Citation Nr: 0810684 Decision Date: 04/01/08 Archive Date: 04/14/08 DOCKET NO. 06-01 547 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to an initial rating in excess of 20 percent for residuals of removal of a pituitary tumor. REPRESENTATION Appellant represented by: None ATTORNEY FOR THE BOARD Heather M. Gogola, Associate Counsel INTRODUCTION The veteran served on active duty from March 1982 to March 1986. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND By a rating decision dated January 2005, the RO granted service connection for residuals of the removal of a pituitary tumor, and assigned a rating of 20 percent, effective May 7, 2004. The veteran asserted he was warranted a higher rating. The Board notes that the veteran was rated at 20 percent for residuals of the removal of a pituitary tumor by analogy under 38 C.F.R. § 4.120, Diagnostic Code 7911 for Addison's disease (adrenal cortical hypofunction). Review of the veteran's medical records show that the veteran has continuously received medications as well as testosterone injections to control his resulting hypopituitarism and hypothyroidism. Additionally, a June 2004 treatment report noted hypothyroidism treated with medication and testosterone supplements, as well as noted complaints of "attacks" characterized as chest/stomach pain with associated palpitations and breathlessness. A February 2006 VA treatment report indicated complaints of episodes of pain in his chest, as well as lightheadedness and occasional falls. A November 2006 VA treatment report noted complaints of dizziness when standing too fast, poor energy, and no weight loss. The Board notes that the veteran was afforded VA examinations in November 2005, October 2006, and November 2006. The November 2005 VA examination noted complaints that the veteran felt overall weaker and the examiner noted some reduction in grip strength on the right side, as well as noted that the veteran was normotensive but with some temperature intolerance. The examiner provided a diagnosis of previous prolactin secreting adenoma that was resected in 1987 that required the supplementation of testosterone as well as thyroid but was clinically stable. The examiner noted that the veteran was already compensated for hypothyroidism, so did not further evaluate the veteran. The October 2006 VA examination thoroughly reviewed the veteran's complaints of pain associated with his diagnosis of fibromyalgia, but did not adequately discuss the veteran's residuals of removal of a pituitary tumor. The examiner only noted a diagnosis of hypotituitarism and hypothyroidism on levothyroxine and testosterone injections. The examiner at the November 2006 VA examination noted that he was asked to evaluate numerous other claimed disorders to determine if they were related to the veteran's residuals of pituitary tumor removal, and stated that the veteran should have been provided a brain and spinal cord examination. The examiner noted a diagnosis of status post transsphenoidal hypophysectomy, status post excision and radiation treatment or prolactin producing pituitary adenoma, no current endocrinopathy. Unfortunately, the VA examinations are sufficient for rating purposes, as they do not address the criteria set forth in 38 C.F.R. § 4.120, Diagnostic Code 7911, under which the veteran is rated. The VA examinations did not discuss whether the veteran experienced "episodes," if any, consisting of anorexia, nausea, vomiting, diarrhea, dehydration, weakness, malaise, orthostatic hypotension, or hypoglycemia and, if so, how many such episodes. They also did not address the number of "crises," if any, consisting of rapid onset of peripheral vascular collapse, with findings that may include anorexia, nausea, vomiting, dehydration, profound weakness, pain in the abdomen, legs, and back, fever, apathy, or depressed mentation. Additionally, while the veteran has hypopituitarism, the examinations also did not address which symptoms may or may not be attributable to the removal of his pituitary tumor. The examinations did not address if the veteran had any of the following symptoms that were attributable to the veteran's residuals of removal of a pituitary tumor; fatigability, mental sluggishness, constipation, muscular weakness, mental disturbance, weight gain, cardiovascular involvement, dementia, or sleepiness. Therefore, the veteran should undergo an additional VA examination in order to better assess the severity, symptomatology, and manifestations of his residuals of the removal of a pituitary tumor. In addition, the RO should obtain and associate with the claims folder all current VA outpatient treatment records dated from November 2006 to the present. 38 U.S.C.A. § 5103A(d)(1); 38 C.F.R. § 3.159(c)(4). Additionally, the veteran's statements indicate that his symptomatology may have worsened since his last VA examination in November 2006. Whether an examination is sufficiently contemporaneous to properly rate the current severity of the veteran's disability depends on the particular circumstances of the individual case. Snuffer v. Gober, 10 Vet. App. 400 (1997). In the instant case, in October 2007, the veteran submitted a statement indicated that he vomited 19 times in one month, has nausea after eating and he "cannot hold water" so is always thirsty. He also stated that he falls asleep a lot and that he felt his heart beat funny. Therefore, the veteran should undergo additional VA examinations of his residuals of removal of a pituitary tumor in order to accurately assess the severity, symptomatology, and manifestations of his disability. 38 U.S.C.A. § 5103A(d)(1); 38 C.F.R. § 3.159(c)(4). Accordingly, the case is REMANDED for the following action: 1. The should obtain and associate with the claims folder all current VA outpatient treatment records dated from November 2006 to the present. 2. The veteran should be scheduled for the appropriate VA examination(s) to ascertain the severity and manifestations of his residuals of the removal of a pituitary tumor, in accordance with the applicable rating criteria. The claims files must be made available to and reviewed by the examiner prior to the examination. The examiner is to conduct all necessary testing and evaluation needed to evaluate the nature and extent of this disorder. The examiner should review the results of any testing prior to completion of the report and should detail the veteran's complaints and clinical findings, clinically correlating his complaints and findings to the disorder. A complete rationale must be provided for any opinion offered. In the report the examiner must specifically address the following: a) whether the veteran experiences episodes as a result of his disability, and if so, how many in the past year. An "episode" is defined as a less acute and less severe event than a crisis and may consist of anorexia, nausea, vomiting, diarrhea, dehydration, weakness, malaise, orthostatic hypotension, or hypoglycemia, but no peripheral vascular disease. b) whether the veteran experiences crises as a result of his disability, and if so, how many in the past year. A "crisis" is defined as a rapid onset of peripheral vascular collapse (with acute hypotension and shock), with findings that may include: anorexia; nausea; vomiting; dehydration; profound weakness; pain in the abdomen, legs, and back; fever; apathy, and depressed mentation with possible progression to coma, renal shutdown, and death. c) whether the veteran has symptoms including fatigability, mental sluggishness, constipation, muscular weakness, mental disturbance, weight gain, cardiovascular involvement, dementia, or sleepiness that are related to his residuals of the removal of a pituitary tumor. 3. After the development requested has been completed, the RO should review the examination report to ensure that it is in complete compliance with the directives of this REMAND. If the report is deficient in any manner, the RO must implement corrective procedures at once. 4. The veteran is hereby notified that it is his responsibility to report for the examination and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2007). In the event that the veteran does not report for the scheduled examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 5. After the foregoing, the RO should review the veteran's claims. If the determination is adverse to the veteran, he and his representative should be provided an appropriate supplemental statement of the case and given an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or 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 Supp. 2007). _________________________________________________ K. J. ALIBRANDO Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2007).