Citation Nr: 21063833 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 15-26 321 DATE: October 18, 2021 ORDER Entitlement to service connection for gout is denied. Entitlement to a rating higher than 0 percent for residuals of a traumatic brain injury (TBI) is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran's claimed gout is etiologically related to service or any disease, injury, or event in service. 2. Throughout the period of appeal, the Veteran's TBI symptoms warrant no higher than level "0" impairment on the table of facets, and headaches have already been assigned a separate rating under the appropriate diagnostic code. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for gout have not been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.303. 2. The criteria for entitlement to a rating higher than 0 percent for residuals of TBI have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 3.102, 3.321, 4.124a, Diagnostic Code 8045. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1983 to August 1993. The Veteran appeared at a January 2015 hearing before a Department of Veterans Affairs (VA) Decision Review Officer (DRO). A hearing transcript is of record. The Veteran appeared at an April 2017 hearing before the undersigned Veterans Law Judge. A hearing transcript is of record. In November 2018, the Board remanded the issues of entitlement to service connection for posttraumatic stress disorder (PTSD), a right knee disability, a left knee disability, gout, erectile dysfunction; higher disability ratings for a lumbar spine disability, radiculopathy of the right and left lower extremities with involvement ot the sciatic and femoral nerves, and residuals of TBI; entitlement to a temporary total rating under the provisions of 38 C.F.R.§ 4.29 for posttraumatic stress disorder; and entitlement to a total rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) to the Agency of Original Jurisdiction (AOJ) for additional development. In June 2021, the Veteran submitted VA form 10-182 (Decision Review Request: Board Appeal), and opted the issues of entitlement to service connection for PTSD, a right knee disability, a left knee disability, erectile dysfunction; higher disability ratings for a lumbar spine disability, radiculopathy of the right and left lower extremities with involvement ot the sciatic and femoral nerves; entitlement to a temporary total rating under the provisions of 38 C.F.R.§ 4.29 for PTSD; and entitlement to a TDIU into the modernized review system, also known as the Appeals Modernization Act (AMA). Therefore, those issues will be adjudicated in a separate decision pursuant to the AMA. Concerning the remaining legacy issues of entitlement to service connection for gout and a higher rating for residuals of TBI, in light of the treatment records that have been obtained and associated with the record, the obtaining of the requested medical opinions, and the further adjudicatory actions taken by the AOJ, the Board finds that there has been substantial compliance with the remand requests. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141 (1999). Service Connection Service connection may be established for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, 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) evidence, generally medical, of a causal relationship between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be established for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Service incurrence will be presumed for certain chronic diseases if manifest to a compensable degree within one year after active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. 1. Entitlement to service connection for gout An October 1987 service medical record contains the Veteran's report that his feet hurt when he ran. The Veteran was treated for a plantar wart on the left foot. After service, a January 2003 VA treatment record contains a diagnosis of gout. A January 2005 VA treatment record shows that the Veteran no longer took allopurinol routinely. The Veteran had not had any flares of gout for a long time. A June 2016 VA treatment record contains the Veteran's self-report of a 30-year history of bilateral foot pain. It was noted that the Veteran had previously been treated for gout. At an April 2017 Board hearing, the Veteran reported that his feet started to bother him during service. He stated that after a few years in service, his feet bothered him. At an August 2020 VA examination, the examiner stated that the examination was subjective only regarding arthritis and gout. The laboratory findings were within normal range. The examiner found no evidence of a previous or current arthritis or gout exacerbation. The Veteran reported experiencing all-over pain and was unable to pinpoint a specific location. The Veteran reported that he took Allopurinol daily. The Veteran used a cane due to chronic pain in the back and knees. An erythrocyte sedimentation rate test had a result of 2. A uric acid test had a result of 6.1. The examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused by service. The examiner noted that the claims file showed that the Veteran had been prescribed Allopurinol as early as 2003, and Allopurinol was used to treat gout. The examiner also noted that a treatment record from October 1995 showed an elevated uric acid reading of 7.1, with a normal range of 3.5 to 7. The examiner noted that on current testing, the Veteran's uric acid reading was normal at 6.1 with a normal range of 3.7 to 8.6. The examiner explained that gout is a common and complex form of arthritis that can affect anyone. The examiner stated that gout occurs when urate crystals accumulate in the joint, which causes inflammation and intense pain. Urate crystals could form when there were high levels of uric accid in the blood, and the body produced uric acid when it broke down purines. Purines were found in certain foods such as steak, organ meats, seafood, alcoholic beverages, and drinks sweetened with fruit sugar. Risk factors for gout included diet, obesity, medical condition, certain medications, family history, age, gender, and recent surgery or trauma. The examiner stated that from the current examination, a review of the service treatment records, and considering the earliest mention of a foot condition was more than two years past the time the Veteran left active duty, it was less likely than not that the Veteran's gout was due to or the result of any incident or foot pain during active service. The examiner also cited to an article from the Mayo Clinic. Having reviewed the evidence pertaining to the claims, the Board has determined that service connection on a presumptive basis for arthritis is not warranted. As the evidence is negative for signs, symptoms, or diagnoses of arthritis to a compensable level during the first year after separation from service. Therefore, service connection for gouty arthritis cannot be granted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. The Board finds that the preponderance of evidence is against a finding that gout was caused or aggravated by active service. The Veteran has sought ongoing medical treatment through VA and private providers. However, the Board finds that the competent evidence of record does not support a finding that relates any current gout to service. The Board ultimately places the most probative weight on the opinion offered by the August 2020 VA examiner. The VA examiner is an objective medical professional, who has the medical training and knowledge to perform and interpret the necessary medical tests. In addition, the Veteran has not submitted any competent medical evidence that supports a finding that gout is due to service, was present in service, or was caused or aggravated by any service-connected disability or any event, injury, or disease during service. Therefore, as there is no competent evidence linking a gout disability to service, the claim must be denied on a direct basis. The Board acknowledges the Veteran's contentions that he experiences gout and foot pain as a result of active duty. Lay persons can attest to factual matters of which they have first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). However, while the Veteran is competent to report what comes to him through his senses, he does not have medical expertise to provide an opinion on the etiology of his gout flares. The etiology of the gout presents a complex medical question as there is no observable cause and effect relationship. Layno v. Brown, 6 Vet. App. 465 (1994). While the Board has considered the Veteran's contentions regarding the presence of symptoms, the Board ultimately places more probative weight on the objective laboratory findings and observations of the VA medical professional, who has the medical training and knowledge to perform and interpret the necessary medical tests. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for gout, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 2. Entitlement to a disability rating higher than 0 percent for residuals of a traumatic brain injury (TBI) The Veteran's residuals of TBI are rated under Diagnostic Code 8045, which provides evaluation for three main areas of dysfunction that may result from TBI and have profound effects on functioning: (1) cognitive, which is common in varying degrees after TBI; (2) emotional/behavioral; and (3) physical. Each of those areas of dysfunction may require evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045. Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain. Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive. Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others. In an individual, symptoms may fluctuate in severity from day to day. Cognitive impairment is evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." 38 C.F.R. § 4.124a, Diagnostic Code 8045. Subjective symptoms may be the only residual of a traumatic brain injury or may be associated with cognitive impairment or other areas of dysfunction. Subjective symptoms that are residuals of a traumatic brain injury, whether or not they are part of cognitive impairment, are evaluated under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." However, any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, should be evaluated separately even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table. 38 C.F.R. § 4.124a, Diagnostic Code 8045. Emotional/behavioral dysfunction is evaluated under 38 C.F.R. § 4.130, the schedule of ratings for mental disorders, when there is a diagnosis of a mental disorder. When there is no diagnosis of a mental disorder, emotional/behavioral symptoms are evaluated under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified." 38 C.F.R. § 4.124a, Diagnostic Code 8045. Physical (including neurological) dysfunction is evaluated based on the following list, under an appropriate diagnostic code: motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions. 38 C.F.R. § 4.124a, Diagnostic Code 8045. The preceding list of types of physical dysfunction does not encompass all possible residuals of a traumatic brain injury. For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code. Each condition is evaluated separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under 38 C.F.R. § 4.25 the evaluations for each separately rated condition. The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations. 38 C.F.R. § 4.124a, Diagnostic Code 8045. The need for special monthly compensation for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, or other reason, must be considered. 38 C.F.R. § 4.124a, Diagnostic Code 8045. Cognitive impairment and subjective symptoms are evaluated using the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" which contains ten important facets of a traumatic brain injury related to cognitive impairment and subjective symptoms. That table provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a fifth level, the highest level of impairment, and labeled total. However, not every facet has every level of severity. The consciousness facet, for example, does not provide for an impairment level other than total, because any level of impaired consciousness would be totally disabling. Assign a 100 percent rating if total is the level of evaluation for one or more facets. If no facet is evaluated as total, the overall percentage rating is based on the level of the highest facet. If the highest is 0, then a 0 percent rating is assigned. If the highest is 1, then a 10 percent rating is assigned. If the highest is 2, then a 40 percent rating is assigned. If the highest is 3, then a 70 percent rating is assigned. 38 C.F.R. § 4.124a, Diagnostic Code 8045. There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. In such cases, more than one evaluation based on the same manifestations is not to be assigned. If the manifestations of two or more conditions cannot be clearly separated, a single evaluation is assigned under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. However, if the manifestations are clearly separable, a separate evaluation is assigned for each condition. 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (1). Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation. 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (2). Instrumental activities of daily living refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone. Those activities are distinguished from activities of daily living, which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet. 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (3). The terms mild, moderate, and severe traumatic brain injury, which may appear in medical records, refer to a classification of traumatic brain injury made at, or close to, the time of injury rather than to the current level of functioning. That classification does not affect the rating assigned under Diagnostic Code 8045. 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (4). The table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" provides the following evaluations: Impairment of memory, attention, concentration, executive functions are assigned numerical designations of 0 for no complaints of impairment of memory, attention, concentration, or executive functions; 1 for a complaint of mild loss of memory (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing; 2 for objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment; 3 for objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment; and total for objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment. Impairment of judgment is assigned numerical designations of 0 for normal; 1 for mildly impaired judgment for complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision; 2 for moderately impaired judgment, for complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions; 3 for moderately severely impaired judgment, for even routine and familiar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision; and total for severely impaired judgment, for even routine and familiar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, for example, unable to determine appropriate clothing for current weather conditions or judge when to avoid dangerous situations or activities. Impairment of social interaction is assigned numerical designations of 0 for social interaction is routinely appropriate; 1 for social interaction is occasionally inappropriate; 2 for social interaction is frequently inappropriate; and 3 for social interaction is inappropriate most or all of the time. Impairment of orientation is assigned numerical designations of 0 for always oriented to person, time, place, and situation; 1 for occasionally disoriented to one of the four aspects (person, time, place, situation) of orientation; 2 for occasionally disoriented to two of the four aspects (person, time, place, situation) of orientation or often disoriented to one aspect of orientation; 3 for often disoriented to two or more of the four aspects (person, time, place, situation) of orientation; and total for consistently disoriented to two or more of the four aspects (person, time, place, situation) of orientation. Impairment of motor activity (with intact motor and sensory system) is assigned numerical designations of 0 for motor activity normal; 1 for motor activity normal most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function); 2 for motor activity mildly decreased or with moderate slowing due to apraxia; 3 for motor activity moderately decreased due to apraxia; and total for motor activity severely decreased due to apraxia. Impairment of visual spatial orientation is assigned numerical designations of 1 for mildly impaired, occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions, is able to use assistive devices such as GPS (global positioning system); 2 for moderately impaired, usually gets lost in unfamiliar surroundings, has difficulty reading maps, following directions, and judging distance, has difficulty using assistive devices such as GPS; 3 for moderately severely impaired, gets lost even in familiar surroundings, unable to use assistive devices such as GPS; and total for severely impaired, may be unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment. Subjective symptoms are assigned numerical designations 0 for subjective symptoms that do not interfere with work, instrumental activities of daily living, or work, family, or other close relationships, examples are mild or occasional headaches, mild anxiety; 1 for three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family, or other close relationships, examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light; and 2 for three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living; or work, family, or other close relationships, examples of findings that might be seen at this level of impairment are: marked fatigability, blurred or double vision, headaches requiring rest periods during most days. Neurobehavioral effects are assigned numerical designations of 0 for one or more neurobehavioral effects that do not interfere with workplace interaction or social interaction, examples of neurobehavioral effects are: Irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, lack of cooperation, inflexibility, and impaired awareness of disability, any of these effects may range from slight to severe, although verbal and physical aggression are likely to have a more serious impact on workplace interaction and social interaction than some of the other effects; 1 for one or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them; 2 for one or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them; and 3 for one or more neurobehavioral effects that interfere with or preclude workplace interaction, social interaction, or both on most days or that occasionally require supervision for safety of self or others. Impairment of communication is assigned numerical designations of 0 for able to communicate by spoken and written language (expressive communication), and to comprehend spoken and written language; 1 for comprehension or expression, or both, of either spoken language or written language is only occasionally impaired, can communicate complex ideas; 2 for inability to communicate either by spoken language, written language, or both, more than occasionally but less than half of the time, or to comprehend spoken language, written language, or both, more than occasionally but less than half of the time, can generally communicate complex ideas; 3 for inability to communicate either by spoken language, written language, or both, at least half of the time but not all of the time, or to comprehend spoken language, written language, or both, at least half of the time but not all of the time, may rely on gestures or other alternative modes of communication, able to communicate basic needs; and total for complete inability to communicate either by spoken language, written language, or both, or to comprehend spoken language, written language, or both, unable to communicate basic needs. Impairment of consciousness is assigned a designation of total for persistently altered state of consciousness, such as vegetative state, minimally responsive state, coma. 38 C.F.R. § 4.124a, Diagnostic Code 8045. At a July 2013 VA TBI examination, the examiner noted that the Veteran's motor activity was normal. The Veteran described subjective symptoms that the examiner stated did not interfere with work, activities of daily living, ability to engage in recreational and/or domestic activities or the ability to interact with friends and family or other close relationships. The subjective symptoms included sleep dysregulation and intermittent tension-type headaches. The Veteran was able to communicate by spoken and written language. He was able to comprehend spoken and written language. The Veteran's consciousness was normal. The examiner stated that there were no other pertinent physical findings, complications, conditions, signs, or symptoms. Another report of a July 2013 VA TBI examination shows that there was no Axis I diagnosis attributable to the claimed head injury. The examiner stated that to a reasonable degree of psychological certainty, the Veteran did not have a cognitive disorder secondary to TBI. There were no complaints of impairment of memory, attention, concentration, or executive functions temporally related to blows to the head. The Veteran's judgment was deemed normal. Social interaction was routinely appropriate with no changes temporally related to blows to the head. The Veteran was always oriented to person, time, place, and situation. Visual spatial orientation was normal. There were no neurobehavioral effects. The examiner reiterated that the Veteran did not have any mental or cognitive residuals attributable to a TBI. The examiner further remarked that the Veteran's insomnia and behavioral effects were due to bipolar disorder. At an August 2020 VA TBI examination, the examiner noted the Veteran's self-report of concentration and memory impairment, migraine pain, and vision issues. The examiner noted that the Veteran had many somatic and joint issues that were unrelated either directly or indirectly to TBI residuals. The examiner opined that there was no impairment of memory, attention, concentration, or executive functions as a residual of TBI. The examiner found that the Veteran's judgment was normal. Social interaction was routinely appropriate, and the Veteran was always oriented to person, time, place, and situation. Motor activity was normal. Visual spatial orientation was normal. The examiner specified that there were subjective symptoms that did not interfere with work, instrumental activities of daily living, or close relationships. The Veteran experienced headaches. The examiner found no neurobehavioral effects due to TBI. The Veteran was able to communicate by spoken and written language and comprehend spoken and written language. Consciousness was normal. The examiner concluded that there were no residual neuro-cognitive or neuro-behavioral issues related to TBI. The examiner stated that it was much more likely than not that the Veteran's comorbid medical and psychiatric issues were the etiology of those types of symptoms. In an August 2020 psychiatric examination report, a VA psychologist opined that the file material indicated that the Veteran had no TBI residuals. The psychologist stated that the Veteran met the criteria for Bipolar I disorder and not PTSD. The psychologist also noted that an August 2020 TBI examination report showed no residual neuro-cognitive or neuro-behavioral issues related to a TBI, while the Veteran gave a self-report that the TBI contributed to mood dysfunction, problems with focusing and memory, and anxiety. The examiner reiterated that examination showed no neuro-cognitive or neuro-behavioral residuals from TBI. As a preliminary matter, the Board notes that the Veteran has been assigned a separate rating for headaches, rated 30 percent. Therefore, the Board will not specifically consider the headaches in rating the TBI as they have been separately rated. 38 C.F.R. § 4.14. As the Veteran has been separately rated for headaches, those symptoms will not be rated under the criteria of 8045. That is consistent with the rule against pyramiding and the instructions of Diagnostic Code 8045, not to assign multiple ratings for the same symptoms. Additionally, at the April 2017 Board hearing, the Veteran specifically withdrew the issue of entitlement to an increased rating for headaches. In accordance with that withdrawal, the rating for the headaches is no longer part of the current appeal. The Board will first discuss each of the facets of cognitive impairment individually under Diagnostic Code 8045. For memory impairment, the Board finds that the evidence shows no higher than a "0" is assignable. Although the Veteran consistently provided subjective reports of memory loss, the VA examiners in July 2013 and August 2020 attributed the Veteran's claimed memory loss to causes other than TBI. Taken as a whole, the Board finds that the evidence of record supports the assignment of a "0" and no higher for this facet. Next, the Veteran's judgment was found to be normal, as shown in the July 2013 VA examination report, thus warranting the assignment of "0." A higher level of severity of "1" is not warranted unless an examiner finds evidence of mildly impaired judgment for complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. The Veteran's social interactions were found to be routinely appropriate, as shown in the July 2013 and August 2020 VA examinations, thus warranting the assignment of "0" for this facet. A higher level of severity of "1" is not warranted unless social interaction is occasionally inappropriate. The Veteran was consistently found to be oriented to person, time, place, and situation. The VA examiners did not find any evidence of occasional disorientation to one of the four aspects (person, time, place, situation) of orientation, which would warrant a higher level of severity of "1." Motor activity was consistently normal, with no evidence of apraxia, the inability to perform previously learned motor activities, despite normal motor function, that would warrant a rating of "1." Concerning visual spatial orientation, the Board finds that the evidence shows no higher than a "0" is assignable for the period of the appeal. The July 2013 and August 2020 VA examination reports indicated that the Veteran's visual spatial orientation was normal. Therefore, the Board finds that the preponderance of the evidence of record supports a finding of normal throughout the period of appeal. Regarding subjective symptoms, the Board finds that the evidence shows no higher than a "0" is assignable for the period of the appeal, as the Veteran's subjective symptoms did not interfere with his work, activities of daily living, ability to engage in recreational and/or domestic activities, or his ability to interact with friends and family or other close relationships, as stated by the July 2013 and August 2020 VA examiners. Taken as a whole, and excluding those symptoms for which a separate rating has already been assigned as required by the rating criteria, the Board finds that the evidence of record supports the assignment of a "0" and no higher for this facet. Concerning neurobehavioral effects, the Board finds that the evidence shows no higher than a "0" is assignable for the period of the appeal, as the Veteran had no neurobehavioral effects attributable to a TBI, as recorded by the July 2013 and August 2020 VA examiners. Taken as a whole, the Board finds that the evidence of record supports the assignment of a "0" and no higher for this facet. The Veteran's communication and consciousness were consistently found to be normal throughout the period of appeal. The rating assigned for cognitive impairment and other residuals of TBI not otherwise classified is based upon the highest level of severity for any facet as determined by examination. Only one rating is assigned for all the applicable facets. The Board finds that the currently assigned 0 percent rating is warranted based upon the highest severity level of "0." The Board finds that a rating higher than 0 percent is not warranted at any point, as the Veteran was never assessed as having a facet evaluated as level "1." The Board finds that the preponderance of the evidence is against a finding that any of the facets warranted the assignment of a level "1" or higher. A separate rating is also not warranted for any physical or cognitive impairment beyond those ratings that have already been assigned. Finally, the Board has also considered the instruction of Diagnostic Code 8045 to consider the need for special monthly compensation. However, neither the Veteran nor the evidence suggests loss of use of an extremity, sensory impairments, or the need for aid and attendance due to residuals of a TBI. After careful review of the available diagnostic codes and the lay and medical evidence of record, the Board finds no other diagnostic codes that would be appropriate to rate the residuals of TBI. The Board acknowledges the Veteran's self-report of symptoms that he feels are attributable to a TBI. The Veteran can attest to factual matters of which the Veteran has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). However, while the Veteran is competent to report what comes to him through his senses, he does not have the medical expertise to attribute symptoms to a specific cause due to the presence of multiple comorbid psychiatric and physical disabilities. Layno v. Brown, 6 Vet. App. 465 (1994). While the Board has considered the Veteran's contentions regarding the presence of symptoms, the Board ultimately places more probative weight on the objective laboratory findings and observations of the VA medical professionals, who has the medical training and knowledge to perform and interpret the necessary medical tests. Accordingly, the Board finds that the preponderance of the evidence is against the claim for a higher rating for residuals of a TBI, and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Layton, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.