Citation Nr: 1630122 Decision Date: 07/28/16 Archive Date: 08/04/16 DOCKET NO. 09-43 342 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, claimed as bipolar disorder. 2. Entitlement to service connection for diabetes mellitus. 3. Entitlement to service connection for erectile dysfunction. 4. Entitlement to service connection for sleep apnea. 5. Entitlement to service connection for gastroenteritis. 6. Entitlement to an initial disability evaluation in excess of 20 percent for a seizure disorder. 7. Entitlement to an initial disability evaluation in excess of 10 percent for paroxysmal auricular fibrillation with mitral valve prolapse. 8. Entitlement to initial compensable disability evaluation for osteoarthritis of the right thumb, status post fracture, prior to June 4, 2014, and a disability evaluation in excess of 10 percent for osteoarthritis of the right thumb, status post fracture, since June 4, 2014. 9. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. G. Mazzucchelli, Counsel INTRODUCTION The Veteran served on active duty from December 1973 to September 1983. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, and January 2008, June 2009, and October 2009 rating decisions of the RO in Houston, Texas. With respect to the psychiatric claim on appeal, the Veteran initially submitted a claim for entitlement to service connection for bipolar disorder. Evidence associated with the claims file includes diagnoses of mood disorder secondary to medical condition as well as bipolar disorder. While the Veteran's claim did not enumerate all his psychiatric diagnoses of record, a claim "cannot be a claim limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed." Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In essence, a veteran does not file a claim to receive benefits for a particular psychiatric diagnosis that is named on a claims form, but instead makes a general claim for compensation for the difficulties posed by the mental condition. Id. Accordingly, the Board has reframed this issue on appeal, as shown on the title page. There is evidence of record that the Veteran's service-connected disabilities may prevent him from being able to work. The United States Court of Appeals for Veterans Claims (Court) has held that a claim for TDIU is part of an initial rating claim when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 477 (2009). In light of Rice, the issue of entitlement to TDIU has been raised by the record and is within the jurisdiction of the Board. The issues of entitlement to service connection for diabetes mellitus, erectile dysfunction, sleep apnea, and gastroenteritis, entitlement to TDIU, and entitlement to extraschedular ratings for seizure disorder, paroxysmal auricular fibrillation, and osteoarthritis of the right thumb are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A mood disorder has been medically associated with the Veteran's service connected seizure disorder. 2. During the appeals period, there was not evidence of at least one major seizure in a six month period; two major seizures in one year; or at least any average of five weekly minor seizures. 3. During the appeals period, the Veteran's paroxysmal auricular fibrillation with mitral valve prolapse has not been manifested by more than four episodes per year documented by electrocardiogram or Holter monitor; beginning May 16, 2009, the metoprolol taken for this condition resulted in sufficient fatigue and shortness of breath to limit his ability to do more than 3-5 METS of activity. 4. For the initial rating period prior to June 4, 2014, the right thumb disability manifested in right thumb arthritis with painful, noncompensable limitation of motion. 5. For the initial rating period since June 4, 2014, the right thumb disability did not manifest in unfavorable ankylosis of the right thumb, or limitation of right thumb motion with a gap of more than two inches between the thumb and fingers, with the thumb attempting to oppose the fingers. CONCLUSION OF LAW 1. The criteria for service connection for a mood disorder, as secondary to service-connected seizure disorder, have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). 2. The criteria for an initial schedular evaluation in excess of 20 percent for seizure disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.400, Part 4, including §§ 4.7, 4.124a, Diagnostic Code 8911 (2015). 3. The criteria for an initial schedular evaluation in excess of 10 percent for paroxysmal auricular fibrillation with mitral valve prolapse prior to May 16, 2009 have not been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.104, Diagnostic Code 7010 (2014). 4. The criteria for an initial schedular evaluation of 30 percent for paroxysmal auricular fibrillation with mitral valve prolapse from May 16, 2009 have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.104, Diagnostic Code 7011 (2014). 5. The criteria for a an initial 10 percent schedular disability evaluation for osteoarthritis of the right thumb, status post fracture, prior to June 4, 2014, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5228 (2015). 6. The criteria for a schedular disability evaluation in excess of 10 percent for osteoarthritis of the right thumb, status post fracture, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5228 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The disability evaluation issues arise from the Veteran's disagreement with the initial disability ratings assigned following the grant of service connection. As entitlement was granted, the claims were substantiated. Additional notice is not required since VA already has given VCAA notice regarding the original claims, and any defect in the notice is not prejudicial and will not be discussed. The Veteran's service treatment records, VA medical records, and relevant private treatment records have been obtained. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claim file. Records were also obtained from the Social Security Administration. The Veteran was provided with VA examinations in December 2006, May 2009, and June 2014. These examinations, in combination with the other evidence of record including the outpatient records and the Veteran's own statements, are sufficient to decide the ratings claims. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. II. Service Connection- Psychiatric Disorder Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2015). "To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be established on a secondary basis for disability shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2015). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by a service-connected disability or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran is service connected for, inter alia, a seizure disorder, currently rated as 20 percent disabling. The record shows that the seizure disorder was present in service. The Veteran contends that he has a psychiatric disorder that is related to his service connected seizure disorder. The Veteran's service treatment records do not show treatment for a psychiatric disorder. In November 1994 the Veteran was hospitalized with a diagnosis of bipolar disorder. A December 2006 VA examination diagnosed bipolar disorder. The examiner opined that it was less likely as not that the Veteran's bipolar disorder was related to his epilepsy. A physician who served with the Veteran in the 1970s provided a statement dated in September 2007 in which he noted that in retrospect the Veteran exhibited behaviors during service that "may have been part of bipolar disorder." In an October 2007 statement, G.L.P., a psychiatrist who had treated the Veteran since 1998, noted that the Veteran's bipolar disorder may have been related to inservice head injuries and "qualifies for consideration of being service connected." VA treatment records dated from April 2009 to September 2009 note a diagnosis of mood disorder secondary to a medical condition, seizure disorder. A January 2010 VA psychology note stated that "I reaffirmed the general opinion of his providers that his mood disorder is secondary to or due to his medical condition, namely his seizure disorder and it is also possible that some of his personality-like traits are also due to either his seizure disorder directly or his mood disorder." While there is conflicting medical evidence in the file that weighs both for and against the Veteran's claim of service connection for a psychiatric disorder, the Board finds that there is competent evidence to support the claim that the Veteran has a mood disorder that is medically related to the service-connected seizure disorder. VA treatment records support this claim. Resolving reasonable doubt in favor of the Veteran, there is a basis of entitlement to service connection for a mood disorder on a secondary basis under 38 C.F.R. § 3.310. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. III. Initial Ratings Disability evaluations are determined by comparing a veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2015). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher of the two evaluations 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 (2015). The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1 (2015); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board must also fully consider the lay assertions of record. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Also, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Seizure Disorder The Veteran contends that his service connected seizure disorder warrants a rating higher than the 20 percent initially assigned in the April 2007 rating decision on appeal. Under 38 C.F.R. § 4.124a, Diagnostic Code 8911, epilepsy, petit mal, is to be evaluated under the general formula for minor seizures. A major seizure is characterized by the generalized tonic-clonic convulsion with unconsciousness. [Note 1]. A minor seizure consists of a brief interruption in consciousness or conscious control associated with staring or rhythmic blinking of the eyes or nodding of the head ("pure" petit mal), or sudden jerking movements of the arms, trunk, or head (myoclonic type) or sudden loss of postural control (akinetic type). [Note 2]. Under the general formula for minor seizures, a 20 percent evaluation is warranted for: At least one major seizure in the last two years; or at least two minor seizures in the last six months. Id. A 40 percent evaluation is warranted for: At least one major seizure in the last six months or two in the last year; or averaging at least five to eight minor seizures weekly. Id. A 60 percent evaluation is warranted when there is an average of one major seizure in four months over the last year; or nine to ten minor seizures per week. An 80 percent rating is assigned when there has been at least one major seizure in three months over the last year, or more than ten minor seizures weekly. A 100 percent rating is warranted when there has been an average one major seizure per month over the last year. Diagnostic Code 8914 addresses psychomotor epilepsy. 38 C.F.R. § 4.124a. Under Diagnostic Code 8914, psychomotor epilepsy is to be rated based on major or minor seizures under the General Rating Formula for Major and Minor Epileptic Seizures. Psychomotor seizures will be rated as "major seizures" when characterized by automatic states and/or generalized convulsions with unconsciousness. Psychomotor seizures will be rated as "minor seizures" when characterized by brief transient episodes of random motor movements, hallucinations, perceptual illusions, abnormalities of thinking, memory or mood, or autonomic disturbances. See 38 C.F.R. § 4.124a , Diagnostic Code 8914. The Veteran was treated in a private emergency room following a petit mal seizure in February 2005. An EEG at that time showed mild to moderate global encephalopathy and non-specific focal dysfunction. "The absence of interictal epileptiform discharges does not rule out an underlying tendency for unprovoked seizures (epilepsy)." On VA examination in December 2006, the Veteran reported that after having a seizure in service that over the years he had experienced "10 to 12 grand mal seizures and about 30 partial-type seizures. Dilantin was stopped about 8 years ago and he presently is on Trileptal 1800 mg a day." A July 2007 VA neurology consultation noted that the Veteran had "experienced about four scintillating scotoma spells, and one secondarily generalized seizure in the last 12 months. The scotomas last about 2-10 minutes." The assessment was "most likely partial seizure disorder." Treatment notes in September 2007, December 2007, January 2008, and March 2008 note no recent seizure activity. In June 2008, the Veteran reported having had no recent grand mal seizures, but that he had been "zoning out" three to four times per day. In September 2008 the Veteran reported having had a major seizure. In October 2008 the Veteran underwent video monitoring EEG. At that time the Veteran reported having had four to five grand mal seizures since the age of 30 (he was currently 57 years old). The Veteran also reported that he had experienced "two of these 'grand mal seizures' in the past three months with last one occurring 1.5 months ago as well as a new onset of spells consisting of a blank stare, unresponsiveness and loss of train of thought during conversations witnessed by his fiancée. These spells occurred once, every couple of days when they first began three months ago 'but are now occurring 3-4x/day lasting 15 sec-1 min. with no aura or postictal confusion." The report of the video EEG monitoring noted that: "The frequent staring spells [the Veteran] describes were not recorded during this evaluation, despite discontinuation of his antiepileptic medications. These episodes may actually be behavioral and not epileptic. We were not able to confirm his diagnosis of focal epilepsy. An interictal SPECT was reported as showing left-sided hypoperfusion, but I was not convinced of this finding on my review. We discharged him on Lamictal and Strattera. However, I am not convinced that he is suffering from active localization-related epilepsy at this time, except for possible visual auras." A progress note dated in October 2008 noted the Veteran had been doing well until three weeks earlier when he had a "grand mal" seizure. Then one week later he had "experienced stroke like symptoms of diplopia, ataxia and slurred speech and was evaluated and treated here for a possible stroke. His CT scan was negative as was his lab values and his AED levels were in the normal range... Since the seizure, pt. states he has been suffering episodic spells of right eye diplopia (superior/inferior orientation) followed by a feeling of mild ataxia." A VA neurology consultation in April 2010 reported that the Veteran "was brought to the ER after episode of seizure activity during an elective Hida scan. Per pt, he was sitting on the table when he lost consciousness, had urinary incontinence, then woke up w/ postictal confusion. Pt felt dizziness before the episode but did not feel usual aura (which consists of visual scotomas/lights/flashes)." A June 2011 progress note reported that the Veteran "currently has 10 staring episodes a week with loss of time. He also has about 4-5 generalized seizures a year, last one being in December." A VA examination was conducted in June 2014. The Veteran reported one episode of urinary incontinence associated with the seizure at VA in April 2010. He also reported that around 2004 he started having a different type of episode manifested by "freezing," usually while "having a conversation." During this time he will "completely zone out of a conversation and the person I'm speaking with will have to bring me back." The symptoms also can happen while watching television, during which time he may miss "five or ten seconds, not terribly long" of the television episode. He also may forget what he reads when he is reading a book. If he were standing he does not fall or injure himself. When asked if he will also continue to walk when having an episode, he states "I don't know if that's ever happened while walking." The Veteran did not consider the episodes to be "crippling" but "more of a nuisance than anything else." The interval between attacks has been as long as four or five days. He states that the greatest number of episodes in a single day is "three or four, maybe." The examiner noted that continuous medication was required for control of the Veteran's seizure activity. The examiner indicated that the Veteran had never had minor or major seizures, but had had minor psychomotor seizures (characterized by brief transient episodes of random motor movements, hallucinations, perceptual illusions, abnormalities of thinking, memory or mood, or autonomic disturbances) nine to 10 times per week over the past six months. The examiner further noted that the Veteran had had major psychomotor seizures (characterized by automatic states and/or generalized convulsions with unconsciousness) at least once in the past six months. The examiner stated that it is "clear that [the Veteran] has had seizures preceded by aura, resulting in convulsive activity... His abnormal EEG is consistent with this history. He also has poorly characterized episodes which, so far, have no electrophysiologic correlate. It is these episodes that occur most frequently and have been most refractory to treatment." The VA examiner noted that: These poorly characterized episodes do not begin in the same way as the seizure episode that occurred during service. So far, they have not responded to medications. On 14 August 2012, repeat Video EEG monitoring was entertained, with the note "Further monitoring with video EEG when available." Follow up notes recorded after this one also indicate that repeat EEG monitoring is planned. The Veteran reports that he is unaware of this plan. We still have no results, nearly two years later. The number of seizures reported above are based on his historical accounts of intermittent "balance issues and double vision." He also reports "zoning out" twice per week. He considers these symptoms to be seizure activity... To reiterate, it is not clear that all (or even most) of the symptoms described are actual epileptic events. Without capturing these events with video EEG monitoring, quantifying the actual number of epileptic events is impossible without resorting to mere speculation. The Board notes that the record demonstrates that the Veteran suffered a major seizure in April 2010, and he reported having suffered another such seizure in September 2008. Additionally, while the Veteran has reported suffering frequent minor seizures (as many as 9 or 10 per week) during the appeals period, the medical evidence does not support a finding that these episodes constitute seizure activity. The October 2008 EEG video monitoring did not confirm that the episodes described by the Veteran were epileptic in nature. Further, the June 2014 VA examiner, after extensive review of the record, similarly found that in the absence of video EEG evidence of these events that it was not clear that they represented seizure activity. The Board has declined to remand the case to order additional video EEG monitoring as the record contains the October 2008 findings of such monitoring that was conducted pursuant to the same reported symptoms by the Veteran. Thus, there is no indication that further such testing would provide a different result. The Board finds the June 2014 VA examiner's opinion to be of significant probative value. The examiner reviewed the Veteran's entire claims file and specifically addressed the Veteran's lay statements in detail in his report. The examiner's opinion included rationale corroborated by the evidence of record. For these reasons, the Board places great weight on the June 2014 opinion. With respect to the June 2014 examiner's characterization of the frequency of the Veteran's seizure activity, the Board notes that while he noted the frequency of major psychomotor seizure as one in the last six months and minor psychomotor seizures as nine to 10 times per week over the past six months, that the examiner specified that these numbers were based on the Veteran's "historical accounts of intermittent 'balance issues and double vision,'" and that the examiner was not able to confirm that "all (or even most)" of the symptoms described by the Veteran were actual epileptic events. The Board finds the Veteran's own reports of symptomatology to be credible. In term of competency, the Board does not find that the Veteran is competent to determine if his reported symptoms are seizures. Although the Board recognizes that a lay person may competently report subjective feelings, the Board looks to the medical evidence of record to determine the severity of his epilepsy disorder. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (noting that the Board, as fact finder, is responsible for assessing the credibility, competence, and probative value of evidence); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining that the situations where "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition," including diagnosing a medically "simple" condition such as a broken leg as opposed to a medically complex condition such as cancer). Complex medical questions not completely understood by the medical profession itself are not within the realm of common lay knowledge. See Mattke v. Deschamps, 374 F.3d 667, 670 (8th Cir. 2004) (citing Warrick v. Giron, 290 N.W.2d 166, 169 (Minn. 1980)). In the absence of medically documented seizure activity demonstrating at least one major seizure in the last six months or two in the last year; or averaging at least five to eight minor seizures weekly, that a higher, 40 percent rating, is not warranted. Heart Disability The Veteran contends that his service-connected paroxysmal auricular fibrillation with mitral valve prolapse is more severe than the current 10 percent evaluation would indicate. The Veteran's paroxysmal auricular fibrillation with mitral valve prolapse has been rated as 10 percent disabling under Diagnostic Code 7010. Pursuant to that code, a 10 percent rating is assigned for supraventricular arrhythmias manifested by permanent atrial fibrillation (lone atrial fibrillation), or one to four episodes/year of paroxysmal atrial fibrillation, or other supraventricular tachycardia documented by electrocardiogram or Holter monitor. A 30 percent rating (the maximum under this diagnostic code) is assigned for paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than 4 episodes/year documented by electrocardiogram or Holter monitor. 38 C.F.R. § 4.104, Diagnostic Code 7010. The Board notes that an evaluation in excess of 30 percent is not available under Diagnostic Code 7010. In May 2009 a VA cardiology consultation was conducted for complaints of palpitations. Echocardiogram revealed normal a size heart, left ventricle systolic function normal, and estimated ejection fraction 60 to 65%. There was no aortic stenosis, and no aortic regurgitation. The mitral valve appeared normal with no prolapse noted. There was no mitral regurgitation or stenosis. Results from a Holter monitor in July 2009 revealed no episodes of atrial fibrillation. The studies were normal for any signs of atrial fibrillation and structural heart disease. A May 16, 2009 treatment record noted that the Veteran's atenolol should be changed to metoprolol. On a June 2014 VA examination, the Veteran reported that while in his twenties he noted sudden onset of palpitations and was seen in ER and found to have atrial fibrillation. He reported that he was started on atenolol initially and later was switched to metoprolol. The Veteran denied chest pain or shortness of breath. He stated that several times a year he will have a brief episode of palpitations; these have not lasted long enough to be evaluated. The Veteran reported that he is currently taking metoprolol 50mg twice daily and aspirin 325 mg daily. The examiner stated that the Veteran had not had a myocardial infarction or congestive heart failure. The examiner noted one to four episodes of atrial fibrillation in the past 12 months based on the Veteran's report. There was no heart valve condition and the Veteran had not been hospitalized. On examination, heart rate was 64 and rhythm regular. Heart sounds were normal. There was no peripheral edema. Blood pressure was 124/76. There was no evidence of cardiac hypertrophy or cardiac dilatation. Chest X-ray in June 2011 and EKG in February 2014 were noted as normal. The examiner noted that interview-based METS testing indicated dyspnea and fatigue with greater than 3 to 5 METS. The examiner noted that the "limitation of his METS is due to the metoprolol that he takes for his paroxysmal atrial fibrillation; he has no underlying cardiac or pulmonary disease. He has no evidence of coronary artery disease (states he has had chemical stress tests in the past that are normal; he is unable to get his heart rate up with walking due to the metoprolol). The metoprolol causes sufficient fatigue and shortness of breath to limit his ability to do more than 3-5 METS of activity." Applying the relevant rating criteria, the Board notes that an evaluation in excess of 10 percent for the Veteran's paroxysmal auricular fibrillation with mitral valve prolapse is not warranted under Diagnostic Code 7010. The evidence of record does not show that the Veteran has experienced paroxysmal atrial fibrillation or other supraventricular tachycardia with more than four episodes per year documented by electrocardiogram or Holter monitor. The Board notes that the Veteran has stated that he experiences episodes several times per year. There is, however, no evidence to demonstrate that the Veteran's "episodes" amounted to episodes of paroxysmal atrial fibrillation or other supraventricular tachycardia that have been documented as required under Diagnostic Code 7010. The Board has also considered whether the Veteran's arrhythmias warrant a rating higher than 10 percent under Diagnostic Code 7011. Under Diagnostic Code 7011, a 30 percent rating is warranted where a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on EKG, ECG, or x-ray. The June 2014 VA examiner noted that the Veteran's metoprolol taken to control his paroxysmal auricular fibrillation causes sufficient fatigue and shortness of breath to limit his ability to do more than 3-5 METS of activity. The Board finds that a 30 percent rating is warranted from May 16, 2009, the date the medication was changed to metoprolol. Right Thumb The Veteran contends that his service connected right thumb fracture residuals warrant higher initial ratings. The June 2009 rating decision on appeal granted service connection for osteoarthritis of the right thumb, status post fracture, assigning an initial noncompensable rating from September 2008. The Veteran disagreed with the initial evaluation. A July 2014 rating decision increased the evaluation to 10 percent from June 4, 2014. The Veteran's right thumb disability is rated pursuant to the criteria under 38 C.F.R. § 4.71a, Diagnostic Code 5228. Under DC 5228, which states the rating criteria for disabilities due to loss of motion of the thumb, a 10 percent disability rating is warranted where loss of thumb motion results in a gap of one to two inches (2.5 to 5.1 centimeters) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. A maximum schedular 20 percent disability rating is assigned for loss of thumb motion that causes a gap of more than two inches (5.1 centimeters) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. Ratings under DC 5228 are the same, regardless of whether the disability in question involves the thumb on the major (dominant) or minor hand. Id. On VA examination in May 2009, the examiner noted an overall decrease in hand strength and hand dexterity. There was pain, limited motion, weakness, and stiffness noted in the right thumb. On examination, active range of right thumb motion showed a gap of less than one inch between the right thumb pad and the fingers. There was objective evidence of pain. There was no objective evidence of pain following repetitive motion with right thumb, and no additional (or new) limitation of motion. There was no ankylosis of one or more digits. There was weakness and loss of dexterity of the right thumb; jar opening and bowling were noted to be very difficult. On VA examination conducted June 4, 2014 the Veteran reported that he has residual limited range of motion and some decrease strength as a result of the right thumb disability. On examination, there was a gap of one to two inches between the thumb pad and fingers with no evidence of painful motion. The same gap was noted after repetitive testing. The right thumb did not exhibit increased pain, weakness, fatigability or incoordination with repetitive testing. There were no reported flare-ups of this condition. There was no gap between any fingertips and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips. There was functional loss of the right thumb in the form of less movement that normal, weakened movement, and incoordination. Hand grip strength was 4/5 for the right hand and 5/5 for the left. There was no ankylosis of the right thumb. X-rays of the right thumb showed joint space loss of the interphalangeal and first MCP joint with minimal subchondral sclerosis. The Veteran reported that he had difficulty grasping tools such as hammers and wrenches; he had difficulty taking lids off of jars; and he had difficulty writing with a pencil. He was able to use a keyboard. The currently assigned 10 percent rating for the Veteran's right thumb disability is based upon the showing of a gap of one to two inches between the thumb pad and fingers on the June 2014 VA examination. The 10 percent rating is proper based upon such findings. The Board finds that the weight of the evidence is against assignment of an initial disability rating in excess of 10 percent for the right thumb disability for the period from June 4, 2014 because the right thumb symptomatology and impairment does not more nearly approximate limitation of thumb motion, with a gap of more than two inches between the right and thumb and fingers with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5228. The June 2014 examination described a gap of one to two inches between the thumb pad and fingers with no evidence of painful motion. The same gap was noted after repetitive testing, and the right thumb did not exhibit increased pain, weakness, fatigability or incoordination with repetitive testing. The Board has considered the potential application of the other provisions of 38 C.F.R., Parts 3 and 4. Schafrath, 1 Vet. App. 589. In doing so, the Board notes that other criteria for rating thumb disabilities are available under Diagnostic Code 5224. This criteria, however, contemplates disabilities due to ankylosis of the thumb. Ankylosis has been defined as, "immobility and consolidation of a joint due to disease, injury, or surgical procedure." See Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 69 (4th ed. 1997)). As discussed above, the evidence shows that there is no ankylosis in the Veteran's right thumb. As such, Diagnostic Code 5224 is not applicable here. Still other potentially applicable rating criteria are available under DC 5010, which pertains to traumatic arthritis that has been substantiated by x-ray findings. To the extent that the evidence discussed above does indeed show radiological findings of traumatic arthritis in the Veteran's right thumb, Diagnostic Code 5010 may be applied in rating the Veteran's right thumb disability. The Board notes, however, that the criteria under Diagnostic Code 5010 instruct that such disabilities are rated as degenerative arthritis. In turn, Diagnostic Code 5003, which states the criteria for rating degenerative arthritis disabilities, provides that, disabilities rated under that code are rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (in this case, DC 5228). Where, however, the limitation of motion of the specific joint or joints involved is non-compensable under the appropriate rating code, a rating of 10 percent is warranted for each such major joint or group of minor joints affected by the limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Additionally, DC 5003 provides that, even in the absence of limitation of motion, a 10 percent disability rating is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups. A 20 percent disability rating is assigned where there is x-ray evidence of involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. These ratings will not be combined with any ratings that are assigned on the basis of limited motion. Disabilities of the musculoskeletal system, such as the Veteran's right thumb disability, are defined primarily by the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the evidence on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. The Board finds that, for the initial rating period prior to June 4, 2014, the evidence in the form of the May 2009 VA examination demonstrates painful motion of the right thumb that results in noncompensable limitation of motion so as to warrant a 10 percent rating under Diagnostic Code 5003. The provisions of 38 C.F.R. § 4.59 establish that a veteran is entitled to a minimum compensable (10 percent) rating for such arthritis-like pain that limits motion to a noncompensable degree. See 38 C.F.R. § 4.71a, DC 5003; DeLuca; Burton v. Shinseki, 25 Vet. App. 1 (2011). During the May 2009 VA examination, the examiner noted pain, limited motion, weakness, and stiffness in the right thumb. Based on the foregoing, although the limitation of right thumb motion does not more nearly approximate one to two inches between the thumb and fingers so as to warrant a compensable rating under DC 5228, the Board finds that the criteria for a higher initial disability rating of 10 percent have been met for the initial rating period prior to June 4, 2014 under Diagnostic Code 5003. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7, 4.59, 4.71a, Diagnostic Code 5003. ORDER Service connection for a mood disorder is granted. An initial disability evaluation in excess of 20 percent for a seizure disorder is denied. An initial disability evaluation in excess of 10 percent for paroxysmal auricular fibrillation with mitral valve prolapse for the period prior to May 16, 2009, is denied. A 30 percent schedular rating for paroxysmal auricular fibrillation with mitral valve prolapse from May 16, 2009, is granted. An initial 10 percent schedular disability evaluation for osteoarthritis of the right thumb, status post fracture, prior to June 4, 2014, is granted. An initial disability evaluation in excess of 10 percent for osteoarthritis of the right thumb, status post fracture, is denied. REMAND As the Board has granted service connection for a mood disorder, the remaining claims for service connection must be remanded for further development as the Veteran has claimed in part that each is secondary to his psychiatric condition. As the Veteran has not been afforded VA examinations to address the etiology of his diabetes mellitus, erectile dysfunction, sleep apnea, and gastroenteritis, and there is insufficient medical evidence for VA to make a decision on these claims, an examination must be scheduled. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran has not been provided notice of the information or evidence needed to establish TDIU, nor has he been provided a VA Form 21-8940, Application for Increased Compensation Based on Unemployability. As entitlement to a TDIU has not been adjudicated by the AOJ in the first instance, this matter is remanded for such consideration. Any development of the TDIU issue may have an impact on the complete picture of the Veteran's service-connected seizure disorder, paroxysmal auricular fibrillation, and right thumb disabilities, and their effect on his employability as it pertains to extraschedular consideration. See Brambley v. Principi, 17 Vet. App. 20, 24 (2003). Thus, the issues of entitlement to extraschedular ratings will also be remanded. Accordingly, the case is REMANDED for the following action: 1. Schedule the appellant for a VA examination in order to ascertain the nature and etiology of his claimed diabetes mellitus, erectile dysfunction, sleep apnea, and gastroenteritis, and the relationship, if any, of each to his period of service or his service-connected disabilities, to include mood disorder. Following a review of the electronic claim file and the clinical evaluation, the examiner is to address the following questions: (a) Is it at least as likely as not (a 50 percent or greater probability) that any currently diagnosed diabetes mellitus, erectile dysfunction, sleep apnea, and gastroenteritis had its onset during or is otherwise related to the Veteran's period of active service? (b) Is it at least as likely as not (a 50 percent or greater probability) that any currently diagnosed diabetes mellitus, erectile dysfunction, sleep apnea, and gastroenteritis was caused by the appellant's service-connected mood disorder, seizure disorder, or paroxysmal auricular fibrillation with mitral valve prolapse? (c) Is it at least as likely as not that the appellant's service-connected mood disorder, seizure disorder, or paroxysmal auricular fibrillation with mitral valve prolapse aggravates any currently diagnosed diabetes mellitus, erectile dysfunction, sleep apnea, or gastroenteritis? The examiner is informed that aggravation is defined for legal purposes as a chronic worsening of the underlying condition, versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of disability present (i.e., a baseline) before the onset of the aggravation. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 2. Then, re-adjudicate the claims remaining on appeal. If any benefit sought is not granted, issue a supplemental statement of the case (SSOC) and return the case to the Board for further review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs