Entitlement to an initial rating in excess of 10 percent for left foot plantar fasciitis is remanded. Entitlement to an initial rating in excess of 10 percent for right bicep strain is remanded. Entitlement to an initial rating in excess of 10 percent for chronic paroxysmal hemicrania, also diagnosed as visual aura associated with migraines (“headache disability”), is remanded. Entitlement to an initial compensable rating for left hand minimal osteoarthritis of the first carpometacarpal (“left hand disability”) is remanded. Entitlement to an initial compensable rating for right knee arthritis is remanded. Entitlement to an initial compensable rating for left knee arthritis is remanded. Entitlement to an initial compensable rating for left ankle tendonitis is remanded. Entitlement to an initial compensable rating for vitreous floaters with photophobia is remanded. Entitlement to an initial compensable rating for bilateral hearing loss is remanded. Entitlement to an initial compensable rating for history of heat injury with rhabdomyolysis is remanded. Entitlement to an initial compensable rating for GERD is remanded. Entitlement to an initial compensable rating for erectile dysfunction is remanded. Entitlement to an initial compensable rating for right leg scar is remanded. Entitlement to an initial compensable rating for left shoulder scar is remanded. FINDINGS OF FACT 1. The Veteran does not have a diagnosis of a TBI. 2. For the entire period of appeal, the Veteran’s tinnitus is assigned a 10 percent rating, which is the maximum schedular rating authorized under Diagnostic Code 6260. 3. For the entire period of appeal, the Veteran’s sleep apnea requires use of a breathing assistance device, and does not result in chronic respiratory failure with carbon dioxide retention or cor pulmonale, or require a tracheostomy. 4. For the period of appeal prior to September 29, 2015, the Veteran’s anxiety disorder was productive of a disability picture that more nearly approximated that of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 5. For the period of appeal from September 29, 2015, the Veteran’s anxiety disorder is productive of a disability picture that more nearly approximates that of occupational and social impairment in most areas, such as work, school, family relations, judgment, thinking, or mood. 6. The Veteran has a bachelor’s degree and worked as a truck driver and manager. 7. The Veteran’s service-connected disabilities consist of sleep apnea with CPAP (50 percent from January 3, 2013); anxiety disorder (30 percent from January 3, 2013, and 70 percent from September 29, 2015); lumbar spine disability (10 percent from January 3, 2013); right plantar fasciitis (10 percent from January 3, 2013); left plantar fasciitis (10 percent from January 3, 2013); right bicep strain (10 percent from January 3, 2013); tinnitus (10 percent from January 3, 2013); chronic paroxysmal hemicrania, also diagnosed as visual aura associated with migraines (10 percent from January 3, 2013); left hand first carpometacarpal minimal osteoarthritis (noncompensable from January 3, 2013); right thumb fracture (noncompensable from January 3, 2013); right knee arthritis (noncompensable from January 3, 2013); left knee arthritis (noncompensable from January 3, 2013); left ankle tendonitis (noncompensable from January 3, 2013); vitreous floaters with photophobia (noncompensable from January 3, 2013); bilateral hearing loss (noncompensable from January 3, 2013); history of heat injury with rhabdomyolysis (noncompensable from January 3, 2013); GERD (noncompensable from January 3, 2013); erectile dysfunction (noncompensable from January 3, 2013); right leg scar (noncompensable from January 3, 2013); and left shoulder scar (noncompensable from January 3, 2013). His combined total rating has been at least 80 percent since January 3, 2013. 8. The evidence is in equipoise on whether the Veteran’s service-connected disabilities preclude him from securing and following substantially gainful employment consistent with his educational and occupational experience. CONCLUSIONS OF LAW 1. The criteria for service connection for a TBI have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 2. For the entire period of appeal, the criteria for a rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.87, Diagnostic Code 6260. 3. The criteria for an initial rating in excess of 50 percent for sleep apnea have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.97, Diagnostic Code 6847. 4. For the period of appeal prior to September 29, 2015, the criteria for the assignment of an initial rating in excess of 30 percent for anxiety disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9413. 5. For the period of appeal from September 29, 2015, the criteria for the assignment of a 70 percent rating, but no more, for anxiety disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9413. 6. Resolving all reasonable doubt in favor of the Veteran, the criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from May 2002 to January 2013, including service in Iraq. His decorations include a Combat Action Ribbon and a Bronze Star Medal. The Veteran initiated an appeal of an initial compensable rating for service-connected right thumb fracture (claimed as a right hand condition). A Statement of the Case (SOC) was issued in April 2018, and the Veteran did not perfect an appeal of the issues by filing a substantive appeal (VA Form 9). As such, the claim is not before the Board. The Board notes that in April 2017, the RO assigned a 100 percent rating for the Veteran’s anxiety disorder from November 1, 2016, to December 31, 2016, for hospitalization over 21 days; and a 30 percent rating from January 1, 2017. The 100 percent rating for the period between November 1 and December 31, 2016, is the maximum rating available; as such, this period of time is not on appeal. The issue otherwise remains on appeal and is for consideration by the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or an increased rating remains in controversy when less than the maximum available benefit is awarded). Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated beyond its natural progress by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310(a), (b). 1. Service connection for a TBI. The Veteran asserts that he has a TBI due to his in-service heat stroke in July 2007. He indicates that his core temperature was 105.9 degrees and he suffered brain stem damage. He also indicates that he had a motorcycle accident in service in October 2008 in which he hit his head on the ground. See the May 2012 VA examination report. Service treatment records (STRs) clearly indicate that the Veteran was diagnosed with heat stroke with complications and put on physical profile; however, they are silent for diagnosis or treatment for a TBI. STRs also document a motorcycle accident in October 2008. However, the Veteran did not report a head injury, nor was he treated for a head injury. In a May 2012 VA examination, Veteran reported that his symptoms included heat stroke-induced headache pain and memory loss, which were worsening. He also had episodic vision problems and photophobia. On examination, the Veteran was not found to have convulsions, taste disturbances, speech difficulty, swallowing difficulty, balance difficulty, cranial nerve symptoms, or autonomic dysfunction. He did have psychological symptoms of mood swings and anxiety, neurobehavior symptom of irritability, and numbness in the right arm. The examiner diagnosed chronic paroxysmal hemicrania, for which service connection has already been granted. The Board notes that the Veteran has also been serviced-connected for an eye disability and anxiety disorder. The examiner indicated that the Veteran did not have a TBI diagnosis. VA treatment records indicate that a January 2013 TBI screening was negative. In an October 2015 disability benefits questionnaire for mental disorder, the evaluating psychologist, Dr. H.H., noted that the Veteran did not have a diagnosis of a TBI. In a March 2017 VA PTSD examination, it was again noted that the Veteran did not have a diagnosed TBI. In sum, the Board finds that the evidence establishes that the Veteran does not have a diagnosis of a TBI and has not had such a diagnosis at any point during the pendency of the appeal. The Board finds the May 2012 VA examiner’s opinion to be competent and credible, and as such, entitled to significant probative weight. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The VA examiner’s opinion was rendered after reviewing the Veteran’s STRs, soliciting a medical history from the Veteran, and conducting a physical examination and clinical testing of the Veteran. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner’s access to the claims folder and the Veteran’s history, and the thoroughness and detail of the opinion). The examiner also provided facts and rationale on which the opinion was based. Finally, the probative value of the VA examiner’s opinion is further bolstered by its consistency with the medical evidence in the Veteran’s medical history, which is silent for mention of diagnosis or treatment of a TBI in service. The Board acknowledges that some post-service treatment records note a “history of a TBI,” including a December 2013 Fort Bragg emergency department record. However, these records are of little probative value, as they are based on self-reports by the Veteran, and not on any clinical or medical determinations by qualified medical professionals. The Board does not doubt the Veteran is sincere in his belief that he has a TBI. As a lay person, the Veteran can report symptoms of a headache or memory loss, but his statements cannot be used to diagnose a TBI or determine the etiology of any such diagnosis. The diagnosis and etiology of a TBI goes beyond a simple and immediately observable cause-and-effect relationship and requires medical knowledge to review and interpret clinical tests. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). As such, the Board finds the Veteran’s statements to be probative with regard to establishing his symptoms, but finds little probative value with regard to establishing service connection. In sum, the weight of the competent and credible evidence of record weighs against the claims for service connection for a TBI. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, service connection for a TBI is not warranted. Increased Ratings Disability evaluations are determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. 2. Increased rating for tinnitus. In Smith v. Nicholson, 19 Vet. App. 63, 78 (2005), the U.S. Court of Appeals for Veterans Claims (the Court) held that the pre-1999 and pre-June 13, 2003 versions of diagnostic code 6260 required the assignment of dual ratings for bilateral tinnitus. VA appealed this decision to the U.S. Court of Appeals for the Federal Circuit (Federal Circuit). In Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006), the Federal Circuit concluded that the Court erred in not deferring to the VA’s interpretation of its own regulations, 38 C.F.R. § 4.25(b) and Diagnostic Code 6260, which limits a Veteran to a single disability rating for tinnitus, regardless whether the tinnitus is unilateral or bilateral. The Veteran’s service-connected tinnitus has been assigned the maximum schedular rating available for tinnitus. 38 C.F.R. §4.87, Diagnostic Code 6260. Thus, as there is no legal basis upon which to award a higher schedular evaluation for tinnitus or separate schedular evaluations for tinnitus in each ear, the Veteran’s appeal must be denied. Sabonis v. Brown, 6 Vet. App. 426 (1994). 3. Increased rating for sleep apnea. The Veteran’s sleep apnea is rated under Diagnostic Code 6847, for sleep apnea syndromes (obstructive, central, mixed). Under this diagnostic code, sleep apnea that manifests in chronic respiratory failure with carbon dioxide retention or cor pulmonale, or; requires tracheostomy, is rated 100 percent disabling. A 50 percent rating is warranted for sleep apnea that requires use of a breathing assistance device such as continuous positive airway pressure (CPAP) machine. Lower ratings of 30 percent and noncompensable (zero percent) are also provided. 38 C.F.R. § 4.97, Diagnostic Code 6847. The Board finds that a rating in excess of 50 percent is not warranted at any point during the period of appeal. Service treatment records (STRs) indicate that the Veteran was diagnosed with sleep apnea and used a CPAP machine prior to discharge from service. In a November 2011 sleep study, the Veteran was noted to tolerate CPAP, and records dated in 2011 and 2012 show the Veteran was rented a CPAP machine. In a May 2012 VA examination, the Veteran reported symptoms of waking up gasping for air. He also indicated he had night sweats, daytime hypersomnolence, and fluctuating weight. He denied having hemoptysis and used CPAP for treatment, which he said helped. Private treatment records dated in January and March 2014 indicate that the Veteran had sleep apnea and used a CPAP machine. VA treatment records dated in November and December 2016 note that the Veteran continued to use a CPAP machine. In sum, the evidence shows that the Veteran has consistently required a CPAP machine throughout the period on appeal, which warrants a 50 percent rating under Diagnostic Code 6847. There is no medical evidence, nor does the Veteran contend, that his sleep apnea has manifested in chronic respiratory failure with carbon dioxide retention or cor pulmonale, or required a tracheostomy, which is required for a higher 100 percent rating under Diagnostic Code 6847. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and a higher rating is not warranted. 4. Increased rating for anxiety disorder. Rating Criteria The rating criteria for rating mental disorders, including anxiety disorder and PTSD, reads as follows: a 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions of hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130. A 70 percent rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing effective work and social relationships. Id. A 30 percent rating requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. The Board notes that the DSM-5 states that it was recommended that the use of Global Assessment of Functioning (GAF) scores be dropped for several reasons, including their conceptual lack of clarity and questionable psychometrics in routine practice. The Board recognizes the Court’s holding in Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) regarding the importance of GAF scores; however, as the medical community has determined that GAF scores are an unreliable measure of a psychiatric disability, the Board will not afford any GAF scores mentioned in the record any probative value in cases where the DSM-5 applies. See also Golden v. Shulkin, No. 16-1208 (U.S. Vet. App. February 23, 2018) (finding that the Board provided an inadequate statement of its reasons or bases for relying on GAF scores in its decision when the appeal was certified after August 4, 2014, and the DSM-5 applied to the claim). In this case, the Veteran’s appeal was certified to the Board in February 2016. As such, the DSM-5 applies and the Board will not afford GAF scores any probative value. Evaluation under § 4.130 is symptom-driven, meaning that symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The Federal Circuit explained that the frequency, severity, and duration of the symptoms also played an important role in determining the rating. Id. at 117. Significantly, however, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration, that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Id. at 443; see also Vazquez-Claudio, 713 F.3d at 117. Period of Appeal Prior to September 29, 2015 After careful review, the evidence shows that for the period of appeal prior to September 29, 2015, the Veteran’s anxiety disorder most closely approximated the criteria for a 30 percent rating under Diagnostic Code 9413. The evidence does not more closely approximate the schedular criteria for the assignment of disability rating in excess of 30 percent for this period of appeal. In a May 2012 VA PTSD examination, the Veteran’s spouse reported that the Veteran was irritable and depressed due to the limitations imposed on him by his chronic pain. She indicated that the Veteran’s other symptoms included being unable to relax, obsessive-compulsive tendencies with regard to needing the laundry and dishes to be done, difficulty adjusting, anger, and impaired sleep. The Veteran noted that he experienced memory loss, secluded himself, and was quick to anger with his spouse. On examination, the Veteran was alert and oriented, and his eye contact, speech, and behavior were within normal limits. There was no evidence of impairment in thought processes or communication, and the Veteran denied having suicidal or homicidal ideations. The Veteran had two close friends and his family, and did not care to meet new people. The examiner concluded that the Veteran did not meet the full criteria for a diagnosis of PTSD. His symptoms included re-experiencing and arousal associated with combat trauma, but he did not meet the criteria for avoidance associated with the trauma. However, the Veteran did have a diagnosis of anxiety disorder NOS. His depressive symptoms were associated with the changes in his lifestyle after heat stroke, but they did not meet the criteria for a mental disorder. The examiner opined that the Veteran was likely to have mild impairments in social, occupational, and academic functioning as a result of his psychiatric disorder. He was able to maintain basic activities of daily living including personal hygiene, was capable of managing his finances, and there was no evidence of inappropriate behavior. The examiner concluded that the Veteran’s psychiatric symptoms were transient or mild and caused a decreased efficiency and ability to perform occupational tasks only during periods of significant stress. Private treatment records dated in January and March 2013 indicate that the Veteran was noted to have anxiety and depression, but that no symptoms were present. In May 2013, the Veteran reported having psychiatric symptoms, including anxiety, change in sleep pattern, depression, easily irritated, insomnia, mood changes, and panic attacks. He denied having delirium, delusions, fear, hallucinations, suicidal ideation, suicidal planning, and personality changes. In a June 2014 Physical Residual Functional Capacity Questionnaire for an SSA disability application, J.Y., a physician assistant, indicated that the Veteran had depression, anxiety, and chronic pain. She noted that emotional factors had a “minimal” contribution to the severity of the Veteran’s symptoms and functional limitations. In sum, for this period of appeal, the weight of the competent and credible evidence preponderates against the assignment of a rating in excess of 30 percent for the Veteran’s anxiety disorder. The probative evidence establishes that the anxiety disorder symptoms did not more nearly approximate occupational and social impairment with reduced reliability and productivity, which would warrant a 50 percent rating under Diagnostic Code 9413. The Board finds that the weight of the competent and credible evidence shows that the Veteran’s anxiety disorder manifested by symptoms including anxiety, depression, sleep impairment, irritability, and anger. Mental health professionals consistently noted that the Veteran’s impairment due to mental health symptoms were mild or minimal. Specifically, the May 2012 VA examiner indicated that the symptoms were transient or mild and caused a decreased efficiency and ability to perform occupational tasks only during periods of significant stress, and the June 2014 SSA questionnaire completed by J.Y. indicated that emotional factors had a “minimal” contribution to the Veteran’s functional limitations. Moreover, the Veteran was married for nearly 20 years, maintains positive relationships with his wife and daughter, had two close friends, was able to maintain basic activities of daily living including personal hygiene, and was capable of managing his finances. Such level of impairment warrants a 30 percent rating. Thus, the Board also finds that for the period of appeal prior to September 29, 2015, the evidence weighs against the assignment of a 50 percent rating for the Veteran’s anxiety disorder. The evidence establishes that for this period of appeal the anxiety symptoms did not more nearly approximate occupational and social impairment with reduced reliability and productivity, which would warrant a 50 percent rating under Diagnostic Code 9413. The Veteran was not found to have flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; or impaired abstract thinking. 38 C.F.R. § 4.130. Although the Veteran reported symptoms of disturbances of mood and difficulty with work and social relationships, the Board does not find this symptom to be of such frequency, severity, and duration that it results in occupational and social impairment with reduced reliability and productivity to warrant a higher 50 percent evaluation at any point during the period of appeal. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (stating that use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating). As discussed above, the Veteran maintained familial relationships, some friendships, and was not noted to be significantly impaired occupationally due to his anxiety symptoms. The Board finds it significant that mental health professionals consistently noted that the anxiety symptoms were mild or minimal, and at times, was even noted to have no symptoms. In short, the Board does not find that the Veteran’s symptoms were of such frequency, severity, and duration that they result in occupational and social impairment with reduced reliability and productivity to warrant a higher 50 percent evaluation during the period of appeal prior to September 29, 2015. Period of Appeal from September 29, 2015 After careful review, the evidence shows that for the period of appeal from September 29, 2015, the Veteran’s anxiety disorder most closely approximates the criteria for a 70 percent rating under Diagnostic Code 9413. The evidence does not more closely approximate the schedular criteria for the assignment of a 100 percent disability rating for this period of appeal. VA treatment records indicate that the Veteran was seen on September 29, 2015, to establish telehealth care. He endorsed suicidal thoughts and initially endorsed suicidal intent without plan; however, he denied any current intentions or plans and reviewed several strong protective factors including his love for his wife and daughter and positive plans for the future. He rated himself a low risk. He was scheduled to start cognitive processing therapy (CPT) the next week, which he eventually began in January 2016. In an October 2015 Residual Functional Capacity Evaluation regarding the Veteran’s mental ability to do work-related activities, Dr. H.H., a psychologist, indicated that the Veteran’s mental problems would cause him to miss three or more days of work per month and to leave early three or more days per month. His mental symptoms would cause him to be unable to sustain concentration to complete simple repetitive tasks more than 3 days per month, and if he were subjected to normal workplace pressures and constructive criticisms of a job he would respond in an angry manner (but would not actually become violent) more than once per month. Dr. H.H. also completed a VA mental disorders disability benefits questionnaire in October 2015. She noted that the Veteran had a DSM 5 diagnosis of unspecified anxiety disorder, which caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and or mood. Dr. H.H. indicated that the Veteran had been married to his wife for 20 years and had one 15-year-old daughter. His wife was his greatest support system, although he occasionally kept some of his struggles to himself. He was socially isolated and withdrawn. The Veteran was noted to take bupropion, Geodon, imipramine, trazodone, quetiapine, citalopram, martazepine, and Cymbalta, which he felt did not work. He saw a VA psychiatrist every three months and had therapy in the past. The Veteran denied having a legal or behavior history (including domestic violence), as well a substance use history. His symptoms included depressed mood; anxiety; suspiciousness; panic attacks more than once a week; near-continuous panic or depression affecting the ability function independently, appropriately, and effectively; chronic sleep impairment, mild memory loss; impairment of short and long term memory; memory loss for names of close relatives, own occupation, or own name; flattened affect, disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; and persistent delusions or hallucinations. Dr. H.H. noted that the veteran’s attention was normal and concentration appeared variable. He struggled remembering basic information. His speech flow was normal and thought content was appropriate. The Veteran was capable of managing his financial affairs. In January 2016, the Veteran began CPT therapy via video telehealth. He completed twelve sessions between January and July 2016. He reported in his final session that he was very interested in participating in the inpatient PTSD unit and planned to submit an application for the unit in the next few weeks. In October 2016, the Veteran was evaluated for admission into the VA specialized inpatient PTSD unit (SIPU) and was determined to meet the admission criteria for admission. The Veteran was subsequently admitted to the SIPU on November 1, 2016, and discharged on December 9, 2016. As noted above, the Veteran was granted a 100 percent rating from November 1, 2016, to December 31, 2016, for hospitalization over 21 days, which is the maximum rating available and as such, this period of time is not on appeal. In March 2017, the Veteran had another VA PTSD examination. He was diagnosed with PTSD and unspecified anxiety disorder. His PTSD symptoms included reoccurring nightmares, flashbacks, intrusive memories, avoidance behaviors, hypervigilance, negative mood, anxiety, arousal, reactivity, and sleep disturbance. His anxiety caused inability to rest, sleep problems, difficulty concentrating, and racing thoughts. Other symptoms included panic attacks that occurred more than once a week, near continuous panic or depression, mild memory loss, flattened affect, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting ot stressful circumstances. He denied suicidal ideation. The examiner opined that the Veteran’s mental health symptoms caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. He was capable of managing his financial affairs. The Board finds that the evidence shows that for the Veteran’s anxiety symptoms significantly worsened in this period of appeal. Specifically, he was diagnosed with PTSD and his symptoms include near continuous panic or depression, anxiety, anger, isolation, sleep impairment, impaired concentration, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and suicidal thoughts at times. Such impairment warrants a 70 percent disability rating for this period of appeal. Thus, the Board also finds that for the entire period of appeal, the evidence preponderates against the assignment of a 100 percent rating for the Veteran’s service-connected anxiety disorder. The evidence establishes that the Veteran’s symptoms do not more nearly approximate total occupational and social impairment, which would warrant a 100 percent rating under Diagnostic Code 9411. The criteria for a 100 percent rating includes symptoms such as gross impairment in thought processes or communication; persistent delusions of hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. In this case, for the relevant time period, the Veteran has not found to have gross impairment in thought processes or communication; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. The Veteran was noted in the October 2015 PTSD disability benefits questionnaire to have hallucinations or delusions; however, that is the sole finding of hallucinations or delusions in six years’ worth of medical evidence, and significantly, he was never found to have hallucinations during his admission in the SIPU. In addition, the Veteran was noted in a September 2015 VA treatment record to have passive thoughts of suicide, but also indicated that he had any current intentions or plans, and rated himself a low risk. As such, the Board does not find these symptoms to be so frequent and disabling as to result in total occupational and social impairment at any point during this period of appeal. See Mauerhan v. Principi, at 442 (2002) (finding that symptoms contained in rating schedule criteria are “not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating.”). Moreover, as described above, the Veteran has maintained a relationship with his wife and daughter, has a couple friends, is competent to handle his financial affairs, and is able to complete his activities of daily living. As such, the Board finds that the Veteran has not had any symptom with such frequency and severity to result in total occupational and social impairment during the period on appeal. Accordingly, for the period of appeal from September 29, 2015, the Board finds that the Veteran’s symptoms of anxiety disorder warrant a 70 percent evaluation, and the claim is granted to that extent. The Veteran’s symptoms are not of such frequency, severity, and duration that they result in total occupational and social impairment to warrant a higher 100 percent evaluation. 5. Entitlement to a TDIU. The Veteran contends that he has been unable to work due to his service-connected disabilities since his separation from service in January 2013. Total disability meriting a 100 percent schedular rating exists “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. §§ 3.340(a)(1), 4.15. Where the schedular disability rating is less than 100 percent, a total rating due to individual unemployability may nonetheless be assigned if a veteran is rendered unemployable as a result of service-connected disabilities, provided that certain regulatory requirements are satisfied. See 38 C.F.R. §§ 3.341(a), 4.16(a). Total disability ratings for compensation may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. “Marginal employment,” for example, as a self-employed worker or at odd jobs or while employed at less than half of the usual remuneration, shall not be considered “substantially gainful employment.” 38 C.F.R. § 4.16(a). The Veteran’s service-connected disabilities consist of sleep apnea with CPAP (50 percent from January 3, 2013); anxiety disorder (30 percent from January 3, 2013, and 70 percent from September 29, 2015); lumbar spine disability (10 percent from January 3, 2013); right plantar fasciitis (10 percent from January 3, 2013); left plantar fasciitis (10 percent from January 3, 2013); right bicep strain (10 percent from January 3, 2013); tinnitus (10 percent from January 3, 2013); chronic paroxysmal hemicrania, also diagnosed as visual aura associated with migraines (10 percent from January 3, 2013); left hand first carpometacarpal minimal osteoarthritis (noncompensable from January 3, 2013); right thumb fracture (noncompensable from January 3, 2013); right knee arthritis (noncompensable from January 3, 2013); left knee arthritis (noncompensable from January 3, 2013); left ankle tendonitis (noncompensable from January 3, 2013); vitreous floaters with photophobia (noncompensable from January 3, 2013); bilateral hearing loss (noncompensable from January 3, 2013); history of heat injury with rhabdomyolysis (noncompensable from January 3, 2013); GERD (noncompensable from January 3, 2013); erectile dysfunction (noncompensable from January 3, 2013); right leg scar (noncompensable from January 3, 2013); and left shoulder scar (noncompensable from January 3, 2013). His combined total rating has been at least 80 percent since January 3, 2013. Thus, the percentage requirements of § 4.16(a) are met. The remaining issue is whether the service-connected disabilities preclude the Veteran from engaging in substantial gainful employment (i.e., work that is more than marginal, which permits the individual to earn a “living wage”). See Moore v. Derwinski, 1 Vet. App. 356 (1991). Regarding the Veteran’s education and employment history, the Veteran indicated in a May 2012 VA PTSD examination that he obtained a bachelor’s degree during his time on active duty. He indicated on February 2013 SSA application that prior to his May 2002 to January 2013 active military duty, he worked as a driver and manager for various companies. The Veteran did not list any employment since his January 2013 discharge from service. The Board finds that the Veteran’s service-connected disabilities are shown to preclude him securing and following substantially gainful employment consistent with his educational and work background. In a June 2014 Physical Residual Functional Capacity Questionnaire, J.Y., a physician assistant, indicated that the Veteran would be able to consistently stand, walk, and sit for less than two hours in a normal eight-hour work day; consistently lift and carry less than 10 pounds in a normal eight-hour work day; would miss three or more days per month due to medical problems; would require more than one extra break per day; and would be unable to stay focused to complete a simple repetitive-type task for at least seven hours of an eight-hour work day more than three days per month. J.Y. opined that because of the Veteran’s service-connected impairments and the impact both physically and mentally of the impairments, the Veteran would not be able to maintain substantially gainful employment. As discussed above, in an October 2015 Residual Functional Capacity Evaluation regarding the Veteran’s mental ability to do work-related activities, Dr. H.H., a psychologist, indicated that the Veteran’s mental problems would cause him to miss three or more days of work per month and to leave early three or more days per month. His mental symptoms would cause him to be unable to sustain concentration to complete simple repetitive tasks more than 3 days per month, and if he were subjected to normal workplace pressures and constructive criticisms of a job he would respond in an angry manner (but would not actually become violent) more than once per month. In a March 2016 vocational opinion, S.B., Doctor of Rehabilitation, reviewed the Veteran’s claims file and opined that the Veteran had emotional and physical conditions that interacted in terms of severity level. Based on review of the evidence, including the May 2012 VA examinations, VA treatment records, and J.Y.’s findings, Dr. S.B. found that the major area of limitations appeared to be mental and physical activity involved in sustaining work, which was extremely limiting for the Veteran. She concluded that the Veteran was totally and permanently precluded from performing work at a substantial gainful level due to the severity of his service-connected disabilities. In sum, there is probative evidence that establishes that the Veteran’s service-connected disabilities significant occupational impairment. There is probative medical evidence that establishes that the Veteran is unable to perform substantially gainful employment due to his mental and physical disabilities. In additions to the opinions above by J.Y., Dr. H.H., and Dr. S.B., the March 2017 VA PTSD examiner opined that the Veteran’s mental health symptoms caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. Moreover, although there is no final SSA disposition in the claims file, Dr. S.B. noted that the Veteran was receiving Social Security disability benefits. As such, the Board finds that the Veteran’s service-connected disabilities prevent him from obtaining and maintaining employment. The Board acknowledges there is also probative evidence that the Veteran’s service-connected disabilities do not cause significant occupational impairment, including findings in the series of 2012 VA examinations and an initial finding by the SSA of “not disabled.” However, under the “benefit-of-the- doubt” rule, where there exists “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993). Accordingly, on this record, affording the Veteran the benefit of the doubt, the Board finds that the Veteran’s service-connected disabilities are shown to prevent him from engaging in any substantially gainful employment. Thus, entitlement to a TDIU by reason of service-connected disabilities is warranted. REASONS FOR REMAND 1. Service connection for disabilities of the toes, neck, right ankle, left ear, abdomen (other than GERD), and rosacea. In May 2012 VA examinations, the Veteran reported having pain and tingling in his toes; pain, muscle aches, and spasms in his neck; pain in his right ankle; intermittent pain in his left ear; abdominal cramping and increased bowel movements; and redness in the face. Upon examination, he was not found to have diagnoses of any disabilities of the toes, neck, right ankle, left ear, abdomen other than GERD, or rosacea. Under 38 U.S.C. § 1117(a)(1), compensation is warranted for a Persian Gulf veteran who exhibits objective indications of a “qualifying chronic disability” that became manifest during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. A “qualifying chronic disability” includes (a) undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C. § 1117(g); 38 C.F.R. §3.317(b). The chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 C.F.R. § 3.317(a)(1)(ii). Effective December 29, 2011, VA extended the presumptive period in 38 C.F.R. § 3.317(a)(1)(i) through December 31, 2016. See 76 Fed. Reg. 81,834, 81,836 (2012). In this case, the Veteran’s DD Form 214 indicates that he served in Iraq from November 2004 to November 2005. Given the Veteran’s service in Southwest Asia during the Gulf War, a medical opinion is needed in order to determine whether the Veteran’s complaints of pain in the toes, neck, right ankle, left ear, abdomen (other than GERD), and rosacea are symptoms of an undiagnosed illness or a medically unexplained multisymptom illness based on the Veteran’s service in the Gulf War. 2. Service connection for a heart condition and an eye disability other than vitreous floaters with photophobia. In May 2012 VA examinations, the Veteran was found to have diagnoses of atrial septal defect, anisometropia, right eye amblyopia, and right eye hyperopic astigmatism. The RO noted in August 2012 and June 2013 rating decisions that service connection for these disabilities was denied on the bases that they were constitutional or developmental abnormalities and therefore not eligible for service connection. The examiners, however, did not specifically opinion on whether the heart and eye conditions constitute developmental defects or diseases. The examiners also did not opine on whether any defects are associated with a superimposed disease or injury during service, or whether any diseases were aggravated by the Veteran’s military service. The Board therefore finds that additional medical opinions are needed. Generally, congenital or developmental defects are not “diseases or injuries” within the meaning of applicable statutes and regulations. 38 C.F.R. § 3.303(c); Winn v. Brown, 8 Vet. App. 510, 516 (1996). The presumption of soundness does not apply when a condition is a congenital or developmental defect, as service connection cannot be granted for such disorder. See Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993) (noting the difference between defect and disease and further noting that service connection may be granted if the congenital or developmental condition is a disease). Nevertheless, service connection may be granted, in limited circumstances, for disability due to aggravation of a constitutional or developmental abnormality by a superimposed disease or injury in service. See Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); Monroe, 4 Vet. App. at 514-15. Therefore, a determination must be made as to the nature of the Veteran’s heart condition and eye disability other than vitreous floaters with photophobia. 3. Increased ratings for the back disability, bilateral plantar fasciitis, right bicep strain, headache disability, left hand disability, bilateral knee arthritis, left ankle tendonitis, vitreous floaters with photophobia, bilateral hearing loss, history of heat injury with rhabdomyolysis, GERD, erectile dysfunction, right leg scar, and left shoulder scar. Remand is required on these increased initial rating claims to obtain outstanding VA and non-VA treatment records. The only treatment records currently associated with the claims file are a series of 2012 VA examination reports, VA psychiatric treatment records dated from September 2015 to present, and non-VA treatment records dated up to May 2014. There are no VA treatment records (other than VA examination reports) dated prior to September 2015, and there are virtually no private treatment records in the claims file for the period on appeal from June 2014 to present, despite evidence suggestive of continuously-prescribed medications and treatment for various conditions during this period of time. As such, the AOJ should attempt to obtain all outstanding VA and non-VA treatment records. Low back, bilateral knees, and left ankle With regard to the claims for increased ratings for the low back, bilateral knees, and left ankle disabilities, remand is necessary for new VA examinations compliant with Correia v. McDonald, 28 Vet. App. 158 (2016). In Correia, the Court held that to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of 38 C.F.R. § 4.59. That final sentence of 38 C.F.R. § 4.59 directs that the joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. Here, the May 2012 VA examinations, the sole examinations on record of these disabilities, provided findings for active ranges of motion, but did not indicate passive ranges of motion, nor did the examiner indicate whether there were differences in weight-bearing and nonweight-bearing. Accordingly, new examinations are necessary. Left hand With regard to claim for an increased rating for the left hand disability, the Board finds the May 2012 VA examination report to be insufficient for adjudication purposes. In the examination, the Veteran reported having right thumb and left hand pain. On examination, the Veteran’s “hand” was examined and ranges of motion including the thumb were noted, but the examiner did not specify which hand was examined. Radiographic imaging notes that the examination title/history stated “left hand” and the images were of the “right hand.” As such, the Board finds that a new examination of the left hand is necessary. History of heat injury with rhabdomyolysis The Veteran was most recently examined for his history of heat injury with rhabdomyolysis in May 2012. He reported symptoms of chronic muscle pain and headaches, with flare-ups that occurred 2-3 times per week. He described the flare-ups as moderate to severe, and were relieved by increased oral fluid and cool down. In July 2013 private treatment records, the Veteran indicated that he had an episode of heat stroke and a flare-up of his rhabdomyolosis. He stated that he started sweating on Friday night and over-heated, and started vomiting on Saturday and was unable to eat or keep food down. He was unable to urinate from Friday to Monday, and when he did it was dark syrup looking. He also indicated that he was having cramping on both sides of his stomach area, and required labs to test his kidney function. In June 2014, the Veteran’s spouse submitted a statement to the SSA indicating that she had lost count of how many “rhabdo episodes” the Veteran had, and when he did, he was bedridden for 3-4 days and did not urinate for 48 hours. The Veteran’s sister, sister-in-law, brother-in-law, and parents-in-law submitted statements in which they indicated that they witnessed the Veteran’s serious rhabdomyolysis episodes. Thus, due to evidence of potentially worsening symptomatology, the Board finds a new VA examination is necessary. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he provide sufficient information, and if necessary authorization, to enable the RO to obtain any non-VA treatment records showing any relevant treatment related to the back disability, bilateral plantar fasciitis, right bicep strain, headache disability, left hand disability, bilateral knee arthritis, left ankle tendonitis, vitreous floaters with photophobia, bilateral hearing loss, history of heat injury with rhabdomyolysis, GERD, erectile dysfunction, right leg scar, and/or left shoulder scar dated from June 2014 to present. The RO should make an attempt to obtain any treatment records identified by the Veteran that are not currently associated with the claims file. 2. Obtain from the VA healthcare system all outstanding, pertinent records of evaluation and/or treatment related to the back disability, bilateral plantar fasciitis, right bicep strain, headache disability, left hand disability, bilateral knee arthritis, left ankle tendonitis, vitreous floaters with photophobia, bilateral hearing loss, history of heat injury with rhabdomyolysis, GERD, erectile dysfunction, right leg scar, and/or left shoulder scar dated from January 2013 to present. All records/responses received should be associated with the claims file. If any records sought are not obtained, a written statement to that effect should be incorporated into the record. 3. Once the record is developed to the extent possible, request an opinion from a physician with sufficient expertise to determine the nature and etiology of the Veteran’s claimed disabilities of the toes, neck, right ankle, left ear, abdomen (other than GERD), and rosacea, in particular to assess the Veteran’s symptoms in relation to the claims based upon medically unexplained chronic multisymptom illness. All pertinent evidence of record must be made available to and reviewed by the physician. Following a thorough review of the record, the physician is requested to: (a) Provide a complete medical opinion and detailed rationale regarding whether the Veteran has an undiagnosed illness(es) of which any of the following are a manifestation: pain in the toes, neck, right ankle, left ear, abdomen (other than GERD), and/or rosacea. (b) If any or all of the claimed disabilities noted above are not deemed manifestations of undiagnosed illness, then provide a complete medical opinion and detailed rationale regarding whether the Veteran’s signs and symptoms (including pain in the toes, neck, right ankle, left ear, abdomen (other than GERD), and/or rosacea) are manifestations of chronic disability resulting from a medically unexplained chronic multisymptom illness. 4. Contact the VA examiners who conducted the May 2012 VA eye and heart conditions examinations (or suitable replacements), and ask the examiners to review the record and prepare addendum medical opinions. The examiners are asked to identify all current heart conditions and eye disabilities other than vitreous floaters with photophobia and provide opinions as to the following: (a) Do the Veteran’s heart conditions and/or eye conditions other than vitreous floaters with photophobia constitute congenital defects or congenital diseases? For VA adjudication purposes, a congenital defect is a condition that can neither improve nor worsen. A congenital disease is a condition that is subject to improvement and worsening. (b) If the Veteran’s heart conditions and/or eye disabilities other than vitreous floaters with photophobia are considered defects, was there any superimposed disease or injury in connection with the congenital defect(s) during service? (c) If the Veteran’s heart conditions and/or eye disabilities other than vitreous floaters with photophobia are diseases, what evidence establishes that the condition pre-existed service? Assuming that the heart conditions and/or eye disabilities other than vitreous floaters with photophobia preexisted service, is there evidence that they underwent permanent increases in severity during active service? If so, was the increase in severity beyond the natural progress of the condition(s)? All findings should be reported in detail and all opinions must be accompanied by a clear rationale. The examiners are advised that the Veteran is competent to report in-service symptoms and history, and such statements must be specifically acknowledged and considered in formulating any opinions. 5. Schedule the Veteran for a VA orthopedic examinations to evaluate the severity of the low back, bilateral knees, left ankle, and left hand disabilities. The examiner is asked to review all relevant records and conduct a clinical evaluation. Based on this review, the examiner is asked to provide an assessment of the current nature of the Veteran’s low back, bilateral knees, left ankle, and left hand disabilities. Ranges of motion should be tested actively and passively, in weight-bearing and nonweight-bearing, and after repetitive use. The examiner should consider whether there is likely to be additional range of motion loss due to any of the following: (1) during flare-ups; and, (2) as a result of pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. If for any reason the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. 6. Schedule the Veteran for a VA examination to determine the severity of his of his history of heat injury with rhabdomyolysis. The examiner is asked to review all relevant records and conduct a clinical evaluation. Based on this review, the examiner is asked to provide an assessment of the current nature of the Veteran’s history of heat injury with rhabdomyolysis disability. The examiner should identify all symptoms attributable to the Veteran’s history of heat injury with rhabdomyolysis and comment on their severity. The examiner should also describe the functional impact of the Veteran’s history of heat injury with rhabdomyolysis. A fully articulated medical rationale for each opinion expressed must be set forth in the medical report. If for any reason the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Nelson, Counsel