Citation Nr: 18158306 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 16-36 029A DATE: December 14, 2018 ORDER Entitlement to service connection for sleep apnea is granted. Entitlement to a disability rating in excess of 70 percent for service-connected posttraumatic stress disorder (PTSD) is denied. Entitlement to a total disability rating based upon individual unemployability (TDIU) is granted. REMANDED Entitlement to service connection for peripheral neuropathy, to include as secondary to herbicide agent exposure, is remanded. Entitlement to service connection for severe rash, to include as secondary to herbicide agent exposure, is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD and arteriosclerotic heart disease and/or exposure to herbicide agents, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected disabilities and/or herbicide agent exposure, is remanded. Entitlement to service connection for irritable bowel syndrome (IBS) is remanded. Entitlement to service connection for rectal fissures, to include as secondary to IBS, is remanded. Entitlement to a disability rating in excess of 10 percent for service-connected pes planus is remanded. Entitlement to a disability rating in excess of 10 percent for service-connected shrapnel wound leg is remanded. FINDINGS OF FACT 1. Giving the Veteran the benefit of the doubt, the preponderance of the competent evidence of record supports a finding that the Veteran has sleep apnea that had an onset in service, or is otherwise related to service. 2. The Veteran’s PTSD is not shown to cause total occupational and social impairment. 3. The Veteran’s service-connected disabilities have rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. Sleep apnea was incurred in or aggravated during active military service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for an initial rating higher than 70 percent for service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.130, Diagnostic Code 9411. 3. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from June 1968 to April 1970. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service the “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). After considering all information including the lay and medical evidence of record in a case with respect to benefits under laws administered by the Secretary, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The benefit of the doubt rule is inapplicable when the evidence preponderates against the claim. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 1. Entitlement to service connection for sleep apnea is granted. The Veteran contends that he has sleep apnea that had its onset during his active military service. In particular, he stated he had major problems sleeping while in Vietnam and some days he did not sleep at all. Alternatively, the Veteran also argues his sleep apnea has been aggravated by his PTSD. See contentions. The Board concludes that the Veteran has a current diagnosis of sleep apnea that began during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Private medical records and VA treatment records show the Veteran has a current diagnosis of obstructive sleep apnea. See records. A VA medical opinion concerning the etiology of the Veteran’s obstructive sleep apnea was requested in an April 2013 VA examination; however, the record does not reflect that an opinion was actually rendered. Nevertheless, the evidence of record does include several lay statements which described the Veteran’s sleep apnea symptoms during his active service. A statement from R.M., who served with the Veteran, reported the Veteran seemed to have difficulties with his sleep. He would snore loudly and had to be awakened or would suddenly wake himself up, appearing to be short of breath. See statement. Another lay statement from F.B., who also served with the Veteran, also reported that the Veteran’s snoring was so loud that it would put others at risk of exposing their safe location while hiding in man holes. See statement. In April 2018, the Veteran submitted a statement dated that same month from his VA treating neurologist, M.B., M.D., Ph.D., who opined that based on current diagnosis and witness statements, that it was more likely than not that the Veteran had sleep apnea that went undiagnosed while on active duty. medical letter. While the Veteran’s service treatment records do not reflect that he complained of sleep apnea in service, the lay and medical statements of record support a finding that he had signs and symptoms of sleep apnea while in service. Accordingly, the Board finds that the evidence of record is sufficient to support a finding that the Veteran’s sleep apnea had its onset during his active service. Consequently, service connection is warranted for sleep apnea. Hickson, 12 Vet. App. 247. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). 2. Entitlement to a disability rating in excess of 70 percent for service-connected posttraumatic stress disorder (PTSD) is denied. The average impairment of earning capacity due to PTSD is determined by the criteria set out in the General Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under these criteria, a 70 percent evaluation is warranted where there is 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; intermittently illogical obscure, or irrelevant speech; 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 100 percent evaluation is warranted where there is 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; memory loss for names of close relatives, own occupation, or own name. Id. Although PTSD is rated under the General Rating Formula, the use of the term “such as” in 38 C.F.R. § 4.130 indicates that the listed symptoms are not intended to constitute an exhaustive list. Rather, the symptoms listed under the General Rating Formula for Mental Disorders are to serve as examples of the type and severity of symptoms or their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The symptoms to be considered when rating a Veteran’s PTSD are not limited to those listed in 38 C.F.R. § 4.130. Instead, VA shall consider all symptoms of a Veteran’s PTSD that affect his level of occupational and social impairment, including, if applicable, those identified in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) provided additional guidance in rating psychiatric disability. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Specifically, the Federal Circuit emphasized that the list of symptoms under a given rating is a non-exhaustive list, as indicated by the words “such as” that precede each list of symptoms. Id. at 2. It held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration. Id. at. Other language in the decision indicates that the phrase “others of similar severity, frequency, and duration,” can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 2. The Veteran’s service-connected PTSD is currently assigned a 70 percent rating. After reviewing the pertinent evidence of record, the Board finds the next higher rating of 100 percent is not warranted. The April 2013 VA examination diagnosed the Veteran with PTSD. At the examination, the Veteran reported symptoms of PTSD including chronic sleep impairment with nightmares and night sweats, avoidance of trauma reminders, difficulty recalling trauma events, emotional numbing and detachment, irritability and hypervigilance. Symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships were also endorsed. The Veteran also reported being irritable “all the time”, experiencing survivor guilt and waking up with night sweats. The examiner found the Veteran’s symptoms caused occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. See examination. In August 2016, the Veteran’s wife submitted a statement describing the Veteran’s PTSD. She described sleep disturbances, including twitching throughout the night, having nightmares and stopping breathing. She also described her fear that the Veteran would wake up from a nightmare and think she was a war enemy. Additionally, the Veteran’s wife reported he was irritable and angry most of the time. His irritability caused her to be afraid to say anything to him for fear of his reaction. She also noted that he would wear the same clothing until she asked him to change. She noted that he had lost interest in all outside activities and become obsessed with checking doors and windows to make sure they were locked. Lastly, their social life was limited to family and friends who were empathetic to his PTSD symptoms. See buddy statement. An updated VA examination was performed in April 2017. At that time, the examiner indicated the Veteran’s PTSD symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation. Notably, the Veteran reported he had separated from his wife of 17 years, indicating “he was never in love” with her. However, he did report he had friends and played golf with other Veterans depending on his money. Occupationally, he reported he was not working and retired in 2007 as a realty specialist for GSA. He indicated he “got tired of working” after he performed the job for 40 years. He further stated he was always able to do the job. On examination, the Veteran presented as very angry. He was upset with how his life had been going and the fact that his marriage was ending. He described nightmares about Vietnam but denied depression, active suicidal ideation but feels much discouragement. He did describe anxiety. He was not in any therapy or under any psychiatric care. The Veteran endorsed symptoms including chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances and instability to establish and maintain effective relationships. He also had non-violent irritability. He appeared neatly but casually dressed but his mood was angry. His affect was appropriate, and he had no delusions, hallucinations or current or past suicidal or homicidal thoughts. See examination. As reported in the April 2017 VA examination, the Veteran was not seeking psychiatric treatment. However, there are some recent VA psychiatric treatment records. In fact, the Veteran had been enrolled in a support group since August 2017, indicating it helped being with other Vietnam veterans that had been through similar war trauma. In May 2018, he reported being on the edge, easily irritable and hypervigilant which increased with recent election and school shootings. He exhibited forward thinking when he talked about managing his PTSD, his grandchildren and spending time with other Vietnam veterans. See CAPRI. After reviewing the foregoing evidence, the Board finds that at no point during the appeal period has the Veteran’s overall symptomatology more nearly approximated the criteria for a 100 percent rating. The Veteran struggles with irritability along with symptoms such as intrusive thoughts, sleep disturbances, hypervigilance and anxiety. These symptoms have negatively impacted his ability to maintain close interpersonal relationships and social relationships in general. There is also evidence that hyperviligance which impact his daily activities, changes in mood, as well as poor sleep. However, with all this said, the record clearly shows that the Veteran was able to maintain a marriage to his wife for over 17 years. Although the most recent VA examination reported that his marriage was ending, his VA treatment records also show that he thinks about his grandchildren and spending time with other Vietnam veterans. He has also reported playing golf with other Vietnam Veterans. Thus, despite not many having friends, the Veteran’s social relationships with his family and fellow veterans, albeit far from ideal, belies the notion of the Veteran having total social impairment. 3. Entitlement to a TDIU is granted. As an initial matter, the Board notes that the Veteran’s claim for TDIU was denied in a May 2018 rating decision, and the Veteran has initiated an appeal of that decision by filing a notice of disagreement also dated May 2018. However, as the Board has jurisdiction over the Veteran’s appeal for an increased rating for his PTSD, and the issue of TDIU is part and parcel of any increased rating claim, the issue of entitlement to TDIU is also within the Board’s jurisdiction. Rice v. Shinseki, 22 Vet. App. 447 (2009). Total ratings, referred to as TDIU, may be assigned in the first instance by the Board or the Regional Office when the disabled person is determined to be unable to secure or follow a substantially gainful occupation as a result of service-connected disability or disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a). In cases where these percentages are not met, but the disabled person is unable to secure and follow a substantially gainful occupation by reason of service-connected disability or disabilities, the case should be submitted to the Director, Compensation Service, for consideration of extra-schedular TDIU. See 38 C.F.R. § 4.16(b). Neither the effect of nonservice-connected disabilities nor of the veteran’s age may be considering in determining whether TDIU is warranted. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The sole fact that the Veteran is unemployed or has difficulty obtaining employment is not enough to warrant TDIU. A high rating is in itself recognition that the disability makes it difficult to obtain and keep employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. In determining whether unemployability exists, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). Notwithstanding the service-connected disability granted herein, the Veteran is presently service-connected for PTSD (assigned a 70 percent disability rating), pes planus (assigned a 10 percent rating), shrapnel wound left leg (assigned a 10 percent rating), tinnitus (assigned a 10 percent rating), arteriosclerotic heart disease (assigned a 10 percent rating), and scars (assigned a noncompensable rating). The Veteran has a combined disability rating of 80 percent, effective June 20, 2012. Therefore, the tenets of 38 C.F.R. § 4.16(a) apply. In his VA 21-8940, the Veteran reported his PTSD prevented him from working. He last worked for the Federal government (Federal Emergency Management Agency (FEMA)) completing intermittent work. He completed two years of college education and has a masters certificate in information technology project management. He also completed security new orientation training. The Veteran submitted a statement with his form, which stated his job at FEMA was very stressful and he was no longer able to deal with it. He also described his struggle to maintain mental, emotional and physical well-being since returning from Vietnam through his jobs as well as in his marriage. See form. At an April 2017 VA examination, the Veteran reported he was not working and retired in 2007 as a realty specialist for GSA. He indicated he “got tired of working” after he performed the job for 40 years. He further stated he was always able to do the job. In contrast to the April 2017 examination report, the Veteran submitted a statement providing more background to his occupational history. He indicated the examiner could only see an angry man. He did not see the pain and anguish and the struggles the Veteran had endured. The examiner left the Veteran with the impression that he did not deserve or need the financial benefit from VA. See statement. Therefore, the Veteran argued the examiner did not accurately describe his occupational abilities. After weighing all the evidence of record, to include those reported earlier in this decision, and resolving all doubt in the Veteran’s favor, the Board finds the Veteran’s service-connected PTSD would render him unable to secure and follow a substantially gainful occupation. While the most recent VA examiner indicated the Veteran merely retired from his prior work and was always able to do the job, the Board finds the Veteran’s reports of his difficulties to complete and maintain working more consistent with the medical evidence of record regarding his PTSD symptoms. In particular, his sleep disturbances, irritability and anger as well as his social isolation would prove difficult from him to work in an office setting. In so finding, the Board acknowledges the Veteran has had extensive education and training which would provide transferable skills to another position, but these skills would not overcome his inability to function daily and work with others. Therefore, the Board resolves all reasonable doubt in favor of the Veteran and finds that his service-connected disabilities prevent him from obtaining and maintaining substantially gainful employment. Accordingly, entitlement to TDIU is warranted. 38 C.F.R. §§ 3.341(a), 4.16, 4.18, 4.19. REASONS FOR REMAND 1. Entitlement to service connection for peripheral neuropathy and severe rash, to include as secondary to herbicide agent exposure, is remanded. The Veteran contends he has peripheral neuropathy and suffers from rashes on his back as a result of his exposure to herbicide agents in service. See contentions. The Veteran’s exposure to herbicide agents (and specifically, Agent Orange) is presumed, as service records show he served in the Republic of Vietnam, during the Vietnam era. 38 C.F.R. § 3.2(f). However, neither peripheral neuropathy (unless it is the “early onset” type) nor rashes are disabilities presumed to be related to herbicide agents exposure. 38 C.F.R. §§ 3.307, 3.309. In spite of this, the law provides that where the evidence does not warrant presumptive service connection, an appellant may also establish service connection with proof of direct causation. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Considering the Veteran’s contentions and the record on appeal, an appropriate VA examination and opinion should be provided to determine the probable etiology of his peripheral neuropathy and any current skin condition. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Notably, with respect to the Veteran’s claim for service connection for a severe rash, his service treatment records show he was treated for heat rash in July 1969 but the available medical records are unclear as to whether the Veteran presently suffers from a rash or a form of chloracne. See STR. Therefore, the VA examination must also address this notation. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD and arteriosclerotic heart disease and/or herbicide agents exposure; and erectile dysfunction, to include as secondary to service-connected disabilities and/or herbicide agent exposure, is remanded. The Veteran essentially contends that he has hypertension and erectile dysfunction that are either related to his exposure to herbicide agents in Vietnam or secondary to his service-connected PTSD. See contentions. With respect to the hypertension claim, the Board notes that the Veteran has also been recently awarded service connection for arteriosclerotic heart disease. In light of the foregoing, the Board finds that a VA examination is necessary to address these claims. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). As was previously noted, the Veteran’s exposure to herbicides agents is presumed because his service records show he served in the Republic of Vietnam during the Vietnam era. 38 C.F.R. § 3.2(f). Although hypertension and erectile dysfunction are not disabilities presumed to be related to herbicide agents exposure, the Veteran is not precluded from establishing service connection with proof of direct causation. Therefore, a VA medical opinion should be obtained to address whether these claimed disabilities are related to his presumed Agent Orange exposure. Additionally, to the extent the Veteran’s hypertension and erectile dysfunction have been claimed as secondary to service-connected disabilities, medical opinions should also be obtained to address this question. Notably, although an April 2013 VA examination addressed the question of whether the Veteran’s hypertension was caused or aggravated by his service-connected PTSD, as noted, he has also been recently awarded service connection for arteriosclerotic heart disease. Therefore, development should be undertaken to address whether there is an etiological relationship between these two disabilities. 3. Entitlement to entitlement to service connection for irritable bowel syndrome (IBS) and entitlement to service connection for rectal fissures to include as secondary to IBS are remanded. The Veteran contends he suffers from IBS as well as hemorrhoids and rectal fissures due to prolonged and untreated diarrhea while on active duty in Vietnam. See contentions. Service treatment records show treatment for diarrhea lasting 5 days in March 1969. See STR. While the medical record indicates the Veteran believed his 2009 colonoscopy was unremarkable, he was assessed with anal or rectal pain with a recommended of another colonoscopy. See record. However, a VA medical examination was not performed to determine whether a present diagnosis of IBS existed and if so, whether the rectal fissures were caused or aggravated by the IBS. 4. Entitlement to a disability rating in excess of 10 percent for service-connected pes planus and entitlement to a disability rating in excess of 10 percent for service-connected shrapnel wound leg are remanded. The Veteran contends he feels pain in his feet every day. Furthermore, he argues he did not inform the VA examiner that his symptoms were relieved by arch support. While he does wear arch support daily, there is little to no relief from the pain in his feet, legs and rest of his body. See contentions. The Board interprets these statements to mean his April 2013 VA examination results do not accurately described his current pes planus disability. Moreover, the Veteran also argued his service-connected shrapnel wound in the left leg is a moderately severe disability. In support of his contention, he argues feels pain in his feet, legs, ankle and back. See contentions. The Board also construes the Veteran’s statements to be describing a worsening in the pain he feels because of his left leg shrapnel wound. In light of the Veteran’s reports of pain in both his left leg and his feet, the Board finds the Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his pes planus and shrapnel wound in the left leg. The matter is REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any peripheral neuropathy. The examiner should provide an opinion as to whether it is at least as likely as not that any current peripheral neuropathy is related to active service, to include exposure to herbicide agents therein. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any skin rash. The examiner should be asked to specify any and all current skin conditions, and to provide an opinion as to whether it is at least as likely as not that any current skin condition is related to active service, to include exposure to herbicide agents therein. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any hypertension. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including in-service exposure to herbicides agents. The examiner must also opine whether it is at least as likely as not caused or aggravated by the Veteran’s service-connected arteriosclerotic heart disease. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any erectile dysfunction. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including in-service exposure to herbicides agents. The examiner must also opine whether it is at least as likely as not caused or aggravated by the Veteran’s service-connected disabilities (either individually and/or in concert). 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any IBS and anal fissures/hemorrhoids. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including prolonged in-service diarrhea. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected pes planus and left leg shrapnel wound. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to pes planus and left leg shrapnel wound alone and discuss the effect of the Veteran’s pes planus and left leg shrapnel wound on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Churchwell, Counsel