Citation Nr: 18160546
Decision Date: 12/27/18	Archive Date: 12/27/18

DOCKET NO. 16-41 589
DATE:	December 27, 2018
ORDER
New and material evidence having been received, the claim of service connection for a lumbar spine disorder is reopened, and to that extent the appeal is granted.  
Service connection for tinnitus is granted.
A 70 percent evaluation, but no higher, for posttraumatic stress disorder (PTSD) is granted.
Entitlement to a total disability rating based on individual unemployability based on individual unemployability due to service-connected disabilities (TDIU) is granted. 
REMANDED
Entitlement to service connection for a lumbar spine disorder is remanded.
Entitlement to service connection for a heart condition, including hypertension and ischemic heart disease and to include as secondary to herbicide exposure, is remanded. 
Entitlement to an evaluation in excess of 40 percent for left below knee amputation with callosity stump is remanded.
FINDINGS OF FACT
1. The Veteran’s claim for service connection for a back disorder was denied in a December 1977 decision; the Veteran did not file a timely notice of disagreement and no new and material evidence was presented within a year of the decision.
2. In an April 1999 decision, the RO found that no new and material evidence had been presented in order to reopen the claim; the Veteran did not file a timely notice of disagreement and no new and material evidence was presented within a year of the decision.
3. The evidence submitted since the April 1999 decision, pertinent to the claim for service connection for a back disorder, is neither cumulative nor redundant, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim.
4. Resolving reasonable doubt in his favor, the Veteran has tinnitus attributable to his active military service.
5. The Veteran’s service-connected PTSD has been productive of occupational and social impairment, with deficiencies in most areas, including work, school, family relations, judgment, thinking, and mood; total occupational and social impairment due to PTSD has not been shown.
6. The Veteran’s service-connected disabilities preclude him from obtaining and maintaining a substantially gainful occupation.
CONCLUSIONS OF LAW
1. Since the April 1999 final decision, new and material evidence has been received, and the claim of entitlement to service connection for a back disorder is reopened.  38 U.S.C. § 5108; 38 C.F.R. § 3.156.
2. The criteria for service connection for tinnitus are met.  38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a).
3. The criteria for a 70 percent evaluation, but no higher, for PTSD are met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.21, 4.130, Diagnostic Code 9411. 
4. The criteria for entitlement to a TDIU are met.  38 U.S.C. §§ 1155, 5107; 38 U.S.C. §§ 3.340, 3.341, 4.16.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from October 1967 to January 1969.  These matters come before the Board of Veterans’ Appeals (Board) on appeal from July 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO).  
The record includes evidence that the Veteran cannot work due to his service-connected PTSD and left leg disability.  As such, claim for TDIU has been raised by the record as part of his increased rating claims for these disabilities. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009) (providing that a request for a TDIU, whether expressly raised by Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather, can be part and parcel of a claim for an initial or increased rating for a disability).
Reopening Service Connection for Lumbar Spine Disorder
Where a claim has been finally adjudicated, a claimant must present new and material evidence to reopen the previously denied claim.  38 U.S.C. § 5108; 38 C.F.R. § 3.156(a).
New evidence is evidence not previously submitted to agency decision makers.  38 C.F.R. § 3.156(a).  Material evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.  Id.  New and material evidence cannot be either cumulative or redundant of the evidence of record at the time of the last prior final denial and must raise a reasonable possibility of substantiating the claim.  Id.
The Court has interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.”  The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which “does not require new and material evidence as to each previously unproven element of a claim.”  Shade v. Shinseki, 24 Vet. App. 110 (2010).  When evaluating the materiality of newly submitted evidence, the focus must not be solely on whether the evidence remedies the principal reason for denial in the last prior decision; rather the determination of materiality should focus on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement.  Shade, 24 Vet. App. at 117.  
For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is presumed.  See Justus v. Principi, 3 Vet. App. 510, 513 (1992).
New theories of entitlement are not a basis for reopening a claim, but if evidence supporting a new theory of entitlement constitutes new and material evidence, then VA must reopen the claim.  Boggs v. Peake, 520 F.3d 1330, 1336-37 (Fed. Cir. 2008).  Lay contentions to support new theories alone are not competent evidence, and cannot serve to support reopening of a claim.  Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011).
The question of whether to reopen a claim should be considered under the standard of 38 C.F.R. § 3.159(c)(4)(iii), consistent with McLendon v. Nicholson, 20 Vet. App. 79 (2006), for determining whether a VA examination is necessary.  If the McLendon standard is met, the claim should be reopened.  See id.
The provisions of 38 U.S.C. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened.  See Evans v. Brown, 9 Vet. App. 273, 282-3 (1996).
The RO denied the Veteran’s initial claim for entitlement to service connection for back disability in a December 1977 decision, finding that that the evidence did not show that the Veteran had a back disability that was causally related to service.  Evidence at that time included an October 1977 VA examination report reflecting no disorders of the back. 
In April 1999, the Veteran filed a claim for service connection for his back disability, contending that he had back pain since landing on his back in service when he stepped on a land mine.  That same month, the RO informed him that he had not submitted any new and material evidence to reopen his claim for service connection for a back disability.  The RO noted that service treatment records did not reflect any in-service back injury.
The Veteran did not file a notice of disagreement with this decision, and no new and material evidence was submitted during in the year following the issuance of the rating decision.  As such, the decision is final.  38 U.S.C. § 7105; 38 C.F.R. § 20.1103.
Since April 1999, substantial pertinent evidence has been added to the claims file.  The Veteran has submitted private medical records showing treatment at the Orthopedic Center of Palm Beach County which reflect diagnosis of foraminal stenosis and degenerative spondylolisthesis.  In addition, the Veteran indicated that his doctors informed him that his back disability is a direct result of his left leg amputation, which has caused him to walk with an altered gait. 
As this evidence was not before VA at the time of the final decision in December 1977, it is new.  It also relates to an unestablished fact necessary to substantiate the claim; that is, it shows that the has a current diagnosed disorder of the lumbar spine and that it may be related to his service-connected left leg amputation.  It is neither cumulative nor redundant of the evidence of record in December 1977 and is presumed credible for the limited purpose of ascertaining its materiality.  Justus.  When considered with the evidence previously of record, it raises a reasonable possibility of substantiating the claim of entitlement to service connection for a back disorder.  In short, the additional evidence is new and material and, therefore, sufficient to reopen the claim.  To that extent, the appeal is granted.  See 38 C.F.R. § 3.156; Shade, supra.  
Service Connection for Tinnitus
Based on the following, the Board concludes that the Veteran has a current diagnosis of tinnitus that began during active service.  38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a).
The evidence of record shows that the Veteran currently has bilateral tinnitus.  The Veteran has reported in several statements that he currently suffers from tinnitus.  Tinnitus is a disorder that is readily observable by laypersons and does not require medical expertise to establish its existence.  See Charles v. Principi, 16 Vet. App. 370 (2002).  Thus, the Board finds that the Veteran has a current tinnitus disability, and the first element of service connection has been met in this case.
Regarding the second element of service connection, the record clearly shows that the Veteran was exposed to loud noise during military service, specifically from a land mine.  Thus, the Board finds that the types, places and circumstances of the Veteran’s service are consistent with the noise exposure he has attested to having during military service.  See 38 U.S.C. § 1154(a).  Consequently, as the second element of service connection has also been met in this case, this case turns on the nexus element.
The Veteran has indicated that his tinnitus began while in service.  In a May 2016 affidavit, the Veteran stated that his tinnitus began while in service, following the explosion of the land mine in Vietnam.  The Veteran’s consistent lay statements indicate that the Veteran’s tinnitus began in service; the Board finds the Veteran’s competent lay statements to be credible.
In light of the Veteran’s consistent and competent lay statements that he had tinnitus ever since his military service, the Board concludes that the Veteran’s tinnitus was incurred in or caused by service.  Accordingly, the Board finds that service connection for tinnitus is warranted.  See 38 C.F.R. §§ 3.102, 3.303; Fountain v. McDonald, 27 Vet. App. 258, 271 (2015) (defining tinnitus as an organic disease of the nervous system included under § 3.309(a), at least when there is evidence of acoustic trauma).  In reaching the above conclusions, the Board has appropriately applied the benefit of the doubt doctrine in this case.  See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102.
Increased Rating Claim - PTSD
Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule).  38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10.
If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned.  38 C.F.R. § 4.7.
In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified.  Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances.  38 C.F.R. § 4.21.
The Veteran’s service-connected PTSD has been rated as 30 percent disabling under Diagnostic Code 9411, which provides ratings under the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130.  
Under the General Rating Formula, a 30 percent disability rating is assigned when the service-connected psychiatric disability results in occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as:  depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events), a 30 percent rating.  38 C.F.R. § 4.125.  
As the United States Court of Appeals for the Federal Circuit recently explained, evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation.  Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013).  The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.”  Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002).  In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation... requires an ultimate factual conclusion as to the Veteran’s level of impairment in ‘most areas.”  Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411.
The Veteran argues that he is entitled to a 70 percent disability rating for his service-connected PTSD.  For the following reasons, the Board agrees.
The Veteran submitted a sworn affidavit in May 2016, noting that he had not been able to receive treatment for his psychiatric disability since he resides in Brazil and could not afford the medical care. 
He indicated that he did not have any friends in Brazil, and could not bring himself to make new friends.  Occasionally, he corresponded with long-distance acquaintances online.  He was estranged from one of his two sisters, and only had contact with the other one every few years.  He reported that he had little patience with people and had been married three times, with two of the relationships ending badly.  He had difficulty sustaining and maintaining relationships with other people, including his current wife and children, separating himself from them when at home.  He did not play with his children most days, and slept in a separate room from his wife due to nightmares.  He reported being depressed every day.  He spent most of his time in his room by himself and would not shower for weeks at a time.  He left his home to go to the grocery store and take his children to school, and every other week, took his kids to the park for less than an hour.  The Veteran reported nightmares occurring two to three times per week.  The content was consistently about his experiences in Vietnam.  The Veteran slept with a pistol under his pillow and was constantly looking over his shoulder to see if something was wrong.  He was vigilant about making sure all the doors and windows in his house were locked, and was rarely at ease.
The Board finds that these symptoms more nearly approximate the rating criteria for a 70 percent disability rating, which is assigned for occupational and social impairment, with deficiencies in most areas, including work, school, family relations, judgment, thinking, and mood.  The criteria list symptoms including near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a worklike setting), and inability to establish and maintain effective relationships.  See 38 C.F.R. § 4.130  
The Board finds that these symptoms, and others reported by the Veteran, but not specifically included on the list set out in the rating criteria, reflect a disability picture contemplated by the 70 percent rating criteria under the General Formula.  
While a 70 percent disability rating is warranted for his service-connected PTSD, the criteria for a 100 percent disability rating have not been met at any time over the appeals period.  
A 100 percent disability rating is assigned for total occupational and social impairment.  Id.
In this case, while the Veteran has significant impairment in forming and maintaining relationships, he is not totally impaired in this regard.  He has ongoing relationships with his wife and children, and is able to go to the grocery store and his children’s school.  
In addition, he has not provided evidence that he experiences the level of severity shown by the symptoms listed in the criteria for a 100 percent rating.  These criteria include 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.  The Board finds that the Veteran’s reported symptoms do not reflect his level of severity for his service-connected PTSD.  As such, a 100 percent rating is not warranted throughout the appeal period.  See 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411.  
TDIU
The Veteran contends that his service-connected disabilities render him unable to secure and maintain gainful employment.  The Board agrees.
VA will grant entitlement to TDIU when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from securing and following “substantially gainful employment” consistent with his education and occupational experience.  38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992).
The regulations provide that if there is only one service-connected disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more.  38 C.F.R. § 4.16(a).  In this case, as the Veteran has now been granted a 70 percent disability rating for his service-connected PTSD and is rated as 40 percent disabling for his service-connected left below the knee amputation, he meets the percentage requirements for a TDIU under 38 C.F.R. § 4.16 (a).  As such, the Board may grant TDIU in the instant case, without the need for referral to the Director of Compensation and Pension under 38 C.F.R. § 4.16 (b).
The central inquiry is, “whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability.”  Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993).  The sole fact that the Veteran was unemployed or has difficulty obtaining employment is not enough.  A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran was capable of performing the physical and mental acts required by employment, not whether he can find employment.  See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993).
The Board must evaluate whether there are circumstances in the Veteran's case, apart from any non-service-connected condition and advancing age, which would justify a total rating based on individual unemployability due solely to the service-connected conditions.  See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993); see also Blackburn v. Brown, 5 Vet. App. 375 (1993).  Marginal employment shall not be considered substantially gainful employment.  38 C.F.R. § 4.16(a).
The Board finds that the evidence in the record support a grant of TDIU for the entire appeals period.  Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) (noting that applicable regulations place responsibility for the ultimate TDIU determination on the [adjudicator], not a medical examiner).  The physical and emotional impairment due to the Veteran’s service-connected PTSD, which has been rated as 70 percent disabling herein, and his service-connected left leg below the knee amputation render him unable to obtain and maintain gainful employment consistent with his education and work background.
Here, the evidence provided by the Veteran—his completed VA Form 21-8940 and a May 2016 private Employment Evaluation and affidavit—show that the Veteran had a GED and that his work history was significant for short-term employment.  Among the jobs he had held were Cashier, Insurance Sales Agent, Small Product Assembler, and Assistant Retail Manager.  The Veteran reported that he had not been employed in 17 years.  
His jobs following discharge were of short duration and typically ended with the Veteran being terminated due to either his inability to perform the physical demands of the job or his inability to effectively communicate with others and deal appropriately with staff and customers. 
The provider who conducted the Employment Evaluation opined that, based on the Veteran’s training, education, and work experience, he did not possess skills that readily transferred to occupations within his physical capabilities.  Additionally, any skills he might have acquired as a result of his past work were no longer applicable, as he had not used these skills in 17-plus years.  The provider found that, based on the Veteran’s difficulty in concentrating, interacting with others, angry outbursts, and physical limitations, he was precluded from performing work at any level, including the sedentary level.  She determined that the Veteran would have no transferable skills to sedentary work based on his vocational history and given his extensive medical and psychological symptoms he could not even perform sedentary unskilled work.  The provider noted that in her opinion that it was at least as likely as not that the Veteran’s service-connected disabilities rendered him unable to secure and follow substantially gainful employment at any time over the appeals period was based on medical records, ongoing severity of symptoms, and the Veteran’s description of his symptoms.  
The Board finds that this opinion is probative as the provider reviewed the medical and lay evidence of record and provided a rationale for her opinion.  The Board is in agreement with the findings of this opinion that the Veteran is precluded from employment due to his service-connected disabilities.  As such, TDIU is granted for the entire appeals period.  See 38 C.F.R. §§ 3.102, 4.16.  
REASONS FOR REMAND
Entitlement to service connection for a back disorder is remanded.
The Veteran has contended that he had a current back disability that is related to service, when he landed on his back after stepping on a land mine, or that in the alternative that it is secondary to his service-connected left leg disorder.  
The Veteran has submitted private medical records dated in March 2016, showing that he has been diagnosed with foraminal stenosis and degenerative spondylolisthesis.  The record also reflects that the Veteran has reported back pain since service.  See April 1999 claim.  His representative submitted a statement in June 2016, arguing that the Veteran has been informed that his back disability is due to the altered gait caused by his service-connected left leg disability.  
Based on this evidence, the Board finds that an opinion should be obtained as to whether the Veteran’s current back disability is due to service or to his service-connected left leg disability.  See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006).
Entitlement to service connection for a heart disorder, to include hypertension, is remanded.
It appears that there are outstanding records that may be relevant to the Veteran’s claim.  VA medical records show that he sought a cardiac work-up in April 2003 because he was experiencing shortness of breath when he exercised.  The Veteran was offered an appointment, but indicated that he would be returning to Brazil and would seek cardiac treatment there.  There are no records in the claims file reflecting cardiac treatment.  A remand is required to allow VA to obtain authorization and request these records.
In addition, the record reflects that the Veteran has a current diagnosis of hypertension.  Due to his presence in Vietnam while in the service in July 1968, the Veteran is presumed to have been exposed to herbicides.  
Although current VA regulations do not provide that hypertension is a presumptive disability associated with herbicide exposure, the National Academy of Sciences (NAS), it was recently upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association.  According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure.  See Veterans and Agent Orange: Update 11 (2018), the National Academies of Sciences, Engineering and Medicine (NAS). 
As there is evidence indicating an association between hypertension and herbicide exposure, a VA opinion is needed to determine whether hypertension is causally related to the Veteran's service.  See Id.
Increased rating for left below knee amputation with callosity stump
It appears that there are outstanding medical records that are relevant to the Veteran’s claim.  In the May 2016 Employment Evaluation, the provider noted that the Veteran reported he had been seen by a prosthetist.  These records are not in the claims file, and should be obtained on remand. 
The matters are REMANDED for the following action:
1. Ask the Veteran to complete a VA Form 21-4142 for cardiac treatment and treatment by a prosthetist in Brazil.  Make two requests for the authorized records from providers identified by the Veteran, unless it is clear after the first request that a second request would be futile.
2. Ensure that the Veteran is scheduled for a VA examination in order to determine whether any lumbar spine disorders are related to service or secondary to his left below the knee amputation.  The claims folder must be made available to and be reviewed by the examiner.  All tests deemed necessary should be conducted and the results reported in detail.  
Following examination of the Veteran and review of the claims file, the examiner must opine whether the Veteran’s lumbar spine disorders at least as likely as not (50 percent or greater probability) began in or is otherwise related to his miliary service, to include any back injury due to stepping on a land mine in service.  
Next, if the examiner does not find that the Veteran’s lumbar spine disorders are directly related to military service, the examiner must opine whether his lumbar spine disorders at least as likely as not are (a) caused by; or, (b) aggravated (i.e., chronically worsened) by the Veteran’s service-connected left below the knee amputation, to include any abnormal gait or weightbearing as a result of that disability.  The examiner is reminded that he or she must address both prongs (a) and (b) above.
In addressing the above, the examiner should consider any of the Veteran’s lay statements regarding symptomatology during service and any continuity of symptomatology since discharge and/or since onset.  The examiner should also consider any other pertinent evidence of record, as appropriate.  All findings should be reported in detail and all opinions must be accompanied by a clear rationale.
3. Ensure that the Veteran is scheduled for a VA examination in order to determine whether his heart condition, including hypertension and ischemic heart disease, is due to his military service.  The claims file must be made available to and be reviewed by the examiner in conjunction with the examination.  All tests deemed necessary should be conducted.
After review of the claims file and examination of the Veteran, the examiner should state any and all heart disorders found, to include whether the Veteran has hypertension and/or ischemic heart disease.  
Respecting any hypertension and/or non-ischemic heart disorder found, the examiner should opine as to whether such disorders at least as likely as not (50 percent or greater probability) began in service or within one year of discharge therefrom, or is otherwise the result of military service, to include the Veteran’s presumed herbicide exposure therein.  
Specifically, the examiner should consider any noted blood pressure readings in service, or within one year after discharge therefrom.  The examiner should address whether any readings during service are initial manifestations of the Veteran’s hypertension.  
Regarding the above opinion as to relation to herbicides, the examiner must take as conclusive fact that the Veteran is exposed to herbicides during military service; the examiner is additionally reminded that merely stating that the disease is not on the list of presumed disease related to herbicide exposure is not an adequate rationale for a negative opinion.  Finally, the examiner MUST discuss the new November 2018 NAS study that indicated that hypertension had switched to the “sufficient” category, and what, if any, effect such study has on the examiner’s rationale.
In addressing the above, the examiner should address any of the Veteran’s lay statements regarding symptomatology during service and any continuity of symptomatology since discharge and/or since onset.  The examiner should also consider any other pertinent evidence of record, as appropriate.  All findings should be reported in detail and all opinions must be accompanied by a clear rationale.
 
MARTIN B. PETERS
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	M. Harrigan Smith 

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