Citation Nr: 0814164 Decision Date: 04/30/08 Archive Date: 05/08/08 DOCKET NO. 04-39 547 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to service connection for traumatic arthritis of the right hand, to include as secondary to service- connected shell fragment wounds. 2. Entitlement to service connection for traumatic arthritis of the right shoulder, to include as secondary to service- connected shell fragment wounds. 3. Entitlement to service connection for traumatic arthritis of the right hip, to include as secondary to service- connected shell fragment wounds. 4. Entitlement to service connection for traumatic arthritis of the right foot, to include as secondary to service- connected shell fragment wounds. 5. Entitlement to an initial evaluation in excess of 30 percent for post-traumatic stress disorder (PTSD) prior to July 3, 2005, and in excess of 70 percent from July 3, 2005, forward. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Nadine W. Benjamin, Counsel INTRODUCTION The veteran (appellant) served on active duty from February 1970 to February 1972. This matter comes to the Board of Veterans' Appeals (Board) on appeal from May 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The issues regarding entitlement to service connection for traumatic arthritis of the right hip, to include as secondary to service-connected shell fragment wounds, and entitlement to service connection for traumatic arthritis of the right foot, to include as secondary to service-connected shell fragment wounds are being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. FINDINGS OF FACT 1. The veteran's arthritis of the right hand, and right shoulder did not have their onset during active service and are not related to any in-service disease or injury or to his service-connected shell fragment wounds. 2. Prior to July 3, 2005, the veteran's PTSD does not result in occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation; and difficulty in establishing and maintaining effective work and social relationships. 3. From July 3, 2005, the veteran's PTSD does not cause total social and occupational impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place, memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2007). CONCLUSIONS OF LAW 1. Arthritis of the right hand was not incurred in or aggravated by service, may not be presumed to have been so incurred, and is not due to or aggravated by service connected disability. 38 U.S.C.A. §§ 1110, 1111, 1112, 1131, 1137, 1153 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307(a), 3.309(a), 3.310 (2007). 2. Arthritis of the right shoulder was not incurred in or aggravated by service, may not be presumed to have been so incurred, and is not due to or aggravated by service connected disability. 38 U.S.C.A. §§ 1110, 1111, 1112, 1131, 1137, 1153 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306, 3.307(a), 3.309(a), 3.310 (2007). 3. The criteria for a disability rating in excess of 30 percent for PTSD prior to July 3, 2005, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.130, and Diagnostic Code 9411 (2007). 4. The criteria for a rating in excess of 70 percent for service-connected PTSD from July 3, 2005 forward, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As required by 38 U.S.C.A. § 5103(a), prior to the initial unfavorable agency of original jurisdiction (AOJ) decision, the claimant must be provided notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). This notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request or tell the claimant to provide any evidence in the claimant's possession that pertains to the claim, or something to the effect that the claimant should give us everything you've got pertaining to your claims. In the instant case, the veteran received timely and compliant notification prior to the initial unfavorable agency decision in May 2003. The RO notice letter dated in November 2002 informed the veteran that he could provide evidence to support his claims for service connection or location of such evidence and requested that he provide any evidence in his possession. The notice letter notified the veteran that VA would obtain all relevant evidence in the custody of a federal department or agency. He was advised that it was his responsibility to either send records pertinent to his claims, or to provide a properly executed release so that VA could request the records for him. The veteran was also asked to advise VA if there were any other information or evidence he considered relevant to this claim so that VA could help by getting that evidence. It is the Board's conclusion that the veteran has been provided with every opportunity to submit evidence and argument in support of his claim, and to respond to VA notices. The duty to notify the veteran was satisfied under the circumstances of this case. 38 U.S.C.A. § 5103. As to the claim for a higher initial evaluation, the veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. In addition, to whatever extent the decision of the Court in Dingess requires more extensive notice in claims for compensation, e.g., as to potential downstream issues such as disability rating and effective date, the Board finds no prejudice to the veteran in proceeding with the present decision. The veteran has been provided the criteria for rating PTSD, and an opportunity to submit additional evidence and argument on the matter of the appropriate disability rating. Since the claim for a higher rating is being denied, no effective date will be assigned, so that issue is moot. A letter properly informing the veteran of the holding in Dingess regarding VCAA notice of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) applying to all five elements of a service connection claim was sent to the veteran in November 2007 as an attachment to notice of the scheduling of a Board hearing. VA must also make reasonable efforts to assist the veteran in obtaining evidence necessary to substantiate the claims for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2007). Service medical records have been obtained. VA treatment records are also on file. No other treatment records have been identified. A VA examination has been conducted and opinions have been rendered. In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the veteran in developing the facts pertinent to the issues on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103 and 5103A; 38 C.F.R. § 3.159. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service, and for some disorders, such as arthritis, may be presumed if manifested to a compensable degree within the first post service year. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a), 3.307, 3.309. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993). Where a veteran served 90 days or more during a period of war or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. § 1101, 1110, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310 (2007). Similarly, any increase in severity of a nonservice- connected disease or injury that is proximately due to or the result of a service- connected disease or injury, and not due to the natural progress of the nonservice- connected disease, will be service connected. Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that 38 C.F.R. § 3.310, the regulation which governs claims for secondary service connection, has been amended recently. The intended effect of this amendment is to conform VA regulations to the Allen decision, supra. 71 Fed. Reg. 52,744 (Sept. 7, 2006) (to be codified at 38 C.F.R. § 3.310(b)). Since VA has been complying with Allen since 1995, the regulatory amendment effects no new liberalization or restriction in this appeal. In evaluating service connection claims, the Board shall consider all information and lay and medical evidence of record. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2002). While the veteran claims that service connection is warranted for arthritis of the right hand and right shoulder, there is no competent evidence of record showing that arthritis of the right hand, or right shoulder, had its onset during active service or is related to any in-service disease or injury, or that it was manifest to a degree of 10 percent or more within one year of service. In this regard, the service medical records are devoid of any reference to arthritis. The veteran was hospitalized in service for shell fragment wounds of the upper and lower extremities in December 1970, and X- rays of the hands showed multiple metallic fragments. The wounds were debrided. The pertinent diagnosis was, multiple fragment wounds, superficial, involving both upper and lower extremities. His separation examination report dated in January 1972 showed no musculoskeletal abnormality. After service the veteran was examined by VA in April 1972. X-rays performed at that time were negative for any arthritis. Arthritis is first shown in February 2002 on VA X-rays. At that time, mild degenerative changes of the right shoulder and right hand were documented. These findings are first noted over thirty years after service discharge. The veteran was examined by VA in December 2002. On examination of the joints, the examiner noted that the claims file had been reviewed. The examiner diagnosed degenerative arthritis of the right shoulder. He offered the opinion that after having reviewed the claims file, the veteran's degenerative arthritis is likely due to the aging process and not likely due to his military service or the result of any shell fragment wounds. The examiner added that the uniformity of the arthritis in the veteran's various joints is such that it is likely degenerative arthritis. It was stated that for traumatic arthritis to occur, the injury of the shrapnel would be different on one side of the body than the other and that therefore, the arthritis that appears is degenerative arthritis and not traumatically induced. On VA examination of the hands in December 2002, the examiner noted that the claims file had been reviewed. After examining the hands, the examiner diagnosed degenerative arthritis of both hands. The examiner stated that it is not as likely as not that degenerative arthritis of the hands is related to the veteran's military service or shrapnel injury. The examiner reported that degenerative arthritis of the hands is mild and is essentially equal in both hands and that therefore these changes most likely represent degenerative arthritic changes and not changes from any shrapnel wounds. The evidence does not support a finding of service connection for these disorders. It is probative that the first indication of any arthritis was in 2002, some 30 years after separation. With respect to negative evidence, the United States Court of Appeals for Veterans Claims (Court) has held that the fact that there was no record of any complaint, let alone treatment, involving the veteran's condition for many years could be decisive. See Maxon v. West, 12 Vet. App. 453, 459 (1999); Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) [noting that it was proper to consider the veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised]; see also Shaw v. Principi, 3 Vet. App. 365 (1992) [a veteran's delay in asserting a claim can constitute negative evidence that weighs against the claim]. Given the lack of any complaints or treatment for many years after service, the Board finds that any ongoing residuals to the veteran's shell fragment wounds in service, in the form of arthritis is not credible. Additionally, there is medical evidence, specifically the December 2002 VA examiners' opinions, stating that the veteran's right shoulder and right hand arthritis is not related to service. The opinions were based upon review of the claims folder and examination of the veteran, and stand uncontradicted in the record. The veteran, as a lay person, is not competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because he does not have the requisite medical expertise. See Routen v. Brown, 10 Vet. App. 183, 186 (1997); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). This determination, however, is not a matter for an individual without medical expertise. Id.. Thus, while the Board has considered the veteran's lay assertions, they do not outweigh the competent medical evidence of record which does not show that the current arthritis of the right hand and right shoulder are due to service. A competent medical expert makes this opinion and the Board is not free to substitute its own judgment for that of such an expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The lay and medical evidence does not establish the existence of right hand or right shoulder arthritis in service, that arthritis of the right hand or right shoulder was manifested within the first post-service year, or that the current right hand or right shoulder disability is causally related to event(s) in service. Accordingly, there is no basis to award service connection on a direct or presumptive basis. As to whether the veteran's arthritis of the right hand and right shoulder are due to or aggravated by his service- connected shell fragment wounds, a review of the claims folder shows that there is no competent evidence suggesting any relationship between the service-connected shell fragment wounds and the current arthritis of the right hand or the right shoulder. Rather, VA clinicians in December 2002 stated that there was no relationship between the right hand or right shoulder arthritis and a shell fragment wound. These findings were based on review of the claims folder, and examination of the veteran, and were supported by rationale. The opinions stand uncontradicted in the record. As noted above, the veteran is not competent to speak to medical etiology. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992); 38 C.F.R. § 3.159(a) (2007). Accordingly, the Board finds by a preponderance of the evidence that the veteran's arthritis of the right hand and of the right shoulder, which first manifested many years after service, did not have their onset during active service and are not related to any in-service disease or injury or to his service-connected shell fragment wounds. The claims, therefore, must be denied. Increased Initial Evaluation Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any doubt regarding the extent of the disability in the veteran's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher evaluation 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. In cases such as this one, where the original rating assigned is appealed, consideration must be given to whether the veteran deserves a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). The veteran seeks a higher evaluation for his service- connected PTSD. According to the general rating formula, a mental disorder is rated 30 percent when it results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with 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, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Code 9411. A rating of 50 percent is assigned when it results in occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A rating of 70 percent is warranted when it results in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned when the condition results in total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The criteria set forth in the rating formula for mental disorders do not constitute an exhaustive list of symptoms, but rather are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Although the extent of social impairment will be considered, an evaluation may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2007). The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). A GAF score of 41 to 50 reflects serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job). A 51-60 GAF score indicates moderate symptoms (e.g., a flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score from 61-70 reflects some mild symptoms, or some difficulty in social, occupational, or school functioning but is generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging from 71 to 80 reflect that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument) and result in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). In May 2003, the RO granted service connection for PTSD and assigned a 30 percent evaluation. During the course of his appeal, his rating was raised to 70 percent in January 2007, effective from July 3, 2005. The Board finds that prior to July 3, 2005, the veteran's overall disability picture is most consistent with a 30 percent rating for PTSD. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2007). The record shows that the veteran's PTSD symptoms resulted in occupational and social impairment with occasional decrease in work efficiency due to symptoms such as depressed mood, anxiety, panic attacks, and chronic sleep impairment. At the time of the July 2002 VA initial psychiatric evaluation, the veteran reported having sleep problems and temper problems. He reported that his major pleasure was work and riding horses. The examiner noted that the veteran had a good work history and had operated his own business for the past ten years. It was noted that he was divorced, and did not socialize with his brothers or sisters. He was noted to live alone and had no close friends. On examination, the veteran had a solemn affect, but not depressed, vocabulary skills in the normal range. His thinking processes were logical and goal directed. There was no suicidal or homicidal ideation, and judgment and insight were good. The veteran was well groomed and alert and oriented times three. PTSD was diagnosed and a GAF score of 75 was assigned. The examiner pointed out that the veteran has a good work record history, is self supporting, owns his own business, but has severe sleep problems and impaired personal relationships. VA outpatient treatment note of October 2002 shows that the veteran was self employed as an auto mechanic. He complained of having nightmares and depression. It was noted that he had a girlfriend which helped. The examiner noted that the veteran did not appear to be markedly depressed or anxious. His GAF was 60. The veteran was examined by VA in December 2002. It was noted that the veteran was divorced and employed as an auto service mechanic, which it was noted he had been doing since 1979. The veteran complained of sleeplessness, nightmares, and intrusive thoughts. He noted that he has a girlfriend and enjoyed raising horses. The examiner noted the veteran's history and stated that his psychosocial functioning after leaving service has been fairly good in that he has suitable recreational pursuits, fair relationship with his two children, has been able to maintain employment and was married for 16 years. On examination, it was noted that the veteran appeared to have no impairment in terms of his communication skills, or his thinking. He did not experience delusions or hallucinations. His interaction was considered appropriate and he was oriented to person, place, situation, and time. He reported some short time memory loss and no panic attacks or unusual anxiety. PTSD was diagnosed and a GAF of 60 was assigned. The examiner noted that the overall high GAF for the past year was estimated to be around 65. The examiner concluded that generally speaking, the veteran had functioned fairly well since service with some difficulty in concentrating in school. It was pointed out that the veteran had been employed most of his adult lifetime, could take care of routine responsibilities of self care, functioned adequately as a parent, was for a time a responsible marriage partner, has several close friends including a girlfriend and had interesting recreational activities. VA outpatient treatment records beginning in 2002 shown treatment for PTSD and counseling appointments. In 2002 the records generally show complaints regarding sleep problems, (see record of November 2002) and temper problems (see October 2002 record). In January 2003, the veteran denied feeling depressed or sad for much of the time in the last year. In April 2003, it was noted that the veteran had made some progress. His GAF was 55 at that time and again in May 2003 when it was noted that he was cooperative, coherent, not psychotic, no violent ideas, with mild depression and clear sensorium. Another 55 GAF was assigned in July 2003, when it was noted that there was depression with some improvement. In December 2003, his GAF was 60. Treatment continued into 2004 with similar findings (see January 2004 and February 2004 records). In March 2004 a GAF 0f 65 was assigned, and in May 2004, it was noted that he was asymptomatic as to PTSD and a GAF or 80 was assigned. In August 2004, it was noted that his PTSD symptoms improved with treatment, and a GAF of 70 was noted with a GSF of 60 assigned later that same month. In September 2004, the veteran reported that his girlfriend had left him due to his anger problems, that he had some grief as to his father's death and that he had nightmares of Vietnam. His GAF was 55. Later that same month as well as in October 2004, the GAF was noted as 65, and in December 2004 it was 70. In January 2005 the veteran's GAF was 80. Thereafter in January 2005, February, March 2005, and June 2005, his GAF was 60. It was noted in March 2005 that the veteran did not seem markedly depressed or anxious, but was angry because his PTSD rating was not increased. It was also noted that he was not working right now. Another treatment record in June 2005 showed a GAF of 75, and in September 2005, his GAF was 65. The evidence of record does not support the assignment of a rating in excess of 30 percent for PTSD prior to July 3, 2005. The GAF scores assigned to the veteran throughout the period in question have ranged between 55 and 80, which represent transient or slight impairment to moderate symptoms. See Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, D.C., American Psychiatric Association (1994) (DSM-IV). GAF scores generally reflect an examiner's finding as to the veteran's functioning score on that day and, like an examiner's assessment of the severity of a condition, is not dispositive. Rather, the GAF score must be considered in light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2007). In this case, the subjective symptoms exhibited by the veteran do include nightmares, occasional intrusive recollections, difficulty getting along with people and showing affection and losing his temper. There is no evidence, however, of such symptoms as panic attacks, flattened affect; circumstantial, circumlocutory, or stereotyped speech; difficulty understanding complex commands; impairment of long-term memory; impaired judgment; or impaired abstract with thinking. Importantly, the veteran reports spending time raising horses, gets along with his sisters and brothers, and is able to attend to his routine responsibilities of self-care. There is no showing of homicidal or suicidal ideation. On VA examinations, mental status examination has been essentially normal, with the exception of a finding of some short term memory loss. The veteran has stated that he is employed and although he reported on VA outpatient treatment in March 2004 that he was not working, on his April 2004 claim for another VA benefit, the veteran indicated that he was self-employed 20 to 30 hours a week as an auto mechanic. As such, a rating in excess of 30 percent for PTSD is not warranted, as the evidence of record does not more nearly approximate the criteria for the next higher rating during this time period. As to entitlement to a higher evaluation beyond 70 percent from July 3, 2005, the evidence of record does not support the assignment of a 100 percent rating for PTSD. The veteran was examined by VA in July 2005. The examiner stated that the claims file was not available and that the results of this examination were the sum total of the examination and testing. The veteran reported that he had not worked since 1999. He reported having insomnia and nightmares and flashbacks of Vietnam. He reported that he isolated himself from people. On mental status examination it was noted that despite the veteran's statements that he is unable to get along with others, he presented as very nice and sincere and polite during the course of the interview. It was noted that the veteran is attractive, articulate, who was very polite. His thought processes were logical, coherent and relevant. He was well dressed and well groomed and was mentally intact and had good social skills. He was noted to seem intelligent and his speech was well understood. The veteran was oriented to time and place, person and situation. His affect was flat and blunted and his reasoning was good. The examiner stated that the veteran endorsed anxiety hyperactivity, panic attacks, depression, insomnia, crying spells and a variety of PTSD symptoms. He stated that he had obsessional ideations, hallucinations, paranoia and homicidal and suicidal ideation. The examiner stated that the veteran was at risk for verbal if not physical aggression since he has stated that in the past he has been involved with the police on many occasions because of combativeness with his wife. It was the examiner's impression that the veteran's PTSD and secondary mood disorder and psychosis have had a destructive effect on his personal, social and occupational functioning. The examiner noted that the veteran has been unable to sustain employment or work-like involvement and continually alienates and isolates himself from others. As to psychological testing the examiner noted that the veteran was administered the MMPI-2 and may have somewhat overdone it as far as reporting psychological symptoms. The examiner found that the overall profile is invalid. PTSD was diagnosed and a GAF of 50 was assigned. The veteran was examined by VA in November 2006. The claims file was reviewed, and his history was documented. He complained of not being able to sleep well and being lonesome. It was reported that his spouse called the police one year prior because the veteran was threatening her. He reported that he last worked in 1999 as a mechanic on his own until he could not get along with his customers. Work impairment was noted to be severe and that there was moderate family impairment. It was noted that his wife had left him several times. He stated that he rarely saw his children or his brothers and sisters, although he did talk to his siblings by telephone. It was stated that he had severe social impairment since he had one friend who seldom talked and helped out with chores, and went to church twice a week. It was stated that he had moderate impairment regarding violence since he threatened a neighbor two weeks prior and slapped his wife a year ago. The veteran was noted to think about not wanting to live every few days. On mental status examination, the veteran's speech was logical and linear thought and the content of the speech was appropriate and well connected to topic of discussion. He reported having auditory hallucinations. His behaviors were appropriate to context. His personal hygiene was fair and activities of daily living were good. Orientation to person, place, time and purpose was good, and long term memory and short term memory were fair. Panic symptoms were pronounced. Insight was fair. PTSD intensity was noted to be moderate. Psychological testing was noted to reflect symptom exaggeration. The finding was, PTSD, chronic and the GAF of 55 with moderate to serious symptoms. VA outpatient treatment records from May 2005 to December 2006 show treatment for various disorders including for PTSD. In September and December 2005 the veteran's GAF was 70 and in December 2006, it was reported that he was doing well and a GAF of 80 was assigned. The Board acknowledges that the veteran is reportedly no longer working, due to his inability to get along with his customers. Despite this problem, the record does not show that based on the rating criteria a 100 percent rating is warranted for PTSD. The Board notes that during the time period in question, his GAF scores have ranged from 50 to 80. See VA records; VA examination reports. The GAF's assigned represented transient to serious symptoms with the majority in the range of transient to mild impairment. See Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, D.C., American Psychiatric Association (1994) (DSM-IV). Most recently, the veteran was assigned a score of 80, which reflects that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument) and result in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). See id. Irrespective of the GAF scores assigned, however, upon reviewing the VA examination reports noted above, there is no evidence of symptoms such 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, disorientation to time or place, or memory loss for names of close relatives, own occupation or own name. While the veteran has indicated that he has auditory hallucinations there is no showing that they are persistent. Additionally, he stated that he had slapped his wife one year prior to his November 2006 examination, but again there is no showing of persistent danger of hurting himself or others. Moreover the veteran reports having a friend and attending church twice a month. He is married, although he has reported some marital problems, and has been for several years. It is noted during the July 2005 examination, the examiner found that that the veteran had been unable to sustain employment and isolates himself, the examiner did not have the claims file and he stated that his findings and conclusions were based on the information obtained during that examination. Additionally the examiner stated that the veteran's testing profile was invalid due to the veteran's overdoing. Even so, the examiner found that a GAF of 50 was appropriate, which supports severe, but not total impairment. The veteran's PTSD disability is severe and is adequately compensated by the 70 percent rating assigned. There is no showing that at any time from July 3, 2005 forward that a rating beyond 70 percent is warranted. Consequently, the Board concludes that the evidence does not show that the veteran's PTSD produces both total social impairment and total occupational impairment, so as to support a schedular 100 percent evaluation from July 3, 2005. ORDER Service connection for traumatic arthritis of the right hand, to include as secondary to service-connected shell fragment wounds is denied. Service connection for traumatic arthritis of the right shoulder, to include as secondary to service-connected shell fragment wounds is denied. An initial evaluation in excess of 30 percent for post- traumatic stress disorder (PTSD) prior to July 3, 2005. and in excess of 70 percent from July 3, 2005, forward is denied. REMAND The veteran seeks service connection for arthritis of the right hip and the right foot to include as due to service- connected shell fragment wounds. The veteran sustained shell fragment wounds in service which included the lower extremities and he is service connected for shell fragment wounds of the right thigh and leg. The veteran underwent a VA foot examination in December 2002 and the examiner noted that the claims file had been reviewed. After examining the veteran, the clinician found that the veteran had osteoarthritis of the right foot, mild, noting that minimal osteoarthritic disease of the narvicular bone was found on X- rays. The examiner did not offer an opinion as to the etiology of the arthritis of the right foot. Additionally, on VA X-rays in February 2002, mild degenerative changes of the right hip were noted. However, on VA examination in December 2002, the examiner stated that X-rays of the hips were normal, and thus a nexus opinion was not given. The X-ray reports referred to were not associated with the examination report. As there appears to be a contradiction as to whether the veteran has arthritis of the right hip, further development on that issue is necessary. The appellant is hereby notified that it is his responsibility to report for any examination scheduled, and to cooperate in the development of the case, and that the consequences of failure to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158 and 3.655 (2007). In view of the foregoing the case is REMANDED to the RO for the following action: 1. Schedule the veteran for an orthopedic examination to determine the nature and etiology of any right hip disorder and the etiology of his right foot arthritis. The claims file and a copy of this remand must be made available to the examiner for review and the examiner must indicate in the examination report that this has been accomplished. All indicated tests and studies, including X-rays should be accomplished. The examiner should indicate if the veteran has arthritis of the right hip and if so offer an opinion with complete rationale as to the etiology of the disorder to include whether it is at least as likely as not (a 50 percent probability or greater) that any diagnosed right hip arthritis is related to the veteran's service or to his service-connected shell fragment wounds. The examiner should also offer an opinion with complete rationale as to the etiology of the veteran's right foot arthritis, to include whether it is at least as likely as not (a 50 percent probability or greater) that the disorder is related to the veteran's service or to his service-connected shell fragment wounds. 2. Then readjudicate the issues on appeal. If any benefit remains denied, issue the veteran a supplemental statement of the case and allow him time to respond. Then the case should be returned to the Board for further appellate consideration, if otherwise in order. 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). ____________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs