Citation Nr: 1313972 Decision Date: 04/26/13 Archive Date: 05/03/13 DOCKET NO. 09-14 337 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent prior to September 29, 2011, and in excess of 30 percent thereafter, for the service-connected hypertension with incomplete right bundle branch block, premature ventricular contractions (PVCs), and atrial fibrillation ("hypertension"). 2. Entitlement to an evaluation in excess of 10 percent prior to September 29, 2011, and in excess of 30 percent, thereafter for the service-connected cluster headaches. 3. Entitlement to an evaluation in excess of 20 percent for the service connection postoperative residuals, right acromioplasty with resection of the distal clavicle ("right shoulder disability"). 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities ("TDIU"). REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD K. L. Wallin, Counsel INTRODUCTION The Veteran served on active duty from October 1974 to August 1985. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a January 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran requested a hearing before the Board, which was scheduled for April 2011. The Veteran failed to appear; consequently, the hearing request is deemed withdrawn. 38 C.F.R. § 20.704(d). In August 2011, the Board determined that new and material evidence had not been submitted to reopen the previously denied claim of service connection for gastroesophageal reflux disease. The same decision denied claims of service connection for a left elbow disability, hernia, and colon cancer and denied claims of increased ratings for a bilateral ankle disability and prostatitis. As such, these matters are no longer in appellate status. The Board additionally remanded the following claims: service connection for left shoulder, back, right wrist, and right thumb disabilities; increased ratings for hypertension, cluster headaches, and right shoulder disability; and TDIU. In September 2012, the RO awarded service connection for lumbar degenerative disc disease, osteoarthritis of the left shoulder with rotator cuff tendonosis, ulnar collateral ligament sprain of the right thumb, and triangular fibrocartilage complete tear of the right wrist; consequently, there no longer remain claims in controversy. The RO additionally awarded increased 30 percent ratings effective from September 29, 2011, for the service-connected hypertension and cluster headaches. As the Veteran is presumed to be seeking the maximum benefit allowed by law and regulation, it follows that his claims remain in controversy as less than the maximum benefit available has been awarded. See AB v. Brown, 6 Vet. App. 35 (1993). The claims for increased rating for a right shoulder disability and TDIU 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. Prior to September 29, 2011, the Veteran's hypertension required continuous medication for control; there was no evidence of diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more; METs resulting in dyspnea, fatigue, angina, dizziness, or syncope was not recorded. 2. From September 29, 2011, the Veteran's hypertension has been estimated by history to have a workload of greater than 5 METs but not greater than 7 METs; there has been no evidence of one episode of acute congestive heart failure in the past year, or workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent; and diastolic pressure has not been shown to be predominantly 120 or more. 3. Prior to September 29, 2011, the Veteran's cluster headaches were not productive of characteristic prostrating attacks; headaches occurred on average no more than once a month over several months. 4. From September 29, 2011, the Veteran's cluster headaches were productive of no more than prostrating attacks of non-migraine headache pain occurring more frequently than once per month. CONCLUSIONS OF LAW 1. The criteria for the assignment of an evaluation in excess of 10 percent prior to September 29, 2011, and in excess of 30 percent thereafter, for the service-connected hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.104, including Diagnostic Codes 7015, 7101 (2012). 2. The criteria for the assignment of an evaluation in excess of 10 percent prior to September 29, 2011, and in excess of 30 percent thereafter, for the service-connected cluster headaches have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.124a, including Diagnostic Code 8100 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In an increased rating claim, VA must notify the Veteran to submit evidence showing (1) a worsening or increase in severity of the disability and (2) the effect that worsening has on the claimant's employment. Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). The RO provided the Veteran pre-adjudication notice by letters dated in September 2006 and September 2007. The Veteran indicated in March 2007 and October 2007 that he had no additional evidence to submit in support of his claims. In December 2008, the RO notified the Veteran of the diagnostic criteria used in assigning his disability ratings for the service-connected cluster headaches and hypertension. VA has obtained service treatment records, assisted the Veteran in obtaining evidence, and afforded the Veteran VA examinations. The Veteran was given the opportunity to give testimony before the Board; however, as noted in the Introduction, he failed to appear for the scheduled hearing. The RO requested records from the Texas Department of Insurance Office of Workers Compensation in August 2011. When no response was received, the RO sent a second request in October 2011. The Veteran was notified in October 2011 that the RO had been unable to obtain his Workers Compensation records. He was asked to submit any records in his possession, which he did not. Any further efforts to obtain these records would be futile. 38 C.F.R. § 3.159(c)(1). All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claims at this time. II. Analysis The Board has reviewed all the evidence in the Veteran's paper claims file and Virtual VA record, which does not contain any additional pertinent information. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. When considering functional impairment caused by a service-connected disorder, evaluations should be based on an assessment of the lack of usefulness, and adjudicators should consider the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's disability. Schafrath, 1 Vet. App. at 594. In general, the degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). The Board also acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation at any stage since the effective date of service connection. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). Hypertension Historically, service connection was awarded for hypertension in a March 1986 rating decision. An initial 10 percent evaluation was assigned effective in August 1985. In an August 1997 rating decision, the RO granted service connection for a heart disorder and included that condition with the already service-connected hypertension. The service-connected disability was thereafter characterized as hypertension with incomplete right bundle block, PVCs and atrial fibrillation. The Veteran filed the most recent increased rating claim in August 2006. The RO continued the 10 percent rating in January 2008. The Veteran disagreed and initiated the instant appeal. In September 2012, the RO awarded an increased 30 percent rating effective from September 29, 2011. His claim remains in controversy as less than the maximum benefit available has been awarded. See AB, supra. The Veteran's hypertension has been rated under 38 C.F.R. § 4.104, Diagnostic Codes 7101 and 7015, as 10 percent disabling prior September 29, 2011, and 30 percent thereafter. 38 C.F.R. § 4.104. Under Diagnostic Code 7101, a 10 percent rating is assigned for diastolic pressure predominantly 100 or more, or systolic pressure predominantly 160 or more or minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control. A 20 percent is assigned for diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more. A 40 percent is assigned for diastolic pressure predominantly 120 or more. A 60 percent is assigned for diastolic pressure predominantly 130 or more. 38 C.F.R. § 4.104 Under Diagnostic Code 7015, a 10 percent is assigned for atrioventricular block with workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication or a pacemaker required. A 30 percent is assigned for 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 electrocardiogram, echocardiogram, or x-ray. A 60 percent is assigned for more than one episode of acute congestive heart failure in the past year, or workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent is assigned for chronic congestive heart failure or workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope or left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. The pertinent facts found in the medical evidence of record are discussed below. Having carefully considered the Veteran's claim in light of the evidence of record and the applicable laws and regulations, and as outlined in the reasons and bases below, the Board finds that the currently assigned 10 percent rating prior to September 29, 2011, and 30 percent thereafter, for hypertension are appropriate and no higher rating is warranted under any applicable diagnostic code for rating diseases of the heart. 38 C.F.R. §§ 4.7, 4.104. VA outpatient treatment records dated in January 2006 show the Veteran's blood pressure was 173/110; however, he ran out of medication three weeks prior. After medication was restarted, his blood pressure was 136/90. In April 2006, the Veteran's blood pressure was 192/106, he was again out of medication. In May 2006, blood pressure readings were 165/91 and 183/116. VA providers noted the Veteran was out of his Lisinopril. In June 2006, the Veteran's blood pressure was 138/82 and 134/90. His Lisinopril was increased to 40 milligrams per day. An entry dated in September 2006 shows blood pressure was good and recorded as 110/69. In October 2006, blood pressure was 153/91. In June 2007 and December 2007 (110/70) blood pressure was considered good. Upon VA examination in August 2007, the Veteran's blood pressure was controlled on Diltiazem and hydrochlorothiazide/Lisinopril. He monitored his own blood pressure at home and stated that his control had been good. He had no complications of his hypertension. Blood pressure readings were 138/84, 137/81, and 129/89. His pulse was 53. His heart had regular rate and rhythm. There were no murmurs, S3 or S4. The Veteran was diagnosed with essential hypertension well controlled on medications without complications. VA outpatient treatment records dated in May 2008, show the Veteran resumed Lisinopril 20 milligrams per day. Blood pressure was 154/91. In June 2008, blood pressure was mildly elevated (141/85) and Lisinopril was again increased to 40 milligrams. On September 29, 2011, the Veteran was afforded a VA examination. The examiner noted the Veteran had been diagnosed with hypertension in 1984. He denied any hospitalization for his hypertension. The examiner noted blood pressure readings as follows: 136/83 in June 2011, 155/92 in September 2011, and 160/102 on the day of examination. The Veteran took continuous medication for hypertension (Diltiazem 240 milligram). The Veteran had Bruce exercise tolerance test (ETT) in August 2010. There was negative maximum ETT at good functional capacity. There was no METs determination. The examiner estimated METs on the day of examination to be between 5 and 7 by history. Resting electrocardiogram (ECG) taken on examination showed incomplete right bundle branch blood only. There was no current congestive heart failure or ischemic heart disease. The examiner indicated it was a normal cardiopulmonary examination. Prior to September 29, 2011, no more than a 10 percent rating was warranted under Diagnostic Code 7101. Notably, there was no evidence of diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more to warrant an increase to 20 percent. 38 C.F.R. § 4.104. At no time prior to September 29, 2011, or since for that matter, has the Veteran's systolic pressure been predominantly 200 or more. While the Veteran's diastolic pressure was 110 in January 2006 and 116 in May 2006, the Veteran was not medicated. Once medication was resumed, the Veteran's diastolic pressure ranged from 69 to 92. Even on examination in August 2007, diastolic pressure ranged from 81 to 89. The Board considered a higher rating under Diagnostic Code 7015, which has been employed since September 29, 2011; however, METs were not recorded. Id. From September 29, 2011, no more than a 30 percent rating is warranted under Diagnostic Code 7015. As indicated above, the examiner estimated METS to be between 5 and 7 based on the history provided by the Veteran. An August 2010 Bruce ETT contained no METs determination. There has been no objective evidence since September 29, 2011, of more than one episode of acute congestive heart failure in the past year, or workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent to warrant a 60 percent rating. Id. The Board has also considered other potentially applicable diagnostic codes for diseases of the heart, arteries, and veins that provide for the assignment of higher evaluations for the Veteran's hypertension. After review, however, the Board observes that no other code provisions can be applied for a higher rating based on the evidence of record throughout the appellate period. "Staged" ratings, other than what are already in effect are not warranted for any period of the appeal. 38 C.F.R. § 4.71a; see Hart, supra. Should the Veteran's disability picture change in the future, he may be assigned a higher rating. See 38 C.F.R. § 4.1. Cluster Headaches Historically, service connection was awarded for headaches in a March 1986 rating decision. An initial 10 percent evaluation was assigned effective in August 1985. The Veteran filed the most recent increased rating claim in August 2006. The RO continued the 10 percent rating in January 2008. The Veteran disagreed and initiated the instant appeal. In September 2012, the RO awarded an increased 30 percent rating effective from September 29, 2011. His claim remains in controversy as less than the maximum benefit available has been awarded. See AB, supra. The Veteran's cluster headaches have been rated by analogy under 38 C.F.R. § 4.124a, Diagnostic Code 8100 as 10 percent disabling prior September 29, 2011, and 30 percent thereafter. Under Diagnostic Code 8100, a 10 percent rating is assigned for migraines with characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent is assigned for characteristic prostrating attacks occurring on average once a month over last several months. A 50 percent is assigned for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. The pertinent facts found in the medical evidence of record are discussed below. Having carefully considered the Veteran's claim in light of the evidence of record and the applicable laws and regulations, and as outlined in the reasons and bases below, the Board finds that the currently assigned 10 percent rating prior to September 29, 2011, and 30 percent thereafter, for cluster headaches are appropriate and no higher rating is warranted under any applicable diagnostic code for rating miscellaneous diseases of the central nervous system. 38 C.F.R. §§ 4.7, 4.124a. VA outpatient treatment records dated in January 2006 show the Veteran complained of frontal headaches of three to four days duration; however, headaches were attributed to uncontrolled hypertension. In April 2006, the Veteran complained of a headache and blurred vision, occurring 24 hours prior. Again, it was noted the Veteran had elevated blood pressure. In May 2006, the Veteran had a history of cluster headaches. There were no neurological problems identified. In September 2006, the Veteran had a past medical history of headaches. The Veteran was afforded a VA examination in August 2007. He complained of headaches occurring about once a week. He indicated this had been unchanged for many years. Some of the headaches were described as very minor without any interruption in activities. Some of the headaches were said to be more severe requiring rest, sitting down, and closing his eyes. Headaches were associated with some nausea and occasionally with photophobia. The headaches lasted anywhere from one hour to eight or nine hours. He did not take any medicine for his headaches, even when they were severe. The Veteran was diagnosed with frequent vascular type headaches, unchanged in frequency and untreated. VA outpatient treatment records dated in 2007 and 2008 were negative for complaints or treatment for headaches, as were private medical records dated between 2009 and 2011. The Veteran was afforded a VA examination on September 29, 2011. The examiner noted migraine headaches, including migraine variants, diagnosed as early as 1979. The headaches were described as bitemporal cluster headaches. He denied any hospitalization for headaches. He took over the counter Ibuprofen as needed only. He complained of constant head pain, pulsating or throbbing head pain, and pain on both sides of the head. He complained of associated nausea and changes in vision. The head pain lasted more than two days. He did not have characteristic prostrating attacks of migraine headache pain. He had prostrating attacks of non-migraine headache pain more frequently than once per month. He had no complications. The Veteran indicated that he had more frequent headaches when he had to use floor buffers or other custodial machinery at work. Prior to September 29, 2011, no more than a 10 percent rating was warranted under Diagnostic Code 8100. Notably, there was no evidence of characteristic prostrating attacks occurring on average once a month over last several months. Reports of headaches early in 2006 were attributed to uncontrolled hypertension. Thereafter, the Veteran gave a history of headaches. There were no complaints of headaches between 2007 and 2011, other than upon VA examination. Even then headaches were said to occur about once a week, though unsupported by the objective medical evidence. Headaches were described as very minor without any interruption in activities or severe requiring rest, sitting down, and closing his eyes. They were not described as prostrating and were said to be untreated. From September 29, 2011, no more than a 30 percent rating is warranted under Diagnostic Code 8100. As indicated above, it was not until VA examination in September 2011 that the Veteran complained of constant head pain, pulsating or throbbing head pain, and pain on both sides of the head. The head pain lasted more than two days and he endorsed prostrating attacks of non-migraine headache pain more frequently than once per month. The Board has also considered other potentially applicable diagnostic codes for miscellaneous diseases of the central nervous system that provide for the assignment of higher evaluations for the Veteran's cluster headaches. After review, however, the Board observes that no other code provisions can be applied for a higher rating based on the evidence of record throughout the appellate period. "Staged" ratings, other than what are already in effect are not warranted for any period of the appeal. 38 C.F.R. § 4.71a; see Hart, supra. Should the Veteran's disability picture change in the future, he may be assigned a higher rating. See 38 C.F.R. § 4.1. Extraschedular Consideration The above determinations are based upon application of the pertinent provisions of VA's rating schedule. With regard to possible extraschedular consideration, the threshold factor is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). The schedular criteria, in general, are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. The Board finds that the symptoms and resulting impairment demonstrated with regard to the Veteran's hypertension and cluster headaches fall within the schedular criteria. The Veteran's hypertension prior to September 29, 2011, is manifested by continuous use of medication for control and from September 29, 2011, by estimated METs between five and seven. The Veteran's cluster headaches prior to September 29, 2011, averaged one in two months over several months and from September 29, 2011, prostrating attacks of non-migraine headache pain once a month over several months. The rating criteria contemplate these symptoms. See Diagnostic Codes 7015, 7101, 8100. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Id. ORDER Entitlement to an evaluation in excess of 10 percent prior to September 29, 2011, and in excess of 30 percent thereafter, for the service-connected hypertension is denied. Entitlement to an evaluation in excess of 10 percent prior to September 29, 2011, and in excess of 30 percent thereafter, for the service-connected cluster headaches is denied. REMAND The Veteran additionally claims entitlement to an evaluation in excess of 20 percent for the service-connected right shoulder disability and TDIU. A preliminary review of the record discloses the matters are not ready for appellate disposition. The record compiled for appellate review of this matter appears incomplete. The Veteran informed the September 2011 VA examiner that he was awaiting bilateral arthroscopic acromioplasty and debridement for chronic bilateral shoulder pain from his non-VA orthopedic surgeon. On October 11, 2011, after VA examination, an arthroscopy with debridement of partial rotator cuff tear with subacromial burscoscopy with anterior inferior acromioplasty, excision of coracoacromial ligament, and resection of distal clavicle, right shoulder, was performed. Only one record of follow-up visit with Dr. RJH, which noted that he was going to start therapy, was associated with the claims folder. Records of follow-up treatment after October 2011 and physical therapy have not been associated with the claims folder. Attempts must be made to obtain them upon Remand. 38 C.F.R. § 3.159(c)(2). As the VA examination was performed prior to the surgery, it is not clear from the current record whether or not the Veteran's service-connected right shoulder increased or decreased in severity. Further examination is needed to address that question. 38 C.F.R. § 3.327(a); See Snuffer v. Gober, 10 Vet. App. 400, 402-03 (1997). 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). In addition, as it appears that there are missing records, and as it is essential that each disability be viewed in relation to its history, re-examination is necessary. 38 C.F.R. § 4.1. As for the TDIU claim, this issue is not ripe for Board adjudication at this time as the potential outcome of the claim for increased rating for a right shoulder disability could affect the issue of whether the Veteran's service connected disabilities render him unemployable. See 38 C.F.R. § 4.16 . Accordingly, the TDIU claim is considered to be inextricably intertwined with the claim for increase. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (providing that two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). VA may not reject the Veteran's TDIU claim without producing evidence, as distinguished from mere conjecture, that the Veteran's disabilities do not prevent him from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995). This may include an examination, which includes an opinion as to what, if any, affect the Veteran's service-connected disabilities have on his ability to work. Friscia, 7 Vet. App. at 297. A VA medical opinion was obtained on this point (regarding the Veteran's employability) in September 2011. After the claim for increased rating for the right shoulder disability is developed, another VA examination should be performed to ascertain the effect of the service-connected disabilities on the Veteran's ability to work. The examiner should be informed that service connection was awarded for additional disabilities (lumbar degenerative disc disease, lumbar radiculopathy of the left lower extremity, osteoarthritis of the left shoulder, and right thumb and wrist disabilities) in September 2012. Ongoing medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). The RO should ensure that all due process requirements are met. The RO should also give the Veteran another opportunity to present information and/or evidence pertinent to the claims on appeal. 38 U.S.C.A. § 5103A (b) (West 2002). Accordingly, the case is REMANDED for the following action: 1. Obtain the records of follow-up treatment by Dr. RJH of the Veteran after the October 2011 right shoulder surgery; obtain names and addresses of all medical care providers who performed physical therapy on the Veteran's right shoulder after his surgery in October 2011. After securing the necessary releases, the obtain these records. 2. Take all indicated action in order to obtain copies of any of the Veteran's VA outpatient treatment records not on file. All records and/or responses received should be associated with the claims file. 3. After completion of the foregoing, schedule the Veteran for a VA orthopedic examination to ascertain the severity of his service-connected right shoulder disability. The Veteran's entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner before the examination. If the examiner does not have access to Virtual VA, any relevant treatment records in Virtual VA that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. All indicated tests or studies must be completed. The examiner should describe all findings in detail. The examiner should describe all findings (to include ranges of motion) in detail. The examiner should perform repetitive range of motion testing and also comment on the degree of limitation of function, if any, due to pain, weakness, lack of endurance, fatigue, or incoordination. The examiner should further indicate whether there is any ankylosis of the scapulohumeral articulation, and/or impairment of the humerus, clavicle, or scapula. The examiner must explain the rationale for all opinions. 4. Then, the RO/AMC should schedule the Veteran for a VA medical examination to address the effects of his service-connected disabilities, to include the newly service-connected disabilities (lumbar degenerative disc disease, lumbar radiculopathy of the left lower extremity, osteoarthritis of the left shoulder, and right thumb and wrist disabilities) on his capacity to obtain and hold employment. The examiner must be provided with the Veteran's claims file for review. The examiner is requested to provide an opinion as to whether the Veteran's service-connected disabilities, either singly or taken together, render him unable to secure or follow a substantially gainful occupation. Detailed rationale is requested for the opinion provided. The examiner is requested to provide a complete rationale for any opinion expressed, based on the examiner's clinical experience, medical expertise, and established medical principles. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 5. In the interest of avoiding further remand, ensure that the requested actions have been accomplished (to the extent possible) in compliance with this REMAND. 6. After completing the requested actions, and any additional notification and/or development deemed warranted, the RO should readjudicate the claims for increase for a right shoulder disability and TDIU in light of all evidence of record, to include any pertinent evidence contained within Virtual VA. If any benefit sought on appeal remains denied, the RO must furnish to the Veteran and his representative with an appropriate supplemental statement of the case and afford a reasonable opportunity for response. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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. 2012). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs