Citation Nr: 18161031 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 16-49 774 DATE: December 28, 2018 ORDER Entitlement to service connection for a bilateral foot disability is denied. Entitlement to service connection for a respiratory disability is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for hypertension (claimed as high blood pressure) is denied. Entitlement to service connection for pancreatitis is denied. Entitlement to service connection for a left hand disability is denied. Entitlement to service connection for a headache disability is granted. Entitlement to an effective date earlier than January 16, 2013, for the grant of service connection for bilateral hearing loss is denied. Entitlement to an effective date earlier than January 16, 2013, for the grant of service connection for tinnitus is denied. Entitlement to an effective date earlier than January 16, 2013, for the grant of service connection for right hand degenerative joint disease (DJD) status-post right thumb skin avulsion with residual scar is denied. Entitlement to an effective date earlier than January 16, 2013, for the grant of service connection for right knee DJD is denied. Entitlement to an effective date earlier than January 16, 2013, for the grant of service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial compensable rating for bilateral hearing loss is denied. Entitlement to an initial rating higher than 50 percent for PTSD is denied. REMANDED Entitlement to service connection for a gastrointestinal disability, claimed as gastroenteritis, is remanded. Entitlement to an initial rating higher than 10 percent for right knee DJD is remanded. Entitlement to an initial compensable rating for right hand DJD, status-post right thumb skin avulsion with residual scar, is remanded. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. A current bilateral foot disability is not shown. 2. A current respiratory disability is not shown. 3. A current diagnosis of sleep apnea is not shown. 4. A current diagnosis of hypertension is not shown. 5. A current diagnosis of pancreatitis is not shown. 6. A current left hand disability is not shown. 7. Resolving all doubt in the Veteran’s favor, his currently diagnosed headaches are etiologically related to his service-connected PTSD. 8. The Veteran’s original service connection claim for bilateral hearing loss, tinnitus, right hand disability, right knee disability, and PTSD was received by VA on January 16, 2013, and no other evidence can be construed as a claim for service connection for any of these disabilities prior to that date. 9. For the entire initial period on appeal, the Veteran’s bilateral hearing loss has been manifested by hearing acuity no worse than Level II in both ears with speech recognition ability not worse than 88 percent in the right ear and 84 percent in the left ear. 10. For the entire initial period on appeal, the probative evidence does not show that the Veteran’s PTSD results in symptoms causing occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria to establish service connection for a bilateral foot disability are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 2. The criteria to establish service connection for a respiratory disability are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 3. The criteria to establish service connection for sleep apnea are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). 4. The criteria to establish service connection for hypertension are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 5. The criteria to establish service connection for pancreatitis are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 6. The criteria to establish service connection for a left hand disability are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 7. The criteria to establish service connection for headaches secondary to service-connected PTSD are met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2017). 8. The criteria for the assignment of an effective date prior to January 16, 2013, for the award of service connection for bilateral hearing loss are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.1, 3.155, 3.400 (2017). 9. The criteria for the assignment of an effective date prior to January 16, 2013, for the award of service connection for tinnitus are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.1, 3.155, 3.400 (2017). 10. The criteria for the assignment of an effective date prior to January 16, 2013, for the award of service connection for a right hand disability are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.1, 3.155, 3.400 (2017). 11. The criteria for the assignment of an effective date prior to January 16, 2013, for the award of service connection for a right knee disability are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.1, 3.155, 3.400 (2017). 12. The criteria for the assignment of an effective date prior to January 16, 2013, for the award of service connection for PTSD are not met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.1, 3.155, 3.400 (2017). 13. The criteria for an initial compensable rating for bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 3.383, 4.85, 4.86, Diagnostic Code (DC) 6100. 14. The criteria for an initial disability rating higher than 50 percent for PTSD are not met or approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1977 to July 1985. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012). A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107 (b)). Service Connection Claims - Bilateral Foot, Respiratory, Sleep Apnea, Hypertension, Pancreatitis, and Left Hand The Veteran seeks service connection for a bilateral foot disability, respiratory disability, sleep apnea, hypertension, pancreatitis, and a left hand disability, The laws authorizing Veterans’ benefits provide benefits only where there is current disability, as identified by a medical diagnosis. In the absence of proof of a current disability, there is no valid claim of service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board concludes that the Veteran has not presented competent evidence showing that he has a current diagnosis of any of the above-mentioned disabilities. See 38 U.S.C. § 5107 (a) (“[A] claimant has the responsibility to present and support a claim for benefits.”); Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009) (holding that it is the claimant’s general evidentiary burden to establish all elements of the claim). Specifically, a review of the medical evidence fails to show current diagnoses of right or left foot disability, respiratory disability, sleep apnea, or left hand disability. Moreover, the Veteran underwent VA examinations for respiratory conditions, gallbladder and pancreas conditions, and hand and finger conditions in December 2013, which concluded that the Veteran had no current diagnosis of either condition. In addition, the Board notes that August 2013 VA treatment records indicated that the Veteran complained of cough, but was not diagnosed with asthma, and indicated that this occurred after smoking or if he got hot, or felt that he had hot flashes. A formal diagnosis of a respiratory disability was not rendered. Regarding the respiratory condition, the VA examiner noted acute respiratory disease in the 1970s and treatment without an actual diagnosis in 1980, but noted no current diagnosis or pathology at the time of the examination. Regarding the claim for hypertension, the Board notes that the medical evidence showed that he had no hypertension in March 2009. Thereafter, in June and July 2013, the medical evidence noted “elevated blood pressure without [diagnosis] of [hypertension],” and subsequent treatment records dated in July 2016 were “negative” for hypertension. Furthermore, a review of the Veteran’s service treatment records showed normal blood pressure readings throughout. Regarding the Veteran’s claim for pancreatitis, the Board notes that the Veteran had a prior diagnosis in 1980s while in-service (unclear if it preexisted service); however, post-service treatment records indicated that he had pancreatitis in 1986 or 1987 (post-service) but “none since” and past medical history significant for “pancreatitis due to ETOH and substance abuse.” Nevertheless, since the date of claim in January 2013, the evidence does show a current diagnosis of pancreatitis. Furthermore, the December 2013 VA examiner indicated that the Veteran’s pancreatitis resolved since he last had it in 1985. Lastly, regarding the Veteran’s claim for sleep apnea, the record reflects that his complaints of general sleep impairment are attributed to, and are being compensated for, by his receipt of service connection for PTSD. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). In other words, any sleep problems generally are considered when evaluating his PTSD, but he does not have a diagnosis of sleep apnea. In analyzing these claims, the Board recognizes that the Veteran is competent to report his observable symptoms and signs of any of the above-mentioned disabilities, to include pain and sleep impairment; however, his lay statements are not competent to establish that he has a current diagnosis of any of these disabilities, as under the facts of this case, he is not shown to be competent to render a medical diagnosis. Lastly, the Board notes that there is no evidence showing that the Veteran has any related symptoms that cause any functional impairment in earning capacity. For the reasons and bases discussed above, the preponderance of the evidence is against the Veteran’s claims for service connection for a bilateral foot disability, respiratory disability, sleep apnea, pancreatitis, and a left hand disability, and therefore they must be denied. Service Connection for Headaches The Veteran asserts that he has a headache disability that is related to a service-connected disability. The medical evidence shows that the Veteran has a current diagnosis of migraine headaches. See e.g., February 2017 private disability benefits questionnaire (DBQ). He is also service connected for PTSD and tinnitus, as relevant here. On review, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s current diagnosis of migraine headaches is etiologically related to his service-connected PTSD. In support of his claim, the Veteran submitted a private February 2017 DBQ authored by a family physician, who diagnosed migraine headaches, including migraine variants. The physician opined that the Veteran’s headaches were as likely as not caused by his service-connected PTSD and tinnitus. The examiner explained that medical research shows that patients with mental health conditions are more likely to develop headaches because pain and mood were regulated by the same part of the brain. The physician added that it was well established that mental disorders both cause and aggravate headaches. The Board finds the February 2017 DBQ thorough, complete, and sufficient upon which to base a decision with respect to the Veteran’s claim. Based on the foregoing, the Board resolves reasonable doubt in the Veteran’s favor to find that he has a current diagnosis of headaches that are etiologically related to his service-connected PTSD. Accordingly, service connection for headaches is granted on a secondary basis. It is noted that the family physician also indicated that it was known that damage to the auditory system resulting from tinnitus could also cause headaches. In support of this opinion, the physician cited to evidence of record as well as to medical literature. Nonetheless, because the Board is granting service connection as secondary to PTSD, the Board need not consider any other theory of entitlement. Earlier Effective Date for Bilateral Hearing Loss; Tinnitus; Right-Hand Disability; Right Knee Disability; and, PTSD An award of direct service connection will be effective on the day following separation from active military service or the date on which entitlement arose if the claim is received within one year of separation from service. Otherwise, except as specifically provided, the effective date of an evaluation and award for pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after a final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. A “claim” is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. See 38 C.F.R. § 3.1 (p). With respect to informal claims, the Board recognizes that this case predates the March 2015 changes to 38 C.F.R. § 3.155, and as such, the older version of the regulation applies. Under the former § 3.155, any communication or action indicating an intent to apply for one or more benefits under the laws administered by VA may constitute an informal claim, provided that such informal claim identifies the benefit sought. 38 C.F.R. § 3.155(a). To determine when a claim was received, the Board must review all communications in the claim file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). Here, on January 16, 2013, the RO received the Veteran’s VA 21-0781, Statement in Support of Claim for PTSD, as well as VA 21-256 Veterans Application for Compensation or Pension, on which he claimed service connection for bilateral hearing loss; tinnitus; right hand disability; right knee disability; and PTSD. Both pieces of evidence are date-stamped as received by VA on January 16, 2013. Subsequently, in a March 2014 rating decision, the RO granted the Veteran’s service connection claims for bilateral hearing loss; tinnitus; right-hand disability; right knee disability; and, PTSD, and assigned an effective date of January 16, 2013, the date of receipt of the Veteran’s original claim. Upon review, the Veteran did not file a service connection claim for the above-mentioned disabilities within the one year following service discharge, and as such, the effective date cannot be the day following the date of service discharge. 38 C.F.R. § 3.400(b)(2). Next, there is no dispute that VA received the Veteran’s original service connection claim for all of the above-mentioned disabilities on January 16, 2013. Indeed, there is no correspondence received by VA prior to January 16, 2013, that can be construed as a claim, informal or formal, for service connection for bilateral hearing loss; tinnitus; right hand disability; right knee disability; or, PTSD. Neither the Veteran nor his attorney has provided any argument or evidence in support of the claims for an earlier effective date for any of the above-mentioned disabilities. Consequently, there is no legal basis upon which to grant an effective date prior to January 16, 2013, for the grant of service connection for bilateral hearing loss; tinnitus; right hand disability; right knee disability; and PTSD. The Board is bound by the law governing the assignment of effective dates in its determination in this case. See 38 U.S.C. § 7104(c). The claims of entitlement to an effective date earlier than January 16, 2013, for the award of service connection for bilateral hearing loss; tinnitus; right hand disability; right knee disability; and PTSD must be denied. Increased Rating Claims Disability evaluations are determined by comparing a veteran’s present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Where the veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Bilateral Hearing Loss – Rating Criteria Under DC 6100, ratings for hearing loss are determined in accordance with the findings obtained on audiometric examination. Evaluations of hearing impairment range from non-compensable to 100 percent based on organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests, together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies 1000; 2000; 3000; and 4000 Hertz (cycles per second). To evaluate the degree of disability from hearing impairment, the rating schedule establishes eleven auditory acuity levels designated from Level I for essentially normal acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, DC 6100. As set forth in the regulations, Tables VI, VIA, and VII are used to calculate the rating to be assigned. See 38 C.F.R. § 4.85, DC 6100. Hearing tests will be conducted without hearing aids, and the results are charted on Table VI and Table VII. See 38 C.F.R. § 4.85. Alternatively, VA regulations provide that in cases of exceptional hearing loss, when the pure tone thresholds at each of the four specified frequencies (1000, 2000, 3000 and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86(a). The provisions of 38 C.F.R. § 4.86(b) further provide that, when the pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever would result in the higher numeral. Bilateral Hearing Loss – Rating Analysis The Veteran’s bilateral hearing loss is rated as noncompensable during the entire initial rating period on appeal. The Veteran seeks a compensable rating. Turning to the evidence, a May 2013 VA audiology consultation revealed that the Veteran had mild sloping to severe sensorineural hearing loss “2-8 kHz” in the right ear, and mild sloping to mod-severe sensorineural hearing loss “2-8 kHz” in the left ear. Audiogram results in decibels were not provided and speech recognition scores were not discussed or included in the report. The Veteran was fitted for hearing aids. At the December 2013 VA audiology examination, pure tone thresholds, in decibels, were recorded as follow: HERTZ AVG 1000 2000 3000 4000 RIGHT 43 30 30 45 65 LEFT 45 30 30 50 70 Speech audiometry revealed speech recognition ability of 88 percent in the right ear, and 84 percent in the left ear. The examiner noted that the test results were valid for rating purposes. Here, applying the December 2013 audiometric result to Table VII, the Veteran had Level II hearing acuity in both the right and left ears, resulting in a non-compensable rating. 38 C.F.R. § 4.85, DC 6100. An exceptional hearing pattern is not demonstrated. Subsequent VA treatment records showed that the Veteran had additional fitting for hearing aids to include after he reported that he lost them in August 2014. The Board considered the Veteran’s assertions that his bilateral hearing loss should be assigned a higher rating; however, in determining the actual degree of disability, the objective examination is more probative of the degree of the Veteran’s impairment than his lay reports. Furthermore, the opinions and observations of the Veteran alone are not sufficient to address the rating criteria under 38 C.F.R. § 4.85, DC 6100 with respect to determining the severity of his service-connected bilateral hearing loss disability. See Moray v. Brown, 2 Vet. App. 211, 214 (1993); see also 38 C.F.R. § 3.159(a)(1) and (2). In addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in the final report. See Martinak v. Nicholson, 21 Vet. App. 447 (2007). Regarding functional effects of the Veteran’s hearing loss, the examiner stated that the he reported “difficulty understanding.” Accordingly, there is no basis to support a compensable rating for the Veteran’s service-connected bilateral hearing loss during this period on appeal. As a preponderance of the evidence is against the assignment of a higher rating, the benefit-of-the-doubt rule does not apply, and the claim must be denied. PTSD – Rating Criteria The criteria for rating psychiatric disabilities, other than eating disorders, are set forth in the General Rating Formula (General Rating Formula) for Mental Disorders. See 38 C.F.R. § 4.130. This appeal stems from a March 2014 rating decision that assigned the initial 50 percent rating for the Veteran’s PTSD. Under the General Rating Formula, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted if the evidence establishes 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; 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); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating (total occupational and social impairment) is warranted 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. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the Veteran’s symptoms, but it must also make findings as to how those symptoms impact a Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran’s impairment must be “due to” those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA’s general Rating Formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the Court further indicated that, without those examples, differentiating between rating evaluations would be extremely ambiguous. PTSD – Rating Analysis The Veteran’s PTSD is rated as 50 percent disabling for the entire initial period on appeal. He asserts that his symptoms are worse than the currently assigned disability rating. After a careful review, the Board finds that an initial rating higher than 50 percent for PTSD is not warranted. According to an initial VA psychiatric evaluation note dated in February 2013, a VA psychiatrist indicated that the Veteran complained of “hot sweats and memories about what happened to [his] hand.” He reported that his mood was “up and down.” He stated that his friend died recently, which affected him, and resulted in “a little tingle on the mind.” He denied suicidal or homicidal ideation, intent, or plans. He also denied hallucinations and psychotic symptoms. He reported problems with sleep, which he described as “stuff running through mind” at bedtime. His appetite was “pretty good” and his energy level was in general adequate for activities of daily living. There was no evidence of anhedonic symptoms and the Veteran stated that he did not “dwell on thoughts of death or dying.” On mental status examination, it was noted that his appearance and hygiene were appropriate. His mood was described as “up and down” and his affect was generally appropriate with full range. His speech was normal, he denied homicidal or suicidal ideation, and his thought form and content were within normal limits with no evidence of delusions. He was fully oriented, his memory was intact in all spheres, his insight was fair, and judgment capacity was adequate. The psychiatrist diagnosed anxiety NOS with possible posttraumatic stress symptoms (PTSS) A subsequent VA mental health treatment note dated in June 2013 indicated that the Veteran reported he was doing better after he was diagnosed with anxiety in February 2013. He reported that his medications helped him with his anxiety and nightmares and stated that he stopped taking drugs such as cocaine since that time. He further reported having dreams of gun-fire and some flashbacks of an incident where a “trip flare” exploded in his hand during service. He denied being depressed or suicidal. It was noted that he lived with his sister and had no current issues. Lastly, he stated that he wanted to continue with his medications at the same dosages, and stated that his sleep and appetite were fine. On mental status examination, it was noted that the Veteran’s hygiene was fair and he was fully oriented. His speech was coherent and unimpaired, his mood was described as “good” and his affect consistent with current mood and “euthymic.” There was no evidence of thoughts of self-harm, paranoia, delusions, or phobia, and the Veteran denied auditory or visual hallucinations. His thought process was coherent, linear, and goal directed. He denied suicidal or homicidal ideation, his insight and judgment were fair, and his attention span and concentration were adequate. The mental health professional rendered diagnoses of anxiety and PTSS and noted a history of cannabis and cocaine use. In December 2013, the Veteran underwent a VA examination for PTSD, at which time the examiner confirmed a diagnosis of PTSD, and indicated that the Veteran did not have a diagnosis of any other mental disorder. The Veteran reported that he had two-sessions with a psychiatrist at the VA, but indicated that he did not have a standing appointment, but was told to call when he needed a refill for his medications. He stated that the reason for his psychiatric consultation was depression and having bad dreams resulting in waking up in the middle of the night sweating with hot flashes. He stated that he did not receive any mental health treatment and was never in a psychiatric inpatient program. He denied any suicidal or homicidal attempt history or current suicidal or homicidal ideation. He further denied any history of violence other than one incident two-months earlier when he became upset and angry because an auto mechanic did not fix his car correctly, at which time he threw down and broke a drinking glass. He reported one significant encounter with the law; in 1995, he was convicted of carrying a concealed weapon without a permit, which involved two offenses and considered a felony for which he served 54-months in prison. In terms of social impairment, the Veteran reported that he had a very good relationship with his mother and a “real good” relationship with his siblings. He described his relationship with his father as “okay” since his parents separated, but indicated that he visited his father about twice a week. it was further noted that he was married once for three-and-half years, which ended in a divorce. He had five grown children and he described his relationship with them as “super.” He also reported that he had a steady girlfriend in the previous six-months and described the relationship with her as “outstanding.” In terms of occupational impairment, it was noted that the Veteran worked for a temporary service for one-year post-service and later worked in a restaurant, predominantly performing dishwashing jobs for one-year. He then worked for three years for an auto sales company and two-and-half years for a landscaping maintenance company. He then worked for seven years as a machine operating and packer and later worked again at an auto dealership for three years. At the time of the examination he was unemployed, but indicated that he was a full-time student, finishing up his first semester studying electronics, and reported that he was succeeding. The examiner identified PTSD symptoms of depressed mood; panic attacks that occur weekly or less often; chronic sleep impairment; and, disturbance of motivation and mood. The examiner indicated that additional PTSD symptoms included those noted in the diagnostic criteria for PTSD, to include recurrent distressing recollections and dreams of the traumatic event; avoidance symptoms; feeling detachment or estrangement from others; and, hypervigilance and exaggerated startle response. The examiner concluded that the Veteran’s PTSD resulted in 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. A review of the Veteran’s VA treatment records dated from December 2013 to March 2015 showed that he had not sought mental health treatment, but called regularly to have his Sertraline prescription renewed. In December 2014 and February 2015, the psychiatrist noted that in order to have his medications renewed, the Veteran should be scheduled for an appointment since he was not seen for more than a year. In his January 2015 application for Social Security Administration (SSA) benefits, the Veteran extensively discussed his physical disabilities, but made limited reference to his psychiatric symptoms. He stated that he sometimes was mad and stressed. Furthermore, he stated that his regular day routine included watching the news; getting something to eat; go by his mother house to check on her and his sister; sit in the backyard to “get a peace of mind” for about an hour or two then go a friend’s house to watch TV for a few hours; and, later go to other friends’ houses to eat something and watch TV until it was time to go to sleep. He further reported that he had a hard time understanding verbal commands. He additionally noted “memory, PTSD, [unable to] complet[e] task[s] because [of] hands and knees.” The SSA records noted anxiety disorders, secondary diagnosis, “non severe.” VA treatment records dated in April 2015 contained a suicide prevention risk assessment screening, in which the Veteran denied having feelings of hopelessness or helplessness or history of suicide attempts or suicidal ideation. A mental health treatment record showed that the Veteran reported living with a friend and noted that he was out of Sertraline for almost a year, but started to take it again a few days earlier from an old bottle. He further reported that he thought about the military, “good and bad at times,” and noted that his sleep was restless and intermittent with night sweats and nightmares approximately three times a week. He had some flashbacks, anger, irritability, and depression, which he rated as seven out of 10 in severity. He also reported constant hypervigilance and feeling “jumpy.” He indicated that he avoided crowds, loud music, and drugs, and liked to isolate and be by himself. He denied suicidal or homicidal ideation and auditory or visual hallucinations. He indicated that he had a good relationship with his five children. On mental status examination, it was noted that the Veteran was casually dressed and was cooperative. His mood was described as “kind of funny” and his affect congruent with current mood, and “looks anxious.” He denied thoughts of self-harm, paranoia, delusions, or phobia. His thought process was linear, logical, and goal directed. He denied auditory or visual hallucinations and suicidal or homicidal ideation. Insight and judgment were “fair” and his memory and concentration were “adequate.” According to a VA psychosocial assessment dated in June 2015, the Veteran was homeless and staying with friends and family. His social support included his children and friends. He indicated that he did recreational/leisure activities, to include playing basketball and reading. He indicated that his goal was “to be much more stable, have another car, be enjoying life again, have housing.” According to a VA homeless program telephone encounter note dated in July 2015, the Veteran was calm and pleasant. He denied suicidal or homicidal ideation or acute distress. Subsequent VA treatment records dated in May 2016 showed that the Veteran stated, “I have cramping in lower back…otherwise I am pretty good.” He indicated that he had a girlfriend but that he lived by himself, which helped deal with his moods and hypervigilance. He further stated that his nightmares and depression were under control and denied suicidal or homicidal ideation. Thereafter, treatment records dated in July 2016 showed that the Veteran had normal mood and affect and he denied suicidal or homicidal ideation. Additional treatment records dated in August 2016 showed that the Veteran reported he was “doing well” and again denied suicidal or homicidal ideation. In March 2017, the Veteran’s attorney submitted a PTSD DBQ dated in January 2017, in which the private psychologist confirmed a diagnosis of PTSD. In terms of social impairment, it was noted that the Veteran was separated from his first wife since 1985 and had five adult children. He had a significant relationship with a girlfriend for three years and lived alone keeping his struggles to himself “not wanting to burden others,” and was socially isolated and withdrawn. In terms of occupational impairment, his last job was an inventory technician for a car dealership for three years, until 2012. The Veteran reported that he saw a psychiatrist at VA every six months; a counselor every month; and indicated that he felt his medications provided symptom relief. The psychologist identified PTSD symptoms of depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; near-continuous panic attacks or depression affecting the ability to function independently, appropriately, and efficiently; chronic sleep impairment; mild memory loss; impairment of short and long term memory; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or worklike setting; inability to establish and maintain effective relationships; suicidal ideation; persistent delusions or hallucinations; and, persistent danger of hurting self or others. The psychologist then indicated that the Veteran detailed great ongoing difficulty with his symptom pattern and stated that he could no longer enjoy the simplest activities. Upon mental status examination, the Veteran’s attention was normal and concentration appeared “variable.” He complained of increased trouble with short and long-term memory, and struggled with remembering basic information. His speech was normal and his thought content was appropriate. The psychologist noted that there were reports of “overt hallucinations,” but did not provide any additional information. His mood was anxious, and his affect restricted. The Veteran reported feeling anxious and depressed, and the psychologist stated, “he endorses symptomatology of PTSD, as he is vague with response, suspicious, and seems rather vigilant when speaking with this examiner.” The psychologist further stated that the Veteran struggled with depressed mood; hypervigilance; disturbances of motivation and mood; and, difficulty maintaining effective relationships, which indicated that he struggled with severe impairment. The psychologist concluded that the Veteran’s PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. On review of all evidence, the Board finds that the weight of the evidence is against the assignment of an initial rating higher than 50 percent. In reaching this conclusion, the Board assigns higher probative value to the Veteran’s ongoing mental health VA treatment records and examination reports dated from January 2013 to the present, while assigning less probative value to the private January 2017 DBQ for the following reasons. Significantly, the Board finds the private January 2017 DBQ to be internally inconsistent. For example, the private psychologist noted that the Veteran had an “inability” to establish and maintain effective relationships, but also noted that the Veteran had a significant relationship for three years. In addition, despite the outpatient records showing that the Veteran continuously and consistently denied suicidal ideation, the private psychologist noted suicidal ideation, as well as “overt hallucinations,” without any supportive explanation or reference to them in the medical records. Furthermore, the private psychologist checked the boxes for both panic attacks occurring “weekly or less often” and “near-continuous panic attacks”; necessarily, it cannot be both. Moreover, although the private psychologist indicated that the December 2013 VA examiner noted that the Veteran’s symptoms “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning,” the psychologist failed to also note that the same December 2013 VA examiner concluded that the Veteran’s PTSD resulted only in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, which is consistent with only a 30 percent rating under DC 9411. Moreover, the private psychologist noted that the Veteran displayed a persistent danger of hurting self or others, but provided no supportive reasoning or evidence, and the Board does not find any. Lastly, the private psychologist failed to address the Veteran’s continuous reports of “feeling good” or “doing well,” and did not reconcile the fact that the Veteran did not seek any mental health outpatient treatment, other than medication management, throughout the pendency of the appeal. Although the Veteran has displayed some difficulty in establishing and maintaining effective work and social relationships, he has maintained a significant relationship with his girlfriend and family members, to include his five children. On his SSA application, he reported seeing friends on a daily basis and attributed his inability to work on physical disabilities, and not mental health problems. Furthermore, at least at the time of the December 2013 VA examination was conducted, he reported being a full-time student, which presumably requires at least some social interaction. The weight of the evidence does not show that the Veteran’s PTSD is productive of symptoms resulting in or approximating occupational and social impairment, with deficiencies in most areas. There is no evidence of any obsessional rituals which interfere with routine activities; neglect of personal appearance and hygiene; or any other more severe symptoms consistent with the criteria for a 70 percent rating. As noted above, while the Veteran had some difficulty in establishing and maintaining effective relationships and a degree of social isolation, the record clearly shows that he had an “outstanding” relationship with his girlfriend despite living separately, a “super” relationship with his children, and a “good” relationship with his mother. Moreover, the Veteran generally noted that he was “feeling good” and reported only mild symptoms throughout the pendency of the appeal. Rather, the Veteran’s PTSD is shown to more nearly result in occupational and social impairment with reduced reliability and productivity. The Veteran’s treatment notes demonstrate that his PTSD symptoms primarily includes mild memory loss; anxiety; depression; suspiciousness; hypervigilance; panic attacks occurring weekly or less often; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances. These symptoms are contemplated by the currently assigned 50 percent disability rating. The Board recognizes that the symptoms listed in VA’s general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. With this in mind, the probative evidence shows that the Veteran’s overall PTSD picture is already adequately contemplated by the 50 percent rating currently assigned. For these reasons, the Board finds that the Veteran’s PTSD disability does not warrant a higher rating and the claim must be denied. Finally, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND As to the remaining claims on appeal, a remand is necessary to provide the Veteran with adequate VA examinations. Regarding the service connection claim for gastroenteritis, the Veteran complained of numerous stomach symptoms in service, and was diagnosed with the stomach on a few occasions. The Veteran was afforded a VA compensation examination in December 2013 and the VA examiner concluded that he did not have a current disability. Specifically, the examiner stated, “I do not think [the patient] still has “active” viral GI infection.” I have given the time record when [the patient] did have it but he does not have any infection of GI tract now which is continuing from 1982.” Since [the patient] “still” [complaints of] the same symptoms he needs to be followed up by a Gastroenterologist and [have] a full work up for his symptoms (if he still has any).” The Board finds that it would be premature to decide the claim given this opinion. First, based on the examiner’s conclusion, a specialist was recommended for follow-up; therefore, the question of a current disability still remains. Second, the Veteran’s active medication list at VA continues to show that he was prescribed medications for stomach symptoms; this evidence also suggests that the Veteran has a current disability or at the very least, recurrent stomach symptoms. The Board finds that a new VA examination is necessary to determine what if any gastrointestinal disability currently exists, and if so, the etiology of such. Regarding the right knee disability, the Veteran last underwent a VA compensation examination in December 2013, at which time, the examiner stated, “There are contributing factors of weakness, fatigability, incoordination or pain during flare-ups or repeated use over time that could additionally limited the functional ability of the knee joint;” however the examiner further stated, “Cannot provide degree of ROM loss without resorting to mere speculation.” Unfortunately, the examiner did not use the information provided by the Veteran or obtain additional information from the Veteran or the treatment records such as the frequency, duration, characteristics, severity, or functional loss during flare-ups. The Court held that “before the Board can accept an examiner’s statement that an opinion cannot be provided without resorting to speculation, it must be clear that this is predicated on a lack of knowledge among the “medical community at large” and not the insufficient knowledge of the specific examiner.” See Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017) (quoting Jones v. Shinseki, 23 Vet. App. 382, 390 (2010)). Therefore, a new examination must be obtained before the right knee claim can be decided on the merits. Regarding the Veteran’s service-connected right hand disability, the Veteran underwent a VA compensation examination in December 2013, at which time no functional loss or functional impairment was noted. Subsequent VA treatment records however reveal the Veteran’s report of right-hand numbness with a weak grip and his report of difficulty performing activities of daily living, such as shaving and bathing. As there is a suggestion of worsening disability, a new examination is necessary to the determine the current severity of his right-hand disability. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Lastly, in light of the above, the issue of a TDIU is inextricably intertwined with the Board’s decision herein and the issue being remanded, and as such, adjudication of TDIU must be deferred pending the proposed development. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Ensure that all outstanding VA treatment records since August 2016 are associated with the claims file. 2. Then, provide the Veteran with a VA examination, to determine the nature and etiology of his claimed gastrointestinal disability. The claims file must be made available to and be reviewed by the examiner. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a thorough review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Identify all currently diagnosed gastrointestinal disability, to include claimed gastroenteritis. (b) For each currently diagnosed disability, provide an opinion as to whether it is at least as likely as not (50 percent probability or higher) that it had its onset during active duty service or is otherwise causally or etiologically related to it. In doing so, the examiner is asked to address service treatment records dated in (a) December 1980 showing complaints of pain in the side of the abdomen; (b) January 1982 showing complaints of stomach pains with an assessment of gastroenteritis; (c) October 1982 showing complaints of stomach cramps, nausea, and vomiting with the assessment of gastroenteritis; (d) November 1982 showing complaints of vomiting, flu symptoms, and diarrhea, with the assessment of acute viral gastroenteritis; (e) March 1983 showing complaints of stomach cramps for 3-years/possible acute gastritis and an assessment of trichomonal cystitis; (f) October 1983 upper GI series impression of gastric ulcer, lesser curvature aspect of the stomach; and, (g) the Veteran’s lay assertions that he continued to have similar symptoms since service as well as the indication that he is regularly prescribed Omeprazole for his stomach. A complete rationale should be provided. 3. Provide the Veteran with a VA examination to identify the severity of his right knee disability. The claims file must be made available to and be reviewed by the examiner. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a thorough review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Elicit from the Veteran all signs and symptoms of his right knee disability throughout the pendency of the appeal from January 2013. In doing so, also obtain information from the Veteran (and the treatment records) as to the frequency, duration, characteristics, severity, or functional loss with any repetitive use or during any flare-ups. (b) Full range of motion testing must be performed where possible. The joint in question and the paired joint should be tested in (1) active motion, (2) passive motion, (3) in weight-bearing, and (4) in nonweight-bearing. 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. If pain is found during the examination, the examiner should note when the pain begins. (c) In assessing functional loss, flare-ups and increased functional loss on repetitive use must be considered. The examiner must consider all procurable and ascertainable data and describe the extent of any pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report functional impairment due to such factors in terms of additional degrees of limitation of motion. **If the examiner is unable to provide such an opinion without resort to speculation, the examiner must provide a rationale for this conclusion, with specific consideration of the instructions in the VA Clinician’s Guide to estimate, “per [the] veteran,” what extent, if any, flare-ups affect functional impairment. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. A complete rationale should be provided. 4. Then, Provide the Veteran with a VA examination to identify the severity of his right hand disability. The claims file must be made available to and be reviewed by the examiner. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a thorough review of the record and examination of the Veteran, the examiner is asked to respond to the following: Elicit from the Veteran all signs and symptoms of his right hand disability throughout the pendency of the appeal from January 2013. In doing so, also obtain information from the Veteran (and the treatment records) as to the frequency, duration, characteristics, severity, or functional loss with any repetitive use or during any flare-ups. (Continued on the next page)   5. Thereafter, readjudicate the service connection claim for a gastrointestinal disability, increased rating claims for the right knee and right hand disabilities, as well as claim for a TDIU. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Yaffe, Associate Counsel