Citation Nr: 18156639 Decision Date: 12/10/18 Archive Date: 12/10/18 DOCKET NO. 17-02 906 DATE: December 10, 2018 ORDER Entitlement to an effective date prior to December 29, 2011 for the award of service connection for PTSD with depressive disorder not otherwise specified is denied. Entitlement to an effective date prior to February 2, 2012 for the award of service connection for migraines is denied. Entitlement to an effective date prior to February 2, 2012 for the award of service connection for cervical fracture C3 with degenerative disc disease and disc bulge is denied. Entitlement to an effective date prior to February 2, 2012 for the award of service connection for gastroenteritis with IBS is denied. Entitlement to an effective date prior to February 2, 2012 for the award of service connection for recurrent UTIs, meatal stenosis, and urethral diverticulum is denied. Entitlement to an effective date prior to February 2, 2012 for the award of service connection for left knee patella femoral syndrome with subpatellar tendonitis and degenerative joint disease is denied. Entitlement to an initial rating in excess of 30 percent for gastroenteritis with irritable bowel syndrome (IBS) is denied. Entitlement to an initial compensable rating of 10 percent prior to August 19, 2016 for recurrent urinary tract infections (UTIs), meatal stenosis, and urethral diverticulum is granted. Entitlement to a rating in excess of 10 percent from August 19, 2016 for recurrent UTIs, meatal stenosis, and urethral diverticulum is denied. Entitlement to an initial rating in excess of 30 percent for migraines is denied. Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) with depressive disorder not otherwise specified is denied. Entitlement to service connection for a left shoulder disability is denied. REMANDED Entitlement to an initial compensable rating prior to August 19, 2016 and in excess of 10 percent thereafter for left knee patella femoral syndrome with subpatellar tendonitis and degenerative joint disease is remanded. Entitlement to an initial rating in excess of 10 percent prior to August 19, 2016 and in excess of 20 percent thereafter for cervical fracture C3 with degenerative disc disease and disc bulge is remanded. Entitlement to service connection for nerve damage is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a bilateral hearing loss disability is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to service connection for traumatic brain injury (TBI) is remanded. Entitlement to service connection for tremors is remanded. Entitlement to service connection for a right ear condition, also claimed as vertigo and loss of balance is remanded. Entitlement to service connection for a vision condition is remanded. Entitlement to service connection for low testosterone is remanded. Entitlement to service connection for diabetes mellitus, type II is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. An informal claim for service connection for PTSD was received on December 29, 2011. 2. An application for service connection for migraines, neck pain, stomach disorders, urethral stricture and knee pain under the Fully Developed Claim (FDC) Program was received on February 2, 2012. 3. The Veteran’s claims for service connection were not processed under the Fully Developed Claim (FDC) Program for administrative reasons. 4. The Veteran’s gastroenteritis with IBS is assigned a 30 percent evaluation, the maximum rating authorized under Diagnostic Code (DC) 7319 for irritable bowel syndrome. 5. The evidence shows that prior to August 19, 2016, the Veteran’s recurrent urinary tract infections, meatal stenosis, and urethral diverticulum was productive of urinary frequency that resulted in daytime voiding intervals between two and three hours. 6. The evidence does not show that from August 19, 2016, the Veteran’s urethral stricture has been manifested by urinary frequency with daytime voiding intervals between one and two hours, or awakening to void three to four times per night; urinary leakage requiring the wearing of absorbent materials which must be changed less than two times per day; or urinary retention requiring intermittent or continuous catheterization. 7. The evidence does not show that the Veteran has had migraines with very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability. 8. The evidence does not show that the Veteran’s PTSD has been manifested by total occupational and social impairment. 9. The evidence does not support a finding that the Veteran has a left shoulder disability that is etiologically related to active duty service. CONCLUSIONS OF LAW 1. The criteria for an effective date earlier than December 29, 2011, for the award of service connection for PTSD with depressive disorder not otherwise specified is denied. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.1, 3.155, 3.159, 3.400. 2. Entitlement to an effective date prior to February 2, 2012 for the award of service connection for migraines is denied. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.1, 3.155, 3.159, 3.400. 3. Entitlement to an effective date prior to February 2, 2012 for the award of service connection for cervical fracture C3 with degenerative disc disease and disc bulge is denied. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.1, 3.155, 3.159, 3.400. 4. Entitlement to an effective date prior to February 2, 2012 for the award of service connection for gastroenteritis with IBS is denied. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.1, 3.155, 3.159, 3.400. 5. Entitlement to an effective date prior to February 2, 2012 for the award of service connection for recurrent UTIs, meatal stenosis, and urethral diverticulum is denied. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.1, 3.155, 3.159, 3.400. 6. Entitlement to an effective date prior to February 2, 2012 for the award of service connection for left knee patella femoral syndrome with subpatellar tendonitis and degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5110; 38 C.F.R. §§ 3.1, 3.155, 3.159, 3.400. 7. There is no legal basis for a disability rating in excess of 30 percent for gastroenteritis and IBS. 38 U.S.C. §§ 1155, 5107(b) 38 C.F.R. §§ 3.321 (b)(1), 4.1, 4.3, 4.7, 4.20, 4.114, Diagnostic Code (DC) 7319. 8. The criteria for entitlement to an initial compensable rating of 10 percent for recurrent urinary tract infections, meatal stenosis, and urethral diverticulum prior to August 19, 2016 have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.115a, 4.115b, DC 7518. 9. The criteria for entitlement to a rating in excess of 10 percent for recurrent urinary tract infections, meatal stenosis, and urethral diverticulum from August 19, 2016 have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.115a, 4.115b, DC 7518. 10. The criteria for entitlement to an initial rating in excess of 30 percent for migraines have not been met. 38 U.S.C. § 1155, 5107(b); § 38 C.F.R. §§ 3.102, 3.159, 4.2, 4.124a, DC 8100. 11. The criteria for entitlement to an initial rating in excess of 70 percent for PTSD with depressive disorder not otherwise specified have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.130, DC 9411. 12. The criteria for entitlement to service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty with the United States Navy from August 1980 to October 1984; in the United States Marine Corps from December 1984 to December 1987; and in the United States Army from December 1990 to May 1992 and October 2007 to November 2008. He had service in both the Persian Gulf and Afghanistan. The Veteran also had additional service in the Navy Reserves and Army National Guard. This case comes before the Board of Veterans’ Appeals (Board) on appeal from December 2013, July 2014, and September 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In his December 2011 claim for benefits, the Veteran indicated a desire to seek entitlement to service connection for “dental issues.” However, this issue has not been developed or adjudicated by the RO. Therefore, the issue of entitlement to service connection for dental issues is referred for appropriate action. 38 C.F.R. § 19.9 (b) (2016). Earlier Effective Dates The Veteran seeks earlier effective dates for PTSD and migraines, neck pain, stomach disorders, recurrent urinary tract infections and knee pain. The law regarding effective dates provides that, unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110 (a). This statutory provision is implemented by a VA regulation, which provides that the effective date of an evaluation and award of compensation based on an original claim or a claim reopened after final disallowance will be the date of receipt of the claim or the date entitlement arose, whichever is the later. See 38 C.F.R. § 3.400. A specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid or furnished to any individual under the laws administered by VA. 38 U.S.C. § 5101 (a); 38 C.F.R. § 3.151 (a). The term “claim” or “application” means a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1 (p). For claims received on or after March 24, 2015, VA amended its regulations governing how to file a claim. The effect of the amendment was to standardize the process of filing claims, as well as the forms accepted, in order to increase the efficiency, accuracy, and timeliness of claims processing, and to eliminate the concept of informal claims. See 38 C.F.R. § 3.155; 79 Fed. Reg. 57660-01. However, prior to the effective date of the amendment, an informal claim was any communication or action, indicating an intent to apply for one or more benefits under the laws administered by VA. Such informal claim must identify the benefit sought. 38 C.F.R. § 3.155 (a) (2014). Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the veteran, it will be considered filed as of the date of receipt of the informal claim. Id. An informal claim for service connection for PTSD is shown to initially have been received by the RO on December 29, 2011 according to the date stamp. The Veteran completed an application for service connection for migraines, neck pain, stomach disorders, urethral stricture and knee pain (VA Form 21-526) using the Fully Developed Claim (FDC) process. This application was signed on December 28, 2011; however, it is not date stamped as having been received by the RO in December 2011. Rather, correspondence shows the VA Form 21-526 was part of a larger packet of materials (which included DD 214s, a DD 215, medical records, and an informal claim for PTSD) submitted to the RO by a Veteran’s Service Officer in February 2012. The date stamp on this packet of information was February 2, 2012. According to 38 U.S.C. § 5110 (b)(2)(A), “the effective date of an award of disability compensation to a veteran who submits an application therefor that sets forth an original claim that is fully-developed as of the date of submittal shall be fixed in accordance with the facts found, but shall not be earlier than the date that is one year before the date of receipt of the application.” A claim for service connection submitted through the FDC process by definition meets the statutory requirement of “an original claim that is fully-developed.” See 38 U.S.C. § 5110. However, in a letter sent to the Veteran in September 2012, he was notified that his claims would not be processed under the FDC Program for administrative purposes because he had amended his claims (and had withdrawn several issues) and the file had to be transferred. Notably, 38 U.S.C. § 5110 (b)(2)(A) does not establish that the effective date for claims filed under the FDC process is automatically one year prior to the date of the filing of the formal claim for service connection. Instead, the statute states that the effective date shall be fixed in accordance with the facts found, so long as the date established by the facts is not earlier than one year prior to the date of the receipt of the application for service connection. As explained in the October 2016 statement of the case, the record reflects that the Veteran did not file any claims, formal or informal, prior to December 29, 2011, for his PTSD. The record also reflects he did not file any claims, formal or informal, for migraines, neck pain, stomach disorders, recurrent urinary tract infections and knee pain prior to February 2, 2012. As explained in the October 2016 statement of the case, after applying the VA laws and regulations, the earliest possible effective date for the award of service connection for PTSD is December 29, 2012; and February 2, 2012 for migraines, neck pain, stomach disorders, recurrent urinary tract infections and knee pain. Accordingly, these appeals must be denied because the RO has already assigned the earliest possible effective date provided by law. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes (DC). When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Where the question for consideration is the propriety of the initial ratings assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where VA’s adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or “staged” ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson, 12 Vet. App. at 126-27. A Veteran’s entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 1. Entitlement to an initial rating in excess of 30 percent for gastroenteritis with irritable bowel syndrome The Veteran’s service-connected gastroenteritis with irritable bowel syndrome (IBS) has been assigned a 30 percent disability rating under 38 C.F.R. §4.114, Diagnostic Code 7319, for the entire period on appeal. This is the maximum schedular rating available for his disability. A 30 percent rating contemplates severe symptomatology, manifested by diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. In a June 2012 VA treatment note, the Veteran reported that his IBS waxed and waned between constipation and diarrhea, “but mostly diarrhea.” He attributed these symptoms to change of diet, lack of exercise, and weight gain. The Veteran was afforded a VA examination in October 2013. The examiner noted “multiple gastrointestinal issues” since 1982, with nausea, vomiting, and diarrhea abdominal cramping, with regular episodes four to five times per month. He reported never having had a colonoscopy or esophagogastroduodenoscopy test and reported no daily medication. The Veteran endorsed symptoms of abdominal pain on a less then monthly basis; transient nausea lasting less than one day three or more times per year; and transient vomiting lasting less than one day three or more times per year. The Veteran denied incapacitating episodes and reported no other conditions. In a March 2014 VA treatment note, the Veteran reported increased symptoms of IBS “with alternating loose watery stools for a few days and then hard stools with straining.” In August 2016, the Veteran reported symptoms of diarrhea “on and off all the time”; alternating diarrhea and constipation “all the time”; and abdominal distention “all the time.” He also reported episodes of bowel disturbance with more or less constant abdominal distress. He reported episodes of exacerbations and/or attacks of his gastrointestinal condition manifested by stomach churning, pain, distention, and diarrhea. The examiner found that the Veteran’s condition caused “mild impairment” in performing both sedentary and physical activities of employment. As previously noted, the Veteran is in receipt of the maximum rating available under the applicable diagnostic code; there is no higher schedular rating that can be assigned by regulation. In a case such as this one where the law and not the evidence is dispositive, the claim is denied on a schedular basis because of the absence of legal merit or the lack of entitlement under the law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Further, there is no evidence to suggest there is a better diagnostic code for application to the Veteran’s symptoms. Based on the foregoing, the claim for a rating in excess of 30 percent is denied. There are no additional expressly or reasonably raised issues on the record related to this claim. 2. Entitlement to an initial compensable rating prior to August 19, 2016 and in excess of 10 percent thereafter for recurrent urinary tract infections, meatal stenosis, and urethral diverticulum The Veteran asserts he is entitled to a compensable rating prior to August 19, 2016 and in excess of 10 percent thereafter for service-connected UTIs, meatal stenosis, and urethral diverticulum. The Veteran’s disability is currently rated under Diagnostic Code 7518, which directs that the disorder be rated under the criteria for a voiding dysfunction (urine leakage, frequency, or obstructed voiding). For urine leakage, a 20 percent evaluation is assigned for continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the wearing of absorbent material which must be changed less than 2 times per day. A 40 percent rating is assigned where the wearing of absorbent materials must be changed 2 to 4 times per day. The maximum rating of 60 percent is warranted when there is urinary leakage requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day. Increased urinary frequency is rated as follows: a 10 percent rating is assigned for daytime voiding interval between two and three hours, or awakening to void two times per night; a 20 percent rating is assigned for daytime voiding interval between one and two hours, or awakening to void three to four times per night; and, a 40 percent rating is assigned for daytime voiding interval less than one hour, or awakening to void five or more times per night. For obstructed voiding, a noncompensable rating is assigned for obstructive symptomatology with or without stricture disease requiring dilatation one to two times per year. A 10 percent rating is assigned for marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: 1) post void residuals greater than 150 cc; 2) uroflowmetry, markedly diminished peak flow rate (less than 10 cc/sec); 3) recurrent urinary tract infections secondary to obstruction; or, 4) stricture disease requiring periodic dilatation every two to three months. A 30 percent rating is assigned for urinary retention requiring intermittent or continuous catheterization. Turning to the evidence of record, the Veteran was afforded a VA examination in connection with his claim in October 2013. The examiner noted that the Veteran had been diagnosed with meatal stenosis, urethral diverticulum, and chronic UTIs during active service. The Veteran reported that his condition became symptomatic in January 2013, with urinary frequency and weak, multi-directional urinary stream. He denied any UTIs or medication over the past 12 months. He reported good urinary flow with a strong stream and denied nocturia. He reported emptying his bladder once every two to three hours during the day. The Veteran reported voiding dysfunction associated with his condition but denied urine leakage, use of an appliance, increased urinary frequency, or signs/symptoms of obstructed voiding. The Veteran reported no long-term drug therapy treatment over the past 12 months. The examiner found no functional impairment due to the Veteran’s condition. The Veteran was afforded another VA examination in August 2016. The Veteran reported in-service treatment for UTIs, which decreased to a rate of 2-3 times per year from 5-6 per year. The Veteran reported voiding dysfunction with an etiology of urethral stricture. He indicated that the voiding dysfunction caused urine leakage but did not require the wearing of absorbent material or use of an appliance. The Veteran reported a daytime voiding interval between two and three hours and nighttime awakening to void two times. The Veteran also reported that his voiding dysfunction caused symptoms of hesitancy, slow stream, weak stream, and decreased force of stream—but not markedly so. The Veteran reported a history of recurrent UTIs but reported receiving no treatment over the past 12 months. The examiner determined that the Veteran’s urinary tract condition created “mild impairment” in performing sedentary activity of employment and “mild to moderate impairment” in performing physical activity of employment. Overall, after careful review of the evidence of record, the Board finds that a 10 percent rating, but no higher, is warranted for the Veteran’s service-connected recurrent urinary tract infections, meatal stenosis, and urethral diverticulum for the entire period on appeal. Although the Veteran’s October 2013 VA examination did not produce evidence of urine leakage or marked obstructed voiding symptomatology, it did show evidence of urinary frequency, with a daytime voiding interval between two and three hours. This is consistent with a 10 percent rating under the assigned diagnostic code. Likewise, the Veteran’s August 2016 VA examination did not produce evidence of urine leakage or marked obstructive voiding symptomatology. The Veteran reported a daytime voiding interval between two and three hours and nighttime awakening to void two times. He reported obstructed voiding symptoms of hesitancy, slow stream, weak stream, and decreased force of stream, but none of these symptoms were “marked.” He denied receiving treatment for UTIs at any point during the previous 12 months. These symptoms are contemplated by the currently assigned 10 percent rating. Therefore, based on the foregoing, the Board finds that the Veteran is entitled to a 10 percent rating for the entire period on appeal. This means that to a limited extent, the Veteran’s claim for a compensable rating prior to August 19, 2016 is granted. However, the evidence does not support a rating in excess of 10 percent at any point during the period on appeal. As such, this aspect of the Veteran’s claim must be denied. 3. Entitlement to an initial rating in excess of 30 percent for migraines The Veteran’s migraine headaches have been assigned a 30 percent rating for the entire period on appeal under Diagnostic Code 8100. Under Diagnostic Code 8100, a 30 percent rating is warranted for migraine headaches with characteristic prostrating attacks occurring on average once a month over the last several months. A maximum 50 percent rating is warranted for migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. The rating criteria do not define “prostrating” as used in Diagnostic Code 8100. By way of reference, the Board notes that according to Webster’s New College Dictionary, 909 (3rd Ed. 2008), “prostrate” is defined as “physically or emotionally exhausted.” “Incapacitated” is listed as a synonym. A very similar definition is found in Dorland’s Illustrated Medical Dictionary, 1554 (31st Ed. 2007), in which “prostration” is defined as “extreme exhaustion or powerlessness.” The use of the conjunctive “and” in a statutory provision means that all of the conditions listed in the provision must be met. See Melson v. Derwinski, 1 Vet. App. 334 (1991). Here, because of the successive nature of the rating criteria, such that the evaluation for each higher disability rating includes the criteria of each lower disability rating (at least what could be considered most of them), each of the criteria listed in the 50 percent rating must be met in order to warrant such a rating. See Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). The term “productive of severe economic inadaptability” is not defined by VA regulations. The Court of Appeals for Veterans Claims (Court), however, has stated that this term is not synonymous with being completely unable to work, and that the phrase “productive of” could be read to mean either “producing” or “capable of producing” economic inadaptability. See Pierce v. Principi, 18 Vet. App. 440, 446-47 (2004). Turning to the evidence of record, the Veteran was afforded a VA examination in connection with his claim in October 2013. He reported that his headaches began during his 2008 deployment to Afghanistan. He described headaches resulting in scomata visual changes but not nausea or vomiting. He also described the headache pain as localized on one side of the head with a progressively worsening dull and constant ache. He reported two to three migraines a week with one severe migraine and eight to ten moderate migraines a month. He indicated that his headache pain typically lasted less than one day. The Veteran denied prostrating attacks of migraine headache pain. The Veteran reported taking medication to mitigate symptoms. In a January 2014 VA treatment note, the Veteran reported experiencing migraine headaches an average of twice per week, with headaches lasting for a few minutes to hours and average pain of “4-10” out of 10. Medication was noted to help with symptoms. The Veteran was afforded another VA examination in October 2016. He reported taking medication (specifically, Sumatriptan) to mitigate his migraine headache symptoms. He further reported symptoms of pulsating or throbbing head pain, pain on both sides of the head, and pain which would worsen with physical activity. He also reported non-headache symptoms of sensitivity to light and sound. He reported that headache pain would typically last less than one day. The Veteran also reported prostrating attacks of headache pain more frequently than once per month. However, he denied very frequent prostrating and prolonged attacks of migraine headache pain and denied prostrating attacks of non-migraine headache pain. Regarding functional impact, the examiner noted that the Veteran’s headache condition created “mild to moderate” impairment in performing both sedentary and physical activities of employment. Overall, after careful review of the evidence, the Board finds that a rating in excess of 30 percent is not warranted at any point during the period on appeal. As previously discussed, a 50 percent rating is warranted for migraines with very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. The evidence in this case does not establish that the Veteran’s migraine headaches have reached such severity. While the Veteran has reported experiencing prostrating headaches more frequently than once a month, he denied very frequent prostrating and prolonged attacks of migraine headache pain and denied prostrating attacks of non-migraine headache pain. Further, the evidence indicates that the Veteran’s headache condition has created only mild to moderate impairment in performing both sedentary and physical activities of employment; there is no evidence that the headaches have been productive of severe economic inadaptability. The severity of the Veteran’s service-connected migraine headaches is best contemplated by the assigned 30 percent rating. Accordingly, the Veteran’s claim for a higher initial rating must be denied. 4. Entitlement to an initial rating in excess of 70 percent for PTSD with depressive disorder not otherwise specified Under the general rating formula for mental disorders, a 70 percent evaluation is assigned when a veteran’s PTSD causes 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); or an inability to establish and maintain effective relationships. A 100 percent rating is assigned when a veteran’s PTSD causes total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal hygiene); disorientation to time or place; or, memory loss for names of close relatives, occupation, or own name. The use of the term “such as” in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms listed after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). VA is not required to find the presence of all, most, or even some of the enumerated symptoms recited for particular ratings. The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating and permits consideration of other symptoms particular to each veteran and disorder and the effect of those symptoms on the Veteran’s social and work situation. Further, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination.” 38 C.F.R. § 4.126 (a). The Board notes that the revised DSM-5, which, among other things, eliminates GAF scores, applies to appeals certified to the Board after August 4, 2014, as is the case here. See 79 Fed. Reg. 45, 093 (Aug. 4, 2014). Consequently, the Board will not consider the previously assigned GAF scores in determining the outcome of this case. See Golden v. Shulkin, 29 Vet. App. 221, 225 (2018). In reaching a decision on this matter, the Board has reviewed all the evidence in the claims file and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C. § 7104 (d)(1); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each and every piece of evidence in exhaustive detail. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122 (2000). Turning to the evidence of record, private treatment records show the Veteran’s psychiatric disability was treated privately before he sought treatment from VA. A private treatment note from March 2012 documents chronic sleep impairment and depression, specifically noting symptoms of depressed mood, poor concentration, weight gain, poor sleep, and irritability and anxiety. Symptoms specifically not noted included suicidal ideation, suicide attempt, loss of interest, or indecisiveness. The Veteran described his condition as moderate in severity and worsening. Private treatment notes from April to May 2012 document treatment from Dr. R.A. and mainly concern the Veteran’s anxiety about his situation at work. The Veteran expressed fears that his supervisor was trying to “get rid of him” due to psychiatric problems. The Veteran also reported “hearing noises outside at night” and increased anxiety “waiting for the bomb to drop.” He reported hypervigilance and sleep impairment. VA treatment records show the Veteran initially sought VA mental health treatment in July 2012 after reporting to his local clinic unscheduled “in somewhat of a crisis mode.” He reported significant work stress, including an upsetting altercation with his supervisor. He denied substance abuse problems and did not express hopelessness or suicidal ideations. The Veteran was subsequently afforded a psychiatric assessment, during which he reported sleeplessness, depressed mood, posttraumatic reactions, and “significant personal distress” causing him to feel unable to function at times. In an August 2012 VA treatment note, the Veteran reported decreased productivity at work and decreased feelings of closeness to his wife. The treating psychologist noted, “these symptoms have been chronic and reportedly have contributed to impaired family, social, and occupational functioning.” On mental status examination, the Veteran appeared casual and neat; speech was normal; he denied suicidal or homicidal ideation or plans; thought was logical and goal directed; insight and judgment were good; intellect was average; and he denied delusions, hallucinations, or flashbacks. A November 2012 VA treatment note documented a phone call from the Veteran’s wife, who relayed financial concerns and reported that the Veteran had missed more than half of his work due to PTSD symptoms. In a January 2013 VA treatment note, the Veteran reported anxiety over progressing financial problems at home. He reported being more depressed with low energy, resulting in an inability to get out of bed for work. He reported increasingly vivid nightmares but improving paranoia. He reported increased anxiety and worsening sleep problems but denied “current lethal ideation intent or plan.” The Veteran denied any past attempts at suicide and denied hallucinations, anxiety attacks, or manic symptoms. At the time of the appointment, the Veteran was noted to be dressed in appropriate attire, was conversant, maintained eye contact, was calm and engaged, exhibited normal speech, organized thoughts, and fair insight and judgment. In an August 2013 written statement in support of his claim, the Veteran described difficulties adjusting to day-to-day life, noting angry outbursts at home and at work and paranoia—for instance, walking around with a loaded gun because he felt like he was being watched by someone. He reported being unable to sleep without medication. He also reported severe depression “to the point that the thought of suicide has often come up.” Additionally, the Veteran reported anxiety manifested by panic attacks several times per month. He described decreased concentration and increased nightmares, despite medication. He reported social and occupational impairment due to his PTSD, to include missing over 600 hours of work due to his symptoms. The Veteran was afforded a VA examination in August 2013. The Veteran was found to have PTSD symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, flattened affect, and disturbances of motivation and mood. The examiner determined that the Veteran’s PTSD caused occupational and social impairment with reduced reliability and productivity. In a September 2014 VA treatment note, the Veteran exhibited a better mood, expressing excitement about his twin granddaughters and a weekend trip. He denied suicidal or homicidal ideation or plan. However, he continued to note chronic sleep impairment, including nightmares. VA treatment notes from December 2015 document severe marital tension, “in setting of PTSD.” The Veteran’s wife reported that the Veteran poured water on her twice and grabbed her wrist. The Veteran reported that his wife was always saying this to “humiliate” him. The Veteran admitted to calling his wife abusive names and grabbing her wrist in a single incident; he otherwise denied violence toward her. On mental status examination, the Veteran exhibited good hygiene, normal speech (but with an angry tone), and was “reasonably civil” with his wife. He denied suicidal or homicidal ideation, hallucinations and/or delusions, and he exhibited no gross or obvious memory defects. Judgment and insight were limited. In a subsequent December 2015 treatment note, the Veteran reported decreased appetite and worsening sleep, though his mental status examination was otherwise normal. In a February 2016 VA treatment note, the Veteran reported continued marital problems but denied any violence. Mental status examination was largely normal, with the Veteran exhibiting good hygiene and denying suicidal or homicidal ideation and denying hallucinations or delusions. In an April 2016 VA treatment note, the Veteran reported decreased concentration and focus but improvements in mood and in his relationship with his wife. The Veteran continued to report chronic sleep impairment. Mental status examination was largely normal, with the Veteran exhibiting good hygiene and denying suicidal or homicidal ideation and denying hallucinations or delusions. The Veteran was afforded another VA examination in August 2016. The Veteran reported significant sleep problems with “some nightmares.” He reported problems with anxiety during the day and “some depression.” He was noted to have irritability, startle, hypervigilance, intrusive memories, and avoidance. He reported increased isolation and withdrawal, loss of energy and loss of interest, and decreased attention span. The examiner found the Veteran able to get along with the public, coworkers, and supervisors; and able to follow complex instructions. He was found to have some decreased attention span, terrible sleep, anxiety, and some irritability. On mental status examination, the Veteran was noted to be pleasant, cooperative, and polite. Speech was normal, and the Veteran communicated well. Regarding affect, the examiner found that the Veteran had depression, psychomotor retardation, and anxiety, with “occasional panic attacks” and “some irritability.” Cognitively, the Veteran was oriented with good concentration; good recent and remote memory; good fund of information, good judgment, fair insight, and average intelligence. He reported being able to perform activities of daily living (ADLs). He reported that he gets along with his children and that he and his wife, while they have some issues, were “basically doing okay.” The examiner found the Veteran “able to establish and maintain effective work and social relationships.” The examiner found that the Veteran’s PTSD was associated with symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner ultimately found that the Veteran’s PTSD caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. In May 2018, the Veteran underwent an examination by private psychologist H.H. Dr. H.H. noted the Veteran was in a “strained marriage,” was isolated and withdrawn, anxious around people, and had intimacy and avoidance issues. She also found him to be hypervigilant and easily startled, which diminished participation in social activities. She noted chronic PTSD symptoms including hypervigilance, flashbacks, increased startle reflex, social and marital deficits, sleep problems, nightmares, mood and motivation disturbances, and daily living and work impairment. She found the presence of symptoms including depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, inability to establish and maintain effective relationships, impaired impulse control, persistent delusions or hallucinations, neglect of personal appearance and hygiene, and intermittent inability to perform ADLs. With regard to ADLs, the Dr. H.H. explained that the Veteran’s wife would perform most household chores, including grocery shopping, meal preparation, cleaning, and financial management—though Dr. H.H. found the Veteran capable of managing his finances. She noted that the Veteran’s day mainly consisted of watching television, taking naps, trying to do “simple chores” such as taking out the garbage and raking leaves, and eating two meals a day. She did not otherwise explain her finding concerning the Veteran’s intermittent inability to perform ADLs. Ultimately, Dr. H.H. found that the Veteran’s PTSD caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Overall, after careful review of the record, the Board finds that a disability rating in excess of 70 percent is not warranted for the Veteran’s service-connected PTSD. The Veteran’s extensive VA and private treatment records, lay testimony, and his 2013 and 2016 VA examination reports chronicle significant work problems due to anxiety, depression, isolation, anger, and irritability and resultant inability to adapt to stressful circumstances. The Veteran’s psychiatric symptoms also resulted in significant relationship difficulties, especially in the context of his marriage. The VA examiners and the May 2018 private examiner documented psychiatric symptoms that have, at most, led to occupational and social impairment with deficiencies in most areas—a level of impairment specifically contemplated by the currently assigned 70 percent disability rating. The weight of the evidence shows that a higher disability rating of 100 percent is not warranted. As previously discussed, a maximum 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Here, the evidence simply does not demonstrate “total” social and occupational impairment. The Veteran has not exhibited gross impairment in thought processes or communication—indeed, the Veteran has been noted to be a good communicator. He has repeatedly denied delusions or hallucinations, as well as suicidal or homicidal ideation or intent. He has never been found to exhibit “grossly inappropriate behavior” and has been repeatedly observed as dressed appropriately and of good hygiene. He has not exhibited disorientation to time or place or memory loss for names of close relatives, his own occupation, or his own name. In short, the evidence does not show the Veteran’s PTSD is of such severity to warrant entitlement to a maximum 100 percent disability rating. Therefore, having resolved all doubt in favor of the Veteran, the Board finds that an initial disability rating in excess of 70 percent for PTSD is not warranted. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). Generally, in order to establish service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 1. Entitlement to service connection for a left shoulder disability Service treatment records show the Veteran suffered a left shoulder strain during service. During his October 2013 VA examination, the Veteran reported that he fell and injured his left shoulder in February 2008 during deployment to Afghanistan. The Veteran reported that a medic put him in a sling and gave him ibuprofen. Diagnostic testing revealed degenerative arthritis (“mild to moderate spurring”) in the left shoulder. In her negative nexus opinion, the examiner acknowledged an in-service left shoulder injury but ultimately found that the current degenerative arthritis was less likely caused by his in-service injury and more likely due to “the process of aging, genetic factors, body habitus and cumulative life.” The VA medical opinion is highly persuasive as the examiner, a physician, reviewed the claims file and discussed the clinical findings, and supported her opinion with cogent rationale. There is no equally probative and competent evidence to the contrary. As a lay person, the Veteran is not competent to establish that arthritis had onset in service, or is related to a strain therein, as there is no indication he has the medical expertise to offer an opinion on such a complex medical question. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board gives more probative weight to the objective medical opinion of the VA examiner. There is no other competent and probative evidence showing left shoulder degenerative arthritis had onset in service or manifested to a compensable degree within a year of discharge. As the preponderance of the evidence is against the claim under the applicable theories of service connection, the benefit of the doubt standard does not apply. Service connection for a left shoulder disability is not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). REASONS FOR REMAND Although the Board regrets the delay, the remaining issues on appeal must be remanded for additional development. 1. Higher ratings for cervical fracture and left knee patella femoral syndrome The Veteran was afforded VA examinations in October 2016 to determine the current severity of his cervical fracture and left knee patella femoral syndrome disabilities. The examinations did not test for passive range of motion. However, the Court recently held that VA examinations of the joints must, if possible, test for pain throughout range of motion in various ways. See Correia v. McDonald, 28 Vet. App. 158, 168-70 (2016); 38 C.F.R. § 4.59. 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.” See 38 C.F.R. § 4.59. As the October 2016 examinations did not test the Veteran’s passive range of motion, remand for new examinations is warranted. 2. Entitlement to service connection for nerve damage, a right shoulder disability, a right knee disability, and a bilateral ankle disability Service connection may be granted to a Persian Gulf veteran who exhibits objective indications of a chronic disability resulting from undiagnosed illness or combination of illnesses manifested by one or more signs or symptoms such as signs or symptoms involving muscle pain, joint pain, neurological signs or symptoms. The Veteran is a Persian Gulf veteran. The illness must become manifest either during active military service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (a)(1)(i)-(ii). The Board was provided with VA examinations in October 2013; diagnoses were not provided for these claimed disabilities. However, the examiner did not discuss whether any of these claimed symptoms may be due to an undiagnosed illness. Thus, another VA examination is warranted. 3. Entitlement to service connection for a bilateral hearing loss and tinnitus The Veteran’s claims of entitlement to service connection for hearing loss and tinnitus must be remanded for another VA examination. The Board acknowledges that an October 2013 VA audiological examination showed normal hearing. The examiner also found tinnitus but gave a negative nexus opinion given the Veteran’s normal hearing. However, also of record are the results of a March 2012 audiogram that shows impaired hearing under VA standards. Specifically, the audiogram showed pure tone thresholds of 40 decibels at 4000 hertz in the left ear and 3000 hertz in the right ear, and a pure tone threshold of 45 decibels at 4000 hertz in the right ear. This indicates that the Veteran meets the criteria of a current disability. Therefore, remand is necessary to obtain a VA opinion concerning the etiology of the Veteran’s hearing loss, as well as the relationship between the Veteran’s tinnitus and hearing loss. 4. Entitlement to service connection for obstructive sleep apnea VA and private medical treatment records show the Veteran has been diagnosed with obstructive sleep apnea. However, while obstructive sleep apnea was noted on the Veteran’s October 2013 VA examination report, the examiner provided no nexus opinion. Given the Veteran’s contentions concerning service connection and the medical evidence showing a current diagnosis, the Board finds that remand is warranted for a VA opinion concerning the nature and etiology of the Veteran’s obstructive sleep apnea. 5. Entitlement to service connection for low testosterone Private medical treatment records show extensive treatment for low testosterone. In her October 2013 VA examination report, the examiner diagnosed the Veteran with hypogonadism but did not provide a nexus opinion. Instead, the examiner provided only general medical treatise information concerning hypogonadism as a condition. Therefore, remand is necessary in order to obtain a nexus opinion concerning the nature and etiology of the Veteran’s diagnosed low testosterone condition. 6. Entitlement to service connection for diabetes mellitus, type II VA treatment records indicate the Veteran has been diagnosed with diabetes mellitus, type II during the period on appeal. However, the Veteran has not yet been afforded a VA examination in connection with his claim for service connection. Private treatment records show the Veteran was diagnosed with hyperglycemia as early as April 2009, less than a year following discharge from active service. Based on this information, the Board finds that remand for a VA examination is warranted. 7. Entitlement to service connection for TBI The Veteran seeks entitlement to service connection for TBI incurred during deployment to Afghanistan. The Veteran’s STRs are of record and include a Post-Deployment Health Re-Assessment (PDHRA) in which the Veteran denied experiencing any blast or explosion, vehicular accident or crash, or fragment or bullet wound above the shoulders. The Veteran reported that he fell but provided no further details. The Veteran denied losing consciousness, feeling dazed or confused, memory loss, concussion, or head injury as a result of the fall. The Veteran was found to have “no evidence of risk” of TBI. Nevertheless, VA treatment records show the Veteran has been treated for residuals of TBI. In 2014 VA treatment notes, the Veteran reported sustaining multiple grade 1 concussions from blast exposures in Afghanistan between 2007-2008. He first underwent screening for TBI in July 2009, but his only problem at that time was insomnia, and he declined treatment. The Veteran was afforded an MRI in March 2014, and the results were normal. However, VA practitioners noted VA and private treatment for TBI residuals such as tremors, balance, and gait problems, as well as cognitive issues like attention deficit disorder. He was noted to have sustained “multiple grade 1 TBIs.” However, one practitioner described the Veteran’s current symptom presentation as “multifactorial” and possibly attributable to a number of different conditions, including chronically poor sleep, behavioral health conditions, and polypharmacy. The Veteran was afforded a VA examination by a VA psychiatrist in connection with his claim in August 2016. The Veteran reported exposure to mortar fire during service in Afghanistan. He stated he was not injured but wondered if he was too close to the mortar tube when it fired. He reported no episodes of alteration or loss of consciousness and no particular episodes where he had to seek treatment afterwards. He reported experiencing headaches a few times after mortars were fired. The examiner ultimately declined to diagnose the Veteran with a TBI or residuals of a TBI, concluding that the Veteran may have experienced mild TBI from being too close to mortar fire, but it had since resolved: “there is no diagnosis because the condition has resolved.” After careful review of the examination report and evidence of record, the Board finds the remand for a new examination is warranted. The August 2016 examiner failed to complete the section of the report concerning TBI residuals, which covers “subjective symptoms or mental, physical, or neurological conditions attributable to a TBI” like migraine headaches, mental disorder, gait disorders, etc.—many of which are documented in the record or are conditions for which the Veteran is currently service connected. The examiner did not fully address these possible residual symptoms, nor did she consider treatment notes from practitioners who have attributed the Veteran’s symptoms of tremors, balance and gait problems, etc. to in-service TBI. Therefore, remand is warranted for a more thorough VA examination and opinion. 8. Entitlement to service connection for tremors Private medical treatment records show the Veteran has a recent history of tremors. Tremors are also noted in VA treatment records. In an April 2013 treatment note, private Dr. C.B. treated the Veteran for tremors and wrote, “[h]e has endured 12 explosions. I feel strongly it is traumatic brain related tremor . . . .” Other private treatment notes suggest a link between the Veteran’s tremors and his military service, including possible exposure to chemicals therein. In a November 2015 VA treatment note, the Veteran was diagnosed with tremors, and the practitioner concluded the tremors were not related to Parkinson’s. The Veteran has not yet been afforded a VA examination concerning his tremors. Therefore, remand for a VA examination is warranted. 9. Entitlement to service connection for a right ear condition, also claimed as vertigo and loss of balance The Veteran asserts he has a right ear condition, also claimed as vertigo and loss of balance, which is etiologically related to active service. Private and VA medical treatment records show the Veteran has a history of dizziness, balance and gait problems. The Veteran attributes these problems to residuals of in-service TBI. However, the Veteran has not been afforded a VA examination to determine the nature and etiology of his claimed disability. Therefore, remand is warranted to schedule the Veteran for a VA examination. 10. Entitlement to service connection for a vision condition The Veteran asserts he has a vision connection that is etiologically related to service. Reserve STRs show the Veteran was treated for left eye irritation after he splashed diesel in his eyes. VA treatment records indicate the Veteran has complained of blurred vision but indicated a possible relationship to his diabetes mellitus, type II. Given the evidence suggesting the presence of an eye condition that is related to service, the Board finds that remand is warranted to schedule the Veteran for a VA eye examination. 11. Entitlement to a TDIU In June 2018, the Veteran’s representative argued that the Veteran’s service-connected disabilities have rendered him unemployable. Therefore, entitlement to TDIU is raised. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). This issue is inextricably intertwined with the higher rating claims that are being remanded for further development and thus will be deferred. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the matters are REMANDED for the following actions: 1. Obtain and associate with the claims file any updated medical treatment records. 2. Schedule the Veteran for additional VA examinations to assess the current nature and severity of his service-connected left knee and cervical spine disabilities. The claims file must be made available to the examiner(s) in conjunction with the examination. All pertinent symptomatology and findings must be reported in detail in accordance with the criteria for evaluating spine disabilities. Any indicated special diagnostic tests that are deemed necessary for an accurate assessment must be conducted. The examiner should report all signs and symptoms necessary for rating the Veteran’s left knee and cervical spine disabilities under the applicable rating criteria. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should be noted, as should any additional disability (including additional limitation of motion) due to these factors. The examiner should also address whether there is any additional functional impairment during flare-ups. The examiner must test and record the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing (if applicable). If 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. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claims file, must be made available for review. 3. Schedule the Veteran for an additional VA examination to determine the nature and etiology of his claimed TBI. The claims folder should be made available to the examiner for review before the examination. The examiner should express an opinion as to whether it is at least as likely as not the Veteran currently has a diagnosis of TBI, or any other current residuals, due to TBI(s) the Veteran claims to have sustained during his 2007-2008 deployment to Afghanistan. The opinion should reflect consideration of the Veteran’s contentions that he stood too close to mortars as they were being fired and experienced headaches following mortar explosions. The opinion should also reflect consideration of private and VA treatment records showing diagnosis of “mild TBI” and TBI residuals. A complete rationale must be offered for all opinions expressed, including a discussion of the evidence and medical principles which led to the conclusions reached. The examiner must identify and explain the medical basis or bases for each opinion, with identification of the evidence of record. 4. Schedule the Veteran for a VA examination by an appropriate medical professional to assess his claimed nerve damage, right shoulder, right knee and bilateral ankles. The electronic claims file, and a copy of the Remand, must be reviewed by the examiner. After examining the Veteran, the examiner is to answer the following questions: Is it at least as likely as not (50 percent or greater probability) that the Veteran’s nerve damage, bilateral shoulder, right knee and bilateral ankle conditions began in or are otherwise the result of military service? Is it at least as likely as not that the Veteran’s nerve damage, bilateral shoulder, right knee and bilateral ankle symptoms are a manifestation of an undiagnosed illness or a medically unexplainable chronic-multisymptom illness under 38 C.F.R. § 3.317; or, are his symptoms attributable to a known clinical diagnosis? The examination report must include a complete rationale for all opinions expressed. All opinions must be accompanied by an explanation. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 5. Schedule the Veteran for appropriate VA examinations to determine the nature and etiology of his claimed low testosterone, obstructive sleep apnea, diabetes mellitus, tremors, right ear disability (also claimed as vertigo and loss of balance), and vision condition. The examiner(s) should be provided with the Veteran’s complete claims file, including a copy of this remand. The file must be reviewed in its entirety and the report should note that review. The examiner must elicit a complete history from the Veteran, and he/she is requested to provide a complete rationale for any opinion. FOR EACH DISABILITY, the examiner is asked to answer the following question: Is it at least as likely as not (50 percent probability or greater) that the Veteran’s disability was incurred during active service? With respect to the Veteran’s claim of entitlement to service connection for diabetes mellitus, type II, the examiner is asked to address the April 2009 private treatment record showing diagnosis of hyperglycemia. With respect to the Veteran’s claims for tremors and a right ear disability (also claimed as vertigo and loss of balance), the examiner is asked to address the Veteran’s contentions that these disabilities are etiologically related to in-service TBI. A complete rationale must be offered for all opinions expressed, including a discussion of the evidence and medical principles which led to the conclusions reached. The examiner must identify and explain the medical basis or bases for each opinion, with identification of the evidence of record. 6. Schedule the Veteran for a VA audiological examination concerning the nature and etiology of his claimed bilateral hearing loss and tinnitus. The entire claims file must be provided to the examiner for review. After a thorough review of the Veteran’s entire claims file, the examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran has a hearing loss disability that is causally or etiologically related to the Veteran’s period of active service. The examiner must specifically address the March 2012 audiogram showing hearing loss for VA compensation purposes and must provide an opinion concerning etiology. The examiner is also asked to provide an opinion as to whether it is at least as likely as not that the Veteran has tinnitus that is etiologically related to the Veteran’s period of active service. A complete rationale must be offered for all opinions expressed, including a discussion of the evidence and medical principles which led to the conclusions reached. The examiner must identify and explain the medical basis or bases for each opinion, with identification of the evidence of record. The examiner is reminded that the absence of STRs showing in-service evidence of acoustic trauma is not fatal to the Veteran’s claim for service connection and should assume that the Veteran is credible with regard to his lay testimony concerning the nature and etiology of his hearing loss. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. T. Raftery, Associate Counsel