Citation Nr: 1002292 Decision Date: 01/14/10 Archive Date: 01/22/10 DOCKET NO. 07-03 470 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for coronary artery disease, including as secondary to the service-connected posttraumatic stress disorder (PTSD). 2. Whether new and material evidence has been received to reopen a claim for service connection for fibromyalgia, including as secondary to the service-connected PTSD. 3. Entitlement to service connection for psoriasis, including as secondary to exposure to herbicides. 4. Entitlement to service connection for hypertension, including as secondary to the service-connected PTSD. 5. Entitlement to an increased disability rating greater than 30 percent for PTSD with dysthymic disorder. 6. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD H. Seesel, Associate Counsel INTRODUCTION The Veteran had active service from June 1967 to April 1970, including tours of duty in the Republic of Vietnam from February 1968 to August 1968 and from April 1969 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2005 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In October 2009, the Veteran testified at a personal hearing over which the undersigned Acting Veterans Law Judge presided while at the RO. A transcript of the hearing has been associated with the Veteran's claims file. During the October 2009 hearing, the Veteran's it was indicated that the claim for psoriasis included the threshold question of whether new and material evidence had been submitted. Significantly, although the RO previously considered and denied service connection for chloracne, the RO never considered the claim for service connection for psoriasis. In this regard a change in diagnosis or the specificity of the claim must be carefully considered in determining whether the claim is based on a distinct factual basis. Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008). In Boggs, the United States Court of Appeals for the Federal Circuit (Federal Circuit) found that a claim for one diagnosed disease or injury cannot be prejudiced by a prior claim for a different diagnosed disease or injury, when it is an independent claim based on distinct factual bases. However, the United States Court of Appeals for Veterans Claims (Court) clarified in Velez v. Shinseki, 23 Vet. App. 199, 204 (2009), that the focus of the analysis must be whether the evidence truly amounted to a new claim based upon a different diagnosed disease or whether the evidence substantiates an element of a previously adjudicated matter. In the present case, the claim for chloracne was denied as there was no current disability. As the RO never considered or discussed whether service connection was warranted for other skin disabilities, including the psoriasis that existed at the time of the prior denial, analysis of whether new and material evidence had been submitted is not appropriate. Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008); Clemons v. Shinseki, 23 Vet. App. 1 (2009). A review of the record reflects the Veteran has raised claims for service connection for sleep apnea and chronic fatigue syndrome. These issues have not been adjudicated and are REFERRED to the RO for appropriate action. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a TDIU claim is part of an increased disability rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. As such, the issues before the Board are as set forth above. The issues of entitlement to service connection for hypertension, psoriasis and coronary artery disease and entitlement to an increased disability rating for PTSD and entitlement to TDIU are being remanded and are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A February 2004 rating decision, which denied service connection for fibromyalgia and a heart disability, is final. 2. The evidence associated with the claims file subsequent to the February 2004 rating decision relates to an unestablished fact necessary to substantiate the claim for service connection for fibromyalgia and raises a reasonable possibility of substantiating the claim. 3. The evidence associated with the claims file subsequent to the February 2004 rating decision relates to an unestablished fact necessary to substantiate the claim for service connection for a heart disability and raises a reasonable possibility of substantiating the claim. 4. The Veteran's service-connected PTSD likely caused or aggravated the fibromyalgia. CONCLUSIONS OF LAW 1. Evidence received since the final February 2004 determination wherein the RO denied the Veteran's claim for service connection for fibromyalgia is new and material, and the Veteran's claim for that benefit is reopened. 38 U.S.C.A. §§ 5103, 5103A, 5104, 5107, 5108, 7105 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.104(a), 3.156, 3.159, 20.1103 (2009). 2. Evidence received since the final February 2004 determination wherein the RO denied the Veteran's claim for service connection for a heart disability is new and material, and the Veteran's claim for that benefit is reopened. 38 U.S.C.A. §§ 5103, 5103A, 5104, 5107, 5108, 7105 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.104(a), 3.156, 3.159, 20.1103 (2009). 3. The criteria for service connection for fibromyalgia have been met. 38 U.S.C.A. §§ 1110, 1112, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist VA has specified duties to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The Board has considered whether further development and notice under the Veterans Claims Assistance Act of 2000 (VCAA) or other law should be undertaken. However, given the results favorable to the Veteran, further development under the VCAA or other law would not result in a more favorable outcome or be of assistance to this inquiry. In this decision, the Board is reopening the Veteran's claims for service connection for fibromyalgia and for a heart disability; is granting the claims for service connection for fibromyalgia; and is remanding the issue of service connection for a heart disability for further development. Because the claims have been reopened, any deficiency regarding notice of the basis for a prior final denial of a claim, or what information or evidence is necessary to reopen a claim, is not prejudicial to the Veteran's respective claims. See Kent v. Nicholson, 20 Vet. App. 1 (2006). For this reason, no further discussion of VA's duties to notify and assist is required. New and Material Evidence The Veteran seeks service connection for fibromyalgia and coronary artery disease. A claim for service connection for fibromyalgia was previously considered and denied by the RO in a September 2001 rating decision. The Veteran did not appeal the decision, and it became final. 38 C.F.R. § 20.1103. The RO again considered and denied the claim in a February 2004 rating decision. The Veteran did not appeal the February 2004 rating decision and, therefore, it became final. 38 C.F.R. § 20.1103. The RO denied service connection for a heart disability in February 1994, September 2001, and February 2004 rating decisions. The Veteran did not appeal these decisions and, therefore, they became final. 38 C.F.R. § 20.1103. As such, the appellant's claims may be reopened only if new and material evidence has been secured or presented since the last final rating decision. See Glynn v. Brown, 6 Vet. App. 523 (1994). The submission of "new and material" evidence is a jurisdictional prerequisite to the Board's review of such an attempt to reopen a claim. Absent the submission of evidence that is sufficient to reopen the claim, the Board's analysis must cease. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996); Butler v. Brown, 9 Vet. App. 167, 171 (1996); McGinnis v. Brown, 4 Vet. App. 239, 244 (1993). The Board may not then proceed to review the issue of whether the duty to assist has been fulfilled, or undertake an examination of the merits of the claim. The Board will therefore undertake a de novo review of the new and material evidence issue. As general rule, a claim shall be reopened and reviewed if new and material evidence is presented or secured with respect to a claim that is final. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. When a claimant seeks to reopen a final decision, the first inquiry is whether the evidence obtained after the last disallowance is "new and material." Under 38 C.F.R. § 3.156(a), new evidence means evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). When determining whether a claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). In order for evidence to be sufficient to reopen a previously denied claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). Furthermore, "material evidence" could be "some new evidence [that] may well contribute to a more complete picture of the circumstances surrounding the origin of the Veteran's injury or disability, even where it will not eventually convince the Board to alter its rating decision." Hodge v. West, 155 F. 3d 1356, 1363 (Fed. Cir. 1998). If it is determined that new and material evidence has been submitted, the claim must be reopened. The VA may then proceed to the merits of the claim on the basis of all of the evidence of record. Initially, it is noted that the evidence to be reviewed for sufficiency to reopen a claim is the evidence submitted since the most recent final denial of the claim on any basis. Evans v. Brown, 9 Vet. App. 273 (1996). At the time of the February 2004 rating decision that last denied service connection for a fibromyalgia and a heart disability, the evidence of record consisted of service treatment records, service personnel records, VA outpatient treatment records and private treatment records along with the reports of VA examinations. Subsequently, additional VA outpatient treatment records and private medical records have been associated with the claims file. The evidence submitted subsequent to the February 2004 decision is new, in that it was not previously of record. The newly submitted evidence is also material. The claims for fibromyalgia and a heart disability were both denied in February 2004 as no new and material evidence had been submitted. The claim for fibromyalgia was first denied in September 2001 as there was no evidence of a nexus to service or the service-connected disability of the hands, and there was no evidence of fibromyalgia during service. The claim for a heart disability was first denied in February 1994 as there was no nexus linking the heart disability to service, and no evidence indicating the heart disability was manifested within one year of the Veteran's separation from service. The September 2001 rating decision continued to deny the claim for a heart disability as there was no evidence of a nexus to service, or a service-connected disability and no evidence of a diagnosis within one year of the Veteran's separation from service. The evidence received subsequent to the February 2004 rating decision includes a January 2005 letter from a private physician that indicated the Veteran's service-connected PTSD aggravated the Veteran's fibromyalgia and coronary artery disease. In other words, these records relate the current condition to a service- connected disability. See Kent, 20 Vet. App. at 10 (finding that "the question of what constitutes material evidence to reopen a claim for service connection depends on the basis on which the prior claim was denied"). Presuming such evidence is credible for the limited purpose of ascertaining its materiality, this would therefore relate to the unestablished element of a nexus which is necessary to substantiate the Veteran's claim. Presumed credible, the additional evidence received since the February 2004 Board decision relates to an unestablished fact necessary to substantiate the claims, and raises a reasonable possibility of substantiating the claims. Accordingly, the Board finds that the claims for service connection for fibromyalgia and a heart disability are reopened. Service Connection - Fibromyalgia Having reopened the claim for fibromyalgia, the Board will address the merits of the claim. After carefully considering the claim in light of the record and the applicable law, the Board is of the opinion that the evidence is at an approximate balance and the appeal will be allowed. Service connection will be granted if it is shown that a Veteran has a disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a preexisting injury or disease contracted in the line of duty in the active military, naval or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. That an injury incurred in service alone is not enough. There must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, to prove service connection, the record must contain: (1) evidence of a current disability, (2) evidence of an inservice incurrence or aggravation of an injury or disease, and (3) evidence of a nexus between the current disability and the inservice disease or injury. Pond v. West, 12 Vet. App. 341 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). In certain cases, competent lay evidence may demonstrate the presence of any of these elements. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). The Veteran has a current diagnosis of fibromyalgia as noted in VA and private medical records. The remaining question, therefore, is whether there is evidence of an inservice occurrence of an injury or disease and medical evidence of a nexus or relationship between the current disability and the inservice disease or injury. Service treatment records fail to reflect any complaints, treatment or diagnosis of fibromyalgia. In fact, the April 1970 examination performed in connection with the Veteran's separation from service described all systems as normal and noted no defects or diagnoses. While the service treatment records reflect some symptoms of fibromyalgia, such as generalized body aches, these were associated with other diagnoses, such as viral syndromes. The Veteran, however, does not contend he was diagnosed with fibromyalgia during service. Rather he contends the fibromyalgia is related to his service-connected PTSD. The law provides that secondary service connection shall be awarded when a disability is "proximately due to or the result of a service-connected disease or injury." 38 C.F.R. § 3.310(a). See Libertine v. Brown, 9 Vet. App. 521, 522 (1996); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). Allen v. Brown, 7 Vet. App. 439, 448 (en banc). Establishing service connection on a secondary basis therefore requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service connected disability. In this regard, the Veteran has a current disability and a service-connected disability of PTSD. The Veteran was afforded a VA examination in January 2001 to assess the presence and etiology of the fibromyalgia. After reviewing the record, considering the Veteran's complaints and examining the Veteran, the examiner concluded that the fibromyalgia had no relationship to the service-connected circulation of the hands; however, the examiner noted that fibromyalgia and chronic fatigue are usually associated with depression. The examiner also indicated that the Veteran treated his depression with medication which to some extent also appeared to help the fibromyalgia. The Veteran submitted a December 2003 letter from a private physician noting that fibromyalgia was an ill-defined disease that was often a disease of exclusion. The physician indicated the service-connected PTSD certainly aggravated the fibromyalgia and fatigue because the sleep disturbances rendered him almost 100 percent disabled. The physician noted that the stress the Veteran was under while in Vietnam and concluded the fibromyalgia was service-connected in this case. The Veteran also submitted a January 2005 letter from a private physician in support of his claim. The private physician explained he had treated the Veteran for over 10 years. The physician related the Veteran had classic PTSD symptoms and explained the Veteran's multiple medical problems, including coronary artery disease, fibromyalgia, and hypertension were all worsened by the PTSD. There can be no doubt that further medical inquiry could be undertaken with a view towards development of the claim. However, under the law, where there exists "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). The mandate to accord the benefit of the doubt is triggered when the evidence has reached such a stage of balance. In the present case, the record clearly notes the Veteran has a current disability of fibromyalgia. Although the Veteran was not diagnosed with fibromyalgia for many years after service, there are several records which indicate the service- connected PTSD aggravated the fibromyalgia and further suggest the conditions were interrelated by noting the treatment for PTSD also alleviated the fibromyalgia. Therefore, the Board is of the opinion that the evidence is at an approximate balance. Accordingly, service connection for fibromyalgia is granted. ORDER New and material evidence having been submitted, the claim for service connection for fibromyalgia is reopened. To this extent and to this extent only, the appeal is granted. New and material evidence having been submitted, the claim for service connection for a heart disability, to include coronary artery disease, is reopened. To this extent and to this extent only, the appeal is granted. Service connection for fibromyalgia is granted. REMAND A preliminary review of the record reflects that further development is necessary. Specifically, the duty to assist has not been satisfied. There appear to be VA outpatient treatment records which have not been obtained. During the October 2009 hearing, the Veteran indicated he was treated at the VA Medical Center and was last seen there around September 2009. Significantly, the most recent VA outpatient treatment records in the claims file are dated in July 2005. VA has a duty to obtain all relevant VA and Governmental records prior to adjudication of a claim. 38 U.S.C.A § 5103A(c)(3); see Bell v. Derwinski, 2 Vet. App. 611 (1992) (Observing that any VA treatment records that have been generated up to and including the date of the Board's decision, whether or not filed in the appellant's claims file, are in the constructive possession of the Board and must be considered). Accordingly, a remand to obtain these records is necessary prior to adjudication of the issue of an increased disability rating for the PTSD and the claims for service connection for hypertension, coronary artery disease, psoriasis, and TDIU. Additionally, the Board is of the opinion that VA examinations are warranted. Concerning the claim for an increased disability rating for PTSD, although the Veteran was afforded a VA examination in July 2005, this examination is too remote in time to address the current severity of the Veteran's service-connected PTSD, particularly as the Veteran has alleged his condition has worsened during the October 2009 Board hearing. VA's General Counsel has indicated that when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (holding that a Veteran was entitled to a new examination after a two year period between the last VA examination and the Veteran's contention that his disability had increased in severity) and Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). Accordingly, another VA examination is warranted. Similarly, for the issue of psoriasis, the record reflects the Veteran was afforded a VA examination of the skin in December 1993. The examiner diagnosed probable dyshidrosis/hand eczema versus possible psoriasis; however, no opinion concerning the etiology of the condition was provided. See 38 C.F.R. § 4.2 (If the findings on an examination report do not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (stating that once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). Concerning the claims for hypertension and coronary artery disease, the Board is of the opinion that a VA examination is necessary. Under the duty to assist, a medical examination or medical opinion is considered necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent medical evidence of a currently diagnosed disability or persistent or recurrent symptoms of a disability; (2) establishes that the Veteran suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with an established event, injury or disease in service or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); see Charles v. Principi, 16 Vet. App. 370 (2002) (Observing that under 38 U.S.C.A. § 5103A(d)(2), VA was to provide a medical examination as "necessary to make a decision on a claim, where the evidence of record, taking into consideration all information and lay or medical evidence [including statements of the claimant]; contains competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; and indicates that the disability or symptoms may be associated with the claimant's active military, naval, or air service; but does not contain sufficient medical evidence for the [VA] to make a decision on the claim."). In the present case, the Veteran has current disabilities of hypertension and coronary artery disease, a service-connected disability of PTSD, and a January 2005 letter from a private physician suggesting the PTSD aggravated the hypertension and the coronary artery disease. Significantly, the January 2005 physician did not provide any rationale for the opinion, and the record is otherwise insufficient to decide the claim. It is well-settled that in its decisions, the Board may not rely upon its own unsubstantiated medical opinion. Allday v. Brown, 7 Vet. App. 517 (1995); Godfrey v. Brown, 7 Vet. App. 398 (1995); Traut v. Brown, 6 Vet. App. 495 (1994); Colvin v. Derwinski, 1 Vet. App. 171 (1991). As such, without further clarification, the Board is without medical expertise to ascertain the relationship, if any, between the hypertension and coronary artery disease and the PTSD or otherwise determine if the disabilities are related to service. Id. As the Veteran has met the criteria of 38 C.F.R. § 3.159, VA examinations should be obtained. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Additionally, Court recently held that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if a disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation. Rice, 22 Vet. App. at 453. If the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability as a result of that disability is warranted. Id at 455. In a prior August 2003 statement, the Veteran indicated the medication for his PTSD made it impossible to concentrate or stay awake, and therefore made it impossible to perform the tasks of his job. Similarly, on the January 2007 Appeal To Board Of Veterans' Appeals (VA Form 9) the Veteran alleged his PTSD had worsened to the point that he had problems performing his job. He explained he feared he would lose his job because of memory loss and his attitude on the job related to PTSD. During the October 2009 Board hearing the Veteran explained he was not working, and related he officially stopped working when he became sick with mononucleosis and had to be on bed rest for eight weeks. The Veteran further argued that the PTSD also was involved in his leaving his job as he could no longer handle confrontation or interactions with others and he forgot things at work. The Veteran has, therefore, raised the issue of a entitlement to a TDIU. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001) (Once a Veteran submits evidence of medical disability and additionally submits evidence of unemployability, VA must consider total rating for compensation based upon individual unemployability). In this regard, the AOJ should send the Veteran a Veterans Claims Assistance Act of 2000 (VCAA) notice letter for the TDIU component of the increased rating claim. This letter should notify the Veteran and his representative of any information or lay or medical evidence not previously provided that is necessary to substantiate the TDIU claim. The notice should also indicate what information or evidence should be provided by the Veteran and what information or evidence VA will attempt to obtain on the Veteran's behalf. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159. See also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The law provides that TDIU may be granted upon a showing that the Veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to a Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or the impairment caused by nonservice- connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. In this regard, TDIU may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. Id. If, however, a Veteran fails to meet the applicable percentage standards enunciated in 38 C.F.R. § 4.16(a), rating boards should refer to the Director, Compensation and Pension Service for extra-schedular consideration all cases where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service- connected disability. 38 C.F.R. § 4.16(b). See also Fanning v. Brown, 4 Vet. App. 225 (1993). The Veteran's service- connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The record shows that the appellant is not working. He alleges that his service connected PTSD, have contributed to his inability to obtain or maintain gainful employment. At the present time, however, the Veteran is in receipt of service connection for PTSD, rated as 30 percent disabling and capillary impairment of the hands, rated as 10 percent disabling. As noted above, however, the Veteran's claims concerning service connection and claim concerning the rating of his PTSD are still pending. Thus, the claim for TDIU should be held in abeyance until the RO adjudicates the remaining claims. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following action: 1. The RO/AMC will advise the Veteran of what evidence would substantiate his claim for entitlement to TDIU. Apart from other requirements applicable under the VCAA, the RO/AMC will comply with any directives of the Veterans Benefits Administration. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009). 2. The RO/AMC should contact the Veteran and ask him to specify all medical care providers who treated him for his claimed disabilities. The RO/AMC should then obtain and associate with the claims file any records identified by the Veteran that are not already associated with the claims file. The RO/AMC should specifically request updated medical records from the Birmingham, Alabama VA Medical Center and associate these records with the claims file. 3. The RO/AMC shall schedule the Veteran for a VA examination to ascertain the present severity of his service-connected PTSD. The relevant evidence in the claims file should be made available to and reviewed by the examiner. All indicated tests should be performed and all findings should be reported. The examiner is requested to review all pertinent records associated with the claims file, particularly records of treatment for PTSD, and offer comments and an opinion as to the severity of the disability. The examiner is asked to opine on the impact of the claimed increase in severity of the disability, if any, on his employment and activities of daily life. A complete rationale for any opinion expressed shall be provided. 4. The RO/AMC shall schedule the Veteran for appropriate VA examination to ascertain the nature, extent, and etiology of the psoriasis. The claims file and a copy of this Remand must be made available to the examiner, and the examiner should indicate in the report that the claims file was reviewed. All tests that are deemed necessary by the examiner should be conducted. The examiner should specifically consider and address the Veteran's report of the onset of symptoms. Following a review of the claims file and examination of the Veteran, the respective examiner is asked to address the following: (a) Whether it is at least as likely as not (at least a 50 percent probability) that any currently diagnosed psoriasis was caused or aggravated (permanently worsened) by any event or incident of service. In doing so, the examiner should acknowledge the Veteran's report of a continuity of symptomatology. A complete rationale for all opinions expressed should be provided. It is requested that the examiner discuss all of the prior medical evidence in detail and reconcile any contradictory evidence. 5. The RO/AMC shall schedule the Veteran for appropriate VA examination to ascertain the nature, extent, and etiology of the asserted hypertension and coronary artery disease. The claims file and a copy of this Remand must be made available to the examiner, and the examiner should indicate in the report that the claims file was reviewed. All tests that are deemed necessary by the examiner should be conducted. Following a review of the claims file and examination of the Veteran, the respective examiner is asked to address the following: (a) Whether it is at least as likely as not (at least a 50 percent probability) that any currently diagnosed hypertension or coronary artery disease was caused or aggravated (permanently worsened) by the service-connected PTSD. (b) Whether it is at least as likely as not (at least a 50 percent probability) that any currently diagnosed hypertension or coronary artery disease is related to any event, incident, or symptoms noted during service. In doing so, the examiner should acknowledge the Veteran's report of a continuity of symptomatology. A complete rationale for all opinions expressed should be provided. It is requested that the examiner discuss all of the prior medical evidence in detail and reconcile any contradictory evidence. 6. The RO/AMC will then review the Veteran's claims file and ensure that the foregoing development actions have been conducted and completed in full, and that no other notification or development action, in addition to those directed above, is required. After review of any evidence submitted by the Veteran, the RO/AMC should take such additional development action as it deems proper with respect to the claims, including the claim for TDIU. In doing so the RO/AMC should conduct any appropriate VA examinations, and consider submission of the claim to the Under Secretary for Benefits or Director of Compensation and Pension Service for extra-schedular consideration, if appropriate. The RO/AMC shall follow any applicable regulations and directives implementing the provisions of the VCAA as to its notice and development. If further action is required, it should be undertaken prior to further claims adjudication. 7. The RO/AMC will then readjudicate the Veteran's claims. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. Thereafter, if appropriate, the case is to be returned to the Board, following applicable appellate procedure. The Veteran need take no action until he is so informed. He has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). The purposes of this remand are to obtain additional information and comply with all due process considerations. No inference should be drawn regarding the final disposition of this claim as a result of this action. This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ______________________________________________ DEMETRIOS G. ORFANOUDIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs